Hypothyrosis syndrome: role of triodthyronine in diagnostics and combination therapy (review of literature)

Hypothyroidism syndrome is one of the most common pathologies of the endocrine system. Assessment of euthyroid status can not always be carried out according to the TSH indicator. In a number of patients with normal TSH levels and a clinical picture of hypothyroidism, the serum T3 concentration is determined at the lower limit of the norm or below it with a high content of free T4 in the blood. In world practice, positive experience has been accumulated in the combined use of preparations of sodium levothyroxine and liothyronine, a synthetic form of exogenous triiodothyronine. A number of studies have noted the advantages of using combination therapy for hypothyroidism over levothyroxine monotherapy in certain groups of patients. Possible reasons for the ineffectiveness of standard treatment for hypothyroidism are described.

Comparison of Block and Replace Regime and Titration Regime in Graves’ Disease

In Graves’ disease (GD), medical treatment is still the cornerstone in its management and there were some studies done on comparison of the block and replace regime and titration regime of the antithyroid drugs (ATDs). In Myanmar, titration regime is mostly practiced for management of GD. In daily clinical practice, frequent hospital visits are needed in titration regime and loss of follow-up is an obstacle in patients treated with titration regime. A hospital based randomized clinical trial was conducted and aimed to compare the proportion of attainment of euthyroid status between block and replace regime and titration regime in patients with recently diagnosed GD. A total of 117 patients; 58 patients in block and replace regime and 59 patients in titration regime, who met the inclusion criteria were included. The results showed that euthyroid status was observed in increasing trend during the study period for both regimes but there was no significant difference of achieving euthyroid status between the regimes at the end of 12 months. Regarding side effects of ATDs, skin rash and pruritus were more frequently occurred during the first 3 months of ATDs but no significant difference was noted between the regimes at the end of study. There was also no case of serious side effects such as agranulocytosis and hepatotoxicity up to the end of 12 months. The results of the study pointed out that block and replace regime was comparable to dose titration regime in attaining euthyroid status. As a conclusion, block and replace regime can be applied as an alternative option where titration regime is not feasible. Reference: (1) Abraham et al., 2005; A systematic review of drug therapy for Graves’ hyperthyroidism. Eur J Endocrinol. 153: 489-98. (2) Vaidya et al., 2014; Block & replace regime versus titration regime of antithyroid drugs for the treatment of Graves’ disease: a retrospective observational study. Clinical Endocrinology. 81: 610–613.

Meibomian glands dropout in patients with inactive thyroid related orbitopathy

Purpose To evaluate the structure and function of meibomian glands in patients with thyroid related orbitopathy (TRO) compared with age- and sex-matched controls without TRO. Methods This cross-sectional study included 106 eyes of 53 patients with TRO and 106 eyes of 53 age- and sex-matched controls without TRO. Patients with TRO were assessed for thyroid hormone status, activity and severity of TRO. All participants completed OSDI questionnaires. Their meibomian glands’ structure and function were assessed, including the area of meibomian gland dropout, lipid layer thickness (LLT), meibum expressibility and quality scores, tear break-up time (TBUT), corneal and conjunctival staining scores. A generalized estimating equation (GEE) was used to compare between the two groups. The correlations between the area of meibomian gland dropout with symptoms and signs of TRO were evaluated using GEE and Spearman correlation. Results All patients with TRO had inactive status. The mean area of meibomian gland dropout was higher in the TRO group (34.5±11.2%) compared with that of controls (30.1±10.7%, P = 0.03). Both mean meibum quality (TRO, 1.6±0.7; Controls, 2.0 ±0.5) and expressibility (TRO, 1.5 ±0.7; Controls, 1.7 ±0.6) scores were slightly better in the TRO group compared with those of controls (P = 0.01). There was no significant difference in OSDI, corneal and conjunctival staining, TBUT and LLT. The area of meibomian gland dropout in patients with TRO was correlated with euthyroid status (P<0.05) and lagophthalmos (P = 0.03). Conclusions Patients with inactive TRO showed significantly higher meibomian gland dropout compared with that of age- and sex-matched controls without TRO.

