Translate

Παρασκευή 14 Ιουνίου 2019

Journal of Medical Case Reports - Latest.. by Matthias Hepprich, Johannes Lorsche.. - 14m ago Preview
  •  
  •  
  • AUTO POST
  •  
  • SAVE TO EVERNOTE
The clinical picture of hypothyroidism, including neurological symptoms, can be multiform, which may delay or hamper the correct diagnosis.
Read Full Article

Introduction
The clinical picture of hypothyroidism, including neurological symptoms, can be multiform, which may delay or hamper the correct diagnosis.

Case presentation
We present an uncommon clinical presentation of a 38-year-old Caucasian man with mild facial palsy on the left side, uvular deviation to the left with preserved gag reflex, tongue deviation to the left, lingual dysarthria, and xerosis by severe hypothyroidism. Blood tests on admission showed elevated serum creatinine of 151 μmol/L (glomerular filtration rate 47 ml/min/1.7 CKD-EPI [Chronic Kidney Disease Epidemiology Collaboration equation]), increased creatinine phosphokinase activity (1243 U/L), markedly elevated thyroid-stimulating hormone (292.2 mIU/L), low free thyroxine level (1.1 pmol/L), and free triiodothyronine level below the limit of detection (< 0.4 pmol/L). Results of brain magnetic resonance imaging and renal ultrasound were unremarkable. Lumbar puncture revealed a normal cell count in cerebrospinal fluid, with an increased protein level of 758 mg/L and a cerebrospinal fluid/serum albumin ratio of 10.5 × 10− 3/L (reference range < 6.7). Further diagnostic workup did not reveal any inflammatory or infectious systemic pathologies as an underlying cause. The patient’s neurological symptoms, as well as laboratory findings including renal function, creatinine phosphokinase, and initially altered blood lipid levels, normalized with levothyroxine substitution.

Conclusions
Multiple cranial neuropathy is an uncommon clinical finding in hypothyroidism, which is an important differential diagnosis in the workup of new neurological deficits.

Keywords
Hypothyroidism
Cranial neuropathy
Myxedema
Hashimoto
Myopathy
Background
Thyroid hormone (TH) is essential for the function and regulation of cellular metabolism in virtually all mammalian cells. Additionally, TH is of paramount importance for neurocognitive development. Signs and symptoms of severe hypothyroidism concerning the cardiovascular system or metabolism, namely bradycardia, edema, or reduced metabolic rate, are well known. Moreover, neurological complications such as lethargy and impairment of attention, as well as diffuse peripheral neuropathy and entrapment neuropathy, are common [1]. We present a case of a patient with severe hypothyroidism presenting with a rare neurological manifestation.

Case presentation
A 38-year-old Caucasian man presented to the emergency department of our hospital with a 3-week history of dysarthria and facial weakness on the left side. A few weeks before symptom onset, he had undergone surgery for carpal tunnel syndrome on the right side. Apart from increasing fatigue and continuous weight gain of almost 20 kg over the last 2 years, his medical and family history was unremarkable. His clinical examination revealed a mild lower motor neuron facial palsy on the left, uvular deviation to the left with preserved gag reflex, tongue deviation to the left, lingual dysarthria, and xerosis. His pupils and eye movements were normal, his power and sensation for all qualities including vibration sense were preserved, his reflexes were present symmetrically, and he had no ataxia. Facial fullness and edematous extremities were noted. His mucous membranes were unremarkable, but his skin was dry. His vital parameters were normal apart from an increased body mass index (31.6 kg/m2) and hypothermic tympanic temperature of 35.6 °C (blood pressure 127/79 mmHg, heart rate 70 beats/min).

