Treatment of Hypothyroidism and Stress Using Neuro-Emotional Technique (NET): A Case Study

Hypothyroidism is generally considered an autoimmune condition, and typical medical management involves taking levothyroxine (synthetic thyroid hormone) for life. This case report details the results of a mind-body intervention (MBI) called the Neuro-Emotional Technique (NET) used to treat a 28-year-old Caucasian female presenting with symptoms and bloodwork markers associated with two years of hypothyroidism and a long history of stress. The patient's medical doctor provided a diagnosis of hypothyroidism after blood tests showed that thyroid-stimulating hormone (TSH) levels were high at 6.87 mIU/L (where the acceptable range is 0.40-3.50 mIU/L) and free T4 (FT4) levels were low at 8.6 pmol/L (where the acceptable range is 9.0-19.0 pmol/L). Psychometric tests were completed at baseline and after 12 weeks of treatment to evaluate changes in mental health and emotional well-being. The Adverse Childhood Experiences Questionnaire (ACE-Q) revealed a high degree of childhood trauma that may have predisposed to the underlying autoimmune thyroid dysfunction. At the conclusion of the treatment period, serum thyroid-stimulating hormone (TSH) and free T4 were within normal ranges and psychometric indicators normalized. We hypothesize that these changes may be due to the stress-reducing mechanism of NET and outline possible mechanisms via the Psycho-Immune-Neuroendocrine (PINE) network. The PINE network model asserts that chronic stress acts as a potential driver of pathophysiology that can lead to one or more medical and mental health conditions. While further studies with larger sample sizes are required to establish whether these results could be extrapolated to a wider population, the results of this case suggest that it may be pertinent to consider co-management of subclinical hypothyroidism with a relatively quick and cost-effective MBI such as NET.

Steroid-Responsive Encephalopathy Associated With Autoimmune Thyroiditis Presenting With Parkinsonism

Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) is a rare condition defined as encephalopathy with a positive antithyroid antibody. We report the case of a 52-year-old woman who presented with Parkinsonism associated with Hashimoto's thyroiditis. A few similar cases have been reported. Our patient responded well to corticosteroids with a significant reduction in symptoms. Diagnosis can pose a significant challenge in SREAT cases because of its variable clinical presentation. Therefore, we recommend evaluating thyroid function and thyroid autoantibodies in the context of acute and subacute encephalopathy. In the elderly population, SREAT, as a cause of Parkinsonism, should not be forgotten because of its simple treatment and significant improvements in neurological symptoms.

An Autobiographical Case Report on Papillary Thyroid Carcinoma with Positive Antithyroid Antibodies: Coincidence or Correlated?

The relationship between autoimmunity and cancer has been a gray area, with many theories but no solid proof so far. Hashimoto's thyroiditis is an autoimmune disorder and a major cause of hypothyroidism, while papillary thyroid carcinoma is the most common thyroid malignancy generally found in patients younger than 45 years of age. The literature on the correlation between these two disorders is somewhat based on potentially biased histopathological examination from pre-operative fine needle aspiration and post-thyroidectomy samples. Although recent studies are evaluating a possible holistic molecular, hormonal, and histopathological foundation for this correlation, a clear causal relationship has not been established yet. This report illustrates the author's case presentation, treatment, and eventual outcome of the disease when she was diagnosed with papillary thyroid cancer at the age of 25 years, with positive antithyroid peroxidase and antithyroglobulin antibodies.

Calcium Hydroxylapatite-Induced Inflammatory Facial Edema and Induration Due to Hashimoto's Thyroiditis

We describe a patient who experienced a diffuse, treatment-refractory facial inflammatory reaction following the injection of calcium hydroxylapatite with lidocaine. The reaction was attributed to undiagnosed Hashimoto's thyroiditis. Exogenous thyroid hormone replacement therapy rapidly resolved the facial inflammation associated with this type of autoimmune hypothyroidism.

Effects of vitamin D treatment on thyroid function and autoimmunity markers in patients with Hashimoto's thyroiditis-A meta-analysis of randomized controlled trials

Introduction

Recent evidence suggested that vitamin D deficiency was associated with Hashimoto's thyroiditis (HT) pathogenesis and thyroid hypofunction. This study aimed to investigate whether vitamin D supplementation would be effective in the prevention and progression of hypothyroidism in patients with HT.

Methods

PubMed, Embase and the Cochrane library were searched for randomized controlled trials (RCTs) and prospective cohort studies published from inception to August 2021.

Results

A total of 7 cohorts of patients from six clinical trials with 258 patients with HT were included. Significant difference was found (WMD = 19.00, 95% CI: 12.43, 25.58, p < 0.001; I² = 90.0%, p_{heterogeneity} < 0.001) between the vitamin D group and control group in serum 25‐hydroxyvitamin D level. And the combined results indicated vitamin D supplementation significantly reduced the level of thyroid peroxidase antibodies (TPO‐Ab) compared to the control group (WMD = −158.18, 95% CI: −301.92, −14.45, p = 0.031; I² = 68.8%, p_{heterogeneity} = 0.007). Whereas no significant differences were found on the levels of thyroid‐stimulating hormone (TSH), free triiodothyronine (FT3), free thyroxine (FT4) compared to the control group (p > 0.05).

What is New and Conclusion

Our study demonstrated that vitamin D treatment might significantly increase the serum 25(OH)D levels and produce changes in TPO‐Ab titres.

No significant association was found between serum vitamin D treatment and the levels of TG‐Ab, TSH, FT3 and FT4, suggesting that vitamin D is not associated with the function of the thyroid in patients with HT.

Associations of Yersinia Enterocolitica Infection with Autoimmune Thyroid Diseases: A Systematic Review and Meta-Analysis

INTRODUCTION

Yersinia enterocolitica infection is reportedly associated with the development of autoimmune thyroid diseases (AITD). However, evidence that such infection can lead to AITD is controversial. Thus, this study was aimed to investigate the associations of Y. enterocolitica infection with AITD.

