32 year old male patient admitted to A&E with a 3 days history of confusion and generalised oedema. History from the mother revealed long standing self-neglect, poor nutrition and prolonged immobility due to abnormal painful sensation and weakness in the lower limbs. This is preceded by a post traumatic drastic change in character of the patient, with resultant agoraphobia and excess consumption of alcohol. Investigations on admission include: TSH 128 ulu/ml (0.27-4.20), T4 <0.5 pmol/l(11.1-22.6); Hb 170g/l(135-175), WBC 10.40 x109 (4-11), Neutrophils 8.14x 109 (2.0-7.5); AKI- eGFR 22 (>90), creatinine 306umol/l(59-104), urea 32.7mmol/l(2.5-7.8); ALT 58U/l(10-50), bilirubin 34umol/l(0-21), GGT 313U/l(10-71; sodium 129mmol/l(133-146), magnesium 0.66mmol/l(0.7-1.0), phosphate 0.50mmol/l(0.80-1.50); Vitamin D level <7.5nmol/l(<50 depicts deficiency); albumin 34.6g/l(35-50), globulin 23g/l(19-35); normal iron studies with elevated ferritin- 1159ng/ml (30-400); TPO 9 IU/ml (0-34), thyroid receptor AB <0.3 IU/l( 0.0-0.9). Thyroid ultrasound demonstrated bulky thyroid with no obvious masses or pathology identified. BMI on admission was 26. He was managed as a complex presentation of severe hypothyroidism of uncertain aetiology, confusion of unknown cause, severe bilateral pneumonia and AKI. He was commenced on levothyroxine 75micrograms. AKI and pneumonia significantly improved with treatment. He had several investigations for a possible underlying aetiology of illness and ongoing confusion, including analysis for possible Prion disease which were all negative. He made a remarkable improvement clinically and was discharged to a neurorehabilitation hospital. On follow up in endocrinology clinic, steady improvement in thyroid function was noted. Levothyroxine was discontinued. He remained euthyroid without levothyroxine and has continued to remain stable. Below is a table demonstrating the trend of thyroid function tests from admission till present:
|Date||TSH (ulu/l) (0.27-4.20)||T4 ( pmol/l) (11.1-22.6)||T3 ( pmol/l) (3.1-6.8)||Treatment with thyroxine|
|Nov 2021||2.97||32.1||4.8||Ongoing treatment|
|November 2022||1.54||21.9||4.8||No treatment|
|Jan 2023||1.70||21.6||5.4||No treatment|
Conclusion: This was a case of transient severe hypothyroidism of uncertain aetiology. Was this severe non-thyroidal illness as an underlying cause of severe hypothyroidism? Or Severe hypothyroidism secondary to malnutrition?