scholarly journals A Rare Phenomenon of Hashimotos Thyroiditis Converting to Graves Disease

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A917-A917
Author(s):  
Ahl Jeffrey Caseja ◽  
Samer Nakhle
Keyword(s):  
Thyroid Function ◽  
Thyroid Function Test ◽  
Primary Care Providers ◽  
Deficiency Anemia ◽  
Graves Disease ◽  
Close Monitoring ◽  
Thyroid Function Tests ◽  
Care Providers ◽  
History Of

Abstract Introduction: Hashimotos thyroiditis and Graves disease are two distinct autoimmune disorders of the thyroid. Conversion of hypothyroidism to hyperthyroidism is even more rare. We report a case of an established Hashimotos thyoiditis patient who converted into Graves disease. Case Description: 67-year old female with a past medical history of iron-deficiency anemia, dyslipidemia, and depression presented with a six-month history of fatigue, cold-intolerance, hair loss, and weight gain in September of 2015. Laboratory tests confirmed diagnosis of Hashimotos thyroiditis with an elevated TSH 80.7 (0.40-4.50 mIU/L), FT4 0.2 (0.8-1.8 ng/dL), and positive thyroid antibodies TPO 24 (0.0-8.9 IU/mL). She was started on Levothyroxine 88 mcg daily. Gradually she had a decreased requirement of Levothyroxine; from February 2016 to March 2017 she maintained a normal TSH range while on 50 mcg/day with resolution of her symptoms. The patient was then lost to follow-up until she presented in the clinic in September 2018 with complaints of several weeks of easy fatigability, 10lb-weight loss, and periorbital edema. She was found to have a suppressed TSH 0.01, and elevated FT4 2.3, and FT3 8.4 (2.3-4.2 pg/mL). Her Levothyroxine 50 mcg/day was discontinued for four days and labs were repeated which still showed suppressed TSH and elevated FT4 and FT3. She was found to have a positive TRAB and a positive TSI which are consistent with hyperthyroidism. Thyroid ultrasound was performed which showed a heterogeneous thyroid gland with increased vascularity, confirming the diagnosis of Graves disease. She was started on Methimazole 10 mg daily. Her Methimazole dose was adjusted according to her thyroid function test until she had a total thyroidectomy in October 2019. She was started on levothyroxine post-operatively and as of March 2020 is on Levothyroxine 50 mcg/daily. Conclusion: Despite the rarity of Hashimotos thyroiditis converting to Graves disease, it is possible that those affected can be encountered by primary care providers and hospitalists and could easily be mistaken for over-replacement of levothyroxine. Close monitoring of the patient along with regular thyroid function tests will be required for ongoing follow-up.

scholarly journals MON-470 Biotin Masquerading as Subclinical Hyperthyroidism

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Anita Eapen ◽  
Hooman Oktaei
Keyword(s):  
Thyroid Function ◽  
Clinical Endocrinology ◽  
Thyroid Function Test ◽  
Graves Disease ◽  
Endocrine Disorders ◽  
Thyroid Function Tests ◽  
Medication History ◽  
Free T4 ◽  
Function Tests ◽  
History Of

