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Okosieme OE, Usman D, Taylor PN, Dayan CM, Lyons G, Moran C, Chatterjee K, Rees DA. Cardiovascular morbidity and mortality in patients in Wales, UK with resistance to thyroid hormone β (RTHβ): a linked-record cohort study. Lancet Diabetes Endocrinol 2023; 11:657-666. [PMID: 37475119 DOI: 10.1016/s2213-8587(23)00155-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/20/2023] [Accepted: 05/21/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Individuals with resistance to thyroid hormone owing to mutations in the thyroid hormone receptor β gene (RTHβ) exhibit impaired tissue sensitivity to thyroid hormones, but retain sensitivity in cardiac tissue. Long-term health and survival outcomes in this rare disorder have not been evaluated. We investigated all-cause mortality and cardiovascular event risk in a cohort of patients with RTHβ, followed-up in UK endocrine clinics. METHODS In a retrospective cohort design, we linked genetically confirmed patients with RTHβ and age-matched and sex-matched population controls to outcomes in datasets within the Welsh Secure Anonymised Information Linkage (SAIL) Databank. Kaplan-Meier and Cox regression models analysed associations of RTHβ with all-cause mortality and cardiovascular events. FINDINGS We identified 61 patients with a genetic diagnosis of RTHβ between Jan 1, 1997, and Dec 31, 2019, and matched them with 2750 controls. Compared with controls, patients exhibited increased risks for all-cause mortality (hazard ratio [HR] 2·84, 95% CI 1·59-5·08), atrial fibrillation (10·56, 4·72-23·63), heart failure (HR 6·35, 95% CI 2·26-17·86), and major adverse cardiovascular events (MACE), comprising cardiovascular death, acute myocardial infarction, heart failure, or strokes (HR 3·49, 95% CI 2·04-5·99). The median age of first occurrence of any adverse event was 11 years earlier in patients (56 years, 95% CI 44-65) compared with controls (67 years, 65-70). Cubic spline analyses showed positive associations between FT4 concentrations at diagnosis and mortality or MACE, with FT4 concentration of 30 pmol/L or greater conferring increased risk. Compared with no intervention, treatment with antithyroid drugs, surgery or radioiodine gland ablation, or thyroxine did not control thyroid hormone excess. INTERPRETATION We have documented reduced survival and increased cardiovascular morbidity in a cohort of patients with RTHβ for the first time. These outcomes might be driven by lifelong cardiac exposure to thyroid hormone excess; and effective therapies, targeting hormone resistant pathways, could potentially curtail this risk. FUNDING Royal College of Physicians, Wellcome Trust Investigator Award, and NIHR Cambridge Biomedical Research Centre.
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Affiliation(s)
- Onyebuchi E Okosieme
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK; Diabetes and Endocrinology Department, Prince Charles Hospital, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK.
| | - Danyal Usman
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Peter N Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Colin M Dayan
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Greta Lyons
- Wellcome Trust-MRC Institute of Medical Science, University of Cambridge, Cambridge, UK
| | - Carla Moran
- Endocrine Section, Beacon Hospital, Dublin, Ireland; Endocrine Department, St Vincent's University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Krishna Chatterjee
- Wellcome Trust-MRC Institute of Medical Science, University of Cambridge, Cambridge, UK
| | - Dafydd Aled Rees
- Neuroscience and Mental Health Innovation Institute, Cardiff University, Cardiff, UK
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Heldmann M, Chatterjee K, Moran C, Rogge B, Steinhardt J, Wagner-Altendorf T, Göttlich M, Schacht H, Schramm P, Brabant G, Münte TF, Cirkel A. Reduced pituitary size in subjects with mutations in the THRB gene and thyroid hormone resistance. Endocr Connect 2022; 11:EC-21-0473.R2. [PMID: 34860176 PMCID: PMC8789019 DOI: 10.1530/ec-21-0473] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 12/03/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Thyroid hormone action is mediated by two forms of thyroid hormone receptors (α, β) with differential tissue distribution. Thyroid hormone receptor β (TRβ) mutations lead to resistance to thyroid hormone action in tissues predominantly expressing the β form of the receptor (pituitary, liver). This study seeks to identify the effects of mutant TRβ on pituitary size. METHODS High-resolution 3D T1-weighted magnetic resonance images were acquired in 19 patients with RTHβ in comparison to 19 healthy matched controls. Volumetric measurements of the pituitary gland were performed independently and blinded by four different raters (two neuroradiologists, one neurologist, one neuroscientist). RESULTS Patients with mutant TRβ (resistance to thyroid hormone β, RTHβ) showed elevated free tri-iodothyronine/thyroxine levels with normal thyroid-stimulating hormone levels, whereas healthy controls showed normal thyroid hormone levels. Imaging revealed smaller pituitary size in RTHβ patients in comparison to healthy controls (F(1,35) = 7.05, P = 0.012, partial η2 = 0.17). CONCLUSION RTHβ subjects have impaired sensitivity to thyroid hormones, along with decreased size of the pituitary gland.
