Hemostasis in Overt and Subclinical Hyperthyroidism

Endothelial dysfunction in children with newly diagnosed Graves' disease

The most frequent cause of hyperthyroidism in children is Graves' disease (GD). Vascular endothelium is a specific target of thyroid hormone. The purpose of this study is to assess flow-mediated dilatation (FMD)% and serum von Willebrand factor (vWF) levels in children with newly diagnosed GD to reflect the extent of endothelial dysfunction in those children. In this study, 40 children with newly discovered GD and 40 children who were healthy served as the control group. Both patients and controls had anthropometric assessment, as well as measurements of fasting lipids, glucose, insulin, high-sensitivity C-reactive protein (hs-CRP), TSH, and free thyroxine (FT4 and FT3), thyrotropin receptor antibodies TRAbs and vWF. Noninvasive ultrasound was utilized to quantify the carotid arteries' intima-media thickness and the brachial artery's FMD. Patients reported significantly reduced FMD response and greater vWF and hs-CRP levels compared to controls (P = 0.001 for each). In multivariate analysis, we reported that vWF was significantly correlated with TSH (OR 2.5, 95% CI 1.32-5.32, P = 0.001), FT3 (OR 3.4, 95% CI 1.45-3.55, P = 0.001), TRAb (OR 2.1, 95% CI 1.16-2.23, P = 0.01), and FMD% (OR 4.2, 95% CI 1.18-8.23, P = 0.001).  Conclusions: Children with newly diagnosed GD have endothelial dysfunction, which is shown by impaired FMD and increased vWF. These findings support the idea that GD may need to be treated as soon as possible. What is Known: • Graves' disease is the most common cause of hyperthyroidism in children. • vWF is a reliable marker for detection of vascular endothelial dysfunction. What is New: • Children with newly diagnosed Graves' disease may have endothelial dysfunction as reflected by impairment of FMD and raised vWF level. • Measurement of vWF level in children with newly diagnosed Graves' disease can be used for early detection of endothelial dysfunction.

Unprovoked Isolated Pulmonary Embolism and Graves’ Disease in a Patient With Dyspnea: A Case Report

Graves’ disease is a commonly diagnosed disease with a plethora of manifestations that can lead to its diagnosis. One of the rarer presentations of Graves’ disease is hypercoagulability with the development of spontaneous venous thrombosis. In patients presenting with unprovoked pulmonary embolism, we suggest evaluating the patient’s thyroid function tests as a potential underlying cause. To bring this issue to attention, we are presenting a rare case of isolated spontaneous pulmonary embolism development secondarily to underlying Graves’ disease.

COVID-19 as a trigger of cerebral venous sinus thrombosis in a patient with autoimmune hyperthyroidism: a case report

Background

Cerebral venous sinus thrombosis (CVST) composes an uncommon subtype of stroke caused by thrombotic occlusion of the cerebral venous system and tends to occur in hypercoagulable states. Albeit exceedingly rare, autoimmune hyperthyroidism and COVID-19 has been implicated as rare risk factors for CVST. As both conditions are capable of inducing degrees of inflammation and hypercoagulability, we postulate that COVID-19 could trigger CVST by superimposing endotheliitis and inflammation on the hypercoagulable and hypofibrinolytic state of hyperthyroidism.

Case presentation

We report the case of an adult male with headache, fever, nausea, vomiting, and previously known autoimmune hyperthyroidism. Diagnostics revealed elevated inflammatory and hypercoagulability markers, free T4, low TSHs, and positive SARS-CoV-2 PCR. Neuroimaging demonstrated an acute intracerebral and subdural hemorrhage attributable to cerebral sinus thromboses. A diagnosis of CVST with associated COVID-19 and autoimmune hyperthyroidism was established, and anticoagulation therapy was initiated. Follow-up examination revealed complete symptomatic resolution and regression of thrombosis.

Conclusions

Clinicians should be aware that even mild COVID-19 could precipitate CVST, especially in presence of other risk factors. Further studies should be conducted to evaluate the effects of mild COVID-19 on existing prothrombic states, including autoimmune hyperthyroidism. Furthermore, a high index of suspicion towards a secondary cause must be maintained for headaches in COVID-19, as it may indicate a serious etiology, including CVST.

