Endocrine Abstracts

A 29 year old lady with a past history of seronegative rheumatoid arthritis, Vitamin B12 deficiency, autoimmune hypothyroidism and fibromyalgia who had feeling unwell with a left sided headache for a few days had a fall at home witnessed by her friend. She was noted to be in peri arrest state by ambulance crew on their arrival. Agonal breathing was noted and monitor revealed VF. She was given 5 DC shocks with return of spontaneous circulation and regained consciousness. She was transferred to ITU where her initial obervations showed oxygen saturation of 94% on oxygen with a respiratory rate of 26 and pulse rate of 106 per minute and a GCS of 15 with a glucose of 12.1 mmol/l. Her recent thyroid biochemistry had revealed poorly controlled hypothyroidism with a TSH of 160.41 miu/l. She had a long history of poor compliance with her thyroid medication and the plan prior to her hospital admission was her to have had a supervised levothyroxine adminstration and absorption test to probe for any issues with malabsorption which unfortunately she could not attend. She was intially commenced on iv liothyronine and hydrocortisone along with fluid resucitation and broad spectrum antibiotics as a CTPA showed widepread lung consolidation with however no pulmonary embolism. A bedside echocardiogram showed evidence of moderate to severe LV impairment with an ejection fraction of 35-40% and a small posterior pericardial effusion of maximum size of 1.3 cm. She was commenced on Ramipril. She made good progress and was switched to oral liothyronine and levothyroxine on day 2 of her stay on ITU. Her TSH showed good recovery with a value of 38.9 on day 3 with further improvement to 20.22 on day 5. An ECHO 2 weeks later showed a slight improvement in her LV function with an EF at 45%. The patient was transferred to the medical ward and made steady progress. Serial ECHO showed a reduction in the pericardial effusion with further improvement in LV function. The patient was subsequently well enough and stable to be discharged home. This case highlights the reversibility of cardiac dysfunction induced by severe hypothyroidism with focussed thyroid replacement in a patient with a history of poor compliance with the management of her hypothyroidism. Severe hypothyroidism can cause reduced ventricular filling and decreased cardiac contractility which in turn leads to reduced cardiac output which in the extreme case of severe hypothyroidism can be life threatening.