Amiodarone-induced type 2 thyrotoxicosis

The authors present a case of a 55-year-old gentleman with a medical history of atrial fibrillation on amiodarone who presented with weight loss, palpitations and exertional dyspnoea. Thyroid function tests revealed thyrotoxicosis with a free thyroxine (T4) of 117 pmol/L and a thyroid-stimulating hormone (TSH) of <0.008 mIU/L. Interleukin-6 level was low. The negative TSH-receptor antibody status, the presence of a small thyroid gland with heterogeneous echotexture and decreased internal vascularity on ultrasound together with the relatively quick drop in free T4 and free tri-iodothyronine (T3) levels once prednisolone therapy was added to carbimazole suggested that this was typical of amiodarone-induced thyrotoxicosis (AIT) type 2. Subsequently, carbimazole was discontinued and treatment with prednisolone was continued. This case highlights that AIT management may be challenging and it is of paramount importance to establish the type of AIT present as this will guide management and is key to improving prognosis.

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In iodine-induced thyrotoxicosis, steroid therapy today could keep the surgical knife at bay

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2017-0485 ◽

2018 ◽

Vol 31 (5) ◽

pp. 585-588 ◽

Cited By ~ 3

Author(s):

Rohan K. Henry ◽

Monika Chaudhari

Keyword(s):

Steroid Therapy ◽

Medical Literature ◽

Urinary Iodine ◽

Thyroid Stimulating Hormone ◽

Thyroid Function Tests ◽

Case Presentation ◽

Total Triiodothyronine ◽

History Of ◽

Daily Allowance

Abstract Background: Amiodarone-induced thyrotoxicosis (AIT) type 2, characterized as a destructive thyroiditis, is well described in the medical literature; however, iodine-induced thyrotoxicosis (IIT) is not, though the latter has similar features and can be managed similarly. Case presentation: We present a 17-year-old female who presented with a history of an intermittent goiter with thyroid function tests (TFTs): thyroid-stimulating hormone (TSH)<0.015 (0.4–4 μU/mL), free thyroxine (T4)≥6 (0.7–2.1 ng/dL) and total triiodothyronine (T3) 651 (50–200 mg/dL). Thyroid antibodies were all negative. Despite methimazole therapy for 6 weeks, hyperthyroidism proved refractory to medical management. 123I scan uptake was suppressed. With hyperthyroidism being recalcitrant to therapy, a nutritional history revealed consumption of an iodine supplement containing at least 7 times the recommended daily allowance (RDA) for 5 years, contributing to the Jod-Basedow phenomenon. Urinary spot and 24-hour urinary iodine were both elevated. Though a surgical consult was obtained, surgery was cancelled once TFTs improved and then normalized with steroid therapy. The TFTs and urinary iodine levels remained normal post steroid therapy. Conclusions: We suggest that in addition to the need for a thorough nutritional history, a trial of corticosteroids should be utilized in the management of IIT which can present with findings similar to AIT type 2 which is recalcitrant to thionamide therapy. If successful, corticosteroids may delay or prevent surgical management thus avoiding possible complications with the latter approach.

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Graves’ Hyperthyroidism-Induced Psychosis Treated With Aripiprazole—A Case Report

Journal of Pharmacy Practice ◽

10.1177/0897190012451934 ◽

2012 ◽

Vol 26 (1) ◽

pp. 59-61 ◽

Cited By ~ 4

Author(s):

Livia R. Macedo ◽

Jehan Marino ◽

Brady Bradshaw ◽

Joseph Henry

Keyword(s):

Atrial Fibrillation ◽

Psychiatric Symptoms ◽

Thyroid Stimulating Hormone ◽

Graves Disease ◽

Long Term Effects ◽

Free T4 ◽

History Of ◽

Antithyroid Peroxidase Antibody ◽

First Time

Graves’ disease is an autoimmune syndrome with symptoms such as tachycardia, atrial fibrillation, and psychiatric symptoms. Limited evidence exists for the treatment of Graves’ hyperthyroidism-induced psychosis with atypical antipsychotics. A 47-year-old female with a psychiatric history of bipolar disorder presented for the first time to the psychiatric hospital. She was agitated and grossly psychotic with delusions. Electrocardiogram showed atrial fibrillation and tachycardia. Drug screen urinalysis was negative. Endocrine workup resulted in a diagnosis of Graves’ disease (thyroid-stimulating hormone [TSH]: 0.005 μIU/mL, triiodothyronine [T3]: 537 ng/dL, thyroxine [T4]: 24 mcg/dL, free T4: 4.5 ng/dL, positive antithyroid peroxidase antibody, and antinuclear antibody). Aripiprazole 10 mg daily was initiated and titrated to 15 mg daily on day 4. On day 16, her suspicious behavior, judgment, and insight improved. Other medications given included aspirin 325 mg daily, metoprolol 25 mg twice daily, titrated to 12.5 mg twice daily, and methimazole 30 mg daily, titrated to 20 mg twice daily, and discontinued on day 29. The patient received radioiodine I-131 treatment 1 week later. We report the first known case on the use of aripriprazole to treat Graves’ hyperthyroidism-induced psychosis. Further studies examining the long-term effects and appropriate dose and duration of aripiprazole in this patient population are needed.