Venous Thromboembolism and Thymic Hyperplasia in the Setting of Silent Graves' Disease

Venous thromboembolism is a common, yet serious life-threatening condition that has many well-recognized associations which include but are not limited to pregnancy, polycythemia, trauma, immobility, and malignancy. The pathophysiology behind the pro-coagulant effects of hyperthyroidism has been well established; however, there are no current guidelines regarding deep venous thrombosis (DVT) surveillance in patients with hyperthyroidism. In this report, we discuss the case of a 36-year-old female with no significant past medical history (PMH) with the exception of a 15 pack-year smoking history, who presented to us with an extensive, rapidly-progressing lower extremity DVT. Despite aggressive treatment measures, she developed a pulmonary embolus in the hospital. During her stay, she was diagnosed with Graves’ disease by hormone profile and thyroid-stimulating hormone receptor (TSH-R) antibody positivity. Additionally, an incidental thymic mass, likely thymic hyperplasia, was found on imaging and presumed to be associated with Graves’ disease. This case study reports a difficult-to-treat venous thromboembolism in the setting of Graves’ disease along with a review of current literature and pathophysiology on the subject.

Potential relationships between COVID-19 and the thyroid gland: an update

In this review, I aim to provide a complete overview of recent advances in knowledge regarding severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2)-induced thyroid dysfunction. I discuss the findings regarding the role of SARS-CoV-2 in the development of thyroid dysfunction, including subacute thyroiditis, Graves’ disease, non-thyroidal illness, thyrotoxicosis and Hashimoto’s thyroiditis during and subsequent to coronavirus disease 2019 (COVID-19). The thyroid gland and the entire hypothalamic–pituitary–thyroid (HPT) axis may represent key targets of SARS-CoV-2. Thyroid dysfunction during and subsequent to COVID-19 has been documented in clinical studies and is usually reversible. Most of the thyroid disorders, including Graves’ disease, euthyroid sick syndrome, Hashimoto’s thyroiditis and subacute thyroiditis, have been documented as sequelae to COVID-19, and the SARS-CoV-2 virus has been implicated in the aetiology of each. COVID-19 has been suggested to trigger the activation of pre-existing thyroid disease or autoimmunity. Furthermore, patients with uncontrolled thyrotoxicosis are at risk of SARS-CoV-2 infection-related consequences. Because of the neutropenia caused by antithyroid medications, which may obscure the signs of COVID-19, this group of patients should receive special attention. It is suggested that thyroid dysfunction during COVID-19 is caused by direct infection of the thyroid or “cytokine storm”-mediated autoimmune effects on the thyroid.

The Effects of Previous Thyroid Disease on the Susceptibility to, Morbidity of, and Mortality Due to COVID-19: A Nationwide Cohort Study in South Korea

This study aimed to investigate the associations of the susceptibility to, morbidity of, and mortality due to coronavirus disease 2019 (COVID-19) with thyroid diseases. Korea National Health Insurance Database Coronavirus disease 2019 (NHID-COVID-19) medical claim code data from 2015 to 2020 were analyzed. A total of 8070 COVID-19 patients and 32,280 matched control participants were evaluated for histories of hypothyroidism, hyperthyroidism, Graves’ disease, thyroiditis, and autoimmune thyroiditis. The relationships of susceptibility to, morbidity of, and mortality due to COVID-19 with hypothyroidism, hyperthyroidism, Graves’ disease, thyroiditis, and autoimmune thyroiditis were analyzed using a conditional logistic regression. Hypothyroidism, hyperthyroidism, Graves’ disease, thyroiditis, and autoimmune thyroiditis were not associated with susceptibility to, morbidity of, or mortality due to COVID-19. Graves’ disease was related to higher odds of mortality due to COVID-19 in the adjusted model but the confidence interval (CI) was wide, probably due to the small number of deaths among patients with Graves’ disease (aOR = 11.43, 95% CI = 1.29–101.22, p = 0.029). Previous histories of hypothyroidism, hyperthyroidism, Graves’ disease, thyroiditis, and autoimmune thyroiditis were not related to susceptibility to COVID-19. In addition, prior histories of thyroid diseases were not related to increased risks of COVID-19-related morbidity and mortality.

