Hypothyroidism Manifesting as a Combination of Ascites and Malnutrition Requiring Total Parenteral Nutrition: A Unique Presentation

[helvella]

A classic example of doing a lot of diagnostic work but sailing straight past "running a thyroid panel". Also, missing clear patient history (though whether that was due to the patient or the doctors is unclear).

Note that the patient LOST weight.

Cureus. 2019 Aug; 11(8): e5338.

Published online 2019 Aug 7. doi: 10.7759/cureus.5338

PMCID: PMC6777928

Hypothyroidism Manifesting as a Combination of Ascites and Malnutrition Requiring Total Parenteral Nutrition: A Unique Presentation

1 Stephanie R Suddaby,2 and Muhammad Shafiq3

Abstract

Ascites is the abnormal buildup of fluid in the abdomen. Despite appropriate workup, including diagnostic paracentesis with fluid analysis and abdominal imaging, the cause of ascites is sometimes unknown. In this case, testing for less common causes should be performed, including checking thyroid function test (TFT) because hypothyroidism has also been reported to be a rare cause of ascites. Patients may also have concomitant malnutrition as an effect of severe hypothyroidism, rather than as its cause. We report the case of a 62-year-old female with a history of hypothyroidism and non-compliance who presented with unexplained ascites and then also developed severe malnutrition, requiring total parenteral nutrition (TPN). Extensive testing, including laparotomy, was unable to reveal the cause of ascites and malnutrition until the patient mentioned, during her hospital stay, non-compliance with her home dose of levothyroxine (175 μg) because of the cost. TFT results indicated that the patient had severe hypothyroidism, with a thyroid-stimulating hormone (TSH) level of 21.9 IU/mL and a free thyroxine level (T4) level of 0.2 IU/mL. The patient’s home levothyroxine dose was resumed. The patient clinically improved and was discharged on an oral diet. The patient’s ascites resolved completely, the TSH level was 2.39 IU/mL, and the T4 level was 1.7 IU/mL at the eight-week follow-up.

Keywords: hypothyroidism, ascites, severe nutrition

Rest of full paper freely available here:

ncbi.nlm.nih.gov/pmc/articl...

[SilverAvocado]

With a TSH of 1.7, maybe she didn't bother with the Levothyroxine because she didn't feel any better!

In terms of patient history, it's not just being aware enough to do the TFTs. Can't they just pull up on the computer all the prescribed medicines and diagnosed illnesses? To me it seems like if a patient comes in with anything that might be called 'unexplained' the first thing that should be done is to work through every known illness they have and thoroughly check whether that is the cause. The very first question on that list being, is the treatment for this illness bring administered correctly and do the markers of the illness show its correctly managed!

But I do feel like even this simple level of data handling and use of evidence is one of the things doctors don't seem to have any training in. They treat every symptom as if it's a completely independent never before seen event, and don't have a strong connection between the evidence in front of them and the conclusions they make (for example, if something is a 1 in 100 event they believe they will never ever see it themselves, even if they see 1000s of patients.).