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Thyroid

Mayo Clinic General Surgery ◽

10.1093/med/9780190650506.003.0018 ◽

2020 ◽

pp. 245-260

Author(s):

Jad M. Abdelsattar ◽

Moustafa M. El Khatib ◽

T. K. Pandian ◽

Samuel J. Allen ◽

David R. Farley

Keyword(s):

Atrial Fibrillation ◽

Weight Loss ◽

Thyroid Gland ◽

Surgical Complications ◽

Nuclear Imaging ◽

Thyroid Stimulating Hormone ◽

Median Raphe ◽

Platysma Muscle ◽

Postoperative Hematoma ◽

Gestational Week

The thyroid gland forms from endoderm beginning at gestational week 5. The butterfly-shaped thyroid gland wraps around the trachea, cricoid, and thyroid cartilages. Excess thyroxine causes hyperthyroidism and suppression of the sensitive thyroid-stimulating hormone value. Hyperthyroidism may cause sweating, irritability, weight loss, and atrial fibrillation. US, nuclear imaging, and CT are useful. Collar incisions of the neck with transection of the platysma muscle, opening the median raphe, and exposing the thyroid isthmus are straightforward steps. Possible surgical complications are postoperative hematoma, RLN injury, and temporary hypoparathyroidism, and they should be avoided at all costs.

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Lenvatinib-Induced Destructive Thyroiditis in a Patient With Hepatocellular Carcinoma

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1920 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A939-A940

Author(s):

Anjani Pandya ◽

Jawairia Shakil

Keyword(s):

Hepatocellular Carcinoma ◽

Thyroid Gland ◽

Thyroid Function ◽

Kinase Inhibitor ◽

Previous History ◽

Thyroid Stimulating Hormone ◽

Thyroid Peroxidase ◽

Thyroid Function Tests ◽

Normal Range ◽

History Of

Abstract Lenvatinib is an antineoplastic oral agent that acts as a multi-kinase inhibitor against vascular endothelial growth factor (VEGF). This drug is commonly known for its use against radioiodine-refractory differentiated thyroid cancer, but it is also approved for unresectable hepatocellular carcinoma (HCC). Side effects such as fatigue, hypertension, palmar-plantar erythrodysesthesia, diarrhea, decreased appetite, and hypothyroidism are frequently reported adverse effects. However, the incidence of hyperthyroidism is a less known phenomenon. This case describes a patient with HCC on lenvatinib therapy who develops destructive thyroiditis. A 69-year-old man with hepatitis c cirrhosis complicated by progressive hepatocellular carcinoma (Child-Pugh class A6) presented with generalized weakness, unintentional weight loss, heat intolerance, palpitations, and tremors. He had been started on chemotherapy with lenvatinib 12 mg/day four weeks prior to presentation. Endocrinology was consulted due to abnormal thyroid function tests (TFTs). He had no previous history of thyroid function abnormalities or family history of thyroid disease. Laboratory tests revealed a hyperthyroid state [total thyroxine (T4), 14.3 µg/dL (normal range 4.5-11.7); free thyroxine (FT4), 1.9 ng/dL (normal range 0.9-1.7); thyroid-stimulating hormone (TSH), 0.07 µIU/mL (normal range 0.27-4.20), and negativity for antibodies [anti-thyroid peroxidase antibody (TPO Ab), 0.8 IU/mL (normal range 0.0-9.0); thyroglobulin antibody (Tg Ab), < 0.9 IU/mL (normal range 0.0-4.0); thyroid stimulating immunoglobulin (TSI), 90% (normal range < 122)]. Ultrasonography revealed a mildly prominent thyroid gland, a homogenous echo texture, and no suspicious thyroid nodules. In addition, a 99m-technetium (99mTc) scintigraphy demonstrated reduced radioactive uptake that was consistent with thyroiditis. Therefore, this patient was diagnosed with lenvatinib-induced destructive thyroiditis. Palpitations improved with a beta-blocker and the patient was resumed on a lower dose of lenvatinib, 8 mg/day, one week later. About six weeks after the initial dose of lenvatinib, his TFT results normalized. Lenvatinib disrupts cell proliferation which can affect many organs, including the thyroid gland. Although several theories have been proposed, the exact underlying mechanism by which this occurs remains unknown. It is important to note that in addition to hypothyroidism, lenvatinib may also cause hyperthyroidism in the form of a transient destructive thyroiditis. This emphasizes the need to routinely check TFTs prior to the initiation of lenvatinib and throughout the course of therapy.

