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Makkonen K, Jännäri M, Crisóstomo L, Kuusi M, Patyra K, Melnyk V, Linnossuo V, Ojala J, Ravi R, Löf C, Mäkelä JA, Miettinen P, Laakso S, Ojaniemi M, Jääskeläinen J, Laakso M, Bossowski F, Sawicka B, Stożek K, Bossowski A, Kleinau G, Scheerer P, FinnGen F, Reeve MP, Kero J. Mechanisms of thyrotropin receptor-mediated phenotype variability deciphered by gene mutations and M453T-knockin model. JCI Insight 2024; 9:e167092. [PMID: 38194289 PMCID: PMC11143923 DOI: 10.1172/jci.insight.167092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 01/05/2024] [Indexed: 01/10/2024] Open
Abstract
The clinical spectrum of thyrotropin receptor-mediated (TSHR-mediated) diseases varies from loss-of-function mutations causing congenital hypothyroidism to constitutively active mutations (CAMs) leading to nonautoimmune hyperthyroidism (NAH). Variation at the TSHR locus has also been associated with altered lipid and bone metabolism and autoimmune thyroid diseases. However, the extrathyroidal roles of TSHR and the mechanisms underlying phenotypic variability among TSHR-mediated diseases remain unclear. Here we identified and characterized TSHR variants and factors involved in phenotypic variability in different patient cohorts, the FinnGen database, and a mouse model. TSHR CAMs were found in all 16 patients with NAH, with 1 CAM in an unexpected location in the extracellular leucine-rich repeat domain (p.S237N) and another in the transmembrane domain (p.I640V) in 2 families with distinct hyperthyroid phenotypes. In addition, screening of the FinnGen database revealed rare functional variants as well as distinct common noncoding TSHR SNPs significantly associated with thyroid phenotypes, but there was no other significant association between TSHR variants and more than 2,000 nonthyroid disease endpoints. Finally, our TSHR M453T-knockin model revealed that the phenotype was dependent on the mutation's signaling properties and was ameliorated by increased iodine intake. In summary, our data show that TSHR-mediated disease risk can be modified by variants at the TSHR locus both inside and outside the coding region as well as by altered TSHR-signaling and dietary iodine, supporting the need for personalized treatment strategies.
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Affiliation(s)
- Kristiina Makkonen
- Department of Clinical Sciences, Faculty of Medicine, and
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Meeri Jännäri
- Department of Clinical Sciences, Faculty of Medicine, and
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Luís Crisóstomo
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Matilda Kuusi
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Konrad Patyra
- Department of Clinical Sciences, Faculty of Medicine, and
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | | | - Veli Linnossuo
- Department of Clinical Sciences, Faculty of Medicine, and
| | - Johanna Ojala
- Department of Clinical Sciences, Faculty of Medicine, and
| | - Rowmika Ravi
- Department of Clinical Sciences, Faculty of Medicine, and
| | - Christoffer Löf
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Juho-Antti Mäkelä
- Integrative Physiology and Pharmacology, Institute of Biomedicine, University of Turku, Turku, Finland
| | - Päivi Miettinen
- New Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Saila Laakso
- New Children’s Hospital, Helsinki University Hospital, Helsinki, Finland
| | - Marja Ojaniemi
- Department of Pediatrics and Adolescence, PEDEGO Research Unit and Medical Research Center, University and University Hospital of Oulu, Oulu, Finland
| | | | - Markku Laakso
- Institute of Clinical Medicine, Internal Medicine, University of Eastern Finland, Kuopio, Finland
| | - Filip Bossowski
- Department of Pediatrics, Endocrinology, Diabetes with a Cardiology Unit, Medical University in Białystok, Bialystok, Poland
| | - Beata Sawicka
- Department of Pediatrics, Endocrinology, Diabetes with a Cardiology Unit, Medical University in Białystok, Bialystok, Poland
| | - Karolina Stożek
- Department of Pediatrics, Endocrinology, Diabetes with a Cardiology Unit, Medical University in Białystok, Bialystok, Poland
| | - Artur Bossowski
- Department of Pediatrics, Endocrinology, Diabetes with a Cardiology Unit, Medical University in Białystok, Bialystok, Poland
| | - Gunnar Kleinau
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and
- Humboldt - Universität zu Berlin, Institute of Medical Physics, Biophysics, Group Structural Biology of Cellular Signaling, Berlin, Germany
| | - Patrick Scheerer
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, and
- Humboldt - Universität zu Berlin, Institute of Medical Physics, Biophysics, Group Structural Biology of Cellular Signaling, Berlin, Germany
| | - FinnGen FinnGen
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
- FinnGen is detailed in Supplemental Acknowledgments
| | - Mary Pat Reeve
- Institute for Molecular Medicine Finland, HiLIFE, University of Helsinki, Helsinki, Finland
| | - Jukka Kero
- Department of Clinical Sciences, Faculty of Medicine, and
- Department of Pediatrics and Adolescent Medicine, Turku University Hospital, Turku, Finland
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Kufoof T, Luxford C, Kannangara K, Clifton-Bligh R, Donaghue KC. A Novel TSHR Gene Mutation in a Family with Non-autoimmune Hyperthyroidism. Med Arch 2024; 78:154-158. [PMID: 38566871 PMCID: PMC10983094 DOI: 10.5455/medarh.2024.78.154-158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 03/02/2024] [Indexed: 04/04/2024] Open
Abstract
Background Familial non-autoimmune hyperthyroidism is a rare disorder characterized by the absence of thyroid autoimmunity, particularly TSH receptor antibody [TRAb]. Objective The aim of this study was to describe a novel TSHR mutation identified in a family of two siblings and their father. Methods Two siblings presented for endocrine assessment at ages 7 and 14 years with mild T3 toxicosis, and the father presented at 30 years of age with non-autoimmune thyrotoxicosis. Both siblings were treated with oral antithyroid therapy to achieve reasonable symptom control and thyroid function normalization. The father was treated with oral antithyroid therapy, radioactive iodine, thyroidectomy, and thyroid replacement therapy. Peripheral blood DNA was extracted from both affected siblings and father. Mutation analysis of TSHR was carried out by PCR and Sanger sequencing of both strands of the extracted DNA. Results Both siblings and their father were heterozygous for the missense TSHR variant c.1855G>C, p.[Asp619His], in exon 10. Conclusions This novel TSHR variant is associated with T3 toxicosis during childhood. Therefore, early identification and treatment may improve patient outcomes.
