Introduction

Hypothyroidism is a common endocrine disorder that mainly affects women in middle and old age [1]. Hypothyroidism is characterized by the slowing of mental and motor activity, depression, constipation, cold intolerance, menorrhagia, stiff muscles, carpal tunnel syndrome, sleep apnea, dry hair and skin, weight gain, snoring and a hoarse voice. [2] Less common symptoms involve the heart, muscles, Joints, and blood. [3] Joints pain as the presenting symptom of hypothyroidism has only been reported once before. [4] Here, we present an unusual case of hypothyroidism on thyroxin treatment from three years presenting with Joints pain which is relieved by  Ayurvedic Panchkarma i.e. Vamana (Emesis).

Case Report

A female, 36-year-old, presented to the clinic with Joints pain- Both Knees, shoulders and wrists, and body ache since one year. On further questioning, it was revealed that there had been episodes of Joints pain, mild fever, snoring, sleep apnea, mild dysphagia. Her past medical history was normal except PUO episode four years back. Clinical examination, including the central nervous system, was normal apart from a slightly puffy face. Her thyroid gland was not palpable. An otolaryngeal examination revealed no local cause for her problem. There was no abnormality in movement of tongue or pharyngeal/palate muscles. A further neurological examination did not show any abnormality. Routine thyroid function tests showed thyroxin level < 4 mg/dl (normal 4.5-12.0 mg/dl), thyroid stimulating hormone level 21.46 mIU/ml (normal 0.30-5.5mIU/ml). A complete blood count film was consistent with iron deficiency, hemoglobin level 9.5 grams (normal 11-16 grams). In Other biochemical abnormalities, her RA test shows negative results, high serum cholesterol level – 225.70 mg% (normal 125-200 mg %), and High LDL cholesterol – 151.24mg% (normal 0.5-1.7 mg %). The Electro cardio-gram (ECG) was normal.

Based on these findings, hypothyroidism was diagnosed. In the light of the patient’s diagnosis, a second history was taken which showed that she suffered from other symptoms of hypothyroidism such as, dry skin, generalized weakness, excessive sleeping, hoarse voice, and menorrhagia. All of these symptoms were neither reported nor elicited. She is already on thyroxin treatment from three years. Initially she got relief for dry skin, generalized weakness, excessive sleeping. But since one year she got symptoms like Joints pain, Pin prick sensation in both eyes, Redness in inner side of eyelids of eyes, hoarse voice, depression, constipation etc.

I decided to give Vamana (Emesis) Panchkarma to the patient in this situation. Because Vamana Karma is consider as best line of purification procedure for Jatrurdhwa vyadhi (above clavicle bone Diseases) and Kaphaja disorders [5]. Vamana is highly beneficial for volunteers of Kapha and Kapha-Pitta constitution and patients suffering from Kapha Rog and associated Pitta Rog or diseases originating or settled in the place of Kapha [6]. Vamana is a procedure in which Doshas (waste products or toxins) are eliminated through upper channels i.e. mouth [7] Diet and Life style advised as per Ayurvedic Dincharya (Daily Regimen) to the patient [5].

After completion of Vamana main procedure, immediately after 20 min, her Joints pain relieved up to 20% and she felt relaxed, reduced heaviness. After next follow up visit her Joints pain, Pin prick sensation in both eyes, redness in inner side of eyelids of both eyes, depression, constipation, was relieved near about 50 %. And the thyroid function tests showed thyroxin level of 10.6 mg/dl (normal 4.5-12.0 mg/dl), thyroid stimulating hormone level 5.2 mIU/ml (normal 0.30-5.5 mIU/ml).

Her thyroxin hormonal dose was also tapered with the help of her Endocrinologist in the next visit.
Next thyroid function tests showed thyroxin level 10.04pmol/L (normal 4.5-12.0 mg/dl), thyroid stimulating hormone level 2.38mIU/ml (normal 0.30-5.00 mIU/ml).

There may be some relation between thyroid hormone replacement therapy and the musculoskeletal related symptoms, Bone metabolism [8][9], or arthropathy.

There was considerable relief in symptoms of the hypothyroid patient by Vamana procedure in the above case. So we can say that Vamana is effective in the hypothyroid patients with Joints pain, and also in patients who are taking thyroid replacement therapy.

