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Campi I, Dell’Acqua M, Stellaria Grassi E, Cristina Vigone M, Persani L. Unusual causes of hyperthyrotropinemia and differential diagnosis of primary hypothyroidism: a revised diagnostic flowchart. Eur Thyroid J 2023; 12:e230012. [PMID: 37067253 PMCID: PMC10305563 DOI: 10.1530/etj-23-0012] [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] [Received: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/18/2023] Open
Abstract
The clinical consequences of primary hypothyroidism include cardiovascular morbidity, increased mortality, and poor quality of life; therefore guidelines endorsed by several Scientific Societies recommend measuring circulating thyroid-stimulating hormone (TSH) in patients at risk. The assessment of serum TSH levels is also deemed to be the most robust and accurate biomarker during the management of replacement therapy in patients with a previous diagnosis of primary hypothyroidism. In line with a reflex TSH laboratory strategy, free thyroxine is measured only if the TSH falls outside specific cutoffs, in order to streamline investigations and save unjustified costs. This serum TSH-based approach to both diagnosis and monitoring has been widely accepted by several national and local health services; nevertheless, false-negative or -positive testing may occur, leading to inappropriate management or treatment. This review aims to describe several infrequent causes of increased circulating TSH, including analytical interferences, resistance to TSH, consumptive hypothyroidism, and refractoriness to levothyroxine replacement treatment. We propose a clinical flowchart to aid correct recognition of these various conditions, which represent important potential pitfalls in the diagnosis and treatment of primary hypothyroidism.
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Affiliation(s)
- Irene Campi
- Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
| | - Marco Dell’Acqua
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Elisa Stellaria Grassi
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | | | - Luca Persani
- Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
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2
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Walther A, Häberle B, Küppers J, Lurz E, Schmid I, Schmidt H, Dubinski I. Severe consumptive hypothyroidism in hepatic hemangioendothelioma. J Pediatr Endocrinol Metab 2022; 35:1560-1564. [PMID: 36190305 DOI: 10.1515/jpem-2022-0347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 08/16/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Consumptive hypothyroidism may occur in hepatic hemangioendothelioma. The altered expression of deiodinases inactivates peripheral thyroid hormones. As a result, serum levels of free triiodothyronine and free thyroxine are reduced to varying degrees. There are no established recommendations for the dosage of sirolimus for this particular indication. We describe for the first time the course of treatment with low-dose sirolimus. CASE PRESENTATION We present a 5-week-old infant with hepatic hemangioendothelioma and severe consumptive hypothyroidism. Due to hepatic infiltration he showed signs of right heart strain. Therapy of hemangioendothelioma was initiated with propranolol and, in the absence of response, methylprednisolone was added. Treatment was continued with low-dose sirolimus (due to side effects) and propranolol. Hypothyroidism was managed with levothyroxine and liothyronine. CONCLUSIONS Consumptive hypothyroidism due to cutaneous hemangioma and hepatic hemangioendothelioma can be managed with propranolol and low-dose sirolimus. Treatment of severe hypothyroidism may require a combinational therapy by substitution of both T3 and T4.
