Cases Of Hyperthyroidism Research Articles

Thyroid Storm in Post-Partum in Bangkalan Hospital: A Case Report

Thyroid crisis is a rare complication of hyperthyroidism, with a greater risk about 10 times during pregnancy,also clinical manifestations and significant increasing of level of thyroxine (T4) and tri-iodothyronine (T3).Thyroid crisis could cause mortality in >10%. A 58-year-old female was referred from Bangkalan Hospital,presented with palpitation, shortness of breath, diarrhea 2-3×/day, vaginal bleeding, fever for 1 day beforeadmittance. Hyperthyroid for 3 years ago and routinely consumed thyrozol (1×2tab) in 2 years but didnot take the medicine for 1 year ago. Physical examination: BP 147/100 mmHg, pulse rate 124×/minute,temperature 38.4 ºC, RR 30/minute, conjunctiva anemia, thyroid palpable, exopthalmus. ECG results:presence of sinus tachycardia, Chest X-Ray: cardiomegaly. Burch Wartofsky Score obtained a total scoreof 45, (temperature 38.5 C=15, diarrhea=10, tachycardia=15, CHF=5). Laboratory results: TSH <0.004 IU/mL, FT4 5.31 ng/dl. Thyroid crisis is a rare case of hyperthyroidism, a greater risk during pregnancy whichcould lead to death. Many symptoms arise in hyperthyroidism which could lead to thyroid crisis. The criteriawhich used to assess thyroid analysis is the Burch Wartofsky Score, FT4 levels increased 5.31 ng/dl. Thispatient was diagnosed as thyroid storm in post-partum, based on Burch Wartofsky Score, low TSH level andan elevated FT4 level and not taking medicine for 1 year ago.

Frequency of Thyroid Dysfunction in Type 2 Diabetes Patients

Thyroid problems are more common in people with type 2 diabetes. They have microvascular problems as a result of hypothyroidism. Patients with diabetes and hypothyroidism have a higher risk of cardiovascular disease. Diabetic individuals who are screened for thyroid dysfunction will be able to receive early therapy for hypothyroidism. The goal of this study was to determine the extent of thyroid dysfunction in people with type 2 diabetes and the relationship between thyroid dysfunction and diabetic complications. This study is to be conducted at a tertiary care hospital in Chennai for a period of 1 year 200 patients were selected 100 were diabetics and 100 were controls (non-diabetic). 24 patients out of 100 subjects were detected to have thyroid dysfunction. 17 patients were detected to have SCH, 6 had primary hypothyroidism and I had primary hyperthyroidism. No case of subclinical hyperthyroidism was detected. TSH values were significantly higher in diabetics. Thyroid dysfunction especially SCH was prevalent in diabetics. There was a poor glycemic control in diabetics with thyroid dysfunction.

Wernicke’s encephalopathy precipitated by neuromyelitis optica spectrum disorder and Graves’ disease: A tale of clinical and radiological dilemmas

AbstractBackgroundNeuromyelitis optica spectrum disorder (NMOSD), an autoimmune astrocytopathy, may share common clinico‐radiological features with Wernicke's encephalopathy (WE). A variant of NMOSD, known as area postrema syndrome (APS), that presents with intractable hiccups and associated vomiting, might lead to the depletion of nutrients if not detected and treated early. Autoimmune thyroid disorders (i.e., Graves’ disease) may be associated with NMOSD. Rarely, thyrotoxicosis can give rise to thiamine depletion and WE.Case presentationHere, we present a case of untreated hyperthyroidism in an Indian female who presented with thyrotoxicosis and later developed WE, possibly also contributed by NMOSD (APS)‐induced recurrent vomiting. The patient recovered with antithyroid drugs, parenteral thiamine, and immunomodulatory therapy. The possible pathogenic mechanisms have been discussed.ConclusionOur case establishes the importance of considering NMOSD variants in metabolic encephalopathy, especially if neuroimaging is suggestive and in the backdrop of another autoimmune disorder.