METHODS

A meta-analysis was performed using PubMed, Web of Science, Embase and Cochrane library to identify relevant studies. The odds ratios (OR) and associated 95% confidence intervals [CI] were obtained. Data were analyzed by STATA 13.0 (Stata Corporation, College Station, TX, USA).

RESULTS

Of 215 articles identified, 8 studies with a total of 1490 participants met the criteria and were included in the meta-analysis. There was a significant association between Y. enterocolitica positivity and AITD (OR: 4.31 [CI 95%: 1.81-10.07], P-value: 0.00). According to the subgroup analysis, Y. enterocolitica infection statistically increased the risk of Graves' disease (GD) (OR: 6.12, [CI 95%: 3.71-10.10], P-value: 0.00). Likewise, the pooled OR of association between Y. enterocolitica positivity and hashimoto's thyroiditis (HT) was 2.84 (CI 95%: 0.71-11.25, P-value: 0.1).

CONCLUSION

The current studies suggest that Y. enterocolitica may be associated with the development of AITD. Further study is needed to explore the underlying mechanisms.

Clinical significance of immunohistochemistry to detect BRAF V600E mutant protein in thyroid tissues

This study investigated the feasibility of using immunohistochemistry (IHC) instead of PCR to detect BRAF V600E mutant protein in papillary thyroid carcinoma (PTC), and to determine the value of using preoperative BRAF V600E mutant protein by IHC to assist in the diagnosis of thyroid nodule patients with Hashimoto's thyroiditis (HT).The expression of BRAFV600E mutant protein was measured in 23 cases of HT+PTC, 31 cases of PTC, and 28 cases of HT by IHC, followed by PCR in the same samples for validation. SPSS 19.0 software was used for statistical analysis.The sensitivity and specificity of IHC to detect BRAF V600E mutation were 100% and 42.86%, respectively. In addition, the mutation rate of BRAF V600E protein in the HT+PTC group (34.78%, 8/23) was lower than that in the PTC group (80.65%, 25/31).The application of IHC to detect BRAF V600E mutant protein has good sensitivity but not specificity to diagnose PTC. IHC can be used as a preliminary screening method to detect BRAF V600E mutation. The strongly positive (+++) staining of IHC potently indicated BRAF V600E gene mutation. For suspicious thyroid nodules combined with HT, the detection of BRAF V600E mutant protein with IHC alone is not of great significance for differentiating benign and malignant nodules.

Hashimoto's Encephalopathy: A Rare Cause of Seizure-like Activity

Hashimoto’s encephalopathy is an uncommon disorder that may present with a wide variety of different neurological signs and symptoms that can include acute altered level of consciousness, psychosis, seizures, ataxia, dementia, myoclonus, and stupor. We present a case of a 60-year-old female patient who was admitted to the internal medicine floor for workup for seizures of unknown etiology. Investigations, including a complete blood count, basic metabolic panel, magnetic resonance imaging (MRI) of the brain, cerebrospinal fluid analysis, and NMDA (N-methyl-D-aspartate) receptor encephalitis screen, were all unremarkable. Thyroid-stimulating hormone levels and anti-thyroid peroxidase antibodies were found to be elevated, suggesting an underlying etiology of Hashimoto’s thyroiditis. Treatment with corticosteroids and levothyroxine can lead to resolution of symptoms. This case report is presented to suggest the importance of serological screening for anti-thyroid antibodies in the workup of all patients with unknown causes of encephalopathy along with providing a review of the literature.

Clinical prognosis and bioinformatic analysis of primary thyroid lymphoma

Primary thyroid lymphoma (PTL) is a rare malignant disease with the most common histological type of diffuse large B-cell lymphoma (DLBCL). Hashimoto's thyroiditis (HT) is closely related to the pathogenesis of PTL. The present study is to explore the clinical prognosis of PTL and analyze the gene correlations between PTL and HT.Thirty-nine patients diagnosed with PTL between 2010 and 2018 in our institute were retrospectively reviewed and clinical features were evaluated on PTL survival. Then, overlapping differentially expressed genes (DEGs) between PTL and HT were evaluated for gene ontology, pathways enrichment, protein-protein interaction network analysis. Furthermore, we used gene expression profiling interactive analysis to evaluate the differential expression of these hub genes.In this analysis, International Prognostic Index (IPI) score ≥3 and high β2-MG (>3 mg/L) were associated with worse prognosis in PTL. Notably, a total of 15 both upregulated DEGs in DLBCL and HT were identified and 10 hub genes with a high degree of connectivity were picked out. Among these 10 hub genes, IL6, IL10, CXCL10, and CXCR3 were higher expressed in DLBCL than the normal tissue but have no significant prognosis of DLBCL.High IPI score and high β2-MG level have a poor prognosis in PTL. Besides, IL6, IL10, CXCL10, and CXCR3 are associated with both DLBCL and HT and may be used for the early diagnosis of PTL.

Minerals: An Untapped Remedy for Autoimmune Hypothyroidism?

