A 73-year-old woman with Graves' disease underwent total thyroidectomy and was being treated with levothyroxine. She developed edema in the lower region of both legs 1 month before hospitalization. She had a high concentration of urine protein and was hospitalized for further assessment. A urine protein concentration of 4.4 g/day was observed, and she was diagnosed with minimal change nephrotic syndrome (MCNS) after kidney biopsy. The patient's thyroid function had declined, as indicated by a thyroid-stimulating hormone (TSH) level of 139.0 lIU/mL and a free thyroxine (fT4) level of 0.66 ng/ dL. She was prescribed 40 mg/day of prednisolone (PSL) and achieved remission. fT4 level normalized on the 36th hospital day. She was in remission subsequently. However, MCNS recurred when PSL was tapered to 10 mg/day. When she was rehospitalized, thyroid function decline was noted once more, with a TSH level of 29.8 lIU/mL and an fT4 level of 0.74 ng/dL. Her oral PSL dose was increased to 30 mg/day, but she did not achieve remission. However, she achieved remission after steroid pulse therapy. After remission, the thyroid function normalized. During the course of her treatment, the levothyroxine dose was maintained at 87.5 lg/day. Therefore, we predicted that the loss of thyroid hormone in urine due to nephrotic syndrome may have led to the aggravation of hypothyroidism. We have reported this case because of its rarity.
Keywords: tuberculous peritonitis, laparoscopic peritoneal biopsy, hemodialysis, tuberculosis specific interferon gamma release assay 〈Abstract〉 A 66 year old male developed a fever that was refractory to antibiotic therapy. He received the antibiotic therapy during long term hospitalization because it was challenging for him to receive home care. He had been diagnosed with chronic kidney disease and had been undergoing maintenance hemodialysis. He was referred to our hospital and was admitted to undergo a detailed examination. A computed tomography scan showed ascites, and the ascitic fluid exhibited an elevated adenosine deaminase level. These findings suggested peritoneal tuberculosis, but the specific interferon gamma release assay(IGRA)produced a negative result. Diagnostic laparoscopy showed peritonitis with peritoneal micronodules. Peritoneal biopsy cultures confirmed the diagnosis of peritoneal tuberculosis. Treatment was initiated using anti tuberculous drugs, including isoniazid, rifampicin, ethambutol, and pyrazinamide, following which the patientʼs fever disappeared. Even though the IGRA is a useful tool for diagnosing tuberculosis, it might infrequently yield false negative results. The aggressive application of diagnostic laparoscopy is imperative for the accurate diagnosis and treatment of suspected peritoneal tuberculosis.
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