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Zhao Q, Song D, Ju H, Xing W, Ma J, Xiao P. Mass spectrometry in measurement of thyroid biomarkers. Clin Chim Acta 2024; 562:119872. [PMID: 39013525 DOI: 10.1016/j.cca.2024.119872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 07/12/2024] [Accepted: 07/12/2024] [Indexed: 07/18/2024]
Abstract
In 2022, the number of patients with thyroid disease in China exceeded 200 million (10 million with hyperthyroidism, 90 million with hypothyroidism, and 100 million with other thyroid disease such as goiter, thyroid nodules, and thyroid cancer). Well-established markers include FT3, FT4, TT3, TT4, and TSH tested by a number of immunoassay methods. This approach is based on the primary binding of antigen with antibody and a subsequent secondary chemical reaction that provides an indirect measure. The use of traceable standards for quantitation remains an important factor to ensure inter-assay reliability and precision. Recently, mass spectrometry (MS) has received considerable attention as an analytic tool due to high resolution and quantitative accuracy. In addition, MS allows for sensitive determination of low-abundance markers making it ideal for development of traceable standards. Furthermore, this technology will allow for the development of highly accurate thyroid biomarker assays to facilitate diagnosis, enable early treatment and improve outcomes. Herein, we provide a systematic review and summary of MS in enhancing the analysis of thyroid biomarkers.
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Affiliation(s)
- Qiang Zhao
- National Institute of Metrology, Beijing 100029, China; Key Laboratory of Chemical Metrology and Applications on Nutrition and Health for State Market Regulation, Beijing 100029, China; Department of Immunology, Harbin Medical University, Harbin 150081, China
| | - Dan Song
- National Institute of Metrology, Beijing 100029, China; Key Laboratory of Chemical Metrology and Applications on Nutrition and Health for State Market Regulation, Beijing 100029, China
| | - Huanyu Ju
- Department of Immunology, Harbin Medical University, Harbin 150081, China
| | - Wenjing Xing
- Department of Immunology, Harbin Medical University, Harbin 150081, China
| | - Jian Ma
- Department of Immunology, Harbin Medical University, Harbin 150081, China.
| | - Peng Xiao
- National Institute of Metrology, Beijing 100029, China; Key Laboratory of Chemical Metrology and Applications on Nutrition and Health for State Market Regulation, Beijing 100029, China.
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2
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Mrosewski I, Dannheim V, Klett R, Urbank M, Stobbe S, Ittner JR, Bidlingmaier M. Rare coincidence: Macro-thyroid-stimulating hormone and multiple manufacturer-specific interferences in thyroid hormone immunoassays. Ann Clin Biochem 2024:45632241262920. [PMID: 38906861 DOI: 10.1177/00045632241262920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/23/2024]
Abstract
Immunoassays are widely used for laboratory assessment of endocrine functions including thyroid hormones. While usually adequate for patient evaluation, they are known to potentially suffer from interference from a variety of factors. We report the case of a 44 year-old male patient without clinical symptoms of thyroid disease who presented for specialist evaluation after pathological thyroid function tests prompted a transferal by his primary care practitioner. Thyroid function tests showed discrepant results across immunoassays and platforms of different manufacturers. Polyethylene glycol precipitation prompted the diagnosis of macro-thyroid-stimulating hormone, while heterophilic and non-specific antibody blocking reagents proved ineffective in eliminating the interference in thyroid-stimulating hormone, free triiodothyronine and free thyroxine measurements. Further assessment ruled out a diagnosis of familial dysalbuminemic hyperthyroxinemia, leaving an exclusion diagnosis of manufacturer-specific interference in free triiodothyronine and free thyroxine assays due to unknown factors. Both clinicians and laboratory specialists must be aware of potential interference in immunoassays which otherwise might be misleading, potentially triggering unnecessary (invasive) follow-up procedures or therapeutic interventions. Close communication is required for successful troubleshooting. To our knowledge, no other case of both macro-thyroid-stimulating hormone and manufacturer-specific interference in a single patient has been documented thus far.
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Affiliation(s)
- Ingo Mrosewski
- Department of Laboratory Medicine, MDI Limbach Berlin GmbH, Berlin, Germany
| | - Viola Dannheim
- Department of Endocrinology, MVZ Praxis im Chilehaus Hamburg, Hamburg, Germany
| | - Robert Klett
- Department of Laboratory Medicine, MDI Limbach Berlin GmbH, Berlin, Germany
| | - Matthias Urbank
- Department of Laboratory Medicine, MDI Limbach Berlin GmbH, Berlin, Germany
| | - Silvia Stobbe
- Department of Laboratory Medicine, Labor Dr. Fenner und Kollegen MVZ GmbH, Hamburg, Germany
| | | | - Martin Bidlingmaier
- Department of Endocrinology, Ludwig-Maximilians-Universität, Munich, Germany
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3
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Zaitoon H, Shefer G, Segev-Becker A, Eyal O, Lebenthal Y, Brener A. Polyethylene glycol thyroid-stimulating hormone (PEG-TSH) testing in the management of pediatric thyroid dysfunction. Endocrine 2024; 84:524-532. [PMID: 37882906 DOI: 10.1007/s12020-023-03575-5] [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: 06/25/2023] [Accepted: 10/16/2023] [Indexed: 10/27/2023]
Abstract
PURPOSE The polyethylene glycol (PEG) methodology is used for investigating incongruities in laboratory assays, such as thyroid-stimulating hormone (TSH) measurements. The aim of the study is to investigate the practical application of PEG-TSH testing in cases of discrepancies between elevated TSH and normal free thyroxine (FT4) levels. METHODS A real-life observational study conducted in a tertiary medical center. The hospital's electronic database was queried for TSH tests performed in pediatric patients between 2015 and 2023. Of those, PEG-TSH were identified. Patients' clinical and biochemical characteristics and PEG-TSH-guided management were assessed. RESULTS In total, 2949 TSH tests were performed in 891 children and adolescents for various indications. Among them were 61 (2.1%) PEG-TSH results, mean age 7.1 ± 5.3 years, of 38 patients (4.3%), comprised of 16 with congenital hypothyroidism, 16 with subclinical hypothyroidism, and 6 with Hashimoto thyroiditis. Both the TSH and the PEG-TSH levels of patients with congenital hypothyroidism were higher than those of the other two groups (P = 0.021 and P = 0.009, respectively), with no group differences in FT4 levels. Spearman's correlation analysis revealed a strong association between TSH and PEG-TSH levels: r = 0.871, P < 0.001. In nearly one-half of the cases, clinical decisions made by clinicians (decreasing the dose or not initiating L-thyroxine treatment) were affected by the PEG-TSH results. CONCLUSION Our findings support PEG-TSH testing for determining appropriate TSH levels and avoid unnecessary thyroid hormone treatment among children and adolescents. We propose the suitability of managing their clinical condition based upon age-appropriate clinical parameters and FT4 levels when their PEG-TSH levels are within the normal range.
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Affiliation(s)
- Hussein Zaitoon
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gabi Shefer
- The Endocrine Laboratory, The Institute of Endocrinology, Metabolism and Hypertension, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Segev-Becker
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ori Eyal
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Lebenthal
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avivit Brener
- The Institute of Pediatric Endocrinology and Diabetes, Dana-Dwek Children's Hospital, Tel Aviv Sourasky Medical Center, affiliated to the Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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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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Unal MC, Bayraktar AC, Uslu T, Yener S. Multiple immunoassay interference in a patient with falsely elevated calcitonin. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2023; 68:e230074. [PMID: 37988668 PMCID: PMC10916793 DOI: 10.20945/2359-4292-2023-0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 06/07/2023] [Indexed: 11/23/2023]
Abstract
Calcitonin (CT) is a diagnostic and follow-up marker of medullary thyroid carcinoma. Heterophile antibodies (HAbs) may interfere during immunometric assay measurements and result in falsely high CT levels and different markers. A 50-year-old female patient was referred to our institution for elevated CT levels (3,199 pg/mL [0-11,5]). Physical examination and thyroid ultrasonography show no thyroid nodules. Because of the discrepancy between the clinical picture and the laboratory results, various markers and hormones were examined to determine whether there was any interference in the immunometric assay. Thyroglobulin (Tg) and Adrenocorticotropic hormone (ACTH) levels were also found inaccurately elevated. After precipitation with polyethylene glycol, CT, Tg, and ACTH levels markedly decreased, showing macro-aggregates. Also, serial dilutions showed non-linearity in plasma concentrations. Additionally, CT samples were pretreated with a heterophilic blocking tube before measuring, and the CT level decreased to < 0.1 pg/mL, suggesting a HAb presence. Immunoassay interference should be considered when conflicting laboratory data are observed. This may help reduce the amount of unnecessary laboratory and imaging studies and prevent patients from complex diagnostic procedures.
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Affiliation(s)
- Mehmet Cagri Unal
- Dokuz Eylul University Faculty of Medicine, Division of Endocrinology and Metabolism, Izmir, Turkey,
| | | | - Tevfik Uslu
- Dokuz Eylul University Faculty of Medicine, Endocrinology Laboratory, Izmir, Turkey
| | - Serkan Yener
- Dokuz Eylul University Faculty of Medicine, Division of Endocrinology and Metabolism, Izmir, Turkey
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Chiardi I, Rotondi M, Cantù M, Keller F, Trimboli P. Macro-TSH: An Uncommon Explanation for Persistent TSH Elevation That Thyroidologists Have to Keep in Mind. J Pers Med 2023; 13:1471. [PMID: 37888082 PMCID: PMC10608259 DOI: 10.3390/jpm13101471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023] Open
Abstract
A macro-thyroid-stimulating hormone (macro-TSH) is an infrequent yet noteworthy phenomenon in the thyroid field. A 69-year-old patient presented with persistently elevated thyroid-stimulating hormone (TSH) levels ranging from 30 to 50 mIU/L, paradoxically accompanied by normal thyroid hormone levels and normal thyroid ultrasound, with no findings on pituitary magnetic resonance. Laboratory studies were conducted to investigate potential interferences impacting the accuracy of TSH measurements. After excluding other potential causes, polyethylene glycol (PEG) precipitation technique was used, which led us to the diagnosis of macro-TSH. This result was confirmed through chromatography. Macro-TSH, although rare, emerged as the key contributor to the patient's unexplained increase in TSH levels. This case highlights the importance of considering macro-TSH as a potential etiology in cases characterized by unexplained TSH elevation, offering insights into diagnostic protocols and expanding our understanding of thyroid function anomalies.
