52-Year-Old Woman With Hypotension, Hypothyroidism, and Hyponatremia

Abstract

Resident in Internal Medicine (C.H.B.) and Fellow in Cardiovascular Diseases (A.M.K.), Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN; Advisor to resident and fellow and Consultant in Primary Care Internal Medicine, Mayo Clinic, Rochester, MN (A.C.G.). A 52-year-old woman with hypothyroidism presented to the emergency department with nausea, malaise, and hyponatremia. Her illness had begun 3 months previously with increasing generalized weakness, fatigue, insomnia, bilateral carpal tunnel syndrome requiring surgical release, and decreased appetite with a corresponding weight loss of 8 kg. At that time, her thyroid-stimulating hormone (TSH) level was 8.0 mIU/L (reference range, 0.3-5.0 mIU/L), so her physician increased her levothyroxine dosage from 75 mg/d to alternating daily doses of 75 mg and 88 mg. Her symptoms had accelerated during the past 2 weeks and now included constipation, worsening exercise tolerance, and vomiting. She noted that most women in her family have hypothyroidism and that her daughter had just been diagnosed as having granulomatosis with polyangiitis. The patient did not smoke tobacco, drink alcohol, or use illicit drugs, had never been incarcerated, had no sick contacts, and had not traveled outside her home state in the Midwest. Because her symptoms had not improved despite treatment during the past 3 months and now had worsened, she sought evaluation in the emergency department. On admission, her temperature was 37 C, and she had orthostatic vital signs. Her supine, sitting, and standing blood pressure and heart rate were 108/68 mm Hg and 79 beats/min, 88/71 mm Hg and 105 beats/min, and 64/39 mm Hg and 64 beats/min, respectively. She was alert and oriented and had a slender body habitus. Her mucous membranes were moist, but she appeared slightly volume depleted because jugular venous pulsations were not visible on examination despite manual pressure applied to her abdomen. Cardiothoracic, neurologic, thyroid, and abdominal examinations yielded normal findings. Her skin appeared slightly hyperpigmented, but there was no buccal or palmar crease hyperpigmentation.