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Affiliation(s)
- Tamara Kufoof
- Department of Pediatrics, Faculty of Medicine, The Hashemite University, Zarqa, Jordan
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, University of Sydney, Australia
| | - Catherine Luxford
- Cancer Genetics Diagnostic Laboratory, Royal North Shore Hospital, Australia
| | | | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital and Kolling Institute, University of Sydney, Australia
| | - Kim C. Donaghue
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, University of Sydney, Australia
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Mégier C, Dumery G, Luton D. Iodine and Thyroid Maternal and Fetal Metabolism during Pregnancy. Metabolites 2023; 13:metabo13050633. [PMID: 37233673 DOI: 10.3390/metabo13050633] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 04/26/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023] Open
Abstract
Thyroid hormones and iodine are required to increase basal metabolic rate and to regulate protein synthesis, long bone growth and neuronal maturation. They are also essential for protein, fat and carbohydrate metabolism regulation. Imbalances in thyroid and iodine metabolism can negatively affect these vital functions. Pregnant women are at risk of hypo or hyperthyroidism, in relation to or regardless of their medical history, with potential dramatic outcomes. Fetal development highly relies on thyroid and iodine metabolism and can be compromised if they malfunction. As the interface between the fetus and the mother, the placenta plays a crucial role in thyroid and iodine metabolism during pregnancy. This narrative review aims to provide an update on current knowledge of thyroid and iodine metabolism in normal and pathological pregnancies. After a brief description of general thyroid and iodine metabolism, their main modifications during normal pregnancies and the placental molecular actors are described. We then discuss the most frequent pathologies to illustrate the upmost importance of iodine and thyroid for both the mother and the fetus.
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Affiliation(s)
- Charles Mégier
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Bicêtre, Université Paris Saclay, 94270 Le Kremlin-Bicetre, France
| | - Grégoire Dumery
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Bicêtre, Université Paris Saclay, 94270 Le Kremlin-Bicetre, France
| | - Dominique Luton
- Assistance Publique-Hôpitaux de Paris, Service de Gynécologie-Obstétrique, Hôpital Bicêtre, Université Paris Saclay, 94270 Le Kremlin-Bicetre, France
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Wiersinga WM, Poppe KG, Effraimidis G. Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis. Lancet Diabetes Endocrinol 2023; 11:282-298. [PMID: 36848916 DOI: 10.1016/s2213-8587(23)00005-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 02/26/2023]
Abstract
Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT4], or high free tri-iodothyonine [FT3]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT4 concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (131I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands
| | - Kris G Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Grigoris Effraimidis
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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Monteiro SS, Monteiro MP, Inocêncio G, Borges T, Garrido S, Pereira MT, Vilaverde J, Sales M, Pinto C, Rodrigues MDC, Guedes-Martins L, Dores J, Reis CF. Letter to the Editor: Successful Prenatal Management of Inherited Congenital Non-Autoimmune Hyperthyroidism. Thyroid 2023; 33:653-654. [PMID: 36719768 DOI: 10.1089/thy.2022.0648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sílvia Santos Monteiro
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Mariana P Monteiro
- Division of Endocrinology, Hospital da Luz Arrábida, Vila Nova de Gaia, Portugal
- Clinical and Experimental Endocrinology, UMIB-Unit for Multidisciplinary Research in Biomedicine, ICBAS, School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
| | - Gonçalo Inocêncio
- Fetal Medicine Centre, Division of Obstetrics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Teresa Borges
- Division of Pediatric Endocrinology, Department of Pediatrics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Susana Garrido
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria Teresa Pereira
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Joana Vilaverde
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Marta Sales
- Fetal Medicine Centre, Division of Obstetrics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Clara Pinto
- Fetal Medicine Centre, Division of Obstetrics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Maria do Céu Rodrigues
- Fetal Medicine Centre, Division of Obstetrics, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Division of Obstetrics and Gynecology, Unidade Local de Saúde de Matosinhos, Matosinhos, Portugal
| | - Luís Guedes-Martins
- Fetal Medicine Centre, Division of Obstetrics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Jorge Dores
- Division of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Cláudia Falcão Reis
- Division of Medical Genetics, Centro de Genética Médica Doutor Jacinto Magalhães, Centro Hospitalar Universitário do Porto, Porto, Portugal
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
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Nishihara E, Fukata S, Miyauchi A, Akamizu T. Long-Term Disproportional TSH Hyposecretion in a Patient With Nonautoimmune Hyperthyroidism After Radioiodine Therapy. JCEM CASE REPORTS 2023; 1:luad026. [PMID: 37908476 PMCID: PMC10580448 DOI: 10.1210/jcemcr/luad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Indexed: 11/02/2023]
Abstract
Nonautoimmune hyperthyroidism (NAH), caused by constitutively active mutants of the thyrotropin receptor (TSHR) gene, is recommended to be treated with total thyroidectomy followed by radioiodine administration. Herein, we present a 39-year-old woman with sporadic NAH caused by a TSHR-L512Q mutation. At the age of 20 years, she presented with a large goiter of 370 mL, treated with thiamazole, and opted for radioiodine therapy as outpatient management. Over the next 17 years, she underwent 6 treatments of 13 mCi radioiodine each. She did not experience a relapse of hyperthyroidism, and thiamazole was reduced and later withdrawn during the final radioiodine treatment. The patient's goiter significantly reduced to 18 mL, and thyroid function tests showed that free thyroxine and free triiodothyronine levels were below the lower limit of the reference ranges, while TSH remained within the reference range for 20 months. Along with an almost normal TSH response to thyrotropin-releasing hormone stimulation, no pituitary atrophy was observed on magnetic resonance imaging. Contrary to the recommended treatment, this case showed that fractionated radioiodine therapy alone is effective in controlling thyroid function and in reducing goiter size. Low TSH levels during treatment should not be assessed as subclinical hyperthyroidism or as risk of relapse.
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Affiliation(s)
- Eijun Nishihara
- Department of Internal Medicine, Center for Excellence in Thyroid Care, Kuma Hospital, Kobe 650-0011, Japan
| | - Shuji Fukata
- Department of Internal Medicine, Center for Excellence in Thyroid Care, Kuma Hospital, Kobe 650-0011, Japan
| | - Akira Miyauchi
- Department of Surgery, Center for Excellence in Thyroid Care, Kuma Hospital, Kobe 650-0011, Japan
| | - Takashi Akamizu
- Department of Internal Medicine, Center for Excellence in Thyroid Care, Kuma Hospital, Kobe 650-0011, Japan
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7
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Nagayama Y, Nishihara E. Thyrotropin receptor antagonists and inverse agonists, and their potential application to thyroid diseases. Endocr J 2022; 69:1285-1293. [PMID: 36171093 DOI: 10.1507/endocrj.ej22-0391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The thyrotropin receptor (TSHR) plays critical roles in thyroid growth and function and in the pathogenesis of several thyroid diseases including Graves' hyperthyroidism and ophthalmopathy, non-autoimmune hyperthyroidism and thyroid cancer. Several low-molecular weight compounds (LMWCs) and anti-TSHR monoclonal antibodies (mAbs) with receptor antagonistic and inverse agonistic activities have been reported. The former binds to the pocket formed by the receptor transmembrane bundle, and the latter to the extracellular TSH binding site. Both are effective inhibitors of TSH/thyroid stimulating antibody-stimulated cAMP and/or hyaluronic acid production in TSHR-expressing cells. Anti-insulin-like growth factor 1 inhibitors are also found to inhibit TSHR signaling. Each agent has advantages and disadvantages; for example, mAbs have a higher affinity and longer half-life but are more costly than LMWCs. At present, mAbs appear most promising, yet the development of more efficacious LMWCs is desirable. These agents are anticipated to be efficacious not only for the above-mentioned diseases but also for resistance to thyroid hormone and have utility for thyroid cancer radionuclide scintigraphy/therapy as a new theranostic.