For decades, the focus of managing autoimmune hypothyroidism has been on thyroxine replacement. Correcting lab parameters such as thyroid stimulating hormone (TSH) has been a primary goal. The increasing prevalence of Hashimoto’s thyroiditis (HT) continues to impact the quality of life in patients. We believe a holistic approach to this disease entity, considering its underlying complex etiopathogenesis, would benefit patients. Nutraceuticals are combinations of essential nutrients and are becoming a part of novel medical treatments despite the lack of regulation. This review aims to present a concise summary of recent developments regarding minerals such as zinc, selenium, magnesium, iron, and their potential clinical benefit as nutraceuticals in patients with HT. We have explored the potential benefits and associations of these minerals in HT and thyroid function. We reviewed relevant articles, metanalyses, and clinical trials in literature platforms such as PubMed, PubMed Central, and Google Scholar. Significant data found in the literature suggesting a potential health benefit of these minerals in HT though there were many studies to the contrary. Many trials demonstrated the restoration of residual symptoms, reversal of HT-associated thyroid morphological changes, and improvement in thyroid functions. Many of these trials lack statistical power due to the small sample sizes, and their external validity may be questionable due to unaccounted confounding factors. In our opinion, to support an evidence-based holistic clinical approach, further scientific evidence is needed. The association of these elements in thyroid function necessitates more large scale pragmatic trials to elucidate the benefits of nutraceuticals in HT.

Myasthenia Gravis and its Association With Thyroid Diseases

Myasthenia gravis (MG) is a rare autoimmune neuromuscular junction disorder, and thyroid disorder is a disorder involving the thyroid receptor, of which Graves' disease (GD) is the most common autoimmune thyroid disorder, in which antibodies develop against thyroid receptors. Both may have similar clinical features. In myasthenia gravis, autoimmune antibodies develop against postsynaptic neuromuscular junction disrupting the neuromuscular transmission, resulting in fluctuating muscle weakness and fatigue. It is a disease of young women and older men. The two pathologies may coexist in a patient or can precede one another. Graves' disease (GD) among thyroid diseases is most often associated with MG. 

Similarities in clinical features lead to difficulty in distinguishing MG and GD. Despite the standard treatment of myasthenia gravis, including steroids, acetylcholinesterases, rituximab, immunosuppressants, and thymectomy, there is still an increased number of relapses and myasthenia crisis. Eculizumab and plasmapheresis are the two new treatment options for MG, with supporting evidence of marked improvement in recent studies. Myasthenia gravis and Graves' disease have a see-saw relationship. Treating one pathology may worsen the other, so physicians should always consider MG as a differential in patients of hyperthyroidism presenting with new symptoms of fatigue or respiratory failure or neuromuscular weakness.

In this comprehensive review article, we tried to establish an association between myasthenia gravis and Graves' disease (GD) by exploring currently available literature from PubMed. However, more studies need to be done to establish an association between pathologies.

Circulating microRNA Expression Profiling Identifies miR-125a-5p Promoting T Helper 1 Cells Response in the Pathogenesis of Hashimoto's Thyroiditis

MicroRNAs (miRNAs) have emerged as key regulators of cellular processes by suppressing target mRNAs at the posttranscriptional level. However, little is known regarding the expression of miRNAs in peripheral blood mononuclear cells (PBMCs) from Hashimoto's thyroiditis (HT) patients. Therefore, 38 HT patients and 36 healthy volunteers were enrolled in this study to identify HT-mediated changes in miRNA expression. Over 1,000 dysregulated miRNAs and their biological functions in the HT patients were identified. Among them, miR-125a-5p expression was upregulated and inversely correlated with low levels of MAF, a transcription factor that inhibits Th1 cells activity and the production of IFN-γ. Luciferase assay results demonstrated that MAF is a direct target gene of miR-125a-5p. Moreover, the proportion of circulating Th1 cells and the transcript levels of IFN-γ were increased in the HT patients. MiR-125a-5p expression positively correlated with the proportion of circulating Th1 cells and the serum concentrations of anti-thyroperoxidase antibodies in the HT patients. Interestingly, knockdown of miR-125a-5p in CD4⁺ T cells resulted in an elevated level of MAF but decreased the proportion of Th1 cells and the transcript level of IFN-γ in vitro. Furthermore, upregulated miR-125a-5p and IFN-γ transcript levels and downregulated MAF expression were detected in thyroid tissues from HT patients. Receiver operating characteristic (ROC) curves suggested that miR-125a-5p has a crucial role in the HT. Our results demonstrate that the elevated levels of miR-125a-5p contribute to the Th1 cells response in the HT patients and may be involved in the pathogenesis of HT.

Pituitary macroadenoma secondary to Hashimoto's thyroiditis: inadvertent diagnosis in a pre-pubertal girl

Pituitary hyperplasia as a result of autoimmune thyroiditis has been rarely reported in children. We report a prepubertal girl with Hashimoto's thyroiditis who was inadvertently diagnosed to have a pituitary macroadenoma based on neuroimaging.

Correlation Between Hashimoto's Thyroiditis-Related Thyroid Hormone Levels and 25-Hydroxyvitamin D

Objective: The purpose of this study was to further clarify the association of Hashimoto's thyroiditis (HT) and vitamin D deficiency, and to seek the connection between them and related influencing factors. Methods: Data were obtained from subjects who underwent health examinations from January 2018 to December 2018. The diagnosis of HT was based on: antithyroid peroxidase antibody (TPO-Ab) levels >35 IU/ml and/or antithyroglobulin antibody (Tg-Ab) levels >40 IU/ml. Based on the Endocrine Society guidelines, 25-hydroxyvitamin D [25(OH)D] levels ≥30.0 ng/ml were classified as a vitamin D sufficiency; those between 20 and 29.9 ng/ml, as an insufficiency; and those <20 ng/ml, as a deficiency. All statistical analysis was performed by software R. Results: Of a total of 75,436 individuals who were physically examined, 5,656 of them had 25(OH)D levels tested at the same time; 5,230 were enrolled. The level of 25(OH)D in the non-HT group was higher than that in the HT group. Multiple regression analysis showed that HT was statistically significantly correlated with being male, body mass index (BMI), waist circumference, and thyroid-stimulating hormone (TSH). TSH levels in the insufficiency group and deficiency group were higher than those in the sufficiency group. Free triiodothyronine (FT3) and thyroxine (FT4) levels in the insufficiency group and deficiency group were lower than those in the sufficiency group. 25(OH)D increased by 1 ng/ml at the normal reference level, with an increase of 2.78 ng/dl in FT4 concentration and a decrease of 0.17 mIU/L in TSH. Conclusions: Patients with HT present with a reduced 25(OH)D level, and TSH is an independent risk factor for HT. TSH is negatively correlated with 25(OH)D level. FT3 and FT4 levels were positively correlated with 25(OH)D levels.

