Triiodothyronine radioimmunoassay

Thyroid Stimulating Hormone and Thyroid Hormones (Triiodothyronine and Thyroxine): An American Thyroid Association-Commissioned Review of Current Clinical and Laboratory Status

Background: Despite being the most performed laboratory endocrine investigation, the optimum use of thyroid tests (thyrotropin [TSH] and thyroid hormone [TH] measurement) is open to question and the interpretation of the results from these tests can be ambiguous. The American Thyroid Association (ATA) with its expertise support the endeavor of the U.S. Centers for Disease Control (CDC) and the International Federation of Clinical Chemistry and Laboratory Medicine (IFCC) to improve and maintain standardization and harmonization of thyroid testing. ATA mandated an international interdisciplinary working group panel to survey the status of thyroid testing by reviewing the recent literature to revise or update the criteria as needed in mutual agreement and to inform clinical care. Summary: This review represents the conclusions on the clinical use of current routine TSH and TH (thyroxine [T4] and triiodothyronine [T3]) assays, taking into account geographic differences in disease prevalence and clinical and laboratory practice among writing members. The interaction between physiological, pathophysiological, and pharmacological factors and thyroid assays can affect their measurements and confound result interpretation. These factors need to be considered in the clinical context of the patient for appropriate test ordering and result interpretation. Despite significant advances in laboratory methods over the past 50 years, routine thyroid assays remain susceptible to idiosyncratic analytical interference that may produce spurious results. Improved standardization needs to be demonstrated through ongoing international efforts before results from different assays can be considered equivalent. Emerging technology (e.g., mass spectrometry) shows promise for improved analytical performance, but more evidence of its clinical utility and improved throughput is required before it can be considered for routine use. Close clinical-laboratory collaboration is encouraged to overcome and avoid the pitfalls in thyroid testing as well as resolve clinically discrepant results. The evidence base supporting the conclusions of this review is summarized in four detailed online technical supplements. Conclusions: Over the past five decades, testing for TSH, T4, and T3 has evolved from manual radioisotopic immunoassays to nonisotopic multiplexed immunometric assays using highly automated equipment. Despite these technical advances, physicians and laboratorians performing these analyses must understand limitations of these methods to properly order tests and interpret results.

Pharmacokinetics of L-Triiodothyronine in Patients Undergoing Thyroid Hormone Therapy Withdrawal

Background: L-triiodothyronine (LT3) is a substitute for levothyroxine (LT4) for thyroid cancer (TC) patients during the preparation for nuclear medicine procedures, and it is used in combination with LT4 in patients who do not respond to the standard treatment for hypothyroidism. This therapy is commonly done by using fixed doses, potentially resulting in supraphysiologic levels of triiodothyronine (T3). A good understanding of the LT3 pharmacokinetics (PK) is necessary to design combination treatment schemes that are able to maintain serum T3 levels within the reference range, but data on the PK of LT3 are conflicting. Here, we present a study designed to characterize the PK of LT3 in patients devoid of endogenous thyroid hormone production, and not receiving LT4 therapy. Methods: We performed an open-label, PK study in patients undergoing thyroid hormone withdrawal in preparation for nuclear medicine procedures for the evaluation and treatment of follicular-derived TC. LT3 was substituted for LT4 at a 1:3 mcg/mcg dosage ratio thrice daily for at least 30 days. PK of the last LT3 dose while at steady state and terminal elimination was assessed over 11 days. Thereafter, a PK study was performed following the nuclear medicine procedure in patients who volunteered for a second study. Results: Fourteen patients age 48.5 ± 16.0 years completed the last dose study and five completed the second PK study. PK analysis indicates a time to maximum serum concentration of 1.8 ± 0.32 hours and two distinct phases of linear elimination, with a fast distribution phase and slow elimination phases with half-lives of 2.3 ± 0.11 hours and 22.9 ± 7.7 hours, supporting a two-compartment model. PK modeling predicts that a twice-daily administration of low-dose LT3 (0.07 mcg/kg twice daily) in combination with LT4 can predictably increase the serum T3 concentration without significant peaks above the reference range. Conclusions: The PK of LT3 is well described by a two-compartment model that assumes elimination only from the sampling compartment, with a rapid distribution phase and a slow elimination phase. This information will contribute to design therapeutic strategies for LT3/LT4 combination therapies directed to maintain stable T3 serum levels.

The Swinging Pendulum in Treatment for Hypothyroidism: From (and Toward?) Combination Therapy

Thyroid hormone replacement for hypothyroidism can be achieved via several approaches utilizing different preparations of thyroid hormones, T3, and/or T4. "Combination therapy" involves administration of both T3 and T4, and was technically the first treatment for hypothyroidism. It was lauded as a cure for the morbidity and mortality associated with myxedema, the most severe presentation of overt hypothyroidism. In the late nineteenth and the early Twentieth centuries, combination therapy per se could consist of thyroid gland transplant, or more commonly, consumption of desiccated animal thyroid, thyroid extract, or thyroglobulin. Combination therapy remained the mainstay of therapy for decades despite development of synthetic formulations of T4 and T3, because it was efficacious and cost effective. However, concerns emerged about the consistency and potency of desiccated thyroid hormone after cases were reported detailing either continued hypothyroidism or iatrogenic thyrotoxicosis. Development of the TSH radioimmunoassay and discovery of conversion of T4-to-T3 in humans led to a major transition in clinical practices away from combination therapy, to adoption of levothyroxine "monotherapy" as the standard of care. Levothyroxine monotherapy has a favorable safety profile and can effectively normalize the serum TSH, the most sensitive marker of hypothyroidism. Whether levothyroxine monotherapy restores thyroid hormone signaling within all tissues remains controversial. Evidence of persistent signs and symptoms of hypothyroidism during levothyroxine monotherapy at doses that normalize serum TSH is mounting. Hence, in the last decade there has been acknowledgment by all thyroid professional societies that there may be a role for the use of combination therapy; this represents a significant shift in the clinical practice guidelines. Further bolstering this trend are the recent findings that the Thr92AlaD2 polymorphism may reduce thyroid hormone signaling, resulting in localized and systemic hypothyroidism. This strengthens the hypothesis that treatment options could be personalized, taking into consideration genotypes and comorbidities. The development of long-acting formulations of liothyronine and continued advancements in development of thyroid regenerative therapy, may propel the field closer to adoption of a physiologic thyroid hormone replacement regimen with combination therapy.