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Affiliation(s)
- Yuji Nagayama
- Department of Molecular Medicine, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki 852-8523, Japan
| | - Eijun Nishihara
- Center for Excellence in Thyroid Care, Kuma Hospital, Kobe 650-0011, Japan
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8
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Maganha CA, Mattar R, Mesa Júnior CO, Marui S, Solha STG, Teixeira PDFDS, Zaconeta ACM, Souza RT. Screening, diagnosis and management of hyperthyroidism in pregnancy. REVISTA BRASILEIRA DE GINECOLOGIA E OBSTETRÍCIA 2022; 44:806-818. [PMID: 36075227 PMCID: PMC9948172 DOI: 10.1055/s-0042-1756521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Affiliation(s)
| | - Rosiane Mattar
- Departamento de Obstetrícia, Escola Paulista de Medicina, São Paulo, SP, Brazil
| | | | - Suemi Marui
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
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Morcel P, Hadjadj S, Ansquer C, Yan Lun A, Cariou B, Delemazure Chesneau AS, Le Bras M, Langlois E, Drui D. Démarche diagnostique et prise en charge thérapeutique de l’hyperthyroïdie. Rev Med Interne 2022; 43:233-241. [DOI: 10.1016/j.revmed.2021.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 11/05/2021] [Accepted: 12/23/2021] [Indexed: 11/16/2022]
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10
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Vieira IH, Rodrigues D, Paiva I. The Mysterious Universe of the TSH Receptor. Front Endocrinol (Lausanne) 2022; 13:944715. [PMID: 35903283 PMCID: PMC9315062 DOI: 10.3389/fendo.2022.944715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 06/10/2022] [Indexed: 12/25/2022] Open
Abstract
The thyroid-stimulating hormone receptor (TSH-R) is predominantly expressed in the basolateral membrane of thyrocytes, where it stimulates almost every aspect of their metabolism. Several extrathyroidal locations of the receptor have been found including: the pituitary, the hypothalamus, and other areas of the central nervous system; the periorbital tissue; the skin; the kidney; the adrenal; the liver; the immune system cells; blood cells and vascular tissues; the adipose tissue; the cardiac and skeletal muscles, and the bone. Although the functionality of the receptor has been demonstrated in most of these tissues, its physiological importance is still a matter of debate. A contribution to several pathological processes is evident in some cases, as is the case of Grave's disease in its multiple presentations. Conversely, in the context of other thyroid abnormalities, the contribution of the TSH-R and its ligand is still a matter of debate. This article reviews the several different sites of expression of the TSH-R and its potential role in both physiological and pathological processes.
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Stephenson A, Punjwani Z, Eszlinger M, Sawicka B, Bossowski A, Paschke R. Report of a family with three generations of undiagnosed familial nonautoimmune hyperthyroidism. Endocrinol Diabetes Metab Case Rep 2021; 2021:EDM-21-0019. [PMID: 34866058 PMCID: PMC8686170 DOI: 10.1530/edm-21-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 11/10/2021] [Indexed: 11/08/2022] Open
Abstract
SUMMARY Familial nonautoimmune hyperthyroidism (FNAH) is rare and occurs due to a constitutively activating thyroid-stimulating hormone receptor (TSHR) germline mutation. Forty-one families with FNAH have been reported so far. In the study, 17 of 41 families were not diagnosed with FNAH until three generations or more were described with hyperthyroidism. We report a case of FNAH diagnosed in the third generation. The index patient was diagnosed with hyperthyroidism at age 3. Large fluctuations in thyroid hormone levels occurred during anti-thyroid drug treatment, and he developed a goiter. The patient's mother had similar history, requiring two surgical interventions and radioiodine treatment. The younger brother of the index patient did not experience large thyroid hormone level fluctuations, nor increased thyroid growth. A heterozygous TSHR c.1357A>G mutation, resulting in a M453V amino acid exchange, was detected in all three patients leading to FNAH diagnosis, with complete genotype-phenotype segregation. Based on Sorting intolerant from tolerant (SIFT) and PolyPhen2 scores of 0.01 and 0.99, respectively, an effect on protein function can be assumed. As illustrated by this family with FNAH, total thyr oidectomy is necessary for patients with nonautoimmune hyperthyroidism. Development of goiter is common, anti-thyroid drug treatment is often difficult, and remission of hyperthyroidism does not occur after discontinuation of anti-thyroid drug treatment. Thus, early diagnosis and appropriate treatment of FNAH is necessary to avoid predictable, unnecessary complications and further surgical interventions. LEARNING POINTS In the study, 19/42 cases of familial nonautoimmune hyperthyroidism (FNAH), including the reported case, were not diagnosed as FNAH until the third generation; this lead to suboptimal treatment and frequent relapses of nonautoimmune hyperthyroidism (NAH). Detection of thyroid-stimulating hormone receptor (TSHR) mutations in patients with suspected FNAH to confirm diagnosis is essential to ensure proper treatment for the patient and further affected family members. NAH will persist without proper treatment by total thyroidectomy. Symptoms and age of onset may vary between family members All family members with a TSHR germline mutation should be monitored with thyroid-stimulating hormone and for symptoms throughout their lives.
