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Lu A, Chen CC, Lin C, Wu TJ, Lin SH. Artificial Intelligence Electrocardiography Detecting Thyrotoxic Periodic Paralysis Following a SARS-CoV-2 Infection. Am J Med 2024; 137:e91-e93. [PMID: 38280555 DOI: 10.1016/j.amjmed.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 01/09/2024] [Accepted: 01/22/2024] [Indexed: 01/29/2024]
Affiliation(s)
- Ang Lu
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Chien-Chou Chen
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan; Department of Internal Medicine, Tri-Service General Hospital Songshan Branch, National Defense Medical Center, Taipei, Taiwan
| | - Chin Lin
- Medical Technology Education Center, School of Medicine, National Defense Medical Center, Taipei, Taiwan; Graduate Institute of Life Sciences, National Defense Medical Center, Taipei, Taiwan; School of Public Health, National Defense Medical Center, Taipei, Taiwan
| | - Tsung-Jui Wu
- Department of Internal Medicine, Hualien Armed Forces General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan.
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Allegretti AS, Czawlytko CL, Stathatos N, Sadow PM. Case 13-2024: A 27-Year-Old Man with Leg Weakness. N Engl J Med 2024; 390:1514-1522. [PMID: 38657248 DOI: 10.1056/nejmcpc2312728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Affiliation(s)
- Andrew S Allegretti
- From the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Harvard Medical School - both in Boston
| | - Cynthia L Czawlytko
- From the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Harvard Medical School - both in Boston
| | - Nikolaos Stathatos
- From the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Harvard Medical School - both in Boston
| | - Peter M Sadow
- From the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Massachusetts General Hospital, and the Departments of Medicine (A.S.A., N.S.), Radiology (C.L.C.), and Pathology (P.M.S.), Harvard Medical School - both in Boston
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Yamaguchi Y, Okajima F, Sugihara H, Iwabu M, Emoto N. Atypical Clinical Courses of Graves' Disease Confound Differential Diagnosis of Hyperthyroidism. J NIPPON MED SCH 2024; 91:48-58. [PMID: 38072422 DOI: 10.1272/jnms.jnms.2024_91-104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND This study examined the appropriateness of the current paradigm for differential diagnosis of painless thyroiditis and Graves' disease (GD) in patients with thyrotoxicosis. METHODS We retrospectively evaluated the clinical course of 343 consecutive patients with hyperthyroidism diagnosed by Tc-99m pertechnetate thyroid uptake (TcTU) testing at our hospital from January 2011 to December 2017. RESULTS Of the 263 patients with normal or high TcTU levels (≥1.0%), 255 (97%) had unequivocal GD and 5 had spontaneous remission GD or atypical GD. Of the 10 patients with low TcTU levels (<1.0% and ≥0.5%), 7 had GD, while others had subclinical GD, spontaneous remission GD with later relapse, and painless thyroiditis. Of those with very low TcTU levels (<0.5%), most had thyroiditis (painless thyroiditis, 33/67 [49%]; subacute thyroiditis, 29/67 [43%]), and some were positive for anti-TSH receptor antibodies. CONCLUSION Given that atypical GD may confound the diagnosis of thyrotoxicosis, it is essential to follow the patient as a tentative diagnosis, whatever the diagnosis. This is the first report clearly demonstrating that so far there is no gold standard for the diagnosis of GD. It is therefore urgent to establish a consensus on the definition of GD so that the specificity and sensitivity of future diagnostic tests can be determined.
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Affiliation(s)
- Yuji Yamaguchi
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
- Department of Diabetes, Endocrinology and Metabolism, Nippon Medical School Chiba Hokusoh Hospital
| | - Fumitaka Okajima
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
- Department of Diabetes, Endocrinology and Metabolism, Nippon Medical School Chiba Hokusoh Hospital
| | - Hitoshi Sugihara
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
- IVY Clinic
| | - Masato Iwabu
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
| | - Naoya Emoto
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
- Department of Diabetes, Endocrinology and Metabolism, Nippon Medical School Chiba Hokusoh Hospital
- Diabetes & Endocrine Clinic, Sakura Chuo Hospital
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Chaker L, Cooper DS, Walsh JP, Peeters RP. Hyperthyroidism. Lancet 2024; 403:768-780. [PMID: 38278171 DOI: 10.1016/s0140-6736(23)02016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/07/2023] [Accepted: 09/16/2023] [Indexed: 01/28/2024]
Abstract
Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from Graves' disease or toxic nodular goitre, whereas thyroiditis (typically autoimmune, viral, or drug induced) causes thyrotoxicosis without hyperthyroidism. The diagnosis is based on suppressed serum concentrations of thyroid-stimulating hormone (TSH), accompanied by free thyroxine and total or free tri-iodothyronine concentrations, which are raised (overt hyperthyroidism) or within range (subclinical hyperthyroidism). The underlying cause is determined by clinical assessment, detection of TSH-receptor antibodies and, if necessary, radionuclide thyroid scintigraphy. Treatment options for hyperthyroidism include antithyroid drugs, radioactive iodine, and thyroidectomy, whereas thyroiditis is managed symptomatically or with glucocorticoid therapy. In Graves' disease, first-line treatment is a 12-18-month course of antithyroid drugs, whereas for goitre, radioactive iodine or surgery are preferred for toxic nodules or goitres. Evidence also supports long-term treatment with antithyroid drugs as an option for patients with Graves' disease and toxic nodular goitre.
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Affiliation(s)
- Layal Chaker
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - David S Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Walsh
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
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Cappellani D, Bartalena L, Bogazzi F. Short review: novel concepts in the approach to patients with amiodarone-induced thyrotoxicosis. J Endocrinol Invest 2024; 47:275-283. [PMID: 37731073 PMCID: PMC10859339 DOI: 10.1007/s40618-023-02168-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/25/2023] [Indexed: 09/22/2023]
Abstract
INTRODUCTION Amiodarone-induced thyrotoxicosis is associated with high morbidity and mortality rates. The approach to this condition is widely variable across different medical specialists and even among expert endocrinologists. As a matter of fact, the approach to amiodarone-induced thyrotoxicosis has always been considered difficult, due to diagnostic uncertainties easily resulting in missteps, and therapeutic challenges easily resulting in unresponsiveness or slow-responsiveness to the administered drugs. PURPOSE Our purpose is to review novelties emerged during the last years about this condition, with the aim to provide novel insights on the diagnostic and therapeutic management of this challenging condition.
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Affiliation(s)
- D Cappellani
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy
| | - L Bartalena
- School of Medicine, University of Insubria, Varese, Italy
| | - F Bogazzi
- Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, via Paradisa 2, 56124, Pisa, Italy.
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Hashimoto T, Yahiro T, Takakura S, Khan S, Kimitsuki K, Hiramatsu K, Nishizono A. Thyroid abscess associated with thyrotoxicosis caused by Yersinia enterocolitica subsp. palearctica in a patient with follicular adenoma of the thyroid gland. BMC Infect Dis 2024; 24:59. [PMID: 38191305 PMCID: PMC10773048 DOI: 10.1186/s12879-024-08974-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/01/2024] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Yersinia enterocolitica is a gram-negative zoonotic bacterial pathogen that is typically transmitted via the fecal-oral route. The most common clinical manifestation of a Y. enterocolitica infection is self-limited gastroenteritis. Although various extraintestinal manifestations of Y. enterocolitica infection have been reported, there are no reports of thyroid abscesses. CASE PRESENTATION An 89-year-old Japanese man with follicular adenoma of the left thyroid gland was admitted to our hospital with a 2-day history of fever and left neck pain. Laboratory tests revealed low levels of thyroid stimulating hormone and elevated levels of free thyroxine 4. Contrast-enhanced computed tomography showed low-attenuation areas with peripheral enhancement in the left thyroid gland. He was diagnosed with thyroid abscess and thyrotoxicosis, and treatment with intravenous piperacillin-tazobactam was initiated after collecting blood, drainage fluid, and stool samples. The isolated Gram-negative rod bacteria from blood and drainage fluid cultures was confirmed to be Y. enterocolitica. He was diagnosed with thyroid abscess and thyrotoxicosis due to be Y. enterocolitica subsp. palearctica. The piperacillin-tazobactam was replaced with levofloxacin. CONCLUSION We report a novel case of a thyroid abscess associated with thyrotoxicosis caused by Y. enterocolitica subsp. palearctica in a patient with a follicular thyroid adenoma.
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Affiliation(s)
- Takehiro Hashimoto
- Infection Control Center, Oita University Hospital, Oita, Japan.
- Department of Microbiology, Oita University Faculty of Medicine, Oita, Japan.
| | - Takaaki Yahiro
- Department of Microbiology, Oita University Faculty of Medicine, Oita, Japan
- Department of Advanced Medical Sciences, Oita University Faculty of Medicine, Oita, Japan
- Research Center for Global and Local Infectious Diseases, Oita, Japan
| | - Sonoka Takakura
- Department of Otolaryngology and Head & Neck Surgery, Oita University Faculty of Medicine, Oita, Japan
| | - Sakirul Khan
- Department of Microbiology, Oita University Faculty of Medicine, Oita, Japan
| | - Kazunori Kimitsuki
- Department of Microbiology, Oita University Faculty of Medicine, Oita, Japan
| | - Kazufumi Hiramatsu
- Infection Control Center, Oita University Hospital, Oita, Japan
- Research Center for Global and Local Infectious Diseases, Oita, Japan
| | - Akira Nishizono
- Department of Microbiology, Oita University Faculty of Medicine, Oita, Japan
- Research Center for Global and Local Infectious Diseases, Oita, Japan
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Hoshina Y, Setterquist H, McConnell TD, Renner DR. Thyrotoxic periodic paralysis presenting with quadriparesis and hyperreflexia. BMJ Case Rep 2023; 16:e256550. [PMID: 38160034 PMCID: PMC10759007 DOI: 10.1136/bcr-2023-256550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism that manifests as painless flaccid paralysis. An East Asian man in his late 20s presented to the emergency department with an acute onset of quadriparesis associated with hypertonia and hyperreflexia. His initial symptoms and signs suggested involvement of the brain and spinal cord; however, MRI of the neuroaxis was normal. His serum potassium concentration was low, and thyroid test results were consistent with hyperthyroidism. The patient was diagnosed with TPP associated with Graves' disease and was treated with potassium supplementation, propranolol and methimazole. Motor strength improved to his baseline level of power; bulk was normal, and tone was increased. Although flaccid paralysis is a typical presentation of TPP, brisk reflexes and muscle spasticity cannot rule out this condition. This case highlights the importance of considering TPP as a possible diagnosis in patients presenting with acute quadriparesis.