COVID-19 and Thyroid Diseases: A Bidirectional Impact

CONTEXT

COVID-19, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), which has become the most lethal and rapidly moving pandemic since the Spanish influenza of 1918-1920, is associated with thyroid diseases.

METHODS

References were identified through searches of PubMed and MEDLINE for articles published from Jan 1, 2019 to February 19, 2021 by use of the MeSH terms "hypothyroidism", "hyperthyroidism", "thyroiditis", "thyroid cancer", "thyroid disease", in combination with the terms "coronavirus" and "COVID-19". Articles resulting from these searches and references cited in those articles were reviewed.

RESULTS

Though preexisting autoimmune thyroid disease appears unlikely to render patients more vulnerable to COVID-19, some reports have documented relapse of Graves' disease (GD) or newly diagnosed GD about 1 month following SARS-CoV-2 infection. Investigations are ongoing to investigate molecular pathways permitting the virus to trigger GD or cause subacute thyroiditis (SAT). While COVID-19 is associated with non-thyroidal illness, it is not clear whether it also increases the risk of developing autoimmune hypothyroidism. The possibility that thyroid dysfunction may also increase susceptibility for COVID-19 infection deserves further investigation. Recent data illustrate the importance of thyroid hormone in protecting the lungs from injury, including that associated with COVID-19.

CONCLUSION

The interaction between the thyroid gland and COVID-19 is complex and bidirectional. COVID-19 infection is associated with triggering of GD and SAT, and possibly hypothyroidism. Until more is understood regarding the impact of coronavirus on the thyroid gland, it seems advisable to monitor patients with COVID-19 for new thyroid disease or progression of preexisting thyroid disease.

Portal and Mesenteric Vein Thrombosis Associated with Hyperthyroidism

Patient: Male, 59-year-old

Final Diagnosis: Portal and mesenteric vein thrombosis

Symptoms: Epigastric pain

Medication: —

Clinical Procedure: —

Specialty: Gastroenterology and Hepatology

Challenges in the Management of Atrial Fibrillation With Subclinical Hyperthyroidism

Subclinical thyroid disorders have a high prevalence among older individuals and women. Subclinical hypothyroidism is diagnosed by elevated serum levels of thyroid-stimulating hormone (TSH) with thyroxine levels within the reference range, and subclinical hyperthyroidism is diagnosed by low TSH in conjunction with thyroxine and triiodothyronine levels within reference ranges. Atrial fibrillation is the most commonly diagnosed cardiac arrhythmia and has been associated with an increased risk of mortality, heart failure, stroke, and depression. Mechanistic data from animal and human physiology studies as well as observational data in humans support an association of subclinical hyperthyroidism with atrial fibrillation. Guidelines recommend the measurement of TSH in the evaluation of new-onset atrial fibrillation. All patients with overt hyperthyroidism should be treated, and treatment of subclinical hyperthyroidism should be considered in patients older than 65 years with TSH < 0.4 mlU/L, or in younger patients with TSH < 0.1 mlU/L. Guidelines also recommend screening for AF in patients with known hyperthyroidism. Wearable devices that measure the heart electrical activity continuously may be a novel strategy to detect atrial fibrillation in patients at risk. In this review, we explore the interplay between thyroid hormones and atrial fibrillation, management controversies in subclinical hyperthyroidism, and potential strategies to improve the management of atrial fibrillation in patients with subclinical hyperthyroidism.

The Differential Effects of Propylthiouracil and Methimazole as Graves' Disease Treatment on Vascular Atherosclerosis Markers: A Randomized Clinical Trial

BACKGROUND

Hyperthyroidism is related to vascular atherosclerosis. Propylthiouracil (PTU) and methimazole, other than their antithyroid effects, may have different mechanisms in preventing atherogenesis in Graves' disease.

OBJECTIVE

This study aimed to investigate the effect of antithyroid drugs on markers of vascular atherosclerosis in Graves' hyperthyroidism.