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Affiliation(s)
- Antonia Walther
- Department of Pediatrics, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Beate Häberle
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Julia Küppers
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Eberhard Lurz
- Division of Pediatric Gastroenterology und Hepatology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Irene Schmid
- Division of Pediatric Hematology and Oncology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Heinrich Schmidt
- Division of Pediatric Endocrinology and Diabetology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
| | - Ilja Dubinski
- Division of Pediatric Endocrinology and Diabetology, Dr. von Hauner Children's Hospital, University Hospital Munich, LMU, Munich, Germany
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3
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Siano MA, Ametrano O, Barbato F, Sammarco E, Ranucci G, Pietrobattista A, Rossomando A, Mandato C. Consumptive Hypothyroidism due to Hepatic Hemangiomas: A Case Series and Review of the Literature. JPGN REPORTS 2022; 3:e270. [PMID: 37168485 PMCID: PMC10158424 DOI: 10.1097/pg9.0000000000000270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 10/06/2022] [Indexed: 05/13/2023]
Abstract
Consumptive hypothyroidism (CH) is a rare and potentially overlooked complication of hepatic hemangiomas (HH) overexpressing the enzyme deiodinase, which converts thyroxine (T4) to reverse triiodothyronine (rT3). Materials and methods Here, we report a case series of 3 patients and a systematic review of the literature. Results Hypothyroidism (mean serum TSH 52.03 mIU/L) was detected at a mean age of 4.6 months (range 3-6) in 3 infants with infantile hepatic hemangiomas, treated with thyroxine (mean dose 12 µg/kg/day). All received treatment with propranolol (1-3 mg/kg/day) from the mean age of 4 months. Hormonal treatment was stopped at a mean age of 20 months (range 12-30). Hypothyroidism reoccurred in a patient concurrently with the increase of liver lesions, requiring liver transplantation (LT) at age 39 months.Literature review retrieved 42 studies (48 patients): HH (n = 43) were isolated in 24 infants and associated with cutaneous hemangiomas in 19. Hemangiomas were only cutaneous in 5.In the first 43 patients, hypothyroidism was detected at a mean age of 1 month; 21 of 43 patients were prescribed propranolol alone (n = 8) or associated with other medicaments (n = 13); 2 of 43 patients underwent LT. Hormonal treatment consisted of T4 in 35 of 43 patients and T3 in 10.CH associated with only cutaneous and extrahepatic visceral hemangiomas (n = 5), detected at a mean age of 7 months (TSH mean levels at diagnosis of 150.3 mIU/L). Three of 5 patients received treatment with propranolol ± other medicaments. All 5 patients were treated with T4. Conclusions Periodical thyroid function assessment is necessary in patients with hepatic hemangiomas, particularly when lesions' size and number increase rapidly.
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Affiliation(s)
- Maria Anna Siano
- From the Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Università di Salerno, Baronissi (Salerno), Italy
| | - Orsola Ametrano
- Department of Pediatric Dermatology, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Filomena Barbato
- Department of Pediatric Dermatology, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Elena Sammarco
- Department of Pediatric Dermatology, Santobono-Pausilipon Children Hospital, Naples, Italy
| | - Giusy Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children Hospital, Naples, Italy
| | | | - Alessia Rossomando
- From the Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Università di Salerno, Baronissi (Salerno), Italy
| | - Claudia Mandato
- From the Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, Università di Salerno, Baronissi (Salerno), Italy
- Department of Pediatrics, Santobono-Pausilipon Children Hospital, Naples, Italy
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4
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Fiore R, La Rosa S, Uccella S, Marchiori D, Kopp PA. Consumptive hypothyroidism in a patient with malignant rhabdoid tumor of the kidney: case report on a newly found association. Eur Thyroid J 2022; 11:e220006. [PMID: 36053775 PMCID: PMC9578057 DOI: 10.1530/etj-22-0006] [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: 08/28/2022] [Accepted: 09/02/2022] [Indexed: 11/08/2022] Open
Abstract
Introduction Consumptive hypothyroidism is a rare paraneoplastic condition most commonly associated with infantile hemangiomas. It is caused by overexpression of deiodinase type 3 (D3), which leads to preferential conversion of thyroxine to the metabolically inactive reverse triiodothyronine (rT3), paralleled by a decrease of the biologically active T3. Case presentation A 46-year-old male patient with previously normal thyroid function was diagnosed with a renal carcinoma with rhabdoid differentiation. He was treated with sunitinib, followed by the immune checkpoint inhibitors ipilimumab and nivolumab, and he developed primary hypothyroidism secondary to thyroiditis. Substitution with unusually high doses of levothyroxine as high as 4.3 µg/kg/day did not normalize his thyroid function. Poor compliance was refuted because there was no improvement after observed administration. He had no malabsorption. Although tyrosine kinase inhibitors can increase the expression of D3, this effect tends to be modest. Therefore, the suspicion of tumor-related consumptive hypothyroidism was raised and supported by low free T3 and elevated rT3 levels. The therapy could not be further modified because the patient opted for palliative care and passed away 12 days later. Immunohistochemistry of the tumor from a sample obtained prior to systemic therapy documented abundant expression of D3, corroborating the diagnosis of consumptive hypothyroidism. Conclusions This observation extends the spectrum of malignancies overexpressing D3. Although rare, increased awareness of this paraneoplastic syndrome is key, if persistent hypothyroidism cannot be explained by compliance issues or malabsorption. Substitution with high doses of levothyroxine, and combination therapy with liothyronine, can correct hypothyroidism in these patients.
