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Refetoff S, Persani L, Visser WE. Increased cardiovascular morbidity and mortality in patients with resistance to thyroid hormone. Lancet Diabetes Endocrinol 2023; 11:628-629. [PMID: 37475120 DOI: 10.1016/s2213-8587(23)00192-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 06/24/2023] [Indexed: 07/22/2023]
Affiliation(s)
- Samuel Refetoff
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Luca Persani
- Department of Endocrine and Metabolic Diseases, IRCCS Istituto Auxologico Italiano, Milan, Italy; BIOMETRA, University of Milan, Milan, Italy
| | - W Edward Visser
- Thyroid Centre, Department of Internal Medicine, Erasmus Medical Centre, Rotterdam 3015 GE, Netherlands.
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Okosieme OE, Usman D, Taylor PN, Dayan CM, Lyons G, Moran C, Chatterjee K, Rees DA. Cardiovascular morbidity and mortality in patients in Wales, UK with resistance to thyroid hormone β (RTHβ): a linked-record cohort study. Lancet Diabetes Endocrinol 2023; 11:657-666. [PMID: 37475119 DOI: 10.1016/s2213-8587(23)00155-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/20/2023] [Accepted: 05/21/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Individuals with resistance to thyroid hormone owing to mutations in the thyroid hormone receptor β gene (RTHβ) exhibit impaired tissue sensitivity to thyroid hormones, but retain sensitivity in cardiac tissue. Long-term health and survival outcomes in this rare disorder have not been evaluated. We investigated all-cause mortality and cardiovascular event risk in a cohort of patients with RTHβ, followed-up in UK endocrine clinics. METHODS In a retrospective cohort design, we linked genetically confirmed patients with RTHβ and age-matched and sex-matched population controls to outcomes in datasets within the Welsh Secure Anonymised Information Linkage (SAIL) Databank. Kaplan-Meier and Cox regression models analysed associations of RTHβ with all-cause mortality and cardiovascular events. FINDINGS We identified 61 patients with a genetic diagnosis of RTHβ between Jan 1, 1997, and Dec 31, 2019, and matched them with 2750 controls. Compared with controls, patients exhibited increased risks for all-cause mortality (hazard ratio [HR] 2·84, 95% CI 1·59-5·08), atrial fibrillation (10·56, 4·72-23·63), heart failure (HR 6·35, 95% CI 2·26-17·86), and major adverse cardiovascular events (MACE), comprising cardiovascular death, acute myocardial infarction, heart failure, or strokes (HR 3·49, 95% CI 2·04-5·99). The median age of first occurrence of any adverse event was 11 years earlier in patients (56 years, 95% CI 44-65) compared with controls (67 years, 65-70). Cubic spline analyses showed positive associations between FT4 concentrations at diagnosis and mortality or MACE, with FT4 concentration of 30 pmol/L or greater conferring increased risk. Compared with no intervention, treatment with antithyroid drugs, surgery or radioiodine gland ablation, or thyroxine did not control thyroid hormone excess. INTERPRETATION We have documented reduced survival and increased cardiovascular morbidity in a cohort of patients with RTHβ for the first time. These outcomes might be driven by lifelong cardiac exposure to thyroid hormone excess; and effective therapies, targeting hormone resistant pathways, could potentially curtail this risk. FUNDING Royal College of Physicians, Wellcome Trust Investigator Award, and NIHR Cambridge Biomedical Research Centre.