METHODS

This study was a single-blind, randomized clinical trial conducted on 36 patients with Graves' disease in Cipto Mangunkusumo General Hospital, Jakarta, Indonesia, from June 2019 until July 2020. Graves' disease was diagnosed from clinical manifestation of hyperthyroidism with diffuse goiter and then confirmed by thyroid stimulation hormone (TSH), free T4 (fT4), and TSH-receptor antibody (TRAb) measurements. Participants were randomly assigned to either a PTU or a methimazole treatment group and followed up for 3 months. Markers of vascular atherosclerosis were represented by adhesion molecules [intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), and E-selectin], carotid artery stiffness [pulse wave velocity (PWV)], and thickness [carotid intima media thickness (cIMT)].

RESULTS

By the end of the study, 24 participants reached euthyroid condition (13 from the PTU group and 11 from the methimazole group). After 3 months of follow-up, in the PTU group, we noticed an improvement of ICAM-1 [pretreatment: 204.1 (61.3) vs. posttreatment: 141.6 (58.4) ng/ml; p = 0.001], VCAM-1 [837 (707-977) vs. 510 (402-630) ng/ml; p < 0.001] and E-selectin [32.1 (24.1-42.7) vs. 28.2 (21.6-36.8) ng/ml; p = 0.045] in the PTU group. In the methimazole group, only VCAM-1 improvement [725 (565-904) vs. 472 (367-590); p = 0.001] was observed. Meanwhile, we found no significant changes in PWV or cIMT in either group.

CONCLUSION

Antithyroid treatment in Graves' disease leads to improvement in adhesion molecules, with a lesser effect on methimazole, whereas there were no significant changes in PWV or cIMT. PTU may have a better mechanism compared with methimazole in terms of improving adhesion molecules.

Thyroid Storm, Rhabdomyolysis, and Pulmonary Embolism: An Unusual Triad Case Report

Introduction: Thyroid storm is a medical emergency associated with significant mortality. Hyperthyroid states have been associated with hypercoagulability as well as rhabdomyolysis. However, the pathophysiology of this association remains under investigation. Case Report: A 62-year-old male patient presented to the emergency department with weakness and was found to have thyroid storm with concurrent submassive pulmonary embolisms and rhabdomyolysis. To our knowledge, this is the first reported presentation of this triad. Conclusion: This case highlights the potentially difficult diagnosis and management of thyroid storm, as well as associated life-threatening complications, including venous thromboemboli and rhabdomyolysis.

Subclinical Hyperthyroidism Could Predict Poor Outcomes in Patients With Acute Ischemic Stroke Treated With Reperfusion Therapy

Background: Evidence for the effect of subclinical thyroid dysfunction on the prognosis of patients suffering from acute ischemic stroke and receiving reperfusion therapy remains controversial. We aimed to investigate the association between subclinical thyroid dysfunction and the outcomes of patients with acute ischemic stroke who were treated with reperfusion therapy.

Methods: One hundred fifty-six consecutively recruited patients with acute ischemic stroke receiving reperfusion therapy (intravenous thrombolysis, intraarterial thrombectomy and combined intravenous thrombolysis and intraarterial thrombectomy) were included in this prospective observational study. We divided patients with subclinical thyroid dysfunction into the following 2 groups and defined a euthyroid group: subclinical hyperthyroidism (a thyroid-stimulating hormone level <0.35 μU/mL), subclinical hypothyroidism (a thyroid-stimulating hormone level >4.94 μU/mL), and a euthyroid state (0.35 μU/mL ≤ thyroid-stimulating hormone level ≤ 4.94 μU/mL). Patients with overt thyroid dysfunction were excluded. The primary outcome was functional disability at 3 months (modified Rankin Scale, mRS), and the secondary outcome was successful reperfusion. A multivariate analysis was performed to evaluate the associations between subclinical thyroid dysfunction and the primary and secondary outcomes.

Results: The subclinical hyperthyroidism group appeared to have poor functional outcomes, but the differences were not significant. However, compared with patients in the euthyroid state, patients with subclinical hyperthyroidism had an increased risk of poor functional outcomes at 3 months after a stroke (adjusted odds ratio [OR] 2.50, 95% confidence interval [CI] 1.01–6.14 for a mRS score of 3 to 6) and a decreased rate of successful reperfusion after reperfusion therapy (OR 0.13, 95% CI 0.04–0.43).

Conclusion: Subclinical hyperthyroidism may be independently associated with a poor prognosis at 3 months and unsuccessful reperfusion in patients with acute ischemic stroke receiving reperfusion therapy.