Dr. Mayura Kale: Primary hypothyroidism with Megaloblastic Anemia
Overview
Thirty two years old gentleman was presented to Dr. Mayura Kale. He was a known case of hypothyroidism. He visited in mid of February with complaints of puffiness of face, pedal edema, pain and swelling of bilateral ankles, knees of around 1 month duration. The puffiness of face and swelling, pain of the joints increased gradually over one month. There was no redness of the painful joints. There was no history of fever or rash anywhere on the body. There was no history of any injury in the recent past.
The patient was diagnosed to have hypothyroidism around 4 years back and had similar complaints at the time of diagnosis. He was maintaining normal thyroid function with 125 mcg/day of thyroxine till around one year back. During lock down, he didn’t follow up and reduced the daily dose of thyroxine to 50 mcg, on his own from September 2020. He became symptomatic around January 2021 onwards.
On examination, puffiness of face and pedal edema, along with swelling of bilateral knees and ankles were confirmed. His blood pressure was 154/92 mm of Hg. Systemic examination was unremarkable.
Laboratory Evaluation
Salient results were as follows
Thyroid function tests
| T3 | 0.83 ng/dL (0.7-2.04), CLIA |
| T4 | 4.18 ug/dL (6.09-12.23), CLIA |
| TSH | 121.58 uIU/mL(0.34-5.60) CLIA |
| AntiTPO antibody Titre | 46.12 IU/ml, CLIA (N < 9) |
| A.S.O Titre | 15.6 IU/ml (normal UP TO 200), |
| S Uric Acid | 6.2 mg/dL (normal 3.6-7.7) |
| ESR | 52 mm/1hr( 0-20) |
Heamogram
| Heamoglobin | 12.3gm/dL |
| Total RBc count | 3.62 /cumm |
| Haematocrit | 38 % |
| MCV | 105fl |
| MCH | 34.1pg |
| MCHC | 32.4 g/dL |
| RDW-CV | 16.8 % |
| Total WBC count | 7230 /cumm |
| Platelet count | 1,69,000 /cumm |
| Vitamin B12 levels | 156 pg/ml (211-911pg/ml) CLIA |
Liver function tests
| Total Bilirubin | 2.0 mg/dL |
| Direct Bilirubin | 0.6 mg/dL |
| Indirect bilirubin | 1.4 mg/dL |
| SGOT | 49.2 IU/L |
| SGPT | 71 IU/L |
Confirming the Diagnosis
High TSH, low T3 & T4, presence of antiTPO antibodies along with high MCV (mean corpuscular volume), high MCH (mean corpuscular heamoglobin), indirect hyperbilirubinemia, mildly deranged liver enzymes and low vitamin B12 levels confirmed primary hypothyroidism with megaloblastic anemia.
Radiological investigations were not done for joint pain and swelling since clinically the likely cause was underlying hypothyroid status. Iron studies and folate levels were not done due to two reasons 1. economic constraints 2. It was not possible for the patient to come on another day in a fasting state as he lived in a faraway village.
Treatment
He was put on 125 mcg of thyroxine along with oral iron (ferrous ascorbate) and folic acid supplements. Injectable vitamin B12 was given, initially every alternate day for first five doses followed by once a week for next five doses. Short course (five days) of analgesic (Etodolac) was advised.
Result
Patient doing well with complete resolution of joint swelling and pain. The TSH level reduced to 23.85 uIU/mL and almost near normalization of the MCV and MCH.
TSH
| TSH | 23.85 uIU/mL (0.34-5.60) CLIA |
Heamogram
| Heamoglobin | 14.6 gm/dL |
| Total RBC count | 4.57 /cumm |
| Haematocrit | 43.9 |
| MCV | 94 |
| MCH | 31.26 pg |
| MCHC | 33.26 |
| RDW-CV | 12.8 |
| Total WBC count | 6200 /cumm |
| Platelet count | 1,48,000 /cumm |
Liver function tests
| Total Bilirubin | 1.2 mg/dL |
| Direct Bilirubin | 0.4 mg/dL |
| Indirect bilirubin | 0.8 mg/dL |
| SGOT | 30.6 IU/L |
| SGPT | 42 IU/L |