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Affiliation(s)
- Isabella Chiardi
- Clinic for Endocrinology and Diabetology, Lugano Regional Hospital, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland
- Faculty of Medicine and Surgery, Humanitas University, 20089 Milan, Italy
| | - Mario Rotondi
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
- Unit of Endocrinology and Metabolism, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Marco Cantù
- Institute of Laboratory Medicine, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland
| | - Franco Keller
- Institute of Laboratory Medicine, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland
| | - Pierpaolo Trimboli
- Clinic for Endocrinology and Diabetology, Lugano Regional Hospital, Ente Ospedaliero Cantonale, 6500 Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
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Fröhlich E, Wahl R. Pars Distalis and Pars Tuberalis Thyroid-Stimulating Hormones and Their Roles in Macro-Thyroid-Stimulating Hormone Formation. Int J Mol Sci 2023; 24:11699. [PMID: 37511458 PMCID: PMC10380753 DOI: 10.3390/ijms241411699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 07/14/2023] [Accepted: 07/18/2023] [Indexed: 07/30/2023] Open
Abstract
Thyroid-stimulating hormone (TSH) and thyroid hormone levels are standard parameters in blood analysis. However, the immunoassays employed may lead to false-positive or false-negative results when the sample contains certain materials that interfere with the assay. Macro-TSH, a complex of TSH with immunoglobulin or albumin, may cause apparently increased TSH concentrations. TSH is produced in the pars tuberalis (PT) of the pituitary gland and by thyrotrophs of the pars distalis (PD). It was found that variable glycosylation can render the molecule more strongly bound to antibodies or albumin in the blood, leading to the hypothesis that macro-TSH consists mainly of PT-TSH. Although less known than PD-TSH, PT-TSH plays an important role in the central regulation of thyroid metabolism. The present review summarizes the physiological function of human PT-TSH and its role in macro-TSH formation. The prevalence of macro-hyperthyrotropinemia, the structure of PT-TSH and macro-TSH, problems in the measurement of TSH, and the action of PT-TSH in animals with seasonal breeding are discussed. Despite the absence of a specific function of macro-TSH in the organism, the identification of macro-TSH is important for avoiding unnecessary treatment based on a falsified readout of increased TSH concentrations as numerous individual case reports describe.
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Affiliation(s)
- Eleonore Fröhlich
- Center for Medical Research, Medical University of Graz, 8010 Graz, Austria
| | - Richard Wahl
- Department for Diagnostic Laboratory Medicine, Institute for Clinical Chemistry and Pathobiochemistry, University Hospital Tübingen, 72076 Tübingen, Germany
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Stelmachowska-Banaś M, Ostrowska M, Goszczyński T, Kowalski K, Korbonits M, Kapuścińska R, Zgliczyński W, Glinicki P. Macro-GH - a clinical entity causing a diagnostic challenge - a case report. Clin Chim Acta 2023; 546:117392. [PMID: 37187223 DOI: 10.1016/j.cca.2023.117392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Revised: 05/10/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023]
Abstract
AIM Presentation of a new case of a patient with macro-GH, that may interfere with different GH assays leading to false-positive results in serum samples. CASE PRESENTATION A 61-year-old female was referred with a pituitary macroadenoma and elevated growth hormone levels The laboratory tests showed increased fasting GH level, measured by a sandwich chemiluminescence immunoassay (LIAISON® XL) without suppression on oral glucose tolerance test and normal IGF-1. The patient did not have the typical signs and symptoms of acromegaly. The patient underwent a transsphenoidal resection of a pituitary tumor, showing only α-subunit immunostaining. Postoperative GH levels remained elevated. An interference in the determination of GH level was suspected. GH was analyzed by three different immunoassays, UniCel DxI 600, Cobas e411 and hGH-IRMA. Heterophilic antibodies and rheumatoid factor were not detected in serum sample. GH recovery after precipitation with 25% polyethylene glycol (PEG) was 12%. Size-exclusion chromatography confirmed the presence of macro-GH in serum sample. CONCLUSION If results of laboratory tests are not consistent with the clinical findings, the presence of an interference within immunochemical assays could be suspected. To identify interference caused by the macro-GH, the PEG method and size-exclusion chromatography should be used.
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Affiliation(s)
| | - Magdalena Ostrowska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Tomasz Goszczyński
- Hirszfeld Institute of Immunology and Experimental Therapy, Polish Academy of Science, Wrocław, Poland.
| | | | - Márta Korbonits
- Department of Endocrinology, William Harvey Research Institute, Barts and the London School of Medicine, Queen Mary University of London, London, UK.
| | - Renata Kapuścińska
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Wojciech Zgliczyński
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Piotr Glinicki
- Department of Endocrinology, Centre of Postgraduate Medical Education, Warsaw, Poland.
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Croce L, Chytiris S, Coperchini F, Ferraro G, Minelli L, Navarra A, Magri F, Chiovato L, Trimboli P, Rotondi M. Unexplained Hyperthyrotropinemia: A Biochemical and Clinical Challenge. J Clin Med 2023; 12:jcm12082934. [PMID: 37109270 PMCID: PMC10146086 DOI: 10.3390/jcm12082934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 03/31/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND A raised serum TSH in the absence of a clear etiology, or "unexplained hyperthyrotropinemia" (UH), can be challenging for clinicians. The aim of the present study was to evaluate potential strategies aimed at a clinical and biochemical characterization of UH patients. METHODS We compared 36 patients with UH with a control group of 14 patients with chronic autoimmune thyroiditis (CAT) and subclinical hypothyroidism. The two groups were compared in terms of the following: (i) the rate of normalization of TSH after repeating with another assay; (ii) the rate of normalization of TSH over time with the same assay; (iii) the reduction in TSH after precipitation with polyethilenglycole (PEG); and (iv) free thyroxine (FT4) levels. RESULTS Similar TSH levels were observed in UH [5.65 (5.21-6.37)] and CAT [5.62 (5.17-8.50)] (p = 0.489). TSH measurement with another assay method showed a normal TSH value in 41.9% of UH vs. 46.1% of CAT patients (p = 0.797). After repeating the TSH measurement in time with the same assay method, an increased TSH value was confirmed in all cases, in both groups (0% in the UH group vs. 0% in the CAT group, p = 1.000). TSH recovery after PEG precipitation was similar in the two groups (% precipitable post-PEG: 68.75 ± 3.14 in UH vs. 68.67 ± 7.18 in CAT, p = 0.960). FT4 levels were similar in the two groups (FT4 1.02 ± 0.20 ng/dl in UH vs. 1.00 ± 0.20 ng/dl in CAT, p = 0.789). CONCLUSIONS The results do not support the concept that laboratory interferences are more frequent in UH patients, suggesting that patients with UH should be managed in the same way as patients with CAT until proven otherwise.
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Affiliation(s)
- Laura Croce
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
- Unit of Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Spyridon Chytiris
- Unit of Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Francesca Coperchini
- Unit of Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Giovanni Ferraro
- Laboratory Service, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Linda Minelli
- Unit of Internal Medicine, Medical-Oncologic Department, ASST Lodi, 26900 Lodi, Italy
| | - Antonella Navarra
- Laboratory Service, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Flavia Magri
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
- Unit of Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Luca Chiovato
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
- Unit of Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
| | - Pierpaolo Trimboli
- Clinic for Endocrinology and Diabetology, Lugano Regional Hospital, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana (USI), 6900 Lugano, Switzerland
| | - Mario Rotondi
- Department of Internal Medicine and Therapeutics, University of Pavia, 27100 Pavia, Italy
- Unit of Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, 27100 Pavia, Italy
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Hattori N, Aisaka K, Yamada A, Matsuda T, Shimatsu A. Prevalence and Pathogenesis of Macro-Thyrotropin in Neonates: Analysis of Umbilical Cord Blood from 939 Neonates and Their Mothers. Thyroid 2023; 33:45-52. [PMID: 36345221 DOI: 10.1089/thy.2022.0457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Background: Macro-thyrotropin (macro-TSH) is a large molecular weight TSH that causes elevated serum TSH concentrations due to its slow clearance. It is primarily a complex of TSH and anti-TSH autoantibodies. The aims of this study were to examine the prevalence and nature of macro-TSH in neonates and to determine how to cope with macro-TSH in neonates suspected to have congenital hypothyroidism through neonatal mass screening. Methods: The presence of macro-TSH was examined using polyethylene glycol (PEG), gel filtration chromatography (GFC), and 125I-TSH binding studies in 939 umbilical cord blood samples from neonates and their mothers. Results: Among 138 serum samples with a PEG precipitation ratio of TSH >68.9% (mean + standard deviation), human anti-mouse antibodies were found in nine samples. The presence of macro-TSH was examined in the remaining 129 serum samples using a 125I-TSH binding study and GFC. The 125I-TSH binding study revealed that four babies (0.43%) had significantly high ratios of 125I-TSH binding to their sera. Two of the babies were siblings, and their mother and the other two mothers also showed significantly high binding ratios. The 125I-TSH binding was displaced by a large amount (1 μg) of unlabeled human TSH in a similar way between babies and their mothers in all cases, suggesting the presence of anti-TSH autoantibodies in their sera. Further characterization of the autoantibodies in one baby and its mother showed a low affinity and high specificity to human TSH, and the nature was very similar between them. These findings may indicate that the anti-TSH autoantibodies that developed in the mother were transferred to the baby through the placenta and formed macro-TSH by binding to neonatal TSH. GFC revealed macro-TSH in only one baby and its mother, probably because of the dissociation of TSH from autoantibodies during the analytical procedure. Conclusions: Macro-TSH was found in 0.43% of neonates, and their mothers all had macro-TSH as well. We recommend that if a baby's serum TSH concentration is high enough to consider levothyroxine treatment suspecting congenital hypothyroidism but the free thyroxine level is normal, their mother's macro-TSH should be checked.
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Affiliation(s)
- Naoki Hattori
- Department of Pharmaceutical Sciences, Ritsumeikan University, Shiga, Japan
| | - Kohzo Aisaka
- Department of Obstetrics and Gynecology, Hamada Hospital, Tokyo, Japan
| | - Ayato Yamada
- Department of Pharmaceutical Sciences, Ritsumeikan University, Shiga, Japan
| | - Takeshi Matsuda
- Department of Pharmaceutical Sciences, Ritsumeikan University, Shiga, Japan
| | - Akira Shimatsu
- Advanced Medical Care Center, Omi Medical Center, Shiga, Japan
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Nishiyama N, Hattori N, Tani Y, Matsuda T, Yamada A, Saito T. A rare case of both macro-TSH and macro-LH: laboratory analysis of the pathogenesis. Clin Chem Lab Med 2022; 61:e81-e84. [PMID: 36513386 DOI: 10.1515/cclm-2022-1149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Norito Nishiyama
- Department of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu, Shiga, Japan
- Department of Orthopedics, Kansai Medical University, Osaka, Japan
| | - Naoki Hattori
- Department of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu, Shiga, Japan
| | - Yuji Tani
- Zushi Kanazawanaika Clinic, Kanagawa, Japan
| | - Takeshi Matsuda
- Department of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu, Shiga, Japan
| | - Ayato Yamada
- Department of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu, Shiga, Japan
| | - Takanori Saito
- Department of Orthopedics, Kansai Medical University, Osaka, Japan
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Peters C, Schoenmakers N. MECHANISMS IN ENDOCRINOLOGY: The pathophysiology of transient congenital hypothyroidism. Eur J Endocrinol 2022; 187:R1-R16. [PMID: 35588090 PMCID: PMC9254299 DOI: 10.1530/eje-21-1278] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 05/19/2022] [Indexed: 11/08/2022]
Abstract
Transient congenital hypothyroidism (TCH) refers to congenital hypothyroidism which spontaneously resolves in the first few months or years of life. Currently, there is a paucity of reliable markers predicting TCH at diagnosis, and the diagnosis is established following the withdrawal of levothyroxine therapy around 3 years of age. The incidence of TCH is increasing, and it is a major contributor to the overall increase in the incidence of CH in recent studies. Both genetic factors, in particular mutations affecting DUOX2 and DUOXA2, and environmental factors, for example, iodine deficiency and excess, anti- TSHR antibodies and exposure to antithyroid or iodine-rich medications, may cause TCH. Resolution of TCH in childhood may reflect both normal thyroid physiology (decreased thyroid hormone biosynthesis requirements after the neonatal period) and clearance or cessation of environmental precipitants. The relative contributions and interactions of genetic and environmental factors to TCH, and the extent to which TCH may be prevented, require evaluation in future population-based studies.