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Affiliation(s)
- Onyebuchi E Okosieme
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK; Diabetes and Endocrinology Department, Prince Charles Hospital, Cwm Taf Morgannwg Health Board, Merthyr Tydfil, UK.
| | - Danyal Usman
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Peter N Taylor
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Colin M Dayan
- Thyroid Research Group, Systems Immunity Research Institute, Cardiff University School of Medicine, Cardiff, UK
| | - Greta Lyons
- Wellcome Trust-MRC Institute of Medical Science, University of Cambridge, Cambridge, UK
| | - Carla Moran
- Endocrine Section, Beacon Hospital, Dublin, Ireland; Endocrine Department, St Vincent's University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
| | - Krishna Chatterjee
- Wellcome Trust-MRC Institute of Medical Science, University of Cambridge, Cambridge, UK
| | - Dafydd Aled Rees
- Neuroscience and Mental Health Innovation Institute, Cardiff University, Cardiff, UK
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Watson L, Cole TJ, Lyons G, Georgiou C, Worsley J, Carr K, Murgatroyd P, Moran C, Chatterjee K, Venables M. Centile reference chart for resting metabolic rate through the life course. Arch Dis Child 2023; 108:545-549. [PMID: 36863849 PMCID: PMC7614669 DOI: 10.1136/archdischild-2022-325249] [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: 12/16/2022] [Accepted: 02/15/2023] [Indexed: 03/04/2023]
Abstract
OBJECTIVE Reference centile charts are widely used for the assessment of growth and have progressed from describing height and weight to include body composition variables such as fat and lean mass. Here, we present centile charts for an index of resting energy expenditure (REE) or metabolic rate, adjusted for lean mass versus age, including both children and adults across the life course. DESIGN, PARTICIPANTS AND INTERVENTION Measurements of REE by indirect calorimetry and body composition using dual-energy X-ray absorptiometry were made in 411 healthy children and adults (age range 6-64 years) and serially in a patient with resistance to thyroid hormone α (RTHα) between age 15 and 21 years during thyroxine therapy. SETTING NIHR Cambridge Clinical Research Facility, UK. RESULTS The centile chart indicates substantial variability, with the REE index ranging between 0.41 and 0.59 units at age 6 years, and 0.28 and 0.40 units at age 25 years (2nd and 98th centile, respectively). The 50th centile of the index ranged from 0.49 units (age 6 years) to 0.34 units (age 25 years). Over 6 years, the REE index of the patient with RTHα varied from 0.35 units (25th centile) to 0.28 units (<2nd centile), depending on changes in lean mass and adherence to treatment. CONCLUSION We have developed a reference centile chart for an index of resting metabolic rate in childhood and adults, and shown its clinical utility in assessing response to therapy of an endocrine disorder during a patient's transition from childhood to adult.
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Affiliation(s)
- Laura Watson
- NIHR Cambridge Clinical Research Facility, Cambridge, UK
| | - Tim J Cole
- Population Policy and Practice Programme, UCL, London, UK
| | - Greta Lyons
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, Cambridge, UK
| | | | | | - Katherine Carr
- NIHR Cambridge Clinical Research Facility, Cambridge, UK
| | | | - Carla Moran
- Beacon Hospital, University College Dublin School of Medicine, Dublin, Ireland
| | - Krishna Chatterjee
- Metabolic Research Laboratories, Wellcome-MRC Institute of Metabolic Science, Cambridge, UK
| | - Michelle Venables
- Stable Isotopes Laboratory, Nutritional Biomarker Laboratory, MRC Epidemiology Unit and Wellcome-MRC Institute of Metabolic Science, Metabolic Research Laboratories, University of Cambridge, Cambridge, UK
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Vidouris M, Worth C, Patel L, Date A, Jasser A, Hird B, Tetlow L, Banerjee I. Notes for the general paediatrician: managing thyrotoxicosis in children and young people. BMJ Paediatr Open 2022; 6:e001582. [PMID: 36645751 PMCID: PMC9685199 DOI: 10.1136/bmjpo-2022-001582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 08/15/2022] [Indexed: 11/23/2022] Open
Abstract
Thyrotoxicosis due to hyperthyroidism is a serious disorder in childhood often presenting to general paediatricians with a range of clinical manifestations. The commonest cause is Graves' disease, an autoimmune disorder resulting from thyrotropin receptor stimulation by autoantibodies. Early recognition and accurate interpretation of investigations are essential to achieve and maintain a euthyroid state. This will not only optimise growth, development and transition from childhood to young adult life but also avoid the potentially severe and life-threatening complications of acute thyrotoxicosis. In this review, we have focussed on the general paediatrician's perspective of the presentation and management of thyrotoxicosis and the need to network with specialist paediatric endocrine centres to optimise patient care. We have discussed nuances of therapy, side effects and long-term outcomes, while recognising that limited remission rates in this age group often necessitate more definitive management. While carbimazole is usually used as first-line medical therapy, we have provided useful information to guide paediatricians in the discussion of individualised safe and effective treatment plans for both short-term and long-term management.
