Poster 06: Multisystem presentation of severe hypothyroidism

McNabb BM; Harper R; Shahzad MA; McHenry CM
Department of Endocrinology, Ulster Hospital Dundonald
 
Severe untreated hypothyroidism leads to chronic altering of physiological mechanisms. Abnormalities in blood line, renal function and liver enzymes are described in myxoedema but our review, to date, has found no report of all three occurring simultaneously. We present a patient referred to nephrology, haematology and hepatology with renal impairment, cytopenia and abnormal liver enzymes, respectively, in whom no unifying diagnosis was reached until thyroid tests (TFT) were checked at the end of a complex investigation pathway.

29 year old male presented to GP with tiredness and leg swelling: creatinine 157umol/L (eGFR 45mL/min). He was referred to nephrology: no proteinuria detected, ultrasound showed structurally normal kidneys. There was mild anaemia (Hb 100-110g/L), neutropenia (1.2-1.9x109/L) and elevated transaminases (AST 170:ALT 107U/L). Bone marrow was hypocellular with islands of normal cellularity; cytogenetics normal.  Liver screen was negative and biopsy showed steatosis, haemosiderosis and ground glass change similar to inherited metabolic disorders. A small pericardial effusion was demonstrated on CT chest/abdomen/pelvis but radiological tests were otherwise unremarkable.

TFT were checked 18 months following presentation: Free T4 <1.3pmol/L and TSH 333mU/L (anti-TPO antibodies positive [69iU/mL]). Levothyroxine 125mcg once daily was commenced. At 2 months, symptoms settled with normalisation of TFT corresponding to complete resolution of renal impairment and transaminitis. At 6 months, haematological abnormalities also returned to normal.

We describe three unusual complications of severe hypothyroidism with complete recovery of abnormalities following 6 months of thyroxine replacement. This highlights importance of checking TFT in the patient with unexplained renal impairment, anaemia/cytopenia or liver abnormalities.

Discipline: 
Diabetes
Clinical taxonomy: 
Type 1 diabetes mellitus
Type 2 diabetes mellitus
Resource taxonomy: 
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