784 - Hypothyroidism, the Great Mimicker

Case Diagnosis: Hypothyroidism presenting similarly to post-stroke symptoms and mood disorders

Case Description: A 57-year-old female with a history of anxiety, insomnia, and diffuse chronic microvascular brain disease presented to our inpatient stroke rehabilitation service following acute scattered lacunar infarctions. She exhibited a flat affect, lethargy, and poor sleep during the first two weeks of admission. She also had poor appetite, spoke with a soft/quiet voice, and reported feeling “down.” She participated poorly in therapies and minimally engaged with staff members.

Discussions: Collectively her symptoms appeared to be related to her stroke/microvascular disease and anxiety/depression. Despite trials of psychotherapy, fluoxetine, mirtazapine, melatonin, and hydroxyzine, the patient’s symptoms remained mostly unchanged. Over her stay we began noticing her room was frequently warm, but she often reported feeling cold and was typically seen bundled under blankets. This prompted us to check her thyroid levels which were on the border of subclinical and overt hypothyroidism. We subsequently started thyroid hormone replacement and over the next few days she demonstrated remarkable changes in mood, engagement, and energy. She smiled noticeably more, was more enthusiastic about therapies, and even reported improvements in pain scores. She also reported improvements in sleep and appetite, ultimately leading to her reporting that she now felt “great.”

Conclusions: Subclinical hypothyroidism can present as difficulty with fatigue, mood, executive function, and/or neuromuscular symptoms. Symptomatic hypothyroidism is often overlooked because symptoms can largely mimic mood disorders and post-stroke changes. Swift recognition is especially important in stroke populations because hypothyroidism also predisposes to increased risk of future ischemic events. To maximize function and recovery in the rehabilitation setting, physiatrists must not only remain vigilant, but also persistently search for causes of abnormal symptoms. Being cognizant of the symptoms of hypothyroidism and evaluating for hypothyroidism when patients’ symptoms are refractory to multiple treatments is one way physiatrists can accomplish this.