Down syndrome with primary thyroid diffuse large B-cell lymphoma and Hashimoto thyroiditis: A CARE compliant case report

RATIONALE

Adult patients with Down syndrome (DS) commonly develop Hashimoto thyroiditis (HT). However, primary diffuse large B-cell lymphoma (DLBCL) of the thyroid is uncommon, and its simultaneous occurrence with HT is very rare. To our knowledge, coexisting DLBCL and HT in a patient with DS has not been reported in the medical literature.

PATIENT CONCERNS

We present a 43-year-old woman with DS who reported progressive swelling of the neck on the right side and dyspnea over the previous 1 month, with associated neck ache, hoarseness, and dysphagia. Thyroid ultrasonography and computed tomography of the neck revealed a large mass in the right lobe compressing the surrounding tissues.

DIAGNOSES

Based on the clinical and histopathologic findings, the patient was diagnosed with coexisting primary thyroid DLBCL and HT.

INTERVENTIONS

A palliative unilateral thyroidectomy was performed; postoperative histopathology and immunohistochemistry revealed thyroid DLBCL and HT. The patient was scheduled for chemotherapy and targeted therapy after recovering from surgery.

OUTCOMES

The patient died 3 weeks after surgery due to asphyxia caused by uncontrollable growth of recurrent tumor.

LESSONS

The coexistence of DS, primary thyroid DLBCL, and HT is very rare. There is no standardized approach to the clinical identification of primary thyroid lymphoma (PTL), making early diagnosis difficult. A multidisciplinary approach and close follow-up are needed. The mechanisms of the link between DS and PTL are poorly understood and remain to be elucidated.

Efficacy of the Autoimmune Protocol Diet as Part of a Multi-disciplinary, Supported Lifestyle Intervention for Hashimoto's Thyroiditis

Background Hashimoto's thyroiditis (HT), also known as chronic lymphocytic thyroiditis, is an autoimmune disorder affecting the thyroid gland and is the most common cause of hypothyroidism in the US. Despite medical management with thyroid hormone replacement, many individuals with HT continue to experience symptoms and impaired quality of life. Given the limited number of efficacious treatments outside of hormone replacement and the overall burden of continued symptomatic disease, this pilot study was designed to determine the efficacy of a multi-disciplinary diet and lifestyle intervention for improving the quality of life, clinical symptom burden, and thyroid function in a population of middle-aged women with HT. Materials and methods The study recruited 17 normal or overweight (body mass index (BMI) <29.9) female subjects between the ages of 20 and 45 with a prior diagnosis of HT. The 17 women participated in a 10-week online health coaching program focused on the implementation of a phased elimination diet known as the Autoimmune Protocol (AIP). The 36-Item Short Form Health Survey (SF-36) and Cleveland Clinic Center for Functional Medicine's Medical Symptoms Questionnaire (MSQ) were used to measure the participant's health-related quality of life (HRQL) and clinical symptom burden, respectively, before and after the 10-week program. The participants completed serologic testing that included a complete blood cell count (CBC) with differential, complete metabolic profile (CMP), thyroid function tests, including thyroid stimulating hormone (TSH), total and free T4, and total and free T3, thyroid antibodies, including thyroid peroxidase antibodies (TPO) and anti-thyroglobulin antibodies (TGA), and high-sensitivity C-reactive protein (hs-CRP).  Results Sixteen women (n = 16) completed the SF-36 and MSQ before and after the 10-week program. There was a statistically significant improvement in HRQL as measured by all eight subscales of the SF-36 with the most marked improvements noted in the physical role functioning, emotional role functioning, vitality, and general health subscales. The clinical symptom burden, as measured by the MSQ, decreased significantly from an average of 92 (SD 25) prior to the program to 29 (SD 20) after the program. There were no statistically significant changes noted in any measure of thyroid function, including TSH, free and total T4, free and total T3 (n = 12), as well as thyroid antibodies (n = 14). Inflammation, as measured by hs-CRP (n = 14), was noted to significantly decrease by 29% (p = 0.0219) from an average of 1.63 mg/L (SD 1.72) pre-intervention to 1.15 mg/L (SD 1.31) post-intervention. Conclusions Our study suggests that an online diet and lifestyle program facilitated by a multi-disciplinary team can significantly improve HRQL and symptom burden in middle-aged female subjects with HT. While there were no statistically significant changes noted in thyroid function or thyroid antibodies, the study's findings suggest that AIP may decrease systemic inflammation and modulate the immune system as evidenced by a decrease in mean hs-CRP and changes in white blood cell (WBC) counts. Given the improvements seen in the HRQL and participants' symptom burden as well as markers of immune activity and inflammation, further studies in larger populations implementing AIP as part of a multi-disciplinary diet and lifestyle program are warranted.

The association between thyroid echogenicity and thyroid function in pediatric and adolescent Hashimoto's thyroiditis

In this study, we evaluated the association between thyroid echogenicity on ultrasonography (US) and thyroid function in pediatric and adolescent Hashimoto's thyroiditis (HT) patients.In 86 pediatric and adolescent HT patients, the association between echogenicity and thyroid function and microsomal autoantibody status was evaluated. Among patients with overt hypothyroidism, 89.2% (33/37) showed a US grade of 3 or 4. All of the patients at grade 4 presented with overt hypothyroidism. In contrast, 97.8% (44/49) of the patients with subclinical hypothyroidism or euthyroidism showed grades 1 or 2. Patients with increased thyroid-stimulating hormone titer also tended to have increased US grades (P < .001). In contrast, free thyroxine levels were significantly decreased with increasing US grade (P < .001).In conclusion, patients with higher US grades had decreased thyroid function (P < .001).