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Affiliation(s)
- Catherine Peters
- Department of Endocrinology, Great Ormond Street Hospital for Children, London, UK
| | - Nadia Schoenmakers
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Correspondence should be addressed to N Schoenmakers;
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13
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Yamada A, Hattori N, Matsuda T, Nishiyama N, Shimatsu A. Clearance of macro-TSH from the circulation is slower than TSH. Clin Chem Lab Med 2022; 60:e132-e135. [PMID: 35285221 DOI: 10.1515/cclm-2022-0131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/04/2022] [Indexed: 11/15/2022]
Affiliation(s)
- Ayato Yamada
- Department of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu-city, Shiga, Japan
| | - Naoki Hattori
- Department of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu-city, Shiga, Japan
| | - Takeshi Matsuda
- Department of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu-city, Shiga, Japan
| | - Norito Nishiyama
- Department of Pharmaceutical Sciences, Ritsumeikan University, Kusatsu-city, Shiga, Japan
| | - Akira Shimatsu
- Advanced Medical Care Center, Omi Medical Center, Kusatsu-city, Shiga, Japan
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14
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Ghazal K, Brabant S, Prie D, Piketty ML. Hormone Immunoassay Interference: A 2021 Update. Ann Lab Med 2022; 42:3-23. [PMID: 34374345 PMCID: PMC8368230 DOI: 10.3343/alm.2022.42.1.3] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/08/2021] [Accepted: 07/21/2021] [Indexed: 12/17/2022] Open
Abstract
Immunoassays are powerful qualitative and quantitative analytical techniques. Since the first description of an immunoassay method in 1959, advances have been made in assay designs and analytical characteristics, opening the door for their widespread implementation in clinical laboratories. Clinical endocrinology is closely linked to laboratory medicine because hormone quantification is important for the diagnosis, treatment, and prognosis of endocrine disorders. Several interferences in immunoassays have been identified through the years; although some are no longer encountered in daily practice, cross-reaction, heterophile antibodies, biotin, and anti-analyte antibodies still cause problems. Newer interferences are also emerging with the development of new therapies. The interfering substance may be exogenous (e.g., a drug or substance absorbed by the patient) or endogenous (e.g., antibodies produced by the patient), and the bias caused by interference can be positive or negative. The consequences of interference can be deleterious when clinicians consider erroneous results to establish a diagnosis, leading to unnecessary explorations or inappropriate treatments. Clinical laboratories and manufacturers continue to investigate methods for the detection, elimination, and prevention of interferences. However, no system is completely devoid of such incidents. In this review, we focus on the analytical interferences encountered in daily practice and possible solutions for their detection or elimination.
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Affiliation(s)
- Khaldoun Ghazal
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
| | - Severine Brabant
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
| | - Dominique Prie
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
| | - Marie-Liesse Piketty
- Assistance Publique Hopitaux de Paris, Department of Functional Explorations, Necker Enfants Malades Hospital, Paris-Centre University, Paris Cedex, France
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15
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Fukushita M, Watanabe N, Yoshimura Noh J, Yoshihara A, Matsumoto M, Suzuki N, Yoshimura R, Sugino K, Ito K. A case of macro-TSH consisting of IgA-bound TSH. Endocr J 2021; 68:1241-1246. [PMID: 34039782 DOI: 10.1507/endocrj.ej21-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
An asymptomatic, 68-year-old Japanese man visited our hospital for further examination of subclinical hypothyroidism. At the first visit, the serum TSH level was markedly elevated (36.6 μIU/mL), but the serum level of free T4 was within the reference interval. Thyroid dysfunction due to dietary iodine excess was initially suspected. However, even after iodine restriction, his thyroid function tests were the same as at the first visit, which suggested false elevation of the TSH level. The TSH levels were compared among three different measurement systems, which showed a similar tendency of TSH elevation above the reference interval, but the different TSH elevation levels among the measurement methods suggested the existence of some interfering substance. Neither serial dilution of the patient's serum nor polyethylene glycol and protein G precipitation tests showed any significant changes in the recovery rate. IgG-bound macro-TSH was ruled out. The TSH peak on gel filtration chromatography was located at a molecular size greater than IgA, which suggested the presence of IgA-bound TSH. After precipitation with Jacalin, which binds specifically to IgA, the TSH level decreased from 30.7 μIU/mL to 2.01 μIU/mL, within the reference interval. Thus, IgA-bound macro-TSH was identified. Macro-TSH is a rare condition in which an immunoglobulin-bound, high-molecular-weight form of TSH results in a false elevation of the serum TSH level. When there is a discrepancy between the results of thyroid function tests and clinical symptoms, and macro-TSH is suspected, it is necessary to know that not only IgG-bound TSH but also IgA-bound TSH could be the cause.
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Affiliation(s)
- Miho Fukushita
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | | | | | - Ai Yoshihara
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | | | - Nami Suzuki
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Ran Yoshimura
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | | | - Koichi Ito
- Department of Surgery, Ito Hospital, Tokyo, Japan
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16
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D'Arcy R, Hunter S, Spence K, McDonnell M. A Case of macro-TSH masquerading as subclinical hypothyroidism. BMJ Case Rep 2021; 14:14/7/e243436. [PMID: 34253523 DOI: 10.1136/bcr-2021-243436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 47-year-old man was commenced on levothyroxine following a diagnosis of subclinical hypothyroidism with nonspecific symptoms. Despite increasing doses of levothyroxine, his thyroid-stimulating hormone (TSH) remained elevated and he was referred for further assessment as he was unable to tolerate further titration. On assessment, his thyroid function demonstrated an elevated TSH and elevated free-T4. The initial impression was of iatrogenic thyrotoxicosis, with possible underlying thyroid hormone resistance, TSHoma or assay interference. After discontinuation of levothyroxine, free-T4 normalised but TSH remained elevated. There was a normal response to thyrotropin-releasing hormone (TRH) testing. T3 suppression testing demonstrated free-T4 reduction but persistently high TSH. THRβ sequencing was normal. TSH measurement by alternative assays revealed discrepant results. Gel filtration chromatography revealed the presence of high-molecular weight TSH variant alongside normal TSH. Macro-TSH is a rare phenomenon with spuriously elevated TSH and which may mimic subclinical hypothyroidism. Recognition of macro-TSH avoids misdiagnosis and prevents inappropriate treatment.
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Affiliation(s)
- Robert D'Arcy
- Regional Centre for Endocrinology & Diabetes, Royal Victoria Hospital, Belfast, UK .,Queen's University Belfast, Belfast, UK
| | - Steven Hunter
- Regional Centre for Endocrinology & Diabetes, Royal Victoria Hospital, Belfast, UK
| | - Kirsty Spence
- Endocrinology Laboratory, Royal Victoria Hospital, Belfast, UK
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17
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Larsen CB, Petersen ERB, Overgaard M, Bonnema SJ. Macro-TSH: A Diagnostic Challenge. Eur Thyroid J 2021; 10:93-97. [PMID: 33777825 PMCID: PMC7983602 DOI: 10.1159/000509184] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 06/03/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Analytical problems should be considered in case of a discrepancy between the results of biochemical tests and the clinical findings. Macro-hormones often artefactually elevate biochemical tests. CASE PRESENTATION A young male was referred with persistently elevated TSH (148 mIU/L) measured by a sandwich electrochemiluminescence immunoassay, ECLIA (Cobas; Roche, Basel, Switzerland). The patient's complaints were unspecific, and he appeared clinically euthyroid. The plasma levels of free T4 and free T3 were within the normal range, thyroid autoantibodies were negative, and thyroid ultrasonography was normal. During a short trial of thyroid hormone substitution, the level of TSH decreased to near-normal levels, but hyperthyroid symptoms emerged. TSH analysed by a different immunoassay (Architect; Abbott, Chicago, IL, USA) yielded similar results. In addition, serial dilutions were performed showing linearity, without detection of heterophilic antibody interference. Gel filtration chromatography confirmed the presence of macro-TSH. CONCLUSION The patient harboured macro-TSH, which is a rare condition. The complex binding of TSH to other plasma proteins, most often immunoglobulins, results in elevated plasma TSH. However, the biologically active fraction of TSH is normal, reflected by clinical and biochemical euthyroidism.
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Affiliation(s)
- Camilla Bøgelund Larsen
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- *Camilla Bøgelund Larsen, Department of Endocrinology, Odense University Hospital, Kløvervænget 6, DK–5000 Odense C (Denmark),
| | - Eva Rabing Brix Petersen
- Department of Clinical Biochemistry and Immunology, Hospital of Southern Jutland, Aabenraa, Denmark
| | - Martin Overgaard
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Department of Clinical Biochemistry and Pharmacology, Odense University Hospital, Odense, Denmark
| | - Steen Joop Bonnema
- Department of Endocrinology, Odense University Hospital, Odense, Denmark
- Department of Clinical Research, University of Southern Denmark, Odense, Denmark
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18
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Ohba K, Maekawa M, Iwahara K, Suzuki Y, Matsushita A, Sasaki S, Oki Y, Nakamura H. Abnormal thyroid hormone response to TRH in a case of macro-TSH and the cut-off value for screening cases of inappropriate TSH elevation. Endocr J 2020; 67:125-130. [PMID: 31645528 DOI: 10.1507/endocrj.ej19-0320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
A 74-year-old asymptomatic Japanese man with suspected thyroid dysfunction was referred to our hospital. He had an elevated TSH (53.8 mIU/L; reference interval: 0.5-5.0) despite a free T4 (FT4) level (1.4 ng/dL; reference interval: 0.9-1.6). Further analysis revealed macro-TSH. A notable finding was that a 500-μg TRH stimulation test revealed a blunted free T3 (FT3) response despite a prolonged TSH response. Macro-TSH typically presents with inappropriately marked elevation of serum TSH levels compared with other thyroid hormones, as exhibited in our case. However, the level of TSH elevation that might differentiate macro-TSH from subclinical hypothyroidism is poorly known. We retrospectively analyzed 8,183 concurrent measurements of TSH and FT4 in individuals previously examined in our hospital to define the cut-off value for screening cases of inappropriate TSH elevation. FT4 values were rounded off to one decimal place, and the 97.5th percentile of TSH against each FT4 value was calculated. The data of our patient and that of 30 cases of macro-TSH extracted from the English literature were then assessed. When the approximate curve obtained from the 97.5th percentile of TSH values was defined as the cut-off value [Log10TSH = 0.700 + 1.549/{1 + (FT4/0.844)6.854}], 25 of the 31 (80.6%) macro-TSH cases were identified. In conclusion, we report for the first time a case of macro-TSH demonstrating an abnormal FT3 response to TRH. A cut-off value of TSH adjusted to the FT4 level may be a good method of screening for inappropriate TSH elevation (or inappropriate hyperthyrotropinemia) including those caused by macro-TSH.