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Affiliation(s)
- Marianna Vidouris
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital. Manchester University NHS Foundation Trust, Manchester, UK
| | - Christopher Worth
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital. Manchester University NHS Foundation Trust, Manchester, UK
- Department of Computer Science, University of Manchester, Manchester, UK
| | - Leena Patel
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital. Manchester University NHS Foundation Trust, Manchester, UK
- North West Paediatric Endocrine Network (NOWPEN), Manchester, UK
| | - Anjali Date
- North West Paediatric Endocrine Network (NOWPEN), Manchester, UK
- Department of Paediatrics, Tameside Hospital NHS Foundation Trust, Ashton-under-Lyne, UK
| | - Anas Jasser
- North West Paediatric Endocrine Network (NOWPEN), Manchester, UK
- Department of Paediatrics, East Lancashire Hospitals NHS Trust, Blackburn, UK
| | - Beverly Hird
- Department of Clinical Biochemistry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Lesley Tetlow
- Department of Clinical Biochemistry, Manchester University NHS Foundation Trust, Manchester, UK
| | - Indraneel Banerjee
- Department of Paediatric Endocrinology, Royal Manchester Children's Hospital. Manchester University NHS Foundation Trust, Manchester, UK
- University of Manchester, Manchester, UK
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Moran C, Schoenmakers N, Visser WE, Schoenmakers E, Agostini M, Chatterjee K. Genetic disorders of thyroid development, hormone biosynthesis and signalling. Clin Endocrinol (Oxf) 2022; 97:502-514. [PMID: 35999191 PMCID: PMC9544560 DOI: 10.1111/cen.14817] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 05/24/2022] [Accepted: 07/04/2022] [Indexed: 11/28/2022]
Abstract
Development and differentiation of the thyroid gland is directed by expression of specific transcription factors in the thyroid follicular cell which mediates hormone biosynthesis. Membrane transporters are rate-limiting for cellular entry of thyroid hormones (TH) (T4 and T3) into some tissues, with selenocysteine-containing, deiodinase enzymes (DIO1 and DIO2) converting T4 to the biologically active hormone T3. TH regulate expression of target genes via hormone-inducible nuclear receptors (TRα and TRβ) to exert their physiological effects. Primary congenital hypothyroidism (CH) due to thyroid dysgenesis may be mediated by defects in thyroid transcription factors or impaired thyroid stimulating hormone receptor function. Dyshormonogenic CH is usually due to mutations in genes mediating thyroidal iodide transport, organification or iodotyrosine synthesis and recycling. Disorders of TH signalling encompass conditions due to defects in membrane TH transporters, impaired hormone metabolism due to deficiency of deiodinases and syndromes of Resistance to thyroid hormone due to pathogenic variants in either TRα or TRβ. Here, we review the genetic basis, pathogenesis and clinical features of congenital, dysgenetic or dyshormonogenic hypothyroidism and disorders of TH transport, metabolism and action.
