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Moran C, Schoenmakers N, Halsall D, Oddy S, Lyons G, van den Berg S, Gurnell M, Chatterjee K. Approach to the Patient With Raised Thyroid Hormones and Nonsuppressed TSH. J Clin Endocrinol Metab 2024; 109:1094-1108. [PMID: 37988295 PMCID: PMC10940260 DOI: 10.1210/clinem/dgad681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/24/2023] [Accepted: 11/20/2023] [Indexed: 11/23/2023]
Abstract
Measurement of free thyroid hormones (THs) and thyrotropin (TSH) using automated immunoassays is central to the diagnosis of thyroid dysfunction. Using illustrative cases, we describe a diagnostic approach to discordant thyroid function tests, focusing on entities causing elevated free thyroxine and/or free triiodothyronine measurements with nonsuppressed TSH levels. Different types of analytical interference (eg, abnormal thyroid hormone binding proteins, antibodies to iodothyronines or TSH, heterophile antibodies, biotin) or disorders (eg, resistance to thyroid hormone β or α, monocarboxylate transporter 8 or selenoprotein deficiency, TSH-secreting pituitary tumor) that can cause this biochemical pattern will be considered. We show that a structured approach, combining clinical assessment with additional laboratory investigations to exclude assay artifact, followed by genetic testing or specialized imaging, can establish a correct diagnosis, potentially preventing unnecessary investigation or inappropriate therapy.
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Affiliation(s)
- Carla Moran
- Endocrine Section, Beacon Hospital, Dublin, D18 AK68, Ireland
- Endocrine Department, St. Vincent's University Hospital, Dublin, D04 T6F4, Ireland
- School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Nadia Schoenmakers
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK
| | - David Halsall
- Department of Clinical Biochemistry, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Susan Oddy
- Department of Clinical Biochemistry, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Greta Lyons
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Sjoerd van den Berg
- Department of Clinical Chemistry, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
| | - Mark Gurnell
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Krishna Chatterjee
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK
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2
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Yao B, Yang C, Pan C, Li Y. Thyroid hormone resistance: Mechanisms and therapeutic development. Mol Cell Endocrinol 2022; 553:111679. [PMID: 35738449 DOI: 10.1016/j.mce.2022.111679] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Revised: 05/03/2021] [Accepted: 05/09/2022] [Indexed: 10/18/2022]
Abstract
As an essential primary hormone, thyroid hormone (TH) is indispensable for human growth, development and metabolism. Impairment of TH function in several aspects, including TH synthesis, activation, transportation and receptor-dependent transactivation, can eventually lead to thyroid hormone resistance syndrome (RTH). RTH is a rare syndrome that manifests as a reduced target cell response to TH signaling. The majority of RTH cases are related to thyroid hormone receptor β (TRβ) mutations, and only a few RTH cases are associated with thyroid hormone receptor α (TRα) mutations or other causes. Patients with RTH suffer from goiter, mental retardation, short stature and bradycardia or tachycardia. To date, approximately 170 mutated TRβ variants and more than 20 mutated TRα variants at the amino acid level have been reported in RTH patients. In addition to these mutated proteins, some TR isoforms can also reduce TH function by competing with primary TRs for TRE and RXR binding. Fortunately, different treatments for RTH have been explored with structure-activity relationship (SAR) studies and drug design, and among these treatments. With thyromimetic potency but biochemical properties that differ from those of primary TH (T3 and T4), these TH analogs can bypass specific defective transporters or reactive mutant TRs. However, these compounds must be carefully applied to avoid over activating TRα, which is associated with more severe heart impairment. The structural mechanisms of mutation-induced RTH in the TR ligand-binding domain are summarized in this review. Furthermore, strategies to overcome this resistance for therapeutic development are also discussed.
