scholarly journals Resistant Thyrotoxicosis in a Patient with Graves Disease: A Case Report

2011 ◽  
Vol 2011 ◽  
pp. 1-4 ◽  
Author(s):  
Taimur Saleem ◽  
Aisha Sheikh ◽  
Qamar Masood
Keyword(s):  
Radioactive Iodine ◽  
Past History ◽  
Beta Blockers ◽  
Adjunctive Treatment ◽  
Definitive Treatment ◽  
Antithyroid Drugs ◽  
Normal Range ◽  
Free T4 ◽  
Management Options ◽  
Thyroid Lobectomy

Background. Conventional management of thyrotoxicosis includes antithyroid drugs, radioactive iodine, and surgery while adjunctive treatment includes beta-blockers, corticosteroids, inorganic iodide and iopanoic acid. Very rarely, patients may be resistant to these modalities and require additional management.Case Presentation. A 50-year-old lady presented with weight loss and palpitations diagnosed as atrial fibrillation. Her past history was significant for right thyroid lobectomy for thyrotoxicosis. Thyroid functions tests at this presentation showed free T4 of 6.63 ng/dl (normal range: 0.93–1.7) and TSH of <0.005 μIU/mL (normal range: 0.4–4.0). She was given aspirin, propranolol, heparin and carbimazole; however free T4 failed to normalize. Switching to propylthiouracil (PTU) did not prove successful. She was then given high doses of prednisolone (1 mg/kg/day) and lithium (400 mg twice daily) which prepared the patient for radioactive iodine treatment by reducing free T4 levels (2.82 ng/dl). Two doses of radioactive iodine were then administered 6 months apart. Subsequently she became hypothyroid and was started on thyroid replacement therapy.Conclusion. This case highlights management options in patients with resistant thyrotoxicosis. Radioactive iodine and surgery are definitive modes of treatment in such complex cases while steroids and lithium play an important role in preparing patients for more definitive treatment.

scholarly journals SUN-520 Graves Disease and T3 Thyrotoxicosis: A Case Report

2020 ◽  
Vol 4 (Supplement_1) ◽  
Author(s):  
Nishanth thalambedu ◽  
Iqra iqbal ◽  
Shristi khanal ◽  
Muhammad Atique Alam Khan
Keyword(s):  
African American Woman ◽  
Beta Blockers ◽  
American Woman ◽  
Care Physician ◽  
Definitive Treatment ◽  
Antithyroid Drugs ◽  
Graves Disease ◽  
Free T4 ◽  
Duration Of Action ◽  
Definitive Therapy

Abstract Introduction: Hyperthyroidism is one of the common problems in the world of endocrinology. Identifying the type of thyrotoxicosis is crucial before starting treatment. We present a case of a 37-year-old woman presented with hyperthyroidism and was started on methimazole. Her symptoms persisted and further workup showed T3 thyrotoxicosis. Her symptoms improved after switching her to PTU. She eventually underwent thyroidectomy. Case description: Thirty-seven-year old African American woman presented to her primary care physician(PCP) with symptoms suggestive of hyperthyroidism for three months. Her past medical history is significant for recent delivery one year ago. Her Physical exam is pertinent for hypertension of 160/80 with a heart rate of 120. Her neck is diffusely enlarged with bilateral bruits. Bilateral lid retraction with lid lag was noted along with left lid proptosis. There were no tremors or leg swelling noted. Her Initial workup showed sinus tachycardia in the electrocardiogram. Her TSH level was &lt;0.010 and a free T4 level of 3.48. Ultrasound showed diffuse enlargement of the thyroid gland with no focal nodule. She was started on methimazole 10mg twice daily and metoprolol 25mg twice daily. Three months later, she presented to the emergency room(ER) with tachycardia of 130 and hypertension of 170/85. Work up showed a TSH level of &lt;0.010 and a free T4 level of 3.94. She was compliant with medications. When free T3 levels were checked it turned out to be &gt;30. She was diagnosed with T3 Thyrotoxicosis and was started on propylthiouracil 150mg every 8 hours. Her metoprolol was increased to 50mg every 12 hours. Her symptoms improved and she finally underwent surgery for thyroidectomy. Discussion: Hyperthyroidism is seen in about 1 in 5000 with a strong female predominance. Graves disease, the most common cause of hyperthyroidism is due to excess production of TSH receptor stimulating antibodies. Hyperthyroid patients with graves disease sometimes have a disproportionate increase in serum T3 levels when compared to serum T4. This is thought to be due to increased T3 production or extrathyroidal conversion of T4 to T3. It is very crucial to identify the free hormone levels in a new patient with hyperthyroidism because of the difference in management. Antithyroid drugs are traditionally the first-line treatment option along with beta-blockers prior to definitive therapy like radioactive iodine or thyroidectomy. The main drugs used are methimazole and propylthiouracil(PTU). Methimazole is more commonly used than PTU because of its rapid efficacy, longer duration of action and less adverse effects. For patients with T3 thyrotoxicosis, PTU is preferred as it is known to reduce the peripheral conversion of T4 to T3. Our patient medication was changed from methimazole to PTU, after which she started to notice improvement. She eventually underwent definitive treatment with thyroidectomy.