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Affiliation(s)
- Alexandra Stephenson
- Department of Biochemistry and Molecular Biology & Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alberta
| | - Zoya Punjwani
- Department of Medical Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Markus Eszlinger
- Department of Oncology, Biochemistry and Molecular Biology, and Pathology and Laboratory Medicine, Cumming School of Medicine & Arnie Charbonneau Cancer Institute, University of Calgary, Calgary, Alberta
| | - Beata Sawicka
- Department of Pediatrics, Endocrinology, Diabetology with Cariology Division, Medical University, Bialystok, Poland
| | - Artur Bossowski
- Department of Pediatrics, Endocrinology, Diabetology with Cariology Division, Medical University, Bialystok, Poland
| | - Ralf Paschke
- Departments of Medicine, Oncology, Pathology and Laboratory Medicine, and Biochemistry and Molecular Biology & Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta
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Bezdicka M, Kleiblova P, Soucek J, Borecka M, El-Lababidi E, Smrz D, Rataj M, Sumnik Z, Malikova J, Soucek O. Novel presentation of the c.1856A > G (p.Asp619Gly) TSHR gene-activating variant: relapsing hyperthyroidism in three subsequent generations manifesting in early childhood and an in vitro functional study. Hormones (Athens) 2021; 20:803-812. [PMID: 34142359 DOI: 10.1007/s42000-021-00299-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/10/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Familial non-autoimmune hyperthyroidism is a rare disease caused by germline activating variants in the thyroid-stimulating hormone receptor (TSHR) gene. The c.1856A > G (p.Asp619Gly) pathogenic variant has been described in cases of toxic adenoma but never before, to our knowledge, in a case of familial non-autoimmune hyperthyroidism. PATIENT FINDINGS A 3-year-old boy was admitted for acute gastroenteritis presenting with goiter and tall stature. Laboratory findings revealed peripheral hyperthyroidism and negativity for thyroid autoantibodies. Antithyroid drug treatment was effective, but relapses occurred shortly after attempts to decrease the drug dose. As the boy's father and paternal grandmother also experienced relapsing hyperthyroidism manifesting in early childhood, genetic testing of TSHR was indicated. The c.1856A > G (p.Asp619Gly) pathogenic variant was found in all three affected family members. Functional in vitro characterization of the variant verified that it enhances constitutional activation of the receptor, leading to increased production of cyclic adenosine monophosphate. Total thyroidectomy was indicated in the boy due to an unsatisfactory prognosis. Due to persistent positive thyroglobulin serum concentration, a diagnostic radioiodine scan was performed approximately 2 years later. Residual thyroid tissue was revealed; therefore, radioiodine ablative therapy was performed. Despite adequate thyroxine substitution over a long period of follow-up, TSH remained suppressed. CONCLUSIONS Unlike Graves' disease, familial non-autoimmune hyperthyroidism cases present with antithyroid drug-dependence. Not ultrasound but positive thyroglobulin serum concentration indicated residual thyroid tissue. Early detection of residual thyroid tissue and radioiodine ablation prevented the subject from experiencing relapsing hyperthyroidism and undergoing unnecessary repeated surgery. Life-long hormone substitution should be adjusted to free thyroxine rather than TSH serum concentrations.
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Affiliation(s)
- Martin Bezdicka
- Vera Vavrova Laboratory/VIAL, Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Petra Kleiblova
- Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
| | - Jiri Soucek
- Private Paediatric Endocrinology Practice, Carlsbad, Czech Republic
| | - Marianna Borecka
- Institute of Biology and Medical Genetics, First Faculty of Medicine, Charles University and General University Hospital in Prague, Prague, Czech Republic
- Institute of Biochemistry and Experimental Oncology, First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Eva El-Lababidi
- Department of Pediatrics, Third Faculty of Medicine, Charles University and Kralovske Vinohrady University Hospital, Prague, Czech Republic
| | - Daniel Smrz
- Department of Immunology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Michal Rataj
- Department of Immunology, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Zdenek Sumnik
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Jana Malikova
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic
| | - Ondrej Soucek
- Vera Vavrova Laboratory/VIAL, Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.
- Department of Pediatrics, Second Faculty of Medicine, Charles University and Motol University Hospital, Prague, Czech Republic.
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13
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Abstract
The term 'hyperthyroidism' refers to a form of thyrotoxicosis due to inappropriate high synthesis and secretion of thyroid hormone(s) by the thyroid. The leading cause of hyperthyroidism in adolescents is Graves' disease (GD); however, one should also consider other potential causes, such as toxic nodular goitre (single or multinodular), and other rare disorders leading to excessive production and release of thyroid hormones. The term 'thyrotoxicosis' refers to a clinical state resulting from inappropriate high thyroid hormone action in tissues, generally due to inappropriate high tissue thyroid hormone levels. Thyrotoxicosis is a condition with multiple aetiologies, manifestations, and potential modes of therapy. By definition, the extrathyroidal sources of excessive amounts of thyroid hormones, such as iatrogenic thyrotoxicosis, factitious ingestion of thyroid hormone, or struma ovarii, do not include hyperthyroidism. The aetiology of hyperthyroidism/and thyrotoxicosis should be determined. Although the diagnosis is apparent based on the clinical presentation and initial biochemical evaluation, additional diagnostic testing is indicated. This testing should include: (1) measurement of thyroid-stimulating hormone receptor (TSHR) antibodies (TRAb); (2) analysis of thyroidal echogenicity and blood flow on ultrasonography; or (3) determination of radioactive iodine uptake (RAIU). A 123I or 99mTc pertechnetate scan is recommended when the clinical presentation suggests toxic nodular goitre. A question arises regarding whether diagnostic workup and treatment (antithyroid drugs, radioiodine, surgery, and others) should be the same in children and adolescents as in adults, as well as whether there are the same goals of treatment in adolescents as in adults, in female patients vs in male patients, and in reproductive or in postreproductive age. In this aspect, different treatment modalities might be preferred to achieve euthyroidism and to avoid potential risks from the treatment. The vast majority of patients with thyroid disorders require life-long treatment; therefore, the collaboration of different specialists is warranted to achieve these goals and improve patients' quality of life.
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Affiliation(s)
- Marek Niedziela
- Department of Pediatric Endocrinology and Rheumatology, Institute of Pediatrics, Karol Jonscher’s Clinical Hospital, Poznan University of Medical Sciences, Poznan, Poland
- Correspondence should be addressed to M Niedziela:
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Konda Y, Minamitani K, Takatani T, Kure S, Sugitani I. A case of "asymmetrical" Graves' disease with lateral radioisotope uptake. Pediatr Int 2021; 63:1137-1139. [PMID: 34227705 DOI: 10.1111/ped.14575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 11/30/2020] [Accepted: 12/08/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Yutaka Konda
- Department of Pediatrics, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Kanshi Minamitani
- Department of Pediatrics, Teikyo University Chiba Medical Center, Chiba, Japan
| | - Tomozumi Takatani
- Department of Pediatrics, Chiba University Graduate School of Medicine, Chiba, Japan
| | - Shoko Kure
- Department of Diagnostic Pathology, Nippon Medical School, Musashi-Kosugi Hospital, Kanagawa, Japan
| | - Iwao Sugitani
- Department of Endocrine Surgery, Nippon Medical School, Tokyo, Japan
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15
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Extrathyroidal Manifestations of Persistent Sporadic Non-Autoimmune Hyperthyroidism in a 6-Year-Old Boy: A Case Report. Life (Basel) 2021; 11:life11070713. [PMID: 34357084 PMCID: PMC8305946 DOI: 10.3390/life11070713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 07/16/2021] [Accepted: 07/17/2021] [Indexed: 11/17/2022] Open
Abstract
Thyroid-stimulating hormone receptor (TSHR) belongs in a subfamily of the G protein-coupled receptors. Thyroid-stimulating hormone receptor gene (TSHR), a gene encoding TSHR, is a major controller of thyroid cell metabolism, and its gain of function mutation leads to non-autoimmune hyperthyroidism (NAH), a condition of a prolonged state of hyperthyroidism. Diverse human diseases, and genetic, constitutional, or environmental factors contribute to the phenotypic variations of TSHR mutations; however, the underlying mechanisms leading to various extrathyroidal manifestations across ages are poorly understood. In 2018, the first Korean case of persistent sporadic NAH due to missense mutation of TSHR was reported, and this report highlights the extrathyroidal manifestations of NAH. Further investigation is warranted to clarify the roles of functional mutations of TSHR by investigating the correlation between G protein-dependent signaling properties and clinical phenotypes associated with persistent hyperthyroidism in order to develop novel therapies that could be provided for numerous conditions caused by NAH.
