Rhabdomyolysis in a Patient with Severe Hypothyroidism

Visfatin (rs3801266) and Adiponutrin (rs738409) gene single nucleotide polymorphisms in patients with Hashimoto's thyroiditis

BACKGROUND

Hashimoto's thyroiditis (HT) is the most common cause of hypothyroidism and is also associated with an increased risk of thyroid malignancy. Identifying the exact initiators of the disease could aid in its accurate prevention and treatment. This study aims to clarify the role of Visfatin and Adiponutrin genes in the development of HT.

METHODS AND RESULTS

This case‒control study was carried out on patients from the Internal Medicine, Endocrinology Department, Menoufia University Hospital. Samples are collected from ninety-six patients with HT and ninety-six controls. The findings of this study indicate that the patient group has a significantly higher Body Mass Index (BMI), lipid dysregulation, and thyroid dysfunction compared to the control group. Additionally, the results suggest that the rs3801266 variant of Visfatin and the rs738409 variant of Adiponutrin are associated with the patient group. Specifically, the CC genotype (16.7% vs. 4.2%) and C allele (40.6% vs. 26.0%) of rs3801266, as well as the GG genotype (11.5% vs. 2.1%) and G allele (35.9% vs. 23.4%) of rs738409, are significantly more frequent in patients, indicating a potential genetic predisposition. Anti-Thyroglobulin (Anti-TG) and Anti-Thyroperoxidase (anti-TPO) levels varied significantly across genotypes. CC and TC carriers of rs3801266 had significantly higher anti-TG levels, while GG carriers of rs738409 showed a marked increase in both anti-TPO and anti-TG levels compared to other genotypes.

CONCLUSION

The involvement of both the Adiponutrin and Visfatin genes is believed to contribute to the pathogenesis of HT, either directly or as a consequence of obesity.

Uncovering non-autoimmune hypothyroidism: A case report of rhabdomyolysis and myocarditis mimicking acute coronary syndrome

RATIONALE

Non-autoimmune hypothyroidism is a rare but significant cause of rhabdomyolysis and myocarditis, which can mimic acute coronary syndrome. Early recognition and treatment of hypothyroidism are crucial, especially in patients with chronic kidney disease (CKD), where delayed diagnosis may lead to life-threatening complications such as acute kidney injury.

PATIENT CONCERNS

A 71-year-old male with diabetes, CKD stage G3aA3, and a history of chronic myelogenous leukemia presented with myalgia, anorexia, and anuria. He also reported intermittent chest pain for 1 month, progressing to severe symptoms including decreased urine output and anuria.

DIAGNOSES

Laboratory findings revealed acute kidney injury (serum creatinine: 12.14 mg/dL), extreme elevations in muscle enzymes (creatine kinase: 250,000 IU/L), and cardiac biomarkers (troponin-T: 543 ng/L). Initial management did not improve his condition. On day 15, thyroid function tests confirmed non-autoimmune hypothyroidism (TSH: 55.58 μIU/mL, free T4: 0.06 ng/dL).

INTERVENTIONS

The patient underwent hemodialysis and conservative treatment initially, followed by levothyroxine replacement therapy on day 16.

OUTCOMES

Renal function, urine output, and muscle enzyme levels gradually improved after thyroid hormone supplementation. By discharge on day 40, the patient's serum creatinine decreased to 3.08 mg/dL, and hemodialysis was discontinued. At 7 months posttreatment, his renal function stabilized at CKD stage G3bA2 with normal thyroid function.

LESSONS

This case highlights the importance of considering hypothyroidism in patients with unexplained rhabdomyolysis and persistent cardiac symptoms, particularly in those with CKD. Early thyroid function testing can lead to timely treatment and improved outcomes in such complex cases.

