Esteban, Mica Gayle C.

Nutrition Therapy II
BS HNCA III-01
December 01, 2014

Medical

Case 2
CASE PRESENTATION
______________________________________________________________________
45 years old Hazel Dela Cruz is diagnosed with hypothyroidism on levothyroxine 50
mcg daily presented with painful progressively enlarging goiter over the course of 3
months ( R>L) associated with compressive symptoms like difficulty breathing and
swallowing, no change in voice. Levothyroxine held for three weeks and CT soft tissue
neck done which showed marked bilateral enlarged thyroid lobes and isthmus, R/L 9
cm/3.5-4.5cm displacing the trachea and mass effect of posteriorly displaced
esophagus. Ht: 55, Weight 185lbs
TSH 26 uIU/mL and FT4 0.7 ng/dl, TPO 21885 IU/mL and TSI 39
Thyroid ultrasound showed heterogeneous echogenicity suspicious for autoimmune
thyroiditis with overall normal vascularity. Also two right sided solid and one left sided
nodules, each > 1 cm found. FNA of the nodules- Both the right sided were negative for
malignancy but the left one was indeterminate-cellular micro follicular proliferation
indicating follicular neoplasm; probably adenoma but cannot exclude follicular
carcinoma. Differential at that time included - thyroid cancer/ lymphoma vrs thyroiditis.
Patient was started on levothyroxine and prednisone taper with some improvement in
symptoms. Surgery referral for thyroidectomy was done given the rapidity of the
enlarging goiter, indeterminate finding on left thyroid FNA, and prior report of
compressive symptoms (improved after prednisone taper) After total thyroidectomy with
parathyroid auto transplantation, initial pathology results consistent with Hashimotos
Thyroiditis with fibrous variant, but lots of plasma cells; immunohistochemistry showed
presence of light chains. Free kappa, lambda light chains, Kappa to Lamda ratio, urine
and serum electrophoresis within normal limits. But the final pathology results were
later addended as follows - Immuno
histochemical stains for CD10 and CD117 interpreted as negative within the plasm
a cell component, and kappa and lambda double stain interpreted as polytypic with
variable kappa-to-lambda ratios of 4-5:1 to 2-3:1.
IgG4 was positive in > 20 plasma cells per high power field meeting a criterion outlined
by Li, et al for IgG4 Hashimoto's Thyroiditis. A form of Hashimotos thyroiditis with
lymphoplasmacytic sclerosing changes and increased numbers of IgG4 -positive
plasma cells has recently been reported in the literature. These histopathological

features suggest that this subtype of Hashimotos thyroiditis may be closely related to
IgG4-related disease. Therefore, this unique form of IgG4-related Hashimotos
thyroiditis, which is referred to as IgG4 thyroiditis, has its own clinical, serological, and
sonographic features that are distinct from those associated with non-IgG4 thyroiditis. It
is associated with rapid progression, subclinical hypothyroidism, higher level of
circulating antibodies and diffuse low echogenicity and male predominance.
DRUG-NUTRIENT INTERACTION
______________________________________________________________________

Drug

Purpose

Side Effects

Prednisone

breathing
problems and
immune system
disorders

Levothyroxine

is a synthetic form
of thyroxine (T4),
an endogenous
hormone secreted
by the thyroid
gland, which is
converted to its
active metabolite,
L-triiodothyronine
(T3).

Interaction with
Food
Sleep problems
Alcoholmay
Increased
increase risk of
appetite
having stomach
Slow
wound
ulcers
and
healing
bleeding in the
Nausea
digestive tract
Dizziness
High
sodium
foods- increases
fluid retention
Potassium and
Calcium
rich
foodseliminated
by
the medication

Headache
Sleep problems
Nervousness
Sweating
Fever

Monitor
fiber
intake
Monitor
soy
products
Monitor
coffee
consumption

NUTRITIONAL ASSESSMENT
_____________________________________________________________________
Subjective:
45-year-old
Female
Height: 55
Weight: 185 lbs or 84 kg
.

