SAT-487 Untreated Primary Hypothyroidism Presenting as Pica with Concurrent Hyponatremia and Rhabdomyolysis

Abstract

Background:Psychosis is a rare but known presentation of hypothyroidism, whereas other mental health disorders are less commonly associated. Pica, the consumption of non-nutritive, non-food substances, has not been reported to be associated with hypothyroidism. We describe a case of untreated severe hypothyroidism in which the patient presented with pica that reversed with treatment with levothyroxine.Clinical case:A 65-year-old female with a history of cigarette smoking and chronic marijuana use was brought to the emergency department by family after she was found attempting to eat non-food objects such as pens and a toothbrush. She reported new onset unsteady gait and having frequent falls over the past several months in addition to being increasingly forgetful. She complained of fatigue and reported recent unintentional weight loss, but denied cold intolerance, skin or hair changes, or constipation. On admission, she was noted to be hypothermic with body temperature between 94-95 degrees Fahrenheit. Physical examination was essentially unremarkable with normal thyroid size and reflexes. No pretibial edema was noted. Admission labs showed hemoglobin of 14.0 g/dL with a white cell count of 8000 cells/uL, without evidence of anemia or infection. Sodium was low at 123 mmol/l and creatinine kinase was elevated at 989 U/L which peaked at 1356 U/L during her admission. CT of the head was negative for any acute intracranial process. Further workup was significant for TSH 85.6 mIU/L (0.27-4.20 mIU/L), free T4 <0.1 ng/dL (0.80-1.90 ng/dL), total T4 0.7 mcg/dL (5.1-11.9 mcg/dL), total T3 < 25 ng/dL (76-181 ng/dL), and TPO antibody 416 IU/ml (<9 IU/ml). AM cortisol was 27.0 ug/dL (6.2-19.4 ug/dL) at 8 AM, ruling out hypocortisolemia. The patient had not seen a medical provider in 10 years, had no recent health maintenance, and had no prior known history of thyroid disease. She was given IV fluids and started on oral levothyroxine 100 mcg daily due to the severity of hypothyroidism. Her sodium improved to 130 mmol/l over the next 4-5 days. Mental status returned to baseline with improvement in memory function and in gait and balance. Creatinine kinase trended down to 688 U/L over the next 2 days. She did not exhibit any additional behavior of eating non-food objects during the hospital stay. Patient was diagnosed to have severe hypothyroidism presenting as pica along with hyponatremia and rhabdomyolysis. Patient was discharged on levothyroxine 75 mcg daily.Clinical lessons/conclusions:Hyponatremia, rhabdomyolysis, and psychosis are relatively uncommon but known reported complications of untreated primary hypothyroidism. Acute psychosis has been reported as a presenting feature of undiagnosed hypothyroidism, but hypothyroidism presenting as pica as seen in our patient is extremely rare. This case highlights the importance of screening for hypothyroidism in patients presenting with unexplained pica.