Palpation thyroiditis following subtotal parathyroidectomy for hyperparathyroidism

Summary Thyrotoxicosis is an under-recognised but clinically important complication of parathyroidectomy. We report a case of a 37-year-old man with tertiary hyperparathyroidism who initially developed unexplained anxiety, diaphoresis, tachycardia, tremor and hyperreflexia one day after subtotal parathyroidectomy. Thyroid biochemistry revealed suppressed thyroid stimulating hormone and elevated serum free T4 and free T3 levels. Technetium-99m scintigraphy scan confirmed diffusely decreased radiotracer uptake consistent with thyroiditis. The patient was diagnosed with thyrotoxicosis resulting from palpation thyroiditis. Administration of oral beta-adrenergic antagonists alleviated his symptoms and there was biochemical evidence of resolution fourteen days later. This case illustrates the need to counsel patients about thyroiditis as one of the potential risks of parathyroid surgery. It also emphasises the need for biochemical surveillance in patients with unexplained symptoms in the post-operative period and may help to minimise further invasive investigations for diagnostic clarification. Learning points Thyroiditis as a complication of parathyroidectomy surgery is uncommon but represents an under-recognised phenomenon. It is thought to occur due to mechanical damage of thyroid follicles by vigorous palpation. Palpation of the thyroid gland may impair the physical integrity of the follicular basement membrane, with consequent development of an inflammatory response. The majority of patients are asymptomatic, however clinically significant thyrotoxicosis occurs in a minority. Patients should be advised of thyroiditis/thyrotoxicosis as a potential complication of the procedure. Testing of thyroid function should be performed if clinically indicated, particularly if adrenergic symptoms occur post-operatively with no other cause identified.

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GHRH secretion from a pancreatic neuroendocrine tumor causing gigantism in a patient with MEN1

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-20-0208 ◽

2021 ◽

Vol 2021 ◽

Author(s):

Vinaya Srirangam Nadhamuni ◽

Donato Iacovazzo ◽

Jane Evanson ◽

Anju Sahdev ◽

Jacqueline Trouillas ◽

...

Keyword(s):

Neuroendocrine Tumour ◽

Primary Tumour ◽

Elevated Serum ◽

Pancreatic Neuroendocrine Tumor ◽

Pituitary Surgery ◽

List Type ◽

Ki 67 ◽

Subtotal Parathyroidectomy ◽

Cross Sectional ◽

Ectopic Acromegaly

Summary A male patient with a germline mutation in MEN1 presented at the age of 18 with classical features of gigantism. Previously, he had undergone resection of an insulin-secreting pancreatic neuroendocrine tumour (pNET) at the age of 10 years and had subtotal parathyroidectomy due to primary hyperparathyroidism at the age of 15 years. He was found to have significantly elevated serum IGF-1, GH, GHRH and calcitonin levels. Pituitary MRI showed an overall bulky gland with a 3 mm hypoechoic area. Abdominal MRI showed a 27 mm mass in the head of the pancreas and a 6 mm lesion in the tail. Lanreotide-Autogel 120 mg/month reduced GHRH by 45% and IGF-1 by 20%. Following pancreaticoduodenectomy, four NETs were identified with positive GHRH and calcitonin staining and Ki-67 index of 2% in the largest lesion. The pancreas tail lesion was not removed. Post-operatively, GHRH and calcitonin levels were undetectable, IGF-1 levels normalised and GH suppressed normally on glucose challenge. Post-operative fasting glucose and HbA1c levels have remained normal at the last check-up. While adolescent-onset cases of GHRH-secreting pNETs have been described, to the best of our knowledge, this is the first reported case of ectopic GHRH in a paediatric setting leading to gigantism in a patient with MEN1. Our case highlights the importance of distinguishing between pituitary and ectopic causes of gigantism, especially in the setting of MEN1, where paediatric somatotroph adenomas causing gigantism are extremely rare. Learning points It is important to diagnose gigantism and its underlying cause (pituitary vs ectopic) early in order to prevent further growth and avoid unnecessary pituitary surgery. The most common primary tumour sites in ectopic acromegaly include the lung (53%) and the pancreas (34%) (1): 76% of patients with a pNET secreting GHRH showed a MEN1 mutation (1). Plasma GHRH testing is readily available in international laboratories and can be a useful diagnostic tool in distinguishing between pituitary acromegaly mediated by GH and ectopic acromegaly mediated by GHRH. Positive GHRH immunostaining in the NET tissue confirms the diagnosis. Distinguishing between pituitary (somatotroph) hyperplasia secondary to ectopic GHRH and pituitary adenoma is difficult and requires specialist neuroradiology input and consideration, especially in the MEN1 setting. It is important to note that the vast majority of GHRH-secreting tumours (lung, pancreas, phaeochromocytoma) are expected to be visible on cross-sectional imaging (median diameter 55 mm) (1). Therefore, we suggest that a chest X-ray and an abdominal ultrasound checking the adrenal glands and the pancreas should be included in the routine work-up of newly diagnosed acromegaly patients.

