A 35-Year-Old Lady With White Scalp Hair

Presented ByDr. S. M. Arafat

FCPS Student, Endocrionology Unit,BSMMU.

Particulars of the patient

• Name : Mrs. M• Age : 35 years• Sex : Female• Occupation : Housewife• Wife of : Mr. E• Date of admission : 29/06/13• Date of examination : 07/07/13

Presenting complaints

• Recurrent loss and eruption of white hair in same area of scalp

History of present illness

• She first observed fall of hair about 2 years back

• Loss of hair in a localized area of scalp

• First visited to an qualified physician and was prescribed inj. Triamcinolone(40mg)

• Eruption of white hair in the same area

• In this setting diagnosed as a case of hypothyroidism

Cont ..

• Referred to an endocrinologist • On asking gave history of menorrhagia ,

constipation and after investigations thyroxine was given

• No improvement of colour of hair

• She again observed fall of hair in previous area on November of last year

Cont…

• Visited dermatologist but no satisfactory improvement

• Again eruption of white hair in January and

February of this year

Cont…

• She also complains of occasional per rectal bleeding during defecation

• Pain in anus• Feeling of something in anus • But does not complain of abdominal pain, oral

ulcer, joint pain , weight loss or fever

Associated illness

• Non hypertensive

• Non diabetic

Personal history

• Non smoker

• Personal hygiene is satisfactory

• No history of contact with sputum positive pulmonary TB patient

Family History

• 1 son and 2 daughters• 3 sisters and 2 brothers

SOCIOECONOMIC HISTORY

• Her husband lives in Saudi Arabia• Monthly income of her family is about

30000/- Tk• Living circumstances : tin shade house with sanitary latrine drinks tube well water (Arsenic present)

Immunization history

• She is immunized completely according to EPI schedule

Treatment history

• She took inj. Triamcinolone acetonide (40mg) i/m - 3 weekly – 3 doses – from 29/7/2011

• She started taking tab. Thyroxine (50µgm) on 21/10/2011

• Again started tab. Thyroxine on 4/5/2012

General examination

• There is whitish hair and loss of hair involving part of left parietal and temporal region and left parietal eminence of scalp

• Other area is normal

Cont…

• Thyroid gland is diffusely enlarged, non-tender, firm in consistency, freely mobile, no retrosternal extension, no bruit

• No palpable lymph node

• No exophthalmos

• No sign of toxicosis

• There is no other abnormality in general examination

Systemic examination

• Systemic examination reveals no abnormality

Clinical diagnosis

• Hypothyroidism and hemorrhoids and anal fissure and ? Poliosis / ? Vitiligo with ? Alopecia areata

Investigations

• 29/07/11 : Hb%-10.6 gm/dl RBS-4.98 mmol/L S. TSH-24.9µIU/ml

• 06/10/12 : S. TSH- >25µIU/ml

Cont…

• 02/07/13 : CBC with PBF – Hb% - 12.5 gm/dl ESR – 65 mm in 1st hr TC – 10500/cumm DC – N: 39% L : 48% M : 3% E : 10% B : 0 % PBF : Eosinophilia

Cont…

• Urine R/M/E : normal

• Serum antibody to Thyroglobulin : >1000 IU/ml

• Serum antibody to thyroid peroxidase : >1000 IU/ml

• Serum TSH : 0.60 µIU/ml

Cont…

• 06/07/13 : ANA – positive

• 07/07/13 : anticardiolipin antibody : negative

• X – ray skull B/V : normal

• X – ray dorsolumbar spine B/V : normal

Plan

• Wood lamp examination

• Consultation with dermatologist

Problem list

• What will be the DX for white hair

• What investigation may we do to confirm the DX