Abstract Introduction: Thyroid conditions are among the most common endocrine disorders. Diagnosis is dependent on interpretation of laboratory tests. The challenge comes when the clinical picture is discordant with laboratory results. Case Report: Patient is a 53-year-old male with history of cardiac transplantation, type 2 diabetes mellitus, history of amiodarone-induced hyperthyroidism. He was noted to have labs indicative of hyperthyroidism, while taking amiodarone, in 2016-2017, which was treated with methimazole. He was then noted to have abnormal thyroid function tests with low TSH to 0.3 IU/L, normal T3 and normal T4 levels. Thyroid stimulating immunoglobulin had been checked multiple times, and was normal, which is inconsistent with Graves’ disease. Prior radioactive iodine uptake scan, while off amiodarone, was noted to be normal. He was also scheduled for thyroidectomy at another hospital, which was cancelled due to normalization of thyroid function tests. Consultation was received for suppressed TSH to 0.323 IU/L, without symptoms of hyperthyroidism. He had been taking biotin during this time, which he subsequently stopped taking. Repeat TSH following discontinuation of biotin, was within normal range, most recent TSH 2.48 IU/L, free T4 1.03 ng/dL, free T3 2.7 pg/mL. Discussion: Thyroid function tests are commonly ordered. Interpretation of these tests relies on the provider’s understanding of thyroid physiology in addition to interferences with medications and other conditions. High doses of biotin, which people take as supplements for multiple sclerosis, or metabolic disorders, or for healthy nails and hair, can cause thyroid function test abnormalities. Streptavidin and biotin are used in some immunoassay platforms to capture antigens (TSH, free T4) or antibodies. High levels of serum biotin can inhibit the formation of T4 antibody complex, which results in a falsely high free T4 result. Conclusion: Thyroid Function tests should be interpreted very cautiously, especially in the setting of discordant clinical findings. Prior to ordering these tests, should attempt to obtain a detailed history of medications including over-the-counter supplements, which are commonly not reported during medication history. References:Elston, Marianne S., et al. “Factitious Graves’ Disease Due to Biotin Immunoassay Interference—A Case and Review of the Literature.” The Journal of Clinical Endocrinology & Metabolism, vol. 101, no. 9, 30 June 2016, pp. 3251-3255., doi:10.1210/jc.2016-1971. Koehler, Viktoria F., et al. “Fake News? Biotin Interference in Thyroid Immunoassays.” Clinica Chimica Acta, vol. 484, 30 May 2018, pp. 320-322., doi:10.1016/j.cca.2018.05.053. Soh, Shui-Boon, and Tar-Choon Aw. “Laboratory Testing in Thyroid Conditions - Pitfalls and Clinical Utility.” Annals of Laboratory Medicine, vol. 39, no. 1, 13 Jan. 2019, pp. 3-14., doi:10.3343/alm.2019.39.1.3.

When thyroid labs do not add up, physicians should ask patients about biotin supplements

2020 ◽  
Vol 13 (3) ◽  
pp. e231337
Author(s):  
Michael S Lundin ◽  
Ahmad Alratroot ◽  
Fawzi Abu Rous ◽  
Saleh Aldasouqi
Keyword(s):  
Thyroid Function ◽  
Dose Adjustment ◽  
Radioactive Iodine ◽  
Graves Disease ◽  
Thyroid Function Tests ◽  
Medication List ◽  
Function Tests ◽  
Extensive Evaluation ◽  
History Of ◽  
Radioactive Iodine Ablation

A 69-year-old woman with a remote history of Graves’ disease treated with radioactive iodine ablation, who was maintained on a stable dose of levothyroxine for 15 years, presented with abnormal and fluctuating thyroid function tests which were confusing. After extensive evaluation, no diagnosis could be made, and it became difficult to optimise the levothyroxine dose, until we became aware of the recently recognised biotin-induced lab interference. It was then noticed that her medication list included biotin 10 mg two times per day. After holding the biotin and repeating the thyroid function tests, the labs made more sense, and the patient was easily made euthyroid with appropriate dose adjustment. We also investigated our own laboratory, and identified the thyroid labs that are performed with biotin-containing assays and developed strategies to increase the awareness about this lab artefact in our clinics.

scholarly journals A case series and review on pediatric thyroid nodules

2020 ◽  
Vol 8 (1) ◽  
Author(s):  
Anju Sukumaran ◽  
Valiparambil B Praveen Kumar
Keyword(s):  
Primary Care ◽  
Thyroid Nodules ◽  
Case Series ◽  
Primary Care Providers ◽  
Close Monitoring ◽  
Care Providers ◽  
Long Term Follow Up ◽  
Risk Of Malignancy ◽  
Work Up

Thyroid nodules have a higher risk of malignancy in children and hence need close monitoring. Primary care providers often obtain the initial thyroid work up. Once there patients are referred to specialists, primary providers are unsure about subsequent management and follow up. We present here three cases of thyroid nodules with different initial presentation, diagnosis and management. This article provides a good brief summary about thyroid nodule and reiterates the importance of long term follow up of these patients by primary care provider and endocrinologists.

scholarly journals COVID-19 Infection Causing Atypical Thyroiditis

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A925-A926
Author(s):  
Rujuta Baban Katkar
Keyword(s):  
Thyroid Function ◽  
Thyroid Disease ◽  
Severe Disease ◽  
Thyroid Function Test ◽  
Thyroid Peroxidase ◽  
Close Monitoring ◽  
Thyroid Function Tests ◽  
Upper Respiratory Tract ◽  
Significant Past Medical History ◽  
Function Test

