History

• 36 yo obese male with no significant past medical history presents with swelling of the hands and forearms for ~2-3 weeks, slowly worsening
• Pt denies pain/numbness of the extremities, but swelling of the fingers is interfering with manual tasks
• Pt notes intermittent cramping of the hands and arms, and worsening diffuse back pain without any history of trauma
• No fevers, erythema, rash, history of tick bites
• No recent illnesses: no cough, sore throat, abdominal pain, vomiting/diarrhea
• No chest pain, dyspnea, changes in urination

Physical Exam

T: 97.7 BP 137/82  HR 83  Pox 98%

• Gen: Well appearing, no distress. +obese with "moon facies" and short neck
• HEENT: large tongue, unable to visualize posterior pharynx
• Lungs: Clear
• Heart: no MRG
• Abd: soft NTND no HSM
• Extrem: +symmetric edema of forearms and hands. Normal pulses. No erythema, warmth, or tenderness along extremities
• Neuro: Normal motor strength, CN II-XII intact, normal sensation to light touch

DDX

• Hypothyroidism
• Congestive heart failure: though no dyspnea, PND, or crackles on exam
• Liver disease: with low protein leading to peripheral edema
• Nephropathy: with protein loss leading to edema 

Workup

• CBC, chem basic, LFTs, TSH with FT4, UA, CXR, pro-BNP

Results

Diagnosis and Management

• Severe hypothyroidism/myxedema with thyroid myopathy with rhabdomyolysis and acute kidney injury
• Patient admitted for initiation of synthroid and IVF therapy for rhabdomyolysis

Pearls

• Rhabdomyolysis is a rare complication of hypothyroid myopathy, which is in and of itself a rare complication of severe hypothyroidism
• Patients often present with proximal (truncal) muscle pain/cramping as in our patient with diffuse back pain
• Treatment involves initiation and titration of synthroid as well as standard treatment of rhabdomyolysis with IVF therapy, cessation of renal toxins, and monitoring of kidney function