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| CASE REPORT |
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| Year : 2021 | Volume
: 9
| Issue : 1 | Page : 38-39 |
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Dysfunctional kidney due to dysfunctional thyroid!
S Rashmi, AC Nirmala
Department of General Medicine, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| Date of Submission | 20-Sep-2019 |
| Date of Decision | 26-Jan-2020 |
| Date of Acceptance | 15-Feb-2020 |
| Date of Web Publication | 03-Feb-2021 |
Correspondence Address:
Dr. S Rashmi
Department of General Medicine, Bangalore Medical College and Research Institute, Bengaluru - 560 002, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/AJIM.AJIM_60_19
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 |
| Introduction | |  |
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 | | |
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].
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 | | |
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 | | |
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 | | |
| 1. | Eckel RH. Hypothyroidism. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J, editors. Harrison's Principles of Internal Medicine. 20 th ed., Ch. 376. New York: McGraw-Hill Education; c2015. p. 2698.  |
| 2. | Kisakol G, Tunc R, Kaya A. Rhabdomyolysis in a patient with hypothyroidism. Endocr J 2003;50:221-3. |
| 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. |
| 4. | Golding DN. The musculo-skeletal features of hypothyroidism. Postgrad Med J 1971;47:611-4. |
| 5. | Achappa B, Madi D. Hoffmann's syndrome- A rare form of hypothyroid myopathy. J Clin Diagn Res 2017;11:OL01-02. |
| 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. |
| 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. |
| 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. |
[Table 1]
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