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Affiliation(s)
- Yoji Hoshina
- Neurology, University of Utah Health, Salt Lake City, Utah, USA
| | - Hana Setterquist
- Psychiatry, University of Utah Health, Salt Lake City, Utah, USA
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Cilia K, Mifsud S, Craus S, Vella S, Dingli N. Encephalitis as an initial presentation of type 2 amiodarone-induced thyrotoxicosis. BMJ Case Rep 2023; 16:e257731. [PMID: 38123318 DOI: 10.1136/bcr-2023-257731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
We report a case of a woman in her mid-20s presenting with encephalitis as the initial presentation of type 2 amiodarone-induced thyrotoxicosis (AIT). She was on amiodarone in view of a history of hypertrophic cardiomyopathy. Symptomatology included acute personality change and focal myoclonic jerks.Cerebrospinal fluid analysis showed a non-specific protein count elevation with negative microbiology, virology, autoimmune screen and onconeural antibodies. The electroencephalogram was consistent with a generalised cerebral dysrhythmia. An MRI of the head revealed symmetrical oedema within the motor cortices and a high T2 signal within the cerebellar dentate nuclei, with no restricted diffusion. Blood investigations confirmed thyrotoxicosis with negative antithyroid antibodies. She did not fulfil the criteria for a thyroid storm. Other possible causes of encephalitis were excluded.There was an excellent clinical, laboratory and radiological response to glucocorticoids, suggesting a diagnosis of steroid-responsive encephalitis secondary to type 2-AIT in the absence of a thyroid storm.
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Affiliation(s)
- Kyle Cilia
- Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta
| | - Simon Mifsud
- Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta
| | - Sarah Craus
- Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta
| | - Sandro Vella
- Department of Diabetes and Endocrinology, Mater Dei Hospital, Msida, Malta
| | - Nicola Dingli
- Department of Neuroscience, Mater Dei Hospital, Msida, Malta
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Adams R, Oh ES, Yasar S, Lyketsos CG, Mammen JS. Endogenous and Exogenous Thyrotoxicosis and Risk of Incident Cognitive Disorders in Older Adults. JAMA Intern Med 2023; 183:1324-1331. [PMID: 37870843 PMCID: PMC10594176 DOI: 10.1001/jamainternmed.2023.5619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 08/15/2023] [Indexed: 10/24/2023]
Abstract
Importance Thyroid hormone is among the most common prescriptions in the US and up to 20% may be overtreated. Endogenous hyperthyroidism may be a risk factor for dementia, but data are limited for iatrogenic thyrotoxicosis. Objective To determine whether thyrotoxicosis, both endogenous and exogenous, is associated with increased risk of cognitive disorders. Design, Setting, and Participants This cohort study performed a longitudinal time-varying analysis of electronic health records for patients receiving primary care in the Johns Hopkins Community Physicians Network between January 1, 2014, and May 6, 2023. Patients 65 years and older with at least 2 visits 30 days apart to their primary care physicians were eligible. None of the 65 931 included patients had a history of low thyrotropin (TSH) level or cognitive disorder diagnoses within 6 months of their first visit. Data analysis was performed from January 1 through August 5, 2023. Exposure The exposure variable was a low TSH level, characterized based on the clinical context as due to endogenous thyrotoxicosis, exogenous thyrotoxicosis, or unknown cause, excluding those attributable to acute illness or other medical factors such as medications. Main Outcomes and Measures The outcome measure was cognitive disorders, including mild cognitive impairment and all-cause dementia, to improve sensitivity and account for the underdiagnosis of dementia in primary care. Results A total of 65 931 patients were included in the analysis (median [IQR] age at first visit, 68.0 [65.0-74.0] years; 37 208 [56%] were female; 46 106 [69.9%] were White). Patients exposed to thyrotoxicosis had cognitive disorder incidence of 11.0% (95% CI, 8.4%-14.2%) by age 75 years vs 6.4% (95% CI, 6.0%-6.8%) for those not exposed. After adjustment, all-cause thyrotoxicosis was significantly associated with risk of cognitive disorder diagnosis (adjusted hazard ratio, 1.39; 95% CI, 1.18-1.64; P < .001) across age groups. When stratified by cause and severity, exogenous thyrotoxicosis remained a significant risk factor (adjusted hazard ratio, 1.34; 95% CI, 1.10-1.63; P = .003) with point estimates suggestive of a dose response. Conclusions and Relevance In this cohort study among patients 65 years and older, a low TSH level from either endogenous or exogenous thyrotoxicosis was associated with higher risk of incident cognitive disorder. Iatrogenic thyrotoxicosis is a common result of thyroid hormone therapy. With thyroid hormone among the most common prescriptions in the US, understanding the negative effects of overtreatment is critical to help guide prescribing practice.
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Affiliation(s)
- Roy Adams
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Esther S. Oh
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Sevil Yasar
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Constantine G. Lyketsos
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jennifer S. Mammen
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Shin K, Kim J, Park J, Oh TJ, Kong SH, Ahn CH, Moon JH, Kim MJ, Moon JH. A machine learning-assisted system to predict thyrotoxicosis using patients' heart rate monitoring data: a retrospective cohort study. Sci Rep 2023; 13:21096. [PMID: 38036639 PMCID: PMC10689821 DOI: 10.1038/s41598-023-48199-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/23/2023] [Indexed: 12/02/2023] Open
Abstract
Previous studies have shown a correlation between resting heart rate (HR) measured by wearable devices and serum free thyroxine concentration in patients with thyroid dysfunction. We have developed a machine learning (ML)-assisted system that uses HR data collected from wearable devices to predict the occurrence of thyrotoxicosis in patients. HR monitoring data were collected using a wearable device for a period of 4 months in 175 patients with thyroid dysfunction. During this period, 3 or 4 thyroid function tests (TFTs) were performed on each patient at intervals of at least one month. The HR data collected during the 10 days prior to each TFT were paired with the corresponding TFT results, resulting in a total of 662 pairs of data. Our ML-assisted system predicted thyrotoxicosis of a patient at a given time point based on HR data and their HR-TFT data pair at another time point. Our ML-assisted system divided the 662 cases into either thyrotoxicosis and non-thyrotoxicosis and the performance was calculated based on the TFT results. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of our system for predicting thyrotoxicosis were 86.14%, 85.92%, 52.41%, and 97.18%, respectively. When subclinical thyrotoxicosis was excluded from the analysis, the sensitivity, specificity, PPV, and NPV of our system for predicting thyrotoxicosis were 86.14%, 98.28%, 94.57%, and 95.32%, respectively. Our ML-assisted system used the change in mean, relative standard deviation, skewness, and kurtosis of HR while sleeping, and the Jensen-Shannon divergence of sleep HR and TFT distribution as major parameters for predicting thyrotoxicosis. Our ML-assisted system has demonstrated reasonably accurate predictions of thyrotoxicosis in patients with thyroid dysfunction, and the accuracy could be further improved by gathering more data. This predictive system has the potential to monitor the thyroid function status of patients with thyroid dysfunction by collecting heart rate data, and to determine the optimal timing for blood tests and treatment intervention.
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Affiliation(s)
- Kyubo Shin
- THYROSCOPE INC., Ulsan, Republic of Korea
| | | | | | - Tae Jung Oh
- Department of Internal Medicine, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Sung Hye Kong
- Department of Internal Medicine, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Chang Ho Ahn
- Department of Internal Medicine, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Joon Ho Moon
- Department of Internal Medicine, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Min Joo Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam, Republic of Korea
| | - Jae Hoon Moon
- THYROSCOPE INC., Ulsan, Republic of Korea.
- Department of Internal Medicine, Seoul National University Bundang Hospital and Seoul National University College of Medicine, Seongnam, Republic of Korea.
- Center for Artificial Intelligence in Healthcare, Seoul National University Bundang Hospital, Seongnam, Republic of Korea.
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Makino M, Koriyama N, Kojima N, Nishio Y. A Rare Case of Painless Destructive Thyroiditis Resulting in Thyroid Storm. Intern Med 2023; 62:3373-3379. [PMID: 37032084 DOI: 10.2169/internalmedicine.1496-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/11/2023] Open
Abstract
Thyroid storm is a life-threatening clinical condition that is usually triggered by untreated or interrupted treatment of Graves' disease, leading to the sudden onset of severe thyrotoxicosis, which requires an immediate diagnosis and treatment based on diagnostic criteria. Cases of thyroid storm caused by painless/painless subacute thyroiditis are very rare. We herein report an 85-year-old man with features of severe thyrotoxicosis caused by painless/painless subacute thyroiditis who had no uptake of 99mTcO4 and was negative for thyroid-stimulating hormone receptor antibodies. In thyroid storm patients in whom the findings are inconsistent with Graves' disease, careful follow-up and management are necessary, assuming the possibility of painless or painless subacute thyroiditis.
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Affiliation(s)
- Miwa Makino
- Department of Diabetes and Endocrinology, National Hospital Organization, Kagoshima Medical Center, Japan
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, Japan
| | - Nobuyuki Koriyama
- Department of Diabetes and Endocrinology, National Hospital Organization, Kagoshima Medical Center, Japan
| | - Nami Kojima
- Department of Diabetes and Endocrinology, National Hospital Organization, Kagoshima Medical Center, Japan
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, Japan
| | - Yoshihiko Nishio
- Department of Diabetes and Endocrine Medicine, National Hospital Organization Kagoshima Medical Center, Japan
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Abstract
Hyperthyroidism is a diagnosis existing along a spectrum of severity. Patients present with a variety of signs and symptoms: tachycardia, elevated heart rate, anxiety, changes in mental status, gastrointestinal disturbances, and hyperthermia. Management of subclinical hyperthyroidism and thyrotoxicosis without thyroid storm is heavily dependent on outpatient evaluation. Thyroid storm is the most severe form of hyperthyroidism with the highest mortality. Management of thyroid storm follows a stepwise approach, with resuscitation and detection of the precipitating cause being paramount. Special attention should be paid to cardiac function in patients with thyroid storm before treatment, as these patients may develop cardiac collapse.
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Affiliation(s)
- Brannon L Inman
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Fu SE, Liang XH, Tang ZP, Kuang YQ, Qiu CC, Liu XF, Yang HY, Huang ZX, Qin YF, Ma Y, Luo ZJ. Acute Thyrotoxic Myopathy Combined with Neck Pain: A Case Report. Neuro Endocrinol Lett 2023; 44:427-431. [PMID: 37874555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 09/04/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Acute thyrotoxic myopathy (ATM) is a rare and potentially lethal complication of thyrotoxicosis. The typical clinical symptoms of ATM are characterized by bulbar paralysis. Reports of the successful treatment of ATM are sporadic due to its low incidence. However, no English literature has reported Chinese patients with ATM and neck pain. Here, we report for the first time a Chinese patient with ATM and neck pain who recovered through large doses of systemic glucocorticoids and one intrathyroidal steroid injection. CASE REPORT A 23-year-old woman visited our hospital with a two-year history of progressive weakness of her bulbar muscles, hoarseness, cough when swallowing, dysphagia, and a one-month history of recurrent painful swelling of the thyroid gland. She was diagnosed with ATM, chronic thyrotoxic myopathy (CTM), and Graves' ophthalmopathy (GO) due to Graves' disease (GD). After she was treated with a combination of low-dose glucocorticoids, antithyroid drugs (ATDs), propranolol, and ultrasound-guided percutaneous intrathyroidal injection of glucocorticoids, her bulbar paralysis, proximal myopathy, and neck pain simultaneously improved without recurrence during follow-up. To our knowledge, this is the first case report of a patient with ATM, CTM, GD, GO and neck pain treated by administering a combination of low-dose glucocorticoids, one intrathyroidal steroid injection and antithyroid agents. CONCLUSIONS Clinicians should consider ATM and intervene with aggressive glucocorticoid therapy, and this is the key to reversing the progression of ATM when a patient has bulbar paralysis and thyrotoxic symptoms. Our case report references the clinical diagnosis and treatment of such cases.