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Familial Non-autoimmune Hyperthyroidism in Family Members Across Four Generations Due To a Novel Disease-causing Variant in The Thyrotropin Receptor Gene. Balkan J Med Genet 2021; 23:87-92. [PMID: 33816077 PMCID: PMC8009563 DOI: 10.2478/bjmg-2020-0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Activating disease-causing variants in the thyrotropin-receptor (TSHR) gene are associated with familial or sporadic congenital non-autoimmune hyperthyroidism. Familial non-autoimmune hyperthyroidism (FNAH) is a rare form of hyperthyroidism with 41 families reported so far in the TSHR gene mutation database. We present clinical and genetic features of 11 patients with FNAH across four generations of a Slovenian family. They all developed clinical features of hyperthyroidism but did not show characteristics of autoimmune hyperthyroidism. Members of the initially diagnosed generation were diagnosed as hyperthyrotic after they developed cardiac complications (rhythm disorders, thromboembolic events, cardiac insufficiency), while patients in the younger generations were diagnosed earlier, and consequently, early cardiovascular complications were less frequent. All patients had a novel heterozygous TSHR variant NP_ 000360.2: p.Met453Val (NM_000369.2: c.1357A>G) predicted to be pathogenic. Therefore, besides expending the mutational spectrum of the activating TSHR variants in FNAH, our experience with this multi-generation family confirms the need for early diagnosis and appropriate treatment of FNAH.
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Suput Omladic J, Pajek M, Groselj U, Trebusak Podkrajsek K, Avbelj Stefanija M, Zerjav Tansek M, Kotnik P, Battelino T, Smigoc Schweiger D. Central TSH Dysregulation in a Patient with Familial Non-Autoimmune Autosomal Dominant Hyperthyroidism Due to a Novel Thyroid-Stimulating Hormone Receptor Disease-Causing Variant. ACTA ACUST UNITED AC 2021; 57:medicina57030196. [PMID: 33669123 PMCID: PMC7996546 DOI: 10.3390/medicina57030196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives. Familial non-autoimmune autosomal dominant hyperthyroidism (FNAH) is a rare cause of childhood hyperthyroidism. It is caused by the thyroid-stimulating hormone receptor (TSHR) gene variants. So far, only around 40 families with FNAH have been reported. Patients with activating TSHR variants demonstrated the same classical signs and symptoms of hyperthyroidism as seen in patients with Graves' disease. Since 2012, ablative therapy is recommended to avoid relapses of hyperthyroidism and its consequences. Case Presentation. We presented a young adult male patient with a novel heterozygous TSHR disease-causing variant p.Arg418Lys (c.1253G>A) in the exon 10, who presented with a mild but progressive FNAH, with a follow-up since infancy. Discussion. Constantly suppressed TSH, including during the euthyreosis in childhood and hypothyreosis after iodine ablation therapy, suggested central dysregulation of the TSH secretion.
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Affiliation(s)
- Jasna Suput Omladic
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Bohoričeva 20, 1000 Ljubljana, Slovenia; (J.S.O.); (U.G.); (M.A.S.); (M.Z.T.); (P.K.); (T.B.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
| | - Maja Pajek
- Department of Paediatric Surgery and Intensive Care, University Medical Centre Ljubljana, Bohoričeva 20, 1000 Ljubljana, Slovenia;
| | - Urh Groselj
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Bohoričeva 20, 1000 Ljubljana, Slovenia; (J.S.O.); (U.G.); (M.A.S.); (M.Z.T.); (P.K.); (T.B.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
| | - Katarina Trebusak Podkrajsek
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
- Clinical Institute for Special Laboratory Diagnostics, University Children’s Hospital, University Medical Centre Ljubljana, Vrazov trg 1, 1000 Ljubljana, Slovenia
| | - Magdalena Avbelj Stefanija
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Bohoričeva 20, 1000 Ljubljana, Slovenia; (J.S.O.); (U.G.); (M.A.S.); (M.Z.T.); (P.K.); (T.B.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
| | - Mojca Zerjav Tansek
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Bohoričeva 20, 1000 Ljubljana, Slovenia; (J.S.O.); (U.G.); (M.A.S.); (M.Z.T.); (P.K.); (T.B.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
| | - Primoz Kotnik
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Bohoričeva 20, 1000 Ljubljana, Slovenia; (J.S.O.); (U.G.); (M.A.S.); (M.Z.T.); (P.K.); (T.B.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
| | - Tadej Battelino
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Bohoričeva 20, 1000 Ljubljana, Slovenia; (J.S.O.); (U.G.); (M.A.S.); (M.Z.T.); (P.K.); (T.B.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
| | - Darja Smigoc Schweiger
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Children’s Hospital, University Medical Centre Ljubljana, Bohoričeva 20, 1000 Ljubljana, Slovenia; (J.S.O.); (U.G.); (M.A.S.); (M.Z.T.); (P.K.); (T.B.)
- Faculty of Medicine, University of Ljubljana, Vrazov trg 2, 1000 Ljubljana, Slovenia;
- Correspondence: ; Tel.: +386-1-522-9235; Fax: +386-1-232-0190
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18
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Taha D, Adhikari A, Flore LA. Familial neonatal nonautoimmune hyperthyroidism due to a gain-of-function (D619G) thyrotropin-receptor mutation. J Pediatr Endocrinol Metab 2021; 34:267-271. [PMID: 33180037 DOI: 10.1515/jpem-2020-0291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 09/13/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Activating germline mutations of the thyroid-stimulating hormone receptor (TSHR) are responsible for a rare form of neonatal nonautoimmune hyperthyroidism (NAH). We report the first case of familial neonatal neonatal nonautoimmune associated with c.1856A>G (p.Asp619Gly) variant in the TSHR gene. CASE PRESENTATION We describe an eight-year-old African-American female presenting with neonatal NAH associated with an inherited heterozygous c.1856A>G (p.Asp619Gly) variant in the TSHR gene. This variant was previously described in one patient presenting with sporadic NAH in adolescence. Our patient was diagnosed with hyperthyroidism in the neonatal period. The mother had a history of hyperthyroidism and had thyroidectomy at the age of 4 years. The patient had goiter and elevated free thyroxine (FT4) and free triiodothyronine (FT3) levels that normalized with methimazole treatment; however, TSH level remained suppressed. Thyroid antibodies were negative. The patient also had bilateral exotropia, a trait shared by the mother and may represent a new association. CONCLUSIONS Familial neonatal NAH is associated with heterozygous c.1856A>G (p.Asp619Gly) variant of the TSHR gene.
