Abstract
Raynaud’s phenomenon is manifested clinically by demarcated color changes the skin of the digits or extremities, typically may be an early clue to the diagnosis of hypothyroidism. In this report, we describe the 8-year-old patient with diagnosed primary hypothyroidism presenting with ceasing the treatment for 1 month that presenting with Raynaud phenomenon.
Keywords: Raynaud’s phenomenon, Hypothyroidism, Case report
Introduction
Raynaud’s phenomenon is a medical condition in which the spasm of small arteries causes episodes of reduced blood flow to end arterioles. Typically, this condition involved the fingers, and less commonly the toes [1]. It is considered primary if it occurs in the absence of any underlying disease and unknown cause and secondary if found in association with a structural vascular disease such as a connective tissue disorder, smoking, thyroid problems, and certain medications such as birth control pills [2, 3].
Hypothyroidism is a disorder of the endocrine system in which the thyroid gland does not produce enough thyroid hormone. People with hypothyroidism often have no or only mild symptoms. It can cause a number of symptoms, such as poor ability to tolerate cold, a feeling of tiredness, constipation, slow heart rate, depression, and weight gain [4, 5].
A causal relationship between thyroid deficiency and Raynaud phenomenon has been reported in a few number of patients. In a multicenter observational study of 761 patients with Raynaud phenomenon, 65% of patients with RP had a secondary condition; only two patients (0.3%) were found to have associated hypothyroidism.
In this study, we describe the 8-year-old hypothyroidism patient with ceasing the treatment for 1 month that presenting with Raynaud phenomenon.
The Ethics Committee of Kerman University of Medical Sciences approved the study protocol by Code: IR.KMU.AH.REC.1396.2294. In addition, written informed consent was obtained from the parents of the patient.
Case Presentation
The 8-year-old girl referred to endocrine clinic about one year ago with enlargement of anterior of neck space and feeling of swelling since 1 month prior to visit. After initial workup and evaluation on her laboratory tests, the Thyroid-stimulating hormone (TSH) was 55 mIU/L and Anti TPO (Anti-thyroid peroxidase) antibodies was 302 IU/mL. In addition, in thyroid sonography, mild goiter was diagnosed for her and medical treatment with tablet of Euthrox 50 mcg daily started with diagnosed of Hashimoto thyroiditis.
She was well and her symptoms was controlled for about 1 year but since 1 month ago due to lack of accessibility to drug she did not use that tablet and came to endocrinologist with low energy level, tiredness and sleepiness, mild to moderate enlargement of neck and alopecia. The rest of her physical examination was within normal. In addition, some medical condition such systemic sclerosis, systemic lupus erythematosus, and other connective tissue diseases was ruled out in this patient in her evaluation.
Investigations revealed normal urea and electrolytes, normal hemoglobin and platelet count and white blood cell count. Thyroid-stimulating hormone (TSH) was 33 mIU/l (normal range 0.1–5.0) and a free T4 (thyroxine) 0.5 ng/dL (normal range 0.7–1.5 ng/dL).
She was started on L-thyroxine therapy with another trade name (Levoxine 50 mcg) daily but on follow up 2 days later, she developed significant color changes and progressive purplish discoloration of the tips of all hand fingers. (Fig. 1)
Fig. 1.
Significant color changes of the tips of all hand fingers of the patient
She had no history of fever or rash and her parents reported that she had no cold exposure, new drug consumption, organic solvents exposure or emotional stress recently. Furthermore, her peripheries were cool on examination but she described no pain and these symptoms revealed a Raynaud phenomenon in this patient.
Discussion
The classical Raynaud’s phenomenon has always been considered a warning of possible systemic disease. Although most cases are idiopathic, the list of conditions associated with this vasospastic response to cold is extended. To the best of study in literature, a causal relationship between thyroid deficiency and Raynaud phenomenon has been reported in a few number of patients. The first reported case of Raynaud phenomenon associated with hypothyroidism was in 1976; Shagan and Friedman described 2 patients with Raynaud phenomenon and hypothyroidism whose symptoms disappeared with thyroid replacement therapy [6].
It is believed that the pathogenesis of RP lies in the reduced digital blood flow due to excessive vasoconstriction. Because of decreasing the metabolic rate of all tissues in hypothyroidism, it is reasonable to expect less digital blood flow at any temperature [7].
The patient clinical scenario described herein suggests an association of Raynaud’s phenomenon and hypothyroidism again and recommend that Raynaud’s phenomenon may be an early clue to the diagnosis of hypothyroidism. The patient’s TSH levels was high (33 mIU/l) and Free T4 was lower than normal range (0.5 ng/dL). In also, she had significant color changes affecting all fingers and cold hands that presented Raynaud phenomenon. The medical therapy with hormone replacement started again and in follow up the symptoms were remised.
Conclusion
This is the case report describing the association of hypothyroidism and RP and leads us to believe that Raynaud’s phenomenon may be an early clue to the diagnosis of hypothyroidism. Although the history and the clinical picture of this report leaves little doubt about the diagnosis this association, further elucidations should have been done to evaluate the Raynaud’s phenomenon and hypothyroidism association.
Acknowledgements
The authors would like to thank Clinical Research Development Units, Shafa hospital, Kerman University of Medical Sciences, Kerman, Iran.
Declarations
Conflict of interest
The authors have no competing interests to declare that are relevant to the content of this article.
Informed Consent
Verbal informed consent was obtained from the parents of this patient.
Footnotes
Publisher’s Note
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