Case Study 5: Disorders of Endocrine Control of Growth and Metabolism

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Case Study 5: Disorders of Endocrine Control of Growth and Metabolism

Bertha is a 71-year-old woman who takes daily medication for Hashimoto thyroiditis. Last winter, she developed pneumonia. Although she did her best to run errands for her husband, she became tired easily and needed to rest frequently. One day, after shoveling the snow outside, her husband came inside to find Bertha lying on the sofa covered in blankets. Her face appeared puffy and her eyelids hung. When he spoke to her, Bertha’s voice was hoarse and her words did not make sense to him. Her respirations were also shallow and slow. Suspecting low thyroid hormone levels were causing the signs, her husband called for an ambulance.

  1. When testing for hypothyroidism, why is the free T4 level an important measurement? What would the TSH and T4 test results indicate in someone with primary hypothyroidism?
  2. Using your knowledge of the function of thyroid hormone in the body, explain why Bertha’s respiratory rate was decreased? Why might pleural effusion be present in someone with hypothyroidism?
  3. What factors in Bertha’s history leave her susceptible to myxedematous coma? What are the physiologic aspects involved in myxedematous coma?

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Answer

Importance of Measuring T4 Levels in Hypothyroidism

The endocrine system is vital in the body because it produces hormones that regulate many processes in the body. Pathologies in the endocrine glands lead to pathologies in other organs and organ systems. The majority of the body processes require hormones to proceed. They include heat regulation, reproduction, metabolism, breathing, and muscle and bone function. The thyroid gland is one of the major glands in the endocrine system and produces T4 (thyroxine) and T3 (Triiodothyronine) hormones. T4 amounts are about 90% more than T3 amounts; hence T4 levels are the most measured. T3 is the more active hormone of the two, and Body tissues convert T4 into T3. T3 and T4 have various functions, including digestion, muscle activity, bone integrity, body weight, cholesterol levels, and heart rate (Armstrong et al., 2019).

TSH and T4 Levels in Primary Hypothyroidism

T3 is the active hormone that stimulates the production of certain hormones and proteins helpful in metabolism. Armstrong et al. (2019) note that the proteins bind these hormones in their transfer, and free lab measures can help calculate each hormone’s total and free levels. Thyroid-stimulating hormone (TSH) stimulates the production of thyroid hormones. TSH deficiency or destruction of the thyroid cells leads to low thyroid stimulation or less production of T3 and T4. In hypothyroidism, there are two primary underlying mechanisms which include the destruction of thyroid tissue or pituitary gland or the hypothalamus malfunctions leading to the low levels of TSH hence low stimulation of the thyroid gland (Armstrong et al., 2019). Due to the shortage, the body binds the free T3 and T4 for use, and the levels drop drastically. Thus, the levels of T4 are usually low in hypothyroidism. Measuring the levels of T4 is therefore paramount when testing for hypothyroidism.

Primary hypothyroidism is decreased T3 and T4 levels resulting from pathologies within the thyroid tissue. These pathologies include infections or autoimmune diseases such as Hashimoto’s thyroiditis (Hegedüs et al., 2019). The thyroid gland fails to function appropriately, hence low T3 and T4. The body produces more thyroid-stimulating hormones to stimulate and increase the production of T3 and T4, thus high levels of TSH (Armstrong, 2019). TSH stimulates the thyroid, but due to the underlying pathology, the T4 levels remain low. T3 levels will thus be normal or low. T4 levels will be low in primary hypothyroidism, while the TSH levels will be high.

Effects of Hypothyroidism on the Respiratory Rate

Destruction of the thyroid by her autoimmune disease leads to low production of thyroid hormones. Insufficient level of thyroid hormones in blood and tissues begins a cascade of pathologies in multiple organs. Kakimoto et al. (2021) note that goiter is common in hypothyroidism and can cause acute respiratory failure. Decreased T3 and T4 levels significantly affect metabolism and availability of energy. Breathing muscles weaken in myxedema /severe hypoxia hence hypoventilation. The chest fails to contract and relax normally, and the respiratory effort is severely reduced, hence Bertha’s shallow and slow breathing. Decreased thyroid hormones also negatively affect the functioning of neurotransmitters in breathing. The central respiratory center may thus fail to respond to hypercapnia and hypoxia triggers and therefore does not signal the breathing muscles to improve the respiratory effort, worsening breathing and causing further shallow and slow breathing (Hwang, 2020). The resulting hypoxia causes further compromise in an endless loop when medical interventions are not delivered.