scholarly journals Oscillating Hypo-Hyperthyroidism; a Rare Type of Autoimmune Thyroiditis in Adolescence

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A944-A945
Author(s):  
Leah I Akinseye
Keyword(s):  
Weight Loss ◽  
Weight Gain ◽  
Radioactive Iodine ◽  
Clinical Course ◽  
Color Doppler ◽  
Definitive Treatment ◽  
Free T4 ◽  
Rare Type ◽  
Definitive Therapy ◽  
Radioactive Iodine Ablation

Abstract Background: Spontaneous conversion of hypothyroidism to hyperthyroidism and vice versa is a unique autoimmune entity characterized by the oscillating activity of thyrotropin blocking inhibiting immunoglobulin (TBII) and thyroid-stimulating immunoglobulin (TSI). The simultaneous presence of both antibodies is a rare phenomenon in children. Clinical Case: At 11 years of age a female with Trisomy 21 and mild developmental delay had elevated TSH 5.4uIU/mL (0.4-4.5), normal thyroxine (T4), negative thyroglobulin peroxide antibody (anti-TPO), and thyroglobulin antibody (Anti-Tg). Levothyroxine (LT4) 1.2mcg/kg/day was started. At 12 years of age, she relocated, and the same treatment was continued. About 7 months later, she was referred for weight loss of 8lbs, tachycardia, high BP, suppressed TSH &lt;0.015uIU/mL, high total T4 15.9ng/dL (4.5-12.0), and anti-TPO 38 IU/mL (&lt;9). She was diagnosed with hyperthyroidism and LT4 was discontinued. Repeat lab showed persistently undetectable TSH, high T4, TBII 70 (normal &lt;16%), and TSI 698 (&lt;140 %). Methimazole (MMI) 0.38mg/kg/day and Atenolol 25mg daily was started for Grave’s disease. At 15 years of age, she presented with symptoms of hypothyroidism; 10lb weight gain in 2months, high TSH &gt;150mIU/L, low FreeT4 0.12ng/dl (0.8-2), anti-TPO 95 IU/mL, and TSI 2.1 IU/L (0.0 - 0.55). MMI was discontinued and she was started on LT4 0.9mcg/kg/day. Repeat TFT’s 5weeks later showed a normal TSH and Free T4. Thyroid ultrasound showed a diffusely enlarged gland; right lobe - 3.9 x 2.0 x 2.0 cm (volume of: 7.6 mL) and left lobe 4.5 x 1.6 x 2.4 cm (volume: 8.6 mL) with increased vascularity on color Doppler consistent with diffuse thyroiditis. A year later, she developed hyperthyroid symptoms for the second time with 6lb weight loss, tachycardia, suppressed TSH &lt;0.015uIU/mL, elevated free T4 &gt;6.9ng/dl, TBII 8.6 U/L (&lt;1.0), and TSI 12 IU/L. However, this time her TSI level was significantly higher than when she was hypothyroid. She was treated with MMI 0.15mg/kg/day which was increased to 0.3mg/kg/day, and 3months later she reverted to hypothyroidism; TSH 17.5uIU/mL, Low free T4 0.54ng/dl, normal total T3, with 15lb weight gain. Her MMI dose was lowered to 0.15mg/kg/day, however more definitive treatment options including thyroidectomy and radioactive iodine ablation was discussed with the family. Conclusion: The spectrum of autoimmune thyroid disorders span between extremes of Hashimoto’s thyroiditis and Graves’ disease, but rarely in adolescents, these conditions can co-exist, and management can be challenging and tedious to the patient, family, and physician. Since autoantibody status/titer may not always predict the clinical course, it is important for clinicians to keep a high index of suspicion of this process when the clinical course is atypical. Definitive therapy with thyroidectomy or radioactive iodine ablation may be a suitable option in these cases.

