MON-435 - A Case of Profound Hypothyroidism Complicated by Rhabdomyolysis

Background
Severe hypothyroidism can affect the various body systems, especially in older adults with multiple medical problems. This case describes a patient with profound hypothyroidism caused by medication non adherence. Her untreated condition led to weakness, repeated falls, and prolonged muscle injury resulted in rhabdomyolysis and acute kidney injury.
Case Presentation
A 66 year old woman with a history of hypothyroidism, coronary artery disease, diabetes mellitus, hypertension, and dementia came to the hospital with worsening generalized weakness and frequent falls. Her home medications included levothyroxine 100 mcg daily, antidiabetic medications, antihypertensive medications, and other non nephrotoxic drugs. Initial laboratory tests showed creatinine 5 mg/dL (normal 0.4–1.2 mg/dL), BUN 94 mg/dL (normal 7–21 mg/dL), TSH 286.88 mIU/L (normal 0.39–4.08 mIU/mL), and free T4 less than 0.25 ng/dL (normal 0.58–1.64 ng/dL). Her 10 o’clock morning cortisol level was 12.4 µg/dL (normal 6.7–27.6 µg/dL), and Creatinine Phosphokinase (CPK) level was greater than 20,000 IU/L (normal 24–205 IU/L). Her family reported that she had not been taking her levothyroxine for an unknown period. She was treated with intravenous levothyroxine. Repeat labs showed improvement, with TSH decreasing to 37.41 mIU/L and free T4 rising to 0.39 ng/dL (normal 0.58–1.64 ng/dL). Her hospital course was complicated by severe hypothyroidism, medication non adherence, recurrent falls, and rhabdomyolysis that progressed to acute kidney injury requiring hemodialysis. After continuous dialysis, her CPK level decreased to 6811 IU/L.
Conclusion
Mild elevation of creatine kinase is common in hypothyroidism and occurs in 30–80% of cases. In uncommon situations, severe rhabdomyolysis can lead to acute kidney failure that may require hemodialysis. This case shows that untreated hypothyroidism can cause profound rhabdomyolysis and kidney injury. It also highlights that the importance of recognizing medication non adherence in patients with hypothyroidism as it can lead to serious complications, including temporary or permanent kidney failure that may require renal replacement therapy.

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