葛瑞夫茲氏症併甲狀腺風暴──以咳嗽臨床表現為例

Cough as the Primary Clinical Manifestation of Graves’Disease with Thyroid Storm: A case Report

咳嗽常被認為與呼吸系統疾病相關，本個案是一位46歲女性患者，咳嗽一個月至診所就醫未改善，此次因出現呼吸喘無法緩解故入院，於入院身體評估檢查發現呼吸音雙側濕囉音併微喘鳴音、雙下肢水腫、出現心雜音第三心音（S3），經實驗室檢驗、胸部X光及心臟超音波檢查，初步診斷急性失償心臟衰竭併肺水腫，予利尿劑及抗心律不整藥物治療，但因心悸及頑固性心博過速加劇，安排甲狀腺超音波檢查，並緊急照會專科抽血檢驗發現有甲狀腺機能亢進，確診為葛瑞夫茲氏症併甲狀腺風暴引發急性失償心臟衰竭、急性肝衰竭及急性B型肝炎感染，開立抗甲狀腺藥物及類固醇合併β-阻斷劑口服治療，其心悸及頑固性心博過速改善後出院返家。咳嗽屬普遍非特異性症狀，易與呼吸道疾病混淆，進而導致錯誤診斷，若治療效果不彰，應即再次詳細病史詢問及理學檢查，執行實驗室及影像學檢查。葛瑞夫茲氏症引起的原因跟遺傳及壓力、抽菸等誘發因素有關，建議避免過大壓力及戒菸，如家族有人罹患葛瑞夫茲氏症，遺傳罹病機率較高。

Cough is often attributed to respiratory diseases. This report describes a case of a 46-year-old woman who presented with a 1-month history of a persistent cough unresponsive to outpatient therapy. She was admitted for progressive dyspnea and wheeze refractory to initial management. Physical examination upon admission revealed bilateral fine crackles and mild wheezing, bilateral lower-limb edema, and a third heart sound (S3; gallop). Laboratory tests, chest X-ray, and echocardiography initially suggested acute decompensated heart failure (ADHF) with pulmonary edema. She received diuretics and antiarrhythmic therapy. However, her palpitations and intractable tachycardia worsened, prompting a thyroid ultrasound and urgent endocrinology consultation with laboratory testing. Laboratory tests confirmed hyperthyroidism, and she was subsequently diagnosed with Graves’disease complicated by thyroid storm, leading to ADHF, acute liver failure, and concurrent acute hepatitis B infection. The patient was treated with a combination of antithyroid drugs, corticosteroids, and oralβ-blockers. Her palpitations and tachycardia improved, and she was discharged in stable condition. Cough is a common and nonspecific symptom often misattributed to respiratory disease, potentially leading to misdiagnosis. If treatment is ineffective, a thorough reassessment should be undertaken, including a detailed medical history, physical examination, and appropriate laboratory and imaging investigations. Graves’disease involves genetic susceptibility, with triggering factors including stress and smoking. Therefore, patients should avoid excessive stress and smoking. Individuals with a family history of Graves’disease are at higher risk of developing the condition than those without such a history.