Rational use of thyroid function tests

In this era of cost containment, it is necessary to efficiently select the most important laboratory investigations for diagnostic and management purposes, with patient benefit as the ultimate objective. Thyroid function tests collectively represent a very costly item for laboratory services and have tended to be unselectively overutilized virtually until the present. Tests available for thyroid function testing include both in vitro and in vivo tests. Virtually all physicians are familiar with the free thyroxine (fT4) or its equivalents (fT4E), total and free triiodothyronine (TT3 and fT3), and sensitive thyrotrophin (TSH) assays, to which may be added plasma thyroglobulin (Tg), and thyroid autoantibodies (TAb) (including thyroid stimulating antibody [TSAb]). In vitro tests include thyroidal uptakes and scans, as well as other imaging techniques (e.g., ultrasound). Other less commonly used or obsolete techniques are not discussed. For screening or case finding where there is little probability that the patient(s) has thyroid dysfunction, a sensitive TSH assay is all that is initially required. If, however, the TSH result is elevated, a fT4E and TAb should then be performed. If the TSH is subnormal, then a fT4E, TT3, and (if still necessary) TSH response to TRH would determine if that patient was truly hyperthyroid (in elderly patients, a low TSH is often not associated with hyperthyroidism!). Conversely, not all patients with elevated fT4 are truly hyperthyroid. Uptakes and scans are primarily of importance in the correct diagnosis of unusual cases of hyperthyroidism and for nodular disease. When patients already diagnosed are being followed, proper selection of testing is again important, sometimes emphasizing one test over others (e.g., TT3); for example, in patients with Graves' Disease on anti-thyroid drugs, the fT4E and TSH values may not reflect the true status of the patient. On the one hand, the TSH may remain low for months after the patient has become euthyroid, and on the other hand, the fT4E may drop even below normal, whereas the T3 remains elevated (and the patient still hyperthyroid). The many other vagaries of these tests are also mentioned.

Differences in response of thyrotropin to 3,5,3'-triiodothyronine and 3,5,3'-triiodothyroacetic acid in patients with resistance to thyroid hormone

This study investigated the response of TSH secretion to 3,5,3'-triiodothyronine (T3) and 3,5,3'-triiodothyroacetic acid (Triac) in patients with resistance to thyroid hormone, and compared the responses with those in patients with TSH-secreting pituitary adenoma and normal subjects. A short-term administration of 75 microg of T3 daily for 7 days suppressed serum TSH concentrations almost completely in normal subjects, but suppressed TSH only partially in patients with resistance to thyroid hormone and TSH-secreting pituitary adenoma. A single-dose administration of 75 microg of T3 gave similar results in regard to TSH suppressibility in these three subjects groups. In contrast, a single-dose administration of 1.4 mg of Triac remarkably suppressed serum TSH concentrations after 2 hours in not only normal subjects (-34 +/- 11% [mean +/- SD] from the basal value) but also in patients with resistance to thyroid hormone (-31 +/- 9%), and this TSH suppression continued for 4 hours. After 24 hours, this TSH suppression persisted in normal subjects (-62 +/- 12%) but was relieved in patients with resistance to thyroid hormone (-23 +/- 14%). After the Triac administration, molar ratios of alpha-subunit to TSH in serum were decreased in patients with TSH-secreting pituitary adenoma but increased in patients with resistance to thyroid hormone. Because the Triac therapy for patients with resistance to thyroid hormone suppressed pituitary-TSH secretion during the early phase of drug ingestion, this drug should be given several times within a day to obtain continuous TSH-suppressive effects.

Identical mutations in unrelated families with generalized resistance to thyroid hormone occur in cytosine-guanine-rich areas of the thyroid hormone receptor beta gene. Analysis of 15 families

Generalized resistance to thyroid hormone (GRTH) is a syndrome of variable reduction of tissue responsiveness to thyroid hormone. 28 different point mutations in the human thyroid hormone receptor beta (TR beta) gene have been associated with GRTH. These mutations are clustered in two regions of the T3 binding domain of the TR beta (codons 310-347 and 417-453). We now report point mutations in the TR beta gene of six additional families with GRTH and show that three mutations occurred each in three families with GRTH, and that three other mutations were each present in two families. In 11 of these 15 families, lack of a common ancestor could be confirmed by genetic analysis. 28 of the 38 point mutations so far identified, including all those occurring in more than one family, are located in cytosine-guanine-rich areas of the TR beta gene. Differences in clinical and laboratory findings in unrelated families harboring the same TR beta mutation suggest that genetic variability of other factors modulate the expression of thyroid hormone action.