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Affiliation(s)
- Carla Moran
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
- Present address:
Beacon Hospital and School of MedicineUniversity CollegeDublinIreland
| | - Nadia Schoenmakers
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
| | - W. Edward Visser
- Department of Internal MedicineErasmus Medical Center, Academic Center for Thyroid DiseasesRotterdamThe Netherlands
| | - Erik Schoenmakers
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
| | - Maura Agostini
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
| | - Krishna Chatterjee
- Wellcome Trust‐MRC Institute of Metabolic ScienceUniversity of CambridgeCambridgeUK
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Chaves C, Bruinstroop E, Refetoff S, Yen PM, Anselmo J. Increased Hepatic Fat Content in Patients with Resistance to Thyroid Hormone Beta. Thyroid 2021; 31:1127-1134. [PMID: 33353459 PMCID: PMC8290309 DOI: 10.1089/thy.2020.0651] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Thyroid hormone (TH) has important functions in controlling hepatic lipid metabolism. Individuals with resistance to thyroid hormone beta (RTHβ) who harbor mutations in the THRB gene experience loss-of-function of thyroid hormone receptor beta (TRβ), which is the predominant TR isoform expressed in the liver. We hypothesized that individuals with RTHβ may have increased hepatic steatosis. Methods: Controlled attenuation parameter (CAP) was assessed in individuals harboring the R243Q mutation of the THRB gene (n = 21) and in their wild-type (WT) first-degree relatives (n = 22) using the ultrasound-based transient elastography (TE) device (FibroScan). All participants belonged to the same family, lived on the same small island, and were therefore exposed to similar environmental conditions. CAP measurements and blood samples were obtained after an overnight fast. The observers were blinded to the status of the patients. Results: The hepatic fat content was increased in RTHβ individuals compared with their WT relatives (CAP values of 263 ± 21 and 218.7 ± 43 dB/m, respectively, p = 0.007). The CAP values correlated with age and body mass index (BMI) (age: r = 0.55, p = 0.011; BMI: r = 0.51, p = 0.022) in the WT first-degree relatives but not in RTHβ individuals, suggesting that the defect in TRβ signaling was predominant over the effects of age and obesity. Circulating free fatty acid levels were significantly higher in RTHβ individuals (0.29 ± 0.033 vs. 0.17 ± 0.025 mmol/L, p = 0.02). There was no evidence of insulin resistance evaluated by the homeostatic model assessment of insulin resistance in both groups studied. Conclusions: Our findings provide evidence that impairments in intrahepatic TRβ signaling due to mutations of the THRB gene can lead to hepatic steatosis, which emphasizes the influence of TH in the liver metabolism of lipids and provides a rationale for the development TRβ-selective thyromimetics. Consequently, new molecules with a very high TRβ affinity and hepatic selectivity have been developed for the treatment of lipid-associated hepatic disorders, particularly nonalcoholic fatty liver disease.
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Affiliation(s)
- Carolina Chaves
- Endocrinologia e Nutrição, Hospital Divino Espirito Santo de Ponta Delgada, EPE, Açores, Portugal
| | - Eveline Bruinstroop
- Department of Endocrinology and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
- Cardiovascular and Metabolic Disorders Program, Duke-NUS Graduate Medical School, Singapore, Singapore
| | - Samuel Refetoff
- Department of Medicine, The University of Chicago, Chicago, Illinois, USA
| | - Paul M. Yen
- Cardiovascular and Metabolic Disorders Program, Duke-NUS Graduate Medical School, Singapore, Singapore
- Duke Molecular Physiology Institute; Durham, North Carolina, USA
- Department of Medicine; Duke University School of Medicine, Durham, North Carolina, USA
| | - João Anselmo
- Endocrinologia e Nutrição, Hospital Divino Espirito Santo de Ponta Delgada, EPE, Açores, Portugal
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Tagami T. An overview of thyroid function tests in subjects with resistance to thyroid hormone and related disorders. Endocr J 2021; 68:509-517. [PMID: 33827995 DOI: 10.1507/endocrj.ej21-0059] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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
Confirmation of sustained syndrome of inappropriate secretion of thyrotropin (SITSH) is a milestone in diagnosis of β type of resistance to thyroid hormone (RTHβ). The differential diagnoses of RTHβ include TSH-producing pituitary adenoma (TSHoma) and familial dysalbuminemic hyperthyroxinemia (FDH), which also present SITSH. Recently, patients with RTHα caused by a mutation in thyroid hormone receptor α were reported and they did not present SITSH but a decline in the serum T4/T3 ratio. This review was aimed to overview thyroid function tests in RTH and related disorders. First, the characteristics of the thyroid function in RTHβ, TSHoma, and FDH obtained from a Japanese database are summarized. Second, the degrees of SITSH in patients with truncations and frameshifts were compared with those in patients with single amino acid deletions and single amino acid substitutions obtained from the literature. Third, the degrees of SITSH in homozygous patients were compared with those in heterozygous patients with cognate mutations. Finally, the FT3/FT4 ratios in RTHα are summarized. In principle, the TSH values in FDH were within the normal range and apparent FT4 values in FDH were much higher than in RTHβ and TSHoma. The FT3/FT4 values in RTHβ were significantly lower than in TSHoma. The degrees of SITSH in patients with truncations and frameshifts were more severe than those in patients with single amino acid deletions and single amino acid substitutions, and those in homozygous patients were more severe than those in heterozygous patients with cognate mutations. The FT3/FT4 ratios in RTHα were higher than 1.0.