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Affiliation(s)
- Shi-En Fu
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xing-Huan Liang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhi-Ping Tang
- Department of Ultrasonic Diagnosis, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ya-Qi Kuang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Cheng-Cheng Qiu
- Department of Ultrasonic Diagnosis, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Xiao-Fan Liu
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Hai-Yan Yang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhen-Xing Huang
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Ying-Fen Qin
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yan Ma
- Department of Ultrasonic Diagnosis, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zuo-Jie Luo
- Department of Endocrinology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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14
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Abstract
Importance Overt hyperthyroidism, defined as suppressed thyrotropin (previously thyroid-stimulating hormone) and high concentration of triiodothyronine (T3) and/or free thyroxine (FT4), affects approximately 0.2% to 1.4% of people worldwide. Subclinical hyperthyroidism, defined as low concentrations of thyrotropin and normal concentrations of T3 and FT4, affects approximately 0.7% to 1.4% of people worldwide. Untreated hyperthyroidism can cause cardiac arrhythmias, heart failure, osteoporosis, and adverse pregnancy outcomes. It may lead to unintentional weight loss and is associated with increased mortality. Observations The most common cause of hyperthyroidism is Graves disease, with a global prevalence of 2% in women and 0.5% in men. Other causes of hyperthyroidism and thyrotoxicosis include toxic nodules and the thyrotoxic phase of thyroiditis. Common symptoms of thyrotoxicosis include anxiety, insomnia, palpitations, unintentional weight loss, diarrhea, and heat intolerance. Patients with Graves disease may have a diffusely enlarged thyroid gland, stare, or exophthalmos on examination. Patients with toxic nodules (ie, in which thyroid nodules develop autonomous function) may have symptoms from local compression of structures in the neck by the thyroid gland, such as dysphagia, orthopnea, or voice changes. Etiology can typically be established based on clinical presentation, thyroid function tests, and thyrotropin-receptor antibody status. Thyroid scintigraphy is recommended if thyroid nodules are present or the etiology is unclear. Thyrotoxicosis from thyroiditis may be observed if symptomatic or treated with supportive care. Treatment options for overt hyperthyroidism from autonomous thyroid nodules or Graves disease include antithyroid drugs, radioactive iodine ablation, and surgery. Treatment for subclinical hyperthyroidism is recommended for patients at highest risk of osteoporosis and cardiovascular disease, such as those older than 65 years or with persistent serum thyrotropin level less than 0.1 mIU/L. Conclusions and Relevance Hyperthyroidism affects 2.5% of adults worldwide and is associated with osteoporosis, heart disease, and increased mortality. First-line treatments are antithyroid drugs, thyroid surgery, and radioactive iodine treatment. Treatment choices should be individualized and patient centered.
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Affiliation(s)
- Sun Y. Lee
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Elizabeth N. Pearce
- Section of Endocrinology, Diabetes, Nutrition, and Weight Management, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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15
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Seyedjavadeyn Z, Miratashi Yazdi SA, Samimiat A, Vahedi M. Thyrotoxicosis as a rare presentation in acute suppurative thyroiditis: a case report. J Med Case Rep 2023; 17:428. [PMID: 37833794 PMCID: PMC10576297 DOI: 10.1186/s13256-023-04119-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/04/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Acute suppurative thyroiditis is a rare and potentially life-threatening disease. A few cases of acute suppurative thyroiditis associated with thyrotoxicosis have been reported in adults. We report a case of acute suppurative thyroiditis that was associated with thyrotoxicosis. CASE PRESENTATION We report the case of a 49-year-old Iranian female presented with a painful neck swelling for a week. Computed tomography showed a well-defined gas-filled collection in the left thyroid lobe with an enhancing margin. The patient underwent two-phase surgery, first left thyroid abscess drainage and then total thyroidectomy. The result of histopathology examination was multinodular goiter with abscess formation without malignancy. CONCLUSION Abscess formation and thyrotoxicosis is a very rare condition that occurs at the same time in acute suppurative thyroiditis. Despite antibiotic therapy being the first line of treatment, surgery is also required when antibiotic therapy fails.
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Affiliation(s)
- Zeynab Seyedjavadeyn
- Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Alireza Samimiat
- Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Matin Vahedi
- Department of General Thoracic Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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16
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Lin Y, Riek AE, Gronowski AM, Farnsworth CW. Limited Utility of Free Triiodothyronine Testing. J Appl Lab Med 2023; 8:847-855. [PMID: 37473430 DOI: 10.1093/jalm/jfad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Accepted: 03/31/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND Free triiodothyronine (fT3) testing is most useful when thyroid stimulating hormone (TSH) is suppressed, and free thyroxine (fT4) is normal or decreased. These laboratory values in a symptomatic patient are referred to as T3 thyrotoxicosis. Standards for fT3 reflex testing have not been established. Herein, we examined the clinical utility of fT3 with the goal of identifying a TSH cutoff in the context of normal/decreased fT4 that maximizes the utility of measuring fT3. METHODS TSH, fT4, and fT3 results between January 2016 and October 2021 were extracted from the laboratory information system and grouped if resulted on the same day for the same patient. Frequency of biochemical T3 thyrotoxicosis was evaluated at different TSH cutoffs and in outpatient vs inpatient settings. RESULTS Of the 4366 TSH-fT4-fT3 results, 70 (1.6%) were consistent with biochemical T3 thyrotoxicosis. The common reasons were previously diagnosed hyperthyroidism on antithyroid medication (n = 28) or hypothyroidism on thyroid medication (n = 18) and newly diagnosed hyperthyroidism (n = 20, 0.5%). The likelihood of detecting T3 thyrotoxicosis increased with lower TSH cutoff (<0.3 μIU/mL, 10.3% vs <0.0 1μIU/mL, 27.6%). All patients with newly diagnosed hyperthyroidism had TSH <0.01 μIU/mL. Higher frequency of T3 thyrotoxicosis was observed in the outpatient setting (34%) relative to the inpatient setting (14%, P < 0.001) when TSH < 0.01 μIU/mL. CONCLUSIONS T3 thyrotoxicosis is a relatively rare diagnosis and fT3 measurement has limited utility in the vast majority of patients. A fT3 reflex for patients with TSH <0.01 μIU/mL and normal/low fT4 may improve clinical utility and reduce unnecessary testing, especially in the outpatient setting.
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Affiliation(s)
- Yanchun Lin
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Amy E Riek
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipid Research, Washington University School of Medicine, St. Louis, MO, United States
| | - Ann M Gronowski
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
| | - Christopher W Farnsworth
- Department of Pathology & Immunology, Washington University in St. Louis School of Medicine, St. Louis, MO, United States
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17
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Guo N, Xue M, Liang Z. Advances in the differential diagnosis of transient hyperthyroidism in pregnancy and Graves' disease. Arch Gynecol Obstet 2023; 308:403-411. [PMID: 36112207 DOI: 10.1007/s00404-022-06774-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Accepted: 08/28/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The occurrence of thyrotoxicosis during pregnancy is mainly attributed to gestational transient thyrotoxicosis (GTT) and Graves' disease (GD). It is important to distinguish between GTT and Graves' disease because the two diseases are treated very differently. However, a gold standard for the differential diagnosis of the two diseases is currently lacking, and the most common method of differentiation is based on past medical history and clinical presentation combined with thyroid-related antibodies. METHODS A literature search of the electronic databases PubMed, Embase, Medline, Google Scholar, Cochrane Library, China Knowledge Infrastructure, Wanfang Database, Chinese Scientific Journals Full Text Database and China Biomedical CD-ROM was performed. The search period ranged from journal inception until 2022. We used the following search terms in "All fields": {["thyroid" (common field) OR "thyroid" (subject line)] OR "hyperthyroidism" (common field)} AND {["pregnancy" (title) OR "pregnancy" (title)] AND "one over" (common field)} OR {["pregnancy" (common field) OR "pregnancy" (common field) OR "pregnancy" (subject line)] AND "Graves'" (common field)}. RESULTS In recent years, some clinical studies at home and abroad have proposed other meaningful differential indicators, such as thyroid stimulating hormone, chorionic gonadotropin, thyroid hormone levels and thyroid ultrasound. CONCLUSION The differential diagnostic significance of each of these indicators is summarised here with the goal of providing a better reference for the differential diagnosis of hyperthyroidism during pregnancy in clinical practice.
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Affiliation(s)
- Nian Guo
- Department of Endocrinology and Metabolism, The Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, China
| | - Meng Xue
- Department of Endocrinology and Metabolism, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China
| | - Zhen Liang
- Department of Endocrinology and Metabolism, The Second Clinical Medical College, Jinan University (Shenzhen People's Hospital), Shenzhen, Guangdong, China.
- Department of Geriatrics, Shenzhen People's Hospital (The Second Clinical Medical College, Jinan University, The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen, Guangdong, China.
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18
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Intenzo C, Miller J, Gulati A, Colarossi D, Parekh M. The Role of Nuclear Medicine in Benign Thyroid Disease. Semin Nucl Med 2023; 53:469-474. [PMID: 37142521 DOI: 10.1053/j.semnuclmed.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/30/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023]
Abstract
Since the mid-twentieth century, the radionuclide thyroid scan has been utilized in the management of benign thyroid disorders. In current medical practice, patients with hyperthyroidism are referred for thyroid scintigraphy, while patients with goiters and thyroid nodules are most often evaluated by ultrasound or computed tomography. Since thyroid scintigraphy reflects the functional state of the gland, it provides information that anatomical imaging lacks. Therefore, radionuclide imaging of the thyroid is the imaging modality of choice in the evaluation of the hyperthyroid patient. In addition, patients with so-called subclinical hyperthyroidism often present a diagnostic dilemma to the clinician since the causative factor must be determined for proper patient management. The aim of this manuscript is to illustrate the imaging characteristics of thyroid disorders commonly seen in clinical practice resulting in thyrotoxicosis or pending thyrotoxicosis, so that correlation with clinical presentation and pertinent laboratory data will lead to the correct diagnosis.
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Affiliation(s)
- Charles Intenzo
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - Jeffrey Miller
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Aishwarya Gulati
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Daly Colarossi
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Maansi Parekh
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
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19
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van Hulsteijn LT, Prins JR, Scheffer-Rath MEA, van Trotsenburg ASP, Links TP, Dullaart RPF. Fetal Thyrotoxicosis due to Maternal TSH Receptor Stimulating Antibodies Causes Infant Central Hypothyroidism. Horm Res Paediatr 2023; 97:180-186. [PMID: 37231969 DOI: 10.1159/000530725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Accepted: 04/11/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Women with a current diagnosis or past history of Graves' disease (GD) are at risk of developing fetal thyrotoxicosis (FT) during pregnancy when they are inadequately treated, or because of placental passage of TSH receptor antibodies (TRAb). It is known that FT induced by high maternal thyroid hormone concentrations may result in infant (central) hypothyroidism. CASE PRESENTATION In a euthyroid woman with a history of GD treated with radioactive iodide (I131), persistently high levels of maternal TRAb resulted in recurrent FT during two separate pregnancies, followed by neonatal hyperthyroidism and infant central hypothyroidism. DISCUSSION This case demonstrates the novel insight that FT due to high fetal thyroid hormone concentrations stimulated by high maternal TRAb levels might also result in (central) hypothyroidism, requiring long-term evaluation of the hypothalamus-pituitary-thyroid axis in these children.