The interaction of L-triiodothyronine and 2,3,7,8-tetrachlorodibenzo-p-dioxin on Ah-receptor-mediated hepatic Phase I and Phase II enzymes and iodothyronine 5'-deiodinase in thyroidectomized rats

Across all levels of L-triiodothyronine (L-T3) treatment, 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) resulted in increased hepatic cytochrome P-450-associated activities of 7-ethoxycoumarin O-deethylase (ECOD), 7-ethoxyresorufin O-dealkylase (EROD) and aryl hydrocarbon hydroxylase (AHH). The treatment of thyroidectomized rats with L-T3 at physiologic replacement levels in concert with TCDD produced an increase in ECOD, EROD and AHH activity above that seen with only TCDD. TCDD as well as L-T3 enhanced the activity of hepatic 1-naphthol glucuronyl transferase (NGT). In addition, the combined effect of L-T3 and TCDD resulted in similar levels of induction of NGT at both physiologic and supraphysiologic doses of L-T3. TCDD treatment resulted in elevated serum T3 levels at both physiologic and supraphysiologic levels of L-T3. One TCDD dose inhibited hepatic microsomal 3,3',5'-triiodothyronine (reverse T3) 5'-deiodinase activity by 61% in thyroidectomized, T3-untreated rats. The inhibition of 5'-deiodinase activity was partially overcome by increasing the T3 dose.

Purification of ornithine decarboxylase-inducing factor from cell-free ascites fluid of Ehrlich ascites tumor and its characteristics

The ornithine decarboxylase-inducing factor (ODC factor) was purified about 1,000-fold in 42% yield from the ascites fluids of an Ehrlich ascites tumor by a combination of centrifugation and concanavalin A (ConA) treatment. A single ip injection of 0.5 micrograms of the purified factor per mouse resulted in half-maximum induction of liver ODC. The factor was found to be a trypsin- and chymotrypsin-resistant, acidic glycoprotein (pI about 4.43) with a minimum molecular weight of about 70 kilodaltons, containing a disulfide bond(s) in its functional domain. It did not react with ConA. This factor induced retrodifferentiation of liver function, causing a marked increase of prototype M2 isozyme of pyruvate kinase. It reduced liver catalase activity, and also modified thyroid hormone metabolism, reducing the serum levels of T4 and T3. These results suggest that the ODC factor is multifunctional and induces many of the changes observed in a tumor-bearing host.

Mechanism of metabolic abnormality of thyroid hormones in Walker 256 carcinosarcoma-bearing rats

We examined the mechanism of abnormality of thyroid hormone metabolism in Walker 256 carcinosarcoma-bearing rats. The serum levels of thyroxine (T4), 3,5,3'-triiodothyronine (T3) and thyroid-stimulating hormone (TSH), and the responses of serum T4 and T3 to exogenous TSH in tumor-bearing rats on day 14 after inoculation of tumor cells were significantly less than those in pair-fed control (PFC) rats, suggesting that the metabolic abnormality of thyroid hormones may be caused by disorder of both peripheral and central functions, and that a certain tumor-derived factor may be involved in this abnormality. An active factor responsible for the metabolic abnormality was found in soluble cytosol fraction (SF) of the tumor cells. Administration of the SF to normal rats significantly reduced their serum T4 and T3 concentrations, liver 5'-deiodinase (5'-DI) activity, responsiveness of the thyroid gland to TSH and food intake compared with those of PFC rats, but, unlike the tumor, did not reduce the serum TSH level. This biologically active factor in the SF was found to be a heat-labile protein and specific to the tumor. It was tentatively named serum thyroid hormone reducing factor (STRF). STRF was partially purified from the SF by ammonium sulfate fractionation and DEAE-cellulose chromatography. Partially purified STRF preparation significantly diminished the serum T4 and T3 concentrations and liver 5'-DI activity and food intake of normal rats compared with those of PFC rats, mimicking the changes associated with the tumor in tumor-bearing animals. These results suggested that abnormality of thyroid hormone metabolism in tumor-bearing animals may partly be caused by STRF-mediated modulation at peripheral and thyroid gland levels. Whether STRF actually induces anorexia remains to be clarified.

Effects of oral erythrosine (2',4',5',7'-tetraiodofluorescein) on the pituitary-thyroid axis in rats

Erythrosine (FD&C Red Dye No.3) is a tetraiodinated derivative of fluorescein. Rats fed a 4% erythrosine diet for 30 months beginning in utero have an increased incidence of thyroid adenomas and adenocarcinomas. These tumors may be secondary to increased stimulation of the thyroid gland by TSH. This study was undertaken to determine if dietary erythrosine disrupts the pituitary-thyroid axis thereby altering serum thyroid hormone levels. TSH levels, or the pituitary's response to TRH. Rats were fed diets containing erythrosine (0.5, 1.0, 4.0%), sodium iodide (0.16%), or fluorescein (1.6%) for 3 weeks after which TRH testing was performed in vivo. Erythrosine produced a dose-dependent increase in serum T4 levels. With the 4% erythrosine diet, serum T4 and T3 levels and the free-T4 index were significantly increased, whereas the free-T3 index were significantly increased, whereas the free-T3 index was unchanged. Rats fed the 4.0% erythrosine diet had an exaggerated TSH response to TRH; 10 min after the TRH injection, serum TSH levels were 80% greater than TSH levels of control rats. Short-term administration of erythrosine to rats decreased hepatic T3 production by decreasing its conversion of T4 to T3, indicating that erythrosine decreases hepatic 5'-deiodinase activity. These data demonstrate that dietary ingestion of 4% erythrosine disrupts the pituitary-thyroid axis as evidenced by an increased TSH response to TRH. This effect is mediated by erythrosine or an iodinated metabolite, since ingestion of its fluorescein nucleus had no effect. Erythrosine's effects were not likely mediated by iodide, because serum T4 and T3 levels were elevated and iodide administration did not increase the TSH response to TRH. These data suggest that erythrosine increases the pituitary's TSH response to TRH by altering thyrotroph cell conversion of T4 to T3. Chronic erythrosine ingestion may promote thyroid tumor formation in rats via chronic stimulation of the thyroid by TSH.

