Factitious thyrotoxicosis: how to find it

Diagnosis ◽  
2020 ◽  
Vol 7 (2) ◽  
pp. 141-145
Author(s):  
Pakaworn Vorasart ◽  
Chutintorn Sriphrapradang
Keyword(s):  
Radioactive Iodine ◽  
Graves Disease ◽  
Case Presentation ◽  
Thyroglobulin Antibodies ◽  
Definitive Therapy ◽  
Thyroid Uptake ◽  
Thyroid Hormone Levels ◽  
Difficult Challenge

AbstractBackgroundAlthough the most common cause of thyrotoxicosis is Graves’ disease, the determination of the cause of thyrotoxicosis is important for establishing appropriate management. Diagnosis of surreptitious ingestion of thyroid hormones or factitious thyrotoxicosis often presents a difficult challenge especially in a patient with previously diagnosed Graves’ disease. The objective of this report was to demonstrate various approaches to support the diagnosis of factitious thyrotoxicosis.Case presentationWe describe a patient with underlying Graves’ disease who underwent definitive therapy and needed long-term levothyroxine (LT4) replacement therapy. Later she developed thyrotoxicosis. Although factitious thyrotoxicosis was suspected because of very low thyroid uptake and low thyroglobulin (Tg) levels with the absence of thyroglobulin antibodies (TgAbs), she still refused any medication or substance use. After the administration of bile acid sequestrant, the thyroid hormone levels rapidly returned to normal within 1 month.ConclusionsThe diagnosis of factitious thyrotoxicosis is based upon the absence of goiter, suppressed serum Tg level, decreased radioactive iodine (RAI) uptake, and excellent response after cholestyramine treatment.

Outcomes analysis of radioactive iodine and total thyroidectomy for pediatric Graves’ disease

2016 ◽  
Vol 29 (3) ◽  
Author(s):  
Reuven Zev Cohen ◽  
Eric I. Felner ◽  
Kurt F. Heiss ◽  
J. Bradley Wyly ◽  
Andrew B. Muir
Keyword(s):  
Children And Adolescents ◽  
Total Thyroidectomy ◽  
Relapse Rate ◽  
Radioactive Iodine ◽  
High Volume ◽  
Graves Disease ◽  
Complication Rates ◽  
Case Volume ◽  
Definitive Therapy

AbstractThe majority of pediatric patients with Graves’ disease will ultimately require definitive therapy in the form of radioactive iodine (RAI) ablation or thyroidectomy. There are few studies that directly compare the efficacy and complication rates between RAI and thyroidectomy. We compared the relapse rate as well as the acute and long-term complications of RAI and total thyroidectomy among children and adolescents with Graves’ disease treated at our center.Medical records from 81 children and adolescents with a diagnosis of Graves’ disease who received definitive therapy over a 12-year period were reviewed.Fifty one patients received RAI and 30 patients underwent thyroidectomy. The relapse rate was not significantly different between RAI and thyroidectomy (12.1% vs. 0.0%, p=0.28). There were no acute or long-term complications in the RAI group, but there were eight cases of hypoparathyroidism (two transient and six permanent) in the thyroidectomy group. None of the patients developed a recurrent laryngeal nerve injury.RAI is a safe and effective option for treatment of children and adolescents with Graves’ disease. In light of the rate of permanent hypoparathyroidism seen at our center with thyroidectomy and previously published long-term safety of RAI, we recommend RAI as the first line treatment for children and adolescents with Graves’ disease. For those centers performing thyroidectomies, we recommend that each center select 1–2 high-volume pediatric surgeons to perform all thyroid procedures, allowing individuals to increases case volume and potentially decrease long-term complications of thyroidectomy.

scholarly journals Clinical experience with radioactive iodine in the treatment of childhood and adolescent Graves' disease

2013 ◽  
Vol 2 (1) ◽  
pp. 32-37 ◽  
Author(s):  
Adriano N Cury ◽  
Verônica T Meira ◽  
Osmar Monte ◽  
Marília Marone ◽  
Nilza M Scalissi ◽  
...  
Keyword(s):  
Children And Adolescents ◽  
Medical Records ◽  
Radioactive Iodine ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Age Group ◽  
Large Goiter ◽  
Definitive Therapy

Background/aims Treatments for Graves' disease (GD) in children and adolescents include oral antithyroid drugs (ATDs), near total thyroidectomy, and radioactive iodine (RAI). ATDs remain the preferred choice in this age group, but because persistent remission occurs in 30% of cases, RAI is becoming a common option for definitive therapy. Methods We performed a review of 65 medical records of GD patients under age 19 years who were followed between 1985 and 2005. Results The prevalence of GD was higher in females (3:1) and during puberty (for both genders). If no remission was detected during ATD treatment, RAI was indicated when the following criteria were present: non-compliance, relapse, or side effects that were related to ATDs, large goiter, and long-term use of ATDs. The majority of patients developed hypothyroidism within 6 months after RAI. A progressive higher dose regimen was implemented in the last 10 years of the study period. A second RAI dose was necessary in eight cases. During the follow-up period, three pregnancies occurred. One patient with a thyroid nodule and benign cytology was detected. Conclusions RAI therapy is effective and safe in the treatment of GD in children and adolescents.

