Myxedema ascites: case report and literature review

Etiology and Outcomes in Patients With Chronic Kidney Disease and Ascites

Introduction Nephrogenic ascites is an uncommon disorder associated with grave prognosis. Studies on etiopathogenesis and outcomes are scarce. This study aimed to identify the etiologies of ascites in patients with chronic kidney disease (CKD) and estimate the proportion of nephrogenic ascites and the 90-day mortality. Methods This was a prospective, observational, and hospital-based study. Consecutive patients with CKD admitted to a tertiary care government teaching hospital were recruited. History, examination, investigations, and evaluation of the etiology of ascites were performed. Ascites was classified into high and low serum albumin-ascites gradient types. Patients with ascites were also followed up for three months to monitor for worsening symptoms, further workup (if necessary), and mortality. Results A total of 355 patients were recruited, with 72.5% being males. Of these, 76 were newly diagnosed with CKD. The most common comorbidities were diabetes mellitus and hypertension. Forty patients had ascites with a mean duration of CKD and hemodialysis of 20.9±23.1 months and 9.3±15.5 months, respectively. Thirteen of the 40 patients with ascites were lost to follow-up. Among the remaining 27, 13 died during follow-up. A known etiology was seen in 29 of the 40 (72.5%) patients. The multiple etiologies group (any combination of cardiac or liver disease, malignancy, and hypothyroidism) constituted 21 patients. Overall, among the 40 patients with ascites, 11 (27.5%) had nephrogenic ascites of whom, four died during follow-up. Conclusions Nephrogenic ascites was observed in 11 patients. Most patients with ascites in CKD have an identifiable etiology. The prognosis of ascites in patients with CKD in our study was dismal.

Ascites, Pleural, and Pericardial Effusion in Primary Hypothyroidism: A Rare Case Report

Hypothyroidism is caused by a deficiency of thyroid hormones and is a common endocrine disorder worldwide. It can affect nearly every organ, resulting in multiple clinical manifestations. Ascites, pleural effusion, and pericardial effusion, although less frequent than peripheral edema, can also be present. These manifestations are thought to be caused by increased vascular permeability to albumin, extravasation of mucopolysaccharides, and inappropriate antidiuretic hormone secretion. Most effusions in hypothyroid patients resolve with thyroxine replacement therapy. However, due to the insidious and nonspecific nature of these symptoms, hypothyroidism is seldom considered a differential diagnosis. We report a case of a 48-year-old male with pericardial effusion, pleural effusion, and ascites due to primary hypothyroidism. Although isolated effusions can be frequent in patients with hypothyroidism, the presentation of Hashimoto's thyroiditis as a combination of pericardial effusion, pleural effusion, and ascites is extremely rare. With this case report, we highlight the importance of considering hypothyroidism as a possible cause of unexplained polyserositis, even in the absence of other signs and symptoms.

From hormone replacement therapy to regenerative scaffolds: A review of current and novel primary hypothyroidism therapeutics

Primary hypothyroidism severely impacts the quality of life of patients through a decrease in the production of the thyroid hormones T3 and T4, leading to symptoms affecting cardiovascular, neurological, cognitive, and metabolic function. The incidence rate of primary hypothyroidism is expected to increase in the near future, partially due to increasing survival of patients that have undergone radiotherapy for head and neck cancer, which induces this disease in over half of those treated. The current standard of care encompasses thyroid hormone replacement therapy, traditionally in the form of synthetic T4. However, there is mounting evidence that this is unable to restore thyroid hormone signaling in all tissues due to often persistent symptoms. Additional complications are also present in the form of dosage difficulties, extensive drug interactions and poor patience compliance. The alternative therapeutic approach employed in the past is combination therapy, which consists of administration of both T3 and T4, either synthetic or in the form of desiccated thyroid extract. Here, issues are present regarding the lack of regulation concerning formulation and lack of data regarding safety and efficacy of these treatment methods. Tissue engineering and regenerative medicine have been applied in conjunction with each other to restore function of various tissues. Recently, these techniques have been adapted for thyroid tissue, primarily through the fabrication of regenerative scaffolds. Those currently under investigation are composed of either biopolymers or native decellularized extracellular matrix (dECM) in conjunction with either primary thyrocytes or stem cells which have undergone directed thyroid differentiation. Multiple of these scaffolds have successfully restored an athyroid phenotype in vivo. However, further work is needed until clinical translation can be achieved. This is proposed in the form of exploration and combination of materials used to fabricate these scaffolds, the addition of peptides which can aid restoration of tissue homeostasis and additional in vivo experimentation providing data on safety and efficacy of these implants.

Myxedema ascites complicated by ischemic colitis

Myxedema Ascites is a rare finding of primary hypothyroidism, thereby leading to delayed diagnosis. However, prompt treatment with levothyroxine leads to complete resolution of the condition. We present a rare case of myxedema ascites in an elderly female and highlight the importance of early diagnosis and management. We also present ischemic colitis in the same patient, which has not been reported thus far in literature as a complication of myxedema ascites.

