An unusual presentation of hypothyroidism

An Unexpected Cause of Catastrophic Bleeding: A Case Report

Profound hypothyroidism has been linked to mild bleeding diathesis such as easy bruising and menorrhagia. Bleeding tendency depends on the severity of hypothyroidism. Those with moderate disease are prone to thrombotic events, while those with profound hypothyroidism are prone to bleeding. This paper reports a case of severe intraoperative bleeding during elective rhinoplasty in a patient with missed profound hypothyroidism. The clinical and laboratory findings are presented with a review of the literature. A 43-year-old female was admitted for an elective rhinoplasty. In the theater, the patient developed massive bleeding at the beginning of surgery. On the next day, the patient was discharged home for further assessment with a massive bruise all over her face. Upon history taking, the patient denied any drug abuse or previous bleeding episode or family history of bleeding disorder. Surprisingly, a transverse scar was noted at the lower part of the neck. The patient admitted that she had thyroidectomy done 2 years ago, and she was kept on thyroxine replacement and stopped it by herself 18 months ago. Thyroid-stimulating hormone (TSH) was 70 mU/L, and von Willebrand factor antigen/ristocetin cofactor was normal. A diagnosis of acquired von Willebrand syndrome type 1 was made. The patient was kept on thyroxine 150 µg/day. Six weeks later, TSH was 0.8 mU/L, and all bleeding parameters were corrected. A careful history taking and general examination looking for hypothyroidism is crucial in the preoperative assessment. It might be prudent to include thyroid function test in the routine preoperative investigation of all patients.

Hemostatic changes in thyroid diseases

Several studies have reported hemostatic abnormalities, both in terms of bleeding or thrombosis, in patients with various thyroid dysfunctions. The aim of this review is to briefly discuss the relationship between thyroid disorders and hemostasis (i.e. primary hemostasis, coagulation factors and fibrinolytic system). From the analysis of the more recent literature data, it appears evident that most of the coagulation abnormalities associated with thyroid disorders are a consequence of a direct action of thyroid hormones on the synthesis of various hemostatic factors or a derangement of immune function. On the whole, these data suggest that a hypercoagulable state is present in hyperthyroid patients, while patients suffering from moderate hypothyroidism are at increased risk of thrombosis contrasting with the bleeding tendency of those presenting severe hypothyroidism.

Supraclavicular swelling in hypothyroidism

Hypothyroidism can have a variety of presentations. We report here a case of acquired hypothyroidism in a pediatric patient who first presented with bilateral supraclavicular swelling. Hypothyroidism and its presenting signs and symptoms are discussed with a focus on the less common findings that can be associated with hypothyroidism in children.

Hypothyroidism and acquired von Willebrand's syndrome: a systematic review

Acquired von Willebrand's syndrome type I is the supposed main underlying cause of bleeding tendency in hypothyroid patients. The purpose of this systematic review was to summarize the published evidence on the association between hypothyroidism and acquired von Willebrand's syndrome. All published clinical epidemiological and interventional studies, case reports and in vitro studies that investigated the association between hypothyroidism and acquired von Willebrand's syndrome were identified by a computer-assisted search of the MEDLINE and EMBASE electronic databases. A quality assessment was performed for clinical epidemiological studies. A total of 41 papers were included. A total of 22 epidemiological in vivo studies, two in vitro studies and 47 case reports were finally analyzed. No high quality in vivo study was identified. Almost all bleeding episodes described in the case reports were mucocutaneous. von Willebrand factor (VWF) antigen value was available for 23 patients: median value 28 U/dL (range: 4-45); VWF activity was available for 24 patients: median value 28.5 U/dL (range: <3-55); factor VIII activity was available for 16 patients: median value 47 U/dL (range: 9-74). Acquired von Willebrand's syndrome may be the main factor responsible for bleeding diathesis in overt hypothyroid patients. Even if bleeding episodes are mainly mild and mucocutaneous, blood transfusion, drug administration or surgical procedure may be required.

Localized Attachment Loss in Pendred Syndrome: Incidental?

BACKGROUND

Pendred syndrome is a rare, inherited, autosomal recessive disorder with an iodine organification defect of thyroxin produced by the thyroid gland. Its clinical features include sensorineural hearing loss, classically congenital and prelingual, and goiter.

METHODS

This is the first case report of Pendred syndrome in the dental literature with oral findings that include localized extensive attachment loss involving mandibular incisor teeth and idiopathic hypercementosis involving multiple teeth in addition to other oral manifestations, suggesting hypothyroidism-like macroglossia and macrocheilia. Furthermore, serum alkaline phosphatase along with inorganic calcium and phosphate levels were also elevated. Peripheral neutrophil function test suggested a defective function of neutrophils.

RESULTS

Management of the case included augmenting thyroxin supplementation, in consultation with an endocrinologist, and extraction of hopeless mandibular central incisors followed by placement of immediate transitional dentures.

CONCLUSION

A comprehensive medical history and systemic and laboratory evaluations should be considered a prerequisite to identify, manage, and report such rare conditions in routine clinical practice.

Acquired von Willebrand's syndrome resulting from untreated hypothyroidism in two prepubertal girls

Acquired von Willebrand syndrome (AvWS) is a rare bleeding disorder associated with a number of different diseases, including hypothyroidism. We describe two prepubertal girls with AvWS and undiagnosed hypothyroidism due to thyroiditis Hashimoto. The patients had neither family history nor symptoms of bleeding disorders. Substitution therapy with levothyroxine led to normalization of the coagulation parameters. We report these cases in order to raise awareness among paediatricians so that the AvWS should be suspected and searched for with the appropriate laboratary tests in all cases of hypothyroidism. Moreover, patients with bleeding diathesis of unknown origin should also be investigated for hypothyroidism.