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Affiliation(s)
- Kenji Ohba
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka 431-3192, Japan
| | - Masato Maekawa
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka 431-3192, Japan
| | - Kunihiro Iwahara
- Department of Laboratory Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka 431-3192, Japan
| | - Yasuhide Suzuki
- Department of Laboratory Medicine, Enshu Hospital, Hamamatsu, Shizuoka 430-0929, Japan
| | - Akio Matsushita
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka 431-3192, Japan
| | - Shigekazu Sasaki
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka 431-3192, Japan
| | - Yutaka Oki
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka 431-3192, Japan
- Department of Family and Community Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka 431-3192, Japan
| | - Hirotoshi Nakamura
- Second Division, Department of Internal Medicine, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka 431-3192, Japan
- Department of Internal Medicine, Kuma Hospital, Kobe, Hyogo 650-0011, Japan
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19
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Kirac CO, Abusoglu S, Paydas Hataysal E, Kebapcilar A, Ipekci SH, Ünlü A, Kebapcilar L. A rare cause of subclinical hypothyroidism: macro-thyroid-stimulating hormone. Diagnosis (Berl) 2020; 7:75-77. [PMID: 31271551 DOI: 10.1515/dx-2019-0026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 05/08/2019] [Indexed: 11/15/2022]
Abstract
Background Subclinical hypothyroidism is a situation in which the thyroid-stimulating hormone (TSH) value exceeds the upper limit of normal, but the free triiodothyronine (T3) and thyroxine (T4) values are within the normal range. The etiology is similar to overt hypothyroidism. Case presentation An 18-year-old female patient was referred to our endocrinology clinic due to elevated TSH levels detected during a routine examination. She was clinically euthyroid and had a normal thyroid ultrasound pattern. The TSH concentration was measured twice independently, giving values of 5.65 μIU/mL and 5.47 μIU/mL. The polyethylene glycol (PEG) method for TSH measurement was used to determine the concentration of macro-TSH (m-TSH), a macromolecule formed between TSH and immunoglobulin (Ig). Using the same blood samples for which the TSH levels were found to be high, the PEG method found TSH levels to be within a normal range, with values of 1.50 μIU/mL (5.65-1.50 μIU/mL measured; a decrease of 75%) and 1.26 μIU/mL (5.47-1.26 μIU/mL measured; a decrease of 77%), respectively. The TSH values determined by the PEG precipitation test were markedly low, with PEG-precipitable TSH ratios greater than 75%. Conclusions The cause of 55% of subclinical hypothyroidism is chronic autoimmune thyroiditis. However, it is necessary to exclude other TSH-elevated conditions for diagnosis. One of these conditions is m-TSH, which should be kept in mind even though it is rarely seen. m-TSH should be considered especially in patients who have a TSH value above 10 μIU/mL without hypothyroidism symptoms or who require a higher levothyroxine replacement dose than expected to make them euthyroid.
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Affiliation(s)
- Cem Onur Kirac
- Selcuk University, Faculty of Medicine, Internal Medicine Department, Division of Endocrinology and Metabolism, Selcuklu, Konya, Turkey
| | - Sedat Abusoglu
- Selcuk University, Biochemistry Department, Faculty of Medicine, Selcuklu, Konya, Turkey
| | - Esra Paydas Hataysal
- Selcuk University, Biochemistry Department, Faculty of Medicine, Selcuklu, Konya, Turkey
| | - Aysegul Kebapcilar
- Selcuk University, Gynecology and Obstetrics Department, Faculty of Medicine, Selcuklu, Konya, Turkey
| | - Suleyman Hilmi Ipekci
- Selcuk University, Internal Medicine Department, Faculty of Medicine, Selcuklu, Konya, Turkey
| | - Ali Ünlü
- Selcuk University, Biochemistry Department, Faculty of Medicine, Selcuklu, Konya, Turkey
| | - Levent Kebapcilar
- Selcuk University, Internal Medicine Department, Faculty of Medicine, Selcuklu, Konya, Turkey
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20
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Ikegami K, Refetoff S, Van Cauter E, Yoshimura T. Interconnection between circadian clocks and thyroid function. Nat Rev Endocrinol 2019; 15:590-600. [PMID: 31406343 PMCID: PMC7288350 DOI: 10.1038/s41574-019-0237-z] [Citation(s) in RCA: 105] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2019] [Indexed: 02/07/2023]
Abstract
Circadian rhythmicity is an approximately 24-h cell-autonomous period driven by transcription-translation feedback loops of specific genes, which are referred to as 'circadian clock genes'. In mammals, the central circadian pacemaker, which is located in the hypothalamic suprachiasmatic nucleus, controls peripheral circadian clocks. The circadian system regulates virtually all physiological processes, which are further modulated by changes in the external environment, such as light exposure and the timing of food intake. Chronic circadian disruption caused by shift work, travel across time zones or irregular sleep-wake cycles has long-term consequences for our health and is an important lifestyle factor that contributes to the risk of obesity, type 2 diabetes mellitus and cancer. Although the hypothalamic-pituitary-thyroid axis is under the control of the circadian clock via the suprachiasmatic nucleus pacemaker, daily TSH secretion profiles are disrupted in some patients with hypothyroidism and hyperthyroidism. Disruption of circadian rhythms has been recognized as a perturbation of the endocrine system and of cell cycle progression. Expression profiles of circadian clock genes are abnormal in well-differentiated thyroid cancer but not in the benign nodules or a healthy thyroid. Therefore, the characterization of the thyroid clock machinery might improve the preoperative diagnosis of thyroid cancer.
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Affiliation(s)
- Keisuke Ikegami
- Department of Physiology, School of Medicine, Aichi Medical University, Nagakute, Japan
| | - Samuel Refetoff
- Department of Medicine, The University of Chicago School of Medicine, Chicago, IL, USA
- Department of Paediatrics and Committee on Genetics, The University of Chicago, Chicago, IL, USA
| | - Eve Van Cauter
- Department of Medicine, The University of Chicago School of Medicine, Chicago, IL, USA
| | - Takashi Yoshimura
- Institute of Transformative Bio-Molecules, Nagoya University, Nagoya, Japan.
- Graduate School of Bioagricultural Sciences, Nagoya University, Nagoya, Japan.
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21
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Chihara K, Hattori N, Matsuda T, Murasawa S, Daimon M, Shimatsu A. Procedures for the diagnosis of macro-follicle stimulating hormone (FSH) in a patient with high serum FSH concentrations. ACTA ACUST UNITED AC 2019; 58:e40-e43. [DOI: 10.1515/cclm-2019-0846] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Accepted: 08/22/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Kazuhisa Chihara
- Department of Pharmaceutical Sciences , Ritsumeikan University , Shiga , Japan
| | - Naoki Hattori
- Department of Pharmaceutical Sciences , Ritsumeikan University , Shiga , Japan
| | - Takeshi Matsuda
- Department of Pharmaceutical Sciences , Ritsumeikan University , Shiga , Japan
| | - Shingo Murasawa
- Department of Endocrinology and Metabolism , Hirosaki University Graduate School of Medicine , Hirosaki , Japan
| | - Makoto Daimon
- Department of Endocrinology and Metabolism , Hirosaki University Graduate School of Medicine , Hirosaki , Japan
| | - Akira Shimatsu
- Advanced Medical Care Center , Kusatsu General Hospital , Kusatsu , Shiga , Japan
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22
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Thayakaran R, Adderley NJ, Sainsbury C, Torlinska B, Boelaert K, Šumilo D, Price M, Thomas GN, Toulis KA, Nirantharakumar K. Thyroid replacement therapy, thyroid stimulating hormone concentrations, and long term health outcomes in patients with hypothyroidism: longitudinal study. BMJ 2019; 366:l4892. [PMID: 31481394 PMCID: PMC6719286 DOI: 10.1136/bmj.l4892] [Citation(s) in RCA: 59] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To explore whether thyroid stimulating hormone (TSH) concentration in patients with a diagnosis of hypothyroidism is associated with increased all cause mortality and a higher risk of cardiovascular disease and fractures. DESIGN Retrospective cohort study. SETTING The Health Improvement Network (THIN), a database of electronic patient records from UK primary care. PARTICIPANTS Adult patients with incident hypothyroidism from 1 January 1995 to 31 December 2017. EXPOSURE TSH concentration in patients with hypothyroidism. MAIN OUTCOME MEASURES Ischaemic heart disease, heart failure, stroke/transient ischaemic attack, atrial fibrillation, any fractures, fragility fractures, and mortality. Longitudinal TSH measurements from diagnosis to outcomes, study end, or loss to follow-up were collected. An extended Cox proportional hazards model with TSH considered as a time varying covariate was fitted for each outcome. RESULTS 162 369 patients with hypothyroidism and 863 072 TSH measurements were included in the analysis. Compared with the reference TSH category (2-2.5 mIU/L), risk of ischaemic heart disease and heart failure increased at high TSH concentrations (>10 mIU/L) (hazard ratio 1.18 (95% confidence interval 1.02 to 1.38; P=0.03) and 1.42 (1.21 to 1.67; P<0.001), respectively). A protective effect for heart failure was seen at low TSH concentrations (hazard ratio 0.79 (0.64 to 0.99; P=0.04) for TSH <0.1 mIU/L and 0.76 (0.62 to 0.92; P=0.006) for 0.1-0.4 mIU/L). Increased mortality was observed in both the lowest and highest TSH categories (hazard ratio 1.18 (1.08 to 1.28; P<0.001), 1.29 (1.22 to 1.36; P<0.001), and 2.21 (2.07 to 2.36; P<0.001) for TSH <0.1 mIU/L, 4-10 mIU/L, and >10 mIU/L. An increase in the risk of fragility fractures was observed in patients in the highest TSH category (>10 mIU/L) (hazard ratio 1.15 (1.01 to 1.31; P=0.03)). CONCLUSIONS In patients with a diagnosis of hypothyroidism, no evidence was found to suggest a clinically meaningful difference in the pattern of long term health outcomes (all cause mortality, atrial fibrillation, ischaemic heart disease, heart failure, stroke/transient ischaemic attack, fractures) when TSH concentrations were within recommended normal limits. Evidence was found for adverse health outcomes when TSH concentration is outside this range, particularly above the upper reference value.