A rare case of osseous metaplasia in anaplastic thyroid cancer

Anaplastic thyroid cancer is the most advanced and aggressive thyroid cancer. It is very rare and isfound in less than 2% of patients with thyroid cancer. It most commonly occurs in people over theage of 60 years. It is usually diagnosed at later stages when the disease has already spread tosurrounding structures or has grown large enough to compress the trachea or esophagus causingpressure symptoms. The patient here, a 75-year-old female, presented with a large swelling in thefront of the neck in euthyroid status which was diagnosed as anaplastic thyroid cancer and wasmanaged surgically and the surgical specimen was sent for histopathological examination. Thepresence of osseous metaplasia with mature bone formation in anaplastic thyroid carcinoma is a rareentity and has been discussed in this case report.

PREVALENCE OF HYPERPROLACTINEMIA IN EUTHYROID INFERTILE FEMALES

Infertility is the inability of a couple to achieve pregnancy over a period of one year despite regular unprotected coitus. It can be due to various causes. This cross sectional study was done to find the prevalence of hyperprolactinemia in euthyroid infertile women.A total of 76 infertile women with normal thyroid function attending the outpatient department were included in this study. Maximum cases were seen in the 25-35 year age group with the mean age of 26.35±3.11 years. The prevalence of hyperprolactinemia in eythyroid infertile women was 9.21%. The mean serum prolactin level in primary infertility women was 14.12±5.54 ng/ml while that in secondary infertility was 18.31±6.12 ng/ml. So, the estimation of serum prolactin levels in infertile patients with euthyroid status could be of great benefit in management of infertility.

Circulating Irisin Level and Thyroid Dysfunction: A Systematic Review and Meta-Analysis

Both thyroid hormones and irisin have profound influences on the metabolism of the human body. Based on their similarities, several studies have been conducted to explore changes in irisin levels in patients with hypothyroidism and hyperthyroidism. This study was conducted in accordance with the PRISMA statement and the MOOSE reporting guideline. Based on a preregistered protocol (PROSPERO—CRD42019138430), a comprehensive search of eight databases was performed from inception to April 2020. Studies with original data collected from patients with thyroid dysfunction were included. Subgroup analysis was performed based on the different types of clinical manifestations and patient characteristics. The quality of each study and the presence of publication bias were assessed by the Newcastle-Ottawa score (NOS) and funnel plot with Egger’s test, respectively. A total of 11 studies with 1210 participants were included. Ten studies were identified as high-quality studies. Pooled analysis indicated decreased irisin levels in patients with hypothyroidism (MD -10.37, 95% CI -17.81 to -2.93). Subgroup analysis revealed an even lower level of irisin in patients with clinical-type hypothyroidism (MD -17.03, 95% CI -30.58 to -3.49) and hypothyroidism caused by autoimmune disease (MD -19.38, 95% CI -36.50 to -2.26). No differences were found after achieving euthyroid status from levothyroxine treatment in patients with hypothyroidism compared with controls. No differences were found between patients with hyperthyroidism and controls. Correlation analyses revealed a possible negative correlation between irisin and TSH and positive correlations between irisin and both fT3 and fT4. Irisin was correlated with TSH receptor antibodies.

A cross-sectional study to find the prevalence of hyperprolactinemia in infertile euthyroid patients in a hospital