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Affiliation(s)
- Marcus Heldmann
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Department of Psychology II, University of Lübeck, Lübeck, Germany
| | - Krishna Chatterjee
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Carla Moran
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Berenike Rogge
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | | | | | - Martin Göttlich
- Department of Neurology, University of Lübeck, Lübeck, Germany
| | - Hannes Schacht
- Department of Neuroradiology, University of Lübeck, Lübeck, Germany
| | - Peter Schramm
- Department of Neuroradiology, University of Lübeck, Lübeck, Germany
| | - Georg Brabant
- Department of Internal Medicine I, University of Lübeck, Lübeck, Germany
- Department of Endocrinology, The Christie, University of Manchester, Manchester, UK
| | - Thomas F Münte
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Department of Psychology II, University of Lübeck, Lübeck, Germany
| | - Anna Cirkel
- Department of Neurology, University of Lübeck, Lübeck, Germany
- Correspondence should be addressed to A Cirkel:
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Suntornlohanakul O, Sriphrapradang C. Pituitary hyperplasia mimicking thyrotropin-producing pituitary adenoma in the patient with resistance to thyroid hormone: a case report. Int J Neurosci 2020; 132:207-211. [PMID: 32727243 DOI: 10.1080/00207454.2020.1803304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The syndrome of inappropriate thyroid-stimulating hormone (TSH) secretion is characterized by high circulating thyroid hormone concentrations in the presence of non-suppressed TSH. After exclusion of the laboratory interference, TSH-secreting pituitary adenoma (TSHoma) or resistance to thyroid hormone-beta (RTH-β) should be suspected. The presence of a pituitary adenoma on the hypothalamic-pituitary imaging supports the diagnosis of TSHoma. However, the incidental findings of non-functioning pituitary adenomas may appear in patients with RTH-β. Abnormal MRI finding in the RTH-β patient also includes pituitary enlargement from thyrotroph hyperplasia. We herein reported a patient with inappropriate TSH secretion who has pituitary hyperplasia mimicking TSHoma. This case illustrates the diagnostic tests to distinguish an RTH-β from TSHoma.
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Affiliation(s)
- Onnicha Suntornlohanakul
- Endocrinology and Metabolism Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Chutintorn Sriphrapradang
- Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Tjörnstrand A, Nyström HF. DIAGNOSIS OF ENDOCRINE DISEASE: Diagnostic approach to TSH-producing pituitary adenoma. Eur J Endocrinol 2017; 177:R183-R197. [PMID: 28566440 DOI: 10.1530/eje-16-1029] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 03/27/2017] [Accepted: 05/30/2017] [Indexed: 01/03/2023]
Abstract
Thyrotropin (TSH)-secreting adenomas (TSHomas) are the rarest form of pituitary adenomas, and most endocrinologists will see few cases in a lifetime, if any. In most cases, the diagnostic approach is complicated and cases may be referred after being presented as a syndrome of inappropriate TSH secretion or as a pituitary mass. This review aims to cover the past, present and possible future diagnostic approaches to TSHomas, including different clinical presentations, laboratory assessment and imaging advances. The differential diagnoses will be discussed, as well as possible coexisting disorders. By evaluating the existing reports and reviews describing this rare condition, this review aims to present a clinically practical suggestion on the diagnosic workup for TSHomas, Major advances and scientific breakthroughs in the imaging area in recent years, facilitating diagnosis of TSHomas, support the belief that future progress within the imaging field will play an important role in providing methods for a more efficient diagnosis of this rare condition.