Abstract Introduction: Coronavirus disease 2019 (COVID-19) has caused significant health burden across the world. Identification of factors contributing to severe disease is important to enable stratification of risk, optimize the reallocation of hospital resources, and guide public health recommendations and interventions. Subacute thyroiditis is an inflammatory thyroid disease characterized by neck pain and is usually preceded by an upper respiratory tract infection. It may be caused by a viral infection or a post-viral inflammatory reaction, and many viruses have been linked to the disease. We present case of atypical thyroiditis associated with COVID-19 infection. Case Report: 27-year-old female with no significant past medical history apart from recent COVID-19 infection is referred to endocrinology for evaluation of abnormal thyroid function test. Patient states around three months ago she was experiencing the symptoms like unintentional weight loss, nausea, palpitation, insomnia, anxiety, fatigue similar to symptoms she experienced 9 years ago while she was pregnant with her daughter so she thought she is pregnant again and visited her gynecologist. But patient had pregnancy test was done and she was found to be negative but her thyroid function test showed low TSH 0.32mIU/ml (0.47-4.68mIU/ml). Patient states around same time she was diagnosed with COVID-19 infection and she lost 5 pounds during that time but even after recovery from the infection she continued to lose weight and lost a total of 18 pounds in 3 months. Patient states during the time of COVID-19 infection she was having difficulty swallowing and painful swallowing but following infection patient denied any current difficulty swallowing or breathing, headache, vision changes, cold or heat intolerance, diarrhea or constipation, tremors, proximal muscle weakness, bulging of her eyes. Patient continue to have regular monthly menstrual cycles. Three months following infection patients repeat thyroid function tests were done and it showed normal TSH 0.56mIU/ml(0.47-4.68mIU/ml),free T4 1.05ng/dL(0.78-2.19ng/dL) and negative thyroid antibodies like TSI index<1.0, Thyroid peroxidase Antibodies 1.4 IU/mL, Thyrotropin Receptor Ab <1.00 IU/L. Patient also had normal thyroid ultrasound. Patient had complete resolution of hyperthyroid symptoms and did not require any medications. Conclusion: In conclusion, physicians should be engaged in close monitoring of thyroid disease in patients with suspected COVID-19, for timely detecting signs of disease progression. Finally, the presence of thyroid disease shall be regarded as an important factor in future risk stratification models for COVID-19.

scholarly journals SUN-504 A Case of T3 Thyrotoxicosis

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Isabelle Daneault Peloquin ◽  
Matthieu St-Jean
Keyword(s):  
Thyroid Function ◽  
Thyroid Function Test ◽  
Nutritional Supplement ◽  
Thyroid Function Tests ◽  
Free T4 ◽  
Endocrine Society ◽  
Product Consumption ◽  
Function Tests ◽  
History Of ◽  
Receptor Antibodies

Abstract Clinical vignette ENDOCRINE SOCIETY 2020 Title: A case of T3 thyrotoxicosis induced by a dietary supplement. A 24 yo man consulted for a 2 weeks history of diaphoresis, fatigue, insomnia, palpitations and headache associated with a 20 pounds lost. The patient didn’t have a goiter or any signs of orbitopathy. The results revealed a free T3 level of 45.8 pmol/L upon arrival (normal (N) 3.4- 6.8 pmol/L), free T4 level of 6.4 pmol/L (N 11.0–22.0 pmol/L) and TSH level less than 0.005 mUI/L (N: 0.35 to 3.50 mUI/L). Facing those results, a complete review of the patient medication and natural product consumption was done. The patient revealed that he was using, since a month, a vegetable extracts nutritional supplement that didn’t included iodine. He was asked to stop the nutritional supplement and propranolol 10 mg twice daily was prescribed. Thyroid function tests were done 3 days after. The results demonstrate a fT3 level of 4.6 pmol/L, a fT4 level of 5.6 pmol/L and a TSH that still suppressed. A thyroid scintigraphy was performed 7 days later and showed a homogeneous uptake of 18.5% (N 7.0% – 35.0%). We saw the patient 2 weeks later and we ordered another thyroid function test with TSH receptor antibodies, TPO antibodies and thyroglobulin. The results were the following: fT3 of 5.1 pmol/L, fT4 of 12.1 pmol/L, TSH of 2.31 mUI/L, thyroglobulin of 19.8 ug/L (N: 1.4 – 78) and normal levels of antibodies against TPO and TSH receptors. To confirm the contamination of the nutritional supplement by fT3 we used a plasma pool of normal patients in which we measured thyroid function tests at baseline and after we have added the nutritional supplement powder to reflect the dose suggested by the manufacturer. The results showed that fT3 level increased by 36.5%, fT4 by 11.2% and TSH didn’t changed. The powder was then analyzed by an external laboratory that wasn’t able to demonstrate the presence of fT3 nor fT4. The two diagnostic possibility facing those results were that the powder induced an interference with immunoassay used to measure fT3 and fT4 but not TSH or thyrotoxicosis induced by the nutritional supplement with limitation in the technique that tried to identify fT3 in the powder. Given the presentation of the patient, we are convinced that this case represents a thyrotoxicosis induced by a nutritional supplement. In conclusion, Graves’ disease is responsible for 60–80% of the cases of hyperthyroidism. However, there are few cases reports of thyrotoxicosis induced by nutritional supplement1,2, but some studies demonstrate the presence of thyroid hormone in significant amounts in some commercially available health supplements3. This case highlights the importance of verifying exposition to medications and natural products when confronted to cases of thyrotoxicosis. 1.Regina A et al. MMWR Morb Mortal Wkly Rep. 2016 2. Panikkath R et al. Am J Ther. 2014 3. Kang GY et al. Thyroid. 2013

