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Rose SR, Wassner AJ, Wintergerst KA, Yayah-Jones NH, Hopkin RJ, Chuang J, Smith JR, Abell K, LaFranchi SH, Wintergerst KA, Yayah Jones NH, Hopkin RJ, Chuang J, Smith JR, Abell K, LaFranchi SH, Wintergerst KA, Bethin KE, Brodsky JL, Jelley DH, Marshall BA, Mastrandrea LD, Lynch JL, Laskosz L, Burke LW, Geleske TA, Holm IA, Introne WJ, Jones K, Lyons MJ, Monteil DC, Pritchard AB, Smith Trapane PL, Vergano SA, Weaver K, Alexander AA, Cunniff C, Null ME, Parisi MA, Ralson SJ, Scott J, Spire P. Congenital Hypothyroidism: Screening and Management. Pediatrics 2023; 151:190308. [PMID: 36827521 DOI: 10.1542/peds.2022-060420] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2022] [Indexed: 12/23/2022] Open
Abstract
ABSTRACT Untreated congenital hypothyroidism (CH) leads to intellectual disabilities. Prompt diagnosis by newborn screening (NBS) leading to early and adequate treatment results in grossly normal neurocognitive outcomes in adulthood. However, NBS for hypothyroidism is not yet established in all countries globally. Seventy percent of neonates worldwide do not undergo NBS.The initial treatment of CH is levothyroxine, 10 to 15 mcg/kg daily. The goals of treatment are to maintain consistent euthyroidism with normal thyroid-stimulating hormone and free thyroxine in the upper half of the age-specific reference range during the first 3 years of life. Controversy remains regarding detection of thyroid dysfunction and optimal management of special populations, including preterm or low-birth weight infants and infants with transient or mild CH, trisomy 21, or central hypothyroidism.Newborn screening alone is not sufficient to prevent adverse outcomes from CH in a pediatric population. In addition to NBS, the management of CH requires timely confirmation of the diagnosis, accurate interpretation of thyroid function testing, effective treatment, and consistent follow-up. Physicians need to consider hypothyroidism in the face of clinical symptoms, even if NBS thyroid test results are normal. When clinical symptoms and signs of hypothyroidism are present (such as large posterior fontanelle, large tongue, umbilical hernia, prolonged jaundice, constipation, lethargy, and/or hypothermia), measurement of serum thyroid-stimulating hormone and free thyroxine is indicated, regardless of NBS results.
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Affiliation(s)
| | | | | | - Nana-Hawa Yayah-Jones
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Robert J Hopkin
- Division of Endocrinology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | - Katherine Abell
- Departments of Pediatrics, Division of Endocrinology & Diabetes, Wendy Novak Diabetes Center, University of Louisville, School of Medicine, Norton Children's Hospital, Louisville, Kentucky.,Division of Genetics and Genomic Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Stephen H LaFranchi
- Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Sciences University, Portland, Oregon
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Russo M, Gullo D, Tumino D, Leonardi D, Malandrino P, Frasca F. Different FT3/TSH correlation in acquired and congenital hypothyroid patients reveals a different hypothalamic set-point. Clin Endocrinol (Oxf) 2023; 98:117-122. [PMID: 35419870 PMCID: PMC10083972 DOI: 10.1111/cen.14738] [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: 11/05/2021] [Revised: 03/08/2022] [Accepted: 03/27/2022] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To understand differences in thyroid hormone replacement therapy with levo-thyroxine (l-T4) between acquired and congenital hypothyroid (CH) patients. DESIGN We compared biochemical thyroid parameters between euthyroid subjects (EU) and both CH adult patients and thyroidectomized patients (TP) under replacement therapy. PATIENTS AND MEASUREMENTS A retrospective analysis was performed on a series of 98 consecutive adult CH patients (27 males and 71 females) with a median age of 24 years (range 18-58). Serum TSH, FT3, FT4, l-T4 dose and body weight were assessed. For comparison purposes, large series of 461 TP for thyroid cancer and 1852 EU followed at our Thyroid Clinic were used as control groups. RESULTS The daily weight-based l-T4 dose was significantly higher in CH than TP group (1.9 vs. 1.7 mcg/kg, p = .03). FT3/FT4 ratio was significantly higher in the EU group, intermediate in CH and lower in TP groups (0.32, 0.28 and 0.24, respectively). Linear regression analysis displayed an inverse correlation between FT4 and TSH in all the groups. An inverse correlation between FT3 and TSH was observed in the TP group, but not in the EU and CH group suggesting that CH patients, under replacement therapy, display biochemical thyroid parameters similar to EU subjects. CONCLUSIONS Adult CH patients require a higher daily l-T4 dose than adult TP. However, the different correlation of TSH and FT3 values between CH and TP patients suggests an adaptive and different hypothalamic-pituitary-thyroid axis regulation that may depend on the early timing of the onset of hypothyroidism in CH.