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Affiliation(s)
- Axel Tjörnstrand
- Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Helena Filipsson Nyström
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Endocrinology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Moran C, Habeb AM, Kahaly GJ, Kampmann C, Hughes M, Marek J, Rajanayagam O, Kuczynski A, Vargha-Khadem F, Morsy M, Offiah AC, Poole K, Ward K, Lyons G, Halsall D, Berman L, Watson L, Baguley D, Mollon J, Moore AT, Holder GE, Dattani M, Chatterjee K. Homozygous Resistance to Thyroid Hormone β: Can Combined Antithyroid Drug and Triiodothyroacetic Acid Treatment Prevent Cardiac Failure? J Endocr Soc 2017; 1:1203-1212. [PMID: 29264576 PMCID: PMC5686666 DOI: 10.1210/js.2017-00204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/01/2017] [Indexed: 11/20/2022] Open
Abstract
Resistance to thyroid hormone β (RTHβ) due to homozygous THRB defects is exceptionally rare, with only five kindreds reported worldwide. Cardiac dysfunction, which can be life-threatening, is recognized in the disorder. Here we describe the clinical, metabolic, ophthalmic, and cardiac findings in a 9-year-old boy harboring a biallelic THRB mutation (R243Q), along with biochemical, physiologic, and cardiac responses to carbimazole and triiodothyroacetic acid (TRIAC) therapy. The patient exhibits recognized features (goiter, nonsuppressed thyroid-stimulating hormone levels, upper respiratory tract infections, hyperactivity, low body mass index) of heterozygous RTHβ, with additional characteristics (dysmorphic facies, winging of scapulae) and more markedly elevated thyroid hormone levels, associated with the homozygous form of the disorder. Notably, an older sibling with similar clinical features and probable homozygous RTHβ had died of cardiac failure at age 13 years. Features of early dilated cardiomyopathy in our patient prompted combination treatment with carbimazole and TRIAC. Careful titration of therapy limited elevation in TSH levels and associated increase in thyroid volume. Subsequently, sustained reduction in thyroid hormones with normal TSH levels was reflected in lower basal metabolic rate, gain of lean body mass, and improved growth and cardiac function. A combination of antithyroid drug and TRIAC therapy may prevent thyrotoxic cardiomyopathy and its decompensation in homozygous or even heterozygous RTHβ in which life-threatening hyperthyroid features predominate.
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Affiliation(s)
- Carla Moran
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Abdelhadi M Habeb
- Department of Paediatrics, Prince Mohammed bin Abdulaziz Hospital for National Guard & Taibah University, Al-Madinah 41511, Kingdom of Saudi Arabia
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz 55101, Germany
| | - Christoph Kampmann
- Department of Paediatric Cardiology, Johannes Gutenberg University Medical Center, Mainz 55101, Germany
| | - Marina Hughes
- Department of Cardiology, Great Ormond Street Hospital for Children, London WC1N 3JH, United Kingdom
| | - Jan Marek
- Department of Cardiology, Great Ormond Street Hospital for Children, London WC1N 3JH, United Kingdom
| | - Odelia Rajanayagam
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Adam Kuczynski
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, United Kingdom
| | - Faraneh Vargha-Khadem
- Department of Neuropsychology, Great Ormond Street Hospital for Children, London WC1N 3JH, United Kingdom
| | - Mofeed Morsy
- Department of Paediatrics, Sohag University, Egypt
| | - Amaka C Offiah
- Academic Unit of Child Health, University of Sheffield, Sheffield S10 2TH, United Kingdom
| | - Ken Poole
- Department of Rheumatology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Kate Ward
- Nutrition and Bone Health, MRC Elsie Widdowson Laboratory, Cambridge CB1 9NL, United Kingdom
| | - Greta Lyons
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - David Halsall
- Department of Clinical Biochemistry, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Lol Berman
- Department of Radiology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - Laura Watson
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - David Baguley
- Department of Audiology, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
| | - John Mollon
- Department of Experimental Psychology, University of Cambridge, Cambridge CB2 3EB, United Kingdom
| | - Anthony T Moore
- Moorfields Eye Hospital, London EC1V 2PD, United Kingdom.,Department of Ophthalmology, Great Ormond Street Hospital for Children, London WC1N 3JH, United Kingdom
| | | | - Mehul Dattani
- Department of Endocrinology and Section of Genetics and Epigenetics in Health and Disease, Great Ormond Street Hospital for Children and University College London Institute of Child Health, London WC1N 3JH, United Kingdom
| | - Krishna Chatterjee
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge CB2 0QQ, United Kingdom
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Amlashi FG, Tritos NA. Thyrotropin-secreting pituitary adenomas: epidemiology, diagnosis, and management. Endocrine 2016; 52:427-40. [PMID: 26792794 DOI: 10.1007/s12020-016-0863-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2015] [Accepted: 01/09/2016] [Indexed: 01/10/2023]
Abstract
Inappropriate secretion of TSH was first described in 1960 in a patient with evidence of hyperthyroidism and expanded sella on imaging. It was later found that a type of pituitary adenoma that secretes TSH (thyrotropinoma) was the underlying cause. The objective of the present review article is to summarize data on the epidemiology, pathogenesis, diagnosis, and management of thyrotropinomas. The prevalence of thyrotropinomas is lower than that of other pituitary adenomas. Early diagnosis is now possible thanks to the availability of magnetic resonance imaging and sensitive laboratory assays. As a corollary, many patients now present earlier in the course of their disease and have smaller tumors at the time of diagnosis. Treatment also has evolved over time. Transsphenoidal surgery is still considered definitive therapy. Meanwhile, radiation therapy, including radiosurgery, is effective in achieving tumor control in the majority of patients. In the past, radiation therapy was used as second line treatment in patients with residual or recurrent tumor after surgery. However, the availability of somatostatin analogs, which can lead to normalization of thyroid function as well as shrink these tumors, has led to an increase in the role of medical therapy in patients who are not in remission after pituitary surgery. In addition, dopamine agonists have shown some efficacy in the management of these tumors. Better understanding of the molecular pathogenesis of thyrotropinomas may lead to rationally designed therapies for patients with thyrotropinomas.
