Unsuspected Celiac Disease Severely Affects Levothyroxine Therapy in Hashimoto’s Thyroiditis: a Case Report

Case Report

Austin J Endocrinol Diabetes. 2014;1(5): 1022.

Unsuspected Celiac Disease Severely Affects Levothyroxine Therapy in Hashimoto’s Thyroiditis: a Case Report

Jha S1, Waghdhare S1, Kuchay MS2 and Siddiqui S3*

1Insttute of Endocrinology and Metabolism, Max Healthcare, India

2Sher-I-Kashmir Institute of Medical Sciences, India

3Department of Clinical Research, Max Super Speciality Hospital, India

*Corresponding author: Siddiqui S, Department of Clinical Research, Max Super Speciality Hospital, 2, Press Enclave Road, Saket, New Delhi, India,

Received: July 10, 2014; Accepted: Aug 05, 2014; Published: Aug 08, 2014


Celiac disease (CD) is relatively common in western populations with estimated prevalence of approximately 1%. With the recent availability of sensitive and specific serological testing, many patients who were either asymptomatic or had subtle symptoms had shown CD. Over the past three decades, the pattern of CD presentation has altered. Many CD cases are now detected in adulthood during investigation of problems as diverse as anemia, osteoporosis, autoimmune disorders, unexplained neurological syndromes and infertility. Hashimoto’s thyroiditis is a common thyroid disorder where hypothyroidism is treated by levothyroxine therapy. In our case report, we present how levothyroxine absorption was severely affected by celiac disease in a patient with Hashimoto’s thyroiditis.

Keywords: Hashimoto’s thyroiditis; Hypothyroidism; Celiac disease; Autoimmunity; Levothyroxine therapy


Among autoimmune disorders, celiac disease (CD) has been increasingly reported in patients with autoimmune thyroid disease, type 1 diabetes mellitus, autoimmune liver diseases, and inflammatory bowel disease [1]. It has 1% to 19% prevalence in patients with type 1 diabetes mellitus, 2% to 5% in autoimmune thyroid disorders and 3% to 7% in primary biliary cirrhosis [2,3]. Though the pathogenesis of co-existent autoimmune thyroid disease and CD is unknown, they shared similar human leukocyte antigen (HLA) haplotypes and have been associated with the gene encoding cytotoxic T-lymphocyte-associated antigen-4[4-6].

Screening high risk patients for CD, such as those with autoimmune diseases, always has been a reasonable strategy. Gluten-free diet is known to reverse the complications of atypical CD like increased need for T4 and hence provide potential benefits to general health and perhaps increase life expectancy 7. It also improves glycemic control in patients with type 1 diabetes mellitus and enhances the absorption of medications for associated hypothyroidism and osteoporosis.

Case Presentation

A 23-year-old female, presented with complaints of unintentional weight loss (6 kg in 3 months), hair loss (diffuse), and poor appetite past 6 months. There was no history of fever, cough, vomiting, loose stools, or pain in abdomen.


On examination, she was a thin-built and a pale person with no edema, clubbing, and lymphadenopathy. Her thyroid examination was unremarkable. Other systemic examination was also within normal limits.

In August 2010, her laboratory reports showed Hb as 5.4mg/dl, MCV as 71.12 fl, TSH as 80μIU/l (0.34-5.6), FT4 as 0.12 (0.58-1.64), and FT3 as 0.23 (2.5-3.9). The anti-TPO antibody was high and iron profile revealed iron-deficiency anemia.


In addition to 25 μg thyroxin, oral iron replacement therapy was instituted which subsequently improved her anemia. However, her requirement of thyroxin kept on increasing. Her TSH levels were never within the normal range despite increasing the thyroxin dose from 25 μg to 125μg. Even after consumption of 150 μg of thyroxin, her TSH levels remained mainly in the range of 300-400μIU/l (Table 1 and Figure 1). The patient was more concerned about her persistent elevated TSH levels. Hence, she was referred to Max Super Specialty Hospital, Saket. At the time (03-Jan-2011) of her visit to the hospital, her TSH level was 486μIU/l. She was highly compliant to her medications and used to take thyroxin empty stomach at 6 am in the morning. She was found positive for IgA anti-tissue transglutaminase (anti-tTG) antibodies. Upper GI endoscopy and duodenal biopsy revealed cryptic hyperplasia and villous atrophy, suggestive of celiac disease. Hence, she was put on gluten-free diet on 12-Mar-2011.

Citation: Jha S, Waghdhare S, Kuchay MS and Siddiqui S. Unsuspected Celiac Disease Severely Affects Levothyroxine Therapy in Hashimoto’s Thyroiditis: a Case Report. Austin J Endocrinol Diabetes. 2014;1(5): 1022. ISSN: 2381-9200.