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Achonu CU, Olopade OB, Yusuf BO, Fadeyi AA, Fasanmade OA. Case Report of Graves' Disease in a 45-Year-Old Woman Secondary to Herceptin Treatment for Breast Cancer. Monoclon Antib Immunodiagn Immunother 2023; 42:194-202. [PMID: 38156888 DOI: 10.1089/mab.2023.0011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Graves' disease is the most common cause of thyrotoxicosis and is characterized by ophthalmopathy with proptosis, chemosis, or conjunctival injection; pretibial myxedema; and thyroid acropachy. It is an autoimmune disease that can be genetic or influenced by coexisting environmental factors such as exposure to anticancer drugs, including immune checkpoint inhibitors. The incidence rate of breast cancer is increasing due to rising awareness of risk factors and screening for breast cancer, and the mortality rate is decreasing due to recent advances in cancer treatment. However, there are side effects that are attributed to these treatment modalities, manifesting in various forms in breast cancer survivors, which are reflected in the patient in this case study.
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Affiliation(s)
- Chinmeri U Achonu
- Faculty of Clinical Sciences, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Oluwarotimi B Olopade
- Department of Medicine, Endocrinology, College of Medicine, University of Lagos, Lagos, Nigeria
| | - Bashir O Yusuf
- Department of Medicine, Federal Teaching Hospital Katsina, Katsina, Nigeria
| | - Abimbola A Fadeyi
- Department of Radiodiagnosis, Lagos University Teaching Hospital, Lagos, Nigeria
| | - Olufemi A Fasanmade
- Department of Medicine, Endocrinology, College of Medicine, University of Lagos, Lagos, Nigeria
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Fukahori K, Sawano K, Yoshida H, Nagasaki K. Asymmetrical Graves' disease in children: potential usefulness of potassium iodide monotherapy. BMJ Case Rep 2022; 15:e249571. [PMID: 35459658 PMCID: PMC9036365 DOI: 10.1136/bcr-2022-249571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/03/2022] Open
Abstract
A male junior high school student presented with failure to gain weight and acceleration of growth for 2 years. Free triiodothyronine and free thyroxine levels were elevated, and the thyroid-stimulating hormone (TSH) level was suppressed. TSH receptor antibody (TRAb) and thyroid-stimulating antibody were negative. On I-123 thyroid scintigraphy, iodine uptake was most pronounced in the upper pole of the right lobe. The patient was initially diagnosed with asymmetrical TRAb-negative Graves' disease (GD). His thyroid hormone level normalised with potassium iodide (KI) alone, and he became TRAb-positive 4 months after the initiation of KI therapy. This case demonstrates a rare presentation of GD that was initially TRAb-negative, which had asymmetrical iodine uptake on a thyroid scan and was confirmed to be TRAb positivity during the follow-up. KI monotherapy could be one of the effective treatment options for GD that is initially TRAb-negative.
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Affiliation(s)
- Kyoko Fukahori
- Department of Pediatrics, Tsuruoka Municipal Shonai Hospital, Tsuruoka, Yamagata, Japan
| | - Kentaro Sawano
- Department of Pediatrics, Tsuruoka Municipal Shonai Hospital, Tsuruoka, Yamagata, Japan
- Division of Pediatrics, Department of Homeostatic Regulation and Development, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hiroshi Yoshida
- Department of Pediatrics, Tsuruoka Municipal Shonai Hospital, Tsuruoka, Yamagata, Japan
| | - Keisuke Nagasaki
- Division of Pediatrics, Department of Homeostatic Regulation and Development, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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Nelson HA, Joshi HR, Straseski JA. Mistaken Identity: The Role of Autoantibodies in Endocrine Disease. J Appl Lab Med 2022; 7:206-220. [PMID: 34996091 DOI: 10.1093/jalm/jfab128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/22/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Autoimmune endocrine diseases can be thought of as a case of mistaken identity. The immune system mistakenly attacks one's own cells, as if they were foreign, which typically results in endocrine gland hypofunction and inadequate hormone production. Type 1 diabetes mellitus and autoimmune thyroid disorders (Hashimoto and Graves diseases) are the most common autoimmune endocrine disorders, while conditions such as Addison disease are encountered less frequently. Autoantibody production can precede clinical presentation, and their measurement may aid verification of an autoimmune process and guide appropriate treatment modalities. CONTENT In this review, we discuss type 1 diabetes mellitus, autoimmune thyroid disorders, and Addison disease, emphasizing their associated autoantibodies and methods for clinical detection. We will also discuss efforts to standardize measurement of autoantibodies. CONCLUSIONS Autoimmune endocrine disease progression may take months to years and detection of associated autoantibodies may precede clinical onset of disease. Although detection of autoantibodies is not necessary for diagnosis, they may be useful to verify an autoimmune process.