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Affiliation(s)
- Roberto Fiore
- Division of Endocrinology, Diabetes and Metabolism, University Hospital of Lausanne and University of Lausanne, Hôtel des Patients, Lausanne, Switzerland
| | - Stefano La Rosa
- Unit of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Silvia Uccella
- Unit of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Deborah Marchiori
- Unit of Pathology, Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Peter A Kopp
- Division of Endocrinology, Diabetes and Metabolism, University Hospital of Lausanne and University of Lausanne, Hôtel des Patients, Lausanne, Switzerland
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Verelst FR, Beyens MMJ, Vandenbroucke E, Forceville K, Th B Twickler M. A decrease in peripheral thyroid hormone conversion efficiency in patients treated with immune checkpoint inhibitors and L-T3 as a possible alternative therapeutic escape option. Eur J Clin Invest 2022; 52:e13790. [PMID: 35428986 DOI: 10.1111/eci.13790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 03/13/2022] [Accepted: 03/31/2022] [Indexed: 11/29/2022]
Abstract
Hypothyroidism is a frequently occurring side effect in patients under treatment with immune checkpoint inhibitors (ICIs). Actually, the origin of hypothyroidism with ICI use is classified as a primary (thyroid) or as secondary/tertiary hypothyroidism (hypothalamus-pituitary). Treatment consists of levothyroxine (L-T4) substitution. Recently, we were rarely confronted with a clinically overt hypothyroidism in three patients under treatment with ICIs who were non-responsive to T4 therapy. As a therapeutical escape, liothyronine (L-T3) was started with a significant clinical and/or biochemical improvement suggesting an underlying functional defect in the peripheral free T4 (fT4) to free T3 (fT3) conversion (as supported by calculation of SPINA-GD). Against this background, we discussed our three patients along an extended review of this clinical topic.
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Affiliation(s)
| | | | - Elke Vandenbroucke
- Department of Pneumology, AZ Monica, Deurne, Belgium.,Department of Pneumology, Antwerp University Hospital, Edegem, Belgium
| | - Katheleen Forceville
- Department of Oncology, AZ Monica, Deurne, Belgium.,Department of Oncology, Antwerp University Hospital, Edegem, Belgium
| | - Marcel Th B Twickler
- Department of Endocrinology, Diabetology and Metabolic Disease, AZ Monica, Deurne, Belgium.,Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium
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6
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Strzałka A, Hogendorf P, Skulimowski A, Spychalski M, Strzelczyk J, Durczynski A. Thyroid hormones concentration in portal and peripheral blood in patients with pancreatic cancer: Preliminary study. Cancer Biomark 2021; 29:301-306. [PMID: 32568183 DOI: 10.3233/cbm-201595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prognostic value of D-dimers concentration in portal blood in patients with pancreatic cancer has been established in several studies. Thyroid hormones and their receptors, especially T3 also seems to have a specific role in process of neoplasia and metastatic spread. OBJECTIVE The aim of the study was to look for changes of thyroid hormones concentration between portal and peripheral blood. METHODS We included prospectively 8 patients with pancreatic cancer, without liver dysfunction, qualified to surgical treatment. D-dimers, THS, fT3, fT4 concentration was determined in blood samples from portal and peripheral vein taken intraoperatively. RESULTS The difference and quotient of portal and peripheral concentration of D-dimers, THS, fT3 and fT4 was calculated (D-dimer-; THS-; fT3-; fT4-d and -q). The level of D-dimers measured in portal blood was > 2700 ng/mL in 3 patients. The peripheral fT3 level was significantly higher In high portal D-dimers group. FT3 change coefficients showed strong statistically significant negative correlation with portal D-dimer concentration level. CONCLUSIONS We suggest that fT3 or its receptors can influence progression of pancreatic malignancies. The results of this study are also a new evidence that both fT3 and portal D-dimers are biologically linked to intensity of local neoplastic process. Nevertheless, deeper knowledge about portal circulation probably constitute missing part in understanding nature of pancreatic neoplasia. Investigations both on larger group and in the field of basic sciences are needed.
