Critical Cases - Thyroid Myopathy!
Tue, 06/08/2021 - 5:11am
Editor:
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