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Affiliation(s)
- Doris Taha
- Division of Pediatric Endocrinology, Central Michigan University College of Medicine, Children's Hospital of Michigan, Detroit, MI, USA
| | - Amita Adhikari
- Division of Pediatric Endocrinology, Central Michigan University College of Medicine, Children's Hospital of Michigan, Detroit, MI, USA
| | - Leigh Anne Flore
- Division of Genetic, Metabolic and Genomic Disorders, Central Michigan University College of Medicine, Children's Hospital of Michigan, Detroit, MI, USA
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Okazaki Y, Arata N, Umehara N, Yamauchi T, Tajiri J, Hishinuma A, Kogai T, Idegami T, Murashima A, Sago H. A CASE OF FAMILIAL NONAUTOIMMUNE HYPERTHYROIDISM DURING PREGNANCY. AACE Clin Case Rep 2020; 6:e94-e97. [PMID: 32524019 DOI: 10.4158/accr-2019-0361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2019] [Accepted: 12/22/2019] [Indexed: 11/15/2022] Open
Abstract
Objective Familial nonautoimmune hyperthyroidism (FNAH) is a rare disease. To date there are few, if any, reports of pregnancies in women with FNAH. Our objective here is to present such a case. Methods Free thyroxine (free T4), free triiodothyronine (free T3), thyroid-stimulating hormone (TSH), and antibodies related to the thyroid were measured. Fetal thyroid function indicators including thyroid volume and ossification were checked using ultrasound. Thyroid-stimulating hormone receptor (TSHR) gene analyses were performed. Results The patient was a 30-year-old woman with no past medical history. She was introduced to our hospital in the fifth gestational week for pregnancy care because her family history revealed that her mother had nonautoimmune hyperthyroidism with a TSHR-activating germ-line mutation (Asn406Ser). The serum free T4 was 1.88 ng/dL (normal, 0.62 to 1.19 ng/dL), free T3 was 3.27 pg/mL (normal, 2.55 to 3.88 pg/mL), TSH was 0.02 μIU/mL (normal, 0.007 to 3.619 μIU/mL), and TSHR was negative which were considered to be consistent with mild primary hyperthyroidism. Serum free T4, free T3, and TSH concentrations were monitored every 4 to 6 weeks with a peak free T4 of 2.23 ng/dL noted at gestational week 9. The patient had no signs related to hyperthyroidism throughout pregnancy. The patient delivered a 3,518 g girl at 40 weeks of gestation. Genetic analysis of her TSHR gene showed heterozygous Asn406Ser mutation. The offspring did not show any signs of prenatal hyperthyroidism, and thyroid function at day 6 after delivery revealed a free T4 of 2.41 ng/dL (normal, 1.83 to 2.91 ng/dL) and a TSH of 3.55 μIU/mL (normal, 0.51 to 4.57 μIU/mL). Conclusion Women with FNAH and mild thyrotoxicosis prior to pregnancy may have continuous hyperthyroidism with additional change due to the series of human chorionic gonadotropin secretion during pregnancy.
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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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Wong FC, Au EY, Ip RW, Yau HC, Lit LC. False-positive TSH receptor antibody results in an infant with activating TSHR mutation. Endocr J 2018; 65:793-794. [PMID: 29925745 DOI: 10.1507/endocrj.ej18-0161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
- Felix Ck Wong
- Department of Chemical Pathology, Prince of Wales Hospital, Hong Kong SAR, China
| | - Elaine Yl Au
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
| | - Ricky Wk Ip
- Division of Clinical Immunology, Department of Pathology, Queen Mary Hospital, Hong Kong SAR, China
| | - Ho Chung Yau
- Department of Paediatrics, Prince of Wales Hospital, Hong Kong SAR, China
| | - Lydia Cw Lit
- Department of Chemical Pathology, Prince of Wales Hospital, Hong Kong SAR, China
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Briet C, Suteau-Courant V, Munier M, Rodien P. Thyrotropin receptor, still much to be learned from the patients. Best Pract Res Clin Endocrinol Metab 2018; 32:155-164. [PMID: 29678283 DOI: 10.1016/j.beem.2018.03.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
In the absence of crystal available for the full-length thyrotropin receptor, knowledge of its structure and functioning has benefitted from the identification and characterization of mutations in patients with various thyroid dysfunctions. The characterization of activating mutations has contributed to the elaboration of a model involving the extracellular domain of the receptor as an inverse tethered agonist which, upon binding of the ligand, relieves the transmembrane domain from an inhibiting interaction and activates it. The models derived from comparisons with other receptors, enriched with the information provided by the study of mutations, have proven useful for the design of small-molecule agonists and antagonists that may be used in the future to treat thyroid dysfunctions. In this review, extrathyroidal expression of the thyrotropin receptor is described, the role of which is still poorly defined.
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Affiliation(s)
- Claire Briet
- Centre de Référence des Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Centre Hospitalo-Universitaire d'Angers, 4 Rue Larrey, Angers, France; Institut MITOVASC, UMR CNRS 6015, INSERM 1083, Université d'Angers, France.
| | - Valentine Suteau-Courant
- Centre de Référence des Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Centre Hospitalo-Universitaire d'Angers, 4 Rue Larrey, Angers, France; Institut MITOVASC, UMR CNRS 6015, INSERM 1083, Université d'Angers, France.
| | - Mathilde Munier
- Centre de Référence des Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Centre Hospitalo-Universitaire d'Angers, 4 Rue Larrey, Angers, France; Institut MITOVASC, UMR CNRS 6015, INSERM 1083, Université d'Angers, France.
| | - Patrice Rodien
- Centre de Référence des Maladies Rares de la Thyroïde et des Récepteurs Hormonaux, Centre Hospitalo-Universitaire d'Angers, 4 Rue Larrey, Angers, France; Institut MITOVASC, UMR CNRS 6015, INSERM 1083, Université d'Angers, France.
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Abstract
Neonatal thyrotoxicosis (hyperthyroidism) is less prevalent than congenital hypothyroidism; however, it can lead to significant morbidity and mortality if not promptly recognized and adequately treated. Most cases are transient, secondary to maternal autoimmune hyperthyroidism (Graves disease [GD]). This article summarizes recommendations for screening and management of hyperthyroidism in both the fetal and neonatal periods, with a focus on neonatal thyrotoxicosis secondary to maternal GD. Early monitoring and treatment are crucial for optimizing short-term and long-term patient outcomes.
