• Users Online: 293
  • Print this page
  • Email this page


 
 
Table of Contents
CASE REPORT
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 38-39

Dysfunctional kidney due to dysfunctional thyroid!


Department of General Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India

Date of Submission20-Sep-2019
Date of Decision26-Jan-2020
Date of Acceptance15-Feb-2020
Date of Web Publication03-Feb-2021

Correspondence Address:
Dr. S Rashmi
Department of General Medicine, Bangalore Medical College and Research Institute, Bengaluru - 560 002, Karnataka
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/AJIM.AJIM_60_19

Rights and Permissions
  Abstract 


Hypothyroidism can have various musculoskeletal manifestations such as myalgia, myopathy, or myositis. However, hypothyroidism causing rhabdomyolysis is rare. Moreover, the occurrence of acute kidney injury due to rhabdomyolysis precipitated by hypothyroidism is a rare, life-threatening yet reversible cause for renal dysfunction. Here, we report a case of an 18-year-old girl who presented with renal dysfunction following acute gastroenteritis, and on evaluation for worsening renal functions, she was found to have rhabdomyolysis due to hypothyroidism.

Keywords: Hypothyroidism, rhabdomyolysis, thyroid myopathy


How to cite this article:
Rashmi S, Nirmala A C. Dysfunctional kidney due to dysfunctional thyroid!. APIK J Int Med 2021;9:38-9

How to cite this URL:
Rashmi S, Nirmala A C. Dysfunctional kidney due to dysfunctional thyroid!. APIK J Int Med [serial online] 2021 [cited 2021 Feb 28];9:38-9. Available from: https://www.ajim.in/text.asp?2021/9/1/38/308650




  Introduction Top


Hypothyroidism can have varied manifestations. The onset is usually insidious and so, many times, the patient may become aware of the symptoms only when euthyroidism is restored.[1] The usual presenting symptoms are tiredness, dry skin, cold intolerance, weight gain, constipation, menstrual disturbances etc.[1] A small proportion of patients with hypothyroidism develop severe muscle weakness.

Thyroxine deficiency results in reduced oxidative capacity of the mitochondria. As a result, there is decreased glycogenolysis and an insulin-resistant state in the muscle cells. As a result, the fast twitching type of muscle fibers undergo atrophy, as they are dependent on glycogenolysis for their energy. Furthermore, there is deposition of glycosaminoglycans in the muscle cells, reduced ATP turnover, and poor contractility of actin-myosin units.[2],[3] This leads to the slowing of muscle contraction as clinically seen in patients with hypothyroidism.

Hypothyroid myopathy principally affects the proximal muscle groups. Hypotonic weakness, with or without muscle atrophy is usually seen in severe hypothyroid myopathy.[4] The usual presenting symptoms are muscle cramps, myalgia, fatigue, and muscle weakness precipitated with exercise. Myasthenic syndrome, Kocher–Debre–Semelaigne syndrome, and Hoffman's syndrome are other manifestations of hypothyroid myopathy.[5] However, rhabdomyolysis is very rare yet severe and life-threatening complication.


  Case Report Top


An 18-year-old female presented with a history of few episodes of loose stools and vomiting following lunch at a community gathering. On evaluation, the patient had pallor and dehydration with stable vital signs. Systemic examination was normal. On investigation, complete blood picture showed normocytic normochromic anemia with a hemoglobin of 10.3 g/dl, mean corpuscular volume 87.7 fl and on evaluation, iron profile, and Vitamin B12 levels were normal. Total counts were mildly elevated at 14,500 cells/mm[3]. The renal function test was abnormal – urea of 71.5 mg/dl and creatinine 3.2 mg/dl suggestive of the prerenal type of acute kidney injury (AKI) initially. The patient was treated with the antibiotics ciprofloxacin and metronidazole and hydrated well.