The effects of chronic ingestion of spironolactone on serum thyrotropin and thyroid hormones in the male rat

Male rats were fed spironolactone admixed with feed at doses of 6, 50, and 200 mg/kg/day for up to 13 weeks. After 13 weeks of treatment, there were dose-related increases in thyroid weight and follicular hypertrophy. Serum thyrotropin (TSH) concentrations were significantly increased throughout the treatment period. Serum thyroxine (T4) and triiodothyronine (T3) were significantly decreased at Weeks 2 and 4, but returned to control concentrations by Week 13. The TSH increase and transient T4 decrease suggested that the thyroid hypertrophy was a compensatory reaction to lowered thyroid hormone levels. To determine the effect of spironolactone ingestion on T4 synthesis and metabolism, male rats were fed spironolactone admixed with feed at 200 mg/kg for 2 weeks. The decrease in T4 was not due to decreased synthesis, since iodide uptake and organification were significantly increased by spironolactone treatment. Since uridine diphosphate glucuronosyl transferase activity was significantly increased by spironolactone treatment, it appears that, by increasing hepatic clearance of T4, spironolactone causes a decrease in the serum concentration of this hormone. The lower T4 level causes a release of feedback inhibition and an increase in TSH resulting in the increase in thyroid gland size and activity.

Effects of low dose oral iodide supplementation on thyroid function in normal men

Previous studies have demonstrated that short-term oral iodide administration, in doses ranging from 1500 micrograms to 250 mg/day, has an inhibitory effect on thyroid hormone secretion in normal men. As iodide intake in the USA may be as high as 800 micrograms/d, we investigated the effects of very low dose iodide supplementation on thyroid function. Thirty normal men aged 22-40 years were randomly assigned to receive 500, 1500, and 4500 micrograms iodide/day for 2 weeks. Blood was obtained on days 1 and 15 for measurement of serum T4, T3, T3-charcoal uptake, TSH, protein-bound iodide (PBI) and total iodide, and 24 h urine samples were collected on these days for measurement of urinary iodide excretion. TRH tests were performed before and at the end of the period of iodide administration. Serum inorganic iodide was calculated by subtracting the PBI from the serum total iodide. We found significant dose-related increases in serum total and inorganic iodide concentrations, as well as urinary iodide excretion. The mean serum T4 concentration and free T4 index values decreased significantly at the 1500 micrograms/day and 4500 micrograms/day doses. No changes in T3-charcoal uptake or serum T3 concentration occurred at any dose. Administration of 500 micrograms iodide/day resulted in a significant increase (P less than 0.005) in the serum TSH response to TRH, and the two larger iodide doses resulted in increases in both basal and TRH-stimulated serum TSH concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Bone mineral density in diabetes mellitus

In the present study bone mineral content (BMC) was measured at 1/3 and 1/10 the length of the radius from the distal end in 100 adult diabetic subjects (55 females, 45 males, 54 insulin-dependent [IDD], 46 non-insulin-dependent [NIDD]), using single photon absorptiometry. Each individual BMC value in the diabetics was first compared to normal BMC values for age obtained in our laboratory from 500 non-diabetic subjects. BMC in the diabetics was within the normal range (M +/- 2 SD) with respect to sex and age. Data from IDD and NIDD males, under and over 50 years of age, and of IDD and NIDD females, pre- and postmenopausal, were compared with the respective control group data after matching each diabetic subject to a non-diabetic one of identical age and menstrual history and of comparable body mass index. In each group BMC in the diabetic subjects was found not to be statistically different from BMC in the control ones. Correlation analysis was carried out between BMC and endocrine or metabolic parameters obtained in 52 of the diabetic patients. BMC in diabetic subjects was not correlated with plasma levels of hormones (thyroid hormones, cortisol, 17-beta-estradiol, testosterone), Ca, P or alkaline phosphatase activity. It was inversely correlated with urinary Ca and P in NIDD women and with urinary Ca in NIDD men. No relationship was found between BMC and the metabolic control of diabetes (evaluated by basal glycemia, 2h-post-prandial glycemia and glycosylated hemoglobin).

Effects of oral erythrosine (2',4',5',7'-tetraiodofluorescein) on thyroid function in normal men

Erythrosine (Er), a tetraiodinated derivative of fluorescein, is a coloring agent widely used in foods, cosmetics, and pharmaceutical products. Because of its high iodine content and previous reports demonstrating an inhibitory effect of erythrosine on hepatic 5'-monodeiodination, we studied the effects of this compound on thyroid function and serum and urinary iodide concentrations in normal subjects. Thirty normal men, equally divided into three treatment groups, each received a 14-day course of oral Er in doses of 20, 60, or 200 mg/day. Serum thyroxine (T4), triiodothyronine (T3), reverse T3 (rT3), thyroid stimulating hormone (TSH), protein-bound iodide (PBI), and total iodide concentrations, serum T3-charcoal uptake, and 24-hour urinary iodide excretion were measured on Days 1, 8, and 15. Thyrotropin-releasing hormone (TRH) tests were performed on Days 1 and 15. There were no significant changes in serum T4, T3, rT3, and T3-charcoal uptake values at any dose. In men receiving 200 mg Er/day, the mean basal serum TSH concentration increased significantly from 1.7 +/- 0.1 (SE) on Day 1 to 2.2 +/- 0.1 microU/ml on Day 15 (p less than 0.05), and the mean peak TSH increment after TRH increased from 6.3 +/- 0.5 to 10.5 +/- 1.0 microU/ml (p less than 0.05). There were no significant changes in basal or peak TSH responses in the men receiving 20 or 60 mg Er/day. Significant dose-related increases in serum total iodide and PBI concentrations occurred during all three doses, and significant dose-related increases in urinary iodide excretion occurred during the 60 and 200 mg/day Er doses. These data suggest that the increase in TSH secretion induced by Er was related to the antithyroid effect of increased serum iodide concentrations, rather than a direct effect of Er on thyroid hormone secretion or peripheral metabolism.