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Affiliation(s)
- Marco Russo
- Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - Damiano Gullo
- Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - Dario Tumino
- Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - Daniela Leonardi
- Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - Pasqualino Malandrino
- Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
| | - Francesco Frasca
- Endocrinology, Department of Clinical and Experimental Medicine, Garibaldi-Nesima Medical Center, University of Catania, Catania, Italy
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Abstract
This section deals with the specificities of managing Graves' disease during pregnancy. Graves' disease incurs risks of fetal, neonatal and maternal complications that are rare but may be severe: fetal hyper- or hypothyroidism, usually first showing as fetal goiter, neonatal dysthyroidism, premature birth and pre-eclampsia. Treatment during pregnancy is based on antithyroid drugs alone, without association to levothyroxine. An history of Graves' disease, whether treated radically or not, with persistent maternal anti-TSH-receptor antibodies must be well identified. Fetal monitoring should be initiated in a multidisciplinary framework that should be continued throughout pregnancy. Neonatal monitoring is also crucial if the mother still shows anti-TSH-receptor antibodies at end of pregnancy or underwent antithyroid treatment. The risk of recurrence of hyperthyroidism in the weeks following delivery requires maternal monitoring. The long-term neuropsychological progression of children of mothers with Graves' disease is poorly known.
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Srichomkwun P, Anselmo J, Liao XH, Hönes GS, Moeller LC, Alonso-Sampedro M, Weiss RE, Dumitrescu AM, Refetoff S. Fetal Exposure to High Maternal Thyroid Hormone Levels Causes Central Resistance to Thyroid Hormone in Adult Humans and Mice. J Clin Endocrinol Metab 2017; 102:3234-3240. [PMID: 28586435 PMCID: PMC5587072 DOI: 10.1210/jc.2017-00019] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 05/31/2017] [Indexed: 12/20/2022]
Abstract
Context Fetuses exposed to the high thyroid hormone (TH) levels of mothers with resistance to thyroid hormone beta (RTH-β), due to mutations in the THRB gene, have low birth weight and suppressed TSH. Objective Determine if such exposure to high TH levels in embryonic life has a long-term effect into adulthood. Design Observations in humans with a parallel design on animals to obtain a preliminary information regarding mechanism. Setting University research centers. Patients or other participants Humans and mice with no RTH-β exposed during intrauterine life to high TH levels from mothers who were euthyroid due to RTH-β. Controls were humans and mice of the same genotype but born to fathers with RTH-β and mothers without RTH-β and thus, with normal serum TH levels. Interventions TSH responses to stimulation with thyrotropin-releasing hormone (TRH) during adult life in humans and male mice before and after treatment with triiodothyronine (T3). We also measured gene expression in anterior pituitaries, hypothalami, and cerebral cortices of mice. Results Adult humans and mice without RTH-β, exposed to high maternal TH in utero, showed persistent central resistance to TH, as evidenced by reduced responses of serum TSH to TRH when treated with T3. In mice, anterior pituitary TSH-β and deiodinase 3 (D3) mRNAs, but not hypothalamic and cerebral cortex D3, were increased. Conclusions Adult humans and mice without RTH-β exposed in utero to high maternal TH levels have persistent central resistance to TH. This is likely mediated by the increased expression of D3 in the anterior pituitary, enhancing local T3 degradation.