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Affiliation(s)
- Fatemeh G Amlashi
- Neuroendocrine Unit, Massachusetts General Hospital, Zero Emerson Place # 112, Boston, MA, 02114, USA
- Harvard Medical School, Boston, MA, USA
| | - Nicholas A Tritos
- Neuroendocrine Unit, Massachusetts General Hospital, Zero Emerson Place # 112, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
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7
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Han R, Ye L, Jiang X, Zhou X, Billon C, Guan W, Gauthier K, Fang W, Wang W, Samarut J, Ning G. Characteristics of patients with late manifestation of resistance thyroid hormone syndrome: a single-center experience. Endocrine 2015; 50:689-97. [PMID: 26041374 DOI: 10.1007/s12020-015-0622-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 04/27/2015] [Indexed: 11/30/2022]
Abstract
Resistance to thyroid hormone (RTH) is a rare genetic disease caused by reduced tissue sensitivity to thyroid hormone. The hallmark of RTH is elevated serum levels of thyroid hormone with unsuppressed thyrotropin (TSH). However, the most common form of RTH results from minor defects in the ligand-binding domain or hinge domain of the TRβ gene, resulting in impaired T3-induced transcriptional activity, often showing mild presentation. Early diagnosis can be challenging. The objective of the current study was to characterize this specific group of RTH patients. This was a retrospective study. Patients diagnosed as RTH with TRβ mutations were enrolled in a single institute between 2004 and 2014. A total of 14 patients were diagnosed as RTH with mutation in THβ gene. The median age at diagnosis was 22.5 (IQR: 13.25-32.75). Goiter was the most common clinical finding. TSH was significantly elevated after TRH injection (median peak was 21.83 μIU/l, IQR: 13.59-31.48), 9.2-fold compared to the basal level. We found 10 mutations in TRβ gene, all located in the last four exons, and including one novel mutation, H271D. In vitro study found that H271D mutation reduced TR affinity to T3. Four patients with intact thyroid were diagnosed after 16 years old, defined as late manifestation. Compared to those diagnosed before 10 years old, patients with late manifestation presented with normal growth and mental development. Interestingly, three of them carried R438H mutation. We identified a novel p.H271D mutation in TRβ associated with RTH. Endocrinologists should be alert that RTH is frequently found in euthyroid patients with mild symptoms and often leads to misleading diagnosis as well as inappropriate treatment.
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Affiliation(s)
- Rulai Han
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Lei Ye
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200025, People's Republic of China.
- Shanghai Key Laboratory for Endocrine Tumors and Shanghai Clinical Center for Endocrine and Metabolic Diseases, Ruijin Hospital, 197 Ruijin 2nd Road, Shanghai, 200025, People's Republic of China.