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Elevated serum IL-10 is associated with severity of neonatal encephalopathy and adverse early childhood outcomes

Pediatric Research ◽

10.1038/s41390-021-01438-1 ◽

2021 ◽

Author(s):

Raymand Pang ◽

Brian M. Mujuni ◽

Kathryn A. Martinello ◽

Emily L. Webb ◽

Angela Nalwoga ◽

...

Keyword(s):

Early Childhood ◽

Neonatal Mortality ◽

Child Death ◽

Elevated Serum ◽

Adverse Outcomes ◽

List Type ◽

Perinatal Infection ◽

Neonatal Encephalopathy ◽

Early Childhood Outcomes ◽

Sub Saharan

Abstract Background Neonatal encephalopathy (NE) contributes substantially to child mortality and disability globally. We compared cytokine profiles in term Ugandan neonates with and without NE, with and without perinatal infection or inflammation and identified biomarkers predicting neonatal and early childhood outcomes. Methods In this exploratory biomarker study, serum IL-1α, IL-6, IL-8, IL-10, TNFα, and VEGF (<12 h) were compared between NE and non-NE infants with and without perinatal infection/inflammation. Neonatal (severity of NE, mortality) and early childhood (death or neurodevelopmental impairment to 2.5 years) outcomes were assessed. Predictors of outcomes were explored with multivariable linear and logistic regression and receiver-operating characteristic analyses. Results Cytokine assays on 159 NE and 157 non-NE infants were performed; data on early childhood outcomes were available for 150 and 129, respectively. NE infants had higher IL-10 (p < 0.001), higher IL-6 (p < 0.017), and lower VEGF (p < 0.001) levels. Moderate and severe NE was associated with higher IL-10 levels compared to non-NE infants (p < 0.001). Elevated IL-1α was associated with perinatal infection/inflammation (p = 0.013). Among NE infants, IL-10 predicted neonatal mortality (p = 0.01) and adverse early childhood outcome (adjusted OR 2.28, 95% CI 1.35–3.86, p = 0.002). Conclusions Our findings support a potential role for IL-10 as a biomarker for adverse outcomes after neonatal encephalopathy. Impact Neonatal encephalopathy is a common cause of child death and disability globally. Inflammatory cytokines are potential biomarkers of encephalopathy severity and outcome. In this Ugandan health facility-based cohort, neonatal encephalopathy was associated with elevated serum IL-10 and IL-6, and reduced VEGF at birth. Elevated serum IL-10 within 12 h after birth predicted severity of neonatal encephalopathy, neonatal mortality, and adverse early childhood developmental outcomes, independent of perinatal infection or inflammation, and provides evidence to the contribution of the inflammatory processes. Our findings support a role for IL-10 as a biomarker for adverse outcomes after neonatal encephalopathy in a sub-Saharan African cohort.