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A Grave Case of COVID-19: SARS-CoV-2 Induced Autoimmune Hyperthyroidism

Journal of the Endocrine Society ◽

10.1210/jendso/bvab048.1863 ◽

2021 ◽

Vol 5 (Supplement_1) ◽

pp. A912-A913

Author(s):

Moises Matos ◽

Hilda Maria Merino-Chavez ◽

Suzanne Martinez

Keyword(s):

Autoimmune Disease ◽

New England ◽

Thyroid Stimulating Hormone ◽

Prior History ◽

Thyroid Peroxidase ◽

Graves Disease ◽

Thyroid Function Tests ◽

Free T4 ◽

History Of ◽

Active Research

Abstract Background: Autoimmune hyperthyroidism also known as Graves’ disease is the leading cause of hyperthyroidism. The pathogenesis of Graves’ disease is still an area of active research. We present a case of Graves’ disease, which developed following SARS-CoV2 infection. Clinical Case: A 43-year-old man with no prior history of thyroid disease, presented for evaluation due to fatigue palpitations, tremors, and hair loss in June 2020. Earlier that month, he was diagnosed with SARS-CoV2 infection and his thyroid function tests (TFTs) during a visit to the emergency department revealed thyroid stimulating hormone (TSH) level of <0.010 mIU/L (0.35-4.94) with a free T4 (FT4) 1.4 ng/dL (0.7-1.5); consistent with subclinical hyperthyroidism. He continued to report palpitations and tremors and further workup was done. A thyroid ultrasound showed two sub-centimeter nodules. A thyroid uptake scan followed, which showed heterogeneous activity in the thyroid gland, (12% and 32% uptake at 6 and 24 hours respectively) with focal increased uptake in the medial lobes, without cold nodules or hot nodules. Repeat TFTs one month later showed a suppressed TSH <0.010 mIU/L, and a normal FT4 1.3 ng/dL. Given suspicion for Graves’ disease, further labs were ordered. Thyroid stimulating immunoglobulin (TSI) were found to be elevated at 173 % baseline (<=140). Thyroid peroxidase (TPO) antibodies and thyroglobulin antibodies were also elevated at 362 IU/mL H* (<=9) and 2 IU/mL H* (<=1) respectively. The overall picture was consistent with evolving early Graves’ disease. Conclusion: Multiple factors are frequently cited in the pathogenesis of autoimmune hyperthyroidism including viral and bacterial infections1 and there have been several reported cases of autoimmune disease related to SARS-CoV2 infection2. This case is one of several emerging cases of autoimmune hyperthyroidism possibly linked to COVID-19. References: 1. Smith, T. J . Graves’ Disease. New England Journal of Medicine. 2016 October 20; 375:1552-1565 2. Mateu-Salat, M., Urgell, E., Chico, A. SARS-COV-2 as a trigger for autoimmune disease: report of two cases of Graves’ disease after COVID-19. Journal of Endocrinological Investigation. 2020 July 19

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Infants Diagnosed with Athyreosis on Scintigraphy May Have a Gland Present on Ultrasound and Have Transient Congenital Hypothyroidism

Hormone Research in Paediatrics ◽

10.1159/000514989 ◽

2021 ◽

pp. 1-8

Author(s):

Niamh McGrath ◽

Colin Patrick Hawkes ◽

Stephanie Ryan ◽

Philip Mayne ◽

Nuala Murphy

Keyword(s):