| | - Xiaohua Jiang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Xiaoyi Zhou
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Cyrielle Billon
- Institut de Génomique Fonctionnelle de Lyon, Université de Lyon, Université Lyon 1, CNRS, INRA, Ecole Normale Supérieure de Lyon, 46 allée d'Italie, 69364, Lyon Cedex 07, France
| | - Wenyue Guan
- Institut de Génomique Fonctionnelle de Lyon, Université de Lyon, Université Lyon 1, CNRS, INRA, Ecole Normale Supérieure de Lyon, 46 allée d'Italie, 69364, Lyon Cedex 07, France
| | - Karine Gauthier
- Institut de Génomique Fonctionnelle de Lyon, Université de Lyon, Université Lyon 1, CNRS, INRA, Ecole Normale Supérieure de Lyon, 46 allée d'Italie, 69364, Lyon Cedex 07, France
| | - Weiyuan Fang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Weiqing Wang
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200025, People's Republic of China
| | - Jacques Samarut
- Institut de Génomique Fonctionnelle de Lyon, Université de Lyon, Université Lyon 1, CNRS, INRA, Ecole Normale Supérieure de Lyon, 46 allée d'Italie, 69364, Lyon Cedex 07, France
| | - Guang Ning
- Shanghai Clinical Center for Endocrine and Metabolic Diseases, Shanghai Institute of Endocrine and Metabolic Diseases, Department of Endocrine and Metabolic Diseases, Rui-Jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, 200025, People's Republic of China
- Laboratory for Endocrine & Metabolic Diseases of Institute of Health Science, Shanghai Jiaotong University School of Medicine and Shanghai Institutes for Biological Sciences, Chinese Academy of Sciences, 227 South Chong Qing Road, Shanghai, 200025, People's Republic of China
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Koulouri O, Moran C, Halsall D, Chatterjee K, Gurnell M. Pitfalls in the measurement and interpretation of thyroid function tests. Best Pract Res Clin Endocrinol Metab 2013; 27:745-62. [PMID: 24275187 PMCID: PMC3857600 DOI: 10.1016/j.beem.2013.10.003] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Thyroid function tests (TFTs) are amongst the most commonly requested laboratory investigations in both primary and secondary care. Fortunately, most TFTs are straightforward to interpret and confirm the clinical impression of euthyroidism, hypothyroidism or hyperthyroidism. However, in an important subgroup of patients the results of TFTs can seem confusing, either by virtue of being discordant with the clinical picture or because they appear incongruent with each other [e.g. raised thyroid hormones (TH), but with non-suppressed thyrotropin (TSH); raised TSH, but with normal TH]. In such cases, it is important first to revisit the clinical context, and to consider potential confounding factors, including alterations in normal physiology (e.g. pregnancy), intercurrent (non-thyroidal) illness, and medication usage (e.g. thyroxine, amiodarone, heparin). Once these have been excluded, laboratory artefacts in commonly used TSH or TH immunoassays should be screened for, thus avoiding unnecessary further investigation and/or treatment in cases where there is assay interference. In the remainder, consideration should be given to screening for rare genetic and acquired disorders of the hypothalamic-pituitary-thyroid (HPT) axis [e.g. resistance to thyroid hormone (RTH), thyrotropinoma (TSHoma)]. Here, we discuss the main pitfalls in the measurement and interpretation of TFTs, and propose a structured algorithm for the investigation and management of patients with anomalous/discordant TFTs.
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Affiliation(s)
- Olympia Koulouri
- Metabolic Research Laboratories, Wellcome Trust – MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Carla Moran
- Metabolic Research Laboratories, Wellcome Trust – MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - David Halsall
- Department of Clinical Biochemistry, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Krishna Chatterjee
- Metabolic Research Laboratories, Wellcome Trust – MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Mark Gurnell
- Metabolic Research Laboratories, Wellcome Trust – MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
- School of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
- Corresponding author. Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Box 289, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK. Tel.: +44 1223 348739; Fax: +44 1223 330598.
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TSH-Secreting Pituitary Macroadenoma in a Girl with Lingual Thyroid. Case Rep Endocrinol 2013; 2013:570847. [PMID: 24151564 PMCID: PMC3787618 DOI: 10.1155/2013/570847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Accepted: 08/14/2013] [Indexed: 11/17/2022] Open
Abstract
Patients with long-standing hypothyroid are, in some cases, reported to develop pituitary gland hyperplasia due to loss of feedback inhibition of thyroxine in hypothalamus—the condition of which typically regresses after thyroxine replacement. Herein, a 15-year-old girl—with long-standing untreated lingual hypothyroid—presents with a pathologically proven TSH pituitary macroadenoma and bilateral large ovarian cysts. Although MR imaging may differentiate between hyperplasia and macroadenoma of the pituitary gland, pathological examination is still a cornerstone to correct diagnosis.
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Canadas KT, Rivkees SA, Udelsman R, Breuer CK. Resistance to thyroid hormone associated with a novel mutation of the thyroid β receptor gene in a four-year-old female. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2011; 2011:3. [PMID: 21860630 PMCID: PMC3159137 DOI: 10.1186/1687-9856-2011-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 06/21/2011] [Indexed: 11/12/2022]
Abstract
Resistance to thyroid hormone (RTH) is a rare syndrome of reduced responsiveness of target tissues to thyroid hormone and is caused mutation in the thyroid β receptor gene. We report a novel mutation, E445X, causing RTH in a 4-year old girl. The patient exhibited extreme signs and symptoms of RTH at an early age, and had a large compressive goiter. Following total extracapsular thyroidectomy, upper airway compression was relieved and symptoms of hyperthyroidism improved. This case appears to be the youngest child recorded to have undergone total thyroidectomy for RTH. Post-operative TSH elevations were managed with every-other-day triiodothyronine therapy.
