Menorrhagia as main presentation sign of severe hypothyroidism in a pediatric patient: a case report

A Salvadoran thirteen years old girl presented to our Emergency Department complaining of menorrhagia for the last fifteen days. She had menarche one year and seven months before, followed by absence of menstruation until the previous month, when she had a menstruation normal in duration and flow. She did not report asthenia nor other symptoms. Family history was negative for coagulopathy, the mother had hypothyroidism in pregnancy and the father had hyperthyroidism.

The objective examination revealed xerotic and desquamating skin, thinning hair and acanthosis nigricans on neck, armpits and ankles. She presented a mildly enlarged thyroid gland at palpation, also visible at extended head, heart rate was 54 beats per minute, nothing relevant was noted at abdominal and pulmonary examination.

She was 133.8 cm tall (-3.53 standard deviation scores, SDS [9]), her mid-parental height was 155 cm (- 1.25 SDS [9]), weight was 44 kg (-0.32 SDS [9]) and Body Mass Index, BMI 24.6 (1.37 SDS [9]). The mother referred stunting of growth in the last two years but no previous height measurements were available.

Abdominal ultrasound showed a vaginal anechoic formation (63 × 61x34 mm) with a non-vascularized hyperechoic structure inside (43 × 36x25 mm), compatible with blood collection with a clot inside, which was spontaneously expelled few hours later, and a right ovarian cyst (40 × 28 mm).

The first blood tests revealed decreased hemoglobin (8 g/dl, N.V. 11.3–14.5 g/dl) and red blood cells (2.63 10^12/L, N.V. 4–5.1 10^12/L), normal prothrombin (PT) ratio, slightly increased activated partial thromboplastin time (aPTT) ratio (1.27, N.V. 0.8–1.18) and mildly decreased levels of fibrinogen (169 mg/dL, N.V. 200–400 mg/dL), von Willebrand Ristocetin Cofactor assay (vWF: Rco) (33%, N.V. 60–200) and von Willebrand factor (VWF) (39%, N.V. 66–176).

Thyroid ultrasound was performed for the suspect goiter, confirming an enlarged thyroid (lobes measuring 17 mm in anteroposterior diameter, isthmus 5.5 mm), with non-homogeneous hypoechogenic structure and hyperechoic linear bands, two hyperechogenic nodules (3 mm) in the right lobe, an increased vascularization and some reactive perithyroid lymph nodes, the major measuring 18 mm in his long axis.

Blood exams to evaluate thyroid function showed an increased thyrotropin releasing hormone (TSH) level (> 100 mU/ml, N.V. 0.660–5.060 mIU/L), with extremely low free thyroxin (fT4) in serum (< 1.5 ng/L, N.V. 7.4–13.5 ng/L), high titer of anti-thyroid peroxidase antibodies (TPOAb) (> 1000 kUI/L, N.V. < 10 kUI/L) and antithyroglobulin antibodies (TGAb) (> 1000 kUI/L, N.V. < 10 kUI/L) and negative TSH receptor autoantibodies (TRAb).

The patient was consequently diagnosed with autoimmune hypothyroidism and the substitutive therapy with levothyroxine was started at 50 mcg/die, then increased to 100 mcg/die after two weeks.

Autoimmune conditions potentially related to Hashimoto thyroiditis (such as type I diabetes, coeliac disease, autoimmune gastritis, hypoparathyroidism and Addison disease) were excluded.

In the second day of hospitalization, she required a red blood cells transfusion for worsening of anemia (hemoglobin 6,3 g/dl). Heavy vaginal bleeding stopped in the fifth day of hospitalization, with subsequent spotting until the following menstruation on the fifteenth day. This menstruation, as the following ones, was still abundant in flow, but lasted for five days.

Cerebral magnetic resonance (MR) was performed to evaluate the possible pituitary functional hypertrophy, with the finding of an enlarged adenohypophysis (16 mm in height) in contact with optic chiasm. Left hand X-Ray showed a bone age of 9.6 years according to TW2 RUS method [10].

The patient reached fT4 normalization after four weeks and TSH normalization after seven weeks of therapy. One month after the beginning of levothyroxine, coagulative parameters were re-dosed with a normalization of aPTT ratio (1.03), fibrinogen (322 mg/dL), vWF: Rco (65%) and VWF levels (83%).

Growth hormone (GH) release after arginine and glucagon tests was dosed one and two months after the beginning of therapy and resulted insufficient (respectively GH 0.61 UI/l, N.V. < 8 UI/l and GH 1.43 mcg/l, N.V. < 8 UI/l), with the diagnosis of GH deficiency. The patient was consequently prescribed with substitutive growth hormone therapy after the second MR, showing resolution of the pituitary hyperplasia after three months of therapy.

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