His blood test results on admission showed elevated serum creatinine of 151 μmol/L (glomerular filtration rate 47 ml/min/1.7 CKD-EPI [Chronic Kidney Disease Epidemiology Collaboration equation]) and increased creatinine phosphokinase (CK) activity (1243 U/L). Results of brain magnetic resonance imaging (MRI) and renal ultrasound were unremarkable. Cerebrospinal fluid (CSF) analysis revealed a normal cell count but increased protein levels of 758 mg/L and a CSF/serum albumin ratio of 10.5 × 10− 3/L (reference range < 6.7) without signs of intrathecal immunoglobulin production or oligoclonal bands. Results of serological testing were unremarkable. MRI of the brain did not show any pathologic lesions or contrast enhancement, especially within the cranial nerves. Multiple cranial neuropathy was presumed, and the patient was admitted to the department of neurology.

On the following day, routinely performed thyroid function tests detected markedly elevated levels of thyroid-stimulating hormone (TSH) (292.2 mIU/L), low free thyroxine levels (1.1 pmol/L), and free triiodothyronine levels below the limit of detection (< 0.4 pmol/L). A diagnosis of overt hypothyroidism was made, and levothyroxine therapy in a dose of 100 μg/d (1.0 μg/kg body weight, 1.3 μg per ideal body weight) was started after hypocortisolism was excluded. Ultrasound revealed a small thyroid gland (4.8 ml) with an inhomogeneous pattern but without signs of focal lesions. Further diagnostic workup showed a markedly reduced basal metabolic rate on indirect calorimetry (1380 kcal/d, reference 1950 kcal/d) and elevated antibodies against thyroid peroxidase (495 IU/mL, reference range < 34 IU/mL). When the patient was discharged 1 week after admission, his symptoms were unimproved. Six weeks later, the patient was seen in our outpatient clinic and reported a substantial improvement of speech quality and general well-being. On clinical examination, no residual pathologic signs were observed. The patient’s levothyroxine dosage was eventually increased to 150 μg/d, and his levels of TSH and free T4 normalized (Table 1). At the following visit, 5 months after initiation of levothyroxine substitution, the patient’s facial features had changed substantially, and all his neurologic symptoms had completely resolved. A loss of 2 kg body weight was noted. The remainder of his physical examination was unremarkable. Laboratory analysis showed normal levels of thyroid hormones and TSH as well as normal creatinine phosphokinase and kidney parameters. Increased total and low-density cholesterol levels at initial presentation also had normalized at the 5-month follow-up visit.
Table 1
Laboratory results at initial presentation and follow-up visits (in bold values below or above reference)


Initial presentation

6 Weeks later

5 Months later

Reference range

Levothyroxine dosage, μg/d



100.00

150.00


Leukocytes, 109/L

6.06

6.67

7.80

3.5–10.0

Hemoglobin, g/L

148.00

138.00

144.00

140–180

Creatinine, μmol/L

151.00

99.00

91.00

49–97

Urea, mmol/L

7.90

6.40

5.00

3.2–7.3

ASAT, U/L

59.00

26.00

nd

11–34

ALAT, U/L

33.00

31.00

nd

9–59

LDH, U/L

417.00

203.00

nd

135–225

Creatinine phosphokinase (CK), U/L

1243.00

106.00

nd

50–200

CK-MB, μg/L

18.40

nd

nd

< 5.0 μg/L

Triglycerides, mmol/L

1.57

1.74

0.72

< 1.7

Total cholesterol, mmol/L

6.71

3.18

4.05

3.0–5.2

HDL cholesterol, mmol/L

1.63

0.85

1.37

0.9–2.2

LDL cholesterol, mmol/L

4.37

1.54

2.35

16.0–3.40

Thyrotropin (TSH), mIU/L

292.00

2.69

2.19

0.332–4.490

Free T4, pmol/L

1.10

21.00

19.30

11.6–22.0

Free T3, pmol/L

< 0.4

5.50

5.40

2.6–5.6

Total T4, nmol/L

6.00

nd

nd

66–181

Total T3, nmol/L

< 0.3

nd

nd

1.2–3.2

Cortisol, nmol/L

449.00

nd

nd

80–638

Glucose, mmol/L

5.00

nd

4.50

3.8–6.1

Glycated hemoglobin A1c, %

5.30

nd

nd

4.8–5.9

Abbreviations: ALAT Alanine aminotransferase, ASAT Aspartate aminotransferase, CK-MB Muscle/brain creatine kinase, HDL High-density lipoprotein, LDH Lactate dehydrogenase, LDL Low-density lipoprotein, nd Not determined, T3 Triiodothyronine, T4 Thyroxine, TSH Thyroid-stimulating hormone

