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Aggressive treatment for acute skin and pulmonary infections and preventing infectious complications is most crucial in management.The clinical presentation of hyperthyroidism in some elderly is similar to that seen in hypothyroidism, and can be obscured by other existing diseases such as diabetes. Only a quarter of elderly hyperthyroid patients have typical symptoms and this incidence falls with increasing age (1). In 1931, www.selleckchem.com/deubiquitinase.html Lehey described a distinct form of thyrotoxicosis characterized by lethargy as the main symptom, with tired and disinterested patients who did not react well to stress; and this presentation was termed ��apathetic thyrotoxicosis�� (2). It is a unique manifestation of hyperthyroidism in which the characteristic mental and physical activation of hyperthyroidism are absent and the chief clinical features are weakness, apathy, and depression; therefore, a diagnosis of thyrotoxic crisis can be missed with consequent fatal outcome (2). The aim of this case report is to review a form of hyperthyroidism that can be confused with hypothyroidism or depression, or may be a secondary cause of diabetes. Case presentation An 84-year-old Asian woman with 1 year history of type 2 diabetes on metformin presented to diabetes clinic with deranged serum Plasmin glucose [Fasting: 140(70�C110 mg/dL) and 2-hour postprandial: 147(selleck 16 kg/m2), and exhibited listlessness, delayed reaction, apathy, tachycardia (108/minute) and hypertension (180/90 mm Hg). She also had diffuse, waxy thickening of skin involving pretibial area and dorsum of the foot with peau d'orange appearance (Fig. 1); however, there were no signs of thyromegaly or ophthalmopathy. Biochemical evaluation revealed thyrotoxicosis [T3: 338.59(60�C181 ng/dL), T4: 19.5(3.2�C12.6?U/dL), TSH: