Self-management is an essential component of chronic care. In this
regard, the patient, even if well-informed about their disease or
condition, needs to appreciate that an unceasing physician’s supervision
is an essential. He or she should also realize that adherence to a joint
decision-making is an obligation. Otherwise, an unanticipated turn of
events is always a possibility.
Ms. M, a 30-year-old biology teacher presented with complaints of
anorexia and weakness and was diagnosed with primary hypothyroidism. On
levothyroxine treatment, her anorexia and weakness subsided and she felt
well. And after her TSH and free T4 returned to a stable normal range,
she was counselled that later on she should come for a visit anytime she
had any symptoms or if she planned pregnancy, otherwise once-yearly
endocrine visit would be good enough. Ms. M was indeed well familiar
with the routine follow-up visits of hypothyroid patients, because she
had almost always accompanied a 25-year-old brother with hypothyroidism
of 6-year duration in his follow-up clinic visits. And she had also read
much about hypothyroidism, and therefore she thought she knew enough to
manage her own disease. She continued to take her medicine regularly
every morning almost 30-60 minutes before breakfast. So, 4 years passed
and Ms. M had not gone for any follow-up visits. Every year she had
referred to a private medical laboratory near her home to have her TSH
checked, and it had remained in a stable normal range. Now in a couple
of months, it would be the 5th year that she was
managing her hypothyroidism, and she sensed that her anorexia and
weakness were making a return. So as usual on her own and almost 1 month
sooner than her usual every year, she referred to the same medical
laboratory and wanted her TSH measured. She expected an elevated TSH.
And, in fact, the laboratory report of a higher than normal TSH further
enhanced her self-confidence. Based on her own knowledge, she concluded
that she needed to increase the daily dose of her thyroid hormone to
recheck a TSH in 2 months for further dose adjustment. But to surmount
that annoying weakness and anorexia sooner, she decided to
temporarily–just for a few days–double the dose of her thyroid
hormone and then cut back and continue with only 25% increase. To the
best of her knowledge in her case there were not any contraindications
for such a brief enhancement of thyroid hormone therapy: she was young
and she did not have any cardiovascular disease.
Just a few days after the doubling of the daily dose of levothyroxine,
she needed an emergency hospitalization for a suspected acute abdomen.
She had experienced a severe abdominal pain with intractable nausea and
vomiting. She had a fever and her blood pressure was low with a
significant orthostatic change. Her routine laboratory data among other
abnormalities revealed a low sodium with elevated potassium. And a low
serum cortisol with elevated ACTH documented an Addisonian crisis (1).
She responded to intravenous normal saline and hydrocortisone and was
discharged on prednisone and fludrocortisone to be followed by her
endocrinologist. The endocrinologist adjusted the doses of her adrenal
medicines, and, much to the patient’s surprise, he cut back on her
thyroid hormone to that usual dosage she was on before. Two months later
she was doing well, had no complaints, and her lab data, including ACTH
and TSH, were all normal. Ms. M had remained curious as to why her
elevated TSH should return to normal with smaller doses of
levothyroxine. The endocrinologist explained in simple terms that an
emerging adrenal insufficiency with loss of cortisol feedback–and not
a worsening hypothyroidism–was the cause of her recent mildly
elevated TSH (2, 3). He continued that ironically this time, her
anorexia and weakness were not related to her thyroid, but they were
indeed the symptoms of that adrenal insufficiency (1). He added that the
later-appearing fever, hypotension, and severe gastrointestinal symptoms
were in fact the manifestations of a life-threatening adrenal crisis
that had been triggered by that enhancement in her thyroid hormone
dosage … (1). The endocrinologist insinuated to her that she had
failed to appreciate the importance of physician’s supervision and
shared decision-making … (4, 5). He added, “In that situation, the
adrenal insufficiency initially did not reveal itself fully but faked a
mild hypothyroidism only to cheat you to open the door to a wolf in
sheep’s clothing!”
References:
- Bornstein SR, Allolio B, Arlt W, Barthel A, Don-Wauchope A, Hammer GD,
Husebye ES, Merke DP, Murad MH, Stratakis CA, Torpy DJ.
Diagnosis and
Treatment of Primary Adrenal Insufficiency: An Endocrine Society
Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;
101: 364-389.
- Barnett AH, Donald RA, Espiner EA. High concentrations of
thyroid-stimulating hormone in untreated glucocorticoid deficiency:
indication of primary hypothyroidism? Br Med J (Clin Res Ed).
1982; 285:172-173.
- Rosario
PW,
Mourão
GF,
Calsolari
MR. Is confirmed elevation of the serum TSH with normal
concentrations of circulating thyroid hormones sufficient for the
diagnosis of subclinical hypothyroidism? Eur Thyroid J 2015; 4:
273-274.
- Pishdad GR, Pishdad R, Pishdad P. From an out-of-date experience. Endocrine. 2020; 69:464-465.
- Rabi DM, Kunneman M, Montori VM. When Guidelines Recommend Shared
Decision-making. JAMA. 2020; 323: 1345-1346.