Levothyroxine pseudo-malabsorption: testing and treatment in the outpatient setting

Persistent elevation of thyroid stimulating hormone (TSH) is a common clinical problem in outpatient clinics treating patients with primary hypothyroidism. One challenge to practitioners involves predicaments where patients have an inadequate response to a seemingly appropriate dose of levothyroxine (L-T4). A patient’s self-assessed compliance to hormone replacement therapy or verification refill history at the patient’s pharmacy might not be a reliable form of confirmation of non-adherence to the drug by the patient, which has been referred to as “L-T4 pseudo-malabsorption.” A fast and inexpensive tool to rule out true LT4 malabsorption and thereby properly diagnosing and ultimately successfully treat LT4 pseudo-malabsorption is available in the outpatient setting. This allows clinicians to identify which patients for individual support in adhering to their prescribed therapy and may also reduce unnecessary referrals for sub-specialty care by endocrinologists.

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Homeopathic Treatment of Subclinical Hypothyroidism—A Series of 19 Cases

Homeopathy ◽

10.1055/s-0041-1734028 ◽

2021 ◽

Author(s):

Luiz Carlos Esteves Grelle ◽

Luiz Antonio Bastos Camacho

Keyword(s):

Subclinical Hypothyroidism ◽

Clinical Importance ◽

Clinical Problem ◽

Thyroid Stimulating Hormone ◽

Exclusion Criteria ◽

The Mean ◽

Common Clinical Problem ◽

Prompt Diagnosis ◽

Serum Tsh ◽

Tsh Levels

Abstract Background Subclinical hypothyroidism (SCH) is a common clinical problem. Controversy surrounds the definition, clinical importance, and need for prompt diagnosis and treatment of the mild form of SCH. Aim The aim of the study was to analyze the evolution of serum thyroid stimulating hormone (TSH) levels after a therapeutic homeopathic intervention in women older than 40 years with SCH. Methods This study is a retrospective series of 19 cases of SCH, with serum TSH levels between 5 and 10 mIU/L, treated exclusively with homeopathic medicines prescribed on an individualized basis. Results Nineteen patients were included according to the inclusion and exclusion criteria. Their mean age was 56 years, they were followed for a mean duration of 69 months, the mean number of serum TSH level measurements was 18, and the intervention was successful for 13 patients. Conclusion The homeopathic therapeutic intervention was successful in 68% of the patients, with serum TSH levels back within the normal range (0.5–5.0 mIU/L).

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SERUM PROLACTIN IN PATIENTS WITH "FUNCTIONLESS" CHROMOPHOBE ADENOMAS BEFORE AND AFTER THERAPY

Acta Endocrinologica ◽

10.1530/acta.0.0840449 ◽

1977 ◽

Vol 84 (3) ◽

pp. 449-460 ◽

Cited By ~ 12

Author(s):

N. A. Samaan ◽

M. E. Leavens ◽

J. H. Jesse

Keyword(s):

Hormone Replacement ◽

Pituitary Surgery ◽

Pituitary Tumour ◽

Pituitary Hormones ◽

Thyroid Stimulating Hormone ◽

High Serum ◽

Primary Hypothyroidism ◽

Pituitary Function ◽

Serum Prolactin ◽

Before And After

ABSTRACT The immunoreactive serum human prolactin (PRL) level was measured before and after intravenous administration of 500 μg of thyrotrophinreleasing hormone (TRH) in 11 patients with "functionless" chromophobe adenomas before and after surgery and after radiotherapy in 6 of these patients. The results were compared to other pituitary function tests. Two of the patients studied had recurrent disease after previous pituitary surgery and radiotherapy. Five patients had pituitary surgery through the transfrontal route, while 6 had adenoma removal via the transnasal transsphenoidal route. Before surgery, the serum PRL concentration was abnormally high in 4 patients, before and after TRH administration. It was normal in 6 and subnormal in 1 patient who had had previous therapy. Two of the patients studied showed high serum thyroid-stimulating hormone (TSH) levels in the presence of low serum T3 and T4 suggesting primary hypothyroidism with a secondary TSH-producing pituitary tumour. After surgery all patients showed a significant decrease of the serum PRL level. This contrasts with more variable results in the measurements of other pituitary hormones. Post-operative radiotherapy produced no significant additional change in serum PRL levels in 5 of the 6 patients measured 6 months to 4 years after radiotherapy. Five of the 6 patients who had adenoma removed via the transsphenoidal route required no cortisol replacement and 4 remained euthyroid, whereas all 5 patients after transfrontal surgery required both cortisol and thyroid hormone replacement. These results indicate: (1) that measurement of serum PRL levels at basal and after TRH administration in patients with "functionless" chromophobe adenomas before and after treatment may be the best index for evaluating the effect of therapy; (2) that adenoma removal may be followed by preservation of normal pituitary function, but this is more likely to occur if the transsphenoidal approach is used; and (3) that primary thyroid insufficiency may be associated with a pituitary adenoma.