Background: Infertility whether primary or secondary, has multi-factorial causation, out of which hormonal imbalance is one of the important factors. Current study evaluates the prevalence of hyperprolactinemia in infertile euthyroid women.Methods: After Ethics Committee approval and written informed consent, all infertile euthyroid women (n=153) with age group 20-40 years attending outpatient department of general hospital, with marriage duration of at least one year and willing to participate in study were recruited. Male factor infertility, women with diagnosed hyperprolactinemia, thyroid abnormality, tubal factors, any congenital anomaly of urogenital tract or obvious organic lesion or with history of anxiety or other psychological disorders and on treatment for same were excluded. Detailed obstetrics history with relevant laboratory, radiological investigations including serum prolactin level was done.Results: Mean serum prolactin level was 13.89±10.03 ng/ml. Out of 153 participants, 13 had hyperprolactinemia which comprised 8.50% of the sample. The mean of the level of serum prolactin level in primary infertility cases was 13.18±8.485 ng/ml while that in secondary infertility was 17.21±15.1 ng/ml. Primary infertility was approximately half (53.85%) in hyperprolactinemia group and majority (85%) in normoprolactinemia group. Duration of married life, infertility and fasting blood sugar were positively correlated with prolactin levels.Conclusions: Prevalence of hyperprolactinemia was 8.50% with higher serum prolactin level in secondary infertility as compared to primary infertility. So, estimation of serum prolactin levels in infertile patients with euthyroid status can help to a large extent in finding the cause of infertility and may help in further management.

Should cardiac surgery be delayed in patients with uncorrected hypothyroidism?

Summary A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: ‘should cardiac surgery be delayed in patients with uncorrected hypothyroidism?’ A total of 1412 papers were found using the reported search, of which 7 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. There was limited high-quality evidence with the majority of the studies being retrospective. One propensity-matched analysis and 6 cohort studies provided the evidence that there was no significant difference in the rate of major adverse cardiac events including mortality based on thyroid status. However, hypothyroidism and subclinical hypothyroidism were associated with higher rates of postoperative atrial fibrillation. Based on the available evidence, we conclude that cardiac surgery should not be delayed to allow achievement of euthyroid status.

Spontaneous Ovarian Hyperstimulation Syndrome: Looking Beyond the Ovary

We report a case of a 22-year-old single female with spontaneous ovarian hyperstimulation syndrome (s-OHSS) referred for transvaginal aspiration of follicles. Investigations revealed primary hypothyroidism, mild hyperprolactinaemia and unelevated levels of both follicle stimulating hormone (FSH) and estradiol. Supplementation with L-thyroxine lead to euthyroid status and gradual resolution of signs and symptoms of ovarian hyperstimulation syndrome (OHSS) over 4 months.

Comparison of 24-Hour Electrocardiogram Parameters in Patients with Graves Disease Before and After Anti-Thyroid Therapy

Background: We aimed prospectively investigate the laboratory and electrocardiographic parameters (hearth rate, QRS, QT, QTc, Tpe, Tpe/QTc, arrhythmia prevalance) in patients with graves disease before and after antithyroid therapy. Methods: 71 patients (48 female, 23 male), age between 18-50 (mean±SD: 36.48±12.20 ) with GD were included into the study. Patients treated with antithyroid therapy (thionamids and/or surgical therapy) to maintain euthyroid status. Patients were examined in terms of electrocardiographic parameters before and after the treatment. Results: Mean TSH, free thyroxin (fT4) and tri-iodothyrionine (fT3) levels of all patients were 0.005±0.21, 3.27± 1.81, 11.42±7.44, respectively. While 9 patients (group 2) underwent surgical therapy, had suspicious of malignant nodule or large goiter and unresponsiveness to medical treatment; the other patients (n=62, group 1) were treated with medical therapy. Patients with surgical therapy had more increased serum fT4 (p=0.045), anti-thyroglobulin value (p=0.018) and more severe graves orbitopathy (n=0.051) before treatment when compared to medical therapy group. Baseline Tpe duration and baseline Tpe/QTc ratio and frequency of supraventricular ectopic beats were found to be significantly higher in group 2 when compared to group 1 (p=0.00, p=0.005). Otherwise baseline mean heart rate, QRS duration, QTc values of both groups were similar. Although the patients became their euthyroid status, group 2 patients had still suffered from more sustained supraventricular ectopics beats than group 1. Conclusion: Distinct from medical treatment group, surgical treatment group with euthyroidism at least 3 months had still suffered from an arrhythmia (Tpe, Tpe/QTc, supraventricular and ventricular ectopic beats).