Severe hypothyroidism causing acute ileus and polyserositis

Abstract

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 o[...].