Acute exacerbation of Hashimoto's thyroiditis in a patient treated with dimethyl fumarate for multiple sclerosis: A case report

INTRODUCTION

Dimethyl fumarate (DMF) has been recently approved for first-line monotherapy of Multiple Sclerosis (MS). Its effects are due to mechanism modulating the immune system and activating antioxidative and neuroprotective pathways.

PATIENT CONCERNS

A 59-year-old female patient affected by chronic Hashimoto's thyroiditis (HT) from 10 years was diagnosed with relapsing remitting MS in 2013. She started therapy with DMF in November 2016.

DIAGNOSIS

After 2 months of therapy with DMF, the results of thyroid function test were abnormal. Thyroid ultrasonography confirmed the diagnosis of acute exacerbation of HT.

INTERVENTIONS

This condition led to discontinuation of DMF therapy.

OUTCOME

Two months after the interruption of DMF therapy, the findings of thyroid function test were within normal limits.

CONCLUSION

The association of MS with autoimmune thyroid diseases supports a common immune-mediated pathogenic mechanism. We assume that the acute exacerbation of HT in our MS patient is associated not with the immunomodulatory effect of DMF but rather with its antioxidative mechanism.Constant monitoring of thyroid hormone levels should be recommended especially if the MS patients in treatment with DMF are affected by concomitant autoimmune thyroid diseases.

Association between BRAF (V600E) mutation and clinicopathological features of papillary thyroid carcinoma: a Brazilian single-centre case series

OBJECTIVES

We aimed to investigate the prevalence of the BRAF (V600E) mutation in consecutive cases of papillary thyroid carcinoma (PTC) in patients diagnosed and treated at the Hospital Sao Rafael (Salvador, BA, Brazil) and evaluate its association with clinical and pathological characteristics of PTC.

SUBJECTS AND METHODS

We retrospectively enrolled in the study a total of 43 consecutive PTC patients who underwent total thyroidectomy. We performed DNA extraction from formalin-fixed paraffin-embedded (FFPE) tumour tissue samples. Polymerase chain reaction (PCR) and direct sequencing were used to determine BRAF (V600E) mutation status. Univariate and multivariate logistic regression analyses were employed to identify independent associations.

RESULTS

The prevalence of BRAF (V600E) mutation was 65.1% (28/43). A high frequency of older patients (p value: 0.004) was observed among the BRAF-mutated PTC group and, in contrast, a low frequency of concurrent Hashimoto's thyroiditis (HT) (p value: 0.011) was noted. Multivariate analysis confirmed that older age (OR: 1.15; 95% CI: 1.00 - 1.33; p value: 0.047) and HT (OR: 0.05; 95% CI: 0.006-0.40; p value: 0.005) were independent factors associated with BRAF (V600E) mutation.

CONCLUSION

We found a high prevalence of BRAF (V600E) mutation in PTC cases. Older age and no concurrent HT were independently associated with BRAF (V600E) mutation.

Prolonged Duration of Hashitoxicosis in a Patient with Hashimoto's Thyroiditis: A Case Report and Review of Literature

Hashitoxicosis is the initial hyperthyroid phase of patients with Hashimoto's thyroiditis and, usually, this phase lasts for one to two months. We report a case of a 21-year-old male who had Hashitoxicosis of two years duration before converting to Hashimoto’s hypothyroidism. He initially presented with complaints of increased appetite, heat intolerance, fatigue, and sweating. On a physical exam, he had mild exophthalmos with lid lag and a fine tremor in the hands. Thyroid function tests also confirmed that the patient had hyperthyroidism. Thyroglobulin antibody and thyroid peroxidase antibody were both positive. He also had mildly elevated thyroid-stimulating immunoglobulin (TSI) but decreased radioactive iodine uptake scan. Based on the clinical presentation and biochemical test, a diagnosis of Hashitoxicosis was made. This hyperthyroid phase lasted for a period of two years. The patient eventually developed hypothyroidism suggesting that Hashimoto's thyroiditis was the most likely diagnosis. He was started on levothyroxine replacement therapy and remained euthyroid on levothyroxine since that day. The initial presentation mimicked Grave’s disease, but with decreased radioiodine uptake, despite the high TSI level, leading us to treat him medically and not with radioactive iodine therapy. The patient was thus spared unnecessary radioactive iodine therapy (RAI) therapy.

Hashimoto's thyroiditis with elevated serum IgG4 concentrations is not equivalent to IgG4 Hashimoto's thyroiditis

BACKGROUND

Hashimoto's thyroiditis (HT) with serum IgG4 concentrations greater than 135 mg/dL can be diagnosed as elevated serum IgG4 HT. HT can also be classified into IgG4 HT and non-IgG4 HT based on an immunohistochemistry analysis of IgG4. The aim of our study was to determine the relationship between elevated serum IgG4 HT and IgG4 HT.

METHOD

Both thyroid tissues and serum samples stored before pathological examination from 93 patients with HT were collected. The serum levels of IgG, IgG4, TgAb IgG, TgAb IgG4, TPOAb IgG and TPOAb IgG4 were measured by ELISAs. The expression levels of IgG4, IgG and TGF-β1 in thyroid tissues were detected by immunohistochemistry.

RESULTS

Patients with HT were divided into two groups: elevated serum IgG4 HT (n = 12) and nonelevated serum IgG4 HT (n = 81). Hypothyroidism was found in 5 of 12 cases (41.7%) in the elevated serum IgG4 HT group and 10 of 81 cases (12.3%) in the nonelevated serum IgG4 HT group (P = .023). Serologically, there were no significant differences in the levels of TgAb IgG, TPOAb IgG, TgAb IgG4 and TPOAb IgG4 between the two groups, and the expression of TGF-β1 in thyroid tissues was not significantly different between the groups. Most importantly, the frequency of patients who satisfied the criteria for IgG4 HT diagnosis was comparable (25% vs 20.9%, P = .756).