Gastrointestinal Manifestations of Systemic Diseases in Critically Ill

Systemic disorders can have gastrointestinal (GI) manifestations which are characterized by nausea, vomiting, diarrhea, constipation, abdominal pain, jaundice, and abnormal liver function tests. These gastrointestinal symptoms can be signs of various immunologic, infectious, and endocrine diseases. Gastrointestinal manifestations can be the first signs and symptoms for which the patient can be admitted in a critical care unit. In this article, we will discuss the GI manifestations of various topical diseases, endocrine diseases, and immunological diseases which are the major bulk of patients in intensive care unit (ICU).

How to cite this article: Panigrahy AK, Srinivasan S. Gastrointestinal Manifestations of Systemic Diseases in Critically Ill. Indian J Crit Care Med 2020;24(Suppl 4):S190–S192.

Myxedema Ascites: An Unusual Presentation of Uncontrolled Hypothyroidism

We describe a case of myxedema ascites in a 64-year-old male with a history of hypothyroidism noncompliant with medical therapy who presented with syncope, hematemesis, melena, and abdominal distension. The patient received intravenous levothyroxine with a good response and improved upon discharge. This case highlights the importance of considering hypothyroidism as an etiology of unexplained ascites. The analysis of ascites from myxedema may not always have a significantly elevated protein (>2.5g/dL). Appropriate diagnosis should also rely on the clinical presentation along with a rapid and positive response to thyroid hormone replacement therapy.

Myxedema Ascites: A Rare Presentation of Uncontrolled Hypothyroidism

Less than four percent of patients with hypothyroidism develop ascites. Ascites as the presenting feature of hypothyroidism is uncommon, hence diagnosis is often delayed. Once it is diagnosed, treatment of hypothyroidism leads to quick clinical improvement in ascites. We report a case of a female patient who presented with ascites secondary to severe hypothyroidism and discuss the diagnostic characteristics of the ascitic fluid in myxedema ascites on the basis of literature review.

Thyroid disorders and gastrointestinal and liver dysfunction: A state of the art review

Thyroid disorders commonly impact on the gastrointestinal system and may even present with gastrointestinal symptoms in isolation; for example, metastatic medullary thyroid carcinoma typically presents with diarrhoea. Delays in identifying and treating the underlying thyroid dysfunction may lead to unnecessary investigations and treatment, with ongoing morbidity, and can potentially be life-threatening. Similarly, gastrointestinal diseases can impact on thyroid function tests, and an awareness of the concept and management of non-thyroidal illness is necessary to avoid giving unnecessary thyroid therapies that could potentially exacerbate the underlying gastrointestinal disease. Dual thyroid and gastrointestinal pathologies are also common, with presentations occurring concurrently or sequentially, the latter after a variable time lag that can even extend over decades. Such an association aetiologically relates to the autoimmune background of many thyroid disorders (e.g. Graves' disease and Hashimoto's thyroiditis) and gastrointestinal disorders (e.g. coeliac disease and inflammatory bowel disease); such autoimmune conditions can sometimes occur in the context of autoimmune polyglandular syndrome. Emphasis should also be given to the gastrointestinal side effects of some of the medications used for thyroid disease (e.g. anti-thyroid drugs causing hepatotoxicity) and vice versa (e.g. interferon therapy causing autoimmune thyroid dysfunction). In this review, we discuss disorders of the thyroid-gut axis and identify the evidence base behind the management of such disorders.

Clinical significance of diffuse intrathoracic uptake on post-therapy I-131 scans in thyroid cancer patients

PURPOSE

The purpose of this study was to identify the frequency and possible cause of diffuse intrathoracic uptake on post-therapy I-131 scans in thyroid cancer patients.

METHODS

We retrospectively reviewed 781 post-therapy scans of 755 thyroid cancer patients who underwent total thyroidectomy and radioactive iodine therapy between January and December 2010. Diffuse intrathoracic uptake on post-therapy scans was examined, and clinical patient characteristics including sex, age, regimen for thyroid-stimulating hormone (TSH) stimulation (thyroid hormone withdrawal or recombinant human TSH injection), TSH, thyroglobulin (Tg) and anti-thyroglobulin antibody (anti-Tg Ab) levels, therapeutic dose of radioactive iodine therapy and prior history of radioactive iodine therapy were recorded.Scan findings were correlated with chest CT, chest radiographs, laboratory tests and/or clinical status. Diffuse intrathoracic uptake without evidence of pathologic condition was categorized as indeterminate. The association between clinical characteristics and intrathoracic uptake were analyzed for negative intrathoracic uptake and indeterminate uptake groups.