Thyroid Gland ◽

Congenital Hypothyroidism ◽

Thyroid Tissue ◽

Thyroid Stimulating Hormone ◽

Thyroid Ultrasound ◽

Free T4 ◽

Median Serum ◽

Thyroid Glands ◽

Rule Out

Scintigraphy using technetium-99m (99mTc) is the gold standard for imaging the thyroid gland in infants with congenital hypothyroidism (CHT) and is the most reliable method of diagnosing an ectopic thyroid gland. One of the limitations of scintigraphy is the possibility that no uptake is detected despite the presence of thyroid tissue, leading to the spurious diagnosis of athyreosis. Thyroid ultrasound is a useful adjunct to detect thyroid tissue in the absence of 99mTc uptake. Aims: We aimed to describe the incidence of sonographically detectable in situ thyroid glands in infants scintigraphically diagnosed with athyreosis using 99mTc and to describe the clinical characteristics and natural history in these infants. Methods: The newborn screening records of all infants diagnosed with CHT between 2007 and 2016 were reviewed. Those diagnosed with CHT and athyreosis confirmed on scintigraphy were invited to attend a thyroid ultrasound. Results: Of the 488 infants diagnosed with CHT during the study period, 18/73 (24.6%) infants with absent uptake on scintigraphy had thyroid tissue visualised on ultrasound (3 hypoplastic thyroid glands and 15 eutopic glands). The median serum thyroid-stimulating hormone (TSH) concentration at diagnosis was significantly lower than that in infants with confirmed athyreosis (no gland on ultrasound and no uptake on scintigraphy) (74 vs. 270 mU/L), and median free T4 concentration at diagnosis was higher (11.9 vs. 3.9 pmol/L). Six of 10 (60%) infants with no uptake on scintigraphy but a eutopic gland on ultrasound had transient CHT. Conclusion: Absent uptake on scintigraphy in infants with CHT does not rule out a eutopic gland, especially in infants with less elevated TSH concentrations. Clinically, adding thyroid ultrasound to the diagnostic evaluation of infants who have athyreosis on scintigraphy may avoid committing some infants with presumed athyreosis to lifelong levothyroxine treatment.

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Determinants of Extraocular Muscle Volume in Patients with Graves' Disease

Journal of Thyroid Research ◽

10.1155/2012/368536 ◽

2012 ◽

Vol 2012 ◽

pp. 1-4 ◽

Cited By ~ 3

Author(s):

Samer El-Kaissi ◽

Jack R. Wall

Keyword(s):

Extraocular Muscle ◽

Tsh Receptor ◽

Graves Disease ◽

Thyroid Function Tests ◽

Thyroid Scintigraphy ◽

Free T4 ◽

Receptor Antibody ◽

Tsh Receptor Antibody ◽

Antibody Positivity ◽

Serum Tsh

Background. To examine factors contributing to extraocular muscle (EOM) volume enlargement in patients with Graves’ hyperthyroidism.Methods. EOM volumes were measured with orbital magnetic resonance imaging (MRI) in 39 patients with recently diagnosed Graves’ disease, and compared to EOM volumes of 13 normal volunteers. Thyroid function tests, uptake on thyroid scintigraphy, anti-TSH-receptor antibody positivity and other parameters were then evaluated in patients with EOM enlargement.Results. 31/39 patients had one or more enlarged EOM, of whom only 2 patients had clinical EOM dysfunction. Compared to Graves’ disease patients with normal EOM volumes, those with EOM enlargement had significantly higher mean serum TSH (0.020±0.005versus0.007±0.002mIU/L;Pvalue 0.012), free-T4 (52.9±3.3versus41.2±1.7 pmol/L;Pvalue 0.003) and technetium uptake on thyroid scintigraphy (13.51±1.7%versus8.55±1.6%;Pvalue 0.045). There were no differences between the 2 groups in anti-TSH-receptor antibody positivity, the proportion of males, tobacco smokers, or those with active ophthalmopathy.Conclusions. Patients with recently diagnosed Graves’ disease and EOM volume enlargement have higher serum TSH and more severe hyperthyroidism than patients with normal EOM volumes, with no difference in anti-TSH-receptor antibody positivity between the two groups.

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Low Dose Ketoconazole Therapy and Thyroid Functions in Rats

Acta Medica (Hradec Kralove Czech Republic) ◽

10.14712/18059694.2019.77 ◽

2002 ◽

Vol 45 (4) ◽

pp. 177-179 ◽

Cited By ~ 1

Author(s):

Hüseyin Çaksen ◽

Ahmet Tutuş ◽

Selim Kurtoğlu ◽

Figen Öztürk ◽

Yüksel Okumuş ◽

...

