Presentation Type
Oral Presentation
Discipline Track
Patient Care
Internal Medicine
Abstract Type
Case Report
Abstract
Background: Hypothyroidism is defined as failure of the thyroid gland to produce sufficient thyroid hormone to meet the metabolic demands of the body. Untreated hypothyroidism can contribute to hypertension, dyslipidemia, infertility, cognitive impairment, and neuromuscular dysfunction. It may occur as a result of primary gland failure or insufficient thyroid gland stimulation by the hypothalamus or pituitary gland. Primary gland failure can result from the congenital abnormalities, autoimmune destruction, iodine deficiency, and infiltrative diseases. Patients can clinically present with weight gain, cold intolerance, depression, muscle fatigue, poor concentration, and menstrual irregularities. The best laboratory test for the thyroid assessment is serum TSH test. If the TSH is elevated the serum free thyroxine (T4) should be done. Therefore, here we present a case of the young lady with severe hypothyroidism presenting with shortness of breath.
Case Discussion: A 31 year old lady with no known significant past medical history presented to the emergency department complaining of the shortness of breath which has been ongoing from last 6 months. She also mentioned that she has been more constipated than usual and attributed her symptoms to constipation. On further evaluation, vitals on admission were HR of 50s and BP 90/50s. The orthostatic vital signs were performed and were negative. The physical examination was positive for hair loss, dry skin, muffled heart sound and pallor of conjunctiva was noted. Further the labs were drawn and significant labs showed hemoglobin of 5.4 g/dl, CK of 344 u/L, LDL of 182 mg/dl. 1 unit of packed red blood cells was given and simultaneously Chest X Ray was done which showed boot shaped heart and EKG was done which showed sinus bradycardia. Another set of blood was collected for the lactic acid, troponin and TSH. All were normal except TSH was 257.34 uIU/ml. The patient was diagnosed with severe hypothyroidism and further free T4 was 0.4ng/dl which was significantly low. Started on the Levothyroxine 1.6 micrograms/kg/day which rounded up as 100 micrograms daily for her. As soon as the levothyroxine was given, within 1 hour her heart rate and blood pressure and her symptoms started resolving. Bedside ultrasound was done which showed the moderate pericardial effusion, which was cause of the dyspnea. The patient was worked up for the autoimmune hypothyroidism and everything was negative, therefore was patient was safely discharged home with Levothyroxine 100 micrograms and advised to follow up with the PCP for the dose titration.
Conclusion: The main learning point from this is that severe hypothyroidism can disguise in different ways and present differently. The key point is to have sharp suspicion for the hypothyroidism if chest xray shows boot shaped heart and bradycardia. The pericardial effusions can occur in patients with severe untreated hypothyroidism and can be just treated with the oral levothyroxine and pericardial effusion will resolve eventually.
Academic/Professional Position
Resident
Mentor/PI Department
Internal Medicine
Recommended Citation
Patel, Shreel H.; Ali, Kashif; Cho, Eunbee; Bello, Fatimah; Suarez Parraga, Andres; and Fleires, Alcibiades, "An Unusual Presentation of the Severe Hypothyroidism Presenting As Shortness of Breath" (2024). Research Symposium. 6.
https://scholarworks.utrgv.edu/somrs/2024/talks/6
Included in
An Unusual Presentation of the Severe Hypothyroidism Presenting As Shortness of Breath
Background: Hypothyroidism is defined as failure of the thyroid gland to produce sufficient thyroid hormone to meet the metabolic demands of the body. Untreated hypothyroidism can contribute to hypertension, dyslipidemia, infertility, cognitive impairment, and neuromuscular dysfunction. It may occur as a result of primary gland failure or insufficient thyroid gland stimulation by the hypothalamus or pituitary gland. Primary gland failure can result from the congenital abnormalities, autoimmune destruction, iodine deficiency, and infiltrative diseases. Patients can clinically present with weight gain, cold intolerance, depression, muscle fatigue, poor concentration, and menstrual irregularities. The best laboratory test for the thyroid assessment is serum TSH test. If the TSH is elevated the serum free thyroxine (T4) should be done. Therefore, here we present a case of the young lady with severe hypothyroidism presenting with shortness of breath.
Case Discussion: A 31 year old lady with no known significant past medical history presented to the emergency department complaining of the shortness of breath which has been ongoing from last 6 months. She also mentioned that she has been more constipated than usual and attributed her symptoms to constipation. On further evaluation, vitals on admission were HR of 50s and BP 90/50s. The orthostatic vital signs were performed and were negative. The physical examination was positive for hair loss, dry skin, muffled heart sound and pallor of conjunctiva was noted. Further the labs were drawn and significant labs showed hemoglobin of 5.4 g/dl, CK of 344 u/L, LDL of 182 mg/dl. 1 unit of packed red blood cells was given and simultaneously Chest X Ray was done which showed boot shaped heart and EKG was done which showed sinus bradycardia. Another set of blood was collected for the lactic acid, troponin and TSH. All were normal except TSH was 257.34 uIU/ml. The patient was diagnosed with severe hypothyroidism and further free T4 was 0.4ng/dl which was significantly low. Started on the Levothyroxine 1.6 micrograms/kg/day which rounded up as 100 micrograms daily for her. As soon as the levothyroxine was given, within 1 hour her heart rate and blood pressure and her symptoms started resolving. Bedside ultrasound was done which showed the moderate pericardial effusion, which was cause of the dyspnea. The patient was worked up for the autoimmune hypothyroidism and everything was negative, therefore was patient was safely discharged home with Levothyroxine 100 micrograms and advised to follow up with the PCP for the dose titration.
Conclusion: The main learning point from this is that severe hypothyroidism can disguise in different ways and present differently. The key point is to have sharp suspicion for the hypothyroidism if chest xray shows boot shaped heart and bradycardia. The pericardial effusions can occur in patients with severe untreated hypothyroidism and can be just treated with the oral levothyroxine and pericardial effusion will resolve eventually.