Hypothyroidism and the Risk for Pleural Effusion

Hypothyroidism symptoms are subtle and insidious, progressing slowly over the years and include goiter from enlargement of the thyroid due to growth of new tissues after stimulation by FSH. Low T3 levels increase the membrane’s permeability in the pleural cavity, causing fluid to leak into the pleural cavity. The hormone deficiency is hence rapid and reversible capillary permeability. Fluid thus accumulates in the pleura after leakage from the lung tissue, a process that takes time (Yuan et al., 2019). The deficient levels of thyroid homes in hypothyroidism can expose an individual to increases capillary and membrane permeability hence accumulation of fluid in the pleural, leading to pleural effusion (Yuan et al., 2019). In some instances, the pericardium (fluid leakage) leads to pericardial effusion, affecting vascular endothelial growth factors, and signs and symptoms such as pleural and pericardial effusion develop slowly over time (Hwang et al., 2020).

Bertha’s History and Susceptibility to Myxedematous Coma

Myxedema is a rare, life-threatening condition resulting from long-term undiagnosed hypothyroidism. Santos et al. (2022) note that the disease is a lethal emergency and the most severe complication of hypothyroidism. Drugs trigger the condition, stress, or infections, and symptoms include intense cold intolerance and feeling exhausted, lethargy, and unconsciousness. A myxedematous coma is a severe form of hypothyroidism that is potentially lethal with mental alteration hence Bertha’s incomprehensible sounds, extreme cold (Bertha has blankets around her), puffy face, and hanging eyelids (Santos et al., 2022). The condition requires emergency medical attention to its critical nature. Bertha has had a long-term illness, hypothyroidism, which is the precursor of the disease. She developed pneumonia last winter, and infections are a risk factor for myxedematous coma. She is old, and the condition is more prevalent in older women with pre-existing hypothyroidism (Santos et al., 2022). Shoveling snow is a hard job that could trigger the body due to the high heat and energy demand, leading to myxedema coma. Working in the cold is dangerous for hypothyroidism and is potentially lethal due to decreased core temperature, which is challenging to raise. The Winter season and exposure to cold aggravate the condition (Santos et al., 2022). These factors in her history could trigger a severe myxedema coma episode.

Physiologic Aspects Involved in Myxedematous Coma

Patients with myxedematous coma are not in an actual coma but experience mental alteration, typically older women with altered consciousness. The mechanism underlying the problem is similar to hypothyroidism, but in a myxedematous coma, the body’s mechanism fails and is unable to maintain homeostasis. It is thus considered the most severe complication of hypothyroidism. The body fails to raise its core temperatures hence cold stress. Decreased metabolism leads to low energy availability for vital organs, consequently reduced brain activity, and thus confusion and altered consciousness (Wartofsky & Klubo-Gwiezdzinska, 2019). The primary physiologic aspects are a decreased level of consciousness, defective thermoregulation, and cardiovascular collapse. Cardiovascular collapse causes low blood pressure and tissue hypoperfusion worsening the condition.

Bertha’s condition is a medical emergency that requires medical attention. The medical team should be swift to raise the low hormone levels and provide supportive care such as ventilatory support. Myxedema coma is potentially fatal, as seen, and prompt action is required. Individuals should work towards preventing the complication through infection prevention, early detection and management, follow-up, and avoiding working in the cold.

References

Armstrong, M., Asuka, E., & Fingeret, A. (2019). Physiology, thyroid function.

Hegedüs, L., Bianco, A. C., Jonklaas, J., Pearce, S. H., Weetman, A. P., & Perros, P. (2022). Primary hypothyroidism and quality of life. Nature Reviews Endocrinology18(4), 230-242. https://doi.org/10.1038/s41574-021-00625-8

Hwang, J. W. (2020). A case of profound hypothyroidism presenting with hypertensive emergency and a large amount of pericardial effusion. The American Journal of Case Reports21, e923299-1. https://doi.org/10.12659/AJCR.923299

Kakimoto, S., Harada, Y., & Shimizu, T. (2021). Acute upper airway obstruction by a goiter due to Hashimoto’s thyroiditis. BMJ Case Reports14(9). https://doi.org/10.1136/bcr-2021-245198

Santos, A., Doukas, S., Enete, C., Santharaman, A., Rommel, E., & Roy, R. (2022). Abstract# 1185196: Myxedema Coma: A Forgotten Lethal Endocrine Emergency. Endocrine Practice28(5), S159. https://doi.org/10.1016/j.eprac.2022.03.371

Wartofsky, L., & Klubo-Gwiezdzinska, J. (2019). Myxedema coma. In the Thyroid and Its Diseases (pp. 281-292 https://doi.org/10.1007/978-3-319-72102-6_20

Yuan, G., Yan, Q., & He, M. (2019). A Case of Pleural Effusion Caused by Hypothyroidism. Journal of Biosciences and Medicines8(1), 1-4. https://doi.org/10.4236/jbm.2020.81001

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