A 44-year-old woman was brought to hospital by police. Over a period of years she had isolated herself and her daughter from society, arousing the concern of neighbours. A scant history of “schizophrenia”, personality disorder and intellectual disability was obtained from distant relatives.
Examination revealed classic clinical features of profound hypothyroidism. In addition, a lump was found on the patient’s ring finger (Box 1, A). Her mental state necessitated admission, after a psychiatric consultation, as an involuntary patient.
Investigations confirmed the diagnosis of hypothyroidism and indicated anaemia due to iron deficiency (Box 2). An x-ray of the lump (Box 1, B) revealed a wedding ring totally encased in the soft tissue. The patient was started on thyroxine and antipsychotic medication and transferred to a psychiatric institution, with marginal improvement in her mental state. Her daughter was removed to the care of child welfare authorities. The wedding ring was surgically removed. Histopathological examination of the lump revealed a foreign body granuloma with chronic low-grade Staphylococcus aureus infection.
2: Results of biochemical and haematological tests
Test |
Result |
Reference range |
|||||||||
TSH (thyrotropin) |
404 mIU/L |
0.1–4.0 mIU/L |
|||||||||
T4 (thyroxine) |
3 pmol/L |
9–26 pmol/L |
|||||||||
Antithyroglobulin antibody |
>2000 IU/mL |
< 100 IU/mL |
|||||||||
Antithyroid peroxidase antibody |
>3000 IU/mL |
<100 IU/mL |
|||||||||
Total cholesterol |
9.0 mmol/L |
2.0–5.5 mmol/L |
|||||||||
Triglycerides |
2.4 mmol/L |
< 1.7 mmol/L |
|||||||||
Haemoglobin |
67 g/L |
115–155 g/L |
|||||||||
White cell count |
4.1 x 109/L |
4.0–11.0 x 109/L |
|||||||||
MCV |
72 fL |
80–96 fL |
|||||||||
MCHC |
315 g/L |
300–350 g/L |
|||||||||
Platelets |
329 x 109/L |
150–400 x 109/L |
|||||||||
Vitamin B12 |
619 pmol/L |
150–600 pmol/L |
|||||||||
Serum folate |
17 nmol/L |
7–39 nmol/L |
|||||||||
Red cell folate |
965 nmol/L |
390–1600 nmol/L |
|||||||||
Iron |
8 μmol/L |
7–35 μmol/L |
|||||||||
Transferrin |
3.5 g/L |
1.9–3.2 g/L |
|||||||||
Transferrin saturation |
9% |
20%–60% |
|||||||||
Ferritin |
7 μg/L |
20–120 μg/L |
|||||||||
MCV = mean cell volume. MCHC = mean cell haemoglobin concentration. TSH = thyroid-stimulating hormone. |
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- Andrei Catanchin1
- Peter R Ebeling2
- Royal Melbourne Hospital, Parkville, VIC.