Cellular mechanisms of acute rhabdomyolysis in inherited metabolic diseases

Acute rhabdomyolysis (RM) constitutes a life-threatening emergency resulting from the (acute) breakdown of skeletal myofibers, characterized by a plasma creatine kinase (CK) level exceeding 1000 IU/L in response to a precipitating factor. Genetic predisposition, particularly inherited metabolic diseases, often underlie RM, contributing to recurrent episodes. Both sporadic and congenital forms of RM share common triggers. Considering the skeletal muscle's urgent need to rapidly adjust to environmental cues, sustaining sufficient energy levels and functional autophagy and mitophagy processes are vital for its preservation and response to stressors. Crucially, the composition of membrane lipids, along with lipid and calcium transport, and the availability of adenosine triphosphate (ATP), influence membrane biophysical properties, membrane curvature in skeletal muscle, calcium channel signaling regulation, and determine the characteristics of autophagic organelles. Consequently, a genetic defect involving ATP depletion, aberrant calcium release, abnormal lipid metabolism and/or lipid or calcium transport, and/or impaired anterograde trafficking may disrupt autophagy resulting in RM. The complex composition of lipid membranes also alters Toll-like receptor signaling and viral replication. In response, infections, recognized triggers of RM, stimulate increased levels of inflammatory cytokines, affecting skeletal muscle integrity, energy metabolism, and cellular trafficking, while elevated temperatures can reduce the activity of thermolabile enzymes. Overall, several mechanisms can account for RMs and may be associated in the same disease-causing RM.

Severe Overt Hypothyroidism-Induced Rhabdomyolysis Complicated by Acute Renal Impairment

Musculoskeletal symptoms in hypothyroidism are often vague and non-specific, but in rare cases, rhabdomyolysis may develop as a serious complication. Here, we report a case of a 25-year-old man with a known history of Hashimoto's thyroiditis who presented with symptoms of rhabdomyolysis complicated by renal impairment secondary to severe overt hypothyroidism in the context of medication non-compliance. He presented with symptoms of generalised myalgia and fatigue. Laboratory investigations were consistent with severe overt hypothyroidism with thyroid-stimulating hormone (TSH) 531.4 mIU/L and free thyroxine (T4) 0.9 pmol/L (0.07 ng/dL). Creatine kinase (CK) levels were elevated at 1052 U/L with associated acute renal impairment, creatinine 129 μmol/L (1.49 mg/dL). Our patient was managed with the recommencement of thyroxine therapy and intravenous hydration. Over the course of hospitalisation, the patient's myalgias gradually improved, with an improvement in CK levels and renal function. Our case highlights the potential consequences of prolonged non-compliance. Clinicians should remain vigilant in monitoring patients' medication adherence and be aware of the possible complications from non-compliance. Early recognition and prompt management of such cases can lead to successful recovery and prevent long-term sequelae.

The Significance of Rhabdomyolysis Secondary to Hypothyroidism

Rhabdomyolysis is a rare but serious complication of hypothyroidism, typically associated with precipitating factors such as medication interactions, strenuous exercise, and illicit drug use. We present a unique case of rhabdomyolysis in an 89-year-old female due to severe hypothyroidism without identifiable precipitating factors. Laboratory results revealed markedly elevated creatine kinase (CK) levels and acute kidney injury (AKI). The diagnosis was confirmed by critically elevated thyroid-stimulating hormone (TSH) and low free thyroxine (FT4) levels. Prompt initiation of levothyroxine supplementation and fluid resuscitation led to clinical improvement and downward trend in creatinine and CK levels. This case highlights the importance of considering hypothyroidism in the differential diagnosis of rhabdomyolysis and the need for timely T4 supplementation and supportive care to prevent severe complications.

Asymptomatic COVID-19 Infection-Induced Rhabdomyolysis in the Backdrop of Statin-Cyclosporine Drug Interaction