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Affiliation(s)
- Leonie T van Hulsteijn
- Department of Endocrinology, University Medical Center Groningen, Groningen, The Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynecology, University Medical Center Groningen, Groningen, The Netherlands
| | - Mirjam E A Scheffer-Rath
- Department of Pediatric Endocrinology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, The Netherlands
| | - A S Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Center, Groningen, The Netherlands
| | - Thera P Links
- Department of Endocrinology, University Medical Center Groningen, Groningen, The Netherlands
| | - Robin P F Dullaart
- Department of Endocrinology, University Medical Center Groningen, Groningen, The Netherlands
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20
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Gulde A, Zhang S, Hussain I. Thyrotoxic Periodic Paralysis: An Under-Recognized Cause of Paralysis in Young Hispanic Men. J Emerg Med 2023; 64:200-207. [PMID: 36710091 DOI: 10.1016/j.jemermed.2022.10.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 09/13/2022] [Accepted: 10/21/2022] [Indexed: 01/29/2023]
Abstract
BACKGROUND Patients presenting to the emergency department with paralysis can have a wide differential diagnosis. Thyrotoxic periodic paralysis (TPP) is a rare disorder causing transient flaccid paralysis in the setting of thyrotoxicosis and hypokalemia. It has been reported in Asian male populations predominantly, and the diagnosis is rarely considered in non-Asian populations. Recent research has identified cases in patients with diverse ethnic backgrounds, although epidemiologic data from the United States are very limited. OBJECTIVE Our aim was to report our experience with TPP at a tertiary care center in the United States. METHODS A retrospective chart review was conducted between January 2006 and February 2022 to identify cases of TPP and determine their demographic and clinical characteristics. Prevalence of TPP was estimated using the institutional hyperthyroidism registry. RESULTS Thirty-three patients with TPP were identified. All of the patients were male; median age was 28 years, and 85% were Hispanic. All patients had hypokalemia at presentation and 23% had rebound hyperkalemia after treatment. Prevalence of TPP in our population of patients with hyperthyroidism was approximately 0.5%. CONCLUSIONS Young Hispanic men presenting with paralysis should be evaluated for TPP, as the prevalence in this population may be higher than estimated previously. Management of TPP involves treatment of underlying hyperthyroidism and cautious potassium repletion, with an initial dose of no more than 60 mEq/L of potassium chloride to avoid rebound hyperkalemia.
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Affiliation(s)
- Andrew Gulde
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Shuyao Zhang
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Iram Hussain
- Division of Endocrinology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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21
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Azeez TA, Lamidi AO, Osin IO. A systematic review and meta-analysis of the etiology and treatment patterns of thyrotoxicosis in Africa. Expert Rev Endocrinol Metab 2022; 17:563-572. [PMID: 36267032 DOI: 10.1080/17446651.2022.2136165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/11/2022] [Indexed: 01/05/2023]
Abstract
INTRODUCTION Thyrotoxicosis is one of the most common endocrine disorders seen in clinical practice. This study aims to determine the etiologies and treatment modalities of thyrotoxicosis in Africa. AREAS COVERED The study design is a systematic review with a meta-analysis. Medical databases and the gray literature were systematically searched following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies done in Africa on the etiology and treatment of thyrotoxicosis were selected. EXPERT OPINION In Africa, it is still believed that autoimmune diseases, generally, are not as common as what is seen in the western world. The frequency of Graves' disease is reportedly lower in Africa. The treatment of thyrotoxicosis depends on the cause. Therefore, it is of substantial importance to establish the etiology following the diagnosis of the clinical syndrome.
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22
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Lantz M, Almquist M, Koutouridou E, Pellby D, Planck T, Tsoumani K, Mijovic Z. [Thyroid ultrasound and its role in the investigation of thyroid disease]. Lakartidningen 2022; 119:22046.. [PMID: 36285373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
In Europe thyroid ultrasound has been used at outpatient endocrine clinics since many years, and in southern Sweden only during the last years. Ultrasound has a role in the investigation of Graves' disease, subacute thyroiditis, gestational thyrotoxicosis, postpartum thyroiditis, amiodarone thyrotoxicosis and goiter with or without adenoma, but adenomas are usually investigated by endocrine surgeons in Sweden. If widely used the risk for detection of incidentaloma increases. Indications have to be strictly used to avoid further investigations. If an adenoma is localized, the risk for malignancy and requirement of aspiration is estimated by use of the EU-TIRADS classification based on morphology and size. The aspirate is judged by the Bethesda classification, which determines if further investigation is needed. The use of ultrasound at the outpatient clinic has improved the diagnostic quality and follow-up of thyroid patients.
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Affiliation(s)
- Mikael Lantz
- docent, överläkare, VE endokrinologi, Skånes universitetssjukhus Malmö/Lund
| | - Martin Almquist
- docent, överläkare, sektionen för endokrinkirurgi, kirurgiska kliniken, Skånes universitetssjukhus Lund
| | | | - David Pellby
- övertandläkare, Neuroradiologi, VO bild och funktion, Skånes universitetssjukhus Lund
| | - Tereza Planck
- docent, överläkare, VE endokrinologi, Skånes universitetssjukhus Malmö/Lund
| | - Kleoniki Tsoumani
- specialistläkare, VE endokrinologi, Skånes universitetssjukhus Malmö/Lund
| | - Zoran Mijovic
- överläkare, gastro-/uroradiologi, VO bild och funktion, Skånes universitetssjukhus Lund
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23
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Hitsuwari T, Tsurutani Y, Yamane T, Sunouchi T, Horikoshi H, Hirose R, Hoshino Y, Watanabe S, Katsuragawa S, Saitou J. Two Cases of Thyrotoxicosis and Euglycemic Diabetic Ketoacidosis Under Sodium-glucose Transport Protein 2 Inhibitor Treatment. Intern Med 2022; 61:3069-3075. [PMID: 35370232 PMCID: PMC9646346 DOI: 10.2169/internalmedicine.8830-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Thyrotoxicosis and sodium-glucose transport protein 2 inhibitors (SGLT2is) are associated with the induction of euglycemic diabetic ketoacidosis (euDKA). We herein report two cases of euDKA in patients with diabetes mellitus wherein both thyrotoxicosis and SGLT2i treatment were the underlying causes. One patient developed thyrotoxicosis during the course of type 2 diabetes mellitus, whereas the other patient was suspected of developing slowly progressive insulin-dependent diabetes mellitus during the course of Graves' disease. Although such cases are rare, there is some concern that similar cases may occur because of the increased frequency of SGLT2i use in recent years.
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Affiliation(s)
| | - Yuya Tsurutani
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Takahiro Yamane
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Takashi Sunouchi
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | | | - Rei Hirose
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | | | - Satoshi Watanabe
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Sho Katsuragawa
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
| | - Jun Saitou
- Endocrinology and Diabetes Center, Yokohama Rosai Hospital, Japan
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Pagán-Rappo MJ, Jurado-Fernández de Lara CE, Castro-Sánchez O, Carpio-Vargas KY, Gutiérrez-Riveroll KI. [Multimodal anesthesia in a patient with Graves' disease and thyrotoxicosis: A case report]. Rev Med Inst Mex Seguro Soc 2022; 60:584-590. [PMID: 36049082 PMCID: PMC10395889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 05/11/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Hyperthyroidism is the increase in the synthesis and secretion of thyroid hormones. It is rare but serious in children and constitutes approximately 5% of all cases; 15% manifests before 10 years of age. The peak of presentation and the majority of cases (80%) are diagnosed around 10-15 years of age. Adolescence is usually the stage with the highest incidence and it is more frequent in women (5:1). Acute thyrotoxic crisis or thyroid storm is rare and only occurs in a poorly controlled hyperthyroid patient or in a hyperthyroid patient undergoing emergency surgery. It is manifested by fever, extreme tachycardia, tachyarrhythmia with atrial fibrillation, vomiting, diarrhea, agitation and mental confusion. CLINICAL CASE 17-year-old adolescent with Graves' disease with uncontrolled clinical manifestations that did not respond to medical treatment and was scheduled for radical thyroidectomy. 35 points were obtained on the Burch and Wartofsky Scale. It was managed with general anesthesia, reducing stimuli for airway and regional control to reduce surgical stimuli. Adjuvant medications such as magnesium sulfate for intraoperative stability were used. CONCLUSION Multimodal anesthesia managed to avoid thyroid storm, postoperative pain, as well as other complications.
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Affiliation(s)
- María José Pagán-Rappo
- Secretaría de Salud, Hospital Para el Niño Poblano, Servicio de Anestesiología Pediátrica. Puebla, Puebla, México
| | | | - Olga Castro-Sánchez
- Secretaría de Salud, Hospital de Alta Especialidad de Veracruz, Servicio de Anestesiología. Veracruz, Veracruz, México
| | - Karen Yarivani Carpio-Vargas
- Secretaría de Salud, Hospital Para el Niño Poblano, Servicio de Anestesiología Pediátrica. Puebla, Puebla, México
| | - Karla Itzel Gutiérrez-Riveroll
- Instituto Mexicano del Seguro Social, Centro Médico Nacional La Raza, Hospital General "Dr. Gaudencio González Garza", Servicio de Anestesiología Pediátrica. Ciudad de México, México
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25
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Al-Mashdali AF, Gul M, Umer W, Omar A, Jones A. Non-diabetic ketoacidosis secondary to primary hyperthyroidism: A case report. Medicine (Baltimore) 2022; 101:e28253. [PMID: 35687767 PMCID: PMC9276427 DOI: 10.1097/md.0000000000028253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 05/04/2022] [Indexed: 01/04/2023] Open
Abstract
INTRODUCTION There are variable complications of hyperthyroidism, including atrial fibrillation, heart failure, osteoporosis, and thyroid storm. One infrequent complication of hyperthyroidism is non-diabetic ketoacidosis (NDKA). To the best of our knowledge, our case is the third report of NDKA related to thyrotoxicosis. PATIENT CONCERN We describe a case of a 41-year-old African lady with no past medical history presented to our hospital with severe abdominal pain and vomiting for three weeks. This was associated with decreased appetite and weight loss. DIAGNOSIS Laboratory findings were significant for high anion gap metabolic acidosis, positive ketones in the urine, and high serum B-hydroxybutyrate. The blood glucose readings and HbA1c were within normal limits. Also, serum lactic acid and salicylate levels were within the normal range. The diagnosis of NDKA was made. Later, the thyroid functions test (TFT) confirmed the diagnosis of primary hyperthyroidism. INTERVENTION AND OUTCOMES The patient was managed initially with intravenous fluid and antiemetics. Then, she was started on propranolol and carbimazole. After which, her symptoms improved dramatically, and the metabolic acidosis (with serum ketones) were corrected within a few days of starting anti-thyroid medications. CONCLUSION Despite its rarity, NDKA can be associated with severe thyrotoxicosis. Vigorous intravenous hydration and anti-thyroid medication are the mainstay treatment. TFT should be requested in a patient with unexplained NDKA.