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Affiliation(s)
- Tetsuya Tagami
- Department of Endocrinology and Metabolism, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
- Clinical Research Institute for Endocrine and Metabolic Diseases, National Hospital Organization Kyoto Medical Center, Kyoto 612-8555, Japan
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Pappa T, Refetoff S. Resistance to Thyroid Hormone Beta: A Focused Review. Front Endocrinol (Lausanne) 2021; 12:656551. [PMID: 33868182 PMCID: PMC8044682 DOI: 10.3389/fendo.2021.656551] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 03/15/2021] [Indexed: 02/06/2023] Open
Abstract
Resistance to thyroid hormone (RTH) is a clinical syndrome defined by impaired sensitivity to thyroid hormone (TH) and its more common form is caused by mutations in the thyroid hormone receptor beta (THRB) gene, termed RTHβ. The characteristic biochemical profile is that of elevated serum TH levels in absence of thyrotropin suppression. Although most individuals are considered clinically euthyroid, there is variability in phenotypic manifestation among individuals harboring different THRB mutations and among tissue types in the same individual due in part to differential expression of the mutant TRβ protein. As a result, management is tailored to the specific symptoms of TH excess or deprivation encountered in the affected individual as currently there is no available therapy to fully correct the TRβ defect. This focused review aims to provide a concise update on RTHβ, discuss less well recognized associations with other thyroid disorders, such as thyroid dysgenesis and autoimmune thyroid disease, and summarize existing evidence and controversies regarding the phenotypic variability of the syndrome. Review of management addresses goiter, attention deficit disorder and "foggy brain". Lastly, this work covers emerging areas of interest, such as the relevance of variants of unknown significance and novel data on the epigenetic effect resulting from intrauterine exposure to high TH levels and its transgenerational inheritance.
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Affiliation(s)
- Theodora Pappa
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Boston, MA, United States
| | - Samuel Refetoff
- Departments of Medicine, Pediatrics and Committee on Genetics, The University of Chicago, Chicago, IL, United States
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Al Mohareb O, AlMalki MH, Mueller OT, Brema I. Resistance to thyroid hormone-beta co-existing with partially empty sella in a Jordanian male. Endocrinol Diabetes Metab Case Rep 2018; 2018:EDM180104. [PMID: 30530874 PMCID: PMC6280128 DOI: 10.1530/edm-18-0104] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 10/25/2018] [Indexed: 12/02/2022] Open
Abstract
Resistance to thyroid hormone-beta (RTHbeta) is a rare inherited syndrome characterized by variable reduced tissue responsiveness to the intracellular action of triiodothyronine (T3), the active form of the thyroid hormone. The presentation of RTHbeta is quite variable and mutations in the thyroid hormone receptor beta (THR-B) gene have been detected in up to 90% of patients. The proband was a 34-year-old Jordanian male who presented with intermittent palpitations. His thyroid function tests (TFTs) showed a discordant profile with high free T4 (FT4) at 45.7 pmol/L (normal: 12–22), high free T3 (FT3) at 11.8 pmol/L (normal: 3.1–6.8) and inappropriately normal TSH at 3.19 mIU/L (normal: 0.27–4.2). Work up has confirmed normal alpha subunit of TSH of 0.1 ng/mL (normal <0.5) and pituitary MRI showed no evidence of a pituitary adenoma; however, there was an interesting coincidental finding of partially empty sella. RTHbeta was suspected and genetic testing confirmed a known mutation in the THR-B gene, where a heterozygous A to G base change substitutes valine for methionine at codon 310. Screening the immediate family revealed that the eldest son (5 years old) also has discordant thyroid function profile consistent with RTHbeta and genetic testing confirmed the same M310V mutation that his father harbored. Moreover, the 5-year-old son had hyperactivity, impulsivity and aggressive behavior consistent with attention deficit hyperactivity disorder (ADHD). This case demonstrates an unusual co-existence of RTHbeta and partially empty sella in the same patient which, to our knowledge, has not been reported before.