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Affiliation(s)
- Benqiang Yao
- The State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Fujian, 361005, China
| | - Chunyan Yang
- The State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Fujian, 361005, China.
| | - Chengxi Pan
- The State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Fujian, 361005, China
| | - Yong Li
- The State Key Laboratory of Cellular Stress Biology, Innovation Center for Cell Signaling Network, School of Life Sciences, Xiamen University, Fujian, 361005, China.
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Xie Z, Li C, An Y, Zhao D, Wang X. Thyroid hormone resistance syndrome due to a novel heterozygous mutation and concomitant Hashimoto's Thyroiditis: A pedigree report. J Int Med Res 2022; 50:3000605221109398. [PMID: 35850606 PMCID: PMC9310067 DOI: 10.1177/03000605221109398] [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] [Indexed: 12/01/2022] Open
Abstract
Thyroid hormone resistance syndrome (THRS) is a rare disease characterized by
reduced sensitivity to thyroid hormones. Mutations in the thyroid hormone
receptor beta (THRB) gene are considered as contributing to the
pathogenesis. This report describes a Chinese pedigree with THRS and Hashimoto’s
thyroiditis (HT) due to novel point mutation in the 11th exon of the
THRB gene (c. 1378 G > A). The proband complained of
goitre with increased thyroid hormone and normal thyroid stimulating hormone
levels. Gene sequencing was performed to confirm the diagnosis. HT was also
diagnosed based on positive thyroid autoantibodies and diffuse, grid-like
changes in the thyroid on ultrasound examination. Additionally, a comprehensive
examination of the proband’s pedigree was conducted. The patient’s father
exhibited the same gene mutation site and was diagnosed with THRS and HT. No
mutation site was detected in three patients with HT only and three healthy
volunteers. Thus, gene sequencing should be considered the gold standard for
diagnosing THRS. Furthermore, treatment should be individualized to control the
patient’s symptoms rather than normalizing thyroid hormone levels. Further
studies that determine the relationship between THRS and TH are warranted.
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Affiliation(s)
- Zongyan Xie
- Department of Clinical Pharmacology, Beijing Luhe Hospital Affiliated to Capital Medical University, Beijing, China
| | - ChenFei Li
- Department of Endocrinology, Beijing Luhe Hospital Affiliated to Capital Medical University, Beijing, China
| | - Yaxin An
- Department of Endocrinology, Beijing Luhe Hospital Affiliated to Capital Medical University, Beijing, China
| | - Dong Zhao
- Department of Endocrinology, Beijing Luhe Hospital Affiliated to Capital Medical University, Beijing, China
| | - Xuhong Wang
- Department of Clinical Pharmacology, Beijing Luhe Hospital Affiliated to Capital Medical University, Beijing, China
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Campi I, Agostini M, Marelli F, de Filippis T, Romartinez-Alonso B, Rajanayagam O, Rurale G, Gentile I, Spagnolo F, Andreasi M, Ferraù F, Cannavò S, Fugazzola L, Chatterjee KV, Persani L. Clinical Consequences of Variable Results in the Measurement of Free Thyroid Hormones: Unusual Presentation of a Family with a Novel Variant in the THRB Gene Causing Resistance to Thyroid Hormone Syndrome. Eur Thyroid J 2021; 10:533-541. [PMID: 34956926 PMCID: PMC8647126 DOI: 10.1159/000519748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 09/18/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Resistance to thyroid hormone β (RTHβ) is an inherited syndrome caused by dominant negative variants in the THRB gene (NM_000461.5). The clinical picture of RTHβ is variable, and patients harboring the same variant may display different degrees of disease severity. CASE PRESENTATION A 30-year-old man presented with thyrotoxicosis and central hyperthyroidism and was found to have a novel variant in the exon 10 of THRB gene (c.C1282G, p.L428V), located within the third hot spot region of the C-terminal of the receptor. Surprisingly, the same variant was found in two other relatives with an apparent normal thyroid function at initial screening. After exclusion of a TSH-secreting adenoma and serum interference in the proband, and the finding that exogenous levothyroxine failed to suppress the TSH in the brother affected by nodular goiter, relatives' thyroid function tests (TFTs) were reassessed with additional analytical method revealing biochemical features consistent with RTHβ in all carriers of the p.L428V variant. Functional studies showed a slightly impaired in vitro transcriptional activity of p.L428V. Interestingly' the expression of the human p.L428V thyroid hormone receptor beta in the zebrafish embryo background generated a phenotype consistent with RTHβ. CONCLUSION Variable results of TFTs on some immunoassays can be a cause of RTHβ diagnostic delay, but the genotype-phenotype correlation in this family and functional studies support p.L428V as a novel THRB variant expanding the spectrum of gene variants causing RTHβ. In vivo, rather than in vitro, functional assays may be required to demonstrate the dominant negative action of THRB variants.
