A Case of macro-TSH masquerading as subclinical hypothyroidism

2021 ◽  
Vol 14 (7) ◽  
pp. e243436
Author(s):  
Robert D'Arcy ◽  
Steven Hunter ◽  
Kirsty Spence ◽  
Margaret McDonnell
Keyword(s):  
Molecular Weight ◽  
Subclinical Hypothyroidism ◽  
Gel Filtration ◽  
Thyroid Stimulating Hormone ◽  
Hormone Resistance ◽  
Free T4 ◽  
Normal Response ◽  
Initial Impression ◽  
Inappropriate Treatment ◽  
Assay Interference

A 47-year-old man was commenced on levothyroxine following a diagnosis of subclinical hypothyroidism with nonspecific symptoms. Despite increasing doses of levothyroxine, his thyroid-stimulating hormone (TSH) remained elevated and he was referred for further assessment as he was unable to tolerate further titration. On assessment, his thyroid function demonstrated an elevated TSH and elevated free-T4. The initial impression was of iatrogenic thyrotoxicosis, with possible underlying thyroid hormone resistance, TSHoma or assay interference. After discontinuation of levothyroxine, free-T4 normalised but TSH remained elevated. There was a normal response to thyrotropin-releasing hormone (TRH) testing. T3 suppression testing demonstrated free-T4 reduction but persistently high TSH. THRβ sequencing was normal. TSH measurement by alternative assays revealed discrepant results. Gel filtration chromatography revealed the presence of high-molecular weight TSH variant alongside normal TSH. Macro-TSH is a rare phenomenon with spuriously elevated TSH and which may mimic subclinical hypothyroidism. Recognition of macro-TSH avoids misdiagnosis and prevents inappropriate treatment.

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

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

<p class="abstract"><strong>Background:</strong> The thyroid is an<strong> </strong>endocrine gland. It secretes two hormones thyroxine (T<sub>4</sub>), triiodothyronine (T<sub>3</sub>). 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.</p><p class="abstract"><strong>Methods:</strong> 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.  </p><p class="abstract"><strong>Results:</strong> 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.</p><p class="abstract"><strong>Conclusions:</strong> 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.</p>

scholarly journals Prevalence of Subclinical Hypothyroidism among Patients with Acute Myocardial Infarction

2011 ◽  
Vol 2011 ◽  
pp. 1-5 ◽  
Author(s):  
Okuyan Ertugrul ◽  
Uslu Ahmet ◽  
Enhos Asim ◽  
Hepgul E. Gulcin ◽  
Ayca Burak ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
Acute Myocardial Infarction ◽  
Subclinical Hypothyroidism ◽  
Large Scale ◽  
Thyroid Stimulating Hormone ◽  
Free T4 ◽  
Upper Limit ◽  
St Elevation ◽  
Elevation Acute Myocardial Infarction ◽  
Tsh Levels

Introduction. Subclinical hypothyroidism (SCH) is defined as a serum thyroid-stimulating hormone (TSH) level above the upper limit of normal despite normal levels of serum free thyroxine. There is growing evidence that SCH is associated with increased cardiovascular risk. We tried to investigate prevalence of SCH in acute myocardial infarction patients. Methods and Results. We evaluate free T3, free T4, and TSH levels of 604 patients (age 58.4) retrospectively, who have been admitted to the coronary intensive care unit between years 2004–2009 with the diagnosis of ST elevation (STEMI) or non-ST elevation acute myocardial infarction (NSTEMI). Mild subclinical hypothyroidism (TSH 4.5 to 9.9 mU/l) was present in 54 (8.94%) participants and severe subclinical hypothyroidism (TSH 10.0 to 19.9 mU/l) in 11 (1.82%). So 65 patients (10.76%) had TSH levels between 4.5 and 20. Conclusions. In conclusion, 65 patients (10.76%) had TSH levels between 4.5 and 20 in our study, and it is a considerable amount. Large-scale studies are needed to clarify the effects of SCH on myocardial infarction both on etiologic and prognostic grounds.

scholarly journals Subclinical Hypothyroidism In Childhood, Treatment Or Only Follow-Up?