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Affiliation(s)
- Heather A Nelson
- Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Hemant R Joshi
- Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Joely A Straseski
- Department of Pathology, University of Utah Health Sciences Center, Salt Lake City, UT, USA
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John M, Jagesh R, Unnikrishnan H, Jalaja MMN, Oommen T, Gopinath D. Utility of TSH Receptor Antibodies in the Differential Diagnosis of Hyperthyroidism in Clinical Practice. Indian J Endocrinol Metab 2022; 26:32-37. [PMID: 35662753 PMCID: PMC9162259 DOI: 10.4103/ijem.ijem_388_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 11/04/2021] [Accepted: 01/09/2022] [Indexed: 11/26/2022] Open
Abstract
Graves' disease (GD) is the most common cause of hyperthyroidism in iodine-sufficient areas. It is important to distinguish GD from other causes of hyperthyroidism for optimal management. Thyroid stimulating hormone receptor antibody (TRAb) test is a commonly used test for this purpose. However, the sensitivity for this test in routine clinical practice may be affected by various factors leading to fallacies in diagnosis. Materials and Methods A retrospective study was performed to assess the utility of an automated electrochemiluminescence TRAb immunoassay (Roche) in differentiating GD from non-Graves' disease (NGD) in routine clinical practice. Results In 227 subjects, 146 had GD and 81 had NGD. Total T3, Total T4, Free T4, and TRAb were significantly higher in people with GD in comparison to NGD. The area under the receiver operating characteristics (ROC) curve for the assay was 0.96 (95% CI: 0.926 to 0.984, P < 0.0001). The optimal threshold for the test derived from the ROC was 3.37 IU/L, which is more than the cut-off of 1.75 IU/L suggested by the manufacturer. The sensitivity/specificity of TRAb in the diagnosis of GD at presentation was 98.4%/62.9% at 1.75 IU/L and 91.2%/90.12% at 3.37 IU/L, respectively. Conclusion The TRAb test is a sensitive test to differentiate between subjects with GD and NGD presenting with hyperthyroidism. However, the cutoff (1.75 IU/L) as per the kit manufacturer may lead to a lower specificity for diagnosis. A modified cut-off of 3.37 IU/L should be considered for optimizing the diagnostic efficacy of the test.
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Affiliation(s)
- Mathew John
- Deparment of Endocrinology, Providence Endocrine and Diabetes Specialty Centre, Trivandrum, Kerala, India
| | - Rejitha Jagesh
- Deparment of Endocrinology, Providence Endocrine and Diabetes Specialty Centre, Trivandrum, Kerala, India
| | - Hima Unnikrishnan
- Deparment of Endocrinology, Providence Endocrine and Diabetes Specialty Centre, Trivandrum, Kerala, India
| | | | - Tittu Oommen
- Deparment of Endocrinology, Providence Endocrine and Diabetes Specialty Centre, Trivandrum, Kerala, India
| | - Deepa Gopinath
- Deparment of Endocrinology, Providence Endocrine and Diabetes Specialty Centre, Trivandrum, Kerala, India
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Abstract
Gestational transient thyrotoxicosis (GTT) is associated with direct stimulation of the maternal thyroid gland by human chorionic gonadotropin (hCG). It is characterized by slightly higher thyroid hormone and lower thyroid-stimulating hormone (TSH) levels in early pregnancy and mild or no symptoms. While GTT must be distinguished from Graves' disease (GD), which is associated with maternal and fetal complications, treated GD and new-onset GD in pregnancy are occasionally challenging to distinguish. Evaluating serum hCG levels and TSH receptor antibody (TRAb) titers can help, but the results are not irrefutable due to pregnancy-related immunosuppression. Moreover, GTT can follow unusual clinical courses in relation to some pregnancy complications. Excessive hCG production can cause severe GTT symptoms in patients with hyperemesis gravidarum, trophoblastic disease, or multiple pregnancies. Thyrotoxicosis can emerge beyond the second trimester in patients with gestational diabetes mellitus and mirror syndrome, because of delayed elevations in the hCG levels. Detailed knowledge about GTT is necessary for correct diagnoses and its appropriate management. This review focuses on the diagnosis of GTT, and, particularly, its differentiation from GD, and unusual clinical conditions associated with GTT that require comprehensive management.
