Endo Case Challenge: Rash, Brain Fog, and Sleep Issues in a 50-Year-Old IT Director

Shahd Bsata, MD; Stephanie L. Lee, MD, PhD


August 19, 2022

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 50-year-old woman with euthyroid Hashimoto thyroiditis and urticaria is referred for evaluation of a thyroid nodule after an insufficient fine-needle biopsy at another institution. She is seen for a second opinion regarding a repeat thyroid biopsy.

She initially presented to her primary care physician with a goiter, without compressive symptoms of dysphagia or throat clearing. Her past medical history is significant for persistent urticaria treated with high-dose antihistamines. She reports brain fog, diminished sleep, irritability, fatigue, reduced executive function, and aches in her wrists and toes.

The patient has not had any exposure to radiation. Her family history is negative for thyroid cancer but is positive for endocrine disease. Her father had Graves hyperthyroidism and a pituitary adenoma. Her brother has hypothyroidism, and her mother has a history of renal stones and surgery for hyperparathyroidism from a single parathyroid adenoma. The patient has no drug allergies. She works as an associate director of information technology.


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