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Affiliation(s)
| | - João Anselmo
- Department of Endocrinology and Nutrition, Hospital Divino Espírito Santo, 9500-370 Ponta Delgada, Azores-Portugal
| | - Xiao-Hui Liao
- Department of Medicine, The University of Chicago, Chicago, Illinois 60637
| | - G. Sebastian Hönes
- Department of Endocrinology and Metabolism, University Hospital Essen, University of Duisburg, Essen 45122, Germany
| | - Lars C. Moeller
- Department of Endocrinology and Metabolism, University Hospital Essen, University of Duisburg, Essen 45122, Germany
| | | | - Roy E. Weiss
- Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida 33136
| | | | - Samuel Refetoff
- Department of Medicine, The University of Chicago, Chicago, Illinois 60637
- Department of Pediatrics and Committee on Genetics, The University of Chicago, Chicago, Illinois 60637
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Ribeiro L, Silva J, Ocarino N, Melo E, Serakides R. Excesso de tiroxina materna associado ao hipertireoidismo pós-natal reduz o crescimento ósseo e o perfil proliferativo e angiogênico das cartilagens de crescimento de ratos. ARQ BRAS MED VET ZOO 2017. [DOI: 10.1590/1678-4162-9175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
RESUMO Foram estudados os efeitos do excesso da tiroxina materna associado ao hipertireoidismo pós-natal sobre o crescimento ósseo e o perfil proliferativo e angiogênico das cartilagens. Dezesseis ratas Wistar adultas foram distribuídas nos grupos tratados com L-tiroxina e controle. A prole do grupo tratado recebeu L-tiroxina do desmame até 40 dias de idade. Ao desmame, foi realizada dosagem plasmática de T4 livre nas mães. Na prole, foram realizados: dosagem plasmática de T3 total e T4 livre, morfometria das tireoides, mensuração do comprimento e largura do fêmur. Nas cartilagens, foi avaliada a expressão imuno-histoquímica e gênica de CDC-47, VEGF, Flk-1, Ang1, Ang2 e Tie2. As médias entre grupos foram comparadas pelo teste T de Student. As concentrações de T4 livre das mães tratadas e de T3 total e T4 livre da prole foram significativamente mais elevadas. A largura do fêmur foi menor nos animais tratados. Houve também redução da imunoexpressão de CDC-47 e de VEGF e dos transcritos gênicos para VEGF e Ang1 nas cartilagens. Conclui-se que o excesso de tiroxina materna associado ao hipertireoidismo pós-natal reduz a largura da diáfise femoral, a proliferação celular e a expressão de VEGF e de Ang1 nas cartilagens de crescimento de ratos.
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Affiliation(s)
| | - J.F. Silva
- Universidade Federal de Minas Gerais, Brazil
| | | | - E.G. Melo
- Universidade Federal de Minas Gerais, Brazil
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van der Kaay DCM, Wasserman JD, Palmert MR. Management of Neonates Born to Mothers With Graves' Disease. Pediatrics 2016; 137:peds.2015-1878. [PMID: 26980880 DOI: 10.1542/peds.2015-1878] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2015] [Indexed: 11/24/2022] Open
Abstract
Neonates born to mothers with Graves' disease are at risk for significant morbidity and mortality and need to be appropriately identified and managed. Because no consensus guidelines regarding the treatment of these newborns exist, we sought to generate a literature-based management algorithm. The suggestions include the following: (1) Base initial risk assessment on maternal thyroid stimulating hormone (TSH) receptor antibodies. If levels are negative, no specific neonatal follow-up is necessary; if unavailable or positive, regard the newborn as "at risk" for the development of hyperthyroidism. (2) Determine levels of TSH-receptor antibodies in cord blood, or as soon as possible thereafter, so that newborns with negative antibodies can be discharged from follow-up. (3) Measurement of cord TSH and fT4 levels is not indicated. (4) Perform fT4 and TSH levels at day 3 to 5 of life, repeat at day 10 to 14 of life and follow clinically until 2 to 3 months of life. (5) Use the same testing schedule in neonates born to mothers with treated or untreated Graves' disease. (6) When warranted, use methimazole (MMI) as the treatment of choice; β-blockers can be added for sympathetic hyperactivity. In refractory cases, potassium iodide may be used in conjunction with MMI. The need for treatment of asymptomatic infants with biochemical hyperthyroidism is uncertain. (7) Assess the MMI-treated newborn on a weekly basis until stable, then every 1 to 2 weeks, with a decrease of MMI (and other medications) as tolerated. MMI treatment duration is most commonly 1 to 2 months. (8) Be cognizant that central or primary hypothyroidism can occur in these newborns.