LRF and TRF test during long-term danazol treatment: increase of the LH and FSH responses but decrease of the prolactin and TSH responses

1983 ◽  
Vol 104 (1) ◽  
pp. 1-5 ◽  
Author(s):  
J. Leppäluoto ◽  
L. Rönnberg ◽  
P. Ylöstalo
Keyword(s):  
Clinical Symptoms ◽  
Follicular Phase ◽  
Blood Samples ◽  
Hormone Levels ◽  
Coefficients Of Variation ◽  
The Mean ◽  
Thyroid Hormone Levels ◽  
Low Serum

Abstract. Seven patients suffering from severe endometriosis were treated with danazol 200 mg × 3 daily for 6 months. Clinical symptoms were alleviated and menses disappeared in response to the treatment. After cessation of the treatment the menstrual bleedings returned in 1–3 months. Blood samples for determination of gonadotrophins, prolactin (Prl), oestradiol (E2), progesterone, thyroid hormones and thyrotrophin in radioimmunoassays were taken and a combined TRF and LRF test carried out in the follicular phase before treatment, at the 6th month of treatment and after reappearance of the first menses. There were no statistically significant changes in the basal levels of serum FSH, LH or TSH during the danazol treatment. Neither was there any change in episodic secretions of FSH, LH or Prl, as determined by the mean coefficients of variation of the hormone levels in seven consecutive samples taken at 20 min intervals. On the other hand, serum E2, Prl and thyroid hormone levels were significantly decreased in the 6th month of treatment. In the TRF-LRF test the responses of serum FSH and LH were significantly higher and those of serum Prl and TSH significantly lower during danazol treatment than before. Prl responses remained lowered after the treatment. It appears that low serum oestrogen levels, induced by the danazol treatment, sensitize the pituitary gonadotrophs to exogenous LRF, but make the sensitivity of thyrotrophs and lactotrophs lower to exogenous TRF. These results thus indicate that danazol does not make the pituitary gonadotrophs insensitive to LRF, but danazol may rather inhibit the secretion of hypothalamic LRF.

scholarly journals Iatrogenic Hyperthyroidism With Recurrent Functioning Thyroid Tissue 40 Years After Thyroidectomy for Graves’ Disease

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A936-A937
Author(s):  
Sara Ashlyn Penquite ◽  
Juan Pablo Galvez
Keyword(s):  
Thyroid Gland ◽  
Laboratory Testing ◽  
Radioactive Iodine ◽  
Thyroid Tissue ◽  
Definitive Treatment ◽  
Endocrine Surgery ◽  
Graves Disease ◽  
Once Daily ◽  
Remnant Thyroid

Abstract Background: Graves’ disease is an immune-mediated cause of thyrotoxicosis treated with anti-thyroid drugs (ADTs), radioactive iodine (RAI) or thyroidectomy. Thyroidectomy has been documented to have the lowest rate of recurrence amongst treatment options1. Data regarding long-term recurrence rates is limited beyond 54 months. Clinical Case: An asymptomatic 59 year old female was found to have recurrent thyrotoxicosis on routine laboratory testing. The patient underwent thyroidectomy at age 19 years for Graves’ disease. Prior records unavailable to clarify initial surgical intervention. The patient had post-surgical hypothyroidism which was managed with levothyroxine 100mcg once daily for over 20 years. A biochemically euthyroid state was clearly documented on prior laboratory testing. Initial laboratory testing with TSH <0.01mIU/L (0.45-4.50), FT3 2.8ng/dL (0.8-1.7). Levothyroxine was discontinued with persistent thyrotoxicosis after 8 weeks: TSH <0.01, FT3 5.7, FT4 1.74. Radioactive Iodine Uptake and scan was obtained after administration of 6uCi of iodine-131 which demonstrated 50.8% uptake of radioactive iodine at 24 hours (Normal 10-30%). The left thyroid gland was noted to be in normal position and enlarged with diffuse increase intensity of radiotracer uptake. The right thyroid gland was surgically absent. The patient subsequently underwent completion thyroidectomy with endocrine surgery with resolution of hyperthyroid state. Surgical pathology was benign and consistent with Graves’ disease and multinodular goiter. The patient did become hypothyroid post-operatively and required levothyroxine replacement. She is clinically and biochemically euthyroid on levothyroxine 100mcg once daily 14 months post-operatively. Conclusion: This is a case of recurrent hyperthyroidism approximately 40 years after definitive treatment with thyroidectomy. Although it is unclear whether patient underwent total thyroidectomy or subtotal thyroidectomy for initial intervention, the recurrence of thyrotoxicosis after such a long period of time has not previously been reported in the literature to the knowledge of this writer. This has important implications regarding the underlying pathophysiology of Graves’ disease and the ability of remnant thyroid tissue to regenerate over time. This also has important implications for long-term monitoring in patients with history of thyroidectomy for Graves’ disease. Reference: 1. Sundaresh, V., Brito, J. P., Wang, Z., Prokop, L. J., Stan, M. N., Murad, M. H., & Bahn, R. S. (2013). Comparative effectiveness of therapies for Graves’ hyperthyroidism: a systematic review and network meta-analysis. The Journal of clinical endocrinology and metabolism, 98(9), 3671–3677.