2020 ◽  
Author(s):  
Marta Murillo-Vallés ◽  
Santiago Martinez ◽  
Cristina Aguilar-Riera ◽  
Miguel Angel Garcia-Martin ◽  
Joan Comós Bel ◽  
...  
Keyword(s):  
Subclinical Hypothyroidism ◽  
Therapy Group ◽  
Roc Curves ◽  
Serum Levels ◽  
Thyroid Stimulating Hormone ◽  
Free T4 ◽  
Laboratory Findings ◽  
Increased Risk ◽  
Group 3 ◽  
Group 1

Abstract Background: Subclinical hypothyroidism is defined as serum levels of thyroid-stimulating hormone (TSH) above the upper limit with normal concentrations of free T4 (fT4). Its management remains challenging. The aim of the study was to evaluate clinical and laboratory findings as well as clinical course of children with SH followed in a third level hospital. 65 patients aged between 2 and 18 years were retrospectively studied. Methods: The patients were followed for a median period of 9 months (range 6 months to 24 months). Those who normalized TSH levels were discharged (Group 1). If TSH persisted mild elevated (5-10µUI/mL) with normal fT4 and negative TPOAb/TgAb were classified as Group 2 and followed semiannually without treatment. In those patients who’s TSH raised ≥10µUI/mL or maintained TSH 5-10µUI/mL and positive TPOAb/TgAb were considered suitable for thyroxin therapy (Group 3, G3). Results: By ROC curves analysis we tested which initial TSH concentration best discriminated between patients who reverted to normality (Group 1) from those who finally required treatment (Group 3), the best cut-off being a TSH concentration >8.1µUI/mL (93.18% E, 57.14% S, AUC 0.765±0.107, p= 0.01). In 89% of our patients, TSH concentrations spontaneously reverted to normality or remained stable without treatment, whereas less than 11% progressed to clinical hypothyroidism. Conclusion: patients with initial TSH concentrations above 8.1µUI/mL have an increased risk of progression to hypothyroidism.

scholarly journals Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline

BMJ ◽  
2019 ◽  
pp. l2006 ◽  
Author(s):  
G E Bekkering ◽  
T Agoritsas ◽  
L Lytvyn ◽  
A F Heen ◽  
M Feller ◽  
...  
Keyword(s):  
Systematic Review ◽  
Thyroid Hormones ◽  
Subclinical Hypothyroidism ◽  
Decision Aids ◽  
Thyroid Stimulating Hormone ◽  
Free T4 ◽  
Strong Recommendation ◽  
Guideline Panel ◽  
Tsh Levels ◽  
Quality Evidence

AbstractClinical questionWhat are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice.Current practiceCurrent guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing.RecommendationThe guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old).How this guideline was createdA guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach.The evidenceThe systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years’ follow-up.Understanding the recommendationThe panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.

scholarly journals Thyroid stimulating hormone resistance syndrome – a case report

2015 ◽  
Vol 8 (1) ◽  
pp. 32-33
Author(s):  
SM Ashrafuzzaman ◽  
Zafar A Latif
Keyword(s):  
Case Report ◽  
Normal Limit ◽  
Thyroid Stimulating Hormone ◽  
Young Girl ◽  
Ectopic Thyroid ◽  
Overt Hypothyroidism ◽  
Hormone Resistance ◽  
Free T4 ◽  
Euthyroid State ◽  
Stimulating Hormone

Resistance to thyrotropin or thyroid stimulating hormone (RTSH) can be defined as decreased responsiveness to thyroid stimulating hormone (TSH) characterized by high TSH with normal but occasionally low T4 and T3 usually in absence of goiter or ectopic thyroid. It can be diagnosed when TSH is >30 mIU/L but free T4 (FT4) is within normal limit. Patient usually presents in euthyroid state with abnormally high TSH but may also present with mild to overt hypothyroidism. The precise prevalence is not known, but 20-30% infants may show transient mild RTSH. In adults it is rare.Here we report a case of RTSH in which a 19 years old young girl presented in euthyroid state with mild goiter.Ibrahim Med. Coll. J. 2014; 8(1): 32-33

scholarly journals Correlation of serum thyroid stimulating hormone with body mass index in healthy adults

2019 ◽  
Vol 2 (3) ◽  
pp. 116-120
Author(s):  
Bishow Raj Baral ◽  
Manoj Koirala ◽  
Buddhi Sagar Lamichhane ◽  
Suresh Raj Paudel ◽  
Laxman Banstola ◽  
...  
Keyword(s):  
Body Mass Index ◽  
Body Mass ◽  
Subclinical Hypothyroidism ◽  
Thyroid Dysfunction ◽  
Thyroid Stimulating Hormone ◽  
Function Evaluation ◽  
Free T4 ◽  
Cross Sectional ◽  
The Mean ◽  
Stimulating Hormone