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Affiliation(s)
- Rasiah Thayakaran
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Joint first authors
| | - Nicola J Adderley
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Joint first authors
| | - Christopher Sainsbury
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Barbara Torlinska
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Kristien Boelaert
- Institute of Metabolism and Systems Research, Edgbaston, Birmingham B15 2TT, UK
- Institute of Translational Medicine, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Edgbaston, Birmingham B15 2TT, UK
| | - Dana Šumilo
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Malcolm Price
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - G Neil Thomas
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Konstantinos A Toulis
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Department of Endocrinology, 424 General Army Training Hospital, Thessaloniki, Greece
| | - Krishnarajah Nirantharakumar
- Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
- Centre for Endocrinology, Diabetes and Metabolism, Edgbaston, Birmingham B15 2TT, UK
- Health Data Research UK Midlands, Institute of Translational Medicine, Edgbaston, Birmingham B15 2TH, UK
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23
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Donadio-Andrei S, Hubert N, Raverot V, Plantin-Carrenard E, Kuczewski E, Charrié A, Ronin C, Gauchez AS, Chikh K. A challenging case: highly variable TSH in a mother and her two children. Clin Chem Lab Med 2019; 57:e114-e117. [DOI: 10.1515/cclm-2018-0871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 09/23/2018] [Indexed: 11/15/2022]
Affiliation(s)
| | - Nathalie Hubert
- Service de pédiatrie, CH Bourges Jacques Cœur , Bourges , France
| | - Véronique Raverot
- Laboratoire de Biochimie, Centre de Biologie Est, Groupement hospitalier Est , Bron cedex , France
- Société Française de Médecine Nucléaire, Groupe de Biologie Spécialisée, Centre Antoine Béclère , Paris , France
- Hospices Civils de Lyon , Lyon , France
| | | | | | - Anne Charrié
- Société Française de Médecine Nucléaire, Groupe de Biologie Spécialisée, Centre Antoine Béclère , Paris , France
- Hospices Civils de Lyon , Lyon , France
- Laboratoire de Biochimie et biologie moléculaire, Centre de Biologie Sud Centre Hospitalier Lyon Sud , Pierre Bénite Cedex , France
- Inserm UMR-1060, Laboratoire CarMeN , Oullins cedex , France
| | - Catherine Ronin
- Siamed’Xpress, Hôtel Technologique Morandat , Gardanne , France
| | - Anne-Sophie Gauchez
- Société Française de Médecine Nucléaire, Groupe de Biologie Spécialisée, Centre Antoine Béclère , Paris , France
- UMR-S INSERM 1039 , Grenoble , France
- Laboratoire du Service de Médecine Nucléaire, Centre Hospitalier Métropole Savoie , Chambéry , France
- Pôle de Biologie, Centre Hospitalier et Universitaire de Grenoble , Grenoble , France
| | - Karim Chikh
- Laboratoire de Biochimie et biologie moléculaire, Centre de Biologie Sud Centre Hospitalier Lyon Sud , 69495 Pierre Bénite Cedex , France
- Société Française de Médecine Nucléaire, Groupe de Biologie Spécialisée, Centre Antoine Béclère , 45 rue des Saints Pères , 75270 Paris , France
- Hospices Civils de Lyon , 69002 Lyon , France
- Inserm UMR-1060, Laboratoire CarMeN, Université Lyon 1 , 165 Chemin du Grand Revoyet, BP12 , 69921 Oullins cedex , France , Phone: (+33) 4 78 86 21 69/ (+33) 6 23 90 08 92
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Raverot V, Bordeau É, Periot C, Perrin P, Chardon L, Plotton I, Nouvel M, Lapoirie M, Borson-Chazot F. Letter to the editor: A case of laboratory-generated “thyroid dysfunction”. ANNALES D'ENDOCRINOLOGIE 2019; 80:140-141. [DOI: 10.1016/j.ando.2018.10.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 10/04/2018] [Accepted: 10/19/2018] [Indexed: 11/29/2022]
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Hattori N, Aisaka K, Chihara K, Shimatsu A. Current Thyrotropin Immunoassays Recognize Macro-Thyrotropin Leading to Hyperthyrotropinemia in Females of Reproductive Age. Thyroid 2018; 28:1252-1260. [PMID: 29943675 DOI: 10.1089/thy.2017.0624] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Macro-thyrotropin (macro-TSH) is a high molecular weight form of TSH that leads to hyperthyrotropinemia. This study was undertaken to examine the prevalence and nature of macro-TSH in females of reproductive age. METHODS Blood samples were taken from 1794 female patients who visited the Hamada Obstetrics and Gynecology Hospital in Tokyo, Japan, complaining of infertility. The serum of 305 patients with TSH concentrations >2.5 mIU/L was screened for macro-TSH by the polyethylene glycol method. Samples with TSH precipitation ratios by polyethylene glycol >70% were further analyzed using gel filtration chromatography (GFC), protein G columns, and 125I-TSH binding experiments. RESULTS Screening of the 305 patients revealed that 63 had serum TSH precipitation ratios >70%. GFC revealed that immunoreactive TSH, with a molecular weight of approximately 150 kDa, eluted at higher ratios (79.6 ± 24.4%) in 27 of the 63 patients compared to 0.4 ± 2.0% in the control group. Serum TSH concentrations in 24 of the 27 patients were spuriously elevated due to human anti-mouse antibodies. Macro-TSH was found in the other three patients, and one of them had detectable anti-TSH autoantibodies. Eight of the remaining 36 patients who did not have high-molecular-weight TSH assessed by GFC had immunoglobulin G-associated TSH. Three commercially available TSH immunoassays (Elecsys®, Centaur®, and Architect®) all recognized macro-TSH leading to the elevated serum TSH concentrations. CONCLUSIONS Macro-TSH was present in 0.17% of infertile women. Commercial TSH immunoassays recognized macro-TSH, resulting in the diagnosis of hyperthyrotropinemia.
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Affiliation(s)
- Naoki Hattori
- 1 Department of Pharmaceutical Sciences, Ritsumeikan University , Shiga, Japan
| | - Kohzo Aisaka
- 2 Department of Obstetrics and Gynecology, Hamada Hospital , Tokyo, Japan
| | - Kazuhisa Chihara
- 1 Department of Pharmaceutical Sciences, Ritsumeikan University , Shiga, Japan
| | - Akira Shimatsu
- 3 Clinical Research Institute , National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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Favresse J, Burlacu MC, Maiter D, Gruson D. Interferences With Thyroid Function Immunoassays: Clinical Implications and Detection Algorithm. Endocr Rev 2018; 39:830-850. [PMID: 29982406 DOI: 10.1210/er.2018-00119] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 06/08/2018] [Indexed: 12/22/2022]
Abstract
Automated immunoassays used to evaluate thyroid function are vulnerable to different types of interference that can affect clinical decisions. This review provides a detailed overview of the six main types of interference known to affect measurements of thyroid stimulating hormone (TSH), free thyroxine (T4) and free triiodothyronine (T3): macro-TSH, biotin, antistreptavidin antibodies, anti-ruthenium antibodies, thyroid hormone autoantibodies, and heterophilic antibodies. Because the prevalence of some of these conditions has been reported to approach 1% and the frequency of testing for thyroid dysfunction is important, the scale of the problem might be tremendous. Potential interferences in thyroid function testing should always be suspected whenever clinical or biochemical discrepancies arise. Their identification usually relies on additional laboratory tests, including assay method comparison, dilution procedures, blocking reagents studies, and polyethylene glycol precipitation. Based on the pattern of thyroid function test alterations, to screen for the six aforementioned types of interference, we propose a detection algorithm, which should facilitate their identification in clinical practice. The review also evaluates the clinical impact of thyroid interference on immunoassays. On review of reported data from more than 150 patients, we found that ≥50% of documented thyroid interferences led to misdiagnosis and/or inappropriate management, including prescription of an unnecessary treatment (with adverse effects in some situations), inappropriate suppression or modification of an ongoing treatment, or use of unnecessary complementary tests such as an I123 thyroid scan. Strong interaction between the clinician and the laboratory is necessary to avoid such pitfalls.
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Affiliation(s)
- Julien Favresse
- Department of Laboratory Medicine, Cliniques Universitaires Saint-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - Maria-Cristina Burlacu
- Service d'Endocrinologie et Nutrition, Cliniques Universitaires Saint-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - Dominique Maiter
- Service d'Endocrinologie et Nutrition, Cliniques Universitaires Saint-Luc and Université Catholique de Louvain, Brussels, Belgium.,Pôle de recherche en Endocrinologie, Diabète et Nutrition, Institut de Recherche Expérimentale et Clinique, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - Damien Gruson
- Department of Laboratory Medicine, Cliniques Universitaires Saint-Luc and Université Catholique de Louvain, Brussels, Belgium.,Pôle de recherche en Endocrinologie, Diabète et Nutrition, Institut de Recherche Expérimentale et Clinique, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
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Goichot B, Leenhardt L, Massart C, Raverot V, Tramalloni J, Iraqi H. Diagnostic procedure in suspected Graves' disease. ANNALES D'ENDOCRINOLOGIE 2018; 79:608-617. [PMID: 30220410 DOI: 10.1016/j.ando.2018.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Diagnostic procedure in suspected Graves' disease has never been studied scientifically and actual practice seems quite variable, notably between countries. Recommendations are few and weak (expert opinion). This article presents the recommendations of an expert consensus meeting organized by the French Society of Endocrinology in 2016. In case of clinically suspected thyrotoxicosis, the first-line biological assessment is of thyroid-stimulating hormone (TSH). Free T4 and possibly free T3 assays assess biological severity and are necessary for treatment efficacy monitoring. Positive diagnosis of Graves' disease after biological confirmation of thyrotoxicosis does not always require complementary etiological examinations if clinical presentation is unambiguous, notably including extra-thyroid signs. Otherwise, first-line anti-TSH-receptor (TSH-R) antibody screening is recommended for its good intrinsic performance (sensitivity and specificity) and ease of access in France. Scintigraphy is reserved to rare cases of Graves' disease with negative antibody findings or when another etiology is suspected. Thyroid ultrasound scan may be contributive, but is not recommended in first line.