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Affiliation(s)
| | - Mohammadshah Gul
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Waseem Umer
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Abeer Omar
- College of Medicine, Qatar University, Doha, Qatar
| | - Akhnuwkh Jones
- Department of Internal Medicine, Hamad Medical Corporation, Doha, Qatar
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Rosario PW. Symptoms of thyrotoxicosis, bone metabolism, and occult atrial fibrillation in older women with mild endogenous subclinical hyperthyroidism: A reassessment after 5 years. Clin Endocrinol (Oxf) 2022; 96:914-915. [PMID: 34369606 DOI: 10.1111/cen.14579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 07/31/2021] [Accepted: 08/01/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Pedro W Rosario
- Instituto de Ensino e Pesquisa, Santa Casa de Belo Horizonte, Belo Horizonte, Minas Gerais, Brazil
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Pla Peris B, Merchante Alfaro AÁ, Maravall Royo FJ, Abellán Galiana P, Pérez Naranjo S, González Boillos M. Thyrotoxicosis following SARS-COV-2 vaccination: a case series and discussion. J Endocrinol Invest 2022; 45:1071-1077. [PMID: 35015288 PMCID: PMC8749352 DOI: 10.1007/s40618-022-01739-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/30/2021] [Indexed: 12/18/2022]
Abstract
AIM To describe a case series of thyrotoxicosis likely triggered by SARS-CoV-2 vaccination and to warn physicians about this potential correlation. To report clinical, laboratory and imaging findings and provide further information that goes in line with the underlying mechanisms. METHODS Single-center case series based on all the information collected in the hospital medical records, as well as the temporal sequence between the onset of symptoms and COVID-19 vaccination. RESULTS We report 8 cases with thyrotoxicosis after SARS-CoV-2 vaccination. 4 cases of Graves' disease (GD), 2 cases of subacute painful thyroiditis (SAT), 1 case of concurrent GD and SAT and 1 case of atypical subacute thyroiditis. Five patients received BNT162b2 mRNA vaccine, 3 patients 1273 mRNA vaccine. The onset of symptoms following vaccination ranged from 10 to 14 days in six of eight patients and from 7 to 8 weeks in two patients. CONCLUSIONS Several hypotheses have been proposed to explain the potential correlation between SARS-CoV-2 vaccination and thyrotoxicosis, including immune system hyper-stimulation, molecular mimicry and Autoimmune/Autoinflammatory Syndrome Induced by Adjuvants (ASIA). We should pay greater attention to thyroid disorders in patients receiving vaccine against SARS-CoV-2.
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Affiliation(s)
- B Pla Peris
- Department of Endocrinology and Nutrition, Hospital General Universitario de Castellón, Avinguda de Benicàssim, 128, 12004, Castelló de la Plana, Castelló, Spain.
| | - A Á Merchante Alfaro
- Department of Endocrinology and Nutrition, Hospital General Universitario de Castellón, Avinguda de Benicàssim, 128, 12004, Castelló de la Plana, Castelló, Spain
- Departament of Medicine, Jaume I University, Castelló de la Plana, Castelló, Spain
| | - F J Maravall Royo
- Department of Endocrinology and Nutrition, Hospital General Universitario de Castellón, Avinguda de Benicàssim, 128, 12004, Castelló de la Plana, Castelló, Spain
- Departament of Medicine, Jaume I University, Castelló de la Plana, Castelló, Spain
| | - P Abellán Galiana
- Department of Endocrinology and Nutrition, Hospital General Universitario de Castellón, Avinguda de Benicàssim, 128, 12004, Castelló de la Plana, Castelló, Spain
- Departament of Medicine, Cardenal Herrera-CEU University, Castelló de la Plana, Castelló, Spain
| | - S Pérez Naranjo
- Department of Endocrinology and Nutrition, Hospital General Universitario de Castellón, Avinguda de Benicàssim, 128, 12004, Castelló de la Plana, Castelló, Spain
| | - M González Boillos
- Department of Endocrinology and Nutrition, Hospital General Universitario de Castellón, Avinguda de Benicàssim, 128, 12004, Castelló de la Plana, Castelló, Spain
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Capezzone M, Tosti-Balducci M, Morabito EM, Caldarelli GP, Sagnella A, Cantara S, Alessandri M, Castagna MG. Silent thyroiditis following vaccination against COVID-19: report of two cases. J Endocrinol Invest 2022; 45:1079-1083. [PMID: 35034341 PMCID: PMC8761095 DOI: 10.1007/s40618-021-01725-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 12/07/2021] [Indexed: 01/19/2023]
Abstract
PURPOSE It is well established that thyroiditis and other thyroid disorders can be induced by COVID-19 infection, but there is limited information about the autoimmune/inflammatory syndrome induced by adjuvants (ASIA) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. We report two cases of thyrotoxicosis following SARS-CoV-2 vaccine. METHODS AND RESULTS Two young health care peoples (wife and husband) received a first dose of SARS-CoV-2 vaccine, and few weeks later developed clinical manifestations of thyroid hyperactivity, with increased thyroid hormone levels on thyroid function tests, suppressed thyroid-stimulating hormone and negative antithyroid antibodies, despite being healthy before vaccination. They were diagnosed at the 4th week after first dose of SARS-Cov-2 vaccine as silent thyroiditis and followed without treatment, since their symptoms were not severe. At the 6th week, the patients became wholly asymptomatic and their thyroid function returned to normal. CONCLUSIONS Thyrotoxicosis can occur after SARS-CoV-2 vaccination probably related to silent thyroiditis.
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Affiliation(s)
- M Capezzone
- Unit of Endocrinology, Department of Internal Medicine, Misericordia Hospital, 58100, Grosseto, Italy.
| | - M Tosti-Balducci
- Unit of Nuclear Medicine, Misericordia Hospital, Grosseto, Italy
| | - E M Morabito
- Unit of Endocrinology, Department of Internal Medicine, Misericordia Hospital, 58100, Grosseto, Italy
| | - G P Caldarelli
- Laboratory Medicine Functional Area, Hospital Misericordia of Grosseto, Grosseto, Italy
| | - A Sagnella
- Section of Endocrinology and Metabolism, Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - S Cantara
- Section of Endocrinology and Metabolism, Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
| | - M Alessandri
- Unit of Endocrinology, Department of Internal Medicine, Misericordia Hospital, 58100, Grosseto, Italy
| | - M G Castagna
- Section of Endocrinology and Metabolism, Department of Medical, Surgical and Neurological Sciences, University of Siena, Siena, Italy
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Ravindra S, Shetty S. Neonatal thyrotoxicosis with maternal hypothyroidism. BMJ Case Rep 2022; 15:e247865. [PMID: 35264385 PMCID: PMC8915356 DOI: 10.1136/bcr-2021-247865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2022] [Indexed: 11/04/2022] Open
Abstract
Neonatal Graves' is uncommon, but a potentially fatal condition caused by transplacental transfer of thyroid stimulating immunoglobulin (TSI). It is seen in 1%-5% of infants born to a mother with Graves' disease. Here, we report a unique case of transient neonatal thyrotoxicosis with positive TSI in a premature neonate born to the mother with primary hypothyroidism. A short course of antithyroid drug treatment leads to significant clinical and biochemical improvement followed by complete recovery.
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Affiliation(s)
- Shruthi Ravindra
- Department of Endocrinology, Manipal Academy of Higher Education (MAHE), Kasturba Medical College Manipal, Udupi, Karnataka, India
| | - Sahana Shetty
- Department of Endocrinology, Manipal Academy of Higher Education (MAHE), Kasturba Medical College Manipal, Udupi, Karnataka, India
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30
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Mahon-Daly F, Liegeois C, Carter JP. Thyrotoxic periodic paralysis (TPP): assessment in the emergency department. BMJ Case Rep 2022; 15:e245830. [PMID: 35217552 PMCID: PMC8883208 DOI: 10.1136/bcr-2021-245830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/31/2021] [Indexed: 11/03/2022] Open
Abstract
A male patient aged in his early twenties presented to the emergency department (ED) with quadriparesis. He was ordinarily fit and well and had exercised and eaten a carbohydrate rich meal the evening before. His point-of-care venous blood sample on arrival to the ED showed hypokalaemia of 1.6 mmol/L. (normal range=3.5-5.0 mmol/L). He was put on a cardiac monitor and started on an intravenous infusion of potassium chloride. With the benefit of hindsight, his male sex, particular features in his history and his initial ECG all pointed to a differential diagnosis of thyrotoxic periodic paralysis (TPP), although a differential diagnosis of a first attack of familial hypokalaemic paralysis was considered. As urgent thyroid function tests were sent promptly, there was minimal delay in reaching a diagnosis of TPP and promptly starting propranolol as a safe and more effective means of reversing TPP, followed by definitive treatment with carbimazole.
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Affiliation(s)
| | - Claire Liegeois
- Emergency Department, Imperial College Healthcare NHS Trust, London, UK
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31
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Fujita N, Ono Y, Sano A, Kimata M, Oyama S, Hashimoto K, Sato I, Kudo M, Miyashiro Y, Fujikata A, Tanaka Y. Serum diiodotyrosine - a biomarker to differentiate destructive thyroiditis from Graves' disease. Eur J Endocrinol 2022; 186:245-253. [PMID: 34874894 DOI: 10.1530/eje-21-0901] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 12/07/2021] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Conventional diagnostic methods are limited in their ability to differentiate destructive thyroiditis from Graves' disease. We hypothesised that serum diiodotyrosine (DIT) and monoiodotyrosine (MIT) levels could be biomarkers for differentiating destructive thyroiditis from Graves' disease. DESIGN Patients with destructive thyroiditis (n = 13) and Graves' disease (n = 22) were enrolled in this cross-sectional study. METHODS We assayed the serum DIT and MIT levels using liquid chromatography-tandem mass spectrometry. A receiver operating characteristic (ROC) curve analysis was used to determine the sensitivity and specificity of the serum DIT and MIT levels as biomarkers for differentiating destructive thyroiditis from Graves' disease. RESULTS The serum DIT and MIT levels were significantly higher in patients with destructive thyroiditis than in those with Graves' disease. The ROC curve analysis showed that the serum DIT levels (≥359.9 pg/mL) differentiated destructive thyroiditis from Graves' disease, significantly, with 100.0% sensitivity and 95.5% specificity (P < 0.001). The diagnostic accuracy of the serum MIT levels (≥119.4 pg/mL) was not as high as that of the serum DIT levels (sensitivity, 84.6%; specificity, 77.3%; P = 0.001). CONCLUSIONS The serum DIT levels may serve as a novel diagnostic biomarker for differentiating destructive thyroiditis from Graves' disease.