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Affiliation(s)
- Shigeo Iijima
- Department of Regional Neonatal-Perinatal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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Patel KA, Knight B, Aziz A, Babiker T, Tamar A, Findlay J, Cox S, Dimitropoulos I, Tysoe C, Panicker V, Vaidya B. Utility of systematic TSHR gene testing in adults with hyperthyroidism lacking overt autoimmunity and diffuse uptake on thyroid scintigraphy. Clin Endocrinol (Oxf) 2019; 90:328-333. [PMID: 30372544 PMCID: PMC6378592 DOI: 10.1111/cen.13892] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 10/24/2018] [Accepted: 10/24/2018] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Patients with hyperthyroidism lacking autoimmune features but showing diffuse uptake on thyroid scintigram can have either Graves' disease or germline activating TSH receptor (TSHR) mutation. It is important to identify patients with activating TSHR mutation due to treatment implication, but the overlapping clinical features with Graves' disease make it difficult to discriminate these two conditions without genetic testing. Our study aimed to assess the potential of systematic TSHR mutation screening in adults with hyperthyroidism, showing diffuse uptake on thyroid scintigraphy but absence of TSH receptor antibodies (TRAb) and clinical signs of autoimmunity. DESIGN A cross-sectional study of Caucasian adults with hyperthyroidism, managed at three endocrine centres in the South West, UK, from January 2006 to April 2017. METHODS We recruited 78 adult Caucasian patients with hyperthyroidism showing diffuse uptake on 99m Tc-pertechnetate thyroid scintigraphy but without TRAb and other autoimmune clinical features of Graves' disease (such as thyroid-associated ophthalmopathy or dermopathy). Genomic DNA of these patients was analysed for variants in the TSHR gene. RESULTS Genetic analysis identified 11 patients with four variants in TSHR [p.(Glu34Lys), p.(Asp36His), p.(Pro52Thr) and p.(Ile334Thr)]. None of these variants were pathogenic according to the American College of Medical Genetics and Genomics guideline. CONCLUSIONS Activating TSHR mutations are a rare cause of nonautoimmune adult hyperthyroidism. Our study does not support the routine genetic testing in adult patients with hyperthyroidism showing diffuse uptake on scintigraphy but negative TRAb and lacking extrathyroidal manifestations of Graves' disease.
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Affiliation(s)
- Kashyap A. Patel
- The Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
- Department of Diabetes and EndocrinologyThe Royal Devon and Exeter NHS Foundation TrustExeterUK
| | - Bridget Knight
- The Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
- NIHR Clinical Research Facility, R&D DepartmentThe Royal Devon and Exeter NHS Foundation trustExeterUK
| | - Aftab Aziz
- Department of Diabetes and EndocrinologyUniversity Hospitals Plymouth NHS TrustPlymouthUK
| | - Tarig Babiker
- Department of Diabetes and EndocrinologyUniversity Hospitals Plymouth NHS TrustPlymouthUK
| | - Avades Tamar
- Department of Diabetes and EndocrinologyThe Royal Devon and Exeter NHS Foundation TrustExeterUK
| | - Joanna Findlay
- NIHR Clinical Research Facility, R&D DepartmentThe Royal Devon and Exeter NHS Foundation trustExeterUK
| | - Sue Cox
- Department of Diabetes and Endocrinology, Torbay and South DevonNHS Foundation TrustTorbayUK
| | - Ioannis Dimitropoulos
- Department of Diabetes and EndocrinologyUniversity Hospitals Plymouth NHS TrustPlymouthUK
| | - Carolyn Tysoe
- Department of Molecular GeneticsThe Royal Devon and Exeter NHS Foundation TrustExeterUK
| | - Vijay Panicker
- Department of EndocrinologySir Charles Gairdner HospitalNedlandsWestern AustraliaAustralia
| | - Bijay Vaidya
- The Institute of Biomedical and Clinical ScienceUniversity of Exeter Medical SchoolExeterUK
- Department of Diabetes and EndocrinologyThe Royal Devon and Exeter NHS Foundation TrustExeterUK
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Peeters D, van Gijlswijk S, Leunissen RW, van der Kaay DCM. Central congenital hypothyroidism caused by maternal thyrotoxicosis. BMJ Case Rep 2018; 2018:bcr-2017-222620. [PMID: 29572363 DOI: 10.1136/bcr-2017-222620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Central congenital hypothyroidism (CCH) is a rare and underdiagnosed disease that sometimes is caused by maternal Graves' disease. We report a case of CCH caused by undiagnosed, initially antibody-negative maternal thyrotoxicosis with possible disruption of fetal hypothalamic-pituitary-thyroid axis maturation. In CCH, maternal thyroid disease should be considered.