Stimulation of thyroid hormone secretion by thyrotropin in beluga whales, Delphinapterus leucas

Bovine thyroid stimulating hormone administered to three beluga whales, Delphinapterus leucas, was effective in producing an increase in circulating levels of triiodothyronine and thyroxine. A single dose of 10 I.U. of thyroid stimulating hormone resulted in a 145% increase in triiodothyronine and a 35% increase in thyroxine after nine hours in a whale tested within two hours after capture. The response was less pronounced in an animal tested with the same does on two occasions after four and eight weeks in captivity. In the third whale, 10 I.U. of thyroid stimulating hormone given on each of three consecutive days produced a marked increase in triiodothyronine and thyroxine. The elevation of thyroxine concentration persisted for at least two days after the last injection of thyroid stimulating hormone. A subsequent decrease in thyroxine to levels below baseline signalled the suppression of endogenous thyroid stimulating hormone. This preliminary study helps to establish a protocol for testing thyroid function in cetaceans.

Myxedema coma during long-term amiodarone therapy

Amiodarone is a potent new antiarrhythmic drug that has multiple effects on thyroid function, including inhibition of extrathyroidal triiodothyronine production and rarely, iodine-induced hypothyroidism. This report describes a man with recurrent ventricular tachycardia in whom hypothyroidism developed during amiodarone therapy and who died of probable myxedema coma. Parenteral and oral thyroxine therapy promptly reduced serum thyroid-stimulating hormone concentrations without increasing the patient's very low serum triiodothyronine concentration. This response to thyroxine suggests that thyroxine itself may have biologic activity and participate directly in regulation of thyrotropin secretion. Because amiodarone-induced hypothyroidism may be life-threatening, thyroid function should be monitored before and during amiodarone therapy, and the drug discontinued or appropriate therapy instituted if hypothyroidism develops.

The differential diagnosis of cystic neck masses by the determination of thyroglobulin concentrations in the aspirates

Thyroglobulin (Tg) concentrations in the aspirates of various types of cystic neck masses were measured by RIA to assess the usefulness of this determination in differential diagnosis. The subjects consisted of 16 patients, whose final diagnoses were all established on the basis of operative results; three patients had follicular thyroid adenomas (F-Ad), 11 had papillary thyroid carcinomas (P-Ca), one had a thyroglossal duct cyst (TDC) and one had a lateral cervical cyst (LCC). Tg concentrations in the cyst fluids of F-Ad and P-Ca were very high (0.042-2.83 mg/ml) compared with serum Tg concentrations. There was no difference in Tg concentrations in the fluids of P-Ca between primary lesions (n = 5) and metastatic lesions (n = 6). On the other hand, Tg concentrations of TDC and LCC were very low (less than 100 ng/ml). Difficulty was experienced in diagnosing three patients, even though they had been examined by all nonsurgical diagnostic techniques. However, an occult thyroid carcinoma with lymph node metastasis was diagnosed by demonstrating a high Tg concentration in the aspirate of the cystic lymph node. T3 concentrations in cyst fluids of F-Ad were higher than those of P-Ca. T3 concentrations in the fluids of P-Ca, TDC and LCC did not differ, and were similar to serum T3 levels. Cytology of cyst fluids was positive in four of 10 patients examined with P-Ca. In conclusion, we can clearly confirm the thyroid origin of a cystic neck mass by demonstrating a high Tg concentration in the aspirate. This is especially useful for diagnosis in patients with thyroid carcinoma, including occult thyroid carcinomas with cystic lymph node metastasis.

Differing thyrotropin responses to increased serum triiodothyronine concentrations produced by overfeeding and by triiodothyronine administration

The effects of overfeeding and triiodothyronine (T3) administration on basal serum thyrotropin (TRH) concentrations and the TSH response to thyrotropin-releasing hormone (TRH) was studied in normal subjects. Eight normal volunteers were fed their usual diet plus 2,000 kcal carbohydrate daily for 7 days. Their mean serum T3 concentrations increased from 102 +/- 6 (SEM) ng/dl to 126 +/- 10 ng/dl; there were no changes in serum thyroxine (T4) and basal serum TSh concentrations or the TSh response to TRH. Five of these subjects were fed their usual diet plus 10 micrograms T3 for 3 days and 20 micrograms T3 for 4 days divided doses. Their mean serum T3 concentrations increased from 104 +/- 6 ng/dl to 140 +/- 8 ng/dl. Mean serum T4 and basal serum TSH concentrations declined and serum TSH responses to TRH were significantly reduced. In both instances serum T3 concentrations remained within the normal range. These results indicate that increases in serum T3 concentrations of similar magnitude induced by augmented extrathyroidal T3 production and T3 administration have different effects on thyrotroph function.

Regulation of the conversion of thyroxine to triiodothyronine in the perfused rat liver

This study was undertaken to determine what factors control the conversion of thyroxine (T(4)) to triiodothyronine (T(3)) in rat liver under conditions approximating those found in vivo. Conversion of T(4) to T(3) was studied in the isolated perfused rat liver, a preparation in which the cellular and structural integrity is maintained and that can perform most of the physiologic functions of the liver. The perfused liver readily extracted T(4) from perfusion medium and converted it to T(3). Production of T(3) by the perfused liver was a function of the size of the liver, the uptake of T(4) by the liver, and the presence of T(4)-5'-deiodinase activity. Production of T(3) was increased by increasing the uptake of T(4) by liver, which could be accomplished by increasing the liver size, by increasing the perfusate T(4) concentration, or by decreasing the perfusate albumin concentration. These changes occurred without altering the conversion of T(4) to T(3). The liver had a large capacity for extracting T(4) and for T(4)-5'-deiodination to T(3), which was not saturated at a T(4) concentration of 60 mug/dl. Production of T(3) was decreased by inhibiting hepatic T(4)-5'-deiodinase with propylthiouracil, which decreased T(3) production by decreasing the conversion of T(4) to T(3). Propylthiouracil did not alter hepatic T(4) uptake. Fasting resulted in a progressive decrease in hepatic T(4) uptake to 42% of control levels by the 3rd d of fasting; this was accompanied by a proportionate decrease in T(3) production. The rate of conversion of T(4) to T(3) did not change during fasting. When T(4) uptake in 2-d-fasted rat livers was raised to levels found in fed rats by increasing the perfusate T(4) concentration from 10 to 30 mug/dl, T(3) production returned to normal. Again, no change in the rate of conversion of T(4) to T(3) was observed. These results indicate that the decreased hepatic T(3) production during fasting primarily results from decreased hepatic uptake of T(4), rather than from changes in T(4)-5'-deiodinase activity. Thus, these studies have delineated a new mechanism that functions independently of enzyme quantity or activity whereby production of T(3) from T(4) is regulated.

