Shock, Severe Hypothyroidism, and Paralytic Large Bowel Ileus in a Patient With Multiple Neoplasms

Introduction: Abnormal thyroid levels are associated with a wide range of symptoms and presentation. Paralytic ileus can be seen in hypothyroidism and is assumed to be due to an autonomic neuropathy affecting the extrinsic nerves of the colon. Although poorly understood some histologist studies hint at hypothyroidism affecting the colon by autonomic neuropathy. When a patient presents with constipation, abdominal pain with distention, physicians usually consider mechanical obstruction, malignancy, inflammatory bowel disease, neurogenic causes, or post-surgical complications. Hypothyroidism may not be at the top of the differential list and untreated severe hypothyroidism can lead to life-threatening Myxedema Coma. Case Description/Methods: 55-year-old woman with history of total thyroidectomy with right radical neck dissection for papillary tumor leading to hypothyroidism, distal pancreatectomy for neuroendocrine tumor, presents with nausea, diarrhea, and on the exam, she was hypotensive with severe abdominal distention. CT abdomen and pelvis showed marked circumferential distention with thickening of the distal transverse colon through the rectum, and a new finding of a 1.1 cm enhancing lesion in the right kidney, consistent with renal cell carcinoma. The patient stated she had stopped her levothyroxine medication 1 year prior. She was found to have TSH 227 with AM cortisol of 10. She was treated for myxedema with adrenal insufficiency with vasopressors, hydrocortisone, levothyroxine, and an aggressive bowel regimen. The patient underwent sigmoidoscopic decompression. The patient improved and was discharged to follow with an endocrinologist and an oncologist. Discussion: Hypothyroidism can slow the motility of the bowel. In our patient, her hypothyroidism severe with myxedema presentation. In patients with myxedema cortisol levels must be checked. Glucocorticoids should be started until adrenal insufficiency is ruled out and patient treated with T4, or T4 and T3. The TSH, Free T4, total T3 labs should be repeated to assess the patient’s improvement. Our patient also had malignancy in the renal, pancreas, and pituitary. Although this is similar to MEN4, not all of the patient’s features match a classical presentation. MEN4 is an autosomal dominant disorder due to cyclin-dependent kinase inhibitor (CDNK1B) mutations. It is characterized by the occurrence of parathyroid and anterior pituitary tumors with other tumors in adrenals, kidneys, and reproductive organs.Figure 1.: Dilated bowel, and renal cell carcinoma.