Case report: allergic rhinitis, asthma, and "sub-laboratory hypothyroidism"

Townsend Letter for Doctors and Patients, May, 2006 by Alan R. Gaby

A 34-year-old female presented with a long history of ocular allergies and perennial allergic rhinitis with seasonal exacerbations. She had been treated with oral, intranasal, and ophthalmic antihistamines and glucocorticoids, with varying degrees of success. She also had suffered from asthma since childhood and required frequent use of inhaled glucocorticoids and bronchodilators. Other symptoms included chronic fatigue, sensitivity to cold, waves of nausea with no relation to meals or time of day, difficulty with mental concentration, a general tendency to edema, a pattern of waking up every night between 2 AM to 4 AM with difficulty falling asleep again, and recurrent palpitations. If she did not eat every two to three hours, she would develop a feeling of agitation, followed by severe fatigue. She also had an eight-year history of irregular menstrual periods, with cycles occurring approximately every 40 to 50 days. Numerous medications, nutritional supplements, and herbs had been tried for her symptoms, but the results had been for the most part unsatisfactory. Two weeks prior to her first visit, she had undergone extensive testing (including TSH and free T4), by an endocrinologist who had concluded that her endocrine system was normal.

On physical examination, her Achilles tendon reflex return was delayed (suggestive of hypothyroidism), and her ankles and lower legs had an appearance of subtle myxedema. Her basal axillary temperature, which had been taken on six occasions prior to her first visit, ranged from 95.8 to 97.2 degrees F. On the basis of her symptoms, physical findings, and sub-normal body temperature (which presumably indicates a low basal metabolic rate), a provisional diagnosis of hypothyroidism was made. The patient was advised to take 15 mg (1/4 grain) of Armour thyroid per day, increasing to 30 mg per day after five days, with a possible further increase, depending on her response and tolerance to the treatment. During the first two weeks, she experienced dramatic improvement in most of her symptoms. Around two months after the start of treatment, there was a recurrence of nausea and a decrease in her energy level. The dose of Armour thyroid was increased to 60 mg per day, and those symptoms again resolved. One month later, a further increase in dosage to 90 mg per day was necessary.

Of note, the patient's asthma and rhinitis improved rapidly after the start of treatment, to the extent that she rarely needed medication for either condition anymore. At her most recent follow-up, ten months after the start of treatment, she rated the degree of improvement in her symptoms as follows (0% indicates no improvement, 100% indicates complete relief): fatigue and low energy (90%), nausea (90%), difficulty concentrating (95%), irregular menses (99%), asthma (85%), ocular allergies (80%; only seasonal exacerbations remained), palpitations (99%), edema (45%), and waking up at night (70%). Her need to eat every two to three hours had been extended to every three to four hours. Her sensitivity to the cold did not improve at all. No adverse side effects occurred, and her pulse rate and blood pressure did not change.

Comment: This case illustrates two important points about which few in the medical community are aware: that hypothyroidism can cause allergic manifestations such as rhinitis and asthma, and that patients with clinical hypothyroidism frequently have normal blood tests for thyroid function. I have treated about 1,500 patients for "sub-laboratory hypothyroidism," and my experiences using thyroid hormone are described in the article cited below.

Gaby AR. "Sub-laboratory" hypothyroidism and the empirical use of Armour thyroid. Altern Med Rev. 2004;9:157-179.

by Alan R. Gaby, MD

drgaby@earthlink.net

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