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Affiliation(s)
- Alicja Strzałka
- General and Transplant Surgery Department, Medical University of Lodz, Lodz, Poland
| | - Piotr Hogendorf
- General and Transplant Surgery Department, Medical University of Lodz, Lodz, Poland
| | - Aleksander Skulimowski
- Department of Plastic and Hand Surgery, University of Freiburg Medical Centre, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Michał Spychalski
- Centre for Bowel Treatment, Specialized Hospital Brzeziny, Brzeziny, Poland
| | - Janusz Strzelczyk
- General and Transplant Surgery Department, Medical University of Lodz, Lodz, Poland
| | - Adam Durczynski
- General and Transplant Surgery Department, Medical University of Lodz, Lodz, Poland
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Civantos Modino S, Pacheco Delgado MS, Martínez-Piñeiro Muñoz JA, Cancer Minchot E, Cánovas Molina G, Rodríguez Robles A. Hipotiroidismo consuntivo en paciente con hipotiroidismo primario previo. ENDOCRINOL DIAB NUTR 2021; 68:76-78. [DOI: 10.1016/j.endinu.2019.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 10/27/2019] [Accepted: 10/29/2019] [Indexed: 11/28/2022]
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8
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Alam MA, Quamri MA, Sofi G, Ansari S. Update of hypothyroidism and its management in Unani medicine. J Basic Clin Physiol Pharmacol 2020; 32:1-10. [PMID: 32776903 DOI: 10.1515/jbcpp-2020-0121] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/22/2020] [Indexed: 06/11/2023]
Abstract
Hypothyroidism is a clinical syndrome caused by thyroid hormone deficiency due to reduced production, deranged distribution, or lack of effects of thyroid hormone. The prevalence of hypothyroidism in developed countries is around 4-5%, whereas it is about 11% in India, only 2% in the UK, and 4·6% in the USA. It is more common in women than in men. Hypothyroidism has multiple etiologies and manifestations. The most common clinical manifestations are weight gain, loss of hair, cold intolerance, lethargy, constipation, dry skin, and change in voice. The signs and symptoms of hypothyroidism differ with age, gender, severity of condition, and some other factors. The diagnosis is based on clinical history, physical examination and serum level of FT3, FT4, and thyroid-stimulating hormone, imaging studies, procedures, and histological findings. The treatment of choice for hypothyroidism is levothyroxine, however; in this review article, we have discussed the epidemiology, etiology, clinical sign and symptoms, diagnosis, complications, and management of hypothyroidism in modern medicine and a comparative treatment by the Unani system of medicine (USM). In the USM, the main emphasis of the principle of treatment (Usool-e-Ilaj) is to correct the abnormal constitution (Su-e-Mizaj) and alter the six prerequisites for existence (Asbab-e-Sitta Zarooriya) to restore normal health. It is a packaged treatment, that is, different components of treatment are given as a package form which includes different drugs, dosages form, and regimens.
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Affiliation(s)
- Md Anzar Alam
- Department of Moalajat, National Institute of Unani Medicine, Bangalore, India
| | | | - Ghulamuddin Sofi
- Department of Ilmul Advia, National Institute of Unani Medicine, Bangalore, India
| | - Shabnam Ansari
- Department of Biotechnology, Natural Sciences, Jamia Millia Islamia, Central University, New Delhi, India
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Kim YH, Lee YA, Shin CH, Hong KT, Kim GB, Ko JS, Lee YJ. A Case of Consumptive Hypothyroidism in a 1-Month-Old Boy with Diffuse Infantile Hepatic Hemangiomas. J Korean Med Sci 2020; 35:e180. [PMID: 32508067 PMCID: PMC7279942 DOI: 10.3346/jkms.2020.35.e180] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 04/28/2020] [Indexed: 11/23/2022] Open
Abstract
Consumptive hypothyroidism is a rare paraneoplastic syndrome characterized by excessive inactivation of the thyroid hormones due to increased type 3 iodothyronine deiodinase activity of tumors. We report the case of severe consumptive hypothyroidism in a 1-month-old boy with infantile hepatic hemangiomas who presented with cardiac failure and cholestasis. Diffuse infiltration of hepatic hemangiomas was detected on abdominal imaging studies, and thyroid function screening test revealed severe hypothyroidism, which necessitated the administration of higher-than-usual doses of levothyroxine for the normalization of thyroid function. The patient was successfully treated with propranolol, prednisolone, and levothyroxine, and he showed normal thyroid function at 3 months of age and normal neurodevelopment at 9 months of age. This case highlights the importance of early recognition and prompt management of consumptive hypothyroidism in patients with infantile hepatic hemangiomas.