scholarly journals A Case of Recurrent Paralysis and Low Potassium: Is It the Thyroid?

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A909-A909
Author(s):  
Justin Do ◽  
Hoveda Mufti
Keyword(s):  
Radioactive Iodine ◽  
Rare Complication ◽  
Periodic Paralysis ◽  
Definitive Treatment ◽  
Free T4 ◽  
Thyrotoxic Periodic Paralysis ◽  
Sodium Potassium ◽  
Potassium Atpase ◽  
Hispanic Male ◽  
Hyperthyroid Patients

Abstract Introduction: Thyrotoxic periodic paralysis (TPP) is a rare complication of hyperthyroidism that is characterized by episodes of hypokalemia and acute weakness. Although hyperthyroidism is more common in females, over 95% of cases of TPP have been observed in males, especially in Asian males with an incidence of 2% among hyperthyroid patients. In non-Asian populations, the incidence in hyperthyroid patients is estimated to be around 0.1 to 0.2% [1]. We describe a case of TPP seen in a Hispanic male. Case Report: A 36-year-old Hispanic male with no past medical history presents with weakness in all extremities and difficulty breathing after consuming a carbohydrate heavy meal the night prior. He reports a recent, similar episode evaluated in another ER, which resolved after given potassium supplementation. He denied any vomiting, diarrhea, polyuria, diaphoresis, use of insulin or other medications, or any family history of paralysis. His labs were significant for hypokalemia of 1.9, TSH of &lt;0.005 (0.358-3.740), free T4 of 2.22 (0.76-1.46), and total T3 of 2.7 (0.60-1.81). Thyroid stimulating immunoglobulin was 0.12 (0.0-0.55). His symptoms improved and potassium levels normalized following the administration of potassium chloride. He was discharged on propranolol and advised to follow up for further workup of his hyperthyroidism with radioactive iodine uptake scan. Discussion: Thyrotoxic periodic paralysis is a potentially life-threatening condition associated with cardiac arrhythmias and respiratory failure. Hyperthyroidism increases response to β-adrenergic stimulation, which increases activity of the sodium-potassium ATPase and causes hyperpolarization of skeletal muscle [2]. Hyperthyroid patients are prone to episodes of paralysis due to their increased susceptibility to the hypokalemic action of insulin, which activates the sodium-potassium ATPase pump, and epinephrine, which stimulates β-adrenoreceptors. Management of an acute attack of TPP includes potassium administration. In cases where paralysis and hypokalemia are not reversed, intravenous propranolol has been shown to resolve the attack by blocking the β-adrenergic receptors. Definitive treatment of TPP includes managing the hyperthyroid state with medical therapy, radioactive iodine therapy, or surgery. Until the euthyroid state is reached, a β-blocker can prevent episodes of acute paralysis. Avoidance of carbohydrate heavy meals, exercise, and stress are recommended as these factors can potentially exacerbate hypokalemia. In patient with acute paralysis, it is important to consider the diagnosis of TPP as this condition can be prevented once euthyroidism is achieved. Diagnosis and management will lead to prevention of morbidity and mortality associated with the hypokalemia. References: 1.Vijayakumar A, et al. J Thyroid Res. 2014;2014:649502. 2.Layzer RB. Annals of Neurology. 1982;11(6):547–552.

