Endocrine Abstracts

Introduction: Hypothyroidism is associated with a spectrum of symptoms affecting almost all bodily functions. We present a case of severe hypothyroidism with multiple body cavity effusions, volvulus of sigma creating ileus.

Case report: A 70 year old female was admitted to emergency department with dyspnea, and acute abdominal pain. Physical examination was notable for anasarca, abdominal fluid wave, lower extremity pitting edema, hypotension. She did not have any comorbidities. Anamnesis of hypothyroidism left unknown during admission. Diagnostic CT scan revealed a volvulus of sigma creating bowel obstruction. Ascites, bilateral pleural effusion, cardiac tamponade were also diagnosed. Sigmostoma was applied for decompression of ileus during urgent laparatomy. Pericardial, pleural and peritoneum drainage was performed. Antibiotics were started due to inflammation (CRP 120 mg/l). Abundant secretion from the peritoneum, pleura and pericardium continued. Polyserositis differential diagnostic tests were done: ANCA –negative, AntiDNA 25.2kU/l, albumine 23.2–16.3 (n–35–52) g/l, liquid from pleura, peritoneum and pericardium had no signs of cancer, tuberculosis. Thyroid function tests showed hypothyreosis: TSH 100 (0.4–3.6) mU/l, FT4 0.1 (9–21.07) pmol/l, FT3 1.17 (3.34–5.34) pmol/l, AntiTPO 63.73kU/l (0–3.2). Adrenal insufficiency was denied: ACTH 7.7 (3–14) pmol/l, morning cortisol 441 nmol/l. Ultrasound of the thyroid gland revealed small lobes and isthmus. Treatment with levothyroxine 50 µg/day was started, human albumin transfusions were applied. Expanded anamnesis revealed that patient had been on levothyroxine replacement but had defaulted treatment for 15 years. Following hospital course was uncomplicated with steadily rising dose of levothyroxine from 50 to 100 µg/day. After 26 days of treatment with levothyroxine TSH was still high (87.5 mIU/l), though FT4 reached 6.73 pmol/l. Abatement of ascites, pleural effusion, tissue oedema and pericardial effusion were observed. Patient continued on a maintenance dose of 100 µg/day levothyroxine with regular follow up.

Conclusion: Isolated ascites (< 4% cases), pericardial effusion (3–6% cases) or pleural effusion is not unusual in hypothyroidism. Volvulus and bowel obstruction were also described as probable rare consequences of hypothyroidism. Multiple body cavities effusions, tissue edema, motility dysfunction causing volvulus and acute ileus and all occurring simultaneously due to hypothyroidism is extremely rare. Due to rarity of these conditions, diagnosis is often difficult and delayed.