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Affiliation(s)
- Daphne Peeters
- Department of Pediatrics, Haaglanden Medisch Centrum (HMC), The Hague, The Netherlands.,Department of Pediatrics, Haga Hospital/Juliana Children's Hospital, The Hague, Netherlands
| | | | - Ralph W Leunissen
- Department of Pediatrics, Haaglanden Medisch Centrum (HMC), The Hague, The Netherlands
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Nishihara E, Tsugawa M, Ozaki Y, Nagayama Y, Fukata S, Hirokawa M, Ito M, Nishikawa M, Nakamura H, Ito Y, Miyauchi A. Long-Term Follow-Up of a Patient with Sporadic Nonautoimmune Hyperthyroidism Due to a Thyrotropin-Receptor Mutation (D619G). AACE Clin Case Rep 2018. [DOI: 10.4158/ep171919.cr] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Mizokami T, Hishinuma A, Kogai T, Hamada K, Maruta T, Higashi K, Tajiri J. Radioiodine Treatment For Hyperthyroidism In A Patient With Pendred Syndrome. AACE Clin Case Rep 2017. [DOI: 10.4158/ep161405.cr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Galofré JC, Díez JJ, Cooper DS. Thyroid dysfunction in the era of precision medicine. ACTA ACUST UNITED AC 2016; 63:354-63. [PMID: 27267315 DOI: 10.1016/j.endonu.2016.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2016] [Revised: 04/09/2016] [Accepted: 04/19/2016] [Indexed: 12/29/2022]
Abstract
The launching of the Precision Medicine Initiative by the President of the United States in January 2015 was an invitation for all healthcare professionals to review their practice. This call should stimulate thyroidologists working in different areas (from basic research or epidemiology to the frontline of the clinical arena or to those designing public health programs) to be aware of this new outlook. The aim of the initiative is to eradicate imprecision in estimating the probability of a correct diagnosis, to be as sure as possible of the most effective treatment, and to maximize the chances of a successful outcome. This paper summarizes some of the current challenges faced by endocrinologists in the field of thyroid dysfunction, and illustrates how precision medicine may improve diagnosis and therapy in the future.
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Affiliation(s)
- Juan C Galofré
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, University of Navarra, Pamplona, Spain; IdiSNA (Instituto de investigación en la salud de Navarra), Spain.
| | - Juan J Díez
- Department of Endocrinology and Nutrition, Hospital Ramón y Cajal, Department of Medicine, University of Alcalá de Henares, Madrid, Spain
| | - David S Cooper
- Division of Endocrinology, Diabetes, and Metabolism, The John Hopkins University School of Medicine, Baltimore, MD, USA
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Baskaran C, Misra M, Levitsky LL. Diagnosis of pediatric hyperthyroidism: technetium 99 uptake versus thyroid stimulating immunoglobulins. Thyroid 2015; 25:37-42. [PMID: 25257665 PMCID: PMC4291090 DOI: 10.1089/thy.2014.0266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Treatment with antithyroid drugs is effective in conditions of increased thyroid hormone production (mostly Graves' Disease; GD), but not in subacute thyroiditis (SAT) or autoimmune thyroiditis (AIT). Positive thyroid stimulating immunoglobulins (TSI) make GD likely. However, not all children with GD have increased TSI. Uptake studies with (123)I or (99)Tc ((99m)Tc) provide accurate and rapid diagnosis but are expensive and involve radiation exposure. Our objective was to compare TSI with (99m)Tc uptake for diagnosis of pediatric hyperthyroidism. METHODS We performed a retrospective chart review of hyperthyroid children who had both TSI estimation and (99m)Tc uptake assessment at presentation. Based on subsequent laboratory studies and follow-up, 37 had GD and 10 had non-GD thyroiditis. The TSI index was considered positive (TSI+) when it was above the upper limit of normal. (99m)Tc uptake was considered positive (Tc+) for any uptake >0.4% and negative (and low) (Tc-) for uptake ≤0.4%. RESULTS Forty-seven youth (83% females), aged 12.3±4.6 years, presented with a suppressed thyrotropin (TSH) and elevated free thyroxine and total triiodothyronine. All 37 patients with GD were Tc+ (100% sensitivity and specificity). The sensitivity of TSI for diagnosing GD was 84%, and the specificity was 100%. Six patients with GD were discordant with Tc+ but TSI-. Elevated TSI correlated with Tc+ (p=0.01) with a degree of agreement (kappa) of 0.69. CONCLUSION (99m)Tc has excellent specificity and sensitivity in diagnosing GD. Given additional costs of (99m)Tc (two and a half times as much as TSI), it is reasonable to reserve (99m)Tc uptake assessment for hyperthyroidism of unclear etiology and negative TSI.
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Affiliation(s)
- Charumathi Baskaran
- Massachusetts General Hospital for Children , Pediatric Endocrinology Unit, Boston, Massachusetts
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