Keyword(s):

Thyroid Gland ◽

Epithelial Cells ◽

Low Dose ◽

Thyroid Stimulating Hormone ◽

Control Group ◽

Histopathological Analysis ◽

Study Group ◽

Thyroid Function Tests ◽

End Of Treatment ◽

Thyroid Glands

To determine whether low dose ketoconazole (KTZ) has antithyroid action, we studied thyroid function tests in the 13 rats treated with KTZ (20 mg/kg twice daily) for thirty days. Serum triiodothyronine and thyroxine levels were decreased (P <0.05) and serum thyroid-stimulating hormone levels were mildly increased (P >0.05) at the end of treatment. Histopathological analysis of the thyroid glands demonstrated an increase in cylindrical cells in study group, but the epithelial cells were mainly cubical in control group. These findings showed that low dose KTZ had antithyroid effect in rats. The responsible mechanisms may be direct effect of the drug on thyroid gland.

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POST-CORONAVIRUS DISEASE 2019 DE QUERVAIN’S THYROIDITIS – A CASE REPORT AND LITERATURE REVIEW

Innovare Journal of Medical Sciences ◽

10.22159/ijms.2021.v9i2.40956 ◽

2021 ◽

pp. 4-6

Author(s):

MOHAMAD SAFWAN ◽

VIJAYAN KN ◽

NAJEEB ◽

JITHU TG

Keyword(s):

Neck Pain ◽

Beta Blockers ◽

Thyroid Stimulating Hormone ◽

Thyroid Function Tests ◽

C Reactive Protein ◽

Free T4 ◽

Persistent Fever ◽

Reactive Protein ◽

Technetium Uptake

De Quervain’s thyroiditis, also known as subacute thyroiditis (SAT), is a self-limiting inflammatory thyroid disease typically occurring a few weeks after a respiratory viral infection. A 29-year-old female with no comorbidities presented with persistent fever, neck pain, and swelling of 10 days duration. She also had tremors, fatigue, and palpitation. A careful enquiry revealed that she had been diagnosed with coronavirus disease 2019 (COVID-19) infection 6 weeks ago and had recovered uneventfully with conservative management. Her laboratories showed leukocytosis, elevated erythrocyte sedimentation rate, and C-reactive protein. Thyroid function tests (TFTs) yielded low thyroid-stimulating hormone, and high T3 and free T4. Ultrasonography neck was suggestive of thyroiditis. Thyroid scintigraphy demonstrated very low technetium uptake which confirmed SAT. Her symptoms ameliorated with nonsteroidal anti-inflammatory drug and beta-blockers and her TFTs improved during follow-up. We report this as emerging sequelae of COVID-19 infection. A persistent fever and neck pain following recent COVID-19 infection should alert clinician toward the possibility of de Quervain’s thyroiditis following severe acute respiratory syndrome coronavirus 2.

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A comparative study on outcomes of preprandial versus postprandial thyroid function test

International Journal of Otorhinolaryngology and Head and Neck Surgery ◽

10.18203/issn.2454-5929.ijohns20194945 ◽

2019 ◽

Vol 5 (6) ◽

pp. 1662

Author(s):

Vasim Ismail Patel ◽

Akshay B. K.

Keyword(s):

Thyroid Function ◽

Subclinical Hypothyroidism ◽

Clinical Symptoms ◽

Thyroid Function Test ◽

Thyroid Stimulating Hormone ◽

Endocrine Gland ◽

Thyroid Function Tests ◽

Sample Collection ◽

Free T4 ◽

Group 2

Background: The thyroid is an endocrine gland. It secretes two hormones thyroxine (T4), triiodothyronine (T3). Hypothyroidism is a common condition encountered by a clinician. Subclinical hypothyroidism (SCH) defined as normal free thyroxine (T4) and elevated thyroid stimulating hormone (TSH), is primarily a biochemical diagnosis with or without clinical symptoms. Studies have observed that TSH levels vary at different times in a day. In practice not much importance is given to the timing of the sample collection (pre-prandial or post-prandial sate). SCH is diagnosed depending on TSH value. So the condition may be under or over diagnosed based on a single value. So we conducted this study to determine whether timing of sample collection had any significant relationship in the determination of levels of thyroid hormones.Methods: The study was carried on 114 patients who visited ENT department, NMCH between July 2018 and June 2019. Group-1 consisted of 38 normal patients. Group-2 consisted of 36 hypothyroidism patients GROUP-3 consisted of 40 subclinical hypothyroidism patients. Thyroid function tests (TSH and free T4) were done in fasting state and 2 hours postprandially. Results: TSH values were found to be significantly lowered after food in all the three groups. Free T4 values did not show any statistically significant alteration after food.Conclusions: There was a significant decline in TSH values postprandially. This might lead to inappropriate diagnosis and management of patients as cases of hypothyroidism, especially in cases of sub clinical hypothyroidism.

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