Rhabdomyolysis involves skeletal muscle breakdown leading to high serum creatine kinase (CK) levels and myoglobinuria. Here, we report the case of a middle-aged man who developed rhabdomyolysis, resulting in acute kidney injury (AKI) over pre-existing chronic kidney disease (stage 3a) secondary to focal segmental glomerulosclerosis (primary FSGS), during an asymptomatic COVID-19 infection. The patient had been on treatment with cyclosporine and statin, among other drugs, for his comorbidities. He had initially presented to the hospital after a fall due to difficulty walking in the setting of increasing edema. Lab workup revealed elevated CK and AKI. Urinalysis showed "large" blood on a dipstick with only two RBCs per high-power field on microscopy, suggesting myoglobinuria. A standard respiratory pathogen polymerase chain reaction panel revealed positive SARS-CoV-2. The chest X-ray and oxygenation were normal, and he had no respiratory symptoms. He was treated with intravenous fluids and albumin, with a steady improvement in renal function. Our case underlines that rhabdomyolysis can occur in asymptomatic COVID-19 infection. Therefore, it may be worth monitoring CK levels in COVID-19-positive patients with risk factors for rhabdomyolysis, such as the concurrent usage of statins and cyclosporine, even if they are otherwise asymptomatic.

Hoffmann's syndrome in subclinical hypothyroidism

Hypothyroidism is an endocrine disorder which occurs due to a deficiency of thyroid hormones. Hoffmann's syndrome is a rare complication of hypothyroidism - presenting as hypothyroid myopathy. We describe the case of a 20-year-old lactating female, known to have hypothyroidism (diagnosed during her pregnancy and having discontinued treatment following delivery), presenting with complaints of pain, swelling of bilateral calf muscles with cramps in bilateral lower limbs. Symptoms of muscle pseudohypertrophy with muscle stiffness are relatively rare in subclinical hypothyroidism and it is important to identify and diagnose this rare condition, and initiate appropriate treatment.

Hashimoto's thyroiditis-related myopathy in a patient with SARS-CoV-2 infection: A case report and systematic literature review

RATIONALE

Hashimoto's thyroiditis (HT) is a common autoimmune disease. However, its presentation and management in the context of COVID-19 are unclear, and COVID-19-triggered HT, along with myopathy and persistent creatine kinase (CK) levels, have not been previously reported. Moreover, no literature review is currently available on HT in the context of COVID-19. This study is a case report and systematic review of the literature.

PATIENT CONCERNS

A 33-year-old man was admitted with acute-onset myalgia, anosmia, loss of taste, fever, and upper respiratory tract symptoms.

DIAGNOSES

He was diagnosed with coronavirus disease (COVID-19) during hospitalization and had abnormal CK levels. The elevated CK level persisted even after the resolution of COVID-19. After excluding myopathies and cardiac factors, HT was diagnosed.

INTERVENTIONS

CK levels did not decrease appreciably until 14 d after levothyroxine administration.

OUTCOMES

The patient was discharged from the hospital in good health. In the systematic literature review, 7 case reports on COVID-19-associated HT were observed, although no incidence of associated myopathy or persistent elevation of CK was noted.

LESSONS

This case report highlights the potential link between COVID-19 and autoimmune thyroid diseases. In particular, this study underscores the significance of recognizing new-onset autoimmune thyroid disease in COVID-19-positive patients with elevated CK levels that cannot be attributed to other factors. This systematic review offers additional perspectives for diagnosing and managing HT in COVID-19 settings. Overall, the findings of this study could have important clinical implications for the care of COVID-19 patients, as early identification and treatment of autoimmune thyroid disease could help prevent long-term complications. Additional research is essential to elucidate the fundamental correlations between COVID-19 and HT and assess the effectiveness of therapeutic approaches for autoimmune thyroid conditions related to COVID-19.

An atypical presentation of hypothyroidism with extremely exaggerated functional impairment

Key Clinical Message

Myopathy-related symptoms are rare manifestations of hypothyroidism. Clinicians should consider hypothyroid myopathy as one of the possible diagnoses for patients with proximal weaknesses.

Abstract

Myopathy-related symptoms are rare manifestations of hypothyroidism. Clinicians should consider hypothyroid myopathy as one of the possible diagnoses for patients with proximal weaknesses. We report a 34-year-old woman, presenting with a new atypical musculoskeletal manifestation of hypothyroidism mimicking polymyositis.

A Rare Case of Hypothyroidism-Induced Rhabdomyolysis

Rhabdomyolysis is a condition caused by muscle breakdown. It can be usually associated with pain, weakness, and elevated creatinine kinase levels on laboratory testing. There are various triggers, some of which can include trauma, dehydration, infections, and, as in this case, autoimmune disorders. Here, we present a case of a patient with worsening muscle pain who was found to have elevated creatinine kinase levels and undiagnosed hypothyroidism, with symptoms improving with intravenous hydration and thyroid supplementation.