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Affiliation(s)
| | - Jonathan D Wasserman
- Division of Endocrinology, The Hospital for Sick Children; and Departments of Paediatrics and
| | - Mark R Palmert
- Division of Endocrinology, The Hospital for Sick Children; and Departments of Paediatrics and Physiology, The University of Toronto, Toronto, Ontario, Canada
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Khadora MM, Al Dubayee M. Neonatal Graves' disease with unusual metabolic association from presentation to resolution. BMJ Case Rep 2014; 2014:bcr2014206725. [PMID: 25422339 PMCID: PMC4244387 DOI: 10.1136/bcr-2014-206725] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2014] [Indexed: 11/03/2022] Open
Abstract
Neonatal Graves' disease is a rare disorder seen in 1 in 25,000 births and in 1% of the offspring of mothers with either established or cured Graves' disease. This is due to transplacental passage of thyroid-stimulating immunoglobulins (TSIs). A higher TSI titre in maternal serum makes hyperthyroidism more likely in the fetus or newborn; however, not all fetuses born by women with positive TSIs develop overt hyperthyroidism. In spite of its rarity, its serious nature (if not treated) and its association with multisystem abnormalities justifies careful clinical screening and management. We report a preterm 30 weeks neonate with neonatal thyrotoxicosis secondary to untreated maternal Graves' disease who, in addition to the typical hyperthyroidism symptoms, had unusual metabolic associations of neonatal cholestasis and hyperammonaemia. The patient was treated accordingly with a good response. This report supports previous reports on the association between neonatal hyperthyroidism and cholestatic liver disease. However, it is the second case report to describe the unusual association of hyperammonaemia and neonatal Graves' disease.
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Affiliation(s)
| | - Mohammad Al Dubayee
- Department of Paediatrics, College of Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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8
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Bagattini B, Cosmo CD, Montanelli L, Piaggi P, Ciampi M, Agretti P, Marco GD, Vitti P, Tonacchera M. The different requirement of L-T4 therapy in congenital athyreosis compared with adult-acquired hypothyroidism suggests a persisting thyroid hormone resistance at the hypothalamic-pituitary level. Eur J Endocrinol 2014; 171:615-21. [PMID: 25305309 DOI: 10.1530/eje-14-0621] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Levothyroxine (l-T4) is commonly employed to correct hormone deficiency in children with congenital hypothyroidism (CH) and in adult patients with iatrogenic hypothyroidism. OBJECTIVE To compare the daily weight-based dosage of the replacement therapy with l-T4 in athyreotic adult patients affected by CH and adult patients with thyroid nodular or cancer diseases treated by total thyroidectomy. DESIGN AND METHODS A total of 36 adult patients (27 females and nine males) aged 18-29 years were studied; 13 patients (age: 21.5±2.1, group CH) had athyreotic CH treated with l-T4 since the first days of life. The remaining 23 patients (age: 24±2.7, group AH) had hypothyroidism after total thyroidectomy (14 patients previously affected by nodular disease and nine by thyroid carcinoma with clinical and biochemical remission). Patient weight, serum free thyroid hormones, TSH, thyroglobulin (Tg), anti-Tg, and anti-thyroperoxidase antibodies were measured. Required l-T4 dosage was evaluated. At the time of the observations, all patients presented free thyroid hormones within the normal range and TSH between 0.8 and 2 μIU/ml. RESULTS Patients had undetectable Tg and anti-thyroid antibodies. The daily weight-based dosage of the replacement therapy with l-T4 to reach euthyroidism in patients of group CH was significantly higher than that in those of group AH (2.16±0.36 vs 1.73±0.24 μg/kg, P<0.005). Patients of group CH treated with l-T4 had significantly higher serum TSH levels than patients of group AH (P=0.05) as well as higher FT4 concentrations. CONCLUSIONS To correct hypothyroidism, patients of group CH required a daily l-T4 dose/kg higher than group AH patients, despite higher levels of TSH. The different requirement of replacement therapy between adult patients with congenital and those with surgical athyroidism could be explained by a lack of thyroid hormones since fetal life in CH, which could determine a different set point of the hypothalamus-pituitary-thyroid axis.