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Recurrent Galactorrhoea: A consequence of unheeded primary hypothyroidism

Babcock University Medical Journal (BUMJ) ◽

10.38029/bumj.v4i1.75 ◽

2021 ◽

Vol 4 (1) ◽

pp. 54-59

Author(s):

Olutomiwa Omokore ◽

Nwachukwu Nwachukwu ◽

Oreoluwa Fuwape ◽

Adetomilayo Arijeniwa ◽

Abiola Adekoya ◽

...

Keyword(s):

Hormone Replacement ◽

Elevated Serum ◽

Signs And Symptoms ◽

Symptomatic Improvement ◽

Thyroid Stimulating Hormone ◽

Pharmacological Therapy ◽

Primary Hypothyroidism ◽

Serum Prolactin ◽

Low Mood ◽

Hormonal Assay

Background: Primary hypothyroidism can lead to hyperprolactinemia through several mechanisms in both men and women, manifesting as galactorrhoea, loss of libido, and infertility in both sexes, as oligomenorrhea/amenorrhea in women, and as gynecomastia and erectile dysfunction in men. Case presentation: Here presented is a 28-year-old Nigerian woman with a history of recurrent bilateral painless galactorrhoea of 12 years’ duration and persistent low mood. Physical examination was unremarkable. The hormonal assay revealed elevated thyroid-stimulating hormone, elevated serum prolactin, low thyroxine, and low triiodothyronine levels. Magnetic resonance imaging of the brain revealed normal findings. A diagnosis of hyperprolactinemia secondary to primary hypothyroidism was made. Pharmacological therapy began with thyroid hormone replacement therapy and a dopamine agonist: 75 micrograms of levothyroxine daily and 0.5 micrograms of cabergoline twice weekly for 8 weeks. After 8 weeks of pharmacological therapy, hormonal assay revealed values within the reference range with significant symptomatic improvement evidenced by cessation of galactorrhoea and low mood. Conclusion: Primary hypothyroidism has been proven to be one of the numerous causes of hyperprolactinemia and it could be unheeded in a patient who does not present with the typical signs and symptoms of primary hypothyroidism.

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Dysphagia for the acute physician

Acute Medicine Journal ◽

10.52964/amja.0050 ◽

2003 ◽

Vol 2 (3) ◽

pp. 86-91

Author(s):

Jonathan Followfield ◽

◽

Hugh Shepherd ◽

Keyword(s):

Elderly Population ◽

Clinical Problem ◽

The Elderly ◽

Outpatient Setting ◽

Initial Management ◽

Possible Cause ◽

Common Clinical Problem ◽

Careful History

Dysphagia (subjective difficulty in swallowing) is a common clinical problem, particularly in the elderly population. Ideally, patients should be assessed promptly in the appropriate outpatient setting, but frequently they will be admitted on an acute medical take due to ‘total’ dysphagia, dehydration, debilitation or possible aspiration. A careful history and examination can usually elucidate the site of the lesion and its possible cause, and thus direct initial management. This article will concentrate on the role of the acute physician in the assessment of patients with dysphagia within the first 48 hours of presentation.