Metabolic Myopathies

PURPOSE OF REVIEW

Metabolic myopathies are disorders that affect skeletal muscle substrate oxidation. Although some drugs and hormones can affect metabolism in skeletal muscle, this review will focus on the genetic metabolic myopathies.

RECENT FINDINGS

Impairments in glycogenolysis/glycolysis (glycogen storage disease), fatty acid transport/oxidation (fatty acid oxidation defects), and mitochondrial metabolism (mitochondrial myopathies) represent most metabolic myopathies; however, they often overlap clinically with structural genetic myopathies, referred to as pseudometabolic myopathies. Although metabolic myopathies can present in the neonatal period with hypotonia, hypoglycemia, and encephalopathy, most cases present clinically in children or young adults with exercise intolerance, rhabdomyolysis, and weakness. In general, the glycogen storage diseases manifest during brief bouts of high-intensity exercise; in contrast, fatty acid oxidation defects and mitochondrial myopathies usually manifest during longer-duration endurance-type activities, often with fasting or other metabolic stressors (eg, surgery, fever). The neurologic examination is often normal between events (except in the pseudometabolic myopathies) and evaluation requires one or more of the following tests: exercise stress testing, blood (eg, creatine kinase, acylcarnitine profile, lactate, amino acids), urine (eg, organic acids, myoglobin), muscle biopsy (eg, histology, ultrastructure, enzyme testing), and targeted (specific gene) or untargeted (myopathy panels) genetic tests.

SUMMARY

Definitive identification of a specific metabolic myopathy often leads to specific interventions, including lifestyle, exercise, and nutritional modifications; cofactor treatments; accurate genetic counseling; avoidance of specific triggers; and rapid treatment of rhabdomyolysis.

Rhabdomyolysis Caused by Hypothyroidism: Research Progress

Rhabdomyolysis (RM) refers to the clinical syndrome caused by the release of intracellular substances into the extracellular fluid and blood circulation after rhabdomyocyte destruction due to various etiologies. In severe cases, RM can lead to life-threatening conditions such as acute kidney injury. Hypothyroidism is a rare cause of RM that can lead to missed diagnosis or misdiagnosis, and the condition worsens in the absence of timely and effective treatment. Herein, reported cases of RM caused by hypothyroidism are summarized, and clinical diagnosis and treatment recommendations are proposed to facilitate early identification and treatment of the disease.

Hypothyroidism as an immune-related adverse event caused by atezolizumab in a patient with muscle spasms: a case report

A 60-year-old man with a history of 4 cycles of atezolizumab treatment for non-small cell lung cancer presented to our hospital with a chief complaint of proximal muscle-dominant spasms. Blood tests showed elevated creatine phosphokinase (CPK) of 8450 U/L and hypothyroidism. There was little improvement even after stopping levetiracetam and pregabalin, and no subspinous physical findings of myositis. After levothyroxine was started for hypothyroidism, his muscle cramps and serum CPK level improved. Hypothyroidism as an immune-related adverse event can cause muscle spasms and is important in the differential diagnosis of muscle spasms in patients treated with immune checkpoint inhibitors.

Severe hypothyroidism-induced rhabdomyolysis: A case report

Hypothyroidism causing rhabdomyolysis is a known but an uncommon entity. Hashimoto's thyroiditis causing rhabdomyolysis in the absence of precipitating factors is even rarer. Here, we report a 42-year-old previously healthy man with hypothyroidism due to Hashimoto's thyroiditis complicated by severe rhabdomyolysis and acute kidney injury in the absence of precipitating factors. The diagnosis was based on his clinical presentation and laboratory investigations, and he was successfully treated with intravenous fluid therapy and oral levothyroxine.