RESULTS

Diffuse intrathoracic uptake on post-therapy scans was demonstrated in 39 out of 755 (5.2 %) patients, among which 3 were confirmed as lung metastasis. The 14 patients that showed high Tg or anti-Tg Ab levels were considered to be at risk of having undetected micrometastasis on other imaging modalities. The remaining 22 were indeterminate (2.9 %).Upon comparison of negative intrathoracic uptake and indeterminate uptake groups, TSH stimulation by thyroid hormone withdrawal was shown to be significantly correlated with diffuse intrathoracic uptake (p < 0.05).

CONCLUSION

The frequency of diffuse intrathoracic uptake on post-therapy scans was 5.2 % and could be seen in thyroid cancer patients with underlying lung metastasis as well as those without definite pathologic condition. In the latter, there was a higher frequency for diffusely increased intrathoracic uptake in those who underwent thyroid hormone withdrawal rather than recombinant human TSH injection.

Subclinical hypothyroidism unmasked by preeclampsia and ascites

Subclinical hypothyroidism is an asymptomatic endocrine disorder while hypothyroidism, on the other hand, can present with a wide range of clinical features which may be nonspecific. We describe a case of subclinical hypothyroidism in a 39-year-old pregnant woman presenting with preeclampsia and ascites. Ascitic fluid was found to be exudative as typically found in persons with hypothyroidism presenting with ascites. Treatment with levothyroxine resulted in complete resolution of ascites. The possibility of subclinical and clinical hypothyroidism should be borne in mind when persons with refractory exudative ascites of unknown origin are being investigated. Also, pregnant women with severe preeclampsia will benefit from screening for subclinical and clinical hypothyroidism.

Intra-abdominal hypertension in patients with sellar region tumors

Background

Data on intra-abdominal hypertension [IAH] and secondary abdominal compartment syndrome [ACS] due to neurological insults are limited.

Methods

This was a prospective observational study conducted between January 2010 and January 2011 in the neurological ICU [NICU]. Forty-one consecutive patients with sellar region tumors [SRT] were enrolled into the study. If conservative therapy was ineffective in patients with ACS, thoracic epidural anesthesia [EA] was performed. Primary endpoint was defined as the efficacy of conservative treatment and EA in patients with IAH and ACS; secondary endpoint, the influence of IAH and ACS on outcomes.

Results

Of the 41 patients, 13 (31.7%) had normal intra-abdominal pressure and 28 (68.3%) developed IAH, of whom 9 (22%) had ACS (group II). On average, IAH developed on the second postoperative day, while ACS, between the third and the fifth day. Multiple organ dysfunction developed in 3 (23.1%) patients of group I and in 23 (82%) patients of group II (p = 0.0003). Ileus due to gastrointestinal dysmotility was present in 6 (46.2%) patients of group I and in all patients of group II (p = 0.0001). Significant risk factors for ileus were diencephalon dysfunction (whole group - in 33 patients (80.5%); group I - in 6 patients (46.2%); group II - in 27 patients (96.4%), p = 0.0002) and sepsis (whole group - in 8 patients (19.5%); group I - no cases; group II - in 8 patients (28.6%), p = 0.03). Conservative treatment was effective in the majority of patients (78.9%) with IAH and only in 3 (33%) patients with ACS. Thoracic EA was performed in four patients with ACS with success. Length of stay in the NICU was 6.5 ± 4.6 days in group I and 24.1 ± 25.7 (p = 0.02) days in group II. Five out of nine (55.6%) patients with ACS died. None of these patients received EA. All patients with EA had favorable outcomes.

Conclusion

The development of IAH is common after SRT surgery. If conservative treatment is ineffective, EA can be considered in patients with secondary ACS. Further studies are warranted.

Thyroid emergencies

This review presents current knowledge about the thyroid emergencies known as myxedema coma and thyrotoxic storm. Understanding the pathogenesis of these conditions, appropriate recognition of the clinical signs and symptoms, and their prompt and accurate diagnosis and treatment are crucial in optimizing survival.

Respiratory failure with myxedema ascites in a patient with idiopathic myxedema

Here we report the case of a 50-year-old woman presenting with weight gain, whole-body edema, and massive ascites. Blood examination revealed primary hypothyroidism with TSH-blocking antibody, and the echocardiogram showed diffuse hypokinesis of the left ventricle with pericardial effusion. Although she received thyroid hormone replacement therapy immediately, her ascites increased and she developed type II respiratory failure requiring transient noninvasive positive pressure ventilation (NIPPV). She recovered following the temporary drainage of the ascites, administration of diuretics, and continuous thyroid hormone replacement. The amount of ascites decreased during therapy, along with an increase in thyroid hormone levels. Finally, the ascites disappeared completely, followed by the normalization of the cardiac wall motion. Herein we report this rare case in detail, and also discuss the mechanism by which primary hypothyroidism induced such severe conditions in our patient.

