It's textbook...

Sometimes, I look at a patient in clinic and think, "This patient belongs in a textbook...in fact, I think I saw a picture like this in a textbook in medical school. If only I could remember what it is..."

This girl was one of those patients who looked like her picture belonged in a book. You can't tell as much from the picture, but she was short/stout.

She is an adolescent with a goiter that had been growing since she was a child. Her parents said that she used to speak as a child but for the past eight years she hasn't made much sense. Although, she understood when I asked her to come and could say her name. But she didn't say much else, she just looked at me with a somewhat vacant, sad stare.

huge goiter

We checked her thyroid function and her TSH was 26. (very high, which means her thyroid isn't working). All of her symptoms (mental deficiency, goiter, stunted physical growth) seem to be from congenital hypothyroidism, which causes cretinism. 

Cretinism. Thats the textbook diagnosis I was looking for. Cretinism is a condition of severely stunted physical and mental growth due to untreated congenital deficiency of thyroid hormones. Its a condition that has been all but eliminated in developed countries due to the introduction of iodised salt and other iodine supplementation. It was so effectively eliminated that I had only seen it in the black-and-white pictures of my medical school textbooks...until now.

typical textbook cretinism photo

I did a little reading and found some quite interesting information:

• According to the World Health Organization, "Iodine deficiency is the single greatest preventable cause of mental retardation."  The Lancet, Iodine deficiency- way to go yet. 
• When iodized salt was introduced and became widely used in the USA in 1924, there was a gradual increase in average intelligence of one standard deviation. IQ increased up to 15 points in iodine deficient areas!  (fascinating article here)
• Millet (one of the staple foods here) decreases iodine absorption (cabbage, corn, and radishes can also).
• We are on the UNICEF list of sixteen "Make-or-Break" countries with high numbers of unprotected newborns, low levels of salt iodization, and a need for a high level of support in attaining universal salt iodization. (UNICEF report here).

The same report shows that from 1995 to 2005 iodine intake has increased from 7% to 46% of households here. Perhaps that is partly due to the ubiquitous, iodine-containing Maggi chicken bullion cube used in cooking here.

Don't forget the iodised salt and MSG!