CONCLUSIONS

The measurement of serum IgG4 allows the identification of patients with HT closely associated with hypothyroidism. However, our study demonstrated that elevated serum IgG4 HT is not equivalent to IgG4 HT.

Serum selenium and selenoprotein-P levels in autoimmune thyroid diseases patients in a select center: a transversal study

OBJECTIVE

Selenium (Se) supplementation has been used to help prevent the progression of Graves' ophthalmopathy (GO) and autoimmune thyroid diseases (AITD) patients. We investigated Se serum and selenoprotein P (SePP) levels in Graves' disease (GD) with and without GO, Hashimoto's thyroiditis (HT) patients and in 27 control individuals (C).

SUBJECTS AND METHODS

We studied 54 female and 19 male patients: 19 with GD without GO, 21 GD with GO, 14 with HT and 19 with HT+LT4. Se values were measured using graphite furnace atomic absorption spectrophotometry. Serum SePP levels were measured by ELISA.

RESULTS

Median Se levels were similar among all groups; GD patients: 54.2 (46.5-61.1 μg/L), GO: 53.6 (43.5-60.0 μg/L), HT: 51.9 (44.6-58.5 μg/L), HT+LT4 54.4 (44-63.4) and C group patients: 56.0 (52.4-61.5 μg/L); P = 0.48. However, serum SePP was lower in GO patients: 0.30 (0.15-1.05 μg/mL) and in HT patients: 0.35 (0.2-1.17 μg/mL) compared to C group patients: 1.00 (0.564.21 μg/mL) as well as to GD patients: 1.19 (0.62-2.5 μg/mL) and HT+LT4 patients: 0.7 (0,25-1.95); P = 0.002. Linear regression analysis showed a significant relationship between SePP and TPOAb values (r = 0.445, R2 = 0.293; P < 0.0001). Multiple regression analysis found no independent variables related to Se or SePP.

CONCLUSION

A serum Se concentration was lower than in some other countries, but not significantly among AITD patients. The low serum SePP levels in GO and HT patients seems to express inflammatory reactions with a subsequent increase in Se-dependent protein consumption remains unclear.

Vitamin D Treatment in Patients with Hashimoto's Thyroiditis may Decrease the Development of Hypothyroidism

The relationship between Hashimoto's thyroiditis and vitamin D has been demonstrated in several studies. The aim of the present study was to evaluate vitamin D concentrations in patients with Hashimoto's thyroiditis, the effect of vitamin D therapy on the course of disease, and to determine changes in thyroid autoantibody status and cardiovascular risk after vitamin D therapy. We included 75 patients with Hashimoto's thyroiditis and 43 healthy individuals. Vitamin D deficiency is defined as a 25-hydroxy vitamin D (25(OH)D3) concentration less than 20ng/mL. Vitamin D deficient patients were given 50.000 units of 25(OH)D3 weekly for eight weeks in accordance with the Endocrine Society guidelines. All evaluations were repeated after 2 months of treatment. Patients with Hashimoto's thyroiditis had significantly lower vitamin D concentrations compared with the controls (9.37±0.69 ng/mL vs 11.95±1.01 ng/mL, p < 0.05, respectively). Thyroid autoantibodies were significantly decreased by vitamin D replacement treatment in patients with euthyroid Hashimoto's thyroiditis. Also, HDL cholesterol concentrations improved in the euthyroid Hashimoto group after treatment. The mean free thyroxine (fT4) concentrations were 0.89±0.02 ng/dL in patients with Hashimoto's thyroiditis and 1.07±0.03 ng/dL in the healthy control group (p < 0.001). The mean thyroid volumes were 7.71±0.44 mL in patients with Hashimoto's thyroiditis and 5.46±0.63 mL in the healthy control group (p < 0.01). Vitamin D deficiency is frequent in Hashimoto's thyroiditis and treatment of patients with this condition with Vitamin D may slow down the course of development of hypothyroidism and also decrease cardiovascular risks in these patients. Vitamin D measurement and replacement may be critical in these patients.

Diplopia in a patient with Hashimoto's thyroiditis: A case report and literature review

BACKGROUND

A case report of Hashimoto's thyroiditis-associated ophthalmopathy that masqueraded as double elevator palsy in 1 eye.

CASE PRESENTATION

A 54-year-old woman presented to our strabismus clinic with diplopia for 1 year. She was diagnosed with double elevator palsy in the left eye. The forced duction test yielded positive findings for the inferior rectus of the left eye; hence, computed tomography of the orbit and thyroid-associated blood tests were performed; surprisingly, the thyroid function test results were consistent with hypothyroidism and the antibody results such as antithyroglobulin and antithyroid peroxidase were markedly elevated, and the patient was diagnosed with Hashimoto's thyroiditis and treated with corticosteroids. Unfortunately, her diplopia was not relieved with medical management. Subsequently, a 9-mm left inferior rectus recession was performed.

CONCLUSION

Clinicians should be aware of the atypical signs of Hashimoto's thyroiditis for its proper diagnosis and management.

[Value of ultrasound shear wave elasticity imaging in diagnosis of Hashimoto's thyroiditis]

OBJECTIVE

To investigate the correlation between Young's modulus of the thyroid tissue measured by in shear wave elastography (SWE) and the clinical manifestations of Hashimoto's thyroiditis in different stages.

