Background

Hashimoto’s thyroiditis is one of the most common causes of hypothyroidism. Hypothyroidism is a known cause of hyperlipidemia. There is a strong correlation between coronary and mesenteric vessel atherosclerosis. Acute mesenteric ischemia is a cause of intestinal hemorrhagic infarction. 

Case history
We present an autopsy case of 35-year-old male who presented with features of obstruction and edema with previously undetected hypothyroidism.

Conclusion

Hypothyroidism   associated with atherosclerosis can lead to fatal intestinal gangrene as corroborated by this autopsy case.

Key words –Hypothyroidism, intestinal gangrene, autopsy, atherosclerosi

E., E.Jayashankar

Patnayak, Rashmi Patnayak

Prayaga, Aruna K. Prayaga

Reddy, Rajasekhar Reddy

S.V.N., S.V.N. Anuradha

English

Cognitive Sciences ePrint Archive

Patnayak et al  
Calicut Medical Journal 2006;4(3):e3 
 
Page 1 (Page number not for indexing purposes) 
Case Report 
An intriguing autopsy case of gangrene intestine 
Rashmi Patnayak, Aruna Prayaga, Rajasekhar Reddy, Anuradha S.V.N., Jayasankar E.   
1
Department of Pathology and Cardiology, Nizam’s Institute of Medical Sciences., Hyderbad, Andhra Pradesh. 
 
 
INTRODUCTION 
Hypothyroidism, or myxedema, is the clinical syndrome that 
results from decreased production of T4 and T3.Most 
patients have primary hypothyroidism .The etiology of adult 
primary hypothyroidism includes autoimmune 
hypothyroidism (Hashimoto’s thyroiditis), post – ablation 
after radio-active iodine, thyroid surgery and drugs such as 
Amiodarone and Lithium. Manifestations are variable and 
proportionate to the degree and duration of thyroid hormone 
deficiency as well as age of onset. The presence of goiter is 
common in younger patients (Hashimoto’s) but often absent 
in the elderly. Clinical features of hypothyroidism are 
insidious and often missed, particularly in the elderly. 
 
Hashimoto’s thyroiditis is one of the most common causes 
of hypothyroidism. Hypothyroidism is often associated with 
of hyperlipidemia, which is a known risk factor for 
atherosclerosis. Atherosclerosis can cause ischemia, which 
in turn can lead to hemorrhagic infarction of intestine [1]. 
 
Hypothyroidism as a cause of hemorrhagic infarction of 
intestine is not described in the literature. We present a case 
of intestinal gangrene with previously undetected 
hypothyroidism 
CASE HISTORY  
A 35-year-old male presented with chief complaint of 
episodic colicky abdominal pain of 2 years duration, which 
was associated with vomiting and constipation, exertional 
dyspnoea of 6 months and swelling of feet of 2 months. 
 
Routine investigations like peripheral blood examination 
showed normocytic, normochromic anemia with macrocytes 
with total WBC count of 8.8x109/L with differentials of 
neutrophils 69%, lymphocytes 26%, monocytes 2%, 
eosinophils 3 % and thrombocytosis. Urine examination 
showed 1+ albumin and 2-3 pus cells per high power field. 
Stool for occult blood was negative. Liver function test and 
renal function tests were with in normal limit. Biochemical 
analysis showed hyperkalemia. 
 
Upper GI endoscopy had evidence of healed duodenal ulcer. 
Ultrasound abdomen was apparently normal. Chest 
radiograph was normal. Echocardiogram finding was 
suggestive of constrictive pericarditis / restrictive 
cardiomyopathy. ECG findings revealed incomplete right 
bundle branch block and 0.5 mm ST depression and T 
inversion in V4- V6. 
 
Patient had no past history of chest pain, diabetes or 
hypertension. On general examination the patient was well 
built and moderately nourished with mild pallor and 
bilateral pedal edema. Systemic examination of central 
nervous system and cardio-vascular system was within 
normal limits. Per abdomen finding did not reveal any 
organomegaly. 
 
 There was no obvious thyromegaly. However T3 was 
decreased and TSH level was elevated as proved by 
hormonal level of T3 – 0.5 nmol/L (1.3-3.0 nmol/L), T4 – 
6.2µg/dL (5.0-14.0µg/dL), TSH – 5.3 µIU/ml (0.2-
4.0µIU/ml). Lipid profile was not done due to short hospital 
stay. 
  