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Affiliation(s)
- Karina T Canadas
- Department of Surgery, Yale Pediatric Thyroid Center, Yale-New Haven Children's Hospital, 2 Park Street, West Pavilion, 2nd Floor, New Haven, CT 06510, USA
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Abstract
Interpretation of thyroid function tests (TFTs) is generally straightforward. However, in a minority of contexts the results of thyroid hormone and thyrotropin measurements either conflict with the clinical picture or form an unusual pattern. In many such cases, reassessment of the clinical context provides an explanation for the discrepant TFTs; in other instances, interference in one or other laboratory assays can be shown to account for divergent results; uncommonly, genetic defects in the hypothalamic-pituitary-thyroid axis are associated with anomalous TFTs. Failure to recognize these potential 'pitfalls' can lead to misdiagnosis and inappropriate management. Here, focusing particularly on the combination of hyperthyroxinaemia with nonsuppressed thyrotropin, we show how a structured approach to investigation can help make sense of atypical TFTs.
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Affiliation(s)
- Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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de Rougemont A, Mourot MG, Riou JP. Atypical thyrotropin-secreting pituitary microadenoma revealed by severe osteoporosis in a young man. J Bone Miner Metab 2009; 27:513-8. [PMID: 19252815 DOI: 10.1007/s00774-009-0050-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2008] [Accepted: 09/08/2008] [Indexed: 10/21/2022]
Abstract
For 10 years, a young man was followed for a severe osteoporosis associated with a considerable reduction in height and a massive weight loss. The constant increase of signs of tissue impregnation with thyroid hormones and the molar ratios of alpha-TSH suggested an inappropriate secretion of thyrotropin. Magnetic resonance imaging finally revealed a thyrotropic microadenoma of the pituitary gland. This case gives some new additional information on thyrotropin-induced osteoporosis. To our knowledge such a case has never been reported in the literature.
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Affiliation(s)
- Alexis de Rougemont
- Service d'Endocrinologie-Diabétologie, Hôpital E. Herriot, Hospices Civils de Lyon, Lyon, 69003, France.
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Marazuela M, Nattero L, Moure D, García-Polo I, Figueroa-Vega N, Guijarro C. Thyroid hormone resistance and pituitary enlargement after thyroid ablation in a woman on levothyroxine treatment. Thyroid 2008; 18:1119-23. [PMID: 18816177 DOI: 10.1089/thy.2007.0375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We report a patient with inappropriate secretion of thyrotropin (TSH) and a pituitary mass. Although she had been treated for biochemical hyperthyroidism with thyroid surgery and radioiodine ablation, she had never complained of specific symptoms or demonstrated signs of overt thyroid dysfunction. On evaluation, she had increased free thyroxine and TSH levels, normal serum glycoprotein alpha-subunit levels, and a significant TSH over-response to exogenous thyrotropin-releasing hormone stimulation. Magnetic resonance imaging with gadolinium enhancement showed a pituitary enlargement with suprasellar extension. An indium In 111 pentetreotide scan showed an abnormal focus of radionuclide accumulation in the pituitary area. Sequencing of the TRbeta gene showed that the patient was heterozygous for a new single nucleotide substitution resulting in the replacement of the normal arginine with a serine at amino acid 320 (R320S). We review the difficulties encountered in establishing a correct diagnosis in patients with inappropriate secretion of TSH in combination with pituitary enlargement. Due to its possible false-negative results, we do not recommend the use of indium In 111 pentetreotide as a tool in the differential diagnosis of inappropriate secretion of TSH.
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Affiliation(s)
- Monica Marazuela
- Endocrinology Department, Servicio de Endocrinología, Hospital de la Princesa, Universidad Autónoma, Madrid, Spain.
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Vecil GG, Papadopoulos NV, Vassilopoulou-Sellin R, McCutcheon IE. Interferon-induced hypothyroidism causing reversible pituitary enlargement. Endocr Pract 2008; 14:219-23. [PMID: 18308662 DOI: 10.4158/ep.14.2.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To present the first reported case of interferon-induced hypothyroidism with radiographic confirmation of secondary pituitary hyperplasia. METHODS We describe the case of a woman with recurrent malignant melanoma, outline the details of her endocrine work-up, and illustrate the serial findings on magnetic resonance imaging of the head. RESULTS A 26-year-old woman underwent surgical excision of a melanoma of the left thigh and 10 years later had a second melanoma removed from her right knee. Metastatic work-up revealed evidence of tumor involvement in the cervical and mediastinal lymph nodes. After treatment with interferon for 1 year, persistent fatigue and menstrual irregularities led to the laboratory diagnosis of hypothyroidism, and magnetic resonance imaging revealed pituitary enlargement. Both her endocrinopathy and the pituitary hyperplasia resolved with discontinuation of the interferon treatment and with institution of thyroid replacement therapy. CONCLUSION Clinicians should be aware of the potential adverse effects of interferon therapy to avoid inappropriate diagnosis of a pituitary adenoma or metastatic lesion in patients with cancer who are treated with interferon. In addition, screening for hypothyroidism should be performed in patients receiving interferon.
