A 25-year-old female presented with weight gain over the past 5 years, gaining approximately 7-8 kg per year. She has been diagnosed with hypothyroidism for the past 3 years and is on thyroid medication. Physical examination found she has a BMI of 39 kg/m2, acanthosis nigricans, and ankle edema. Laboratory tests showed hyperlipidemia and impaired glucose tolerance. Based on her history and test results, she was diagnosed with metabolic syndrome complicated by primary hypothyroidism.

1. A 25-year-old female presented
with weight gain
Presenter
Dr. Md. Ahamedul Kabir
MD Phase A Resident
Dept. Of Endocrinology
BSMMU

2. Particulars Of the Patient
• Name: Miss. Laboni Khan
• Age: 25 year
• Unmarried
• Student of BA ( Hons.)
• Address: Shibaloy, Manikgonj
• Date of admission: 08.04.13

3. Presenting complaints
 Gradual weight gain for last 5 years
• Associated with intermittent swelling of the
body for last 3 years, relieved by taking
frusemide.
• On an average weight gain about 7-8 Kg per
year.
• Documented weight was 79 Kg at 3 years back
and now on admission 94 Kg.

4. Continued
• Diagnosed case of Hypothyroidism for last 3 years & patient
on thyroxin therapy

5. Continued
 Headache for last 10 years.
• Dull aching in & sometimes tight
band like .
• Intermittent, bilateral on frontal
region, more on evening
• No H/O visual aura, relieved by taking
paracitamol.

6. Family History
• 5 Brothers & 3 sisters. All are in good health.
• Father died on 1997 due to CVD.
• Mother is alive & have hypertension.
• No family H/O obesity`

7. Personal History
• Non smoker
• Non alcoholic
• Used to lead a sedentary life style
• Tendency to have more sleep

8. Menstrual History
 Irregular menstruation for last 3 years
• Oligomenorrhoric for fast 2 years ( 45-50 days cycle)
with average flow.
• Amenorrhoric for next 6 months.
• Now regular menstruation ( 28 ± 2 day cycle ) with
average flow for last 3 months.
• LMP : 03.04.2013

9. Drug History
• Tablet Thyroxin (50 µg )
 1 Tab daily for 6 months
 1.5 tab. for 8 months
 0.5 tab daily for 1 year
 Now 1.5 tab daily from 13.03.13
• Tablet Metformin (500 mg) – 1 tab bd for 1.5 years
• Tablet Paracitamol
• Tablet Prochlorperazine
• No history of taking steroid or other drug related to
weight gain

10. Physical Examination
 General Examination:
• Co-operative but
• Depressed looking
• Rounded face
• Acanthosis nigricans present around the neck
• Ankle oedema +
• Pulse - 80 bits/min
• BP - 130/80 mm/hg
• No history of Hirsutism

11. Continued
Measurements:
• Height -156 cm
• Weight – 94 Kg
• BMI – 39 kg/m²
• WC – 112 cm
Other systemic examination reveals no abnormality

12. Provisional Diagnosis
• Metabolic syndrome with hypothyroidism

13. Differential Diagnosis
• PCOS (Polycystic ovarian syndrome ) with hypothyroidism
• Cushing syndrome with hypothyroidism
• Primary obesity with hypothyroidism

14. Investigations
• Urine R/M/E : Normal Finding
• Fasting blood sugar: 5.74 mmol/L ( On 13.03.13 )
5.10 mmol/L ( On 18.04.13 )
• 2hr after breakfast : 7.30 mmol/L ( On 18.04.13 )
• S.Creatinine : 1.10 mg/dl
• SGPT : 40 U/L
• Fasting lipid profile :
S.cholesterol – 234 mg/dl
HDL - 58 mg/dl
LDL - 125 mg/dl
TG - 252 mg/dl

15. Continued
• USG of W/A : Fatty liver
Bilateral prominent ovary
• X-ray skull : Normal finding
• Serum electrolyte : Na – 144 mmol/L , K - 4.1 mmol/L
Cl –106 mmol/L, CO2 – 25 mmol/L
• FT4 : 1.25 ng/dl,
TSH – 3.31 µIU/ml ( On 23.03.23 )
• ACTH : 21.50 pg/ml ( Ref : 03-52 pg/ml )
• FSH : 6.14 IU/L ( Ref : 04-13 IU/L)
• LH : 7.25 IU/L ( Ref : 01.68-15 IU/L)

16. Continued
• Mid night Cortisol : 314.5 nmol/L
• Overnight Dexamethason
Suppression test : Serum Cortisol at 08.00 am –
56.3 nmol/L
• Serum Testosterone : 0.42 ng/dl (Ref : 0.15-0.90 ng/dl )
• Serum DHEA : 6.12 ng/dl (Ref : 1.30-9.80 ng/dl )

17. Clinical Diagnosis
• Metabolic Syndrome with Primary
Hypothyroidism.

18. Problem List
• Intermittent swelling of the both legs ( Ankle oedema )
• Unable to reduce weight despite of diet control and exercise.
• Should we start anti-obesity drug?

19. THANK YOU All