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Affiliation(s)
- Bernard Goichot
- Service de médecine interne, endocrinologie et nutrition, hôpital de Hautepierre, hôpitaux universitaires de Strasbourg, avenue Molière, 67098 Strasbourg cedex, France.
| | - Laurence Leenhardt
- Unité thyroïde tumeurs endocrines, institut E3M, hôpital Pitié-Salpêtrière, 75013 Paris, France
| | - Catherine Massart
- Service de biochimie-toxicologie, laboratoire d'hormonologie, CHU de Rennes, 35033 Rennes Cedex 09, France
| | - Véronique Raverot
- Service de biochimie et biologie moléculaire, laboratoire d'hormonologie, groupement hospitalier Est, CHU de Lyon, 69500 Bron, France
| | | | - Hinde Iraqi
- Service d'endocrinologie, CHU de Rabat, Rabat, Morocco
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28
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Drees JC. Case of the Improbably High TSH. Clin Chem 2018; 64:872-873. [DOI: 10.1373/clinchem.2017.280040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 08/30/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Julia C Drees
- The Permanente Medical Group, Kaiser Permanente Regional Laboratories, Richmond, CA
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29
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Nakagawa Y, Nishikimi T, Sakai H, Ohno S, Kinoshita H, Inazumi H, Moriuchi K, Kuwahara K, Horie M, Kimura T. Macro-pro-B-type natriuretic peptide (proBNP) and hidden macro-N-terminal proBNP: Case report. Clin Biochem 2018; 52:148-152. [DOI: 10.1016/j.clinbiochem.2017.10.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 09/23/2017] [Accepted: 10/31/2017] [Indexed: 11/15/2022]
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Giusti M, Conte L, Repetto AM, Gay S, Marroni P, Mittica M, Mussap M. Detection of Polyethylene Glycol Thyrotropin (TSH) Precipitable Percentage (Macro-TSH) in Patients with a History of Thyroid Cancer. Endocrinol Metab (Seoul) 2017; 32:460-465. [PMID: 29271618 PMCID: PMC5744732 DOI: 10.3803/enm.2017.32.4.460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Revised: 09/22/2017] [Accepted: 10/10/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Owing to its large molecular size, polyethylene glycol (PEG)-precipitable thyrotropin (TSH) can accumulate in the circulation, elevating TSH levels. PEG-precipitable TSH can be used to detect macro-TSH (mTSH) in serum. Our aim was to evaluate the prevalence of mTSH in patients who had undergone thyroidectomy for thyroid cancer. METHODS Seventy-three thyroid cancer patients and 24 control subjects on levothyroxine (LT4) TSH-suppressive or replacement therapy were evaluated. Screening for mTSH was performed by adding PEG to serum in order to precipitate γ-globulin. A percentage of PEG-precipitable TSH ≥80% was considered suggestive of mTSH. RESULTS No correlation between free-T4 (fT4) and TSH levels was found. PEG-precipitable TSH was 39.3%±1.9% in thyroid cancer patients and 44.1%±3.9% in controls. Macro-TSH was deemed to be present in one thyroid cancer patient and in two control subjects. Only in the thyroid cancer group was PEG-precipitable TSH found to be negatively correlated with fT4 concentration. No correlation was found between PEG-precipitable TSH and other clinical conditions in any patients. CONCLUSION The presence of mTSH seems to be a rare phenomenon in thyroid cancer. In some patients with low PEG-precipitable TSH, a reduction in LT4 dosage could be suggested. LT4 dosage adjusted to body weight is the main factor in maintaining TSH in a semi-suppressed or normal range. Evaluation of mTSH could be necessary in patients in whom a balance is required between adequate TSH suppression and the avoidance of unnecessary exogenous hyperthyroxinemia.
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Affiliation(s)
- Massimo Giusti
- Department of Internal Medicine, University of Genoa, Genoa, Italy.
- Endocrine Unit, San Martino University Hospital, Genoa, Italy
| | - Lucia Conte
- Endocrine Unit, San Martino University Hospital, Genoa, Italy
| | | | - Stefano Gay
- Endocrine Unit, San Martino University Hospital, Genoa, Italy
| | - Paola Marroni
- Laboratory Analysis Unit, San Martino University Hospital, Genoa, Italy
| | - Miranda Mittica
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Michele Mussap
- Laboratory Analysis Unit, San Martino University Hospital, Genoa, Italy
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Serum Macro TSH Level is Associated with Sleep Quality in Patients with Cardiovascular Risks - HSCAA Study. Sci Rep 2017; 7:44387. [PMID: 28287185 PMCID: PMC5346998 DOI: 10.1038/srep44387] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Accepted: 02/07/2017] [Indexed: 11/24/2022] Open
Abstract
Macro thyroid-stimulating hormone (TSH) has been reported to be associated with seasonality and regulated by changes in day length in rodents, different from free TSH. In the present study, we investigated structural differences between macro TSH and free TSH levels in human serum, as well as the association of macro TSH with sleep quality. We enrolled 314 patients registered in the Hyogo Sleep Cardio-Autonomic Atherosclerosis (HSCAA) study. Sleep quality shown by actigraphy, sleep physical activity, and percent sleep in all and TSH closely matched subjects were significantly associated with high macro TSH levels. Macro and free TSH were similarly increased following thyrotropin-releasing hormone (TRH) stimulation, while circadian changes associated with those were distinct. To further analyze the structure of macro TSH, serum samples were separated by gel filtration chromatography. Although treatment with glycosidase did not affect morbidity, the macro TSH fraction had a markedly low affinity to the Con A column as compared with free TSH, indicating a distinct glycosylation structure. In conclusion, an increase in serum macro TSH is associated with low sleep quality and regulated in a manner distinct from free TSH, potentially due to an altered glycosylation structure.
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Church D, Cardoso L, Bradbury S, Clarke C, Stears A, Dover A, Halsall D, Semple R. Diagnosis of insulin autoimmune syndrome using polyethylene glycol precipitation and gel filtration chromatography with ex vivo insulin exchange. Clin Endocrinol (Oxf) 2017; 86:347-353. [PMID: 27588366 PMCID: PMC5324546 DOI: 10.1111/cen.13179] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/23/2016] [Accepted: 08/24/2016] [Indexed: 02/02/2023]
Abstract
CONTEXT Insulin-binding antibodies may produce severe dysglycaemia in insulin-naïve patients ('insulin autoimmune syndrome' (IAS) or Hirata disease), while rendering routine insulin assays unreliable. OBJECTIVE To assess the performance of clinically used insulin assays and an optimal analytical approach in the context of IAS. DESIGN Observational biochemical study of selected patients with hyperinsulinaemic hypoglycaemia. PATIENTS Three patients without diabetes with recurrent spontaneous hyperinsulinaemic hypoglycaemia and 'positive' insulin antibodies. MEASUREMENTS A panel of clinically used insulin assays (Siemens ADVIA® Centaur, Siemens Immulite® 2000, DiaSorin LIAISON® XL, PE AutoDELFIA® and the Beckman Coulter Access® 2) were used before and after plasma dilution or polyethylene glycol (PEG) precipitation. Anti-insulin IgG antibodies were measured by Isletest™ -IAA ELISA. Gel filtration chromatography (GFC) was undertaken with and without preincubation of plasma with exogenous insulin. RESULTS Dilution of IAS plasma with assay-specific buffer increased insulin recovery, supporting negative immunoassay interference by antibodies. PEG precipitation of IAS plasma decreased insulin recovery using all assays except the Immulite® 2000. GFC discriminated high molecular weight and monomeric insulin, while ex vivo addition of exogenous insulin to plasma increased insulin bound to antibody, thereby improving the sensitivity of detection of insulin immunocomplexes. CONCLUSIONS Immunoprecipitation with PEG must be used with caution in screening for insulin-antibody complexes as results are assay dependent. GFC with addition of exogenous insulin can identify significant insulin immunocomplexes with enhanced sensitivity, with attendant greater clinical utility and avoidance of radiolabelled reagents.
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Affiliation(s)
- David Church
- The University of Cambridge Metabolic Research LaboratoriesWellcome Trust‐MRC Institute of Metabolic ScienceCambridgeUK
- The National Institute for Health Research Cambridge Biomedical Research CentreCambridgeUK
- The Pathology PartnershipDepartment of Clinical Biochemistry and ImmunologyAddenbrooke's HospitalCambridgeUK
| | - Luís Cardoso
- Department of Endocrinology, Diabetes and MetabolismCentro Hospitalar e Universitário de CoimbraCoimbraPortugal
| | - Sonia Bradbury
- The Pathology PartnershipDepartment of Clinical Biochemistry and ImmunologyAddenbrooke's HospitalCambridgeUK
| | - Catriona Clarke
- Department of Clinical BiochemistryWestern General HospitalNHS LothianEdinburghUK
| | - Anna Stears
- Cambridge University Hospitals NHS Foundation TrustCambridge Biomedical CampusCambridgeUK
| | - Anna Dover
- Edinburgh Centre for Endocrinology and DiabetesRoyal Infirmary of EdinburghEdinburghUK
| | - David Halsall
- The Pathology PartnershipDepartment of Clinical Biochemistry and ImmunologyAddenbrooke's HospitalCambridgeUK
| | - Robert Semple
- The University of Cambridge Metabolic Research LaboratoriesWellcome Trust‐MRC Institute of Metabolic ScienceCambridgeUK
- The National Institute for Health Research Cambridge Biomedical Research CentreCambridgeUK
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Hattori N, Ishihara T, Matsuoka N, Saito T, Shimatsu A. Anti-Thyrotropin Autoantibodies in Patients with Macro-Thyrotropin and Long-Term Changes in Macro-Thyrotropin and Serum Thyrotropin Levels. Thyroid 2017; 27:138-146. [PMID: 27785976 DOI: 10.1089/thy.2016.0442] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Macro-thyrotropin (TSH) is a high-molecular-weight form of TSH. Most cases of macro-TSH are TSH complexed with immunoglobulin G. This study was undertaken to characterize macro-TSH. METHODS Blood samples taken from patients with subclinical hypothyroidism were screened for the presence of macro-TSH with the polyethylene glycol method and confirmed with gel filtration chromatography. TSH receptor antibody was quantified with an electrochemiluminescence immunoassay. Binding studies were performed using 125I-human TSH, and the specificity of anti-TSH autoantibodies was tested by displacement experiments using excess amounts of the unlabeled related peptides. Macro-TSH and serum TSH levels were evaluated twice over a one- to four-year interval. RESULTS Sixteen patients (11 females and 5 males; aged 8-82 years) were diagnosed as having macro-TSH. None of the patients with macro-TSH tested positive for TSH receptor antibody. Judging from the affinity and the binding capacity of anti-TSH autoantibodies, two classes of binding sites were identified. Regarding specificity, there were anti-human TSH-β autoantibodies that were partially cross-reactive to bovine and/or rat TSH-β. There were also autoantibodies against human glycoprotein α, a common subunit among human TSH, luteinizing hormone, and follicle stimulating hormone. Macro-TSH persisted in 11/13 patients who could be reevaluated over a one- to four-year interval after the first evaluation. Serum TSH levels returned to normal in the remaining two patients whose macro-TSH disappeared. CONCLUSIONS It is concluded that anti-human TSH autoantibodies are a major cause of macro-TSH and that macro-TSH may persist for a long time.