Background: Obesity, a chronic disease that is increasing in prevalence in adults, adolescents and children, is now considered a global epidemic. Thyroid dysfunction contributes to the pathogenesis of obesity. Many clinical studies raise the questions of whether thyroid-stimulating hormone (TSH) changes in physiological limits is associated with obesity and whether there is a link between adipose tissue and hypothalamo-thyroidal axis. Materials and Method: This was a cross-sectional study. All clinically euthyroid patients and healthy volunteer adults of age 18 to 60 years of either gender were included in the study. Fasting blood sample was taken for thyroid function evaluation, which included Free T3, Free T4 and thyroid stimulating hormone. Height, weight, waist circumference and hip circumference were measured. The results were compared with calculated Body Mass Index (BMI). Results: 61 patients who met the inclusion criteria were studied. Among 61 patients 16 had subclinical hypothyroidism, 2 patients had hypothyroidism and 43 were euthyroid. Similarly, 2 underweight patients were observed, 7 had normal weight, 13 were over weight and 39 were obese. The mean TSH according to BMI were 3.8, 4.04, 3.88 and 6.19 respectively. Conclusion: The result in this study showed that the mean TSH increased as BMI increased with significant relationship between serum TSH and BMI (p <0.001). Thus thyroid dysfunction mainly subclinical hypothyroidism and hypothyroidism could be found in association with increased body weight.

scholarly journals Effect of Contrast Media used in Coronary Angiography on Thyroid Function

2019 ◽  
pp. 339-344
Author(s):  
Khaled S. El-Hadidy ◽  
Rania E. Sheir ◽  
M.N. Salem ◽  
Ahmed M. EL-Dien ◽  
Yasser A. Abd El-Hady
Keyword(s):  
Coronary Angiography ◽  
Contrast Media ◽  
Thyroid Function ◽  
Subclinical Hypothyroidism ◽  
Thyroid Dysfunction ◽  
Thyroid Stimulating Hormone ◽  
P Value ◽  
Free T4 ◽  
Iodinated Contrast ◽  
Significant Difference

Radiocontrast-induced thyroid dysfunction prevalence has not been assessed accurately. It is greater among patients with pre-existing thyroid disease. Aim of this work to investigate effect of iodinated radiographic contrast media used in coronary angiography on the thyroid function in euthyroid patients. This study was conducted on 85 patients underwent elective coronary angiography. Baseline assessment of Free Thyroxine (FT4) and Thyroid-stimulating hormone (TSH) for the patients and three months later after Coronary Angiography. We observed that there was a statistically significant increase of TSH levels from baseline till 3 months following administration of contrast media (P-value=0.007). However, there was no statistical significant difference of Free T4 level from baseline till 3 (P-value=0.765). The incidence of increased TSH above normal range was 2.4% after 3 months ( 2 subclinical hypothyroidism cases). We noticed that there were no effect of age, gender, hypertension, diabetes, type of contrast, creatinine level or GFR on increased the level of TSH above normal value after 3 months. So, administration of Iodinated Contrast Media (ICM) associated with thyroid dysfunction mainly subclinical hypothyroidism so we should closely monitor patients after receiving ICM especially who have thyroid dysfunction.

scholarly journals Subclinical Hypothyroidism Prevalence in Pregnant Ladies in AL-Hilla city in Iraq

2018 ◽  
Vol 26 (8) ◽  
pp. 157-163
Author(s):  
Ban Amer Mousa ◽  
Sijal Fadhil Farhood Al Joborae
Keyword(s):  
Subclinical Hypothyroidism ◽  
First Trimester ◽  
Cross Sectional Study ◽  
Thyroid Stimulating Hormone ◽  
Adverse Outcomes ◽  
Screening Tests ◽  
Overt Hypothyroidism ◽  
Free T4 ◽  
Cross Sectional ◽  
Normal Value

Recent guidelines adapted unique pregnancy thyroid function screening tests because pregnancy subclinical hypothyroidism is associated with different adverse outcomes.  There are no data from Iraq about the prevalence of thyroid hypofunction in the 1st trimester of pregnancy. This study aims to find the prevalence of thyroid dysfunction in the 1st trimester.                                              Patients and Methods: In this descriptive cross-sectional study, thyroid stimulating hormone (TSH) was measured in 100 pregnant women from  May 2017-December 2017 in Babylon teaching hospital for maternity and pediatric and in private clinic. If TSH was more than 2.5 mIU/L in the first trimester, free T4 was measured to diagnose then differentiate between subclinical & overt hypothyroidism. If free T4 was in the normal value (0.7-1.8 ng/dl) the diagnosis was subclinical hypothyroidism and if below the normal value, overt hypothyroidism was diagnosed.