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Approach to Subclinical Thyroid Diseas

Journal of Bangladesh College of Physicians and Surgeons ◽

10.3329/jbcps.v26i2.4187 ◽

1970 ◽

Vol 26 (2) ◽

pp. 91-96

Author(s):

Satya Ranjan Sutradhar

Keyword(s):

Subclinical Hypothyroidism ◽

Thyroid Dysfunction ◽

Hormone Level ◽

Elevated Serum ◽

Thyroid Stimulating Hormone ◽

Good Evidence ◽

Reference Ranges ◽

Mineral Density ◽

Asymptomatic Patients ◽

Stimulating Hormone

Subclinical thyroid dysfunction is defined as an abnormal serum thyroid-stimulating hormone level and free thyroxine and triiodothyronine levels within their reference ranges. The prevalence of subclinical hyperthyroidism is about 2 percent. Subclinical hypothyroidism is found in approximately 4 to 8.5 percent of the population. Most national organizations recommend against routine screening of asymptomatic patients, but screening is recommended for high risk populations. The management of subclinical thyroid dysfunction is controversial. There is good evidence that subclinical hypothyroidism is associated with progression to overt disease. Patients with a serum thyroid-stimulating hormone level greater than 10 mIU/L have a higher incidence of elevated serum low density lipoprotein cholesterol concentrations; however, evidence is lacking for other associations. There is insufficient evidence that treatment of subclinical hypothyroidism is beneficial. A serum thyroid stimulating hormone level of less than 0.1 mIU/L is associated with progression to overt hyperthyroidism, atrial fibrillation, reduced bone mineral density, and cardiac dysfunction. There is little evidence that early treatment alters the clinical course. DOI: 10.3329/jbcps.v26i2.4187 J Bangladesh Coll Phys Surg 2008; 26: 91-96

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The association of neurofibromatosis and autism symptomatology is confounded by behavioral problems

10.1101/2019.12.20.19015420 ◽

2019 ◽

Author(s):

Hadley Morotti ◽

Sarah Mastel ◽

Kory Keller ◽

Rebecca A. Barnard ◽

Trevor Hall ◽

...

Keyword(s):

Adaptive Behavior ◽

Behavioral Problems ◽

Neurofibromatosis Type ◽

Social Responsiveness ◽

List Type ◽

Autism Symptoms ◽

Simons Simplex Collection ◽

Autism Symptomatology ◽

The Difference ◽

Clinically Significant

AbstractAimto evaluate if autism symptoms and diagnoses are raised in children with neurofibromatosis type 1 (NF1), to which levels, and to determine if co-occurring symptomatology accounts for this elevation.MethodWe interrogated our hospital electronic medical records. We collected parental reports of autism symptomatology, adaptive behavior, and co-occurring behavioral and emotional problems on a subsample of 45 children (9 years 2 months, 49% male). Age- and sex-matched controls with (N=180) or without ASD (N=180) were drawn from the Simons Simplex Collection and compared cross-sectionally to participants with NF1.ResultsDiagnoses of ADHD (8.8%), not of ASD (2.1%), were raised among 968 children with NF1 identified through electronic search. Mean Social Responsiveness Score (55.9) was below the cut-off of 60 for significant autism symptoms. Participants with NF1 had significantly more autism and behavioral symptoms than typically developing (TD) controls, and significantly less than controls with autism, with one exception: ADHD symptom levels were similar to those of autistic controls. When emotional, ADHD, and communication scores were covaried, the difference between participants with NF1 and TD controls disappeared almost entirely.InterpretationOur results do not support an association between NF1 and autism, both at the symptom and disorder levels.What this paper addsDiagnoses of ADHD, not of ASD, were raised among children with NF1.Increases in autism symptoms did not reach clinically significant thresholds.Co-occurring ADHD symptoms accounted for increased autism questionnaire scores.Adaptive behavior in NF1 participants showed normal socialization but lower communication proficiency.