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Affiliation(s)
- Naoki Hattori
- 1 Department of Pharmaceutical Sciences, Ritsumeikan University , Shiga, Japan
| | - Takashi Ishihara
- 2 Department of Endocrinology, Kobe City General Hospital , Kobe, Japan
| | - Naoki Matsuoka
- 2 Department of Endocrinology, Kobe City General Hospital , Kobe, Japan
| | - Takanori Saito
- 3 Department of Orthopedic Surgery, Kansai Medical University , Osaka, Japan
| | - Akira Shimatsu
- 4 Clinical Research Institute , National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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Loh TP, Lim XC, Kieu K, Sajiir H, Neo SF, Cheng WL, Sethi SK. Recovery of spiked troponin I in four routine assays. Biochem Med (Zagreb) 2016; 26:233-9. [PMID: 27346968 PMCID: PMC4910266 DOI: 10.11613/bm.2016.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 04/25/2016] [Indexed: 11/23/2022] Open
Abstract
Introduction This study aimed to examine the recovery of spiked human cardiac troponin I (cTnI) results measured by four routine assays, and investigate possible interference from microclots. Materials and methods 457 consecutive samples with cTnI concentration below limit of quantitation (12 ng/L), declared by the Vitros TnI ES assay (reference assay), were measured on Beckman Coulter Accu TnI+3, Siemens TnI-Ultra and Roche TnI STAT assays. These samples were enriched with native full-length cTnI to a concentration of 100 ng/L and retested. A post-spiking result that exceeded the critical difference at a predefined probability of 0.0005 of the target concentration (the median post-spiking result for each individual assay) was considered as outlier. To determine whether microclots were a significant cause of critically discrepant outlier results, a separate 50 samples were centrifuged twice between two post-spiking measurements using the Vitros TnI ES assay. Results The median recovery of the enriched cTnI was highest with the Roche assay (271 ng/L) and lowest with the Vitros assay (29 ng/L). The Vitros assay had the highest percentage of results that exceeded the critical difference (49%), followed by the Siemens (38%), Roche (18%) and Beckman Coulter (7%) assays. None of the 50 additional samples produced a critically lower cTnI result after re-centrifugation. Conclusions Our findings underscored the variability of cTnI assays in measuring native cTnI. The lack of cTnI results that became significantly lower after re-centrifugation suggested that microclots are unlikely to be a major cause of the outlier results.
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Affiliation(s)
- Tze Ping Loh
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Xiong Chang Lim
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Karize Kieu
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Haressh Sajiir
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Siew Fong Neo
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Wan Ling Cheng
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
| | - Sunil Kumar Sethi
- Department of Laboratory Medicine, National University Hospital, Singapore, Singapore
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Choy KW, Teng J, Wijeratne N, Tan CY, Doery JCG. Immunoassay interference complicating management of Cushing’s disease: the onus is on the clinician and the laboratory. Ann Clin Biochem 2016; 54:183-184. [DOI: 10.1177/0004563216657362] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Kay W Choy
- Department of Pathology, Monash Medical Centre, Victoria, Australia
| | - Jessie Teng
- Department of Endocrinology, Monash Medical Centre, Victoria, Australia
| | - Nilika Wijeratne
- Department of Pathology, Monash Medical Centre, Victoria, Australia
- Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Dorevitch Pathology, Victoria, Australia
| | - Chin Y Tan
- Department of Endocrinology, Monash Medical Centre, Victoria, Australia
| | - James CG Doery
- Department of Pathology, Monash Medical Centre, Victoria, Australia
- Department of Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
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Belaidi N, Georges A, Lacroix I, Croisonnier A, Ducros V, Souberbielle JC, Corcuff JB. Hypercalcemia and elevated concentration of vitamin D: A case report too easy to be true. Clin Chim Acta 2016; 457:123-4. [PMID: 27095608 DOI: 10.1016/j.cca.2016.04.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 04/10/2016] [Accepted: 04/13/2016] [Indexed: 12/31/2022]
Abstract
BACKGROUND Endogenous (heterophile, human anti-animal …) antibodies are a known cause of interference in immunoassays. CASE REPORT A patient with hypercalcemia and low PTH levels was investigated. The serum 25OH vitamin D (25OHD) concentration was above the analytical range of the automated analyser (>150ng/mL) but serum dilutions were not linear. A myeloma-related monoclonal peak of immunoglobulin G (30g/L) was found. RESULTS Alternative 25OHD assays (RIA, automated analysers, mass spectrometry) all found concentrations <25ng/mL. NabTM columns (Thermo Scientific) eliminated the endogenous immunoglobulin from the serum thus allowing the initial analyser to provide correct results. DISCUSSION AND CONCLUSION The potentially misleading point was that the apparent very high 25OHD levels were concomitant with hypercalcemia and low PTH levels thus mimicking vitamin D intoxication. Identifying assay interferences requires clinical awareness but, when suspected, one should be aware that technical tools or alternate assays are available to correct some interferences, including monoclonal immunoglobulins.
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Affiliation(s)
- Nassima Belaidi
- Laboratoire d'hormonologie, CHU de Bordeaux, 33604 Pessac, France
| | - Agnès Georges
- Laboratoire d'hormonologie, CHU de Bordeaux, 33604 Pessac, France; Groupe de Biologie Spécialisé, Société Française de Médecine Nucléaire, 75270 Paris, France
| | - Isabelle Lacroix
- Groupe de Biologie Spécialisé, Société Française de Médecine Nucléaire, 75270 Paris, France; Laboratoire Cerba, 95310 Saint-Ouen, l'Aumône, France
| | - Anne Croisonnier
- Laboratoire, Groupe Hospitalier Mutualiste, Clinique des Eaux Claires, 38000 Grenoble, France
| | - Véronique Ducros
- Département de biochimie, toxicologie et pharmacologie, CHU de Grenoble, 38043 Grenoble, France
| | | | - Jean-Benoît Corcuff
- Laboratoire d'hormonologie, CHU de Bordeaux, 33604 Pessac, France; Groupe de Biologie Spécialisé, Société Française de Médecine Nucléaire, 75270 Paris, France; Laboratoire Nutrition et Neurobiologie intégrée, UMR 1286, Université de Bordeaux, 33076 Bordeaux, France.
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Hari Kumar KS, Garg MK, Mahalle N. Laboratory evaluation of thyroid function: Dilemmas and pitfalls. MEDICAL JOURNAL OF DR. D.Y. PATIL UNIVERSITY 2016. [DOI: 10.4103/0975-2870.186054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Minkovsky A, Lee MN, Dowlatshahi M, Angell TE, Mahrokhian LS, Petrides AK, Melanson SEF, Marqusee E, Woodmansee WW. HIGH-DOSE BIOTIN TREATMENT FOR SECONDARY PROGRESSIVE MULTIPLE SCLEROSIS MAY INTERFERE WITH THYROID ASSAYS. AACE Clin Case Rep 2016; 2:e370-e373. [PMID: 27917400 DOI: 10.4158/ep161261.cr] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To review cases and increase awareness in clinicians treating patients who may be taking biotin. METHODS We describe the presentation and workup of a woman with secondary progressive multiple sclerosis on high dose biotin with laboratory studies suggestive of thyrotoxicosis. RESULTS Plasma samples showed laboratory evidence of elevated thyroid hormone levels with elevated free thyroxine >7.8 ng/dl (reference interval (RI) 0.9-1.7 ng/dl) and decreased thyroid stimulating hormone <0.02 uIU/ml (RI 0.50-5.70 uIU/ml). Laboratory values normalized when biotin was withheld prior to repeat testing. CONCLUSIONS Our case report demonstrates that ingestion of high dose biotin in multiple sclerosis patients can cause interference with laboratory assessment of thyroid function. This interference causes laboratory values suggestive of thyrotoxicosis and can lead to unnecessary evaluation. Clinicians should be aware of the risk of laboratory interference in this patient demographic.
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Affiliation(s)
- Alissa Minkovsky
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Mark N Lee
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Mitra Dowlatshahi
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Trevor E Angell
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Lilian S Mahrokhian
- Department of Medicine, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Athena K Petrides
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Stacy E F Melanson
- Department of Pathology, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Ellen Marqusee
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
| | - Whitney W Woodmansee
- Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital/Harvard Medical School, Boston, MA
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Hattori N, Ishihara T, Yamagami K, Shimatsu A. Macro TSH in patients with subclinical hypothyroidism. Clin Endocrinol (Oxf) 2015; 83:923-30. [PMID: 25388002 DOI: 10.1111/cen.12643] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 09/30/2014] [Accepted: 10/18/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE TSH is a sensitive indicator of thyroid function. In subclinical hypothyroidism, however, serum TSH concentrations are elevated despite normal thyroid hormone levels, and macro TSH is one of the causes. This study aimed to clarify the prevalence and nature of macro TSH in patients with subclinical hypothyroidism. DESIGN We conducted a 2-year cross-sectional observational study. PATIENTS We included 681 patients with subclinical hypothyroidism and 38 patients with overt hypothyroidism (controls). MEASUREMENTS Macro TSH was screened by polyethylene glycol (PEG) method and analysed by gel filtration chromatography and bioassays. RESULTS Among 681 serum samples, 117 exhibited PEG-precipitable TSH ratios greater than 75% (mean + 1·5 SD in controls) and were subjected to gel filtration chromatography. TSH was eluted at a position greater than 100 kDa in 11 patients with subclinical hypothyroidism (1·62%); these patients were diagnosed with macro TSH. The nature of macro TSH included eight anti-TSH autoantibodies of IgG class, two non-IgG-associated and one human anti-mouse antibody (HAMA). Macro TSH showed low bioactivity. CONCLUSIONS Macro TSH was heterogeneous, but it is mostly comprised of TSH and anti-TSH autoantibodies. When PEG-precipitable TSH exceeds 90% in serum samples with TSH above 10 mU/l, clinicians should strongly suspect the presence of macro TSH and confirm it by gel chromatography. Because macro TSH exhibited low bioactivity, thyroid hormone replacement therapy may not be required in patients with subclinical hypothyroidism due to macro TSH except for those with high serum free TSH levels.