A case report of rhabdomyolysis and osteofascial compartment syndrome in a patient with hypothyroidism and diabetes

BACKGROUND

Hypothyroidism is frequent and has various forms of muscle involvement. We report the diagnosis and treatment of a case of rhabdomyolysis, bilateral osteofascial compartment syndrome (OCS) of the lower extremities, and peroneal nerve injury causing bilateral foot drop in a diabetic patient with hypothyroidism.

CASE PRESENTATION

A 66-year-old man with diabetes for 22 years was admitted because of drowsiness, tiredness, facial swelling, and limb twitching for 2 months, and red and swollen lower limb skin for 3 days. Serum creatinine kinase (CK), CK-MB, myoglobin (Mb), blood glucose, and HbA1c were elevated. TSH, thyroid peroxidase antibodies, and antithyroglobulin antibodies were elevated. FT3 and FT4 were low. Urine was dark brown. He was diagnosed with hypothyroidism, rhabdomyolysis, and OCS. CK, CK-MB, and Mb returned to normal after treatment with thyroid hormone, insulin, albumin infusion, ceftriaxone, ulinastatin, and hemofiltration, and the redness and swelling of the lower limbs were relieved, but the patient developed dropping feet. The patient recovered well but had to undergo rehabilitation.

CONCLUSION

Hypothyroidism may induce rhabdomyolysis, OCS, and other complications. This case reminds us of the importance of screening for hypothyroidism and strengthens the clinicians' understanding of the disease.

Severe Hypothyroidism Complicated by Myopathy and Neuropathy with Atypical Demyelinating Features

Autoimmune hypothyroidism may result in a wide range of neuromuscular disorders. The frequently observed neurological manifestations of acquired hypothyroidism include mild to moderate myopathy and sensorimotor neuropathy, which usually resolve by clinical and electrophysiological criteria, in adults treated with thyroid hormone replacement. We report a case of a 30-year-old male with severe hypothyroidism secondary to chronic autoimmune thyroiditis who presented with a 2-year history of progressive fatigue, upper and lower limb weakness, myalgia, and intermittent paraesthesia. His neurological exam demonstrated proximal and distal muscle weakness, lower limb areflexia, and relatively intact sensory modalities. The patient's biochemistry revealed unusually and profoundly raised the thyroid stimulating hormone (TSH) level of 405.5 mIU/L (reference range (RR): 0.27–4.2 mIU/L) and creatine kinase (CK) level of 20,804 U/L (RR: 45–250 U/L), while his nerve conduction studies (NCS) demonstrated severe sensorimotor polyneuropathy with both axonal and demyelinating features. Thyroid hormone replacement therapy over the first 3 months resulted in biochemical normalization of his extremely deranged thyroid function tests (TFTs) and CK levels. At 12 months, despite maintaining euthyroidism and noticeable improvement in strength, his nerve conduction studies (NCS) demonstrated the continued absence of distal motor and sensory responses in his lower limbs with only partial improvement in sensory amplitudes and conduction velocities in his upper limbs. This report highlights the potential for severe neuromuscular consequences from advanced and chronic autoimmune hypothyroidism. The patient's myopathy has resolved over a period of three months with prompt normalization of CK levels. Concerningly, the patient achieved significant but incomplete recovery from his mixed axonal and demyelinating neuropathy with residual mild distal weakness and areflexia in his lower limbs and persistent motor and sensory impairments on his NCS. The severity and incomplete resolution of our patient's neurological manifestations emphasize the importance of early diagnosis and the need for prompt therapeutic intervention for hypothyroidism.

Severe Hypothyroidism Presenting With Rhabdomyolysis in a Young Patient

Rhabdomyolysis is an uncommon but potentially life-threatening medical condition. The acute muscle breakdown leads to the release of toxic muscle contents which can damage the kidneys and can cause the development of acute kidney injury (AKI) and fatal electrolyte imbalances associated with high morbidity and mortality. There are a variety of causes including exposure to extremely hot weather, toxins, trauma, certain drugs, and rarely endocrine disorders in particular thyroid dysfunction. It is more common among a certain group of people, for example, enthusiastic athletes, physical laborers, military and police personnel working in hot and humid weather. Moreover, it is also seen in patients using certain medications, and in the elderly following a fall and prolonged laying on the floor. The majority of the patients develop acute kidney failure and treatment with intravenous hydration and the underlying cause remains the mainstay of management.

