20F HYPOTHYROIDISM 20YRS(SINCE BIRTH) MADHYA PRADESH PaJR.
This is an online E Log book to discuss our patients de-identified health data shared after taking her signed informed consent. Here we discuss our patient's problems through series of inputs from available global online community experts with an aim to solve those patients clinical problems with collective current best evidence based inputs.
To begin with the 20F is a case of congenital hypothyroidism since birth. The patient is suffering with severe headache since 2012. She also has anxiety disorders which continue for one whole day or may subside after a few hours. The patient is also suffering with hair loss and pain in the scalp.
If we go into the past of this patient and another patient with the same problem of congenital hypothyroidism, the outcome of these two cases of late diagnosis is given below.
OUTCOME OF TWO CASES WITH LATE
DIAGNOSIS OF CONGENITAL HYPOTHYROIDISM. A CASE REPORT.
Composite of Regional Centre for Persons With Disabilities, Department of Disability Affairs, Ministry of Social Justice and Empowerment, Government of India,
Punarvas Bhavan, Khajuri Kalan, Pilani,
Bhopal- 462022.
AUTHOR FOR CORRESPONDENCE
ABSTRACT
Two girls with hypothyroidism followed up at our Centre are presented. The time of diagnosis, Institution of Medical Management and Therapeutic Inputs are compared with the outcome in their growth and development. While early identification and Thyroxine Supplementation from the core management strategy, this case study emphasizes how Therapeutic inputs of Composite nature improve the outcome in cases of congenital hypothyroidism.
KEYWORDS
Congenital Hypothyroidism, Thyroxine, Child Development, Early Diagnosis.
INTRODUCTION
Early diagnosis and treatment can prevent disability arising due to congenital hypothyroidism. Health policies in developing countries have taken successful steps to prevent hypothyroidism through ionization of edible salt. However they are lagging in screening for C.H, which should be given equal importance, just like universal immunization for any child.
CASES
PRESENTING CONCERNS
Two girls of different ages reported at Composite Regional Centre for Persons with Disabilities (CRC), Bhopal at different times.
The presenting concerns were stunted growth and delay in speech.
CLINICAL FINDINGS
CASE
A one and half year old girl was brought to CRC Bhopal in Yr 2004 by her mother with presenting complaint of delayed speech.
She was from lower socioeconomic status with 3 elder siblings having normal developmental history and was staying in a nuclear family. Her height was 67cm(below 10 percentile for age), had rough skin and lanugo hair. Her Serum TSH level was 87 IU /ml.
Indian Journal of Medical Case Reports
ISSN: 2319-3832 (online) An open access, Online International Journal available at
http://wwwcibtech.org/jcr.htm 2014 vol 3
(3) July- Sep. PP. 3-5/Joshi and Joshi.
CASE REPORT
Diagnostic Focus and Assessment
The developmental delay, stunted growth, facial features and raised TSH pointed to
Congenital hypothyroidism. The diagnosis was confirmed from pediatrician and endocrinologist. The main challenge was the delay in instituting Thyroxine supplementation.
Therapeutic Focus and Assessment
The patients were started with Tab.levo-
Thyroxine 50 micrograms daily once in Early morning on empty stomach. Comprehensive developmental therapy services were provided at this Centre with occupational and speech therapy. The caretakers were counselled for regular Thyroxine supplements and developed therapy.
FOLLOW UP AND OUTCOMES
Thyroxine dose was adjusted according to clinical response and TSH level in both cases. Clinical Psychology for behavior management and special education for school readiness were provided at CRC Bhopal.
CASE
She had fever and Tachycardia intermittently that was managed by reducing dose of Thyroxine. Presently at the age of 10yrs she has attained 140cm height, 33 kg weight , IQ- 55, speaks and walks well and is attending 2nd standard in a normal school.
PATIENT PERSPECTIVE
CASE
The mother is happy with normal growth of the patient but is anxious about her school performance.
CONCLUSION
We conclude that rehabilitation medicine inputs with Thyroxine Supplementation should be instituted as soon as possible in cases of congenital hypothyroidism. It is high time to implement active case identification, treatment and rehabilitation of congenital hypothyroidism for all infants so that children achieve maximum potential of development and growth.
Informed consent- Obtained
Competing interests- Nil
Ethics approval - The authors followed the guidelines of WMA Declaration of
Helsinki.
De-identification- Yes.
REFERENCES
DGHS, MoHFW, GOI (2006). Revised Policy Guidelines on National Iodine Deficiency Disorder Control Programe. NRHMIDD and Nutrition Cell. Gu X et.al., (2008). Newborn screening in China- Phenylketonuria congenital hypothyroidism and expanded screening.