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Affiliation(s)
- Brunella Bagattini
- Endocrinology SectionDepartment of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, Cisanello, Pisa 56124, Italy
| | - Caterina Di Cosmo
- Endocrinology SectionDepartment of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, Cisanello, Pisa 56124, Italy
| | - Lucia Montanelli
- Endocrinology SectionDepartment of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, Cisanello, Pisa 56124, Italy
| | - Paolo Piaggi
- Endocrinology SectionDepartment of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, Cisanello, Pisa 56124, Italy
| | - Mariella Ciampi
- Endocrinology SectionDepartment of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, Cisanello, Pisa 56124, Italy
| | - Patrizia Agretti
- Endocrinology SectionDepartment of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, Cisanello, Pisa 56124, Italy
| | - Giuseppina De Marco
- Endocrinology SectionDepartment of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, Cisanello, Pisa 56124, Italy
| | - Paolo Vitti
- Endocrinology SectionDepartment of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, Cisanello, Pisa 56124, Italy
| | - Massimo Tonacchera
- Endocrinology SectionDepartment of Clinical and Experimental Medicine, University Hospital of Pisa, University of Pisa, Via Paradisa 2, Cisanello, Pisa 56124, Italy
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9
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Uenaka M, Tanimura K, Tairaku S, Morioka I, Ebina Y, Yamada H. Risk factors for neonatal thyroid dysfunction in pregnancies complicated by Graves’ disease. Eur J Obstet Gynecol Reprod Biol 2014; 177:89-93. [DOI: 10.1016/j.ejogrb.2014.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2013] [Revised: 02/24/2014] [Accepted: 03/05/2014] [Indexed: 01/02/2023]
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10
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Tonyushkina KN, Shen MC, Ortiz-Toro T, Karlstrom RO. Embryonic exposure to excess thyroid hormone causes thyrotrope cell death. J Clin Invest 2014; 124:321-7. [PMID: 24316972 PMCID: PMC3871235 DOI: 10.1172/jci70038] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 09/27/2013] [Indexed: 11/17/2022] Open
Abstract
Central congenital hypothyroidism (CCH) is more prevalent in children born to women with hyperthyroidism during pregnancy, suggesting a role for thyroid hormone (TH) in the development of central thyroid regulation. Using the zebrafish embryo as a model for thyroid axis development, we have characterized the ontogeny of negative feedback regulation of thyrotrope function and examined the effect of excess TH on thyrotrope development. We found that thyroid-stimulating hormone β subunit (tshb) and type 2 deiodinase (dio2) are coexpressed in zebrafish thyrotropes by 48 hours after fertilization and that TH-driven negative feedback regulation of tshb transcription appears in the thyroid axis by 96 hours after fertilization. Negative feedback regulation correlated with increased systemic TH levels from the developing thyroid follicles. We used a transgenic zebrafish that expresses GFP under the control of the tshb promoter to follow thyrotrope fates in vivo. Time-lapse imaging revealed that early exposure to elevated TH leads to thyrotrope cell death. Thyrotrope numbers slowly recovered following the removal of excess TH. These data demonstrate that transient TH exposure profoundly impacts the thyrotrope population during a critical period of pituitary development and may have long-term implications for the functional reserve of thyroid-stimulating hormone (TSH) production and the TSH set point later in life.
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Affiliation(s)
- Ksenia N. Tonyushkina
- Department of Pediatrics, Baystate Medical Center, Springfield, Massachusetts, USA.
Department of Biology, University of Massachusetts, Amherst, Massachusetts, USA
| | - Meng-Chieh Shen
- Department of Pediatrics, Baystate Medical Center, Springfield, Massachusetts, USA.
Department of Biology, University of Massachusetts, Amherst, Massachusetts, USA
| | - Theresa Ortiz-Toro
- Department of Pediatrics, Baystate Medical Center, Springfield, Massachusetts, USA.
Department of Biology, University of Massachusetts, Amherst, Massachusetts, USA
| | - Rolf O. Karlstrom
- Department of Pediatrics, Baystate Medical Center, Springfield, Massachusetts, USA.