Our case demonstrates the rare occurrence of AKI induced by rhabdomyolysis in patients with severe hypothyroidism. A 36-years-old male presented with generalized body pains, arthralgias, weight gain, and ankle edema of three months duration. On investigations, he was found to have severe hypothyroidism, AKI along with raised creatinine kinase (CK) and myoglobin indicating severe muscle damage. He was treated with intravenous (IV) fluids and oral levothyroxine in accordance with endocrine team advice.

This case highlights the significance of investigating acute rhabdomyolysis with thyroid function tests if no other cause is apparent from history like hyperthermia/drugs/toxins as in our case. Timely diagnosis and treatment of underlying pathology improve patient outcomes.

Rhabdomyolysis Secondary to Hypothyroidism: Report of a Case

Rhabdomyolysis has many causes; however, hypothyroidism is a rare cause of such a condition. Usually, management is similar in many cases, but some exceptions do exist, especially in the case of hypothyroidism. Thus, we reviewed the literature to investigate further precipitant factors, clinical presentations, complications, management, and prognoses. We report a 19-year-old male with a history of hypothyroidism who was brought in for questionable suicidal ideation. Although asymptomatic, he was found to have an acute kidney injury (AKI). Further investigations revealed significantly elevated levels of creatine kinase (CK) and thyroid-stimulating hormone (TSH) in the setting of medication non-compliance. Management with intravenous (IV) fluids and thyroid hormone replacement resulted in an improvement in AKI and CK levels.

The endocrinology of sarcopenia and frailty

Sarcopenia describes low muscle mass and strength associated with ageing, whilst reduced physical performance indicates the severity of the condition. It can happen independently of other medical conditions and can be a key feature of the frailty phenotype. Frailty is a syndrome of increased vulnerability to incomplete resolution of homeostasis, following a stressor event. Researchers have described the implications of hypothalamic pituitary dysregulation in the pathogenesis of both entities. This review summarizes the recent evidence in this area as well as other endocrine factors such as insulin resistance and vitamin D status and outlines current research priorities. We conducted searches to PubMed and Embase databases for articles, reviews and studies reporting new data on the interaction between hormones of the endocrine system and frailty and/ or sarcopenia in the last 5 years. Interventional studies, cohort studies, case-control studies and animal studies were included. Clinical trials register was also searched to identify ongoing relevant studies. Studies have given us insights into the complex relationships between factors such as anabolic hormones, glucocorticoids and vitamin D on muscle strength and performance and their involvement in ageing phenotypes. However, robust randomized controlled trials are needed to consolidate existing evidence in humans and inform clinical practice. Current evidence supports hormone replacement in patients with confirmed deficiencies, to optimize health and prevent complications. Hormone replacement has limited use for age-related conditions. Current interest is focused on muscle/bone/fat interactions and health outcomes in "sarcopenic obesity." A life-course approach to improving 'health-span' is advocated. Lifestyle factors such as nutrition and physical activity have important interactions with body composition, physical function and metabolic outcomes. Large-scale clinical trials will determine the efficacy and long-term safety of hormone supplementation in the management of sarcopenia and frailty.

Endocrine myopathies: clinical and histopathological features of the major forms

Endocrinopathies, such as thyroid and parathyroid diseases, disorders of the adrenal axis, and acromegaly are included among the many causes of myopathy. Muscle disturbances caused by endocrine disorders are mainly due to alterations in the protein and carbohydrate metabolisms. Either a deficiency or excess of hormones produced by the glands can cause muscle dysfunction that can be reversed by starting hormone replacement therapy or acting on hormone dysfunction. The diagnosis is usually easy if a muscle disorder occurs in an overt endocrinopathy; however, in few patients, myopathy could be the first manifestation of the underlying endocrinopathy. In this article we discuss pathophysiology, clinical features and management of muscle involvement related to the major endocrine diseases.

Rhabdomyolysis due to hypothyroidism without any precipitating factor

Rhabdomyolysis may develop due to hypothyroidism alone without any precipitating factors, but such reports are rare. We report as such the first manifestation of hypothyroidism.

