Endocrine Abstracts

Case presentation: This detailed case report delves into the complex clinical trajectory of a 37-year-old Afro-Caribbean woman hailing from Zimbabwe, who presented with a diverse array of symptoms. Among these were diarrhea, tremor, anxiety, abdominal distension, amenorrhea and a staggering unintentional weight loss of 1 kg over the past year. Notably, her medical history features a previous open left-sided salpingectomy undertaken for a ruptured ectopic pregnancy. The persistence of diarrhea, initially attributed to a chronic intestinal infection, led to her relocation to the UK in early 2023. Following a referral to the Gynae-Oncology team due to elevated CA-125 levels, a meticulous examination ensued to probe the possibilty of gynaecological malignancy. The speculum test yielded normal findings, and bimanual palpation failed to reveal any palpable masses. Remarkably, the patient, abstinent for over a year, declined a pregnancy test. Despite negative results from contrast-enhanced computed tomography of the chest, abdomen, pelvis (CTCAP), with specific consideration given to the differential diagnosis of struma ovarii, the gynae-oncology multidisciplinary team (MDT) dismissed ovarian cancer as the likely diagnosis, prompting further exploration of alternative causes. Subsequent referral was made to the endocrine team for symptoms suggestive of hyperthyroidism and neck swelling, the patient exhibited normal anti-TSH receptor antibodies but a significant elevation in anti-TPO antibodies. Biochemical analysis confirmed hyperthyroidism, prompting the initiation of treatment with carbimazole and propranolol by the GP. Subsequent imaging, CTCAP and computed tomography pulmonary angiography (CTPA), revealed a substantial right-sided pleural effusion and ascites, generalized soft tissue edema, hyperdense gastro-intestinal tract and negative for pulmonary embolism. This necessitated therapeutic thoracocentesis, which, upon analysis of the pleural fluid, revealed a transudative lymphocytic effusion, effectively excluding malignancy as a contributing factor to the observed symptoms. Surprisingly, further cardiac investigations unraveled an additional layer of complexity: severe non-ischemic dilated cardiomyopathy with reduced ejection fraction. This manifested as impaired left ventricular function, dilation in all cardiac chambers and valvular regurgitations possibly complicated by a late diagnosis of long-standing autoimmune hyperthyroidism. In conclusion, early detection of autoimmune hyperthyroidism is imperative, considering the characteristic symptoms. The presence of anti-TPO antibodies and myxedema, typically associated with Hashimoto’s thyroiditis, adds diagnostic intricacy. Notably, this presentation can also occur in Graves’ disease where severe heart failure with myxedema becomes a complication of long-standing hyperthyroidism. This highlights the crucial role of vigilant clinical suspicion, recognizing diverse manifestations, and swift diagnosis of hyperthyroidism, emphasizing the need for interdisciplinary collaboration in addressing complex clinical scenarios.