G171(P) The curious case of the thyroid; reversibility of severe profound hypothyroidism

Aims Worldwide incidence of autoimmune disease and especially autoimmune thyroid disease (AITD) in children in increasing. Reversal from severe autoimmune hypothyroidism is a rare occurrence. We report a case of a patient with profound hypothyroidism that returned to a euthyroid state within 13 months. Results A 15-year-old girl presented with seven months of excessive tiredness, aches and pains all over the body, low mood and difficulty concentrating. Initial results showed severe primary hypothyroidism, with a TSH >100 mU/L (0.30 4.20 mU/L) and a free T4 of 1.6 pmol/L (12.0–22.0 pmol/L), positive antiTPO antibody at 150 IU/ml (0.00 – 30.00 IU/ml) and negative TSH receptor antibody (TRAbs). The patient was commenced on levothyroxine and 3 months later, the patient was diagnosed with coeliac disease and commenced a gluten free diet. After 9 months of levothyroxine, she presented with pain and soreness in the neck area, excessive perspiration, intermittent heat intolerance and was now hyperthyroid (TSH 0.01 mU/L and free T4 25.9 pmol/L). Levothyroxine was therefore stopped. Off medication, 13 months from her initial presentation, she remains clinically and biochemically euthyroid. Discussion Reversal of mild hypothyroidism has been often noticed in clinical practice. However, reversal of severe profound hypothyroidism is rare, especially in patient with multiple autoimmune involvements. Medications, transient TSH receptor blocking antibodies and iodine containing products have been implicated. An Italian study also found that half of the patients with autoimmune hypothyroidism, who followed a gluten free diet, recovered to a state of euthyroidism. We wonder if gluten free diet played a role in our patient’s recovery from such a profound hypothyroidism. It is important to note, that throughout the course of treatment for hypothyroidism, our patient was not on any other medication and the only major change to her lifestyle was the avoidance of gluten. Conclusions This case report demonstrates possibility of spontaneous recovery from severe profound hypothyroidism in children. The mechanism of this is not yet understood and role of gluten free diet cannot be ruled out. Further study into similar cases may allow better insights and understanding of immunoregulation, causation and reversal of immunological phenomenon in AITD.