Rhabdomyolysis in a Young Patient due to Hypothyroidism without Any Precipitating Factor

Hypothyroidism is characterized by decreased hormone production, which results in various clinical manifestations in different organ systems. Muscular symptoms are common in patents with clinical hypothyroidism which includes muscle cramps, myalgia, and mild to moderate elevation of creatinine kinase less than five times the upper limit of normal. However, rhabdomyolysis due to hypothyroidism is rare and in most of the reported cases a precipitating factor has been found. We report a unique case of a 35-year-old male with no past medical history who presented with rhabdomyolysis due to newly diagnosed hypothyroidism without any precipitating factors and was treated successfully with intravenous fluids and levothyroxine.

Non-traumatic and non-drug-induced rhabdomyolysis

Rhabdomyolysis (RM), a fortunately rare disease of the striated muscle cells, is a complication of non-traumatic (congenital (glycogen storage disease, discrete mitochondrial myopathies and various muscular dystrophies) or acquired (alcoholic myopathy, systemic diseases, arterial occlusion, viral illness or bacterial sepsis)) and traumatic conditions. Additionally, RM can occur in some individuals under specific circumstances such as toxic substance use and illicit drug abuse. Lipid-lowering drugs in particular are capable of causing RM. This comprehensive review will focus on non-traumatic and non-drug-induced RM. Moreover, the pathology of RM, its clinical manifestation and biochemical effects, and finally its management will be discussed.

Acute psychosis and concurrent rhabdomyolysis unveiling diagnosis of hypothyroidism

Neuropsychiatric and muscular symptoms can develop as part of hypothyroidism. However, frank psychosis or rhabdomyolysis due to hypothyroidism are uncommon and have been reported rarely as the first presenting features of hypothyroidism. We report a case of a 44-year-old man who presented with a 2-week history of delusions, hallucinations and mild bilateral leg pain, without apparent signs of myxedema. Investigations revealed raised thyroid stimulation hormone >100 mIU/L and high creatine kinase >21 000 U/L. Diagnosis of hypothyroidism-induced psychosis and rhabdomyolysis was made. He received thyroxine, olanzapine and a short course of steroids. His symptoms improved after 2 weeks of treatment and he remained free of symptoms at 6 months of follow-up. To the best of our knowledge, this is the first case of concomitant psychosis and rhabdomyolysis leading to hypothyroidism diagnosis. This case highlights the importance of hypothyroidism screening when faced with unexplained psychosis or rhabdomyolysis, especially if combined.

A case of severe hypothyroidism due to lenalidomide

Lenalidomide, an immunomodulatory drug often used to treat multiple myeloma, can cause hypo- or hyperthyroidism. We present a patient being treated with lenalidomide for 2 years who developed severe hypothyroidism that was complicated by rhabdomyolysis and acute kidney injury. Thyroid function tests should be serially monitored in patients taking lenalidomide.

Severe hypothyroidism presenting as reversible proteinuria: two case reports

Background

Hypothyroidism is a common medical disorder which results in many metabolic effects, such as dyslipidemia, hypertension, accelerated atherosclerosis, and coronary artery disease. Hypothyroidism affects the renal physiology by affecting the renal blood flow, vascular resistance, and sodium handling. Recent studies have shown hypothyroidism is associated with decreased estimated renal function and proteinuria. Rhabdomyolysis and acute renal insufficiency have also been described in association with hypothyroidism. The severity of the proteinuria was directly proportional to thyroid-stimulating hormone levels. Currently, there is a lack of evidence on the reversibility of proteinuria in hypothyroidism. This is the first report in the literature, to the best of our knowledge, demonstrating the reversibility of proteinuria associated with hypothyroidism, with treatment.

Case presentation

Here we describe two cases, a 72-year-old Sinhalese man and a 47-year-old Tamil woman, from Sri Lanka, presenting with overt hypothyroidism; they were found to have elevated creatinine, proteinuria, and elevated creatinine kinase levels. Due to lack of active sediment in urine analysis, these patients were observed after the initiation of thyroxine therapy. They were investigated in the adult-onset proteinuria pathway, excluding common reasons for proteinuria. Both patients responded to treatment: their serum creatinine, creatinine kinase, and urine protein levels reverted to physiological levels within 6 months of treatment with thyroxine, and with normalization of thyroid-stimulating hormone.