METHODS

A total of 104 patients with the clinical diagnosis of Hashimoto's thyroiditis were enrolled in this study, including 26 with hyperthyroidism, 29 with normal thyroid function, 27 with subclinical hypothyroidism, 22 with clinical hypothyroidism, with 50 healthy volunteers serving as the healthy control group. All the subjects underwent SWE to obtain the Young's modulus value of the thyroid tissue. Univariate analysis of variance was used to compare the Young's modulus among the groups, and Pearson correlation analysis was used to analyze the correlation between the Young's modulus of the thyroid tissue and serum levels of thyroid microsomal antibody (TMAb) and thyroid globulin antibody (TGAb).

RESULTS

In the 4 groups of patients, the Young's modulus increased significantly in the order of hyperthyroidism group, normal thyroid function group, subclinical hypothyroidism group and clinical hypothyroidism group (F=60.983, P<0.01). The Young's modulus was significantly lower in hyperthyroidism group than in the other 3 groups (P<0.05), and was significantly lower in normal thyroid function group than in subclinical hypothyroidism group and clinical hypothyroidism group (P<0.05).

CONCLUSION

The Young's modulus of the thyroid tissue measured by shear wave elastography is related with the clinical manifestations of Hashimoto's thyroiditis in different stages, but the relevance needs to be further confirmed by multi-center, randomized, controlled studies involving a larger sample size.

An unusual cause of orthopnoea-hashimoto's thyroiditis presenting as bilateral diaphragmatic palsy

We report a case of 36 yr old male without any comorbidities, who presented with a history of gradually progressive dyspnoea and orthopnoea for 6 months. Physical examination revealed bradycardia, paradoxical respiration suggestive of bilateral diaphragmatic palsy. Fluoroscopy demonstrated the presence of bilateral diaphragmatic paralysis. Etiological work up showed evidence of autoimmune hypothyroidism due to hashimoto's thyroiditis. Other possibilities were ruled out with appropriate tests. He was started on thyroxine and showed symptomatic improvement.

Clinical, biochemical & cytomorphologic study on Hashimoto's thyroiditis

BACKGROUND & OBJECTIVES

Despite, the extensive salt iodization programmes implemented in India, the prevalence of goiter has not reduced much in our country. The most frequent cause of hypothyroidism and goiter in iodine sufficient areas is Hashimoto's thyroiditis (HT). This study records the clinical presentation, biochemical status, ultrasonographic picture and cytological appearance of this disease in a coastal endemic zone for goiter.

METHODS

Case records of patients with cytological diagnosis of HT were studied in detail, with reference to their symptoms, presence of goiter, thyroid function status, antibody levels and ultrasound picture. Detailed cytological study was conducted in selected patients.

RESULTS

A total of 144 patients with cytological proven HT/lymphocytic thyroiditis were studied. Ninety per cent of the patients were females and most of them presented within five years of onset of symptoms. Sixty eight per cent patients had diffuse goiter, 69 per cent were clinically euthyroid and 46 per cent were biochemically mildly hypothyroid. Antibody levels were elevated in 92.3 per cent cases. In majority of patients the sonographic picture showed heterogeneous echotexture with increased vascularity. Cytological changes were characteristic.

INTERPRETATION & CONCLUSIONS

Our study showed predominance of females in the study population in 21-40 yr age group with diffuse goiter. We suggest that in an endemic zone for goiter, all women of the child bearing age should be screened for HT.

Hashimoto's Thyroiditis and Medullary Carcinoma of Thyroid

Hashimoto's thyroiditis (HT) has been found to be associated with lymphoma, papillary carcinoma and Hürthle cell neoplasms of thyroid. In contrast, there are only a few reports of co-existence of HT with medullary carcinoma of thyroid. An overall prevalence of medullary carcinoma of only 0.35% has been reported in HT patients. Such a rare combination is being presented here. A 33 year old female presented with history of goiter for one year. Fine needle aspiration cytology (FNAC) of the swelling revealed cytological features suggestive of medullary carcinoma of thyroid. Histopathological examination of total thyroidectomy specimen revealed Hashimoto's thyroiditis along with medullary carcinoma of thyroid. Although Hashimoto's thyroiditis can uncommonly co-exist with thyroid neoplasm, its association with medullary carcinoma is extremely rare and hence being presented.

Hashimoto's thyroiditis associated Evans syndrome: A rare case report on the clustered autoimmune disease triad

Evans syndrome is a rare combination of autoimmune hemolytic anemia and immune thrombocytopenia. Their association with autoimmune thyroid diseases has been reported by few authors; however, a sequential development of the Evans syndrome in cases of Hashimoto's thyroiditis is extremely rare. The clustering of these autoimmune diseases might share a common pathogenic pathway. We present the fourth such case in world literature, of a 34-year-old female diagnosed with Hashimoto's thyroiditis in 2006, who has been taking synthetic thyroid hormone since then. Her condition is now clinically complicated with the development of the Evans syndrome.

The role of the resistive index in Hashimoto's thyroiditis: a sonographic pilot study in children

OBJECTIVE

The role of Doppler ultrasonography in the diagnosis of diffuse thyroid diseases is not well established. In particular, Doppler ultrasonography findings in children with Hashimoto's thyroiditis are very limited. We examined gray-scale and Doppler ultrasound findings in Hashimoto's thyroiditis in children in an attempt to understand the feasibility of future prospective controlled studies.

MATERIALS AND METHODS

Twenty-one children with newly diagnosed Hashimoto's thyroiditis were recruited in the study. The patients were euthyroid or had subclinical hypothyroidism at the time of the ultrasonography examination. According to the color Doppler scale developed by Schulz et al., thyroid glands were classified into four patterns based on visual scoring and the mean resistive index (RI), which was calculated via measurements from both lobes, and these results were compared with gray-scale findings.