HOSPITAL COURSE 
Patient stayed in hospital for four days with chief complaint 
of progressive abdominal pain associated with distension 
and vomiting. 
 
Per rectal examination revealed rectum loaded with faeces. 
Patient symptomatically improved with enema but the 
symptoms recurred. Subsequently he developed sudden 
onset of poor respiratory effort with bilateral extensive 
ronchi and severe metabolic acidosis. 
 
Patient was intubated, put on ventilator and given ionotropic 
support. Repeat Echocardiogram revealed dilated right 
atrium, right ventricle with pulmonary arterial hypertension 
.He developed refractory hypotension and later on had 
cardio respiratory arrest. 
 
AUTOPSY FINDINGS 
 
Complete body autopsy was performed and in situ 
examination revealed grossly dilated and discolored 
intestine (Figure – 1) with no evidence of free fluid in any 
of the body cavity. 
 
The small intestine was markedly dilated and discolored. 
There was no adhesion or growth to substantiate sub-acute 
intestinal obstruction and histologically it showed patchy 
Patnayak et al  
Calicut Medical Journal 2006;4(3):e3 
 
Page 2 (Page number not for indexing purposes) 
hemorrhagic infarction (Figure – 2,3). However multiple 
sections from mesenteric vessels did not reveal any 
evidence of thrombus or atheroma. 
 
Thyroid histologically showed features of Hashimoto’s 
thyroiditis in the form of follicular destruction by 
lymphocytes and presence of Hurthle cells. (Figure – 4) 
Heart revealed presence of left ventricular hypertrophy and 
microscopically perivascular myxoid change with 
coronaries and aorta revealing presence of Grade IV 
atherosclerotic change. There was no evidence of 
constrictive pericarditis / restrictive cardiomyopathy. 
 
Grossly the brain showed normal gyral and sulcal pattern 
and the vessels forming the Circle of Wills were 
unremarkable. Coronal sections revealed normal grey and 
white matter distinction. Histological examination revealed 
features of hypoxia manifesting as loss of Purkinje cells 
with few showing bright eosinophilic cytoplasm in 
cerebellum. 
 
Organs like lungs, liver, and kidney showed features of 
hypoxia. Multiple sections from other endocrine organs like 
pituitary, pancreas and adrenal did not reveal any 
abnormality.  
 
DISCUSSION 
Hashimoto’s thyroiditis is one of the most common cause of 
hypothyroidism .It is most commonly seen in females of 45-
65 year age group. Hashimoto’s thyroiditis is an 
autoimmune thyroiditis where important mechanisms are 
CD8+ cytotoxic Tcell mediated cell death and anti thyroid 
antibodies[.2, 3]. 
 
This patient was a male with previously undetected 
hypothyroidism, which was proven biochemically as T3 was 
decreased and TSH level was elevated however T4 level 
was within normal limits. The probable sequence of events 
proposed in the present case is hypothyroidism leading to 
hyperlipidemia. The histological features are consistent with 
Hashimoto’s thyroiditis. Clinically also this fact was 
substantiated as the patient had constipation of long 
duration, distension of abdomen and edema. 
 
The coronaries and aorta showed evidence of Grade IV 
atherosclerosis though we did not have biochemically 
proven values of hyperlipidemia. 
 
Hypothyroidism is a known cause of hyperlipidemia, due to 
defect in LDL receptors.4 Necropsy data suggest that the 
hypocholesterelomia of hypothyroidism predisposes to 
coronary atherosclerosis only in the presence of 
hypertension; in normotensive hypothyroid patients the 
degree of coronary atherosclerosis appears to be similar to 
that in age- and sex- matched normotensive control 
subjects.[5]  
However, in some studies, no association was found 
between hypertension and hypothyroidism,[6, 7 5 ] and this 
patient was normotensive. 
The most striking finding in this case was gangrene of 
intestine, which was patchy in nature. This can be explained 
by probable mesenteric artery atherosclerosis. Though 
multiple sections from mesenteric vessels did not reveal any 
evidence of thrombus or atheroma. 
 