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Affiliation(s)
- Naoya Fujita
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Yosuke Ono
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Azusa Sano
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Motohiro Kimata
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Seigo Oyama
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Kenichi Hashimoto
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
| | - Ikuya Sato
- ASKA Pharmaceutical Co., Ltd., Minato-ku, Tokyo, Japan
| | - Masahiko Kudo
- ASKA Pharmaceutical Co., Ltd., Minato-ku, Tokyo, Japan
| | | | - Akira Fujikata
- ASKA Pharma Medical Co., Ltd., Fujisawa, Kanagawa, Japan
| | - Yuji Tanaka
- Department of General Medicine, National Defense Medical College, Tokorozawa, Saitama, Japan
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Abstract
RATIONALE Thyrotoxic periodic paralysis (TPP) characterized by the triad of muscle paralysis, acute hypokalemia, and the presence of hyperthyroidism is often reported in young adults but rarely reported in age >60 year-old. PATIENT CONCERNS Two sexagenarian males (age 61 and 62) presenting to the emergency department with progressive muscle paralysis for hours. There was symmetrical flaccid paralysis with areflexia of lower extremities. Both of them did not have the obvious precipitating factors and take any drugs. DIAGNOSIS Their Wayne scores, as an objective index of symptoms and signs associated with thyrotoxicosis, were <19 (7 and 14, respectively). Their blood pressure stood 162/78 and 170/82 mm Hg, respectively. Their thyroid glands were slightly enlarged. Both of them had severe hypokalemia (1.8 and 2.0 mmol/L). Their presumptive diagnosis of mineralocorticoid excess disorders with severe potassium (K+) deficit were made. However, low urine K+ excretion and relatively normal blood acid-base status were suggestive of an intracellular shift of K+ rather than K+ deficit. Hormone studies confirmed hyperthyroidism due to Graves disease. INTERVENTIONS A smaller dose of K+ supplementation (only a total of 50 and 70 mmol K+, respectively) were prescribed for the patient. OUTCOMES After treatment, their serum K+ levels became normal with a full recovery of muscle strength. LESSONS Our 2 cases highlight the fact that thyrotoxic periodic paralysis must be still kept in mind as the underlying cause of hypokalemia with paralysis and hypertension in elderly patients to avoid missing curable disorders.
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Affiliation(s)
- Ang Lu
- Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
| | - Shih-Hua Lin
- Division of Nephrology, Department of Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan
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Okazaki-Hada M, Maruoka A, Yamamoto M, Ito M, Hirokawa M, Nishikawa M, Akamizu T, Miyauchi A, Toyoda N. Poorly Differentiated Thyroid Carcinoma Coexisting with Graves' Disease Involving T3 Thyrotoxicosis due to Increased D1 and D2 Activities. Thyroid 2021; 31:1592-1596. [PMID: 34278816 DOI: 10.1089/thy.2021.0082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Background: Poorly differentiated thyroid carcinoma is rare and patients are typically euthyroid. We report a novel rare case of poorly differentiated thyroid carcinoma with triiodothyronine (T3) thyrotoxicosis. Patient's Findings: A 77-year-old man presented to Kuma Hospital due to a neck tumor. A thyroid ultrasonography revealed a 220-mL mass in the right lobe. Laboratory data showed low serum thyrotropin (TSH), low free thyroxine (fT4), and high free T3 (fT3) levels. Anti-TSH receptor antibodies and thyroid-stimulating antibodies were positive. 131I scintigraphy showed diffuse uptake only in the left thyroid lobe. The patient underwent a total thyroidectomy and histological examination identified as poorly differentiated thyroid carcinoma. He was diagnosed with poorly differentiated thyroid carcinoma coexisting with Graves' disease. The tumor showed elevated type 1 iodothyronine deiodinases (D1) and type 2 iodothyronine deiodinases (D2) activities compared with that of the left thyroid lobe. Summary and Conclusions: Increased D1 and D2 activities in poorly differentiated carcinoma resulted in T3 toxicosis with a high serum fT3/fT4 ratio.
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Affiliation(s)
| | - Azusa Maruoka
- Internal Medicine II, Kansai Medical University, Hirakata City, Japan
| | | | - Mitsuru Ito
- Center for Excellence in Thyroid Care, Kuma Hospital, Kobe, Japan
| | | | | | - Takashi Akamizu
- Center for Excellence in Thyroid Care, Kuma Hospital, Kobe, Japan
| | - Akira Miyauchi
- Center for Excellence in Thyroid Care, Kuma Hospital, Kobe, Japan
| | - Nagaoki Toyoda
- Internal Medicine II, Kansai Medical University, Hirakata City, Japan
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Cappellani D, De Marco G, Ferrarini E, Torregrossa L, Di Certo AM, Cosentino G, Urbani C, Marconcini G, Mattiello A, Manetti L, Agretti P, Basolo F, Tonacchera M, Bartalena L, Bogazzi F. Identification of Two Different Phenotypes of Patients with Amiodarone-Induced Thyrotoxicosis and Positive Thyrotropin Receptor Antibody Tests. Thyroid 2021; 31:1463-1471. [PMID: 34271828 DOI: 10.1089/thy.2021.0118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Introduction: Serum thyrotropin (TSH) receptor antibodies (TRAbs) are occasionally found in patients with amiodarone-induced thyrotoxicosis (AIT), and usually point to a diagnosis of type 1 AIT (AIT1) due to Graves' disease (GD). However, the TRAb role and function in AIT have not been clarified. Methods: A retrospective cohort study of 309 AIT patients followed at a single academic center over a 30-year period. AIT TRAb-positive patients (n = 21, 7% of all cases) constituted the study group; control groups consisted of type 2 AIT (AIT2) TRAb-negative patients (n = 233), and 100 non-AIT patients with GD. Clinical and biochemical data at diagnosis and during the course of disease were compared. Histological samples of patients who had total thyroidectomy were reviewed. Stored serum samples were used for a functional assay of TRAb class G immunoglobulins (IgGs) in Chinese hamster ovary (CHO) cells stably transfected with complementary DNA encoding for the TSH receptor. Results: TRAb-positive patients were grouped according to color flow Doppler sonography, radioactive iodine thyroid uptake, and duration of amiodarone therapy before thyrotoxicosis in type 1 (n = 9, 43%; TRAb1) or type 2 (n = 12, 57%; TRAb2) AIT. TRAb1 patients had clinical and biochemical features indistinguishable from GD controls, and were responsive to methimazole. Conversely, TRAb2 patients had clinical features similar to AIT2 controls, and were responsive to glucocorticoids, but not to methimazole. The CHO cell functional assay demonstrated that TRAb1 IgGs had a stimulatory effect on cyclic AMP production, which was absent in TRAb2 IgGs. Pathology in TRAb1 showed hyperplastic thyroid follicles and mild lymphocyte infiltration, reflecting thyroid stimulation. On the contrary, TRAb2 samples revealed follicle destruction, macrophage infiltration, and sometimes fibrosis, consistent with a destructive process. Conclusions: Almost 60% of TRAb-positive AIT patients had a destructive thyroiditis. TRAb-positive tests in AIT patients do thus not necessarily imply a diagnosis of GD and AIT1, and should be evaluated in the clinical and biochemical setting of each AIT patient and confirmed by measuring thyroid-stimulating immunoglobulins.
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Affiliation(s)
- Daniele Cappellani
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giuseppina De Marco
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Eleonora Ferrarini
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Liborio Torregrossa
- Pathology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Agostino Maria Di Certo
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giada Cosentino
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Claudio Urbani
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Marconcini
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alessandro Mattiello
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Manetti
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Patrizia Agretti
- Laboratory of Chemistry and Endocrinology, University Hospital of Pisa, Pisa, Italy
| | - Fulvio Basolo
- Pathology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, Pisa, Italy
| | - Massimo Tonacchera
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fausto Bogazzi
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Abstract
Thyrotoxic periodic paralysis (TPP) is a rare presentation of thyrotoxicosis most commonly associated with Graves' disease. It is rare in Caucasians, but it affects approximately 2% of Asians (occurring in those of Chinese, Japanese, Vietnamese, Filipino, and Korean descent) with thyrotoxicosis of any cause. Typical thyrotoxic features may be absent despite biochemical thyrotoxicosis. Hypokalemia and muscle paralysis are the result of an acute intracellular shift of potassium and not due to total body potassium deficiency. TPP is a self-limiting condition that is easily corrected by treatment of the thyrotoxicosis. We present a case of a Filipino man, aged 47 years, who presented to the emergency department with acute bilateral lower extremity weakness and hypokalemia who was subsequently diagnosed with TPP due to Graves' disease.
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Affiliation(s)
- Matthew Patel
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karim Ladak
- Division of Education and Innovation, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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36
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Affiliation(s)
- Jonathan Schimmel
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eva L Alba
- Division of Endocrinology, Diabetes and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Angela Chen
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Matthew Russell
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Reshmi Srinath
- Division of Endocrinology, Diabetes and Bone Diseases, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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Takizawa T, Kurihara I, Suzuki N, Nakahara J, Shibata M. Painless Thyroiditis Presenting with Headache. Intern Med 2021; 60:2693-2696. [PMID: 33678752 PMCID: PMC8429306 DOI: 10.2169/internalmedicine.6975-20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Although headache attributed to hypothyroidism is coded within The International Classification of Headache Disorders, 3rd edition, an association between headache and thyrotoxicosis (hyperthyroidism) is mentioned only in the appendix. Reports on relevant cases are too scarce to establish a causal relationship. A young man with a history of migraine with aura arrived at our headache clinic with a 10-day history of headache and weight loss. Brain MRI revealed normal findings. Blood tests revealed thyrotoxicosis. A test for thyroid-related antibodies was negative. Thus, the patient was diagnosed with painless thyroiditis. The patient's headache resolved as his thyroid hormone levels decreased. To the best of our knowledge, this is the first reported case of headache exaggerated by painless thyrotoxicosis.
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Affiliation(s)
- Tsubasa Takizawa
- Departments of Neurology, Keio University School of Medicine, Japan
| | - Isao Kurihara
- Departments of Endocrinology, Metabolism, and Nephrology, Keio University School of Medicine, Japan
| | - Norihiro Suzuki
- Departments of Neurology, Keio University School of Medicine, Japan
| | - Jin Nakahara
- Departments of Neurology, Keio University School of Medicine, Japan
| | - Mamoru Shibata
- Departments of Neurology, Keio University School of Medicine, Japan
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38
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Khalaili L, Aker A, Naoum I, Kassem S. [AMIODARONE-INDUCED THYROTOXICOSIS - RISK FACTORS AND PREDICTORS OF OUTCOME: A RETROSPECTIVE STUDY]. Harefuah 2021; 160:514-519. [PMID: 34396727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Amiodarone induced thyrotoxicosis (AIT) occurs with considerable incidence and is associated with significant morbidity and mortality. Factors that predict poor prognosis in this disease have not yet been sufficiently investigated. OBJECTIVES We examined the characteristics and short-term clinical outcomes of patients with AIT (up to six months from diagnosis). We evaluated the relationship between T3 and T4 levels at time of presentation and complications associated with AIT. METHODS A retrospective epidemiological study was conducted reviewing all cases diagnosed with thyrotoxicosis and amiodarone consumption of patients treated in the Carmel Medical Center between the years 2004-2008. We examined the characteristics of patients who tend to develop AIT. In addition, we examined whether T3 and T4 levels at the time of presentation were a predictor of a poor prognosis. Three major complications associated with AIT were defined as primary outcomes within six months of diagnosis: 1. mortality; 2. development of AIT-related complications that required hospitalization; 3. the need for thyroidectomy. RESULTS A total of 400 patients were diagnosed with thyrotoxicosis and consumed amiodarone. However, only 39 patients met the definition of AIT. The composite outcome of mortality, AIT-related complications and thyroidectomy were found in the vast majority of patients (94.8%, 37 out of 39 participants); 3 (7.6%) died and 35 (89.7%) were hospitalized with AIT-related complications and 8 (20.5%) required thyroidectomy. We found a statistically significant relationship between high T4 levels (above 64.3 mcg/dL or above 3 times the upper limit of the norm) and the composite of two main endpoints: mortality and the need for thyroidectomy in the first half year of diagnosis (P=0.009). CONCLUSIONS AIT is associated with significant morbidity and mortality. An elevated level of free T4 reflects the severity of AIT. In patients with significantly increased T4 values, an early surgical intervention should be considered.