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Off-label prescribing of quetiapine in HMP Elmley, a Category B remand prison: a re-audit

BJPsych Open ◽

10.1192/bjo.2021.262 ◽

2021 ◽

Vol 7 (S1) ◽

pp. S85-S85

Author(s):

Nosa Igbinomwanhia ◽

Kathleen McCurdy

Keyword(s):

Mental Health ◽

Royal College ◽

Health Assessment ◽

List Type ◽

Physical And Mental Health ◽

Off Label ◽

The Past ◽

Number Of Patients ◽

Prescribing Practice ◽

Potential Risks

AimsThis was a re-audit of off-label prescribing of quetiapine in order to identify the number of patients on off-label quetiapine in HMP Elmley, to monitor compliance by the Mental Health Inreach Team (MHIRT) psychiatrists with the Royal College of Psychiatrists guideline on off-license prescribing, to compare findings with the baseline audit and to identify areas for improvement.MethodAll patients on quetiapine in HMP Elmley were identified and their electronic patient record was reviewed against the standards outlined in the Royal College of Psychiatrists “Use of licensed medicines for unlicensed applications in psychiatric practice (2nd edition).ResultThere were 60 residents on off-license quetiapine prescription in HMP Elmley.Of this number, four had their prescription initiated by a general practitioner, either while in prison or in the community. Two residents were on quetiapine first prescribed while they were on admission in hospital. 5 patients had been initiated by the MHIRT psychiatrists. 38 residents were commenced off-license quetiapine by another psychiatrist, either while they were in the community or in another prison. In 17 patients, electronic records were inadequate to determine who had prescribed the quetiapine.The number of inmates prescribed off-label quetiapine in HMP Elmley had dropped from 82 to 60 in the 1 year since the initial audit. Of these figures, prescriptions initiated by the MHIRT psychiatrists, had dropped from 28.1% (23/82) to 8.3% (5/60).For those prescribed quetiapine by the HMP Elmley psychiatrists, notes were audited against the RCPsych guidelines: Licensed medication was considered first in 80.0%Risks and benefits were considered and documented in 80.0%The benefits and potential risks were explained to patient in 80.0%There was documentation of informed consent in 80.0%Quetiapine was started at a low dose and monitored in 100%No residents required withdrawal of medication due to ineffectiveness or adverse effects.Baseline physical health assessment was performed in 80.0%, though all had an ECG done.ConclusionOver the past year there has been an improvement in off-label antipsychotic prescribing practice within the MHIRT.However, the number of off-label antipsychotic prescriptions still remains high throughout the prison. There should be continued effort at minimizing off-label prescribing within the MHIRT, monitored by auditing. However, work needs to be done jointly with other prescribers, such as GP colleagues, in order to avoid unnecessary prescriptions and to monitor regularly the physical and mental health of those on off-label quetiapine.

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Challenges in the functional diagnosis of thyroid nodules before surgery for TSH-producing pituitary adenoma

Endocrinology Diabetes and Metabolism Case Reports ◽

10.1530/edm-20-0221 ◽

2021 ◽

Vol 2021 ◽

Author(s):

Keita Tatsushima ◽

Akira Takeshita ◽

Shuji Fukata ◽

Noriaki Fukuhara ◽

Mitsuo Yamaguchi-Okada ◽

...

Keyword(s):

