A Perplexing Case of Pituitary Apoplexy Masquerading as Meningoencephalitis

Pituitary apoplexy (PA) is extremely rare in children and adolescents. It is a life-threatening condition usually results from sudden hemorrhage or infarction induced swelling in a pituitary adenoma. The clinical manifestations of PA include severe headaches, impaired consciousness, fever, visual disturbance, and variable ocular paresis. Therefore, the presence of meningeal irritation may lead to misdiagnosis as a case of meningoencephalitis or spontaneous subarachnoid hemorrhage, and delay in the proper management of the disease. We report a case of 17-year-old pubertal boy who developed sudden severe headache, vomiting, slurring of speech and abnormal behaviour followed by impaired sensorium with fever. The patient who was initially diagnosed with meningoencephalitis (ME) based on clinical presentation and cerebrospinal fluid (CSF) analysis, which was consistent with bacterial meningitis. MRI of brain was performed, confirming a pituitary macroadenoma with hemorrhage and ischemic changes in both basal ganglia and pons. A complete analysis of the pituitary hormones revealed decreased cortisol and thyroid hormone level and hyperprolactinemia and he was subsequently started on placement corticosteroid and L-thyroxine therapy and cabergoline. After 14/ days of antimicrobial therapy with ceftriaxone and ampicillin, the patient improved and was discharged on hormone replacement therapy and surgical advised. Hereby, we report our case with a review of literatures. Bangladesh J Medicine July 2022; 33(1) : 85-88

Association between hypertensive disorders of pregnancy and long-term neurodevelopmental outcomes in the offspring

Objective: The long-term impact of hypertensive disorders of pregnancy (HDP) exposure on offspring health is an emerging research area. The objective of this study was to evaluate the association between a maternal diagnosis of HDP (gestational hypertension and preeclampsia) and adverse neurodevelopmental outcomes in the offspring. Study Design: A secondary analysis of two parallel multicenter clinical trials of thyroxine therapy for subclinical hypothyroid disorders in pregnancy. Women with singleton non-anomalous gestations diagnosed with subclinical hypothyroidism or hypothyroxinemia were randomized to thyroxine therapy or placebo. The primary outcome was child intelligence quotient (IQ) at 5 years of age. Secondary outcomes were Bayley-III cognitive, motor and language scores at 12 and 24 months, DAS-II scores at 36 months, the Conners’ Rating Scales-Revised at 48 months, and scores from the Child Behavior Checklist at 36 and 60 months. Associations between neurodevelopment outcomes and maternal HDP were examined using univariable and multivariable analyses. Results: A total of 112 woman-child dyads with HDP were compared with 1067 woman-child dyads without HDP. In univariable analysis, mean maternal age (26.7±5.9 vs. 27.8±5.7 years, p=0.032) and nulliparity (45.5% vs. 31.0%, p=0.002) differed significantly between the two groups. Maternal socioeconomic characteristics did not differ between the groups. After adjusting for potential confounders, there were no significant differences in primary or secondary neurodevelopment outcome between offspring exposed to HDP and those unexposed. However, when dichotomized as low or high scores, we found higher rates of language delay (language scores <85: -1 standard deviation) at two years of age among offspring exposed to HDP compared with those unexposed (46.5% versus 30.5%, adjusted odds ratio 2.22, 95% CI 1.44 - 3.42). Conclusions: In this cohort of pregnant women, HDP diagnosis was associated with language delay at 2 years of age. However, other long-term neurodevelopmental outcomes in offspring were not associated with HDP.

Hypothyroidism Therapy

Hypothyroidism refers to the common pathological disorder of thyroid hormone deficiency. The successful therapy for hypothyroidism is levothyroxine (LT4) administration, which is the same as thyroxine but produced synthetically. Serum thyrotropin (TSH) normalization with LT4 replacement therapy in hypothyroidism is generally needed to restore a euthyroid state. The daily dose of thyroxine therapy depends on various factors, such as body weight, age, and severity. It also differs from hypothyroidism during pregnancy to congenital hypothyroidism. The presence of various comorbidities may exist such as myxoedema coma, coronary artery disease, obesity, anemia and COVID-19 which necessitate individualized treatment. LT4 intolerance manifested with sympathetic hyperactivity may appear during the first hours after the LT4 administration. It requires starting with very low doses of LT4 that should be increased gradually, and reaching normal TSH may take several months. The sympathetic hyperactivity may be attributable to the presence of uncorrected iron-deficiency anemia that worsens by the use of thyroid hormone.

