565 566

Pulse—50/min, regular, high volume, normal in character

BP—120/90 mm Hg
Weight gain and swelling of the whole body for … months
Neck veins—not engorged
Cold intolerance for … months
Precordium—no abnormality detected.
Increased sleepiness, lethargy, anorexia and weakness for … months
Constipation for … months
Lack of concentration and poor memory for … months.
Higher psychic functions:

History of present illness: According to the statement of the patient, she was alright … months
Motor functions:
back. Since then, she is suffering from weight gain and generalized swelling of the whole body, which
Slow relaxation of the ankle jerks
is progressively increasing in spite of her less appetite. The patient also complains of intolerance to
cold and prefers warm environment. For the last … months, she feels very lethargic, extremely weak,
Sensory functions—intact.
generalized body ache and constipation. She also feels sleepiness during most of the time even during
working hours, lack of concentration and disturbance of memory since the beginning of her illness.
Recently, her voice has changed and become hoarse. She also noticed that her skin is rough and dry.
There is no history of chest pain, palpitation, breathlessness, tingling, numbness of hands or feet or
loss of consciousness.
History of past illness: There is no history of thyroid disease, thyroid surgery, radiation to the neck Examination of other systems reveals no abnormalities.

Menstrual history: She complains of excessive menstrual bleeding for the last 3 months, though it
was normal previously.
Family history: No such illness in her family. All the family members are alright.
Socioeconomic history: She is a housewife in a middle-class family.
Drug and treatment history: Prior to her present illness, she did not take any drugs. There is no
history of taking any oral contraceptive pill. After the illness, she has only taken multivitamin tablets
and iron tables prescribed by a local physician.
The patient looks pale and apathetic
The whole body is swollen
The face is coarse and puffy with periorbital swelling, baggy eye lids and loss of outer one-third
of the eyebrows
She is mildly anemic, but there is no jaundice, cyanosis, clubbing, koilonychia or leukonychia
There is nonpitting edema
Mrs. …, 35 years old, housewife, normotensive, nondiabetic, hailing from …, presented with the
weight gain and generalized swelling of the whole body for … months, which is progressively
increasing inspite of her less appetite. The patient also complains of intolerance to cold and prefers
warm environment. For the last … months, she feels very lethargic, extremely weak, generalized
body ache and constipation. She also feels sleepiness during most of the time even during working
hours, lack of concentration and disturbance of memory since the beginning of her illness. Recently,
her voice has changed and become hoarse. She also noticed that her skin is rough and dry. There is
no history of chest pain, palpitation, breathlessness, tingling, numbness of hands or feet or loss of
consciousness. She also complains of excessive menstrual bleeding for the last 3 months, although
it was normal previously. There is no history thyroid disease, thyroid surgery, radiation to the neck
of taking drugs including oral contraceptive pills prior to her present illness. There is no family history
of similar illness. She was treated with calcium tablet and vitamins.
On Examination
General examination—mention as above
Systemic examination—mention as above.

My diagnosis is hypothyroidism (myxedema).

Pulse—50/min, high volume Q. What is the difference between myxedema and hypothyroidism?
BP—120/90 mm Hg A. Myxoedema is always associated with hypothyroidism, due to deposition of mucopolysaccharide
substances, but all hypothyroidism may not be associated with deposition of mucopolysaccharide
 567 568 to 8 weeks. Once TSH is normal, maintenance dose should be continued as a single daily therapy.
For follow up—annual thyroid function test should be done.
Q. What are your differential diagnoses?
A. As follows:
Nephrotic syndrome
Cushing’s syndrome.
Q. Why not this is nephrotic syndrome?
A. Q. Why thyroxine should be started in low dose?
pitting in nature. There is history of scanty micturition. All these are absent in this patient. On the
A. Because if high dose is given, it may precipitate anginal attack.
other hand, the patient has cold intolerance, sleepiness, lack of concentration, non pitting edema and
slow relaxation of ankle jerk and change of voice. These are not found in nephrotic syndrome. Q. How long will you continue the treatment?
A. Life long.
Q. Why not Cushing’s syndrome?
A. In Cushing’s syndrome, there is central obesity along with relatively thin limbs. Other signs Q. In hypothyroidism, if there is no response after thyroxine therapy, what are the
possibilities?
A. As follows:
Q. What do you think the cause in this case?
Associated hypopituitarism or Addison’s disease
A.
Pernicious anemia.
Q. If there is goiter with hypothyroidism, what is the likely cause?
A.
Q. What investigations do you suggest in hypothyroidism?
Q. What are the causes of hypothyroidism?
A. As follows:
A. As follows:
1. Serum FT3, FT4 , low FT4
3 1. Autoimmune:
Spontaneous atrophic hypothyroidism
Hashimoto’s thyroiditis
3. Other routine tests:
2. Iatrogenic:
Ultrasonogram of the neck Radioiodine therapy for thyrotoxicosis

