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Thursday, 28 November 2013

Thyroid disease: Hypothyroidism – The Misdiagnosis and Diagnosis

Thyroid disease is defined as a condition of malfunction of thyroid. Hyperthyroidism is a condition in which the thyroid gland is over active and produces too much thyroid hormones. Hypothyroidism is a condition in which the thyroid gland is under active and produces very little thyroid hormones.
D.1. Misdiagnosis
1. Normal aging process and to the patient’s other health conditions
A diagnosis of hypothyroidism in the elderly can easily be overlooked if we rely exclusively on its clinical presentation because this may be highly non-specific, since the signs and symptoms of the disease are common to other diseases typical of old age, and even to the normal aging process. There is a report of a case of primary hypothyroidism that was diagnosed late because the correlated signs and symptoms (asthenia, bradycardia, pleural effusions, hyponatremia, worsening renal and respiratory insufficiency, hoarseness) had previously been attributed to the normal aging process and to the patient’s other health conditions (Parkinson’s disease, PD; chronic obstructive pulmonary disease, COPD)(40).
2. Reversal deterioration of renal function
There are a report of two patients with elevated serum creatinine levels due to primary autoimmune hypothyroidism, with complete recovery of creatinine clearance after thyroid hormone substitution therapy are presented. The first patient was a young male whose laboratory tests suggested acute renal failure, and the delicate clinical presentation of reduced thyroid function. The second patient was an elderly woman with a history of a long-term signs and symptoms attributed to ageing, including the deterioration of renal function, with consequently delayed diagnosis of hypothyroidism, according to the study by the Military Medical Academy, Clinic of Endocrinology(41).
3. Respiratory failure
There is a report of a 36 years male, admitted to the hospital for progressive respiratory failure. Chest X ray and CT scan were normal. On admission, a severe bradycardia and slow intellectual activity were noted. Serum thyroid function tests showed a TSH over 150 microU/ml and T3 of 75 ng/ml. Thyroid substitution therapy was associated with a progressive improvement of respiratory function, according to the study by the Servicio de Medicina del Hospital(42).
4. Brain stem infarct
Myxedema coma is the extreme form of untreated hypothyroidism. There is report of a patient with myxedema coma which was initially misdiagnosed as a brain stem infarct. The diagnosis of myxedema coma was often missed or delayed due to various clinical findings and concomitant medical condition and precipitating factors. It is more difficult to diagnose when a patient has no medical history of hypothyroidism, according to the study by the Hallym University(43).
5. Statin intolerance
There is a report of a case of Hypothyroidism misdiagnosed initially as statin intolerance, according to the study by Krieger EV, and Knopp RH(44).
6. Hypercholesterolaemia and simvastatin-induced myositis
There is a report of report of a 50-year-old woman who presented with hypertension. She was given simvastatin for hypercholesterolaemia. The creatine kinase level was 3180 U/L at the 3-month follow-up visit, which was thought to be due to simvastatin treatment. Although treatment was discontinued, the creatine kinase level 4 months later remained higher than 3000 U/L. Echocardiography revealed mild pericardial effusion and normal left ventricular function; the electromyogram was also normal. The patient subsequently showed signs and symptoms suggestive of hypothyroidism, which was confirmed by measurements of the concentration of thyroid-stimulating hormone (>100 mU/L) and free thyroxine (<2 pmol/L)(45)
D.2. Diagnosis
If you are experience certain symptoms of above and/or have had previous thyroid problems or goiter. , your doctor may suspect that you have underactive thyroid. Your doctor may order blood test to measure the level of TSH and the level of the thyroid hormone thyroxine and triiodothyronine, depending to the stage of the diseases. According to the study by the College of Medicine, Mayo Clinic, hypothyroidism is the result of inadequate production of thyroid hormone or inadequate action of thyroid hormone in target tissues. Primary hypothyroidism is the principal manifestation of hypothyroidism, but other causes include central deficiency of thyrotropin-releasing hormone or thyroid-stimulating hormone (TSH), or consumptive hypothyroidism from excessive inactivation of thyroid hormone. Subclinical hypothyroidism is present when there is elevated TSH but a normal free thyroxine level(46).
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Sources
(a) http://www.ncbi.nlm.nih.gov/pubmed/17933284
(40) http://www.ncbi.nlm.nih.gov/pubmed/21640396
(41) http://www.ncbi.nlm.nih.gov/pubmed/22500378
(42) http://www.ncbi.nlm.nih.gov/pubmed/15379058
(43) http://www.ncbi.nlm.nih.gov/pubmed/20808690
(44) http://www.ncbi.nlm.nih.gov/pubmed/19581652
(45) http://www.ncbi.nlm.nih.gov/pubmed/11177166
(46) http://www.ncbi.nlm.nih.gov/pubmed/22443971