scholarly journals The Efficacy and Short- and Long-Term Side Effects of Radioactive Iodine Treatment in Pediatric Graves’ Disease: A Systematic Review

2021 ◽  
pp. 1-11
Author(s):  
Sarah L. Lutterman ◽  
Nitash Zwaveling-Soonawala ◽  
Hein J. Verberne ◽  
Frederik A. Verburg ◽  
A.S. Paul van Trotsenburg ◽  
...  
Keyword(s):  
Systematic Review ◽  
Side Effects ◽  
Radioactive Iodine ◽  
Definitive Treatment ◽  
Antithyroid Drugs ◽  
Dosing Regimen ◽  
The Past ◽  
Short And Long Term ◽  
Iodine Treatment

<b><i>Background:</i></b> Graves’s disease (GD) is the most common cause of hyperthyroidism. Maximal 30% of pediatric GD patients achieve remission with antithyroid drugs. The majority of patients therefore require definitive treatment. Both thyroidectomy and radioactive iodine (RAI) are often used as definitive treatment for GD. However, data on efficacy and short- and long-term side effects of RAI treatment for pediatric GD are relatively scarce. <b><i>Methods:</i></b> A systematic review of the literature (PubMed and Embase) was performed to identify studies reporting the efficacy or short- and long-term side effects of RAI treatment in pediatric GD. <b><i>Results:</i></b> Twenty-three studies evaluating 1,283 children and adolescents treated with RAI for GD were included. The treatment goal of RAI treatment changed over time, from trying to achieve euthyroidism in the past to aiming at complete thyroid destruction and subsequent hypothyroidism in the last 3 decades. The reported efficacy of a first RAI treatment when aiming at hypothyroidism ranged from 42.8 to 97.5%, depending on the activity administered. The efficacy seems to increase with higher RAI activities. When aiming at hypothyroidism, both short- and long-term side effects of treatment are very rare. Long-term side effects were mainly seen in patients in whom treatment aimed at achieving euthyroidism. <b><i>Conclusion:</i></b> RAI is a safe definitive treatment option for pediatric GD when aiming at complete thyroid destruction. When aiming at hypothyroidism, the efficacy of treatment seems to increase with a higher RAI activity. Prospective studies are needed to determine the optimal RAI dosing regimen in pediatric GD.

scholarly journals Tailoring the approach to radioactive iodine treatment in thyroid cancer

2021 ◽  
Author(s):  
Sarah E. Mayson ◽  
Christine M. Chan ◽  
Bryan R. Haugen
Keyword(s):  
Thyroid Cancer ◽  
Radioactive Iodine ◽  
Disease Free Survival ◽  
Management Options ◽  
Thyroid Lobectomy ◽  
Risk Patients ◽  
Iodine Treatment ◽  
Structural Disease ◽  
Therapeutic Decision Making ◽  
Optimal Approach

The treatment of differentiated thyroid cancer continues to move away from a ‘one size fits all’ approach to a process of tailored therapeutic decision-making that incorporates disease-specific factors and individual patient preferences. Management options range from active surveillance to thyroid lobectomy to total thyroidectomy with or without the use of postoperative radioactive iodine (RAI). RAI may be administered for one or more reasons: Thyroid remnant ablation, adjuvant therapy, or therapy for persistent structural disease. It is important to be cognizant of the therapeutic intent of RAI and weigh the risks and benefits of treatment for each individual patient. Risk stratification should be used to identify those patients who are most likely to benefit from RAI and guide therapeutic choices. Available data suggest that RAI can be safely deferred for most patients considered at low risk for structural recurrence, while adjuvant RAI is associated with improved disease-free survival in patients with higher risk disease. Although progress has been made, many areas of uncertainty related to the use of RAI remain. These include: 1) The appropriate selection of intermediate risk patients to receive adjuvant RAI, 2) the superiority or inferiority of different RAI dosing activities, 3) the optimal approach to the use of RAI in special populations, including patients with ESRD and children and 4) the management of patients with RAI-refractory disease.