Post-radiotherapy in neck
Drugs—such as lithium, amiodarone and antithyroid drug therapy.
CPK, LD 3. Others:

Q. Tell one single investigation to diagnose hypothyroidism. Postpartum thyroiditis

A. Serum TSH level. Rarely, dyshormonogenesis
Q. What are the biochemical abnormalities (other than thyroid hormones) in
hypothyroidism? Q. What are the causes of goitrous hypothyroidism?
A. As follows: A. As follows:
Hypercholesterolemia and hypertriglyceridemia Hashimoto's thyroiditis

High CPK and LDH

Hyperprolactinemia. Drugs—lithium, amiodarone, iodide
Q. What is the treatment of hypothyroidism? Rarely, dyshormonogenesis.
A. Thyroxine—it should be started with low dose. The dose should be increased gradually after three Q. What are the causes of nongoitrous hypothyroidism?
A. As follows:
 Following radio-iodine therapy for thyrotoxicosis
569 570 Other factors responsible—menorrhagia in female, anorexia.
Post radiotherapy in the neck

Secondary to hypopituitarism, hypothalamic disorders.

Q. What are the thyroid functions in secondary hypothyroidism?
A. Low FT3, FT4 Q. What are the cardiovascular problems in myxedema?
Q. How to investigate in such case? A. As follows:
A. Causes may be in the pituitary or hypothalamus. TRH stimulation test should be done. After Sinus bradycardia
giving TRH, if TSH is high, the cause is in the hypothalamus. If there is no or little rise of TSH, the Pericardial effusion and pericarditis
cause is in the pituitary. Congestive cardiac failure

Q. If the patient has ischemic heart disease with hypothyroidism, how to treat? Ischemic heart disease
A. As follows: Hypertension.

dose Q. What are the neurological features in hypothyroidism?

A. As follows:
Coronary dilator, calcium antagonist may be added
Coronary angiography followed by angioplasty or coronary artery bypass surgery may be needed.
3. Myxedema coma.
Q. How to treat an elderly patient with hypothyroidism?
4. Cerebellar syndrome.
A. Treatment is same. But one should take care whether the patient is suffering from any ischemic
heart disease. Following thyroxine, it may precipitate angina and myocardial infarction. Treatment
is same as above.
Q. Why hypothyroidism in Graves’ disease? Peripheral neuropathy
A. Natural history of Graves’ disease is hyperthyroidism, followed by euthyroidism and
Proximal myopathy
Pseudodementia
Drop attack.
Q. What bedside physical sign will you see in myxedema?
A. Q. What is Hoffman’s syndrome?
A. In a patient with myxedema, there may be myotonia with pain and swelling in the muscles after
exercise, called Hoffman’s syndrome.
Q. How slow relaxation is best elicited in the ankle? Why slow relaxation?
A. It is best elicited in kneel down position on a chair or bedside. Slow relaxation is due to decreased Q. What is Pendred’s syndrome?
rate of muscle contraction and relaxation. A. It is an autosomal recessive disorder in which there is sensori-neural deafness with goiter. It is
due to inborn error of thyroid hormone synthesis.
Q. Why nonpitting edema in myxedema?
A. Due to deposition of mucopolysaccharide substances. Q. What is subclinical hypothyroidism (borderline hypothyroidism or compensated
euthyroidism)?
Q. What are the types of anemia in hypothyroidism?
A. In this condition, T3 and T4 are in the lower limit of normal and TSH is slightly high. The patient
A. Anemia may be:
may be clinically euthyroid. This may persist for many years, though overt hypothyroidism may
Usually normocytic normochromic
occur. Conversion to overt hypothyroidism is more common in men or when thyroid peroxidase