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Isolated Adrenocorticotropic Hormone Deficiency Accompanied by Impaired Cognitive Function: A Case Report

10.21203/rs.3.rs-460503/v1 ◽

2021 ◽

Author(s):

ATSUKO IKENOUCHI ◽

Issei Seki ◽

Naomichi Okamoto ◽

Yuki Konishi ◽

Reiji Yoshimura

Keyword(s):

Cognitive Functions ◽

Adrenocorticotropic Hormone ◽

Psychiatric Symptoms ◽

Hormone Replacement ◽

Adjustment Disorder ◽

Pituitary Hormones ◽

Thyroid Stimulating Hormone ◽

Primary Hypothyroidism ◽

Hormone Deficiency ◽

Physical Treatment

Abstract Background: Isolated adrenocorticotropic hormone (ACTH) deficiency (IAD) is an adrenal insufficiency caused by a decrease in ACTH alone among the anterior pituitary hormones. IAD is often overlooked because it causes nonspecific symptoms. We report a case of IAD diagnosed after the appearance of mild cognitive impairment (MCI).Case presentation: Our department was consulted on a case of a 46-year-old man for whom dementia was suspected because he was speaking incoherently, wiped his nose with his hands and showed mild brain atrophy on MRI. He was previously diagnosed with some psychiatric diseases, such as narcolepsy and adjustment disorder. He could not continue working due to somnolence, general fatigue and appetite loss. At the examination, he had difficulty concentrating and sustaining attention, exhibited restlessness, and scored 25 points on the Mini Mental State Examination-Japanese (MMSE-J); MCI was observed. Blood tests showed decreased ACTH, cortisol and free thyroxine and increased thyroid-stimulating hormone levels. He received further evaluation, and he was diagnosed with IAD and primary hypothyroidism. Hydrocortisone (15 mg) was started, after which his physical problems and his difficulty concentrating disappeared. His MMSE-J score also increased to 30. His cognitive functions completely recovered. He returned to work and continued to work stably.Conclusion: This patient was diagnosed with IAD and treated with adrenocortical hormone replacement therapy. His cognitive functions recovered, his physical and mental disorders were alleviated, and he returned to society. It is important not to miss neurological and psychiatric symptoms that can be cured by physical treatment.

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How we evaluate and treat neutropenia in adults

Blood ◽

10.1182/blood-2014-02-482612 ◽

2014 ◽

Vol 124 (8) ◽

pp. 1251-1258 ◽

Cited By ~ 48

Author(s):

Christopher Gibson ◽

Nancy Berliner

Keyword(s):

Primary Care ◽

Adult Patient ◽

Primary Care Physicians ◽

Clinical Presentation ◽

Clinical Status ◽

Clinical Problem ◽

Outpatient Setting ◽

Practical Approach ◽

Major Focus ◽

Common Clinical Problem

Abstract Isolated neutropenia is a common clinical problem seen by primary care physicians and hematologists. The evaluation of neutropenia is dictated by the acuity of the clinical presentation and the duration, age, and clinical status of the patient. In this review, we provide a practical approach to the evaluation of the adult patient with neutropenia, with the major focus on the evaluation of neutropenia in the outpatient setting.

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Van Wyk-Grumbach syndrome with hemangioma in an infant

Journal of Pediatric Endocrinology and Metabolism ◽

10.1515/jpem-2018-0049 ◽

2018 ◽

Vol 31 (9) ◽

pp. 1057-1060

Author(s):

Moumita Biswas ◽

Malay Kumar Sinha ◽

Mrinal Kanti Das ◽

Sumantra Sarkar

Keyword(s):

Thyroid Hormone ◽

Congenital Hypothyroidism ◽

Hormone Replacement ◽

Signs And Symptoms ◽

Bone Age ◽

Infantile Hemangioma ◽

Thyroid Stimulating Hormone ◽

High Serum ◽

Primary Hypothyroidism ◽

Thyroid Hormone Replacement

Abstract Background Van Wyk-Grumbach syndrome (VWGS) is characterized by juvenile primary hypothyroidism, delayed bone age and isosexual incomplete precocious puberty with reversal to the prepubertal state following thyroid hormone replacement. Case presentation In this case, an 18-month-old girl presented with premature menarche since 9 months of age, delayed bone age and enlarged bilateral multicystic ovaries along with a superficial infantile hemangioma over the upper anterior chest. VWGS was diagnosed based on the clinical features. High serum thyroid stimulating hormone and low free thyroxine with the absence of any carpal bones in the wrist X-ray were suggestive of congenital hypothyroidism. Interestingly, the coexisting hemangioma could also play a role in the etiology of the hypothyroidism through “consumptive hypothyroidism”. Thyroid hormone replacement resulted in the complete resolution of signs and symptoms. Conclusions Untreated congenital hypothyroidism of short duration, onset of symptoms in infancy and association of an infantile hemangioma in VWGS were the unique features in our case.

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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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