Category: Thyroid

FOOT DROP AND MUSCLE DESTRUCTION: A RARE CASE OF HYPOTHYROIDISM MYOPATHY IN A YOUNG MALE

Monday, Apr 8
1:00 AM – 2:00 AM

Objective : Severe myopathy is a rare presentation of hypothyroidism which requires prompt recognition to avoid complication.


Methods :

26 year old man with hypothyroidism status post radioactive Iodine treatment for Graves’ disease presented with three days of lower limbs pain, numbness and edema which impaired ambulation. He denied any trauma or any form of strenuous exercise. He was noncompliant with medications until a month ago when restarted on levothyroxine. He noted fifteen pound weight gain in six months, generalized swelling, predominantly lower extremities and fatigue. Examination  noted limbs muscle swollen predominantly lower extremity with bilateral foot drop with decreased sensation over the dorsum of both feet. Relaxation of deep tendon reflexes was delayed. Pulses were presents bilaterally. Labs shown creatinine1.34mg/dl, glucose 154mg/dl, elevated LFT,CPK 54,740IU/l. TSH 63uIU/mL, free T4 0.49ng/dl. Urine toxicology and Immunology panel was negative.UA revealed 3+heme, 3+protein, and rare non-dysmorphic RBCs, no casts.He received intravenous fluid and IV levothyroxine.Renal function and rhabdomyolysis improved. MRI revealed abnormal appearance of the muscles of the proximal leg with abnormal enhancement and mass effect on common peroneal nerve. EMG noted bilateral fibular neuropathies with myositis and slightly decreased sural nerve action potentials.He continued levothyroxine with improvement of sensation deficit but had persistent foot drop.


Results : .


Discussion :

Rhabdomyolysis is a rapid breakdown of skeletal muscle tissue leading to release of its contents into systemic circulation. It is a life-threatening condition, may occur due to physical factors including severe exercise, trauma, convulsions, as well as to statin or chemical drugs and on rare occasions to hormonal causes. Hypothyroidism presents with different spectrum of myopathy from delayed deep tendon reflexes to myopathy and rhabdomyolisis which may progress to compartment syndrome with neurological consequences of muscle paralysis.  Bilateral foot drop in this patient was from fibular neuropathy due to pressure of glycosaminoglycan deposition in the perineural sheath and possible muscle destruction and inflammation. Treatment of underlying hypothyroidism leads to improvement of rhabdomyolisis and of myopathy.


Conclusion :

Hypothyroidism can manifest with different degree of muscle involvement and severe myopathy with rhabdomyolysis is a rare presentation which can be complicated with neuropathy and muscle paralyses. Clinician awareness and prompt recognition of this condition is necessary to avoid irreversible neurologic damage and disease progression.

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Jonila Murati

Chief Medical Resident
Berkshire Medical Center
West Roxbury, Massachusetts

Medical School : University of Medicine of Tirana; Internal Medicine Residency : Berkshire Medical Center

Preeyanka Sundar

Resident
Berkshire Medical Center

.

Ines Kurjakovic

resident
Berkshire Medical Center

.

Amnah Andrabi

resident
Berkshire Medical Center

.

Gabriela Ciofoaia

Hospitalist
Berkshire Medical Center
West Roxbury, Massachusetts

.

Steven Lamontagne

Nephrologist
Berkshire Medical Center

.