Hyperthyroidism

1994 ◽  
Vol 15 (11) ◽  
pp. 417-421
Author(s):  
Irene N. Sills
Keyword(s):  
Thyroid Hormone ◽  
Children And Adolescents ◽  
Radioactive Iodine ◽  
Clinical Findings ◽  
Autoimmune Response ◽  
Graves Disease ◽  
Thyroid Antibodies ◽  
Thyroid Hormone Levels ◽  
Therapeutic Alternatives ◽  
Physical Findings

Hyperthyroidism in children and adolescents usually is due to Graves disease. The diagnosis may not be recognized promptly, and clinical findings initially may be attributed incorrectly to cardiac or psychological disorders. Once suspected, history and physical findings and measurements of TSH level, thyroid hormone levels, and thyroid antibodies make the diagnosis apparent. Treatment varies among endocrinologists and includes antithyroid medication, surgery, and radioactive iodine. Much is being learned about the autoimmune response that causes the disease, and the hope is that therapies directed at altering the autoimmune abnormalities ultimately will offer the best therapeutic alternatives.

Surgical treatment of diffuse toxic goiter in children. A review of the literature

2013 ◽  
Vol 4 (4) ◽  
pp. 69-76
Author(s):  
Alexander Vadimovich Gostimsky ◽  
Sergey Sergeevich Peredereev
Keyword(s):  
Surgical Treatment ◽  
Radioactive Iodine ◽  
Term Treatment ◽  
Graves Disease ◽  
Radioactive Iodine Therapy ◽  
Review Of The Literature ◽  
Large Size ◽  
Long Term Treatment ◽  
Toxic Goiter

Diffuse toxic goiter (DTG) is an autoimmune disease, to which there is a genetic predisposition. In children DTG is less common than in adults. Manifestation of graves‘ disease in childhood has a number of peculiarities. During the DTG in children is usually manifested thyrotoxicosis, requiring long-term treatment to achieve euthyroid, tendency to relapse and more frequently than adults, accompanied by ophthalmopathy and the large size of goiter. Diagnosis of graves‘ disease is based on the clinical picture of thyrotoxicosis, the existence of which is confirmed by the level of thyroid hormones and TSH in the blood. There are three types of treatment of patients DTG: medical, radioactive iodine therapy and surgery. There is no а single glance at the choice of the volume of operations in children.

scholarly journals Graves’ Disease Causing Pancytopenia and Autoimmune Hemolytic Anemia at Different Time Intervals: A Case Report and a Review of the Literature

2013 ◽  
Vol 2013 ◽  
pp. 1-4 ◽  
Author(s):  
Peyman Naji ◽  
Geetika Kumar ◽  
Shabana Dewani ◽  
William A. Diedrich ◽  
Ankur Gupta
Keyword(s):  
Hemolytic Anemia ◽  
Autoimmune Hemolytic Anemia ◽  
Radioactive Iodine ◽  
Graves Disease ◽  
Time Intervals ◽  
Thyroid Stimulating Immunoglobulins ◽  
Thyroid Uptake ◽  
Antithyroid Treatment ◽  
Positive Direct ◽  
Radioactive Iodine Ablation