scholarly journals A study of levothyroxine substitution therapy on subclinical hypothyroid patients and its effects on lipid profile in the department of medicine at tertiary care hospital

2020 ◽  
Vol 4 (2) ◽  
pp. 4-11
Author(s):  
Binod Raut ◽  
N Paudel ◽  
N Bhosekar
Keyword(s):  
Lipid Profile ◽  
Subclinical Hypothyroidism ◽  
Tertiary Care ◽  
Serum Triglyceride ◽  
Thyroid Stimulating Hormone ◽  
High Serum ◽  
Slight Reduction ◽  
Care Hospital ◽  
Free T4

Background: Subclinical hypothyroidism is represented by high serum thyroid stimulating hormone (TSH) and normal serum free T4 and T3, Recent studies on subclinical hypothyroidism and lipid profile indicates that the serum total cholesterol, LDL-C, and total triglycerides were significantly increased. Clinical evidence suggests that thyroid replacement therapy with levothyroxine has beneficial effect. Methods: It is a hospital based prospective observational study involving 122 patients based on non probability sampling conducted in the Department of Internal Medicine. The study involved patients who have been diagnosed with subclinical hypothyroidism with normal level of free T4, T3 and elevated levels of TSH with positive Thyroperoxidase (TPO) antibodies. Patients were advised to investigate lipid profile before and after prescribing levothyroxine. Follow up was done after 6-9 wks. Results: In this study 122 patients diagnosed with Subclinical hypothyroidism were prescribed with levothyroxine in which 112 came for follow up. The mean age of the patient was 46.81. There was significant reduction in mean TSH from 12.09 (±1.89)mIU/L to 7.97(±1.59)mIU/L,TC from 217.12( ±20.87)mg/dl to 198.47( ±17.34)mg/dl and LDL from 137.16(±14.57)mg/dl to 124.62( ±12.89)mg/dl was found along with significant reduction in VLDL was found after levothyroxine therapy, There was slight reduction in serum triglyceride was found with no significant alteration in HDL and BMI levels. Conclusion: The study showed significant reduction in the lipid profile including TC, LDL and VLDL after levothyroxine therapy. There was significant reduction in the level of TSH was also found whereas the level of free T4 and T3 were not much altered. There was no significant change found in the level of HDL and BMI.  

scholarly journals No association between subclinical hypothyroidism and dyslipidemia in children and adolescents

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Ashkan Habib ◽  
Asadollah Habib
Keyword(s):  
Lipid Profile ◽  
Subclinical Hypothyroidism ◽  
Meta Analysis ◽  
Cross Sectional Study ◽  
Thyroid Stimulating Hormone ◽  
Pediatric Endocrinology ◽  
Free T4 ◽  
Cross Sectional ◽  
Significant Difference ◽  
Tsh Levels

Abstract Background There are controversies about the correlation between higher levels of thyroid stimulating hormone (TSH) and dyslipidemia in children. This study was designed to assess the relation between lipid profile components and TSH levels in children. Method This cross-sectional study was performed in a pediatric endocrinology growth assessment clinic in Shiraz, southern Iran. Children aged 2–18 years who referred to the clinic from January until April 2018 were included. TSH levels equal or above 5 mIU/L and lower than 10 mIU/L with normal free T4 (FT4) were considered as having subclinical hypothyroidism (SH). Results Six hundred sixty-six children were euthyroid while 181 had SH. No significant difference was found between the mean serum total cholesterol (P = 0.713), LDL-C (P = 0.369), HDL-C (P = 0.211), non-HDL-C (P = 0.929), and triglyceride (P = 0.215) levels between euthyroid children and subjects with SH. There was also no significant difference in the prevalence of dyslipidemias in any lipid profile components between the two groups. The adjusted correlation was not significant between TSH levels and any lipid profile component. Conclusion Based on the results of our study, we found no correlation between SH and dyslipidemia in children. The association between dyslipidemia and SH in children still seems to be inconsistent based on the results of this and previous studies. We recommend a meta-analysis or a significantly larger retrospective study on this subject.

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