Discussion
We report an unusual case of severe hypothyroidism due to autoimmune thyroiditis with myxedema, neuromyopathy, and renal affection. Hypothyroidism is the leading thyroid disorder worldwide, with autoimmune causation being the most common [2], and a prevalence of 3.05% in Europe with a female preponderance [3]. Typical signs of hypothyroidism such as fatigue, weight gain, hypothermia, dry skin, and myxedema with facial fullness, as in our patient, are well known but are neither sensitive nor specific, and the clinical picture can vary substantially with a slow long-term progression often leading to non- or misdiagnosis [2].

Thyroid hormones are ubiquitously required for development and maintenance of cellular functions and are paramount for the development of the central nervous system [4]. Thus, thyroid hormone deficiency can affect the central and peripheral nervous systems. A decline or slowing of neurocognitive functions (memory loss, ataxia), probably due to altered synaptic plasticity, is commonly observed in patients with myxedema, but it is often only partially reversible even under appropriate treatment [2].

In our patient, the clinical syndrome of multiple clinical neuropathy without clinical evidence of further involvement of the peripheral nervous system led to the initial differential diagnosis of an inflammatory cranial neuropathy or a brainstem pathology. However, MRI showed no lesions in the brainstem or inflammatory changes of the cranial nerves. CSF protein levels were increased, which is most likely related to blood-brain barrier dysfunction rather than an autoimmune process in patients with overt hypothyroidism and has been reported to be fully reversible [5]. While diffuse peripheral neuropathy and entrapment neuropathy are common in hypothyroidism—the latter being found in up to 35% of patients—dysfunction of cranial nerves is seen much less frequently [1, 6]. Compression of the optic chiasm by pituitary gland enlargement, as well as hearing impairment, may occur and can be detected already in an early stage of the disease with visual and brainstem auditory evoked potentials [1, 7]. However, to the best of our knowledge, multiple cranial neuropathy with facial and lower cranial nerve palsy has not been reported previously. In general, neuropathy in hypothyroidism seems to be caused primarily by a metabolic dysfunction due to the lack of thyroid hormone and thereby disrupting the function of the myelin sheath rather than a compressive neuropathy due to mucinous deposits [8].

Muscular manifestations such as weakness, cramps, and myalgia are common in hypothyroidism but can be oligosymptomatic, as in our patient, despite markedly elevated CK levels at initial presentation.

Renal impairment in hypothyroidism is associated with increase of serum creatinine and decline of glomerular filtration rate. It is caused by direct effects on glomerular and tubular function and indirectly through alterations in cardiac and vascular function, as well as decreased renin-angiotensin system leading to lowered renal plasma flow [9]. In turn, after levothyroxine substitution, renal function improves significantly or normalizes fully [9, 10], as seen in our patient.

The long duration with initial hypothyroid symptoms starting already 2 years before cranial nerve symptoms occurred, with extremely low thyroid hormone levels at presentation, may be an explanation for the clinical symptoms of our patient. Most of the patients may present at earlier stages before onset of symptoms. When untreated, severe hypothyroidism can be life-threatening and can lead to myxedema coma. This is usually precipitated by an additional hit, such as an acute infection, trauma, or other forms of stress [11]. Shortly before his initial presentation, our patient underwent surgery for carpal tunnel syndrome, which may have been prevented or could have led to an earlier diagnosis of the underlying thyroid disorder.

Conclusions
As hypothyroidism can cause a wide variety of neurological symptoms, any unclear neurological findings should prompt thyroid function testing. Multiple cranial neuropathy is a rare manifestation of hypothyroidism and was fully reversible in our patient with levothyroxine substitution.

Notes
Matthias Hepprich and Johannes Lorscheider contributed equally to this work.