Amyloid goitre in familial Mediterranean fever

Three patients known to suffer from familial Mediterranean fever (FMF), systemic amyloidosis and chronic renal failure developed large amyloid goitres. Amyloid goitre is an extremely rare complication of systemic amyloidosis not previously described in FMF. The clinical and pathological features of these three cases were similar to those previously described in amyloid goitre. In two of the patients abnormalities in thyroid function were consistent with those documented in chronic renal failure. There was evidence of hypothyroidism in a third patient. There was no evidence of amyloid induced dysfunction of other endocrine organs.

Circadian rhythms of anterior pituitary hormone secretion: effects of dexamethasone

Circadian rhythms of hormone secretion are by now well recognized but there are limited data available to compare such rhythms of multiple hormones in individual subjects. Therefore concentrations of serum thyrotropin (TSH), cortisol, growth hormone (GH), triiodothyronine (T3) and prolactin (PRL) were determined in blood samples from six healthy males over periods of 24 hours. A circadian periodicity was identified for cortisol, GH, PRL and TSH; maximum concentrations for TSH and PRL occurred at dissimilar times, namely respectively before and after the GH peak. Maximum TSH coincided with nadir values forplasma cortisol. Dexamethasone administration (3 mg over 36 hours) lowered serum T3 concentration and abolished TSH periodicity without affecting the PRL rhythm. These data suggest that a) nocturnal TSH and PRL maximum levels do not have common mediation; b) there may be an inverse relationship between cortisol and TSH, and c) glucocorticoids at low doses preferentially affect secretion of thyrotropin.

Longitudinal study or serum thyroid hormones, chorionic gonadotrophin and thyrotrophin during and after normal pregnancy

Measurements of serum levels of thyroxine (T4), free T4, 3,5,3'-triiodothyronine (T3), free T3, 3,3',5'-triiodothyronine (reverse T3, rT3), thyroxine-binding globulin capacity (TBGcap), chorionic gonadotrophin (hCG) and thyrotrophin (TSH) were carried out prospectively in eight women with uncomplicated pregnancies, in order to examine interrelationships between the thyroid gland and thyroid stimulating hormones during pregnancy. During pregnancy the levels of T4, free T4, T3, rT3 and TBGcap were significantly elevated, and TSH was decreased. It was noted that the elevation of T4 was maintained from the 8th to the 27th week of gestation while the level of TBGcap progressively increased. The levels of free T4 and rT3 in the first and third trimesters were significantly higher than those of age-matched, non-pregnant women. The levels of hCG showed a biphasic variation, with a peak in the 8th to 15th weeks, followed by a decline in the second trimester and a small, secondary elevation in the 32nd to 39th weeks. This later elevation was positively correlated with changes in free T4 and free T3 levels. The increase of serum T4 accompanied by an increase of free T4 in the first trimester appeared due to augmented secretion of T4, rather than being secondary to the elevated levels of TBGcap.

Effect of tri-iodothyronine replacement on the metabolic and pituitary responses to starvation

To determine the implication of decreased T3 production during fasting, seven normal men were fasted for 80 hours on two occasions; they received 5 microgram of T3 every three hours durnig the second fast. The mean serum T3 concentration declined during the control fast from 120 to 73 ng per deciliter (P less than 0.01), but remained slightly above base-line values during the T3 fast. Mean serum T4 concentrations did not change, and mean serum rT3 concentrations increased, during both fasts. The peak serum TSH increment after TRH was 11.1 micromicron per milliliter before fasting, 8.9 (not significant) after the control fast and 2.2 (P less than 0.01) after the T3 fast. Urea excretion was 9.1 per cent higher during the T3 fast; there were no differences in the changes in blood glucose, plasma fatty acids or other substrates during the two fasts. Pretreatment with potassium iodide lowered serum T4 concentrations and increased the serum TSH response to TRH after fasting. We conclude that the decrease in serum T3 concentrations during fasting spares muscle protein. Fasting is accompanied by a lower set point of TSH secretion, which remains sensitive to changes in serum thyroid hormone concentrations.

Surge of fetal plasma triiodothyronine before birth in sheep

Plasma thyroid hormone and cortisol concentrations were measured from early third trimester to delivery in seven pregnant ewes and their fetuses. A surge in fetal plasma triiodothyronine was found during the six days prior to delivery, the mean values rising from less than 30 to 125 ng. per deciliter. During this period the fetal plasma cortisol also increased from less than 1 to 8.1 microgram per deciliter. During this period there was no significant change in fetal plasma thyroxine (T4) or reverse T3 concentrations and no change in maternal plasma concentrations of any of these hormones. The abrupt increase in fetal plasma T3 concentrations with no rise in plasma T4 suggests that there was an alteration in extrathyroidal conversion of T4 to T3 rather than an increase in thyroid secretion, since the latter would be expected to cause an increase in both plasma T4 and plasma T3. The changes in plasma T3 and cortisol concentrations in a fetus that died in utero eight to 10 days before term resembled those occurring prior to normal parturition.