Annals Academy of Medicine. Singapore
37(Suppl 3) 107-10.
Olney RS. Grosse SD and Vogt RF(2010).
Prevalence of congenital hypothyroidism-
Current trends and future directions:
Workshop Summary. Pediatrics 125(Suppl.2) S 31-36
Virginity A et.al., (1989). Profile of thyroid disorders in a referred Centre in North India. Indian Pediatrics 26(3) 265-9.
18-09-2024
PA- The patient is taking 125mcg Thyronorm.
PPM 2- Since when?
PA- From June 26, the patient is taking 125mcg Thyronorm.
Recurring complaints of Headache, Sweating, Palpitations and Fear of death.
PPM 2
1. Please share the patient's problems (present and past since birth).
2. The pattien's 24 hr activities.
3. Which activity did the patient find painful like being awake, sleeping, studying, playing, eating or other activities.
4. What is the primary requirement of her health issues? Pain relief, relief from fear or to have a good sleep.
PA- The patient is suffering with severe headache.
PPM 1- Since when, how many years does the patient have headache?
PA- The patient is suffering with this problem since 2012.
PPM 1- Since 2012 how frequently has she experienced this headache? Does it happen once every 6 months or in weeks or in days? Once the headache starts how long does it last?
PA- The patient feels anxiety or nervousness and suddenly gets relief. Sometimes it continues for one day.
PPM 2- The doctor has prescribed Naprosyn if the pain is severe.
PA- Okay thanks.
PPM 2- Don't take on empty stomach.
23-09-2024
PPM 2- How is the patient's headache?
PPM 1- We may need to start her on a prophylactic to reduce the frequency and duration of her headache. But before that we need some detailed history regarding the frequency and duration of her headache. What routine hourly activities could she accomplish yesterday inspite of her headache and what routine activities suffered yesterday because of her headache?
PA- Doctor, the headache is unbearable and doesn't allow anything to be done. It is so severe that it cannot be explained.
26-09-2024
PA- The patient is complaining of hair loss and thinning. Sometimes she feels pain in the scalp.
27-09-2024
PPM 1- Best evaluation of hair loss is if the patient can count the number of hairs lost each day.
@Meta AI what's the best way to evaluate hair loss?
Meta AI:- Evaluating hair loss involves a combination of Medical history, physical examination, and Diagnostic tests.
Here's a comprehensive approach:
Medical History:
1. Duration and Progression of hair loss.
2. Family history of hair loss.
3. Medical Conditions (eg., Thyroid Disorders, Autoimmune Diseases).
4. Medications (eg., Chemotherapy, Harmonal Therapies).
5. Hairstyling habits (eg., Tight hairstyles, heat styling).
6. Nutritional Deficiencies (eg., Iron, Zinc, Biotin).
Physical Examination:
1. Pattern of hair loss (eg., Male/Female pattern baldness, Alopecia Areata).
2.Hair Density and Thickness
3. Scalp Conditions (eg., Dandruff, Psoriasis).
4. Hair Shaft Abnormalities (eg., Brittle, Broken Hairs).
Diagnostic Tests
1. Pull Test: Gentle hair pulling to assess shedding.
2. Pluck Test: Examining hair roots for growth patterns.
3. Trichoscopy: Digital Microscopy for hair and scalp analysis.
4. Blood Tests: Thyroid function (TSH, free T4)
- Iron levels (ferritin)
- Zinc and Biotin levels.
- Autoimmune disease markers (eg., ANA)
5. Scalp Biopsy (rarely needed).
Classification Systems.
1. Norwood- Hamilton Scale (male pattern baldness.
2. Ludwig Scale (Female pattern hair loss)
3. Savin Scale (Female pattern hair loss).
Additional Tools
1. Hair Diameter Measurement
2. Hair Growth Tracking (eg., With photography).
3. Trichogram (Hair growth analysis).
Consult a dermatologist or health care professional for personalized evaluation and guidance.
PPM 1- @Meta AI What is the sensitivity specificity of hair count in monitoring hair loss? Please substantiate your reply with valid references.
Meta AI:- Evaluating hair loss involves various methods and hair count is one of them. However it's sensitivity and specificity are not explicitly stated in the available literature.
Hair count is part of non invasive methods used for Evaluating hair loss, including daily hair counts, standardized wash tests and 60 sec hair counts. 1.
These methods are valuable for patient diagnosis and monitoring but have limitations.
For accurate diagnosis and monitoring health care professionals use a combination of methods, such as Global Photography: Taking pictures of the scalp to track changes over time.2.
Trichoscopy:- Using a digital microscope to analyze hair and scalp Conditions.1.