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Affiliation(s)
- Young Ho Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Kyung Taek Hong
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Gi Beom Kim
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jae Sung Ko
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Yun Jeong Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea.
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10
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Bauer AJ, Wassner AJ. Thyroid hormone therapy in congenital hypothyroidism and pediatric hypothyroidism. Endocrine 2019; 66:51-62. [PMID: 31350727 DOI: 10.1007/s12020-019-02024-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 07/17/2019] [Indexed: 12/11/2022]
Abstract
The evaluation and management of hypothyroidism in children are similar to adults, but there are important differences based on the dependence on normal thyroid function for neurocognitive and physical development. In the pediatric population, hypothyroidism is frequently categorized as congenital or acquired hypothyroidism, depending on the age of presentation and the underlying etiology. The evaluation and management of children and adolescents with hypothyroidism are determined by the etiology as well as by the age at diagnosis, severity of the hypothyroidism, and the response to thyroid hormone replacement therapy. Children and adolescents require higher weight-based doses for thyroid hormone replacement than do adults, likely due to a shorter half-life of thyroxine (T4) and triiodothyronine (T3) in children, but weight-based dose requirements decrease as the child advances into adulthood. Multiple gaps in knowledge remains regarding how to optimize the treatment of hypothyroidism in pediatric patients, including (but not limited to) the selection of patients with subclinical hypothyroidism for treatment, and the potential benefit of combined LT3/LT4 therapy for patients with persistent symptoms and/or low T3 on LT4 monotherapy. The life-long impact on growth and development, and potentially on long-term cardiovascular and psychosocial health, are significant and highlight the importance of future prospective studies in pediatric patients to explore these areas of uncertainty.
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Affiliation(s)
- Andrew J Bauer
- The Thyroid Center, Division of Endocrinology and Diabetes, The Children's Hospital of Philadelphia, The Perelman School of Medicine, The University of Pennsylvania, 3500 Civic Center Boulevard, Buerger Center, 12-149, Philadelphia, PA, 19104, USA.
| | - Ari J Wassner
- Thyroid Program, Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, 333 Longwood Avenue, 2nd floor, Boston, MA, 02115, USA
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11
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Igarashi A, Hata I, Yuasa M, Okuno T, Ohshima Y. A case of an infant with extremely low birth weight and hypothyroidism associated with massive cutaneous infantile hemangioma. J Pediatr Endocrinol Metab 2018; 31:1377-1380. [PMID: 30367808 DOI: 10.1515/jpem-2018-0369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 10/02/2018] [Indexed: 01/21/2023]
Abstract
Background Although hepatic infantile hemangioma (IH) may correlate with consumptive hypothyroidism consequent to the overexpression of thyroid hormone inactivating enzyme by hemangioma cells, hypothyroidism has been rarely recognized in infants with cutaneous hemangioma. Case presentation A male infant born at 28 weeks of gestational age with an extremely low birth weight (775 g) developed a massive cutaneous hemangioma on his neck and severe abdominal distension. Imaging examinations detected a small mass lesion in the brain but no hepatic hemangioma. Laboratory findings at the age of 26 days revealed hypothyroidism. Although high-dose levothyroxine therapy failed to normalize the thyroid function, hypothyroidism improved and cutaneous hemangioma regressed after initiating propranolol therapy. Conclusions Our findings suggest that consumptive hypothyroidism should be considered as a critical comorbidity in patients with massive cutaneous IH. Propranolol therapy can effectively normalize thyroid function and cause hemangioma regression.