Pituitary Adenoma ◽

Thyroid Hormone ◽

Thyroid Nodule ◽

Thyroid Nodules ◽

Thyroid Stimulating Hormone ◽

Somatostatin Analogue ◽

Postoperative Phase ◽

List Type ◽

Thyroid Scintigraphy ◽

Serum Tsh

Summary A 50-year-old woman with thyroid-stimulating hormone (TSH)-producing pituitary adenoma (TSHoma) was diagnosed due to symptoms of thyrotoxicosis. Preoperatively, she showed thyrotoxicosis with the syndrome of inappropriate secretion of TSH (SITSH) and had a 5 cm nodule in her thyroid gland. Octreotide was administered preoperatively, which helped lower her serum TSH level but not her thyroid hormone level. These findings were atypical for a patient with TSHoma. The TSHoma was completely resected, and the TSH level dropped below the sensitivity limit shortly after surgery. Interestingly, however, thyroid hormone levels remained high. A clear clue to the aetiology was provided by consecutive thyroid scintigraphy. Although preoperative thyroid scintigraphy did not show a hot nodule and the mass was thought to be a non-functional thyroid nodule, the nodule was found to be hot in the postoperative phase of TSH suppression. By focusing on the atypical postoperative course of the TSHoma, we were able to conclude that this was a case of TSHoma combined with an autonomously functioning thyroid nodule (AFTN). Learning points The diagnosis of autonomously functioning thyroid nodules (AFTNs) depends on suppressed serum TSH levels. If thyroid hormones are resistant to somatostatin analogue therapy or surgery for TSHoma, complications of AFTN as well as destructive thyroiditis need to be considered. It is important to revisit the basics when facing diagnostic difficulties and not to give up on understanding the pathology.

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Treatment with Myo-Inositol and Selenium Ensures Euthyroidism in Patients with Autoimmune Thyroiditis

International Journal of Endocrinology ◽

10.1155/2017/2549491 ◽

2017 ◽

Vol 2017 ◽

pp. 1-6 ◽

Cited By ~ 8

Author(s):

Maurizio Nordio ◽

Sabrina Basciani

Keyword(s):

Autoimmune Thyroiditis ◽

Single Case ◽

Elevated Serum ◽

Thyroid Stimulating Hormone ◽

Free Triiodothyronine ◽

Hyperthyroid Patient ◽

Normal Thyroid Function ◽

Complete Restoration

Clinical evidences have highlighted the efficacy of myo-inositol and selenium in the treatment of autoimmune thyroiditis. Aim of this study was to further analyze the role of myo-inositol plus selenium (Myo-Ins-Se) in restoring a normal thyroid function of Hashimoto’s patients with subclinical hypothyroidism. Eighty-six patients with Hashimoto’s thyroiditis having thyroid-stimulating hormone (TSH) levels between 3 and 6 mIU/L, elevated serum antithyroid peroxidase (TPOAb) and/or antithyroglobulin (TgAb), and normal free thyroxine (fT4) and free triiodothyronine (fT3) levels were enrolled in the study: one hyperthyroid subject with TSH about 0.14 μU/ml was included in this trial as a single case. Patients were assigned to receive Myo-Ins-Se. TSH, TPOAb, and TgAb levels were significantly decreased in patients treated with combined Myo-Ins-Se after 6 months of treatment. In addition, a significant fT3and fT4increase, along with an amelioration of their quality of life, was observed. Remarkably, TSH values of the hyperthyroid patient increased from 0.14 μU/ml up to 1.02 μU/ml, showing a complete restoration of TSH values at a normal range. In conclusion, the administration of Myo-Ins-Se is significantly effective in decreasing TSH, TPOAb, and TgAb levels, as well as enhancing thyroid hormones and personal wellbeing, therefore restoring euthyroidism in patients diagnosed with autoimmune thyroiditis.

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Digoxin and Low-Birth-Weight Infants

PEDIATRICS ◽

10.1542/peds.70.6.1011a ◽

1982 ◽

Vol 70 (6) ◽

pp. 1011-1012

Author(s):

DAVID S. OLANDER ◽

MICHAEL MAURER

Keyword(s):

Birth Weight ◽

Low Birth Weight ◽

Premature Infants ◽

Elevated Serum ◽

Alternative Therapies ◽

Digoxin Toxicity ◽

Low Birth Weight Infants ◽

Serum Digoxin ◽

Clinically Significant

In their recent communication, Johnson et al suggested that conventional digoxin use may be sufficiently toxic forlow-birth-weight infants to prompt consideration of alternative therapies. This conclusion was supported by their detection of digitalis associated illness in 9/18 small premature infants receiving digoxin in doses of 0.003 to 0.005 mg/kg twice per day. The documentation of abnormally elevated serum digoxin concentrations in 7/9 patients further supports the possibility of clinically significant digoxin toxicity. Akin to the findings of Berman et al and Pinsky et al, this investigation only confirms the observation that overdosage of infants with digoxin may result in digitoxicity.