Scalp Biopsy:- Examining scalp tissue to diagnose underlying Conditions.3.
Hair weight management: Measuring hair weight to track changes.2.
These methods provide a more comprehensive understanding of hair loss and are used in conjunction with hair count for monitoring. If you are experiencing hair loss, consult a dermatologist for personalized guidance and diagnosis. They'll recommend the most suitable evaluation methods for your specific situation.
References 1 2 3.
Hair evaluation methods
Merits and Demerits.
pubmed.ncbi.nih.gov.
30-09-2024
PA- The patient is suffering with hair loss and pain in the scalp.
PPM 1- Where is the pain , the patient is suffering?
PPM 2- Hair loss after injection on scalp to treat headache. It was given 1yr ago.
PPM 1- What injection? Where?
PPM 2- The prescription is lost . The Neurologist perhaps gave steroid injection around occipital nerve on right side at 2 points on the scalp.
PPM 1- What diagnosis would have made him give scalp steroids?
PPM 3- Alopecia Areata or Psoriasis.
PPM 2- Steroids not sure. For headache only.
PPM 1- Yes it is generally commonly indicated only for such scalp inflammatory Conditions.
PPM 2- Prescription is missing. Neurologist doesn't deal with these.
PPM 3- I thought the hair loss and the pain in scalp was the reason for steroids and not the other way round. My apologies.
PPM 2- No never complained of this. Areata not visible in the picture.
03-10-2024
PPM 2- Please send the prescription of the steroid injection. The injection was given on 19-08-2023 by Neurologist. It caused increased pain for a day. Perhaps steroid around greater/lesser occipital nerve.
PPM 1- No mention of injection in the prescription. Is he the son of the previous HoD Dr. Dubey?
PPM 2- Injection was written on small chit separately.
05-10-2024
PPM 2- Can the patient advocate count the numbers of hair fall? So that we can compare the previous and the present hair fall.
PPM 4 - Hello Sir, I am currently in Bangalore doing my DM 2nd Yr residency in Endocrinology. I will see the case details and get back to you.
PPM 1 - Where in Bangalore? Would you recommend anyone in Bhopal who would like to review this patient and share his or her inputs with the team here?
PPM 2 - This is a wish come true for our patient. God is great.....
PPM 4 - I am at M S Ramaiah Medical College and Hospital. In Bhopal I believe residents under the guidance of Dr. Sushil Jindal Sir at People's Hospital can take care of these patients.
PPM 2 - Someone residing near Bhopal Railway station would be preferable. Dr.Sushil Jindal has seen her in People's Hospital. The patient is currently under the care of Dr.Somnath, GMC Bhopal.
17-10-2024
PPM 2 - @PPM 1 Sir, is it possible to arrange this family adoption by local MBBS students with the new NMC Policy?
Prominent cricoid due to absence of thyroid gland.🤔
Short fingers, severe loss of hair. Need advice 🙏
Started using Minoxidil lotion.
Height 4'11"
Weight 60.
PA - Sir the patient is suddenly feeling anxiety and nervousness while writing and is not feeling to do anything. Earlier she had this episode of anxiety and missed her exam. The patient experiences this problem of anxiety for no reason and becomes unconscious.
PPM 1 - Yes a PaJR for every patient in every family is a family adoption tool. Unable to see any clinical images of the same.
PPM 2 - Can't appreciate because earlier comparison is not available. It was told that hair was so dense that comb did not reach deep. Now the braided hair is very thin and short. The lost hair was shown. It can fill a small pillow.
@PA please share the patient's 24hrs activities hourly.
The patient is complaining of fear, Palpitations and unable to concentrate. Loss of consciousness sometimes
@PPM 1.
PPM 1 - Lost hair collection over 1 day?
Anxiety symptoms.
PPM 2 - No. Over a week perhaps.
PPM 1 - Yes we need to correlate her hourly work activities with her symptoms.
@Meta AI What is the normal hair loss count for every 24hrs and over one week?
Would the resulting volume of normal hair loss be adequate enough to cover an entire pillow?
Meta AI- The normal hair loss count varies from person to person, but here are some guidelines.
Daily hair loss: On average a healthy person loses around 50- 10 hairs per day. This is a normal part of hair growth cycle, where old hairs fall out and new ones grow
In.
Weekly hair loss: Over a 7 day period, you can expect to lose around 350 - 700 hairs.
Hair loss volume: Now let's estimate the volume of hair loss. Assuming an average hair length of 20-30cm(8-12 inches) and a hair Thickness of 0.07 mm(average human hair diameter). We can calculate the volume of hair lost.
Let's use the higher end of the daily hair loss estimate (100hairs) for simplicity.