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Affiliation(s)
- Ohoud Al Mohareb
- ObesityEndocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - Mussa H AlMalki
- ObesityEndocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
| | - O Thomas Mueller
- Department of Pathology and Laboratory MedicineMolecular and Biochemical Section, All Children Hospital, St Petersburg, Florida, USA
| | - Imad Brema
- ObesityEndocrine and Metabolism Centre, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia
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Zimering MB. Thyroid Hormone Resistance in Identical Twin Sisters with Atrial Fibrillation: Case Report and Review of the Literature. JOURNAL OF ENDOCRINOLOGY AND DIABETES 2018; 5:10.15226/2374-6890/5/4/01111. [PMID: 30148208 PMCID: PMC6107079 DOI: 10.15226/2374-6890/5/4/01111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
AIM To report identical twin sisters harboring the A317T mutation in the thyroid hormone beta receptor gene (TR β) who developed atrial fibrillation and refractory congestive heart failure in the sixth decade of life. To critically assess whether the A317T mutation may be responsible for increased cardiotoxicity compared to other thyroid hormone beta receptor gene mutations. METHODS A 59-year-old woman referred for evaluation of abnormal thyroid function tests had been experiencing frequent spells of tachycardia associated with dyspnea, and dizziness necessitating multiple hospitalizations. Elevation in free thyroxine (T4), total triiodothyronine (T3) and inappropriately normal thyroid stimulating hormone (TSH) was consistent with a clinical diagnosis of thyroid hormone resistance. Magnetic resonance imaging of the brain was negative for a TSH-secreting pituitary adenoma. A blood sample was sent for thyroid hormone receptor gene mutational analysis, but it would require eight weeks to complete processing. RESULTS A modified L-T3 suppression test was used to assess thyroid-pituitary axis feedback. After three weeks' of cytomel (L-T3) (25 micrograms daily) TSH decreased by 50%, and free T4 level decreased by 22% compared to baseline levels. Genetic testing revealed a heterozygous A317T mutation in the thyroid hormone beta receptor gene. Serial two-dimensional echocardiography demonstrated evolution to left atrial enlargement over a three-year period. Prior published literature suggests a less than 10% prevalence of atrial fibrillation in adults with thyroid hormone resistance harboring various TR-β gene mutations. Yet all five of five (100%) adults having the A317T mutation were reported to experience atrial fibrillation by age 50. CONCLUSIONS A new kindred with resistance to thyroid hormone harboring the A317T disease-causative mutation is described in which identical twin sisters had a mid-life onset of atrial fibrillation and refractory congestive heart failure.
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Affiliation(s)
- Mark B. Zimering
- Center for Health, Education, Medicine and Dentistry, 1771 Madison Ave, Lakewood, NJ
- Endocrinology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ
- Veterans Affairs New Jersey Healthcare System, 385 Tremont Ave, East Orange, New Jersey
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