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Oliver-Petit I, Savagner F, Grunenwald S, Vialon M, Edouard T, Caron P. Severe thyrotoxicosis in an infant revealing familial nonautoimmune hyperthyroidism with a novel (C672W) stimulating thyrotropin receptor germline mutation. Clin Case Rep 2017; 5:1980-1987. [PMID: 29225840 PMCID: PMC5715599 DOI: 10.1002/ccr3.1178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Revised: 06/21/2017] [Accepted: 08/13/2017] [Indexed: 11/22/2022] Open
Abstract
We describe severe thyrotoxicosis in young members of a family with nonautoimmune hyperthyroidism caused by a C672W germline mutation in exon 10 of TSHR gene. In this family, lack of genotype‐phenotype correlation and anticipation across generations could be linked to an increased iodine intake as recently observed in France.
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Affiliation(s)
- Isabelle Oliver-Petit
- Endocrine, Genetics, Bone Diseases, and Paediatric Gynecology Unit Children's Hospital CHU Toulouse Toulouse France
| | - Frédérique Savagner
- Biochemistry and Genetic laboratory Federative institute of biology CHU Purpan Toulouse Toulouse France
| | - Solange Grunenwald
- Department of Endocrinology and Metabolic Diseases Cardio-Vascular and Metabolic Unit CHU Larrey Toulouse France
| | - Magaly Vialon
- Department of Endocrinology and Metabolic Diseases Cardio-Vascular and Metabolic Unit CHU Larrey Toulouse France
| | - Thomas Edouard
- Endocrine, Genetics, Bone Diseases, and Paediatric Gynecology Unit Children's Hospital CHU Toulouse Toulouse France
| | - Philippe Caron
- Department of Endocrinology and Metabolic Diseases Cardio-Vascular and Metabolic Unit CHU Larrey Toulouse France
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Carlé A, Andersen SL, Boelaert K, Laurberg P. MANAGEMENT OF ENDOCRINE DISEASE: Subclinical thyrotoxicosis: prevalence, causes and choice of therapy. Eur J Endocrinol 2017; 176:R325-R337. [PMID: 28274949 DOI: 10.1530/eje-16-0276] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Revised: 12/23/2016] [Accepted: 03/08/2017] [Indexed: 12/25/2022]
Abstract
Subclinical thyrotoxicosis is a condition affecting up to 10% of the population in some studies. We have reviewed literature and identified studies describing prevalences, causes and outcomes of this condition. Treatment should be considered in all subjects if this biochemical abnormality is persistent, especially in case of symptoms of thyrotoxicosis or in the presence of any complication. In particular, treatment should be offered in those subclinically thyrotoxic patients with a sustained serum TSH below 0.1 U/L. However it is important to recognise that there are no large controlled intervention studies in the field and thus there is no high quality evidence to guide treatment recommendations. In particular, there is no evidence for therapy and there is weak evidence of harm from thyrotoxicosis if serum TSH is in the 0.1-0.4 IU/L range. In this review, we describe the different causes of subclinical thyrotoxicosis, and how treatment should be tailored to the specific cause. We advocate radioactive iodine treatment to be the first-line treatment in majority of patients suffering from subclinical thyrotoxicosis due to multinodular toxic goitre and solitary toxic adenoma, but we do generally not recommend it as the first-line treatment in patients suffering from subclinical Graves' hyperthyroidism. Such patients may benefit mostly from antithyroid drug therapy. Subclinical thyrotoxicosis in early pregnancy should in general be observed, not treated. Moreover, we advocate a general restriction of therapy in cases where no specific cause for the presumed thyroid hyperactivity has been proven.
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Affiliation(s)
| | - Stine Linding Andersen
- Department of Endocrinology
- Department of Clinical BiochemistryAalborg University Hospital, Aalborg, Denmark
| | - Kristien Boelaert
- Institute of Metabolism and Systems ResearchSchool of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Peter Laurberg
- Department of Endocrinology
- Department of Clinical MedicineAalborg University, Aalborg, Denmark
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Abstract
Hyperthyroidism is a clinical state that results from high thyroid hormone levels which has multiple etiologies, manifestations, and potential therapies. Excluding the autoimmune Graves disease, autonomic adenomas account for the most import cause of non-autoimmune hyperthyroidism. Activating germline mutations of the TSH receptor are rare etiologies for hyperthyroidism. They can be inherited in an autosomal dominant manner (familial or hereditary, FNAH), or may occur sporadically as a de novo condition, also called: persistent sporadic congenital non-autoimmune hyperthyroidism (PSNAH). These three conditions: autonomic adenoma, FNAH and PSNAH constitute the inheritable and sporadic non-autoimmune hyperthyroidism. Particularities in epidemiology, etiology, molecular and clinical aspects of these three entities will be discussed in this review in order to guide to an accurate diagnosis allowing among others genetic counseling and presymptomatic diagnosis for the affected families. The optimal treatment based on the right diagnosis will avoid consequences of a persistent or relapsing hyperthyroidism.
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Affiliation(s)
- Carolina Ferraz
- Endocrinology and Metabolism of Faculty of Medical Science of Santa Casa de São Paulo, FCMSCSP, Brazil.
| | - Ralf Paschke
- Division of Endocrinology and Metabolism, Chair Provincial Endocrine Tumour Team, Departments of Medicine, Oncology, Pathology and Biochemistry and Molecular Biology & Arnie Charbonneau Cancer Institute, Cumming School of Medicine, University of Calgary, HMRB, Room 382B, 3330 Hospital Dr NW, Calgary, Alberta, T2N 4N1, Canada.
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27
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Alexander EK, Pearce EN, Brent GA, Brown RS, Chen H, Dosiou C, Grobman WA, Laurberg P, Lazarus JH, Mandel SJ, Peeters RP, Sullivan S. 2017 Guidelines of the American Thyroid Association for the Diagnosis and Management of Thyroid Disease During Pregnancy and the Postpartum. Thyroid 2017; 27:315-389. [PMID: 28056690 DOI: 10.1089/thy.2016.0457] [Citation(s) in RCA: 1303] [Impact Index Per Article: 186.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Thyroid disease in pregnancy is a common clinical problem. Since the guidelines for the management of these disorders by the American Thyroid Association (ATA) were first published in 2011, significant clinical and scientific advances have occurred in the field. The aim of these guidelines is to inform clinicians, patients, researchers, and health policy makers on published evidence relating to the diagnosis and management of thyroid disease in women during pregnancy, preconception, and the postpartum period. METHODS The specific clinical questions addressed in these guidelines were based on prior versions of the guidelines, stakeholder input, and input of task force members. Task force panel members were educated on knowledge synthesis methods, including electronic database searching, review and selection of relevant citations, and critical appraisal of selected studies. Published English language articles were eligible for inclusion. The American College of Physicians Guideline Grading System was used for critical appraisal of evidence and grading strength of recommendations. The guideline task force had complete editorial independence from the ATA. Competing interests of guideline task force members were regularly updated, managed, and communicated to the ATA and task force members. RESULTS The revised guidelines for the management of thyroid disease in pregnancy include recommendations regarding the interpretation of thyroid function tests in pregnancy, iodine nutrition, thyroid autoantibodies and pregnancy complications, thyroid considerations in infertile women, hypothyroidism in pregnancy, thyrotoxicosis in pregnancy, thyroid nodules and cancer in pregnant women, fetal and neonatal considerations, thyroid disease and lactation, screening for thyroid dysfunction in pregnancy, and directions for future research. CONCLUSIONS We have developed evidence-based recommendations to inform clinical decision-making in the management of thyroid disease in pregnant and postpartum women. While all care must be individualized, such recommendations provide, in our opinion, optimal care paradigms for patients with these disorders.