Graves’ disease (GD) is associated with various hematologic abnormalities but pancytopenia and autoimmune hemolytic anemia (AIHA) are reported very rarely. Herein, we report a patient with GD who had both of these rare complications at different time intervals, along with a review of the related literature. The patient was a 70-year-old man who, during a hospitalization, was also noted to have pancytopenia and elevated thyroid hormone levels. Complete hematologic workup was unremarkable and his pancytopenia was attributed to hyperthyroidism. He was started on methimazole but unfortunately did not return for followup and stopped methimazole after a few weeks. A year later, he presented with fatigue and weight loss. Labs showed hyperthyroidism and isolated anemia (hemoglobin 7 g/dL). He had positive direct Coombs test and elevated reticulocyte index. He was diagnosed with AIHA and started on glucocorticoids. GD was confirmed with elevated levels of thyroid stimulating immunoglobulins and thyroid uptake and scan. He was treated with methimazole and radioactive iodine ablation. His hemoglobin improved to 10.7 g/dL at discharge without blood transfusion. Graves’ disease should be considered in the differential diagnosis of hematologic abnormalities. These abnormalities in the setting of GD generally respond well to antithyroid treatment.

scholarly journals Long-Term Antithyroid Treatment in Pediatric and Juvenile Graves’ Disease

2020 ◽  
Vol 18 (Suppl) ◽  
Author(s):  
Hossein Delshad ◽  
Miralireza Takyar
Keyword(s):  
Pediatric Patients ◽  
Radioactive Iodine ◽  
Remission Rate ◽  
Current Evidence ◽  
Graves Disease ◽  
Age Group ◽  
Pediatric Age ◽  
Pediatric Age Group ◽  
Review Articles

Context: Thyroid hormones can affect the development and function of the central nervous system and various other organs. As such, the pathologic excess of these hormones, known as thyrotoxicosis, can be the source of significant damage during childhood and adolescence. The objective of this study was to review the management of Graves’ disease (GD) in the pediatric age group, especially concerning long-term antithyroid drug (ATD) treatment. Evidence Acquisition: A thorough search of literature published from 1980 to 2019 was performed in PubMed only for English language literature. The following key terms were used: “Graves’ disease, hyperthyroidism, thyrotoxicosis in children, thyrotoxicosis remission, thyrotoxicosis relapse, definite therapy, radioactive iodine, thyroidectomy, anti-thyroid drugs, propylthiouracil, methimazole, and carbimazole”. We also did a thorough search in review articles, observational studies, open-label/controlled randomized/non-randomized trials, and meta-analyses, as well as the articles cited by textbooks, chapters, and review articles, which led us to locate older sources of information on the topic. Results: More than 90% of thyrotoxicosis in the pediatric age group is attributable to GD. A host of strategies, including ATDs, radioiodine therapy, and surgery, are employed to treat this entity. However, there is still significant controversy regarding the most optimal strategy. Current evidence suggests that ATDs are the best initial treatment in pediatric patients with GD. Although ATDs are widely used, the duration of their administration is controversial and varies significantly between protocols. A major problem is the high relapse rate (up to 70%), but extending the duration of such treatment could potentially bring the remission rate up to 88%. Indications for using radioactive iodine treatment include the lack of remission following years of receiving ATDs, poor compliance, and the emergence of a major side effect. In pediatric patients aged five-years-old or younger who suffer from very large goiter, severe ophthalmopathy, and persistent hyperthyroidism, as well as those with the lack of response to or showing adverse effects of ATDs, it is advisable to consider total or near-total thyroidectomy. Conclusions: Antithyroid drugs are the mainstay of treatment of juvenile GD, and long-term methimazole therapy increases the remission rate in pediatric GD.

Sinusitis, an under-reported adverse effect in children treated with radioactive iodine therapy and review of the current literature

2020 ◽  
Vol 33 (1) ◽  
pp. 171-173 ◽  
Author(s):  
Elizabeth T. Walsh ◽  
Janel D. Hunter ◽  
David F. Crudo ◽  
Cathrine Constantacos
Keyword(s):  
Adverse Effect ◽  
Adverse Effects ◽  
Current Literature ◽  
Facial Pain ◽  
Radioactive Iodine ◽  
Graves Disease ◽  
Radioactive Iodine Therapy ◽  
Pediatric Case ◽  
Case Presentation ◽  
A Site

AbstractBackgroundRadioactive iodine (RAI) therapy is prevalent in the treatment of Graves’ disease. Adverse effects in pediatrics are not well-described.Case presentationA 13-year-old female underwent RAI therapy for Graves’ disease. Eight days later, she developed facial pain and forehead burning. She was diagnosed with sinusitis and started on pseudoephedrine with resolution in 24 h.ConclusionsShe endured prolonged discomfort due to an under-recognized adverse effect of RAI. Studies identify the nose as a site of RAI accumulation and smaller nasal passages may predispose children to sinusitis. We report the first pediatric case of sinusitis following RAI. With the increasing use of RAI to treat Graves’ disease, clinicians must recognize this adverse effect.

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