P-I-12. Endocrine disorder, Case 4

Anamnesis: 52-year-old woman presents to her GP with the following symptoms: recently very weak, depressed, increased need for sleep. She complains of feeling generally unwell because she has not been able to perform as well as usual at work lately. She has poor concentration and often naps at work when she has the opportunity. She feels uncomfortable because, despite eating little, she keeps putting on weight. She has put on 8 kg in the last 2 months, even though she has been on a low-carbohydrate, low-calorie diet, eating fibre-rich foods since she noticed the weight gain (about 1 month ago), because she is constipated.

Physical examination: Female patient of medium physical development, height: 158 cm, weight: 70 kg. BMI: 28. Skin pale, cool, dry, “pasty” to touch. Blood pressure: 130/90 mm Hg, resting pulse 56/min. Respiration rate: 10/min. Chubby cheeks. Her sweater has a noticeable amount of hair loss. Physical examination reveals no thyroid gland. Faint heart sounds, bradycardia. No other abnormalities on examination of lungs and heart. Abdomen is soft, palpable, no abnormal tenderness or abnormalities. Liver and spleen not accessible. Decreased bowel sounds. The aa. dors pedis are weakly palpable. Bilaterally, reflexes are poor.

ECG: Sinus bradycardia. Low voltage in all 12 leads. ST depression marked from V1 to V4. No other abnormalities.

Laboratory tests: From the laboratory results it should be noted that the patient had a sedimentation rate of 26 mm/h, fasting blood glucose: 3.1 mmol/L, total cholesterol: 7.4 mmol/L, triglyceride: 3.4 mmol/L, fT4 and fT3 were significantly decreased, TSH 40 mIU/L ↑↑. Anti TPO: ↑↑; anti TG ↑↑.

Ultrasound: The thyroid gland is smaller than average, its structure is not typical of the thyroid gland, but has areas of what can be described as fibrotic. A fine needle aspiration biopsy is recommended.

Scintigraphy: The thyroid gland is smaller than usual. Isotope uptake is reduced throughout the thyroid area. No nodules are seen.

Results of the fine-needle biopsy: Lymphocytic and plasma cell infiltration of thyroid cells is seen in the sample. In some places fibrotic transformed cells are visible. Conclusion: chronic thyroid inflammation.

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Key Quotes & What They Tell Us

Quote / Value	Interpretation
“very weak, depressed, increased need for sleep”; poor concentration; naps at work	Slowed metabolism and CNS depression from thyroid hormone deficiency
“despite eating little, she keeps putting on weight” (8 kg/2 months); constipation	Reduced metabolic rate and gut hypomotility
Skin “pale, cool, dry, pasty”; chubby cheeks; hair loss	Myxoedematous skin changes typical of hypothyroidism
Pulse 56/min; RR 10/min; “reflexes are poor”	Bradycardia, slow respiration, and delayed reflex relaxation — generalized slowing
ECG: sinus bradycardia, “low voltage in all 12 leads”	Reduced electrical activity ± pericardial effusion typical of hypothyroidism
fT4 and fT3 decreased; TSH 40 mIU/L (↑↑)	Primary hypothyroidism — low hormones with compensatory high TSH
Total cholesterol 7.4, triglyceride 3.4 mmol/L (high); glucose 3.1 (low)	Hypothyroid dyslipidaemia (reduced clearance) and tendency to hypoglycaemia
Anti-TPO ↑↑; anti-TG ↑↑; FNA: “lymphocytic and plasma cell infiltration … fibrotic”	Autoimmune (Hashimoto’s) chronic thyroiditis → gland destruction/atrophy

Key Points

• Diagnosis: Hashimoto’s thyroiditis causing primary hypothyroidism.
• Pathophysiology: Autoimmune lymphocytic destruction of the thyroid → deficient fT4/fT3 → compensatory rise in TSH; gland becomes small and fibrotic.
• Clinical picture: Generalized slowing — fatigue, weight gain, constipation, bradycardia, cold/dry skin, hair loss.
• Metabolic effects: Hypercholesterolaemia/hypertriglyceridaemia from reduced lipid clearance; hypoglycaemia tendency.
• Contrast with Graves’: High TSH with low free hormones and a small/atrophic gland — the mirror image of the hyperthyroid case.