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Affiliation(s)
- Erik K Alexander
- 1 Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital and Harvard Medical School , Boston, Massachusetts
| | - Elizabeth N Pearce
- 2 Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine , Boston, Massachusetts
| | - Gregory A Brent
- 3 Department of Medicine, VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA , Los Angeles, California
| | - Rosalind S Brown
- 4 Division of Endocrinology, Boston Children's Hospital , Harvard Medical School, Boston, Massachusetts
| | - Herbert Chen
- 5 Department of Surgery, University of Alabama at Birmingham , Birmingham, Alabama
| | - Chrysoula Dosiou
- 6 Division of Endocrinology, Stanford University School of Medicine , Stanford, California
| | - William A Grobman
- 7 Department of Obstetrics and Gynecology, Northwestern University , Chicago, Illinois
| | - Peter Laurberg
- 8 Departments of Endocrinology & Clinical Medicine, Aalborg University Hospital , Aalborg, Denmark
| | - John H Lazarus
- 9 Institute of Molecular Medicine, Cardiff University , Cardiff, United Kingdom
| | - Susan J Mandel
- 10 Division of Endocrinology, Diabetes and Metabolism, Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
| | - Robin P Peeters
- 11 Department of Internal Medicine and Rotterdam Thyroid Center, Erasmus Medical Center , Rotterdam, The Netherlands
| | - Scott Sullivan
- 12 Department of Obstetrics and Gynecology, Medical University of South Carolina , Charleston, South Carolina
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Abstract
Hyperthyroidism is a form of thyrotoxicosis in which there is excess thyroid hormone synthesis and secretion. Multiple etiologies can lead to a common clinical state of "thyrotoxicosis," which is a consequence of the high thyroid hormone levels and their action on different tissues of the body. The most common cause of thyrotoxicosis is Graves' disease, an autoimmune disorder in which stimulating thyrotropin receptor antibodies bind to thyroid stimulating hormone (TSH) receptors on thyroid cells and cause overproduction of thyroid hormones. Other etiologies include: forms of thyroiditis in which inflammation causes release of preformed hormone, following thyroid gland insult that is autoimmune, infectious, mechanical or medication induced; secretion of human chorionic gonadotropin in the setting of transient gestational thyrotoxicosis and trophoblastic tumors; pituitary thyrotropin release, and exposure to extra-thyroidal sources of thyroid hormone that may be endogenous or exogenous. © 2017 American Physiological Society. Compr Physiol 7:67-79, 2017.
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Affiliation(s)
- Ishita Singh
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare Systems, Los Angeles, California, USA
| | - Jerome M Hershman
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare Systems, Los Angeles, California, USA
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Abstract
Five syndromes share predominantly hyperplastic glands with a primary excess of hormones: neonatal severe primary hyperparathyroidism, from homozygous mutated CASR, begins severely in utero; congenital non-autoimmune thyrotoxicosis, from mutated TSHR, varies from severe with fetal onset to mild with adult onset; familial male-limited precocious puberty, from mutated LHR, expresses testosterone oversecretion in young boys; hereditary ovarian hyperstimulation syndrome, from mutated FSHR, expresses symptomatic systemic vascular permeabilities during pregnancy; and familial hyperaldosteronism type IIIA, from mutated KCNJ5, presents in young children with hypertension and hypokalemia. The grouping of these five syndromes highlights predominant hyperplasia as a stable tissue endpoint and as their tissue stage for all of the hormone excess. Comparisons were made among this and two other groups of syndromes, forming a continuum of gland staging: predominant oversecretions express little or no hyperplasia; predominant hyperplasias express little or no neoplasia; and predominant neoplasias express nodules, adenomas, or cancers. Hyperplasias may progress (5 of 5) to neoplastic stages while predominant oversecretions rarely do (1 of 6; frequencies differ P<0.02). Hyperplasias do not show tumor multiplicity (0 of 5) unlike neoplasias that do (13 of 19; P<0.02). Hyperplasias express mutation of a plasma membrane-bound sensor (5 of 5), while neoplasias rarely do (3 of 14; P<0.002). In conclusion, the multiple distinguishing themes within the hyperplasias establish a robust pathophysiology. It has the shared and novel feature of mutant sensors in the plasma membrane, suggesting that these are major contributors to hyperplasia.
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Affiliation(s)
- Stephen J Marx
- Genetics and Endocrinology SectionNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Building 10, Room 9C-103, Bethesda, Maryland 20892, USA
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30
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Abstract
Changes in thyroid hormone concentrations that are characteristic of hyperthyroidism must be distinguished from physiological changes in thyroid hormone economy that occur in pregnancy, especially in the first trimester. Approximately one to two cases of gestational hyperthyroidism occur per 1000 pregnancies. Identification of hyperthyroidism in a pregnant woman is important because adverse outcomes can occur in both the mother and the offspring. Graves' disease, which is autoimmune in nature, is the usual cause; but hyperthyroidism in pregnancy can be caused by any type of hyperthyroidism--eg, toxic multinodular goitre or solitary autonomously functioning nodule. Gestational transient thyrotoxicosis is typically reported in women with hyperemesis gravidarum, and is mediated by high circulating concentrations of human chorionic gonadotropin. Post-partum thyroiditis occurs in 5-10% of women, and many of those affected ultimately develop permanent hypothyroidism. Antithyroid drug treatment of hyperthyroidism in pregnant women is controversial because the usual drugs--methimazole or carbimazole--are occasionally teratogenic; and the alternative--propylthiouracil--can be hepatotoxic. Fetal hyperthyroidism can be life-threatening, and needs to be recognised as soon as possible so that treatment of the fetus with antithyroid drugs via the mother can be initiated. In this Review, we discuss physiological and pathophysiological changes in thyroid hormone economy in pregnancy, the diagnosis and management of hyperthyroidism during pregnancy, severe life-threatening thyrotoxicosis in pregnancy, neonatal thyrotoxicosis, and post-partum hyperthyroidism.
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Affiliation(s)
- David S Cooper
- Division of Endocrinology and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Peter Laurberg
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
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31
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Affiliation(s)
- Patrice Rodien
- *Patrice Rodien, Endocrinologie, CHU d'Angers, FR–49933 Angers Cedex 09 (France), E-Mail
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