Discussion

Joints pain may be caused by Autoimmune diseases such as rheumatoid arthritis and lupus, Bursitis, Gout Infections caused by a virus, Rheumatic fever, Osteoarthritis, Osteomyelitis etc.[2] The second may be attributable to congenital, traumatic, inflammatory, tumors. These causes were unlikely in this patient, because she showed no associated clinical features of these diseases besides the normal neurological examination and investigations. Other causes such as congenital or acquired storage disorders such as amyloidosis and such endocrine disorders as acromegaly were not found. The most likely cause for the Joints pain in this patient was hypothyroidism. This was supported by the abnormal thyroid functions and other associated symptoms.

Iron deficiency anemia in this patient was due to menorrhagia, which is one of the characteristic features of the disease. [2] Hyperlipidemia may also be due to hypothyroidism, a known association. [2]

Clinical implication of the presented patient was Joints pain, Body ache may be the presenting symptoms of hypothyroidism, even if other symptoms had been present for a long time. There is a high prevalence of bone loss in patients with subclinical hypothyroidism treated with exogenous thyroxin [8]. Thyroid hormones are essential for growth and development during childhood and for the maintenance of bone in adulthood [9]. In children with hypothyroidism one sees stunted growth with epiphyseal dysgenesis and delayed skeletal maturation while in adults the phases of bone renewal are prolonged with reduced osteoblast activity and increased cortical bone thickness [9]. Hypothyroidism as the cause of Joints pain was confirmed with the discovery of additional symptoms in the patient’s history. Vaman is not indicated for joint pain in routine line of treatment. In this case, Patient had history of thyroid before joints pain. Vamana Karma is considered as best line of treatment/procedure for Jatrurdwa vyadhi (above clavicle bone Diseases). Thyroid disease can be subtitled under Jatrurdwa vyadhi so I decided to do vamana. Prompt recovery of Joints pain is expected after Panchkarma (Vamana) therapy. And there was considerable relief in the symptoms of hypothyroid patient by Vamana procedure in the above case. So we can say that Vamana is effective in the hypothyroid patients with Joints pain, and also in patients who are taking thyroid replacement therapy. There must be further research work in this field.

References

1. So M, MacIsaac RJ, Grossmann M .Hypothyroidism.,AustFam Physician. 2012 Aug;41(8):556-62. PMID: 23145394 [PubMed]
2. Wilson JD, Braunwald E. Harrison’s Principles of Internal Medicine. 14th ed. New York: McGraw-Hill; 1998.
3. Review Unusual manifestations of hypothyroidism. Klein I, Levey GS, Arch Intern Med. 1984 Jan; 144(1):123-8.[PubMed]
4. Krupsky M, Flatau E, Yarom R, Resnitzky P. Musculoskeletal symptoms as a presenting sign of long-standing hypothyroidism, Isr J Med Sci. 1987 Nov;23(11):1110-3. PMID: 3436793 [PubMed]
5. Kushwaha HS. Carakasamhita.1st edi. Varanasi: Chaukhambha orientalia; 2009. Vol2  p 851.
6. SantoshkumarBhatted,V. D. Shukla, AnupThakar, and N. N. Bhatt. A study on VasantikaVamanaa (therapeutic emesis in spring season) – A preventive measure for diseases of Kapha origin Ayu. 2011 Apr-Jun; 32(2): 181–186. PMCID: PMC3296337
7. AcharyaYadavajiTrikamji., editor. Kalpasthana. 4. Vol. 1. Varanasi: Chaukhamba Sanskrit series; 1992. Charakasamhita with Ayurveda Dipika Comm. of Chakrapani.
8. Pedro J. TárragaLópez, Carmen FriasLópez, Francisco Naharro de Mora, José Antonio Rodríguez Montes, Juan SoleraAlbero, Antonio NaharroMañez, and Arancha Galvez Casas.,  Osteoporosis in patients with subclinical hypothyroidism treated with thyroid hormone., Clin Cases Miner Bone Metab. 2011 Sep-Dec; 8(3): 44–48.PMCID: PMC3279063.
9. Fardella C, Poggi H, Gloger S, Rojas A, Velasquez CG, Barroileth S, Figueroa R, Alvarez C, Salgado C, Gajardo C, Foradori A, Montero J., High prevalence of subclinical thyroidal disease among individuals attended in health control]., Rev Med Chil. 2001 Feb; 129(2):155-60.[PubMed]