Abbreviations
ALAT:
Alanine aminotransferase

ASAT:
Aspartate aminotransferase

CK-MB:
Muscle/brain creatine kinase

CSF:
Cerebrospinal fluid

HDL:
High-density lipoprotein

LDH:
Lactate dehydrogenase

LDL:
Low-density lipoprotein

MRI:
Magnetic resonance imaging

T3:
Triiodothyronine

T4:
Thyroxine

TH:
Thyroid hormone

TSH:
Thyroid-stimulating hormone

Declarations
Acknowledgements
We thank the patient for giving his informed consent to publish this case report and Joe Monaghan for proofreading our article.

Funding
No targeted funding.

Authors’ contributions
MH and JL contributed equally to this article. All authors were involved in the clinical course and treatment of the patient as well as in the entire writing process of the article. All authors read and approved the final manuscript.

Ethics approval and consent to participate
This case report was written in accordance with the recommendations of the Declaration of Helsinki. The patient is described anonymously and gave written informed consent for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Competing interests
The authors declare that they have no competing interests.

Open Access
This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References
Wood-Allum CA, Shaw PJ. Thyroid disease and the nervous system. Handb Clin Neurol. 2014;120:703–35.
PubMed
View Article
Google Scholar
Chaker L, Bianco AC, Jonklaas J, Peeters RP. Hypothyroidism. Lancet. 2017;390(10101):1550–62.
PubMed
View Article
Google Scholar
Garmendia Madariaga A, Santos Palacios S, Guillen-Grima F, Galofre JC. The incidence and prevalence of thyroid dysfunction in Europe: a meta-analysis. J Clin Endocrinol Metab. 2014;99(3):923–31.
PubMed
View Article
Google Scholar
Chan S, Kilby MD. Thyroid hormone and central nervous system development. J Endocrinol. 2000;165(1):1–8.
PubMed
View Article
Google Scholar
Nystrom E, Hamberger A, Lindstedt G, Lundquist C, Wikkelso C. Cerebrospinal fluid proteins in subclinical and overt hypothyroidism. Acta Neurol Scand. 1997;95(5):311–4.
PubMed
View Article
Google Scholar
Khedr EM, El Toony LF, Tarkhan MN, Abdella G. Peripheral and central nervous system alterations in hypothyroidism: electrophysiological findings. Neuropsychobiology. 2000;41(2):88–94.
PubMed
View Article
Google Scholar
Gupta N, Arora M, Sharma R, Arora KS. Peripheral and central nervous system involvement in recently diagnosed cases of hypothyroidism: an electrophysiological study. Ann Med Health Sci Res. 2016;6(5):261–6.
PubMed
PubMed Central
View Article
Google Scholar
Shirabe T, Tawara S, Terao A, Araki S. Myxoedematous polyneuropathy: a light and electron microscopic study of the peripheral nerve and muscle. J Neurol Neurosurg Psychiatry. 1975;38(3):241–7.
PubMed
PubMed Central
View Article
Google Scholar
Iglesias P, Bajo MA, Selgas R, Diez JJ. Thyroid dysfunction and kidney disease: an update. Rev Endocr Metab Disord. 2017;18(1):131–44.
PubMed
View Article
Google Scholar
Hataya Y, Igarashi S, Yamashita T, Komatsu Y. Thyroid hormone replacement therapy for primary hypothyroidism leads to significant improvement of renal function in chronic kidney disease patients. Clin Exp Nephrol. 2013;17(4):525–31.
PubMed
View Article
Google Scholar
Wiersinga WM. Myxedema and coma (severe hypothyroidism). In: De Groot LJ, Chrousos G, Dungan K, Feingold KR, Grossman A, Hershman JM, et al., editors. Endotext. South Dartmouth: MDText, Inc.; 2000 [updated 25 Apr 2018].
Google Scholar
Copyright
© The Author(s). 2019

Δεν υπάρχουν σχόλια:

Δημοσίευση σχολίου

Αρχειοθήκη ιστολογίου

Translate