Case report: rapid spontaneous recovery from severe hypothyroidism in 2 teenage girls

Hypothesis: Persistently normal TSH levels may be used to recognize patients with transient forms of hypothyroidism and to suggest treatment withdrawal

There are no text-book recommendations on when or if treatment should or could be stopped in patients with a diagnosis of hypothyroidism, and these patients usually receive lifelong thyroxine therapy (despite the fact that some of them may have forms of transient hypothyroidism that will later recover function). Since TSH fluctuations during thyroxine treatment are common and a lack of this fluctuation might be used to identify patients who no longer need thyroxine treatment, we hypothesize that by offering patients with persistently controlled TSH levels a withdrawal trial of thyroxine treatment we may identify those who no longer need life-long treatment.

A Review of the Phenomenon of Hysteresis in the Hypothalamus-Pituitary-Thyroid Axis

The existence of a phase of prolonged suppression of TSH despite normalization of serum thyroid hormones over a variable period of time during the recovery of thyrotoxicosis has been documented in literature. Conversely, a temporary elevation of TSH despite attainment of euthyroid levels of serum thyroid hormones following extreme hypothyroidism has also been observed. This rate-independent lag time in TSH recovery is an evidence of a "persistent memory" of the history of dysthyroid states the hypothalamus-pituitary-thyroid (HPT) axis has encountered after the thyroid hormone perturbations have faded out, a phenomenon termed "hysteresis." Notwithstanding its perplexing nature, hysteresis impacts upon the interpretation of thyroid function tests with sufficient regularity that clinicians risk misdiagnosing and implementing erroneous treatment out of ignorance of this aspect of thyrotropic biology. Mathematical modeling of this phenomenon is complicated but may allow the euthyroid set point to be predicted from thyroid function data exhibiting strong hysteresis effects. Such model predictions are potentially useful for clinical management. Although the molecular mechanisms mediating hysteresis remain elusive, epigenetics, such as histone modifications, are probably involved. However, attempts to reverse the process to hasten the resolution of the hysteretic process may not necessarily translate into improved physiology or optimal health benefits. This is not unexpected from teleological considerations, since hysteresis probably represents an adaptive endocrinological response with survival advantages evolutionarily conserved among vertebrates with a HPT system.