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Question 325 · LEK · Primary (Addison's disease)

A 27-year-old woman, nicely tanned, came to the doctor in February complaining of fatigue, nausea, lightheadedness and scotoma, especially upon standing up. She lost about 4 kg. She’s going to get married in May and she’s planning pregnancy. On clinical examination: blood pressure 105/60 mmHg, pulse about 90/minute, TSH concentration 7.85 µIU/mL (normal range 0.27-4.2). Indicate the correct management:

  1. A. because of the planned pregnancy, levothyroxine should be given in a dose of at least 50 µg/daily.
  2. B. because of the fact that free concentrations of thyroid hormones fall only at TSH concentration >10 µIU/mL the determination of TSH, fT4 and anti-thyroid peroxidase antibodies (anti-TPO) should be repeated in 3-4 months.
  3. C. cortisol concentration in the morning, electrolytes and anti-TPO antibodies should be urgently determined.
  4. D. ultrasound scan of the thyroid should be performed and levothyroxine in a dose of 25-50 µg daily should be immediately introduced if a hypoechoic and heterogeneous echotexture of the thyroid resembles the image typical of chronic thyroiditis.
  5. E. because of the elevated TSH concentration and tachycardia the treatment with Thiamazole and a beta-blocker should be provided.
Hint

A suntan in February, low blood pressure and orthostatic symptoms point beyond the thyroid; what must be excluded before treating a raised TSH?

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