RESULTS

The mean RI value, calculated as the mean of the RI values of both lobes obtained from each patient, was found to be 0.57 ± 0.05 (range 0.48-0.67) cm/sn. The distribution of thyroid classifications was as follows: Pattern 0, n = 7; Pattern I, n = 6; Pattern II, n = 4; and Pattern III ("thyroid inferno"), n = 4. The mean RI values in patients with normal or near-normal gray-scale findings (n = 10) and patients with more substantial gray-scale changes (n = 11) were not significantly different and were lower than the values in normal children previously presented in the literature.

CONCLUSION

The results indicated that the RI may be more sensitive than other ultrasound parameters for the diagnosis of Hashimoto's thyroiditis.

Concurrence of Multifocal Motor Neuropathy and Hashimoto's Thyroiditis

Background

Multifocal motor neuropathy (MMN) is an immune-mediated disorder that is characterized by slowly progressive and asymmetrical weakness, but its pathophysiological mechanism is uncertain. The hypothesis that MMN is an immunological disease has been supported by the proven therapeutic effects of intravenous immunoglobulin and the detection of antiganglioside antibodies in MMN patients. The coexistence of MMN with other immune diseases has been rarely reported.

Case Report

A 37-year-old woman visited our hospital complaining of weakness in both hands. The clinical manifestations coincided well with MMN: predominantly distal upper-limb weakness, asymmetric involvement, a progressive course, absence of sensory symptoms, absence of pyramidal signs, and sparing of the cranial muscles. The electrophysiological findings also supported a diagnosis of MMN, with motor nerve conduction block in the median, ulnar, and radial nerves, without sensory nerve involvement. The patient was simultaneously diagnosed as having Hashimoto's thyroiditis, which is a well-known immune-mediated disease.

Conclusions

The concurrence of MMN and Hashimoto's thyroiditis in our patient is significant for understanding the immunological characteristics of the two diseases.

Vitamin D and autoimmune thyroid diseases

The role of vitamin D as an immune modulator has been emphasized in recent years, and low levels of the hormone were observed in several autoimmune diseases including multiple sclerosis and systemic lupus erythematosus. Vitamin D mediates its effect though binding to vitamin D receptor (VDR), and activation of VDR-responsive genes. While VDR gene polymorphism was found to associate with autoimmune thyroid diseases (AITDs), few studies examined levels of vitamin D in these patients and those that did yielded conflicting results. We therefore undertook to evaluate the levels of vitamin D in patients with AITDs compared to patients with non-AITDs and healthy controls. Serum vitamin D (25-OH) levels were measured in 50 patients with AITDs, 42 patients with non-AITDs and 98 healthy subjects, utilizing the LIAISON chemiluminescence immunoassay (DiaSorin, Saluggia, Italy). Vitamin D deficiency was designated at levels lower than 10 ng/ml. Antithyroid antibodies, thyroid functions and demographic parameters were evaluated in all patients. The prevalence of vitamin D deficiency was significantly higher in patients with AITDs compared with healthy individuals (72% versus 30.6%; P<0.001), as well as in patients with Hashimoto's thyroiditis compared to patients with non-AITDs (79% versus 52%; P<0.05). Vitamin D deficiency also correlated to the presence of antithyroid antibodies (P=0.01) and abnormal thyroid function tests (P=0.059). Significantly low levels of vitamin D were documented in patients with AITDs that were related to the presence of anti thyroid antibodies and abnormal thyroid function tests, suggesting the involvement of vitamin D in the pathogenesis of AITDs and the advisability of supplementation.

Co-existence of Hashimoto's thyroiditis with familial Mediterranean fever: is there a pathophysiological association between the two diseases?

Familial Mediterranean fever is an autosomal recessive disease characterized by periodic attacks of fever and polyserositis, while Hashimoto's thyroiditis is the most common cause of hypothyroidism. We suggest that common autoimmune mechanisms may underlie both disorders, describe their clinical co-existence in a patient, and discuss a possible causal link between them.

Idiopathic retroperitoneal fibrosis associated with Hashimoto's thyroiditis in an old-aged man

Idiopathic retroperitoneal fibrosis (IRPF) is a rare disease characterized by a retroperitoneal inflammatory proliferative fibrosing process. Hashimoto's thyroiditis is the most common inflammatory condition of the thyroid gland; and is a frequently-occurring autoimmune disorder manifesting predominantly in middle-aged women. We report a rare association of IRPF with Hashimoto's thyroiditis in a 67-year-old man demonstrating good response to steroid therapy.

Intrathyroidal cytokine gene expression in Hashimoto's thyroiditis

Hashimoto's thyroiditis (HT) is an organ-specific autoimmune disease in which cytokines are likely to have a role in the initiation and perpetuation of the disease. Using the reverse transcription-polymerase chain reaction (RT-PCR) we analysed the cytokine profile in four HT tissue samples. Furthermore, cell fractionation was carried out on two tissue samples and cytokine profile was studied in CD4+ and CD8+ T cells, in addition to the residual cellular infiltrate composed of CD4- and CD8- cells. Our results showed IL-1 beta, IL-4 and IL-6 mRNA expression in three out of four tissue samples, whereas IL-1 alpha, IL-2, IL-8, IL-10, interferon-gamma (IFN-gamma) and tumour necrosis factor-alpha (TNF-alpha) were expressed in all tissue samples studied. Expression of IL-1 alpha and IL-1 beta was absent in both CD4+ and CD8+ subsets. However, IL-2, IL-4, IL-6, IL-8, IFN-gamma and TNF-alpha mRNA were detected in both CD4+ and CD8+ subsets. IL-10 was expressed in the CD4+ subset in one sample, whereas it was negative in both CD8+ fractions. All the cytokines studied were expressed in the residual infiltrate. These results suggest a mixed Th1 and Th2 response in HT, both of which may have an important role in the pathophysiology of the thyroid destructive process through cell-mediated cytotoxicity, and/or humoral autoimmunity manifested by autoantibody production.