A nice academic demonstration of the Woltman’s sign in a patient with profound hypothyroidism, who’s TSH was 200 mIU/L. Delayed relaxation of the ankle reflex normalized as TSH improved with proper thyroid hormone supplementation. The Woltman’s sign could be useful if thyroid laboratory testing is not available and the patient’s baseline ankle reflex is known.
N E J M
A 53-year-old man presented to the endocrinology clinic with a 6-month history of progressive generalized fatigue and increased sensitivity to cold. At the time of presentation, a physical examination was notable for the presence of a diffusely enlarged thyroid gland and delayed relaxation of the ankle jerk reflex.
Laboratory investigations were notable for a TSH of 200 mIU/L (reference range, 0.35-5.50) and a serum FT4 of 0.05 ng/dL (reference range, 0.89 to 1.76 ng/dL). Woltman’s sign, which refers to the delayed relaxation phase of a deep-tendon reflex, is a neurologic manifestation of hypothyroidism. This delayed relaxation can also be associated with pregnancy, anorexia nervosa, diabetes mellitus, and advanced age.
The patient received thyroid hormone replacement therapy with levothyroxine for primary hypothyroidism. One month later, the serum free thyroxine level had increased to 1.23 ng/dL, the TSH was 20.5 mIU/L, and the patient’s ankle jerk relaxation had normalized. The thyrotropin level normalized to 3.2 mIU/L at the subsequent follow-up visit.