Looking Beyond Thyroid in a Thyroid Disorder Patient
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Thyroid disorders are very common in India. Prevalence of hypothyroidism (overt & subclinical) and hyperthyroidism (overt & subclinical) in India is 13.3% and 2.9% respectively. These two disorders are usually associated with various psychiatric disorders like depression, anxiety, mood disorder and others. Many times, patients with thyroid disorders continue to suffer from nonspecific symptoms like fatigue, giddiness, anorexia, weight loss and muscle weakness even when their thyroid function test have become normal.

There are many reasons for this like D2 deiodinase polymorphism, selenium deficiency, tissue hypothyroxinemia, depression and other diseases associated with thyroid disorders. Primary care physician (PCP) often diagnose thyroid disorder patient with these non-specific symptoms as a case of depression and/or poor physical fitness. But certain diseases which are associated with thyroid disorder patients remain undiagnosed. Here we are reporting two thyroid disorder cases which were suffering from non-specific symptoms even when their thyroid function test (TFT) had become normal.

Case 1
A 40-year-old female was diagnosed 2 years back as a case of primary hypothyroidism (TT4=3 mcg/dl, TSH= 68Miu/ml, Anti TPO=200 IU/ml) by her PCP and was put on levo-thyroxine (100 mcg/day). She was quite well initially but since the last 6 months, she had started feeling nonspecific symptoms like fatigue, muscle pain, giddiness and anorexia. She was given supportive treatment but was not relieved. Two weeks ago, she developed nausea and vomiting, for which she was admitted and diagnosed as a case of gastroenteritis and hyponatremia.

She improved on supportive treatment but her nonspecific symptoms persisted and for this she was referred to us. On examination there was hypotension, hyperpigmentation and diffuse goiter. She was suspected as a case of Addison’s disease. Laboratory test showed hyponatremia, hyperkalemia, hypocortisolism and raised ACTH. TFT, blood glucose, LFT and KFT were normal. Plasma renin activity, aldosterone and markers of autoimmunity (21 hydroxylase Ab, GAD Ab, IC Ab, Ttg Ab) were not done due to paucity of money. Patient was diagnosed as a case of Autoimmune Polyglandular Syndrome -2. She was put on hydrocortisone and fludrocortisone along with thyroxine. At present she is doing well.

Case 2
A 48-year-old known case of grave’s disease presented to our clinic with severe fatigue, weakness and muscle pain. He was on adequate dose of neomercazole as his TFT was normal. He was diagnosed as a case of depression by his PCP because of financial loss in business and was put on antidepressant. But there was no relief with medication and he consulted to us for nonspecific symptoms. Routine laboratory tests were sodium (135 mEq/l), potassium (2.6 mEq/l), Total Testosterone (330 ng/dl). CBC, LFT and KFT were normal. He was diagnosed as a case of hypokalemia (Hypokalemic periodic paralysis). He was put on oral potassium supplementation and nonspecific betablocker and now he is doing well.

Authors report these two cases where diseases associated with thyroid disorder are often missed. Initially both patients were diagnosed as depression along with thyroid disorder which was not the case. First one was suffering from Addison’s disease along with thyroid disorder and second from hypokalemia along with thyroid disorder. So, if a patient of thyroid disorder shows persistence of nonspecific symptoms in spite of normal TFT, we should suspect other associated conditions like Addison’s disease, hypokalemia, diabetes mellitus, hypoparathyroidism and others.

Source: https://www.japi.org/x27484b4/looking-beyond-thyroid-in-a-thyroid-disorder-patient
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