However, the creatinine levels continued to increase and the patient developed oliguria [Table 1].
Table 1: Trend of renal parameters

Click here to view


However, gastroenteritis had completely resolved and total counts were normal. Liver function test showed mildly elevated enzymes. Urine routine was normal. The patient was initiated on hemodialysis for renal dysfunction. She was evaluated for the cause of anemia and worsening renal function despite treatment for gastroenteritis. She was found to have hypothyroidism with thyroid-stimulating hormone levels of 331.23 mIU/l. Anti-thyroid peroxidase antibodies were strongly positive-400 U/ml. On further evaluation, creatine phosphokinase (CPK) levels were found to be elevated at 8976 IU/ml. Lactate dehydrogenase was slightly elevated at 762 U/L. Serum complement levels and ANA screening were normal. Hemolysis was ruled out as there was no drop in hemoglobin, and peripheral smear was normal. The patient was diagnosed to be having rhabdomyolysis, which was precipitated by hypothyroidism and infection.


  Discussion Top


This patient was found to be having multifactorial AKI. The patient was treated for the presenting illness of acute gastroenteritis. Loose stools resolved, the patient was afebrile and total counts were normal. However, the worsening of renal function and development of oliguria even after correction of the presenting illness strongly proves that the cause was attributable to hypothyroidism-induced rhabdomyolysis. Serum potassium levels were normal. Ciprofloxacin can cause rhabdomyolysis but since our patient had AKI even before the treatment with ciprofloxacin was initiated, it was not considered a causative factor. Muscle biopsy was deferred, as it was not absolutely necessary for the diagnosis. The patient was initiated on hemodialysis and thyroxine supplementation. The patient responded to hormone therapy and over the next few days, the patient's urine output gradually improved and hemodialysis was withheld. RFT returned to baseline, CPK levels decreased to 3350 IU/ml.

Muscular symptoms with mild-to-moderate elevation in creatine kinase levels are common in patients with hypothyroidism. However, only a few progress to develop overt rhabdomyolysis.[6]


  Conclusion Top


The patients who develop rhabdomyolysis may usually have precipitating factors such as exertion, exercise, dehydration, noncompliance to medications, drug therapy with statins etc.[7],[8] In this case, gastroenteritis resulting in dehydration might have been a precipitating factor. However, even in the absence of any precipitating factor, hypothyroidism can cause rhabdomyolysis.[6]

Awareness regarding this rare complication and a high index of suspicion is required for the diagnosis of this condition. It is a treatable and reversible cause of renal dysfunction.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Eckel RH. Hypothyroidism. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 20th ed., Ch. 376. New York: McGraw-Hill Education; c2015. p. 2698.  Back to cited text no. 1
    
2.
Kisakol G, Tunc R, Kaya A. Rhabdomyolysis in a patient with hypothyroidism. Endocr J 2003;50:221-3.  Back to cited text no. 2
    
3.
Wiles CM, Young A, Jones DA, Edwards RH. Muscle relaxation rate, fibre-type composition and energy turnover in hyper- and hypo-thyroid patients. Clin Sci (Lond) 1979;57:375-84.  Back to cited text no. 3
    
4.
Golding DN. The musculo-skeletal features of hypothyroidism. Postgrad Med J 1971;47:611-4.  Back to cited text no. 4
    
5.
Achappa B, Madi D. Hoffmann's syndrome- A rare form of hypothyroid myopathy. J Clin Diagn Res 2017;11:OL01-02.  Back to cited text no. 5
    
6.
Salehi N, Agoston E, Mun?ir I, Thompson GJ. Rhabdomyolysis in a patient with severe hypothyroidism. Am J Case Rep 2017;18:912-8.  Back to cited text no. 6
    
7.
Yeter E, Keles T, Durmaz T, Bozkurt E. Rhabdomyolysis due to the additive effect of statin therapy and hypothyroidism: A case report. J Med Case Rep 2007;1:130.  Back to cited text no. 7
    
8.
Sekine N, Yamamoto M, Michikawa M, Enomoto T, Hayashi M, Ozawa E, et al. Rhabdomyolysis and acute renal failure in a patient with hypothyroidism. Intern Med 1993;32:269-71.  Back to cited text no. 8
    



 
 
    Tables

  [Table 1]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed118    
    Printed2    
    Emailed0    
    PDF Downloaded19    
    Comments [Add]    

Recommend this journal