A 15-YEAR-OLD black girl presented with complaints of intermittent vomiting, abdominal pain, and vaginal bleeding during the past month. She gave a history of having been raped 2 months earlier.
On pelvic examination, the uterine size was consistent with a 12-week pregnancy. Her last menstrual period had occurred 10 weeks earlier. Medical history was noteworthy only for easily controlled asthma. She was taking no medications. The urine pregnancy test results were positive. β-Human chorionic gonadotropin (hCG) concentration in blood was 673160 IU/L (normal for this stage, <200000 IU/L). Abdominal ultrasound showed a 10.6×7.0×10.0-cm heterogeneous mass involving the uterus and containing cystic areas.
Suction dilatation and curettage were done. A brownish-tan, irregularly shaped, membranous, spongy mass with multiple translucent, membranous cysts was removed (Figure 1 and Figure 2). During the procedure, the patient had a narrow complex tachycardia with a heart rate in the 180 range (prior to surgery, 95). The ECG revealed sinus tachycardia (130-150 /min) with a short PR interval and a delta wave consistent with a diagnosis of Wolff-Parkinson-White syndrome (WPW).
Because of the sinus tachycardia, hematocrit and thyroid function tests were ordered. The hematocrit had decreased to 0.18, from a level of 0.39 before surgery. The patient was given 1 U of packed RBCs.
The thyroid function tests revealed the following values: thyroxine (T4), 464 nmol/L (36.2 µg/dL) (normal range, 64-144 nmol/L [5.0-11.2 µg/dL]); triiodothyronine (T3) uptake, 0.225 (normal range,0.245-0.39); free thyroxine index (FTI), 8.15 (normal range, 1.75-3.23); and thyrotropin (TSH), <0.01 mU/L (normal range, 0.3-4.0 mU/L. The β-hCG level fell to 82824 IU/L 2 days after surgery.
Pediatric Endocrinology Service was consulted 3 days after the surgery when the thyroid function test results became available. The patient then had no signs of hyperthyroidism, except for a heart rate of 120 and a wide pulse pressure of 128/50 mm Hg. The thyroid was not palpable. No nodules or Delphian node was palpated. She had no eye abnormalities or resting tremor of the tongue or the extremities. She reported no symptoms of hyperthyroidism before or after surgery, except occasional tachycardia (possibly due to the undiagnosed WPW). Bowel movements were normal. No antithyroid medication was given.
Four days after the surgery, β-hCG concentration was 21330 IU/L and thyroid function test values were T4, 246 nmol/L (19.2 µg/dL); T3 uptake, 0.27 FTI, 5.2; T3, 29 nmol/L (normal range, 1.2-2.9 nmol/L); and TSH, <0.01 mU/L. The patient was discharged home feeling well.
Repeated β-hCG concentration 5 days later was 957 IU/L, decreasing to 218 IU/L after 1 more week. One month after the surgery, the β-hCG level was 16 IU/L.
At 3 weeks after initial presentation, she remained clinically euthyroid. Her T4 level was 101 nmol/L (7.9 µg/dL); T3, 1.92 nmol/L; and TSH, 0.99 mU/L.
Sanchez JC, Sanchez JE. Pathological Case of the Month. Arch Pediatr Adolesc Med. 1998;152(8):827-828. doi:10.1001/archpedi.152.8.827