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Affiliation(s)
| | - Amir Aker
- Carmel Medical Center, Haifa, Israel
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39
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Abstract
Objective Painless thyroiditis (PT) is characterized by transient hyperthyroidism with a low 99mTc uptake. We herein describe 11 cases of PT that occurred during treatment with potassium iodide (KI) for Graves' disease (GD). Methods From August 2016 to December 2018, 11 women with GD who developed PT during treatment with KI were enrolled. Of these patients, 10 discontinued antithyroid drug (ATD) because of side effects and began KI, and 1 patient switched from thiamazole to KI because she was planning a pregnancy. The mean patient age was 40.1 years old. Thyroid function tests, thyroid autoantibodies including anti thyroglobulin antibody (TgAb), anti-thyroperoxidase antibody (TPOAb), and M22-TRAb, and the 99mTc uptake were evaluated at the time of PT. Results All 11 women patients presented with transient thyrotoxicosis in which 99mTc scans revealed a low uptake of 0.34±0.15% (normal 0.70-1.02%). M22-TRAb was absent in all cases except for one (2.4 IU/L), whereas TgAb and TPOAb were present in 10 and 6 cases, respectively. Ten patients returned to a euthyroid status without passing through the post-hypothyroid phase, and one patient underwent total thyroidectomy during the euthyroid phase of PT. Only four patients require beta-blocker therapy. All patients with KI-induced PT except 1 displayed GD remission during a mean observation period of 23.3 months, and 1 patient had recurrence of GD after PT. Conclusion We encountered 11 GD patients who developed PT during treatment with KI, which was initiated after ATD had been discontinued due to side effects.
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Affiliation(s)
- Keiichi Kamijo
- Department of Internal Medicine, Kamijo Thyroid Clinic, Japan
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40
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Tura Bahadır Ç, Yılmaz M, Kılıçkan E. Free triiodothyronine to free thyroxine ratio in the differential diagnosis of thyrotoxicosis and hyperthyroidism: A retrospective study. Int J Clin Pract 2021; 75:e14003. [PMID: 33403716 DOI: 10.1111/ijcp.14003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/03/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Thyroid ultrasound, thyroid scintigraphy and radioactive iodine uptake (RAIU) tests are helpful in the differential diagnosis of thyrotoxicosis and hyperthyroidism. In the setting where these techniques are unavailable or unusable more accessible, and cheaper techniques would be helpful. AIMS We evaluated the capability of free triiodothyronine to free thyroxine ratio (FT3/FT4) to differentiate Graves' Disease (GD) and destructive thyroiditis (DT). METHODS In total, 318 patients with GD and 140 patients with DT were included in the study. Patients were assigned to two groups: GD and DT (subacute thyroiditis, painless thyroiditis, postpartum thyroiditis). Serum thyroid-stimulating hormone (TSH), FT4, FT3 levels and FT3/FT4 ratio were evaluated in each group. To obtain the optimal diagnostic cut-off value of FT3, FT4 and FT3/FT4 ratio, ROC curve analysis was performed of all untreated thyrotoxicosis patients. RESULTS The optimal FT3/FT4 ratio cut-off value was 2.96, with a sensitivity of 71.7%, the specificity of 88.6%. The area under the ROC curve of the FT3/FT4 ratio regarding the diagnosis of GD was 0.864 (95% CI: 0.830-0.894). The cut-off level of FT3 for GD was determined as 6.6 pg/mL which had a sensitivity of 72.3% and specificity of 68.6% (AUC = 0.771 P < .001). The cut-off level of FT4 for GD was determined as 3.65 ng/dl with a sensitivity of 35.5% and specificity of 83.6% (AUC = 0.615 P < .001). When a high specificity is needed, FT3/FT4 cut-off value increases to 3.63 with 99.3% specificity and 36.5% sensitivity. CONCLUSIONS FT3/FT4 ratio helps distinguish GD and DT. In cases of situations where RAIU/scintigraphy and TRAb cannot be studied, the FT3/FT4 ratio is a viable diagnostic tool. Cut-off values with higher specificity can be more helpful in differential diagnosis of GD.
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Affiliation(s)
- Çiğdem Tura Bahadır
- Department of Endocrinology and Metabolism, Faculty of Medicine, Amasya University, Amasya, Turkey
| | - Merve Yılmaz
- Department of Endocrinology and Metabolism, Gazi State Hospital, Samsun, Turkey
| | - Elif Kılıçkan
- Department of Endocrinology and Metabolism, Ondokuz Mayıs University, Samsun, Turkey
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Abstract
Both hyperthyroidism and hypothyroidism can have adverse effects in pregnancy. The most common causes of thyrotoxicosis in pregnancy are gestational transient thyrotoxicosis and Graves' disease. It is important to distinguish between these entities as treatment options differ. Women of reproductive age who are diagnosed with Graves' disease should be counseled regarding the impact of treatment options on a potential pregnancy. Although the absolute risk is small, antithyroid medications can have teratogenic effects. Propylthiouracil appears to have less severe teratogenicity compared to methimazole and is therefore favored during the first trimester if a medication is needed. Women should be advised to delay pregnancy for at least 6 months following radioactive iodine to minimize potential adverse effects from radiation and ensure normal thyroid hormone levels prior to conception. As thyroid hormone is critical for normal fetal development, hypothyroidism is associated with adverse obstetric and child neurodevelopmental outcomes. Women with overt hypothyroidism should be treated with levothyroxine (LT4) to a thyrotropin (thyroid-stimulating hormone; TSH) goal of <2.5 mIU/L. There is mounting evidence for associations of maternal hypothyroxinemia and subclinical hypothyroidism with pregnancy loss, preterm labor, and lower scores on child cognitive assessment. Although there is minimal risk of LT4 treatment to keep TSH within the pregnancy-specific reference range, treatment of mild maternal thyroid hypofunction remains controversial, given the lack of clinical trials showing improved outcomes with LT4 treatment.
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Affiliation(s)
- Sun Y Lee
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
- Correspondence: Sun Y. Lee, MD, MSc, Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, 720 Harrison Avenue, Suite 8100, Boston, MA 02118, USA.
| | - Elizabeth N Pearce
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
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Buehler L, Movahed A, Zhou K, Lansang MC. Serum thyroid stimulating hormone level for predicting utility of thyroid uptake and scan. Endocr Res 2021; 46:10-13. [PMID: 32875953 DOI: 10.1080/07435800.2020.1810064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Thyroid uptake and scan (TUS) is a clinical tool used for differentiation of thyrotoxicosis etiologies. Although guidelines recommend ordering a TUS for evaluation of low TSH levels, no specific value is defined. This study aimed to determine a TSH cutoff at which TUSs yield a greater likelihood of successful determination of etiology to avoid unnecessary testing. METHODS This was a retrospective study on 137 patients seen by an endocrinologist who underwent TUS for evaluation of low TSH (<0.4 μU/mL). A receiver operating curve analysis was performed to determine the TSH cutoff with maximal sensitivity and specificity for prediction of diagnostic utility. RESULTS Ninety percent of TUSs (n = 123) led to a diagnosis, while 10% (n = 14) were inconclusive or normal. Diagnoses included Graves' diseases (52%), toxic multinodular goiter (19%), thyroiditis (12%), and solitary toxic adenoma (7%). The median TSH value was 0.008 μU/mL (IQR 0.005, 0.011), and the median free T4 value was 1.7 μU/mL (IQR 1.3, 2.8). The ROC analysis produced an area under the curve of 0.86. The optimal TSH cutoff value was 0.02 μU/mL (sensitivity 80%, specificity 93%) for prediction of diagnostic yield. CONCLUSION This study demonstrates that TSH is a useful predictor of the utility of TUS in yielding an etiology of thyrotoxicosis. Our analysis showed that TUS had a greater likelihood of determining an etiology when TSH was ≤0.02 μU/mL. This information can help clinicians avoid unnecessary cost and patient time burden when TUS is unlikely to aid in determining the etiology of thyrotoxicosis.
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Affiliation(s)
- Lauren Buehler
- Department of Endocrinology & Metabolism, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Alireza Movahed
- Department of Internal Medicine, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Keren Zhou
- Department of Endocrinology & Metabolism, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - M Cecilia Lansang
- Department of Endocrinology & Metabolism, Cleveland Clinic Foundation , Cleveland, OH, USA
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43
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Neinstein AB, Masharani U. Letter to the Editor: "Approach to the Patient with Thyrotoxicosis Using Telemedicine". J Clin Endocrinol Metab 2021; 106:e1060-e1061. [PMID: 33038240 DOI: 10.1210/clinem/dgaa723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022]
Affiliation(s)
- Aaron B Neinstein
- Department of Medicine, University of California, San Francisco, San Francisco, California
- UCSF Center for Digital Health Innovation, San Francisco, California
| | - Umesh Masharani
- Department of Medicine, University of California, San Francisco, San Francisco, California
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Lui DTW, Lee CH, Chow WS, Lee ACH, Tam AR, Fong CHY, Law CY, Leung EKH, To KKW, Tan KCB, Woo YC, Lam CW, Hung IFN, Lam KSL. Thyroid Dysfunction in Relation to Immune Profile, Disease Status, and Outcome in 191 Patients with COVID-19. J Clin Endocrinol Metab 2021; 106:e926-e935. [PMID: 33141191 PMCID: PMC7665541 DOI: 10.1210/clinem/dgaa813] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related thyroiditis is increasingly recognized. The role of thyroid autoimmunity and SARS-CoV-2 viral load in SARS-CoV-2-related thyroid dysfunction is unclear. We evaluated the thyroid function of a cohort of coronavirus disease 2019 (COVID-19) patients, in relation to their clinical features, and biochemical, immunological, and inflammatory markers. METHODS Consecutive adult patients, without known thyroid disorders, admitted to Queen Mary Hospital for COVID-19 from July 21 to August 21, 2020, were included. Serum levels of thyroid-stimulating hormone (TSH), free thyroxine, free triiodothyronine (fT3), and antithyroid antibodies were measured on admission. RESULTS Among 191 patients with COVID-19 (mean age 53.5 ± 17.2 years; 51.8% male), 84.3% were mild, 12.6% were moderate, and 3.1% were severe. Abnormal thyroid function was seen in 13.1%. Ten patients had isolated low TSH, suggestive of subclinical thyrotoxicosis due to thyroiditis, although the contribution of autoimmunity was likely in 2 of them. Autoimmune thyroiditis probably also contributed to subclinical hypothyroidism in another patient. Ten patients had isolated low fT3, likely representing nonthyroidal illness syndrome. Lower SARS-Cov-2 polymerase chain reaction cycle threshold values and elevated C-reactive protein were independently associated with occurrence of low TSH (P = .030) and low fT3 (P = .007), respectively. A decreasing trend of fT3 with increasing COVID-19 severity (P = .032) was found. Patients with low fT3 had more adverse COVID-19-related outcomes. CONCLUSION Around 15% of patients with mild to moderate COVID-19 had thyroid dysfunction. There may be a direct effect of SARS-CoV-2 on thyroid function, potentially leading to exacerbation of pre-existing autoimmune thyroid disease. Low fT3, associated with systemic inflammation, may have a prognostic significance.