scholarly journals Plasmapheresis as an Effective Treatment for Thyroid Storm in Critical Patients: Case Reports and Systematic Literature Review

2021 ◽  
Vol 5 (Supplement_1) ◽  
pp. A947-A948
Author(s):  
Vanessa Cherniauskas ◽  
Andre Laffranchi Santos ◽  
Danielle Daffre Carvalho ◽  
Maria Cristina Albe Olivato ◽  
Rosalia de Prado Padovani ◽  
...  
Keyword(s):  
Case Reports ◽  
Trigger Factor ◽  
Definitive Treatment ◽  
Thyroid Storm ◽  
Antithyroid Drugs ◽  
Free T4 ◽  
Treatment Type ◽  
Initial Symptoms ◽  
Thyrotoxic Crisis ◽  
Organ Dysfunctions

Abstract Background: Thyrotoxic crisis is a rare, multisystemic and lethal condition, especially when its reversal is delayed. The Burch Wartofsky score establishes severity and predicts the indication of plasmapheresis, but once there is organ dysfunction this therapy should be considered despite of the score. When it is added to conventional treatments it is really effective because of the quick clinical compensation of critically ill patients regardless of the main trigger factor of this emergency. Clinical Cases: 5 patients with thyrotoxic crisis, 1 man and 4 women that had Graves’disease (4 cases) or TSH-secreting tumor (1 case). The precipitating factors were: 1 case due to orchitis, 2 due to poor adhesion, 1 due to antithyroid drugs hepatoxicity and 1 due to ketoacidosis. All them had elevated free T4 ranging from 3.38 to &gt;7.77 ng/dL. All them had high Burch Wartofsky scores (55 to 70) and severe organ dysfunctions: 4 cases with hepatopathy (hepatosplenomegaly, jaundice and coagulopathy) and cardiopathy (diastolic dysfunction and pulmonary hypertension) and 1 case with severe diabetic ketoacidosis. Plasmapheresis (2 to 3 sessions were performed) were indicated for clinical compensation and so subsequent definitive treatment: 3 cases received radioiodine therapy and 1 case had total thyroidectomy. All of them progressed well. The patient who died had already severe prior comorbidities. We performed a systematic survey on PubMed of English articles (case reports and reviews) in humans and we analyzed our 5 cases along with the 108 articles about the use of plasmapheresis in thyroid storm from 1970 to 2020 and we compare them to 394 ones of conventional treatments in past 10 years. Our objective was to evidence plasmapheresis is not related to a higher mortality of patients who underwent to it. We found 7% of mortality in both groups. The chi square test showed an Odds Ratio of (CI 95%) = 1,091 reinforcing there is no relation between number of deaths and treatment type. Conclusion: Plasmapheresis is a therapeutic option with few reports in the literature and without clear guidelines about indication criteria or better timing to initiate it. The statistical analysis showed that 3 or more organ dysfunctions in thyroid storm are related to higher death rates. Its early employment within 24 hours of the initial symptoms and the prompt normalization of free T4 are related to lower mortality. It is a safe and effective therapy that allows thyroid storm patients to be compensated to receive definitive treatment with lower chances of death. Reference: Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Factors Associated With Mortality of Thyroid Storm: Analysis Using a National Inpatient Database in Japan. Medicine (Baltimore). 2016;95(7):e2848.