[Role of the endocrine system in the pathogenesis of non-alcoholic fatty liver disease]

The most frequent liver disorder in metabolic syndrome is the nonalcoholic fatty liver disease. Its pathogenesis is a complex, multifactorial process, characterized by insulin resistance and involvement of the endocrine system. Hypothyroidism may lead to nonalcoholic steatohepatitis via hyperlipidemia and obesity. Adult patients with growth hormone deficiency have a metabolic syndrome-like phenotype with obesity and many characteristic metabolic alterations. The chronic activation of the hypothalamic-pituitary-adrenal axis results in metabolic syndrome as well. Cushing's syndrome has also features of metabolic syndrome. Mild elevation of transaminase activities is commonly seen in patients with adrenal failure. Non-alcoholic steatosis is twice as common in postmenopusal as in premenopausal women and hormonal replacement therapy decreases the risk of steatosis. Insulin resistance, diabetes mellitus type 2, sleeping apnoe syndrome, cardiovascular disorders and non-alcoholic fatty liver disease are more frequent in polycystic ovary syndrome. Hypoandrogenism in males and hyperandrogenism in females may lead to fatty liver via obesity and insulin resistance. Adipokines (leptin, acylation stimulating protein, adiponectin) have a potential role in the pathogenesis of nonalcoholic fatty liver. The alterations of endocrine system must be considered in the background of cryptogenic liver diseases. The endocrine perspective may help the therapeutic approaches in the future.

Consequences of dysthyroidism on the digestive tract and viscera

Thyroid hormones define basal metabolism throughout the body, particularly in the intestine and viscera. Gastrointestinal manifestations of dysthyroidism are numerous and involve all portions of the tract. Thyroid hormone action on motility has been widely studied, but more complex pathophysiologic mechanisms have been indicated by some studies although these are not fully understood. Both thyroid hormone excess and deficiency can have similar digestive manifestations, such as diarrhea, although the mechanism is different in each situation. The liver is the most affected organ in both hypo- and hyperthyroidism. Specific digestive diseases may be associated with autoimmune thyroid processes, such as Hashimoto’s thyroiditis and Grave’s disease. Among them, celiac sprue and primary biliary cirrhosis are the most frequent although a clear common mechanism has never been proven. Overall, thyroid-related digestive manifestations were described decades ago but studies are still needed in order to confirm old concepts or elucidate undiscovered mechanisms. All practitioners must be aware of digestive symptoms due to dysthyroidism in order to avoid misdiagnosis of rare but potentially lethal situations.

Endocrine and liver interaction: the role of endocrine pathways in NASH

This article reviews evidence that causally links hormonal disorders with hepatobiliary disease, and gives particular focus to nonalcoholic steatohepatitis (NASH). The downstream mechanisms by which endocrine disturbances cause liver disease might be similar to those involved in the development of primary liver disease. Hypothyroidism, for example, might lead to NASH, cirrhosis and potentially liver cancer via the development of hyperlipidemia and obesity. Patients with growth hormone deficiency have a metabolic-syndrome-like phenotype that is also associated with the development of NASH. Polycystic ovary syndrome is a common endocrine disorder that is often associated with insulin resistance, the metabolic syndrome, altered levels of liver enzymes and the development of NASH. Recent findings support a role of dehydroepiandrosterone sulfate deficiency in the development of advanced NASH. In addition, adrenal failure is increasingly reported in patients with end stage liver disease and in patients who have received a liver transplant, which suggests a bidirectional relationship between liver and endocrine functions. Clinicians should, therefore, be aware of the potential role of endocrine disorders in patients with cryptogenic liver disease and of the effects of liver function on the endocrine system.

Endocrine and liver interaction: the role of endocrine pathways in NASH

This article reviews evidence that causally links hormonal disorders with hepatobiliary disease, and gives particular focus to nonalcoholic steatohepatitis (NASH). The downstream mechanisms by which endocrine disturbances cause liver disease might be similar to those involved in the development of primary liver disease. Hypothyroidism, for example, might lead to NASH, cirrhosis and potentially liver cancer via the development of hyperlipidemia and obesity. Patients with growth hormone deficiency have a metabolic-syndrome-like phenotype that is also associated with the development of NASH. Polycystic ovary syndrome is a common endocrine disorder that is often associated with insulin resistance, the metabolic syndrome, altered levels of liver enzymes and the development of NASH. Recent findings support a role of dehydroepiandrosterone sulfate deficiency in the development of advanced NASH. In addition, adrenal failure is increasingly reported in patients with end stage liver disease and in patients who have received a liver transplant, which suggests a bidirectional relationship between liver and endocrine functions. Clinicians should, therefore, be aware of the potential role of endocrine disorders in patients with cryptogenic liver disease and of the effects of liver function on the endocrine system.