Lesson of the week: Deterioration of symptoms after start of thyroid hormone replacement

doi:10.1136/bmj.323.7308.332

BMJ 2001;323:332-333 ( 11 August )

Clinical review

Lesson of the week

Deterioration of symptoms after start of thyroid hormone replacement

Suspect Addison's disease if a patient's symptoms worsen after thyroxine is given for suspected hypothyroidism

Jonathan Stephen Murray, medical student ^a, Rubaraj Jayarajasingh, medical student ^a, Petros Perros, consultant endocrinologist ^b.

^a Medical School, Newcastle upon Tyne NE2 4HH, ^b Freeman Hospital, High Heaton, Newcastle upon Tyne NE7 7DN

Correspondence to: P Perros Petros.Perros@ncl.ac.uk

The first 150 words of the full text of this article appear below.

Doctors often arrange thyroid function tests for patients presenting with general symptoms of tiredness, and in some caseshypothyroidism is subsequently diagnosed. Lack of clinical responseto thyroxine replacement is not uncommon in cases of "subclinicalhypothyroidism." A deterioration of symptoms, however, may signifya potentially life threatening alternativediagnosis.

Case reports

Case 1
A 26 year old woman with type 1 diabetes,presented with a five week history of lethargy, nausea, feelinglightheaded on standing, occasional vomiting, and four unexplainedsevere hypoglycaemic episodes. The hypoglycaemic episodes occurredunexpectedly (no change in dietary intake, amount of physicalexertion, amount of alcohol ingestion, or dose or timing of insulintherapy).

Thyroid function tests showed a serum concentration of thyroid stimulating hormone of 37.30 mU/l (reference range 0.5-5.7mU/l) and free thyroxine 12.7 pmol/l (9-22 pmol/l). The patientwas started on 25 µg thyroxine daily. This resulted in an immediateexacerbation of symptoms, which prompted a referral to an endocrinologist.. . . [Full text of this article]

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