Radioimmunoassay of triiodothyronine and thyroxine in capillary blood

A radioimmunoassay technique for the estimation of T3 and T4 levels in capillary blood is described and evaluated in comparison to a simultaneously drawn and equally analyzed sample from the cubital vein. A total number of 236 samples thus received from the capillary and the vein from euthyroid, hypo- and hyper-thyroid patients were collected. For both T3 and T4 a good correlation (r = 0.94) was obtained. The clinical implication would especially be for paediatric practice.

Differentiation of thyrotoxicosis induced by thyroid destruction from Graves' disease

Thyroid function was tested in untreated patients with Graves' disease or thyrotoxic subacute thyroiditis, and in patients with autoimmune thyroiditis who showed postpartum or spontaneous transient thyrotoxicosis. The serum triiodothyronine/thyroxine ratio (T3/T4) was greater than 20 ng/microgram in Graves' disease but less than 20 in all patients with subacute thyroiditis and 9 of 11 patients with autoimmune thyroiditis. Thus, like radioactive iodine uptake, the serum T3/T4 ratio is useful for differentiating destruction-induced thyrotoxicosis from the stimulation-induced hyperthyroidism of Graves' disease.

Recent developments in thyroid hormone metabolism: interpretation and significance of measurements of reverse T3, 3,3'T2, and thyroglobulin

The development of specific radioimmunoassays has allowed measurements of 3,3',5'-triiodothyronine (reverse T3), 3,3'-diiodothyronine (3,3'T2), and thyroglobulin to be performed in serum and in various biological fluids both in normal and in altered states of thyroidal economy. The physiology, kinetics, and metabolic actions of reverse T3, 3,3'T2 and thyroglobulin are reviewed. Presently, it appears that reverse T3 and 3,3'T2 measurements in amniotic fluid and cord serum may potentially be useful in diagnosing fetal or neonatal thyroid dysfunction, and serum thyroglobulin measurements appear to be important as a measure of the efficacy of treatment of patients with differentiated thyroid carcinoma.

Iodothyronine metabolism in rat liver homogenates

To investigate mechanisms of extrathyroidal thyroid hormone metabolism, conversion of thyroxine (T(4)) to 3,5,3'-triiodothyronine (T(3)) and degradation of 3,3',5'-triiodothyronine (rT(3)) were studied in rat liver homogenates. Both reactions were enzymatic. For conversion of T(4) to T(3), the K(m) of T(4) was 7.7 muM, and the V(max) was 0.13 pmol T(3)/min per mg protein. For rT(3) degradation, the K(m) of rT(3) was 7.5 nM, and the V(max) was 0.36 pmol rT(3)/min per mg protein. Production of rT(3) or degradation of T(4) or T(3) was not detected under the conditions employed. rT(3) was a potent competitive inhibitor of T(4) to T(3) conversion with a K(i) of 4.5 nM; 3,3'-diiodothyronine was a less potent inhibitor of this reaction. T(4) was a competitive inhibitor of rT(3) degradation with a K(i) of 10.2 muM. Agents which inhibited both reactions included propylthiouracil, which appeared to be an allosteric inhibitor, 2,4-dinitrophenol, and iopanoic acid. Sodium diatrizoate had a weak inhibitory effect. No inhibition was found with alpha-methylparatyrosine, Fe(+2), Fe(+3), reduced glutathione, beta-hydroxybutyrate, or oleic acid. Fasting resulted in inhibition of T(4) to T(3) conversion and of rT(3) degradation by rat liver homogenates which was reversible after refeeding. Serum T(4), T(3), and thyrotropin concentrations fell during fasting, with no decrease in serum protein binding as assessed by a T(3)-charcoal uptake. There was no consistent change in serum rT(3) concentrations. Dexamethasone had no effect in vitro. In vivo dexamethasone administration resulted in elevated serum rT(3) concentrations after 1 day, and after 5 days, in inhibition of T(4) to T(3) conversion and rT(3) degradation without altering serum T(4), T(3), or thyrotropin concentrations. Endotoxin treatment had no effect of iodothyronine metabolism in liver homogenates. In kidney homogenates the reaction rates and response to propylthiouracil in vitro were similar to those in liver. No significant T(4) to T(3) conversion or rT(3) production or degradation could be detected in other tissues. These data suggest that one iodothyronine 5'-deiodinase is responsible for both T(4) to T(3) conversion and rT(3) degradation in liver and, perhaps, in kidney. Alterations in serum T(3) and rT(3) concentrations induced by drugs and disease states may result from decreases in both T(3) production and rT(3) degradation consequent to inhibition of a single reaction in the pathways of iodothyronine metabolism.

Why does anyone still use desiccated thyroid USP?

The effect on thyroid status of changing from thyroid USP to sodium L-thyroxine was evaluated in 40 patients. With thyroid, abnormally high triiodothyronine (T3) levels were seen in 36 of 38 patients receiving doses of 90 to 240 mg; compared to sodium L-thyroxine, 0.15 to 0.2 mg, the serum T3 was higher (289 +/- 15 ng/dl versus 176 +/- 9 ng/dl, p less than 0.0005) and the thyroxine (T4) lower (7.4 +/- 0.3 microgram/dl versus 11.6 +/- 0.5 microgram/dl, P less than 0.01). Thyrotoxic symptoms occurred in six patients and diminished or disappeared after the change to sodium L-thyroxine, suggesting that the raised T3 level with thyroid may have undesirable effects in some patients. The T4 level, because it is low whether symptoms are present or not, may inadvertently suggest the need for higher dosage of desiccated thyroid in patients who have already received adequate replacement. The dose of sodium L-thyroxine was adequately assessed by measurement of both T4 and T3 levels. Thyroid USP should be discontinued as thyroid medication since it produces thyroid hormone levels that are misleading estimates of thyroid function and can cause thyrotoxic symptoms.

