A 37-year-old woman with a history of
Hashimoto's thyroiditis presents to the primary care physician with a several-month history of fatigue and pain after eating. The patient reports burning pain approximately twenty to thirty minutes after every meal with associated nausea. She reports that she drinks one glass of wine with dinner every night. She does not have worsening of the symptoms with any particular food items, and she has not had any recent changes in diet. Temperature is 37°C (98.6°F),
pulse is 84/min, respirations are 14/min and
blood pressure is 110/62 mmHg. Physical exam shows conjunctival pallor as well as a smoothened and shiny tongue, fissures at the angles of the
lips, and a wide-based gait. Laboratory findings are demonstrated below:
| Laboratory value | Result |
| CBC, Serum |
| Hemoglobin | 10.2 g/dL |
| Hematocrit | 33.6% |
| Leukocyte count | 9,000 /mm3 |
| Platelet count | 200,000/mm3 |
| MCV | 109 fL |
| RDW | 11.5-14.5% |
| Serum |
| Sodium | 134 mEq/L |
| Potassium | 4.2 mEq/L |
| Chloride | 96 mEq/L |
| BUN | 37 mg/dL |
| Creatinine | 1.8 mg/dL |
| Albumin | 3.5 g/dL |
Which of the following best describes the mechanism underlying this patient’s clinical manifestations?
