L. G.

, 59 years, female First admission in our department in october 2011 Complaints: Fatigue Cold intolerance Constipation Progressive weight gain (15 kg in the last year) Dysphony / deep hoarse voice

 Family history: Her father with cardiac pathology (?) Personal history: - pericardial effusion in may 2011 - arterial hypertension - ischemic heart disease - chronic obstructiv pulmonary disease - dyslipidemia - hepatitis B in 1985 Smoker:
1- 2 cigarettes/ day since march 2011, before 10 cigarettes/ day

Alcohol occasionally

Chronic medication: Atacand (candesartan) 16mg 1 0 0 Olicard (isosorbid mononitrat) 40 mg 1 0 1 Carvedilol 6.25mg 1 0 1 Amlodipine 10 mg 1 0 0 Ramipril 10 mg 1 0 1 Spironolactone 25 mg 1 1 0 Furosemid 40 mg 1 2 cp/ week Simvastatine 20 mg 0 0 1 Salbutamol 100g/ dose 2x1

Course of the disease

The patient noticed a progressive weight gain over the last year (15 kg), associated with fatigue, cold intolerance, constipation. In may 2011 he was diagnosed with pericarditis (on echocardiography, performed during a cardiologic reevaluation). A TB etiology of pericardial effusion was excluded. A glucocorticoid therapy was initiated, but without favorable clinical response. The patient was adressed to our department for further investigations.

Clinical exam
Dull expressionless face, periorbital puffiness. Dry, pale, slightly yellowish skin. Sparse hair. H: 165 cm; W: 100,7 kg; BMI: 37 kg/m Muscles weakness. Dyspnea with medium effort. Bradycardia (55 b/min), dimmed heartbeats. BP 120/80mmHg. Constipation. Bradylalia, bradykinesia, hypoacusis. Thyroid: palpable, elevated consistency, irregular surface, without palpable nodules or cervical adenopathies.

Presumptive diagnosis:
Hypothyroidism. Chronic autoimmune thyroiditis. Myxedematous pericarditis.
What lab test you need?

Lab tests
Blood Count: Hgb 10.5 g/dl, Htc 32.7%, MCV: 90 fl, MCHC: 32.1 g/l (moderate normocytic normochromic anemia). Total cholesterol: 273 mg/dl; triglycerids: 284 mg/dl (mixed dyslipidaemia). Fasting glycaemia: 132 mg/dl (impaired fasting glycaemia). Uric acid: 6.47 mg/dl Creatinine: 1.49 mg/dl, creatinine clearence (MDRD): 59 ml/min (CKD stage 3) Na: 136 mmol/l; K: 4.5 mmol/l Normal liver enzymes. TSH: 178.570 UI/ml ( 0.38 4.31) FT4: 0.07 ng/ dl (0.82 1.63) TPO AB: 1000 UI/ml (0 3.2)

Is there any imaging method needed ? Which one?

Paraclinical examination
Thyroid ultrasound: Right lobe 48/23/24 mm, volume 15 ml. Left lobe 31/ 28/ 31 mm, volume 14 ml. Hypoechoic thyroid parenchyma, heterogeneous echostructure with pseudonodular areas.

Chronic autoimmune thyroiditis ultrasound aspect

Chest X rays: pericardial effusion

Final diagnosis
Chronic autoimmune thyroiditis (elevated TPO Ab) Severe primary hypothyroidism (myxoedema; high TSH with very low FT4) Myxedematous pericarditis Normocytic normochromic anemia Mixed dyslipidaemia Obesity Impaired fasting glycaemia Arterial hypertension Ischemic heart disease Chronic Kidney Disease stage 3

Differential diagnosis
Other causes of primary hypothyroidism: - iodine induced hypothyroidism - transient -drugs induced (Lithium, ATS, amiodarone, interferon alpha, stavudine) -iatrogenic Central hypothyroidism Generalized resistance to thyroid hormones: clinical signs and symptoms of hypothyroidism (TSH, FT3, FT4) Euthyroid sick syndrome: FT3 , normal FT4 or both (FT4+FT3) , without TSH augmentation (severe infections, terminal neoplasias, AIDS, burned, denutrition Other causes of anaemia, dyslipideamia Cardiac, renal or hepatic oedema

Course and prognosis

Untreated hypothyroidism: slow deterioration, potentially leading eventually to myxedema coma and death. Appropriate treatment: excellent long-term prognosis.

Treatment
Substitution with L Thyroxine (Euthyrox) Older patients with cardiovascular disease: increase dose cautiously! L T4 25g (a daily oral intake) for 1-2 weeks, increasing by 25g every 1-2 weeks until a daily dose of 100g. This dose is continued for about 6 weeks. Serum TSH and Ft4 is then measured and the dosage adjusted accordingly.

Follow - up
Monitor the serum FT4 and TSH every 6 weeks until equilibrium is reached. Thereafter, FT4 and TSH can be monitored once every 6 12 weeks. Reassess blood count, plasmatic lipids, uricemia after hypothyroidism treatment.