Department of Biology, University of Massachusetts, Amherst, Massachusetts, USA
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11
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Persani L. Clinical review: Central hypothyroidism: pathogenic, diagnostic, and therapeutic challenges. J Clin Endocrinol Metab 2012; 97:3068-78. [PMID: 22851492 DOI: 10.1210/jc.2012-1616] [Citation(s) in RCA: 178] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
CONTEXT Central hypothyroidism (CH) is a particular hypothyroid condition due to an insufficient stimulation by TSH of an otherwise normal thyroid gland. This condition raises several challenges for clinicians; therefore, a review of the most relevant findings on CH epidemiology, pathogenesis, and clinical management has been performed. METHODOLOGY The relevant papers were selected by a PubMed search using appropriate key words. MAIN FINDINGS CH can be the consequence of various disorders affecting either the pituitary gland or the hypothalamus, but most frequently affecting both of them. CH is about 1000-fold rarer than primary hypothyroidism. Except for the neonatal CH due to biallelic TSHβ mutations, the thyroid hormone defect is rarely as profound as can be observed in some primary forms. In contrast with primary hypothyroidism, CH is most frequently characterized by low/normal TSH levels, and adequate thyroid hormone replacement is associated with the suppression of residual TSH secretion. Thus, CH often represents a clinical challenge because physicians cannot rely on the systematic use of the "reflex TSH strategy." The clinical management of CH is further complicated by the frequent combination with other pituitary deficiencies and their substitution.
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Affiliation(s)
- Luca Persani
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy.
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12
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Effects of experimentally induced maternal hypothyroidism and hyperthyroidism on the development of rat offspring: II—The developmental pattern of neurons in relation to oxidative stress and antioxidant defense system. Int J Dev Neurosci 2012; 30:517-37. [DOI: 10.1016/j.ijdevneu.2012.04.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Revised: 04/30/2012] [Accepted: 04/30/2012] [Indexed: 11/17/2022] Open
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Abstract
This article summarizes the ontogenesis and genetics of the thyroid with regards to its possible congenital dysfunction and briefly refers to the roles of the mother-placenta-fetal unit, iodine effect, and organic and functional changes of the negative feedback mechanism, as well as maturity and illness, in some forms of congenital hypo- and hyperthyroidism. This article also describes the published literature and the authors' data on the clinical aspects of congenital hypothyroidism, on the alternating hypo- and hyperthyroidism in the neonatal period, and on neonatal hyperthyroidism.
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Affiliation(s)
- Ferenc Péter
- Department of Pediatrics, Division of Endocrinology, St Johns Hospital and United Hospitals of North-Buda, Buda Children's Hospital, 1023 Bolyai-u. 5-9 Budapest, Hungary.
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14
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Delayed recognition of central hypothyroidism in a neonate born to thyrotoxic mother. Indian Pediatr 2010; 47:795-6. [DOI: 10.1007/s13312-010-0104-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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15
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Ahmed O, Abd El‐Tawab S, Ahmed R. Effects of experimentally induced maternal hypothyroidism and hyperthyroidism on the development of rat offspring: I. The development of the thyroid hormones–neurotransmitters and adenosinergic system interactions. Int J Dev Neurosci 2010; 28:437-54. [DOI: 10.1016/j.ijdevneu.2010.06.007] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2010] [Revised: 06/16/2010] [Accepted: 06/18/2010] [Indexed: 01/05/2023] Open
Affiliation(s)
- O.M. Ahmed
- Zoology DepartmentDivision of Physiology, Faculty of ScienceBeni Suef UniversityBeni SuefEgypt
| | - S.M. Abd El‐Tawab
- Zoology DepartmentDivision of Physiology, Faculty of ScienceBeni Suef UniversityBeni SuefEgypt
| | - R.G. Ahmed
- Zoology DepartmentDivision of Comparative Anatomy and Embryology, Faculty of ScienceBeni Suef UniversityEgypt
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El‐bakry A, El‐Gareib A, Ahmed R. Comparative study of the effects of experimentally induced hypothyroidism and hyperthyroidism in some brain regions in albino rats. Int J Dev Neurosci 2010; 28:371-89. [DOI: 10.1016/j.ijdevneu.2010.04.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2010] [Revised: 04/07/2010] [Accepted: 04/09/2010] [Indexed: 11/17/2022] Open
Affiliation(s)
- A.M. El‐bakry
- Zoology Department, Faculty of ScienceBeni Suef UniversityEgypt
| | - A.W. El‐Gareib
- Zoology Department, Faculty of ScienceCairo UniversityEgypt
| | - R.G. Ahmed
- Zoology Department, Faculty of ScienceBeni Suef UniversityEgypt
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Ogundele MO, Quinn MW, Salzmann M. Investigation of infants born to mothers with thyroid disorders: an ongoing search for consensus. J Eval Clin Pract 2010; 16:206-8. [PMID: 20367836 DOI: 10.1111/j.1365-2753.2009.01140.x] [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] [Indexed: 11/27/2022]
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Abstract
This article summarizes the ontogenesis and genetics of the thyroid with regards to its possible congenital dysfunction and briefly refers to the roles of the mother-placenta-fetal unit, iodine effect, and organic and functional changes of the negative feedback mechanism, as well as maturity and illness, in some forms of congenital hypo- and hyperthyroidism. This article also describes the published literature and the authors' data on the clinical aspects of congenital hypothyroidism, on the alternating hypo- and hyperthyroidism in the neonatal period, and on neonatal hyperthyroidism.