 
 The gangrene in turn can explain features of shock in 
organs like liver, lungs and kidney. There are studies 
showing correlation between coronary and mesenteric 
vessel atherosclerosis.[8]  
 
 
 
 
Figure – 1   Hypothyroidism causing intestinal gangrene, 
proposed hypothesis 
 
 
Superior mesenteric vessels supply intestine by a unique 
blood supply known as collaterals or by parallel blood 
supply. So incidence of gangrene intestine is rare. However 
there are several causes of intestinal ischemia. In the present 
Patnayak et al  
Calicut Medical Journal 2006;4(3):e3 
 
Page 3 (Page number not for indexing purposes) 
case the important causes are shock and atherosclerosis. 
Others are acute vascular obstruction by thrombus, embolus, 
necrotising enterocolitis, vasculitides and vasculopathies, 
hypercoagulable state, drug effect, vascular compression, 
volvulus, celiac axis compression, infection associated with 
DIC or vasculitis, amyloidosis, diabetes and radiation 
damage [1]. 
 
Acute mesenteric ischemia is a cause of intestinal 
hemorrhagic infarction. It is mostly seen in elderly patients 
with severe cardio-vascular disease, [9] however this case 
was only 35 years old. 
 
 
 
Figure – 2        Dilated and congested intestine 
 
 
 
Figure – 3 Hemorrhagic infarction of intestine (H&E; X100) 
 
 
 
Figure – 4 Hemorrhagic infarction of intestine (H&E; X100) 
 
 
 
 
Figure – 5       Hashimoto’s thyroiditis (H&E; X100) 
 
 
 
 CONCLUSION 
 
Hypothyroidism as a cause of hemorrhagic infarction of 
intestine is not described in the literature. Hence 
hypothyroidism associated with hyperlipidemia can produce 
fatal intestinal gangrene as evidenced by the present case. 
 
 
REFERENCES 
 
1. Cecilia M. Fenoglio-Preiser, Amy E. Noffsinger, 
Grant N. Stemmermann, Patrick E. Lantz, 
Margaret B. Listrom, Franco O. 
Rilke.Nonneoplastic lesions of the small intestine. 
In: Gastrointestinal Pathology, eds.2nd edition. 
Philadelphia, Lippincott-Raven, 1998,341-348 
Patnayak et al  
Calicut Medical Journal 2006;4(3):e3 
 
Page 4 (Page number not for indexing purposes) 
2. Stassi G, De Maria R: Autoimmune thyroid 
disease: new models of cell death in autoimmunity. 
Nat Rev Immunol2 (3): 195-204,2002 
3. Pearce EN, Farwell AP, Braverman LE: 
Thyroiditis Engl J Med 348:2646,2003 
4. Thompson GR, Soutar AK, Spengel FA, Jadhav A, 
Gavigan SJ, Myant NB 1981      Defects of 
receptor-mediated low density lipoprotein 
catabolism in homozygous familial 
hypercholesterolemia and hypothyroidism in vivo. 
Proc Natl Acad Sci USA 78:2591–2595 
5. Steinberg AD.Myxedema and coronary artery 
disease: a comparative autopsy study. Ann Intern 
Med 1968; 68:338 – 344. 
6. Bergus. GR, Randall. C, Van.Peursem.R, Lack of 
association between hypertension and 
hypothyroidism in a primary care setting Hum 
Hypertens. 1999; 13:231 – 5. 
7. Bergus. GR, Randall. C, Van.Peursem.R, Lack of 
association between hypertension and 
hypothyroidism in post-menopausal women in a 
primary care setting AM Board – Fam – 
Pract.1997; 10:185-01. 
8. Jrven O, Laurika J, Salenius JP, Tarkka M, Acute 
intestinal ischemia: a review of 214 cases .Ann 
Chir Gynaecol 1994; 83:22-25 
9. Reinus JF, Brandt LJ, Boley SJ.Ischemic disease of 
the bowel. Gastroenterol Clin North Am 1990; 
19:319-343 


Autoimmune thyroid disease: new models of cell death in autoimmunity.

Defects of receptor-mediated low density lipoprotein catabolism in homozygous familial hypercholesterolemia and hypothyroidism in vivo.

Franco O. Rilke.Nonneoplastic lesions of the small intestine. In:

An intriguing autopsy case of gangrene intestine

An intriguing autopsy case of gangrene intestine

Abstract

Similar works

Full text

Available Versions

Cognitive Sciences ePrint Archive