Severe Acquired Primary Hypothyroidism in Children and its Influence on Growth: A Retrospective Analysis of 43 Cases

Introduction Severe acquired hypothyroidism in childhood is a rare condition, mostly caused by autoimmune thyroiditis. Scarce and inconsistent data based on small patient numbers exist concerning its impact on growth in height. Methods Patient files at a single centre university hospital over 8 years were retrospectively reviewed. We identified 43 patients (mean age 10.6 years, 3.3–15.25, 59% prepubertal, 88% females) in a cohort of children older than 3 years with an initial TSH>30 mIU/l and reduced T4 or fT4; congenital and drug-induced hypothyroidism were excluded. Results All patients had signs of autoimmune thyroiditis (93% positive autoantibodies, 95% typical ultrasonography, 63% goiter). Median TSH was 100 mIU/l [0.3–4 mIU/l]), median fT4 3.55 pg/ml [8–19 pg/ml], median T4 2.85 µg/dl [5.3–11 µg/dl]. Presenting symptoms included goiter (26%), tiredness (23%), weight gain (19%), and growth retardation (19%). The diagnosis was made incidentally in 26% patients. In 75% growth was retarded (median height standard deviation score (SDS)-0.55), in 17% height SDS was<-2 at diagnosis. Midparental height SDS at diagnosis correlated significantly with T4 and fT4 (r=0.77, p=0.0012 and r=0.53, p=0.021 respectively). Catch-up growth under T4 substitution was significantly greater in prepubertal than in pubertal children (p 0.049). Conclusion This so far largest pediatric cohort with severe acquired hypothyroidism confirms a serious impact on growth which, however in most cases, showed a certain catch-up growth after adequate L-thyroxine therapy. The pubertal state seems to be important for catch-up growth. A significant number of patients were not diagnosed clinically, although affected by severe hypothyroidism.

Favorable Early Outcomes With Thyroid Lobectomy for Low-Risk Papillary Thyroid Cancer: The Mayo Clinic Experience

Background Until 2015, standard of care for low-risk papillary thyroid cancer (PTC) >1 cm was a total or near-total thyroidectomy. Despite changes in guidelines and surgical management of low-risk PTC since 2015, little data are available regarding the effect on the need for additional surgery or risk for development of lymph node metastases. Our aim was to determine outcomes in patients who underwent initial thyroid lobectomy for low-risk PTC at a high-volume tertiary care institution. Methods Retrospective review of patients ≥18 years old with biopsy proven low-risk PTC 1-4 cm who underwent partial thyroidectomy (eg, lobectomy/isthmusectomy) at Mayo Clinic, Rochester, MN, between March 2016 and June 30, 2019. Results From 1481 thyroidectomies performed during study period, 940 contained PTC on final pathology. Of these, 87 (of 123) patients who had an initial thyroid lobectomy met inclusion criteria. Five (6%) of these patients proceeded to completion thyroidectomy (CT), with 3 requiring CT and radioactive iodine in the first postoperative year and 2 undergoing only CT in the second postoperative year. No postoperative complications were reported. No patient in this cohort required additional surgery or treatment for newly discovered lymph node metastases during the follow-up period. 43 (of 72, 60%) patients not on thyroxine therapy preoperatively were started on thyroxine therapy postoperatively. Conclusions Early outcomes for those undergoing thyroid lobectomy for low-risk PTC at our institution have been favorable. These results support the 2015 American Thyroid Association guidelines to offer lobectomy for those with low-risk PTC 1-4 cm.