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Affiliation(s)
- Naoki Hattori
- Department of Pharmaceutical Sciences, Ritsumeikan University, Shiga, Japan
| | - Takashi Ishihara
- Department of Endocrinology, Kobe City General Hospital, Kobe, Japan
| | - Keiko Yamagami
- Internal Medicine, Endocrinology, Osaka City General Hospital, Osaka, Japan
| | - Akira Shimatsu
- Clinical Research Institute, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
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Estrada JM, Soldin D, Buckey TM, Burman KD, Soldin OP. Thyrotropin isoforms: implications for thyrotropin analysis and clinical practice. Thyroid 2014; 24:411-23. [PMID: 24073798 PMCID: PMC3949435 DOI: 10.1089/thy.2013.0119] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Serum thyrotropin (TSH) is considered the single most sensitive and specific measure of thyroid function in the general population owing to its negative logarithmic association with free triiodothyronine and free thyroxine concentrations. It is therefore often the test of choice for screening, diagnosis, and monitoring of primary hypothyroidism. Serum TSH concentrations can be analyzed quantitatively using third-generation immunoassays, whereas its bioactivity can be measured by TSH activity assays in cell culture. Theoretically, if serum TSH concentrations are directly related to TSH activity, the two tests should yield comparable results. However, on occasion, the results are discordant, with serum concentrations being higher than TSH biological activity. This review focuses on the dissociation between the clinical state and serum TSH concentrations and addresses clinically important aspects of TSH analysis.
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Affiliation(s)
- Joshua M. Estrada
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Danielle Soldin
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Timothy M. Buckey
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
| | - Kenneth D. Burman
- Endocrine Section, Medstar Washington Hospital Center, Washington, District of Columbia
| | - Offie P. Soldin
- Department of Oncology, Lombardi Comprehensive Cancer Center, Georgetown University Medical Center, Washington, District of Columbia
- Department of Medicine, Georgetown University Medical Center, Washington, District of Columbia
- Department of Obstetrics and Gynecology, Georgetown University Medical Center, Washington, District of Columbia
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Kharb S, Gundgurthi A, Dutta MK, Garg MK. Reversible adrenal insufficiency and heterophile antibodies in a case of autoimmune polyendocrinopathy syndrome. Indian J Endocrinol Metab 2013; 17:S700-S702. [PMID: 24910843 PMCID: PMC4046608 DOI: 10.4103/2230-8210.123572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
A 27-year-old male was admitted with diabetic ketoacidosis and altered sensorium with slurring of speech and ataxia. He was managed with intravenous insulin and fluids and later shifted to basal bolus insulin regimen and during further evaluation was diagnosed to be suffering from primary hypothyroidism and adrenal insufficiency. He was started on thyroxin replacement and steroids only during stress. After three months of follow up he was clinically euthyroid. His glycemic control was adequate on oral anti-hyperglycemic drugs and adrenal insufficiency recovered. However, his thyrotropin levels were persistently elevated on adequate replacement doses of thyroxin. His repeat TSH was estimated after precipitating serum with polyethylene glycol which revealed normal TSH. Here we report reversible adrenal insufficiency with hypothyroidism with falsely raised TSH because of presence of heterophile antibodies in a case of poly glandular endocrinopathy syndrome.
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Affiliation(s)
- Sandeep Kharb
- Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, India
| | - Abhay Gundgurthi
- Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, India
| | - Manoj K. Dutta
- Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, India
| | - M. K. Garg
- Department of Endocrinology, Army Hospital (Research and Referral), Delhi Cantt, India
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Abstract
Diagnoses of subclinicaal hypothyroidism (SCH) is biochemically made, when serum thyroid stimulating hormone (TSH) levels is elevated while free thyroid hormone levels are within normal reference range. SCH is diagnosed after excluding all other causes of elevated TSH levels. Symptoms of SCH may vary from being asymptomatic to having mild nonspecific symptoms. The risk of progression to overt hypothyroidism is related to number of factors including initial serum TSH concentration, presence of auto antibodies, family history and presence goiter. Various screening recommendations for thyroid function assessment are in practice. There are still controversies surrounding SCH and associated risk of various cardiovascular diseases (CVDs), pregnancy outcomes, neuropsychiatric issues, metabolic syndrome, and dyslipidemia. Consensus will require more large randomized clinical studies involving various age groups and medical condition, especially in developing countries. All these efforts will definitely improve our understanding of disease and ultimately patient outcomes.
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Affiliation(s)
- Syed Abbas Raza
- Department of Internal Medicine, Shaukat Khanum Hospital and Research Center, Lahore, Pakistan
| | - Nasir Mahmood
- Department of Internal Medicine, Junnah Hospital, Lahore, Pakistan
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Abstract
PURPOSE OF REVIEW In this article, we will consider the failure of thyroid hormone replacement therapy to normalize serum thyroid stimulating hormone concentrations. We will review circumstances and causes for failures, discuss pertinent unpublished personal cases of didactical value, and provide practical suggestions for providers encountering patients with similar presentations. RECENT FINDINGS Recent data are available on the benefit of novel formulations of levothyroxine therapy on malabsorption. SUMMARY Most frequently, reasons for ineffectiveness are noncompliance, inappropriate administration of levothyroxine, gastrointestinal disorders, and drug interactions. The diagnostic work-up should include careful history to elucidate the potential reasons for the ineffective therapy.
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Affiliation(s)
- Salvatore Benvenga
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
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van Deventer HE, Soldin SJ. The expanding role of tandem mass spectrometry in optimizing diagnosis and treatment of thyroid disease. Adv Clin Chem 2013; 61:127-52. [PMID: 24015601 DOI: 10.1016/b978-0-12-407680-8.00005-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This review discusses the state-of-the-art measurement of free and total thyroid hormones in clinical laboratories. We highlight some of the limitations of currently used immunoassays and critically discuss physical separation methods for the measurement of free thyroid hormone. Physical separation methods, such as equilibrium dialysis or ultrafiltration, followed by tandem mass spectrometry for the measurement of free thyroid hormones offer many advantages, which we feel, can deepen our understanding of thyroid hormone metabolism and improve patient diagnosis and care. Problems with direct analogue immunoassay methods for FT4/FT3 as well as immunoassay methods for total T3 at low T3 concentrations and during pregnancy are highlighted. Improved diagnosis and patient management can be achieved utilizing tandem mass spectrometry for these measurements.
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Dietrich JW, Landgrafe G, Fotiadou EH. TSH and Thyrotropic Agonists: Key Actors in Thyroid Homeostasis. J Thyroid Res 2012; 2012:351864. [PMID: 23365787 PMCID: PMC3544290 DOI: 10.1155/2012/351864] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 11/21/2012] [Indexed: 12/11/2022] Open
Abstract
This paper provides the reader with an overview of our current knowledge of hypothalamic-pituitary-thyroid feedback from a cybernetic standpoint. Over the past decades we have gained a plethora of information from biochemical, clinical, and epidemiological investigation, especially on the role of TSH and other thyrotropic agonists as critical components of this complex relationship. Integrating these data into a systems perspective delivers new insights into static and dynamic behaviour of thyroid homeostasis. Explicit usage of this information with mathematical methods promises to deliver a better understanding of thyrotropic feedback control and new options for personalised diagnosis of thyroid dysfunction and targeted therapy, also by permitting a new perspective on the conundrum of the TSH reference range.
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Affiliation(s)
- Johannes W. Dietrich
- Lab XU44, Medical Hospital I, Bergmannsheil University Hospitals, Ruhr University of Bochum (UK RUB), Bürkle-de-la-Camp-Platz 1, 44789 Bochum, NRW, Germany
| | - Gabi Landgrafe
- Lab XU44, Medical Hospital I, Bergmannsheil University Hospitals, Ruhr University of Bochum (UK RUB), Bürkle-de-la-Camp-Platz 1, 44789 Bochum, NRW, Germany
- Klinik für Allgemein- und Visceralchirurgie, Agaplesion Bethesda Krankenhaus Wuppertal gGmbH, Hainstraße 35, 42109 Wuppertal, NRW, Germany
| | - Elisavet H. Fotiadou
- Lab XU44, Medical Hospital I, Bergmannsheil University Hospitals, Ruhr University of Bochum (UK RUB), Bürkle-de-la-Camp-Platz 1, 44789 Bochum, NRW, Germany
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Lewandowski KC, Dąbrowska K, Lewiński A. Case report: When measured free T4 and free T3 may be misleading. Interference with free thyroid hormones measurements on Roche® and Siemens® platforms. Thyroid Res 2012; 5:11. [PMID: 23107155 PMCID: PMC3520776 DOI: 10.1186/1756-6614-5-11] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 10/24/2012] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED : A 59-year old female patient presented with apathy and 6 kg weight gain. Investigations revealed severe primary hypothyroidism (TSH>100 μIU/ml). L-thyroxine (L-T4) was started and titrated up to 75 μg, once daily, with clinical improvement. Other investigations revealed very high titres of anti-thyroid peroxidase (anti-TPO) and anti-thyroglobulin (anti-Tg) antibodies. After three months, there was a fall in TSH to 12.74 μIU/ml, however, with unexpectedly high free T4 (FT4) - 6.8 ng/ml and free T3 (FT3) - 6.7 pg/ml concentrations [reference range (rr): 0.8-1.9 ng/ml and 1.5-4.1 pg/ml (Siemens®), respectively]. At this stage L-T4 was stopped, and this was followed by a rapid increase in TSH (to 77.76 μIU/ml) and some decrease in FT4 and FT3, however FT4 concentration remained elevated (2.1 ng/ml). Following this, L-T4 was restarted. On admission to our Department, she was clinically euthyroid on L-T4, 88 μg, once daily. Investigations on Roche® platform confirmed mildly elevated TSH - 5.14 (rr: 0.27-4.2 μIU/ml) with high FT4 [4.59 (rr: 0.93-1.7 ng/ml)] and FT3 [4.98 (rr: 2.6-4.4 pg/ml)] concentrations. Other tests revealed hypoechogenic ultrasound pattern typical for Hashimoto thyroiditis. There was no discrepancy in calculated TSH value following TSH dilution (101% recovery). Concentrations of FT4 and FT3 were assessed on the day of discontinuation of L-T4 and after four days by the means of Abbott® Architect I 1000SR platform. These revealed FT4 and FT3 concentrations within the reference range [e.g., FT4 - 1.08 ng/ml (rr: 0.7-1.48)] vs 4.59 ng/ml (rr: 0.93-1.7, Roche®), FT3 - 3.70 pg/ml (rr: 1.71-3.71) vs 4.98 (rr: 2.6-4.4, Roche®)], confirming assay interference. Concentrations of ferritin and SHBG were normal. CONCLUSIONS Clinicians must be aware of possible assay interference, including the measurements of FT4 and FT3 in the differential diagnosis of abnormal results of thyroid function tests that do not fit the patient clinical presentation.
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Affiliation(s)
- Krzysztof C Lewandowski
- Department of Endocrinology and Metabolic Diseases, Polish Mother's Memorial Hospital - Research Institute, Rzgowska St, No, 281/289, 93-338 Lodz, Poland.
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Ramos-Leví AM, Montáñez MC, Ortega I, Cobo MJ, Calle-Pascual AL. [A case of biochemical assay discrepancy: Interference with measurement of thyroid-stimulating hormone due to rheumatoid factor]. ACTA ACUST UNITED AC 2012; 60:342-5. [PMID: 23108053 DOI: 10.1016/j.endonu.2012.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2012] [Revised: 07/22/2012] [Accepted: 07/23/2012] [Indexed: 10/27/2022]
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