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Affiliation(s)
- Giacomo G Vecil
- The Department of Neurosurgery, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030-4009, USA
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Mannavola D, Persani L, Vannucchi G, Zanardelli M, Fugazzola L, Verga U, Facchetti M, Beck-Peccoz P. Different responses to chronic somatostatin analogues in patients with central hyperthyroidism. Clin Endocrinol (Oxf) 2005; 62:176-81. [PMID: 15670193 DOI: 10.1111/j.1365-2265.2004.02192.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Central hyperthyroidism is mainly due to two different causes, TSH-secreting pituitary adenoma (TSH-oma) and resistance to thyroid hormone in its pituitary variant, i.e. patients presenting with signs and symptoms of hyperthyroidism (PRTH). Because therapeutic approach and the clinical follow-up are extremely different in these two disorders, a correct differential diagnosis is mandatory. Unfortunately, no definite pathognomonic tool is presently available and an extensive biochemical and instrumental workup is frequently needed in order to reach the correct diagnosis. Aim of the present study was to investigate the use of somatostatin analogues in the differential diagnosis between TSH-omas and PRTH, as well as the possible treatment of PRTH with these analogues. DESIGN AND PATIENTS Eight patients with TSH-oma and four with PRTH underwent the acute test with somatostatin analogue Octreotide (0.1 mg subcutaneously), as well as long-acting Octreotide-LAR (30 mg intramuscularly every 28 days) for two months. MEASUREMENTS Serum TSH, FT3 and FT4 were evaluated in basal condition, at time 0 and every hour for 6 h during acute test, and every 15 days for 2 months during chronic treatment. RESULTS During acute test, in both patients with PRTH and TSH-oma, a similar reduction in immunoreactive TSH and FT3 levels was observed, while no variations were found in FT4 concentrations. In contrast, during the administration of Octreotide-LAR, no significant variations of all tested parameters were observed in PRTH group, whereas FT3 and FT4 concentrations normalized or presented a significant reduction (> 30% of pretreatment values) in seven of eight patients with TSH-oma, despite minor variation of immunoreactive TSH levels. CONCLUSIONS Chronic administration of long-acting somatostatin analogues in patients with central hyperthyroidism caused a marked decrease of FT3 and FT4 levels in all patients but one with TSH-oma, while patients with PRTH did not respond at all. Thus, administration of long acting somatostatin analogues for at least 2 months can be useful in the differential diagnosis in problematic cases of central hyperthyroidism. Furthermore, the present findings exclude the possibility of a beneficial effect of chronic administration of somatostatin analogues in controlling thyrotoxic symptoms in PRTH patients.
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Affiliation(s)
- Deborah Mannavola
- Institute of Endocrine Sciences, University of Milan, Ospedale Maggiore IRCCS and Istituto Auxologico Italiano IRCCS, Milan, Italy
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Abstract
Thyroid hormone plays important roles in metabolism, growth, and differentiation. Germline mutations in thyroid hormone receptor beta (TRbeta) have been identified in many individuals with resistance to thyroid hormone (RTH), a syndrome of hyposensitivity to T3. However, it has become increasingly apparent that somatic mutations can also occur in individual tissues, and are associated with tumors and malignancies in man. Herein we review the occurrence and identification of germline and somatic TR mutations and characterization of their pathological effects on hormone resistance and tumorigenesis.
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Affiliation(s)
- P M Yen
- Molecular Regulation and Neuroendocrinology Section, Clinical Endocrinology Branch, National Institute of Diabetes, Digestive and Kidney Disease, National Institutes of Health, Bethesda, MD 20892, USA.