Increased Serum Concentration of Free L-Triiodothyronine in Patients Treated with L-Thyroxine

1983 ◽  
Vol 22 (05) ◽  
pp. 251-254
Author(s):  
R. Schmitz ◽  
H. Bongers ◽  
A. Löw ◽  
J. Mahlstedt ◽  
K. Joseph ◽  
...  
Keyword(s):  
Oral Dose ◽  
Serum Concentration ◽  
Normal Level ◽  
Binding Sites ◽  
Carrier Proteins ◽  
Normal Range ◽  
Free T4 ◽  
Normal Concentration ◽  
Free T3 ◽  
High Doses

This study demonstrates that in spite of measured normal concentrations of carrier proteins one cannot deduce in all cases a normal fT3 from a normal level of TT3 when 1-thyroxine given for diagnostic or therapeutic purposes is present in excess. The displacement of 1-triiodothyronine from its binding sites is shown in 35 patients with non-toxic goitre who received an oral dose of 200 μg 1-thyroxine/die for two weeks. Apart from a significant increase of TT4 (from 7.85 to 14.21 μg/dl ≙ + 81 %) and of fT4 (from 1.58 to 3.7 ng/dl ≙ + 134%) there is only a slight increase in TT3 from 148 to 158 ng/dl (≙ + 10%) after 14 days of treatment. By contrast fT3 rises clearly from 4.97 to 8.07 pg/ml ≙ + 63% (normal range: 2.8-5.6 pg/ml). Compared with the increase of TT3 (+ 10%) the free T3 rises by a factor of 6.3 (63 %/10%). On account of higher affinity of 1-thyroxine to binding proteins the free T4 is influenced to a lesser degree. Compared with the increase of TT4 (+ 81 %) free T4 rises by a factor of 1.6 (134%/81 %). It is supposed that the serum concentration of free T3 can be increased despite a normal concentration of TT3 when 1-thyroxine is present in excess. Therefore, for laboratory work fT3 should be assigned a higher validity than TT3 when patients are treated with comparatively high doses of 1-thyroxine.

scholarly journals Rescue pre-operative treatment with Lugol’s solution in uncontrolled Graves’ disease

2017 ◽  
Vol 6 (4) ◽  
pp. 200-205 ◽  
Author(s):  
Jan Calissendorff ◽  
Henrik Falhammar
Keyword(s):  
Heart Rate ◽  
Thyroid Hormone ◽  
Side Effects ◽  
Definitive Treatment ◽  
Graves Disease ◽  
Free T4 ◽  
Hormone Levels ◽  
Free T3 ◽  
Adherence To Medication ◽  
Thyroid Hormone Levels

Background Graves’ disease is a common cause of hyperthyroidism. Three therapies have been used for decades: pharmacologic therapy, surgery and radioiodine. In case of adverse events, especially agranulocytosis or hepatotoxicity, pre-treatment with Lugol’s solution containing iodine/potassium iodide to induce euthyroidism before surgery could be advocated, but this has rarely been reported. Methods All patients hospitalised due to uncontrolled hyperthyroidism at the Karolinska University Hospital 2005–2015 and treated with Lugol’s solution were included. All electronic files were carefully reviewed manually, with focus on the cause of treatment and admission, demographic data, and effects of iodine on thyroid hormone levels and pulse frequency. Results Twenty-seven patients were included. Lugol’s solution had been chosen due to agranulocytosis in 9 (33%), hepatotoxicity in 2 (7%), other side effects in 11 (41%) and poor adherence to medication in 5 (19%). Levels of free T4, free T3 and heart rate decreased significantly after 5–9 days of iodine therapy (free T4 53–20 pmol/L, P = 0.0002; free T3 20–6.5 pmol/L, P = 0.04; heart rate 87–76 beats/min P = 0.0007), whereas TSH remained unchanged. Side effects were noted in 4 (15%) (rash n = 2, rash and vomiting n = 1, swelling of fingers n = 1). Thyroidectomy was performed in 26 patients (96%) and one was treated with radioiodine; all treatments were without serious complications. Conclusion Treatment of uncontrolled hyperthyroidism with Lugol’s solution before definitive treatment is safe and it decreases thyroid hormone levels and heart rate. Side effects were limited. Lugol’s solution could be recommended pre-operatively in Graves’ disease with failed medical treatment, especially if side effects to anti-thyroid drugs have occurred.

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