12
Treatment—thyroxine therapy may be given if TSH is persistently raised above 10 mU/L or when
Q. What are the causes of anemia in hypothyroidism?
there are symptoms or high titre of thyroid antibodies or lipid abnormalities. If only TSH is marginally
A. Causes of anemia:
high with vague symptoms, thyroxine may be given sometimes. However, in female TSH should be
Anemia of chronic disorder
normalized during pregnancy to avoid any adverse effect in fetus.
Vitamin B12
Q. What is the difference between primary and secondary hypothyroidism? 571 572 Q. How to investigate and treat hypothyroidism in pregnancy?
A. As follows: A.
Primary hypothyroidism means cause in the thyroid gland. It is usually associated with myxedema. with many features of hypothyroidism such as cold skin, cold intolerance, weight gain, constipation.
High degree of suspicion is essential.
myxedema is rare. There are other features of hypopituitarism also. Most sensitive investigation is TSH, which is high. Also, FT3 and FT4 3
and T4
Q. What is myxedema coma? What are the mechanisms? How to treat?
A. Myxedema coma is characterized by depressed level of consciousness or even coma. Convulsion
may occur. It is rare, may occur in severe hypothyroidism, usually in elderly. CSF studies shows high
placenta and also increased serum TBG in pregnancy which binds thyroxine, resulting in less FT3
pressure and protein is also high. There is 50% mortality.
and FT4.
Causes of myxedema coma:

Hypoxemia Q. What is Hashimoto’s thyroiditis?

Hypercapnia A.
Hypothermia leading to atrophic change with regeneration and goiter formation. It is more common in middle aged
Hypoglycemia woman.
Other factors—cardiac failure, infection, use of sedative.
to hard.
Treatment of myxedema coma: It is better to be treated in ICU. Before starting treatment, blood is
taken for FT3, FT4, TSH and cortisol.
1. T3 is not available, also slow to
4 About 25% patients are hypothyroid at presentation. In the remaining patients, serum T4 is normal
is not available, oral thyroxine through Ryle’s tube should be given.
3 and TSH is normal or raised. There is risk of developing overt hypothyroidism in future. Initially,
the patient may present with features of toxicosis, called Hashi-toxicosis.
3. Other treatment:
Slow rewarming Since this is an autoimmune disease, it may be associated with other autoimmune diseases like
2
therapy
syndrome, ulcerative colitis, autoimmune hemolytic anemia.
Antibiotic, if infection is suspected
Assisted ven
Q. What is the radio-iodine uptake in Hashimoto’s thyroiditis?
Q. What is myxedema madness? A. It shows the following:
A. It may occur in severe hypothyroidism in the elderly. There is dementia or psychosis or delusion.
Sometimes, these features may occur shortly after starting thyroxine replacement. Depression is After few days or weeks—normal uptake
common in hypothyroidism.
Q. What is sick euthyroid syndrome? Q. What are the histological
A. In any severe acute nonthyroidal illness or after surgery, there may be abnormal thyroid function A. As follows:
tests although the patient is euthyroid, it is called sick euthyroid syndrome. It may occur after

Usually, there is normal TSH, normal or low T4 and low T3. Levels are usually mildly below normal Hurthle cell.

of systemic illness.
Biochemical thyroid function should not be done in patient with acute nonthyroidal illness, unless

Mechanisms of sick euthyroid syndrome:

4
and T3.
Reduced peripheral conversion of T4 to T3, occasionally, more rT3 3
Reduced hypothalamic pituitary TSH production, hence low T3 and T4.