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Affiliation(s)
- Irene Campi
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Maura Agostini
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Federica Marelli
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Tiziana de Filippis
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Beatriz Romartinez-Alonso
- Department of Molecular and Cell Biology, Leicester Institute of Structural and Chemical Biology, University of Leicester, Leicester, United Kingdom
| | - Odelia Rajanayagam
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Giuditta Rurale
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
| | - Ilaria Gentile
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
| | - Federica Spagnolo
- Unit of Endocrinology, University Hospital “G. Martino”, Messina, Italy
| | - Massimiliano Andreasi
- Laboratorio Analisi Cliniche, Centro di Ricerche e Tecnologie Biomediche, IRCCS Istituto Auxologico Italiano, Cusano Milanino, Italy
| | - Francesco Ferraù
- Unit of Endocrinology, University Hospital “G. Martino”, Messina, Italy
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
| | - Salvatore Cannavò
- Unit of Endocrinology, University Hospital “G. Martino”, Messina, Italy
- Department of Human Pathology of Adulthood and Childhood, University of Messina, Messina, Italy
| | - Laura Fugazzola
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Krishna V. Chatterjee
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Luca Persani
- Division of Endocrine and Metabolic Diseases and Laboratory of Endocrine and Metabolic Research, Istituto Auxologico Italiano, Istituto Di Ricovero e Cura a Carattere Scientifico (IRCCS), Milan, Italy
- Department of Medical Biotechnology and Translational Medicine, University of Milan, Milan, Italy
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Pappa T, Refetoff S. Resistance to Thyroid Hormone Beta: A Focused Review. Front Endocrinol (Lausanne) 2021; 12:656551. [PMID: 33868182 PMCID: PMC8044682 DOI: 10.3389/fendo.2021.656551] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/15/2021] [Indexed: 02/06/2023] Open
Abstract
Resistance to thyroid hormone (RTH) is a clinical syndrome defined by impaired sensitivity to thyroid hormone (TH) and its more common form is caused by mutations in the thyroid hormone receptor beta (THRB) gene, termed RTHβ. The characteristic biochemical profile is that of elevated serum TH levels in absence of thyrotropin suppression. Although most individuals are considered clinically euthyroid, there is variability in phenotypic manifestation among individuals harboring different THRB mutations and among tissue types in the same individual due in part to differential expression of the mutant TRβ protein. As a result, management is tailored to the specific symptoms of TH excess or deprivation encountered in the affected individual as currently there is no available therapy to fully correct the TRβ defect. This focused review aims to provide a concise update on RTHβ, discuss less well recognized associations with other thyroid disorders, such as thyroid dysgenesis and autoimmune thyroid disease, and summarize existing evidence and controversies regarding the phenotypic variability of the syndrome. Review of management addresses goiter, attention deficit disorder and "foggy brain". Lastly, this work covers emerging areas of interest, such as the relevance of variants of unknown significance and novel data on the epigenetic effect resulting from intrauterine exposure to high TH levels and its transgenerational inheritance.
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Affiliation(s)
- Theodora Pappa
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA, United States
| | - Samuel Refetoff
- Departments of Medicine, Pediatrics and Committee on Genetics, The University of Chicago, Chicago, IL, United States
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