Neonatal thyroid storm: the importance of an accurate antenatal history

2021 ◽  
Vol 14 (1) ◽  
pp. e239278
Author(s):  
Sean Tamgumus ◽  
Elisabeth Lauesen ◽  
Michael A Boyle
Keyword(s):  
Thyroid Function ◽  
Neonatal Intensive Care ◽  
Thyroid Function Test ◽  
Term Infant ◽  
Thyroid Storm ◽  
Graves Disease ◽  
Free T4 ◽  
Post Surgery ◽  
History Of ◽  
Near Term

A near-term infant became unwell immediately after birth with cardiorespiratory compromise—persistent tachycardia, pulmonary hypertension and reduced cardiac function. There had been no concerns during the pregnancy and the obstetrical and maternal medical history was unremarkable apart from hypothyroidism. A thyroid function test on admission revealed a significantly elevated free T4 and a diagnosis of a thyroid storm was made. On questioning it became apparent that she had Graves’ disease after her last pregnancy and was rendered hypothyroid post surgery, she was not aware of the relevance of this at her booking visit. This case highlights the importance of monitoring of women who have a history of a diagnosis of Graves’ disease, regardless of thyroid function status, to allow for appropriate antenatal monitoring, preparedness of the NICU (neonatal intensive care unit) team and correct follow-up of the neonate. It also demonstrates the importance of ensuring a patient is properly educated about their condition.

Heart failure from thyrotoxicosis due to Graves’ disease

2021 ◽  
Vol 20 (1) ◽  
pp. 68-73
Author(s):  
Avinash Aujayeb ◽  
◽  
James Dundas ◽  
Keyword(s):  
Heart Failure ◽  
Beta Blockers ◽  
Pernicious Anaemia ◽  
Graves Disease ◽  
Thyroid Function Tests ◽  
Past Medical History ◽  
Pleuritic Chest Pain ◽  
History Of

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.

scholarly journals PROSPECTIVE STUDY OF THYROID DYSFUNCTION IN POST RADIOTHERAPY PATIENTS WITH HEAD AND NECK CANCERS

2020 ◽  
Vol 4 (4) ◽  
Author(s):  
Manish Kumar Chaturvedi ◽  
Rameshwaram Sharma ◽  
Rohitashwa Dana ◽  
Prashant Dadhich ◽  
Pawan Kumar ◽  
...  
Keyword(s):  
Head And Neck Cancer ◽  
Prospective Study ◽  
Head And Neck ◽  
Thyroid Function ◽  
Neck Cancer ◽  
Thyroid Function Test ◽  
P Value ◽  
Head Neck Cancer ◽  
Thyroid Function Tests

Background: The purpose of our study is to identify the incidence of hypothyroidism following radiotherapy in head and neck cancer patients in Rajasthan India and to assess the time period for the development of hypothyroidism for early treatment to reduce hypothyroid related morbidity and mortality. Methods: A prospective study conducted in Department of Radiation Oncology, S.M.S Medical College and attached group of hospital, Jaipur, Rajasthan. with 50 patients of histopathologically proven head and neck cancer receiving external beam to whole neck on telecobalt. Results: The patients were followed up for a period of six months. 7 (14%) patients were found to have hypothyroidism which was strongly significant with the p value of 0.02. Conclusion: We concluded that thyroid function tests should be made routine prior RT and during follow up period as early as 6 months and carried out lifelong. Keywords: Thyroid function test, Head neck cancer, Follow-up.

scholarly journals Cytomegalovirus-mononucleosis-induced thyroiditis in an immunocompetent patient