Objective:
Medical Diagnosis:
Hypothyroidism
Goiter
Hashimotos Thyroiditis with fibrous
variant
Symptoms:
Difficulty breathing
Difficulty Swallowing
No change in voice
Findings:
CT scan on the neck was made which
shows a bilateral enlarged thyroid
lobes and isthmus, R/L 9 cm/3.5-4.5cm
Thyroid
ultrasound
showed
heterogeneous echogenicity suspicious
for autoimmune thyroiditis with overall
normal vascularity.
Surgery referral for thyroidectomy was
done given the rapidity of the enlarging
goiter, indeterminate finding on left
thyroid FNA, and prior report of
compressive symptoms
initial pathology results consistent with
Hashimotos Thyroiditis with fibrous
variant
final pathology results were kappa-tolambda ratios of 4-5:1 to 2-3:1
Hashimotos thyroiditis may be closely
related to IgG4-related disease

BIOCHEMICAL PARAMETERS
TSH 26 uIU/mL (normal
range: 0.35-5.5 uIU/mL )
FT4 0.7 ng/dl normal

normal range: 0.35-5.5

uIU/mL
normal range: 0.7-1.9 ng/dl

Increased

TPO 21885 IU/mL

normal range: <35 IU/mL

increased

TSI 39

normal range: <130%

normal

Kappa to Lambda Ratio 45:1 to 2-3:1

normal range: 3:1

increased

normal

NUTRITIONAL DIAGNOSIS:
Difficulty in swallowing and breathing
BMI: 31 (obese 1)
In risk of Hypertension
NUTRITIONAL INTERVENTION:

Low Carbohydrate
Low Sodium
Low Calorie
High Potassium
Soft Diet

Kcal: 2000 ; CHO: 250g ; CHON: 100g ; Fat: 70g

DBW:

TER:

BMI:

65*2.54-100-10%
=165.1-100-10%
=65.1-6.51=
58.59 or 59kg

84*30= 2,520-500
= 2,020 or 2,000 kcal

84/ 2.72
=30.8 or 31 (Obese I)

CHO: (50%)
2,000*.50/4
=250

CHON: (20%)
2,000*.20/4
=100g

FAT: (30%)
2,000*.30/9=
66.66 or 70g

Food List
Veg A.
Veg B.
Fruit
Milk:
Whole
Low Fat
Skimmed
Sugar
Rice
Meat:
Low Fat
Medium Fat
High Fat

No. of Ex
4
6
4

CHO
6
18
50

CHON
2
6
-

FAT
-

KCAL
32
96
200

2
1
1
3
5

12
12
12
15
115

8
8
8
10

10
5
-tr
-

170
125
80
60
500

3
2
2

24
16
16

3
12
20

123
172
244

Fat
Total

240g

99g

20
50g

180
1, 982 kcal

Breakfast
2
1

AM snack
1

Food List
Veg A.
Veg B.
Fruit
Milk:
Whole
Low Fat
Skimmed
Sugar
Rice
Meat:
Low Fat
Medium
Fat
High Fat
Fat

No. of Ex
4
6
4
2
1
1
3
5
3
2
2
4

Lunch
2
3
-

PM snack
1

Dinner
3
1

1
1
1

1
1
1
1

1
2
2

1
1
3

1
1

MENU:
Breakfast:
Corned beef with cabbage and potato (1ex. Medium fat meat, 2 ex. Vegetable
A., 1 ex. Rice)
1 glass of milk with 1tsp. sugar ( 1ex. Low fat milk, 1 ex. Sugar)
cup rice (1 ex. Rice)
1 slice papaya (1 ex. Fruit)
AM snack:
1 pc. Boiled egg (1ex. Medium at meat)
1 cup strawberries ( 1 ex. Fruit)
1 glass of fresh milk (1 ex. Whole milk)
Lunch:
cup kalabasa, okra, kadyos, string beans, ampalaya, (3 ex. Vegetable B, 2
ex. Vegetable A)
2 slices pork tenderloin, 1 slice pork pigue (2 ex. Low fat meat, 1ex. High fat
meat)
3 tsp. olive oil (3 ex fat)
=to make Pinakbet with pork
1 cup steamed rice (1 ex. Rice)
1 pc. Ice drop (1 ex. Sugar)
PM Snack:
2 pcs whole wheat bead ( 1 ex. Rice)
1 slice cheese ( 1 ex. High fat meat)
1 slice of mango (1 ex. Fruit)
Dinner:
Grilled herbed chicken with buttered corn and asparagus with blanched
carrots. ( 1 ex. Low fat meat, 3 ex. Vegetable b, 1 ex. Fat)
cup yoghurt with grapes (1 ex. Skimmed milk, 1 ex fruit)
1 pc. Yema ( 1 ex. Sugar)

MONITORING & EVALUATION

 Monitor the improvement of the swallowing and breathing for the transition of
soft diet to normal diet
Do light exercise 30 minutes every day like walking
Limit sodium intake to 1,300mg per day