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Affiliation(s)
- Ferenc Péter
- Department of Pediatrics, Division of Endocrinology, St. Johns Hospital and United Hospitals of North-Buda, Buda Children's Hospital, 1023 Bolyai-u. 5-9, Budapest, Hungary.
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Yamada M, Mori M. Mechanisms related to the pathophysiology and management of central hypothyroidism. ACTA ACUST UNITED AC 2008; 4:683-94. [PMID: 18941435 DOI: 10.1038/ncpendmet0995] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Accepted: 09/01/2008] [Indexed: 01/25/2023]
Abstract
Central hypothyroidism (CH) is defined as hypothyroidism due to insufficient stimulation of the thyroid gland by TSH, for which secretion or activity can be impaired at the hypothalamic or pituitary levels. Patients with CH frequently present with multiple other pituitary hormone deficiencies. In addition to classic CH induced by hypothalamic-pituitary tumors or Sheehan syndrome, novel causes include traumatic brain injury or subarachnoid hemorrhage, bexarotene (a retinoid X receptor agonist) therapy, neonates being born to mothers with insufficiently controlled Graves disease, and lymphocytic hypophysitis. Growth hormone therapy, which may be used in children and adults, is now also recognized as a possible cause of unmasking CH in susceptible individuals. In addition, mutations in genes, such as TRHR, POU1F1, PROP1, HESX1, SOX3, LHX3, LHX4 and TSHB, have been associated with CH. The difficulty in making a clear diagnosis of CH is that the serum TSH levels can vary; values are normal in most cases, but in some might be low or slightly elevated. Levels of endogenous T(4) in serum might also be subnormal. Appropriate doses of levothyroxine for T(4) replacement therapy have not been confirmed, but might need to be higher than presently used empirically in patients with CH and should be adjusted according to age and other hormone deficiencies, to achieve free T(4) concentrations in the upper end of the normal range.
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Affiliation(s)
- Masanobu Yamada
- Department of Medicine and Molecular Science, Gunma University Graduate School of Medicine, Gunma, Japan.
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Hernandez A, Martinez ME, Liao XH, Van Sande J, Refetoff S, Galton VA, St Germain DL. Type 3 deiodinase deficiency results in functional abnormalities at multiple levels of the thyroid axis. Endocrinology 2007; 148:5680-7. [PMID: 17823249 DOI: 10.1210/en.2007-0652] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The type 3 deiodinase (D3) is a selenoenzyme that inactivates thyroid hormones and is highly expressed during development and in the adult central nervous system. We have recently observed that mice lacking D3 activity (D3KO mice) develop perinatal thyrotoxicosis followed in adulthood by a pattern of hormonal levels that is suggestive of central hypothyroidism. In this report we describe the results of additional studies designed to investigate the regulation of the thyroid axis in this unique animal model. Our results demonstrate that the thyroid and pituitary glands of D3KO mice do not respond appropriately to TSH and TRH stimulation, respectively. Furthermore, after induction of severe hypothyroidism by antithyroid treatment, the rise in serum TSH in D3KO mice is only 15% of that observed in wild-type mice. In addition, D3KO animals rendered severely hypothyroid fail to show the expected increase in prepro-TRH mRNA in the paraventricular nucleus of the hypothalamus. Finally, treatment with T(3) results in a serum T(3) level in D3KO mice that is much higher than that in wild-type mice. This is accompanied by significant weight loss and lethality in mutant animals. In conclusion, the absence of D3 activity results in impaired clearance of T(3) and significant defects in the mechanisms regulating the thyroid axis at all levels: hypothalamus, pituitary, and thyroid.