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Affiliation(s)
- Aiko Igarashi
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
| | - Ikue Hata
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
| | - Miori Yuasa
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
| | - Takashi Okuno
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
| | - Yusei Ohshima
- Department of Pediatrics, Faculty of Medical Sciences, University of Fukui, Matsuoka, Eiheiji-cho, Yoshida-gun, Fukui, Japan
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12
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Goemann IM, Marczyk VR, Romitti M, Wajner SM, Maia AL. Current concepts and challenges to unravel the role of iodothyronine deiodinases in human neoplasias. Endocr Relat Cancer 2018; 25:R625-R645. [PMID: 30400023 DOI: 10.1530/erc-18-0097] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022]
Abstract
Thyroid hormones (THs) are essential for the regulation of several metabolic processes and the energy consumption of the organism. Their action is exerted primarily through interaction with nuclear receptors controlling the transcription of thyroid hormone-responsive genes. Proper regulation of TH levels in different tissues is extremely important for the equilibrium between normal cellular proliferation and differentiation. The iodothyronine deiodinases types 1, 2 and 3 are key enzymes that perform activation and inactivation of THs, thus controlling TH homeostasis in a cell-specific manner. As THs seem to exert their effects in all hallmarks of the neoplastic process, dysregulation of deiodinases in the tumoral context can be critical to the neoplastic development. Here, we aim at reviewing the deiodinases expression in different neoplasias and exploit the mechanisms by which they play an essential role in human carcinogenesis. TH modulation by deiodinases and other classical pathways may represent important targets with the potential to oppose the neoplastic process.
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Affiliation(s)
- Iuri Martin Goemann
- Thyroid Unit, Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Vicente Rodrigues Marczyk
- Thyroid Unit, Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Mirian Romitti
- Institut de Recherche Interdisciplinaire en Biologie Humaine et Moléculaire, Université Libre de Bruxelles, Brussels, Belgium
| | - Simone Magagnin Wajner
- Thyroid Unit, Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ana Luiza Maia
- Thyroid Unit, Endocrine Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
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13
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Simsek E, Demiral M, Gundoğdu E. Severe consumptive hypothyroidism caused by multiple infantile hepatic haemangiomas. J Pediatr Endocrinol Metab 2018; 31:823-827. [PMID: 29953409 DOI: 10.1515/jpem-2018-0055] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 05/28/2018] [Indexed: 01/05/2023]
Abstract
Background Infantile hepatic haemangiomas (IHHs) produce an excess of the thyroid hormone inactivating enzyme type-3 iodothyronine deiodinase (D3), leading to rapid degradation of thyroid hormones and consumptive hypothyroidism. The L-thyroxine replacement dose in patients with consumptive hypothyroidism is inappropriately higher than that in congenital hypothyroidism. Case presentation A 4-month-old boy presented with abdominal distention. Thyroid function tests (TFTs) revealed an elevated thyroid-stimulating hormone (TSH) level of 177 mU/L, normal free thyroxine (fT4) of 1.23 ng/dL, low free tri-iodothyronine (fT3) of 1.55 pg/mL and increased reverse T3 (rT3) of 1240 ng/dL. Abdominal ultrasound and magnetic resonance imaging (MRI) revealed multiple IHHs. Based on his TFTs, ultrasonography and MRI evidence, he was diagnosed with consumptive hypothyroidism, and L-thyroxine replacement at 15 μg/kg/day was started. The L-thyroxine dose was increased gradually to 35 μ/kg/day until a stabilising euthyroid status was achieved. By the age of 8 months, the TSH concentration was decreased to normal levels; the L-thyroxine dose was gradually reduced and finally discontinued at the age of 12 months. Repeat abdominal ultrasound and MRI revealed a reduction in the number and size of the haemangiomas. The TFTs were at normal reference levels. The patient remains in active follow-up. Conclusions Neonatal screening for congenital hypothyroidism is usually negative in cases of IHH, as seen in our case. A high index of suspicion is necessary to diagnose hypothyroidism in cases of IHH. The present case required very high doses of levothyroxine to achieve a euthyroid status. In cases of hypothyroidism in the first year of life with consumptive hypothyroidism caused by hepatic haemangioma, aggressive L-thyroxine replacement is required with no upper limit. The dose should be increased gradually until a stabilising euthyroid status is achieved.
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Affiliation(s)
- Enver Simsek
- Eskisehir Osmangazi University, School of Medicine, Department of Pediatric, Division of Pediatric Endocrinology, Meselik, Eskisehir, Turkey
| | - Meliha Demiral
- Eskisehir Osmangazi University, School of Medicine, Department of Pediatric, Division of Pediatric Endocrinology, Meselik, Eskisehir, Turkey
| | - Elif Gundoğdu
- Eskisehir Osmangazi University, School of Medicine, Department of Radiology, Meselik, Eskisehir, Turkey
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