Daily volume 100 hairs *20cm(length)
*0.007 mm(thickness)~ 1.4cm3(or 0.14mL)
Weekly volume- 700 hairs *20 cm(length)
*0.07mm(thickness)~9.8cm3(or 0.98mL)
To put this volume into perspective a standard pillow is approximately 50cm×30cm×10cm(19.7inches×
11.8 inches×3.9 inches)
The volume of hair lost in a week could cover an area of about:
Area covered : 9.8 cm3/150cm2
(Pillow surface area) ~0.0065% of the pillow surface. So would the resulting volume of normal hair loss cover an entire pillow? No, not even close! The volume of hair lost in a week would barely cover a small coin!
Keep in mind that these estimates vary depending on individual factors. Such as
•Hair length
•Thickness
•Growth rate
•Genetics
•Age
•Health Conditions.
•Hair care habits
If you are concerned about excessive hair loss, consult a dermatologist or health care professional for personalized advice. Hope this helps!
PPM 1- Cosmetic issue?
PPM 2 - Not expressed but an issue of added anxiety.
22-10-2024
PPM 3 - What dose is she currently on?
PPM 2 - 125mcg. Complaining of Chest pain (heart) and headache (brain) to severe extent.
PPM 3 - Looks Adequate. Any symptoms otherwise?
PPM 2 - Severe episodes of fear, Palpitations, unable to concentrate, loss of consciousness. Wt.60. Prominent cricoid due to absence of thyroid gland.
23-10-2024
PPM 2 - Good to have a modest reduction of dose.
PA - The patient's headache is becoming severe day by day. Even now she is suffering.
PPM 2 - Headache continues. Can take naproxen. Perhaps needs cardiology opinion with ECHO. Please suggest a facility in Bhopal.
PPM 1 - Why
PPM 2 - Recurring Palpitations, fear attacks continue.
PPM 1 - The physician should have been able to deal with her symptoms. If we could get her hourly activities and at what hourly point the symptoms are triggered it would be fairly simple to Crack this mystery.
PPM 2 - The physician gives a few minutes in busy OPD of GMC.
PPM 1 - @ PPM 5 Can you provide a telephonic appointment time for you to assess her symptoms! @ PPM 2 can
you find a physician who can do basic clinical examination and tell us the findings of general examination vitals and cardiovascular and if any clinical signs of hyperthyroidism? @ PPM 4 do you know any such physician in Bhopal among your friends there?
PPM 2 - First let us Crack the ice(ice breaker) by understanding process here.
PPM 1 - 👍 Yes we are unable to communicate with the patient properly here due to our asynchronous stance.
PPM 4 - Hello Sir, from the few messages I saw above she's a case of congenital hypothyroidism on treatment with adequate supplementation (T4 in upper half of normal) with anxiety episodes.
I did like to ask more history and do examination regarding pheo first. Also do cardiovascular examination ECG and ECHO should be the basic work up then.
Considering the poor financial status I'd still advise them to go to some medical college like People's. LN or Chirayu and get properly worked up.
PPM 2 - She has been to People's with Dr.Jindal. Then attending Dr. Somnath at GMC.
PPM 4 - To follow up with same Doctor many patients don't bring old records and get unnecessarily worked up repeatedly without any firm treatment plan.
PPM 1 - 👍 Have you seen both the case reports linked in the description box?
If doctor has ruled out hyperthyroidism as the current case of her symptoms then we need @ PPM 5 or someone else to dig deeper into her anxiety. Can she visit us in NKP here?
PPM 2 - NKP?
PPM 1 - We have had many patients coming here from WB, Chattisgarh, Bhopal, Nepal.
PPM 2 - No, But she can tell.
PPM 1 - We would need to meet her face to face.
PPM 2 - I met.
PPM 1 - Your notes?
16-11-2024
PA - Sir the patient is suffering with severe headache and taking many tablets. Please advise. The headache starts at 4pm and continues till 9.30pm. She is having headache daily despite medicine. 4 - 9.30pm.
PPM 1 - What medication is she currently on?
PA - Naprosyn SOS.
PPM 1 - This won't do. Let her take Tab.Dolo 650 every six hours today for one day and then revert.
PPM 2 - She should stop Naprosyn.
PPM 1 - She also needs a prophylactic!
Tab Amytriptyline 10mg one hour before dinner to continue.
PPM 2 -The patient should take paracetamol 650.
PPM 1 - Every six hours.
PPM 2 - The patient should take Tryptomer 10mg every day one hour before dinner.
22-11-2024
PA - The patient did not start Amitriptyline still. She is experiencing anxiety and stomach pain. Her BP is 136/92.
PPM 1 - 👍Let her start the medicine.
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