Conclusion

Hypothyroidism can present as renal insufficiency, proteinuria, and can mimic rhabdomyolysis. Prompt initiation of thyroxine treatment and control of thyroid-stimulating hormone levels could reverse these changes.

Untreated primary hypothyroidism with simultaneous rhabdomyolysis, pericardial effusion, and sudden sensorineural hearing loss: a case report

BACKGROUND

Hypothyroidism, one of the prevalent endocrine disorders worldwide, has a broad spectrum of clinical manifestations, from an asymptomatic condition to myxedema coma. Although the majority of patients with hypothyroidism have minor clinical symptoms, which are recovered with levothyroxine treatment, some patients occasionally do experience fatal complications. Here we report, for the first time, the case of a patient who had hypothyroidism with simultaneous occurrence of rhabdomyolysis with acute kidney injury, moderate pericardial effusion, and sudden sensorineural hearing loss.

CASE PRESENTATION

A 57-year-old man with a previous history of dyslipidemia and untreated hypothyroidism was admitted to the hospital due to shortness of breath, lethargy, lower extremity discomfort, and unilateral hearing loss. Laboratory results revealed rhabdomyolysis with acute kidney injury and severe hypothyroidism. We detected cardiomegaly without lung parenchymal infiltration on chest radiography and moderate pericardial effusion on transthoracic echocardiography. We performed pure tone audiometry and identified profound unilateral sensorineural hearing loss. Aggressive fluid resuscitation, levothyroxine treatment, and systemic and intratympanic steroid therapy alleviated the patient's severe hypothyroidism, rhabdomyolysis, and pericardial effusion; however, sensorineural hearing loss was not fully recovered.

CONCLUSIONS

Early recognition of life-threatening complications is important in patients with severe hypothyroidism to prevent adverse outcomes. This case suggests that hypothyroidism should be considered in patients who have rhabdomyolysis with acute kidney disease and pericardial effusion. Moreover, sudden sensorineural hearing loss should be kept in mind as a rare complication of hypothyroidism.

Rhabdomyolysis in a patient complicated with hypopituitarism and multiple organ dysfunction syndrome and the literature review

INTRODUCTION

Muscular symptoms, including stiffness, myalgia, cramps, and fatigue, are present in the majority of the patients with hypopituitarism, adrenal insufficiency and hypothyroidism, but rhabdomyolysis, the rapid breakdown of skeletal muscle, is a rare manifestation. In most patients who develop rhabdomyolysis, precipitating factors, such as strenuous exercise or use of lipid-lowering drugs, can be identified.

CASE REPORT

We report the case of a 23-year-old male with primary hypopituitarism who developed acute renal impairment (AKI) with rhabdomyolysis after strenuous physical activity (push-ups). His blood test confirmed marked hypopituitarism. Severe elevation of serum CK consistent with rhabdomyolysis was noted and an elevated creatinine indicated AKI and multiple organ dysfunction syndrome (MODS). Patient's condition improved significantly after continuous renal replacement therapy (CRRT), glucocorticoid hormone replacement therapy and aggressive hydration. MODS with rhabdomyolysis in patients with hypothyroidism is quite rare and we expect that this case report adds to the existing literature on this subject. We also emphasize that thyroid and adrenal gland status should be evaluated in patients with unexplained AKI, MODS and presenting with the symptoms of muscle involvement.

LITERATURE REVIEW

We respectively reviewed 23 patients with hypopituitarism, adrenal Insufficiency and hypothyroidism induced rhabdomyolysis who were involved in the past 40 years relevant literatures.

CONCLUSION

We report a successfully treated case of rhabdomyolysis, which is a rare but potentially serious complication of hypopituitarism. Screening for endocrine abnormality in patients with elevated muscle enzymes should be considered, since an early diagnosis and prompt treatment is essential to prevent rhabdomyolysis and its consequences.