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Kendler BS. Nutritional Endocrinology. New York, New York, USA, March 3, 2002. Nutrition 2003; 19:86-9. [PMID: 12507651 DOI: 10.1016/s0899-9007(02)00924-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Ando S, Sarlis NJ, Krishnan J, Feng X, Refetoff S, Zhang MQ, Oldfield EH, Yen PM. Aberrant alternative splicing of thyroid hormone receptor in a TSH-secreting pituitary tumor is a mechanism for hormone resistance. Mol Endocrinol 2001; 15:1529-38. [PMID: 11518802 DOI: 10.1210/mend.15.9.0687] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Patients with TSH-secreting pituitary tumors (TSHomas) have high serum TSH levels despite elevated thyroid hormone levels. The mechanism for this defect in the negative regulation of TSH secretion is not known. We performed RT-PCR to detect mutations in TRbeta from a surgically resected TSHoma. Analyses of the RT-PCR products revealed a 135-bp deletion within the sixth exon that encodes the ligand-binding domain of TRbeta2. This deletion was caused by alternative splicing of TRbeta2 mRNA, as near-consensus splice sequences were found at the junction site and no deletion or mutations were detected in the tumoral genomic DNA. This TRbeta variant (TRbeta2spl) lacked thyroid hormone binding and had impaired T3-dependent negative regulation of both TSHbeta and glycoprotein hormone alpha-subunit genes in cotransfection studies. Furthermore, TRbeta2spl showed dominant negative activity against the wild-type TRbeta2. These findings strongly suggest that aberrant alternative splicing of TRbeta2 mRNA generated an abnormal TR protein that accounted for the defective negative regulation of TSH in the TSHoma. This is the first example of aberrant alternative splicing of a nuclear hormone receptor causing hormonal dysregulation. This novel posttranscriptional mechanism for generating abnormal receptors may occur in other hormone-resistant states or tumors in which no receptor mutation is detected in genomic DNA.
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Affiliation(s)
- S Ando
- Molecular Regulation and Neuroendocrinology Section, Clinical Endocrinology Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland 20892, USA
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Safer JD, Colan SD, Fraser LM, Wondisford FE. A pituitary tumor in a patient with thyroid hormone resistance: a diagnostic dilemma. Thyroid 2001; 11:281-91. [PMID: 11327621 DOI: 10.1089/105072501750159750] [Citation(s) in RCA: 63] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Resistance to thyroid hormone (RTH) is due to mutations in the beta-isoform of the thyroid hormone receptor (TR-beta). RTH patients display inappropriate secretion of thyrotropin-releasing hormone (TRH) from the hypothalamus and thyrotropin (TSH) from the anterior pituitary, despite elevated levels of thyroid hormone thyroxine (T4) and triiodothyronine (T3). Thyrotropin-secreting tumors are presumed to represent clonal expansion of abnormal cells. Because the diagnosis of TSH-secreting tumors tends to be delayed and curative surgical resection remains under 50%, early diagnosis is paramount. Current diagnostic strategies suggest that RTH patients are distinguishable from patients with TSH-secreting pituitary tumors by the use of standard laboratory tests and imaging. Here, we present a woman in whom the standard evaluation for inappropriate TSH secretion was insufficient to distinguish these entities. The patient had a low-normal TRH stimulation test and an unmeasurable alpha-glycoprotein subunit level; however, a pituitary magnetic resonance imaging (MRI) revealed an adenoma. More testing using a T3 suppression test supported a RTH diagnosis and a R438H mutation was found in the TR-beta gene. To our knowledge, this represents the first report of an apparently incidental pituitary adenoma in the setting of documented resistance to thyroid hormone. As such, it raises the question of whether RTH predisposes to pituitary hyperplasia and adenoma development.
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Affiliation(s)
- J D Safer
- Section of Endocrinology, Metabolism, and Diabetes, Boston University School of Medicine, Massachusetts 02118, USA.
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Affiliation(s)
- R E Weiss
- Thyroid Study Unit, MC 3090, Department of Medicine, University of Chicago, 5841 S. Maryland Ave, Chicago, IL 60637, USA.
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Abstract
INTRODUCTION Syndromes of resistance to thyroid hormone correspond to variable clinical states which are usually transmitted as autosomal dominant traits and characterized by the lack of sensitivity of target tissues to triiodothyronine (T3). The diagnosis has to be performed in order to offer an appropriate therapy. CURRENT KNOWLEDGE AND KEY POINTS Clinical states range between two extremes: the generalized form, with global euthyroidism, and the predominantly pituitary form, with thyrotoxicosis. Surprisingly, these various clinical situations are usually determined by the same genetic defect, i.e., an anomaly of one of the two alleles of the gene encoding the thyroid hormone receptor TR beta. High levels of circulating thyroid hormones in the presence of detectable thyroid stimulating hormone (TSH) levels is the characteristic biological feature. Pituitary thyreotropic adenoma, another etiology of inappropriate secretion of TSH, needs thus to be ruled out. No treatment is required in case of generalized resistance to thyroid hormone, whereas two specific drugs (TRIAC and D-T4) appear to be useful in the predominantly pituitary form. FUTURE PROSPECTS AND PROJECTS Mechanisms of resistance have been well documented, therefore allowing better understanding of T3 action on its nuclear receptor. Several transcriptional cofactors or corepressors have been identified and have to be investigated to explain the intriguing inter- and intra-familial, and even intra-individual, phenotypic variability. New insights should, furthermore, be gained from these studies to precisely determine how therapeutic agents work in resistance to thyroid hormone.
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