Chamba and colleagues, working in Tanzania, describe the effective use of high dose oral levothyroxine to treat profound hypothyroidism. They report the case of a 67-year-old woman who had undergone total thyroidectomy for multinodular goitre, who was prescribed levothyroxine (100µg daily) for thyroid replacement.

After 3 years, she presented with breathlessness, weight gain, constipation and cold intolerance. Clinical examination revealed hypothermia and signs of congestive cardiac failure. Investigations demonstrated hyponatraemia, hypocalcaemia and an elevated partial thromboplastin time. Left ventricle dilatation was evident on echocardiogram, and electrocardiogram showed low voltage activity and a prolonged QT interval. The course of hospital admission was complicated by spontaneous bleeding (haematuria, ecchymosis), and a reduced level of consciousness. A review of thyroid biochemistry demonstrated elevated levels of thyroid-stimulating hormone for at least 1 year preceding admission, and markedly low free thyroid hormone levels at presentation.

The team initiated oral levothyroxine (300µg daily), intravenous hydrocortisone and oral calcium, plus supportive treatment for heart failure and hypothermia. Over the following 3 weeks, the patient made a gradual recovery, and was euthyroid at follow-up 3 months later.

In summarising her case, the team discuss the features of severe hypothyroidism (myxoedema coma), and the use of levothyroxine and liothyronine in its management.

Read the full article in Endocrinology, Diabetes & Metabolism Case Reports doi:10.1530/EDM-21-0197