2017 ◽  
Vol 2017 ◽  
Author(s):  
V Larouche ◽  
M Tamilia
Keyword(s):  
Physical Examination ◽  
Liver Enzymes ◽  
Hormone Secretion ◽  
Thyroid Storm ◽  
Graves Disease ◽  
List Type ◽  
Thyroid Function Tests ◽  
Elevated Liver Enzymes ◽  
History Of

Summary Enteroviruses, including coxsackieviruses and Echovirus, are well known pathogens responsible for the development of thyroiditis. We describe the case of a 49-year-old woman with no personal or family history of thyroid disease who presented to the emergency room with a two-week history of daily fevers up to 39°C, a sore throat, occasional palpitations and diaphoresis, decreased appetite and an unintentional 10 kg weight loss over the same time course Physical examination revealed mild tachycardia, an intention tremor and a normal-sized, nontender thyroid gland without palpable nodules. The remainder of the physical examination was unremarkable and without stigmata of Graves’ disease. Her initial blood tests revealed overt thyrotoxicosis, elevated liver enzymes, an elevated C-reactive protein, a negative monospot and a positive CMV IgM antibody. Thyroid sonography revealed areas of hypoechogenicity and relatively low vascularity. Fine-needle biopsy showed a lymphocytic infiltrate. The patient was treated symptomatically with propranolol. On follow-up, the patient became euthyroid, and her liver enzymes normalised. Previous cases of CMV-induced thyroiditis occurred in immunosuppressed patients. This is the first reported case of a CMV-mononucleosis-induced thyroiditis in an immunocompetent adult patient and serves as a reminder that viral illnesses are a common cause of thyroiditis with abnormal liver enzymes. Learning points: The differential diagnosis of thyrotoxicosis with abnormal liver enzymes includes severe hyperthyroidism and thyroid storm caused by Graves’ disease as well as the thyrotoxic phase of a thyroiditis, usually caused by a virus such as coxsackievirus or, in this case, cytomegalovirus. Cytomegalovirus appears to be a recently recognized causal agent for thyroiditis, both in immunosuppressed and immunocompetent patients. Careful follow-up of thyroid function tests in patients with thyroiditis allows clinicians to determine if patients’ thyroid hormone secretion normalizes or if they remain hypothyroid.

scholarly journals A case of thyroid storm caused by Graves’ disease misdiagnosed as panic attack due to panic disorder

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Manabu Yasuda ◽  
Jun Kumakura ◽  
Kiyonori Oka ◽  
Kazuhito Fukuda
Keyword(s):  
Panic Disorder ◽  
Thyroid Function ◽  
Panic Attack ◽  
Thyroid Function Test ◽  
Outpatient Setting ◽  
Panic Attacks ◽  
Thyroid Storm ◽  
Graves Disease ◽  
Thyroid Function Tests ◽  
Sunday Morning

Abstract Background Graves’ disease is characterized by hyperthyroidism and its symptoms often overlap with those of panic disorder, which may make it difficult to distinguish between the two conditions. In this report, we describe how proper diagnosis of thyroid disease in patients with mental illness can lead to appropriate treatment. Case presentation We encountered a 34-year-old woman in whom thyroid crisis from Graves’ disease was misdiagnosed as panic attack. The patient was being managed as a case of panic disorder and bipolar disorder in a psychiatric outpatient setting. About 6 months before presentation she had lost about 16 kg in weight, and a month before presentation she developed several unpleasant symptoms as her condition worsened. Several weeks before she had had severe palpitations, tachycardia, and discomfort in her throat. She became unable to eat solids, ate only yogurt and gelatin, and felt it difficult to take psychiatric drugs. She visited our emergency outpatient department on a Sunday morning, presenting with nausea, severe tachycardia, fever, and restlessness with anxiety. We treated her as panic disorder with fever, but noted proptosis and considered the possibility of Graves’ disease. Thyroid function tests were performed even though data from her clinic was not available because it was a weekend. Because there was no improvement in her condition after her first visit, she returned to our hospital early the next morning. We had misdiagnosed her as having severe panic attacks due to panic disorder, and after a diazepam injection had allowed her to go home. Later that day, the thyroid function test results became available, and her symptoms and the results strongly indicated a thyroid storm. The endocrinology department was consulted immediately, and she was referred for hospitalization the next day. During hospitalization, she was treated with steroid and radioactive iodine therapy and was discharged from hospital in 3 weeks. Conclusion Psychiatrists and doctors engaged in psychosomatic medicine need to consider the possibility of severe hyperthyroidism as a differential diagnosis of panic disorder.

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