Role of thyroxine in reducing the size of benign thyroid swellings and pre-treatment thyroid stimulating hormone as a predictor of response to therapy

Background: Conservative management for benign thyroid swellings which do not require surgery is a matter of controversy. There has been studies and trials on the role TSH suppression in reducing thyroid volume, but low dose thyroxine was never been properly studied. Being such a common disorder, more studies have to be undertaken to have an idea on managing the goitres conservatively.Methods: Patients with benign thyroid goitres without indications for surgery and who were on 50-100 µg of thyroxine per day was included in the study. Their initial thyroid hormone levels, volume on ultrasonogram, and fine needle aspiration cytology were collected along with biodata. They were reassessed after 6 months and 1 year for change in volume of thyroid.Results: Majority of patients showed a decreasing trend in volume of thyroid after 1 year of thyroxine therapy, even though the amount of reduction was not statistically significant. Rate of decrease in thyroid volume was significantly higher in patients with higher TSH values.Conclusions: Thyroxine therapy has got a role in reducing and arresting further growth of benign thyroid swellings which doesn’t require surgical management. Pre-treatment TSH can be used a predictor of response to thyroxine therapy.

Thyroidectomy- And Ptu-Induced Hypothyroidism: Effect of L-Thyroxine on Suppression of Spatial and Non-Spatial Memory Related Signaling Molecules

The calcium/calmodulin protein kinase II (CaMKII) signaling cascade is crucial for hippocampus-dependent learning and memory. In adult rats, Hypothyroidism impairs hippocampus-dependent learning and memory, which can be prevented by simple replacement therapy with L-thyroxine (thyroxine, T4) treatment. In this study, we compared animal models of hypothyroidism induced by thyroidectomy and treatment with propylthiouracil (PTU). Our findings show that thyroidectomy and PTU models are equally effective as indicated by the identical plasma levels of thyroid stimulating hormone (TSH) and T4. The two model produced identical degree of inhibition of synaptic plasticity as indicated by depression of LTP. We then investigated the effect of thyroidectomy hypothyroidism and thyroxine treatment on the underlying molecular mechanism of spatial and non-spatial types of memory. To generate spatial memory, we used training in the radial arm water maze (RAWM) where rats had to locate a hidden platform. For non-spatial memory, rats were trained to swim to a clearly visible platform in an open swim field. Western blot analysis of hippocampal area CA1 revealed that training, on both mazes, of control and thyroxine-treated hypothyroid rats produced significant increases in the P-CaMKII, PKCγ, calcineurin and calmodulin protein levels, but the training failed to induce such increases in untreated thyroidectomized rats. As expected, we show that thyroxine therapy prevented the deleterious effects of hypothyroidism at the molecular level.

The use of L-thyroxine in the treatment of thyroid pathologies and problems of therapy control (literature review)

Background. Thyroid disease is one of the most common pathologies in the world, wich includs hypothyroidism, hyperthyroidism and thyroid cancer. At the present, there is an increase in their cases. The thyroid gland is an extremely important for the health of a person, thyroid hormones are necessary for the normal functioning of all tissues in the body. Purpose. To structure and summarize scientific findings on the role of thyroid hormones (T4, T3 and rT3) in the development of hypothyroidism, their effect on inhibiting the growth of cancer cells and the cytotoxic effects of these hormones on thyroid cells. Results and discussion. In spite of a careful study of thyroid function, the use of thyroid hormones and laboratory monitoring in the treatment of various thyroid pathologies remains debatable up to now. In particular, it concerns LT4 + LT3 combination and the role of reversible T3. This is due to a complex regulation system depending on many factors: hormonal homeostasis, nutritional factors, physiological conditions, etc., which together maintain appropriate thyroid functioning. LT4 monotherapy remains the standard method of replacement therapy, however, according to the ETA recommendations, it is possible for individual patients to prescribe combination therapy LT4 + LT3 as an experimental approach. The use of the rT3 test as a prognostic / diagnostic indicator for monitoring the therapy of patients receiving L-thyroxine therapy is discussed. The use of L-thyroxine as a thyrotropic suppressive therapy in the treatment of thyroid cancer requires careful dose adjustment depending on the health status of each patient, the risk of recurrence, which requires monitoring and dynamic reassessment. Long-term suppressive therapy of LT4 can affect metabolism, contributing to weight loss. Conclusions. Given the analysis of the literature, which covered 20 years, today L-T4 monotherapy is the standard therapy for patients with hypothyroidism. LT4 + LT3 combination therapy can be recommended in patients receiving L-T4 treatment with complaints characteristic of hypothyroidism despite normal TSH levels, with the exception of other chronic and concomitant autoimmune diseases that may be the cause.