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Kempers MJE, van Trotsenburg ASP, van Rijn RR, Smets AMJB, Smit BJ, de Vijlder JJM, Vulsma T. Loss of integrity of thyroid morphology and function in children born to mothers with inadequately treated Graves' disease. J Clin Endocrinol Metab 2007; 92:2984-91. [PMID: 17504907 DOI: 10.1210/jc.2006-2042] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
CONTEXT Central congenital hypothyroidism (CH-C) in neonates born to mothers with inadequately treated Graves' disease usually needs T(4) supplementation. The thyroid and its regulatory system have not yet been extensively studied after T(4) withdrawal, until we observed disintegrated thyroid glands in some patients. OBJECTIVE The aim was to study the occurrence and pathogenesis of disintegrated thyroid glands in CH-C patients. DESIGN, SETTING, PATIENTS, PARTICIPANTS: Thyroid function was measured and thyroid ultrasound imaging was performed in 13 children with CH-C due to inadequately treated maternal Graves' disease after T(4)-supplementation withdrawal (group Aa). In addition, thyroid ultrasound imaging was performed in six children with CH-C born to inadequately treated mothers with Graves' disease, in whom T(4) supplementation was not withdrawn yet (group Ab) or never initiated (group Ac), in six euthyroid children born to adequately treated mothers with Graves' disease (group B), and in 10 T(4)-supplemented children with CH-C as part of multiple pituitary hormone deficiency (group C). MAIN OUTCOME MEASURES Thyroid function and aspect (volume, echogenicity, echotexture) were measured. RESULTS In group A, five children had developed thyroidal hypothyroidism characterized by persistently elevated TSH concentrations and exaggerated TSH responses after TRH stimulation. In the majority of patients in groups A and C, thyroid echogenicity and volume were decreased, and echotexture was inhomogeneous. Thyroid ultrasound imaging was normal in group B children. CONCLUSIONS Inadequately treated maternal Graves' disease not only may lead to CH-C but also carries an, until now, unrecognized risk of thyroid disintegration in the offspring as well. We speculate that insufficient TSH secretion due to excessive maternal-fetal thyroid hormone transfer inhibits physiological growth and development of the child's thyroid.
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Affiliation(s)
- Marlies J E Kempers
- Academic Medical Center, University of Amsterdam, G8-205, Emma Children's Hospital Academic Medical Center, Department of Pediatric Endocrinology, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands.
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Hernandez A, Martinez ME, Fiering S, Galton VA, St Germain D. Type 3 deiodinase is critical for the maturation and function of the thyroid axis. J Clin Invest 2006; 116:476-84. [PMID: 16410833 PMCID: PMC1326144 DOI: 10.1172/jci26240] [Citation(s) in RCA: 231] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2005] [Accepted: 11/01/2005] [Indexed: 12/22/2022] Open
Abstract
Developmental exposure to appropriate levels of thyroid hormones (THs) in a timely manner is critical to normal development in vertebrates. Among the factors potentially affecting perinatal exposure of tissues to THs is type 3 deiodinase (D3). This enzyme degrades THs and is highly expressed in the pregnant uterus, placenta, and fetal and neonatal tissues. To determine the physiological role of D3, we have generated a mouse D3 knockout model (D3KO) by a targeted inactivating mutation of the Dio3 gene in mouse ES cells. Early in life, D3KO mice exhibit delayed 3,5,3'-triiodothyronine (T3) clearance, a markedly elevated serum T3 level, and overexpression of T3-inducible genes in the brain. From postnatal day 15 to adulthood, D3KO mice demonstrate central hypothyroidism, with low serum levels of 3,5,3',5'-tetraiodothyronine (T4) and T3, and modest or no increase in thyroid-stimulating hormone (TSH) concentration. Peripheral tissues are also hypothyroid. Hypothalamic T3 content is decreased while thyrotropin-releasing hormone (TRH) expression is elevated. Our results demonstrate that the lack of D3 function results in neonatal thyrotoxicosis followed later by central hypothyroidism that persists throughout life. These mice provide a new model of central hypothyroidism and reveal a critical role for D3 in the maturation and function of the thyroid axis.
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Affiliation(s)
- Arturo Hernandez
- Department of Medicine, Dartmouth Medical School, Lebanon, New Hampshire 03756, USA.
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