Review of systems was remarkable for lethargy, cold intolerance, constipation, menorrhagia for 5 years, nocturnal snoring, frequent awakening, and daytime fatigue for about 4 months.
When asked about compliance, the patient insisted that she had been taking levothyroxine l -T 4 everyday with her breakfast, which includes a cup of coffee. On physical examination, our patient was sitting upright and in moderate respiratory distress. There was no pulsus paradoxus. Heart sounds were regular with no extra-heart sound, murmur, or gallop.
Neck circumference was 18 inches with no jugular venous distension JVD. Which of the following is the most likely explanation for the shortness of breath in this patient?
Despite the past medical history of asthma in our patient, the absence of rhonchi and the presence of bilateral basal inspiratory crackles make the diagnosis of acute asthma exacerbation less likely. The history of significant orthopnea and findings of peripheral pitting edema and bilateral lung crackles on examination favor the diagnosis of pulmonary edema. Pneumonia is less likely in the absence of fever and sputum production. It is also very unlikely that our patient had a PE, given that she was not hypoxic or tachycardic and had no risk factors for PE.
Given the timeline of the symptoms and the acute presentation of orthopnea a few days after upper respiratory tract infection, our most likely diagnosis was cardiogenic pulmonary edema possibly secondary to viral myocarditis and non-ischemic cardiomyopathy. The plasma level of BNP can be measured in the ED and utilized as a simple and reliable biomarker to differentiate cardiogenic pulmonary edema from non-cardiogenic pulmonary edema 2.
The results of her remaining blood tests are outlined in Table 1 including a thyrotropin TSH level of Computed tomography of the chest showed ground-glass densities predominant in the lung-dependent regions compatible with pulmonary edema and no PE Fig.
Computed tomography of the chest showing ground-glass densities compatible with pulmonary edema. At this stage, our working diagnosis changed from cardiogenic to non-cardiogenic pulmonary edema.
The patient was advised to take l -T 4 first in the morning on an empty stomach. Over the course of 2 weeks, the shortness of breath and orthopnea subsided gradually and by the fourth night, the patient was able to sleep on one pillow with no orthopnea. Two weeks later, her shortness of breath, orthopnea, and lower extremity edema resolved and furosemide was discontinued.
Four weeks later, her TSH level dropped to 0. She declined the sleep study and wanted to be treated only for hypothyroidism. Identifying the underlying etiology of the first episode of pulmonary edema can sometimes be challenging as all causes of pulmonary edema share the same clinical features to some extent.
The first step in approaching pulmonary edema is to differentiate cardiac etiologies from non-cardiac etiologies. Clinical features that point toward cardiogenic pulmonary edema include history of acute coronary syndrome or congestive heart failure and the finding of S3, JVD, or peripheral pitting edema on physical examination. Symptoms of myxedema coma include a severe drop in body temperature, reduced breathing, and central nervous system failure, alongside other symptoms of hypothyroidism.
The sooner a person with advanced hypothyroidism receives treatment, the less likely they are to develop dangerous complications. Even with treatment, the mortality rate for a person with myxedema coma is relatively high. A person has a much higher chance of recovery if myxedema is recognized and treated early with thyroid replacement therapy and supportive care.
Do gluten-free or low-GI diets help? A hyperactive thyroid is when the body produces too much of the hormone thyroxine. If people do not control this, thyroid storm can occur. Goiter is an enlarged thyroid gland. A person with goiter can have normal levels of thyroid hormone, excessive levels, or levels that are too low…. Hypothyroidism is when the thyroid gland is not making enough hormones for good health. Symptoms can progress slowly and be vague and hard to identify.
Can yoga be beneficial for people with hypothyroidism and hyperthyroidism? We look at the evidence and list the best yoga poses for thyroid health. What is myxedema and how is it treated? Medically reviewed by Daniel Murrell, M.
Along with the signs and symptoms of severe hypothyroidism, symptoms of myxedema crisis can include:. Myxedema crisis can cause death often due to complications from infection, bleeding, or respiratory failure. It can occur during pregnancy as well. Myxedema is a result of undiagnosed or untreated severe hypothyroidism. It can also develop when someone stops taking their thyroid medication. Deposits of chains of sugar molecules in the skin cause the skin condition myxedema.
These compounds attract water, which leads to swelling. These skin changes are a result of hypothyroidism. Myxedema crisis often occurs after a long history of hypothyroidism.
Any of the following can trigger it:. Your symptoms will lead your doctor to suspect severe hypothyroidism. Blood tests can help your doctor confirm this.
In other words, a high level of TSH could mean you have hypothyroidism. A TSH test is typically checked along with a thyroxine T4 test.
This test measures the level of T4, a hormone produced directly by your thyroid. If you have low levels of T4 coupled with a high level of TSH, you have hypothyroidism. Your doctor will likely want to perform more tests to determine your thyroid function and other conditions that may be affecting it. Myxedema crisis is a medical emergency.
Answer Once the third space disappeared, the thyroid hormones with their carrier proteins no longer transuded from the blood vessels.
Her hematocrit at discharge was Since her body weight at admission was The amount of systemic edema The patient had a large third space at admission. If the Thus, the dose of levothyroxine may be increased in patients with edema. Thyroid hormones and carrier protein levels in pleural fluid of patients with hyperthy-roidism were recently reported, 6 this is the first report on those in hypothyroidism.
Medical practitioners ought to pay attention to thyroid hormones in patients with edema, particularly those with nephrosis, because the loss of protein to urine can cause hypothyroidism, 2 , 3 , 4 , 5 and both nephrosis and hypothyroidism can cause edema.
This case report might contribute to the better understanding and treatment for patients with hypothyroidism and edema. Further studies are required to verify these results. National Center for Biotechnology Information , U. Journal List Clin Pract v. Clin Pract. Published online Oct Author information Article notes Copyright and License information Disclaimer. Received Aug 6; Accepted Sep Kinoshita et al. This article has been cited by other articles in PMC.
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