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Affiliation(s)
- David Tak Wai Lui
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Chi Ho Lee
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Wing Sun Chow
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Alan Chun Hong Lee
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Anthony Raymond Tam
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Carol Ho Yi Fong
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Chun Yiu Law
- Division of Chemical Pathology, Queen Mary Hospital, Hong Kong, China
| | - Eunice Ka Hong Leung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Kelvin Kai Wang To
- Department of Microbiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Kathryn Choon Beng Tan
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Yu Cho Woo
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Ching Wan Lam
- Department of Pathology, The University of Hong Kong, Hong Kong, China
| | - Ivan Fan Ngai Hung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
| | - Karen Siu Ling Lam
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
- Address Correspondence to: Professor Karen Siu Ling Lam, Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, Telephone number: +852 2255-4783, Fax number: +852 2816-2863, Email
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45
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Sonowal R, Anjali A, Kumar A. Neonatal Thyrotoxicosis Co-existing With Early Onset Sepsis. Indian Pediatr 2021; 58:86. [PMID: 33452787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Rimjhim Sonowal
- Division of Neonatology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India.
| | - Akanksha Anjali
- Division of Neonatology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashok Kumar
- Division of Neonatology, Department of Pediatrics, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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46
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Gao HT, Lasoff D, Minns A. Two Cases of Thyrotoxicosis due to Redotex Ingestion, a Mexican Weight Loss Drug. J Emerg Med 2021; 60:495-497. [PMID: 33414048 DOI: 10.1016/j.jemermed.2020.10.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 10/03/2020] [Accepted: 10/15/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Redotex™ is a Mexican weight-loss supplement that is not U.S. Food and Drug Administration-approved. It consists of the following five ingredients: tri-iodothyronine 75 μg, atropine 0.36 mg, diazepam 8 mg, aloin 16 mg, and d-norpseudoephedrine 50 mg per tablet. There are few case reports with clinically severe ingestions. We report two cases of clinical thyrotoxicosis due to use of Redotex. CASE REPORTS A 29-year-old woman presented to the emergency department (ED) with anxiety and palpitations. She reported taking Redotex daily for 1 week. Her temperature was 37.1°C, blood pressure (BP) was 166/104 mm Hg, and heart rate (HR) was 140 beats/min. Laboratory analysis was significant for a bicarbonate level of 20 mmol/L (reference 22-29 mmol/L), free T4 0.75 ng/dL (reference 0.93-1.70 ng/dL), and thyroid-stimulating hormone (TSH) 0.05 uIU/mL (reference 0.27-4.20 uIU/mL). She was treated with 2 mg i.v. lorazepam and 20 mg oral propranolol. A 37-year-old woman presented with chest pain, palpitations, and nausea after taking Redotex 1 to 2 tablets daily for 6 weeks. Her HR was 134 beats/min and BP was 130/66 mm Hg. Thyroid function tests on initial presentation showed a TSH of 0.013 uU/mL, free T4 of 0.24 ng/dL, and free T3 of >30 pg/mL. She was treated with propranolol 1 mg i.v. twice per day and 2 doses of lorazepam 1 mg. Both patients had resolution of their symptoms. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: When taken chronically and at recommended doses, Redotex can present with clinically significant T3 thyrotoxicosis. This has not been seen in prior reports.
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Affiliation(s)
- Han Tony Gao
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Diego, San Diego, California
| | - Daniel Lasoff
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Diego, San Diego, California
| | - Alicia Minns
- Department of Emergency Medicine, Division of Medical Toxicology, University of California, San Diego, San Diego, California
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47
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Aujayeb A, Dundas J. Heart failure from thyrotoxicosis due to Graves' disease. Acute Med 2021; 20:68-73. [PMID: 33749695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
A 30-year-old female patient with a past medical history of pernicious anaemia presented with pleuritic chest pain, palpitations, fatigue, coryzal symptoms and a high temperature. She was hypoxic and tachycardic and was extensively investigated as well as aggressively treated. A type 1 'gut feeling' assessment by the admitting medical registrar made the diagnosis possible as thyroid function tests were grossly deranged and pointed to Graves' disease causing heart failure, complicated by pneumonia. The patient was discharged on carbimazole, antibiotics and beta blockers. Due to a resultant thrombocytopaenia, she has now been swapped onto propylthiouracil and is under active follow up.
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Affiliation(s)
- A Aujayeb
- Respiratory and Acute Medicine Consultant, Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - J Dundas
- Northumbria Healthcare NHS Foundation Trust
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48
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Timmons JG, Mukhopadhyay B. Hyperthyroxinemia with a non-suppressed TSH: how to confidently reach a diagnosis in this clinical conundrum. Hormones (Athens) 2020; 19:311-315. [PMID: 32128699 PMCID: PMC7426307 DOI: 10.1007/s42000-020-00180-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/03/2020] [Indexed: 01/15/2023]
Abstract
Disorders of thyroid function are among the commonest referrals to endocrinology. While interpretation of thyroid function testing is usually straightforward, accurate interpretation becomes significantly more challenging when the parameters do not behave as would be expected in normal negative feedback. In such cases, uncertainty regarding further investigation and management arises. An important abnormal pattern encountered in clinical practice is that of high normal or raised free thyroxine (fT4) with inappropriately non-suppressed or elevated thyroid-stimulating hormone (TSH). In this short review using two clinical vignettes, we examine the diagnostic approach in such cases. A diagnostic algorithm is proposed to ensure that a definitive diagnosis is reached in these challenging cases.
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Affiliation(s)
- J G Timmons
- Department of Diabetes and Endocrinology, University Hospital Hairmyres, East Kilbride, Glasgow, UK.
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
| | - B Mukhopadhyay
- Department of Diabetes and Endocrinology, University Hospital Hairmyres, East Kilbride, Glasgow, UK
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49
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Quinn M, Bashari W, Smith D, Gurnell M, Agha A. A remarkable case of thyrotoxicosis initially caused by graves' disease followed by a probable TSHoma - a case report. BMC Endocr Disord 2020; 20:133. [PMID: 32854689 PMCID: PMC7457301 DOI: 10.1186/s12902-020-00611-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 08/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Graves' disease is the commonest cause of thyrotoxicosis whilst thyrotropin (TSH)-producing pituitary adenomas (thyrotropinomas, TSHomas) are very rare and account for just 1-2% of all pituitary adenomas. Coexistence of a TSHoma and Graves' disease has been very rarely reported. Here, we report a case of a patient whose initial presentation with primary thyrotoxicosis due to Graves' disease, was subsequently followed by a relapse of thyrotoxicosis due to a probable TSHoma. CASE A sixty-eight year old woman was referred to our department with classical features of thyrotoxicosis. Initial biochemistry confirmed hyperthyroxinaemia [free thyroxine (fT4) 20.4 pmol/L (reference range 7.0-16.0)] and a suppressed TSH [< 0.02mIU/L (0.50-4.20)]. A technetium pertechnetate uptake scan was consistent with Graves' Disease. She was treated with carbimazole for 18 months and remained clinically and biochemically euthyroid. After stopping carbimazole her fT4 started to rise but TSH remained normal. Laboratory assay interference was excluded. A TRH stimulation test demonstrated a flat TSH response and pituitary MRI revealed a microadenoma. Remaining pituitary hormones were in the normal range other than a slightly raised IGF-1. An 11C-methionine PET/CT scan coregistered with volumetric MRI (Met-PET-MRICR) demonstrated high tracer uptake in the left lateral sella region suggestive of a functioning adenoma. The patient declined surgery and was unable to tolerate cabergoline or octreotide. Thereafter, she has elected to pursue a conservative approach with periodic surveillance. CONCLUSION This is a very unusual case of thyrotoxicosis caused by two different processes occurring in the same patient. It highlights the importance of considering dual pathology when previously concordant thyroid function tests become discordant. It also highlights a potential role of Met-PET-MRICR in the localisation of functioning pituitary tumours.
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Affiliation(s)
- Mark Quinn
- Department of Diabetes and Endocrinology, Beaumont Hospital and the RCSI, Dublin, Ireland.
| | - Waiel Bashari
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Diarmuid Smith
- Department of Diabetes and Endocrinology, Beaumont Hospital and the RCSI, Dublin, Ireland
| | - Mark Gurnell
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Amar Agha
- Department of Diabetes and Endocrinology, Beaumont Hospital and the RCSI, Dublin, Ireland
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50
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Griffith ML, Bischoff LA, Baum HBA. Approach to the Patient With Thyrotoxicosis Using Telemedicine. J Clin Endocrinol Metab 2020; 105:5856156. [PMID: 32525973 PMCID: PMC7454600 DOI: 10.1210/clinem/dgaa373] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 05/30/2020] [Accepted: 06/08/2020] [Indexed: 12/15/2022]
Abstract
CONTEXT The potential for endocrine care via telemedicine has been recognized since the early 2000s when clinical outcome data demonstrated improvements in glycemic control with telemedicine. The widespread use of telemedicine during the COVID-19 pandemic has pushed telemedicine beyond diabetes care and into clinical areas with a paucity of published data. The evaluation and treatment of thyrotoxicosis heavily relies on laboratory assessment and imaging with physical exam playing a role to help differentiate the etiology and assess the severity of thyrotoxicosis. CASE DESCRIPTION We describe a patient presenting for evaluation of new thyrotoxicosis via telemedicine, and describe modifications to consider for thorough, safe evaluation via telemedicine. CONCLUSION Telemedicine may be an ideal way to assess and treat patients with thyrotoxicosis who are not able to physically attend a visit with an endocrinologist but still have access to a laboratory for blood draws. Potential challenges include access to imaging and high-volume surgeons if needed. Clinical and economic outcomes of telemedicine care of thyrotoxicosis should be studied so that standards of care for endocrine telemedicine can be established.
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Affiliation(s)
- Michelle L Griffith
- Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lindsay A Bischoff
- Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Howard B A Baum
- Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, Nashville, Tennessee
- Correspondence and Reprint Requests: Howard B.A. Baum, MD, Division of Diabetes, Endocrinology, and Metabolism, Vanderbilt University Medical Center, MCE 8210, 1215 21st Avenue South, Nashville, TN 37232. E-mail:
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