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Subclinical hypothyroidism

Oxford Textbook of Endocrinology and Diabetes ◽

10.1093/med/9780199235292.003.3252 ◽

2011 ◽

pp. 543-547

Author(s):

Jayne A. Franklyn

Keyword(s):

Thyroid Function ◽

Subclinical Hypothyroidism ◽

Expert Panel ◽

Elevated Serum ◽

Thyroid Stimulating Hormone ◽

Free Thyroxine ◽

Thyroid Function Tests ◽

Free Triiodothyronine ◽

Function Tests ◽

Serum Tsh

Subclinical hypothyroidism is defined biochemically as the association of a raised serum thyroid-stimulating hormone (TSH) concentration with normal circulating concentrations of free thyroxine (T4) and free triiodothyronine (T3). The term subclinical hypothyroidism implies that patients should be asymptomatic, although symptoms are difficult to assess, especially in patients in whom thyroid function tests have been checked because of nonspecific complaints such as tiredness. An expert panel has recently classified individuals with subclinical hypothyroidism into two groups (1): (1) those with mildly elevated serum TSH (typically TSH in the range 4.5–10.0 mU/l) and (2) those with more marked TSH elevation (serum TSH >10.0 mU/l).

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CUSHING DISEASE MASQUERADING AS GLAUCOMA

AACE Clinical Case Reports ◽

10.4158/accr-2019-0097 ◽

2019 ◽

Vol 5 (5) ◽

pp. e290-e293

Author(s):

Yumiko Tsushima ◽

Lubna Bashir Munshi ◽

Charit Taneja ◽

Se-min Kim

Keyword(s):

Adrenocorticotropic Hormone ◽

Case Reports ◽

Elevated Serum ◽

Serum Cortisol ◽

Thyroid Stimulating Hormone ◽

Pituitary Hormone ◽

Cushing Disease ◽

Corticosteroid Administration ◽

Late Night ◽

Stimulating Hormone

Objective: Glaucoma is a well-recognized side effect of corticosteroids. However, steroid-induced glaucoma typically refers to that caused by exogenous corticosteroid administration. Glaucoma secondary to endogenous overproduction of corticosteroids has only been reported in a few case reports. We aim to bring attention to glaucoma as a rare but important manifestation of endogenous hypercortisolism. Methods: Patient history, physical exam, laboratory results, and imaging studies were reviewed. Results: We report a case of glaucoma as the initial presentation of Cushing disease (CD). The patient was diagnosed with glaucoma 16 months prior to his endocrinology evaluation. At our initial encounter, the patient had a cushingoid appearance. Levels of 24-hour urinary cortisol and late-night salivary cortisol were elevated. Serum cortisol was not suppressed by 1 mg of dexamethasone overnight, but it was suppressed by 8 mg of dexamethasone. Adrenocorticotropic hormone was also elevated. All other pituitary hormone axes were unremarkable (thyroid-stimulating hormone, free thyroxine, follicle-stimulating hormone, luteinizing hormone, growth hormone, prolactin, and insulin-like growth factor). Pituitary magnetic resonance imaging suggested a small adenoma (2 to 3 mm); therefore, the patient underwent inferior petrosal sinus sampling. The results were consistent with CD. Transsphenoidal resection was performed and final pathology confirmed an adrenocorticotropic hormone-positive adenoma. Hypercortisolism and intraocular pressures improved after the surgery. Conclusion: Glaucoma can lead to irreversible blindness if left untreated or uncontrolled. However, endogenous hypercortisolism-induced glaucoma can be reversed with treatment of the underlying CD. Thus, heightened awareness of extraocular manifestations of secondary causes of glaucoma such as endogenous hypercortisolism is necessary in order to promote prompt evaluation and treatment.

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