Bawaskar Hospital and Clinical research center, Mahad, Raigad Maharashtra, India.

The condition known as hypothyroidism is quite common and can have a serious negative effect on a person's health. In the context of replacing thyroid hormone, there is still no one precise ideal target zone for thyroid stimulating hormone concentration. Due to the disease's sluggish progression and sneaky onset, it frequently goes unnoticed.

The condition known as hypothyroidism is quite common and can have a serious negative effect on a person's health. In the context of replacing thyroid hormone, there is still no one precise ideal target zone for thyroid stimulating hormone concentration. Disease frequently goes undiagnosed because of its slow progression and sneaky beginning. Myxomatous tissue deposition causes oedema and neuro-vascular compression, both of which can impact the outflow of the blood and cerebrospinal fluid (CSF) [1].

On October 15, 2019, a 24-year-old woman went to the outpatient clinic complaining of eyesight blurriness and diminution that had been going on for the previous six days. She discovered that when she fixed her attention on an object, it progressively became clearer over time, maybe due to delayed accommodation. She complained of irregular menstrual cycles dating back 18 months, paresthesia in both hands and feet dating back a year, recurring persistent abdomen, chest, and calf cramps, and once severe masseter pains. Her mother reportedly claimed that she snored loudly as she slept, and she also suffered hoarseness of voice, weakness, and sloth.

She was able to remove a large number of hairs from her scalp with ease; throughout the preceding year, the skin on her palms and soles had grown chilly and dry; and she frequently experienced upper respiratory infections. The patient denied ever experiencing headache, vomiting, delirium, or convulsions. She also denied that a related ailment ran in her family. She underwent numerous medical examinations, took multivitamins, and used diuretics for quite some time. She had been on a rigorous diet for the preceding 18 months, but when she was examined, her weight was close to 63 kg, up almost 10 kg from her previously recorded weight. The girl's hair was brittle, her face was puffed up (appendix A), and both of her feet were swollen (appendix B). Her speech was slurred and delayed, and her ankle movements slowly relaxed (appendix video 1). She responded to light with a gradual iris contraction and relaxation (appendix video 2a). Her abdomen was covered with a severe fungal infestation as well. Skin temperature was low, heart rate was 88 beats per minute, and blood pressure was 110/80 mm Hg. The finger counting was delayed in both eyes. Bilateral papilledema with disc vasculature obscuration was seen on fundus examination, along with significant nerve fibre layer elevation, venous congestion, and absence of late cup and venous pulsation with dilated tortuous arteries (Figure-1a arrow). Haemoglobin was found to be 10.2 g/dl, platelet count was 82,000/ul, LDL cholesterol was 132.50 mg/dl (normal= 8-100), total T-3 was 0.5 g/dl (normal=1.3-3.1), T4 was 7.7 g/dl (normal=66.181), TSH was >100 microIU/ml (normal=0.33-5.5), and thyroxin peroxidase MRI brain imaging indicated a normal scan without any evidence of increased intracranial pressure (appendix MRI of brain). A low voltage, total sum of R wave in limb leads I+II+III = 8.5mm(n>15mm), low T wave electrocardiogram with a heart rate of 86 beats per minute was seen on the electrocardiogram (Figure-1b) dated October 15th, 2019. She started taking levothyroxine 100ug daily on an empty stomach, and the dosage was progressively increased to 125ug daily. Her vision has sufficiently improved after 15 days of treatment to make easy number counting possible.Her heart rate was 83 beats per minute on an ECG taken on December 23rd (Figure 1b), and the total voltage of the R waves in her limb leads was I+II+III=22 mm Hg. Her body started to warm up, her voice stopped sounding hoarse, and she stopped snoring while she slept. A bit more than 3 kg of her weight had been dropped. She underwent a second evaluation on December 27 and was reported to have less papilledema. You can follow the vessels from the disc's head all the way to where they turned straight and prominent.

We conducted searches in PubMed and Google Scholar and discovered that, to far, no cases of papilledema without increased intracranial pressure and normal MRI findings have been published [2]. There have been reports of pseudotumor cerebri caused by levothyroxine medication for infantile hypothyroidism [4] and a case of papilledema secondary to systemic hypertension with elevated CSF pressure and myxedema [3]. However, this is the first instance of primary optic nerve papilledema reported without elevated intracranial pressure or any associated symptoms. The primary cause of visual blurring and delayed accommodation is thought to be a gradual axoplasmic flow standstill. Myxomatous tissue deposited at the optic foramen may cause compressive optic neuropathy, which can result in a halt of the venous and CSF flow.

An individual's health can be significantly impacted by the relatively widespread illness known as hypothyroidism.For the concentration of thyroid stimulating hormone, there is yet no single precise ideal target zone that exists while thyroid hormone replacement is taking done.

1.Chaker L,Bianco AC,Jonklaas J,Peeters RP. Hypothyrodism

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3.Wella JR,Vaphiades M . Papilledema in myxedema Neuro-opthalmology 2008;32:303-304 View at Publisher | View at Google Scholar

4.Strickler C,Pilon AF. Presumed leothyroxine –induced pseudotumor cerebri in a pediatric patient being treated for congenital hypothyroidism. Clinical opthlamology 2007; 4:545-549. View at Publisher | View at Google Scholar

Himmatrao saluba. principal bilateral Papilledema due to myxe. Insights of Clinical and Medical Images 2022.