Primary hypothyroidism and galactorrhea

Ten of 16 women with primary hypothyroidism and high thyrotropin (TSH) concentrations had high serum prolactin (PRL) concentrations. A positive correlation was observed between the basal TSH and PRL levels in the hypothyroid patients. Five of these patients complained of persistent galactorrhea after delivery. After treatment with triiodothyronine (T3), the elevated TSH and PRL levels fell to within normal ranges, and the galactorrhea disappeared. It is suggested that the elevated serum PRL levels of patients with primary hypothyroidism are mediated by feedback-induced thyrotropin-releasing hormone (TRH) secretion or an enhanced response to endogenous TRH, and that the combination of delivery and the PRL excess may induce persistent galactorrhea in patients with primary hypothyroidism.

Acute effect of inorganic iodide after 131I therapy for hyperthyroidism

Patients treated with inorganic iodide weeks to years following 131I therapy for hyperthyroidism do not adapt to its antithyroid effect. To determine whether such adaptation occurs soon after 131I therapy, serum thyroxine (T4) and triiodothyronine (T3) concentrations were measured daily for 9-14 days following 131I therapy in seventeen hyperthyroid patients. Nine patients received 150 mg KI daily starting 48 h after 131I administration; eight received only 131I. Serum T4 and T3 concentrations did not change significantly in the patients who received only 131I. In the patients who received 131I and KI, serum T4 and T3 concentrations fell promptly, reaching nadir values 2-10 days after initiation of iodide, and then increased despite continuation of KI therapy. The mean maximal fall in serum T4 was 34% and in serum T3 42%. These results show that "escape" from the acute anti-thyroid effect of iodide occurs when it is given immediately after 131I therapy, thus limiting the utility of iodide as a therapeutic agent at this time.

The radioimmunoassay of 3,3',5' - triiodothyronine (reverse T3) in unextracted human serum

A specific, sensitive and simple double antibody radioimmunoassay for total serum 3,3',5'-triiodothyronine (reverse T3, rT3) in small volumes of unextracted human serum is described. High titre antisera were raised in rabbits using dl=rT3 or l-rT3 conjugated to bovine serum albumin. The selected antisera cross reacted less than 0-003% with triiodothyronine (T3) and 0-14% with thyroxine (T4). A stable high activity rT3 tracer was prepared by iodination of 3,3"-diiodo-l-thyronine by the chloramine-T method, and purified by column chromatography on Sephadex LH-20. Binding of rT3 to endogenous serum proteins was blocked by including 8-anilino-1-naphthalene sulphonic acid (ANS) in the assay. Mean rT3 levels in healthy euthyroid adults are 0-27 nmo1/1 (range 0-21-1-18); in cord sera 3-67 nmo1/1 (range 2-30-7-45) and in amniotic fluid taken during the second trimester 4-70 nmo1/1 (range 2-22-8-00). In approximately half the hypothyroid subjects, rTO levels were undetectable ( less than0-05 nmo1/1) and in the remaining subjects the mean rT3 level was 0-10 nmo1/1 (range 0-05-0-25).

Solid-phase radioimmunoassay of plasma triiodothyronine

A direct radioimmunoassay method for circulating triiodothyronine was set up, using an insolubilized (cellulose-coupled) antiserum and 8-anilino-1-naphthalene-sulfonic acid (ANS) as a protein inhibitor. Particular attention was paid to the evaluation of changes in the physico-chemical properties of the antibody sites under the experimental conditions adopted: no substantial decrease of immunoreactivity was found to be associated with the insolubilization process, while complex effects following the use of protein inhibitors were observed. The standardized procedure was defined in terms of analytical reliability both by a comparison with a reference (charcoal-dextran) method and by evaluation of sensitivity, precision and accuracy.

Triiodothyronine and thyroxine interrelationships in health and disease

With the recent development of radioimmunoassay techniques for the measurement of serum triiodothyronine (T3) concentration, new concepts have arisen regarding the biologic role of T3 in health and disease and its interrelationships with thyroxine (T4). An awareness of the influence of clinical conditions that affect binding of thyroid hormone to plasma proteins is required in the interpretation of moderately increased or decreased serum T3 values. Hormone preparations containing T3 may produce transient increases in T3 concentration into the hyperthyroid range. Measurements of serum T3 concentration appear to be particularly indicated in clinical situations in which hyperthyroidism is suspected but serum T3 resin uptake and serum T4 values are normal, to exclude the T3-toxicosis syndrome. Also, when serum T4 values are in the hypothyroid range, measurement of serum T3 as well as serum thyrotropin (TSH) concentrations can lead to recognition of abnormalities in thyroid gland biosynthesis. Before a diagnosis of hypothyroidism is made on the basis of a low serum T3 value, one must exclude a variety of clinical nonthyroidal conditions that can result in changes in plasma T3 protein binding or impaired peripheral conversion of T4 to metabolically active T3 without producing a hypometabolic state.

Serum triiodothyronine determination in clinical use

Two radioimmunassays for the determination of serum triiodothyronine (T3) were developed. The assay of T3 in unextracted serum had several advantages over the assay on extracted serum and was chosen for the routine determination of T3 in serum from 117 patients requiring assessment of their thyroid status. In 53 subjects considered retrospectively not to have thyroid dysfunction nor to have been on steroid contraceptives or therapy, the pooled mean serum T3 concentration was 1-92 (actual range 0-88-2-62) nmol/l. A significant inverse relationship was observed between the serum T3 level and the age of the subject. Serum total T3 levels discriminate clearly between hypo-,eu- and hyperthyroid patients and provide a rather more sensitive index of hyperthyroid function than total serum T4. In the face of normal serum T4 the T3 level was depressed in five patients with marked hypoproteinaemia and elevated in two patients taking heroin.