Management and Outcomes of Pregnancy with Gestational Hypertension and Hyperthyroidism: A Case Report

Introduction: Hyperthyroidism associated increases in thyroid hormone concentrations have to be differentiated from physiological adjustments in thyroid hormone economic system that rise up all through being pregnant, especially in the first trimester. For one thousand births, one or two instances of gestational hyperthyroidism exist. It's critical to stumble on hyperthyroidism in a pregnant female due to the fact it is able to have harmful outcomes for each the mom and the infant.
 Presenting Complaint and Investigations: Patient’s chief complaints were vomiting, discomfort since 2 days. After physical examination and investigations, doctor diagnosed this as case of G2A1 with 35 weeks gestational age. This was a known case of gestational hypertension with hyperthyroidism. Investigations included Blood test, urine test, thyroid Profile, USG.
 Obstetric History: Patient had bad obstetric history. 2.5 months spontaneous abortion was reported.
 The Main Diagnoses, Therapeutic Interventions, and Outcomes: Gestational Hypertension with Known case of Hyperthyroidism. The patient had undergone various investigations like blood tests, USG, Physical examination. After physical examination and investigation doctor took a decision of emergency Lower segmental Caesarean section. Under spinal anaesthesia Lower segmental Caesarean section was done and outcome is good.
 Nursing Perspectives: Administered fluid replacement i.e. DNS and RL, Fetal monitoring, monitored all vital signs and observed the outcomes of treatment.
 Conclusion: Treatment and control of hypertension and hyperthyroidism in pregnancy at the right time increases the pregnancy's outcome.

UNEXPLAINED DELIRIUM : THINK OF THYROID STORM

Background: Thyroid storm is a life-threatening Endocrine emergency with an incidence rate of 1% to 2% all over the world. It is a systemic condition leading to increased production of Thyroid Hormone and its release leading to Thermoregulatory, Adrenergic, Neuropsychiatric, Cardiovascular, and Abdominal Manifestations. Thyroid storm with Malignant Arrhythmia and delirium both together is rare entity, but the mortality rate is very high. The presentation of Malignant Arrhythmias and delirium together in the initial phase of the disease is much less common with only a few isolated cases described in the scientic literature. Objective: To present a case in which a patient had two simultaneous complication of thyroid storm i.e. delirium and ventricular tachycardia. Case Study: We report a 65 years-year-old man who came with complaints of Diarrhea, Fever, Breathlessness and psychosis. His serum tsh was <0.015 and anti tpo antibodies was 83. He was diagnosed to be in Thyroid storm and later had complications including Ventricular Tachycardia and delirium in an undiagnosed case of Hyperthyroidism. He was started on anti thyroid medication and slowly as his condition improved he was discharged. Conclusion: Patients with Thyrotoxicosis need to be closely monitored for complications since its early diagnosis and treatment may save lives.

Thyrotoxicosis and dilated cardiomyopathy in developing countries

BackgroundThyrotoxicosis is the state of thyroid hormone excess. But, in sub-Saharan Africa (SSA), specifically Northern Ethiopia, scientific evidence about thyrotoxicosis and its cardiac complications like dilated cardiomyopathy is limited. Therefore, this study aimed to explore the thyrotoxicosis presentation and management and identify factors associated with dilated cardiomyopathy in a tertiary hospital in Northern Ethiopia.MethodsAn institution-based cross-sectional study was conducted in Ayder Comprehensive Specialized Hospital from 2017 to 2018. Data from 200 thyrotoxicosis cases were collected using a structured questionnaire. After describing variables, logistic regression was conducted to identify independent predictors of dilated cardiomyopathy. Statistical significance was declared at p < 0.05.ResultsMean age at presentation of thyrotoxicosis was 45 years and females accounted for 89 % of the cases. The most frequent etiology was multinodular toxic goiter (51.5 %). As well, the most common symptoms and signs were palpitation and goiter respectively. Thyroid storm occurred in 6 % of the cases. Out of 89 patients subjected to echocardiography, 35 (39.3 %) of them had dilated cardiomyopathy. And, the odds of dilated cardiomyopathy were higher in patients who had atrial fibrillation (AOR = 15.95, 95 % CI:5.89–38.16, p = 0.001) and tachycardia (AOR = 2.73, 95 % CI:1.04–7.15, p = 0.040). All patients took propylthiouracil and 13.0 % of them experienced its side effects. Concerning β-blockers, propranolol was the most commonly (78.5 % of the cases) used drug followed by atenolol (15.0 %). Six patients underwent surgery.ConclusionsIn developing countries like Ethiopia, patients with thyrotoxicosis have no access to methimazole which is the first-line anti-thyroid drug. Besides, they greatly suffer from dilated cardiomyopathy (due to late presentation) and side effects of propylthiouracil. Therefore, we recommend that patients should get adequate health information about thyrotoxicosis and anti-thyroid drugs including their side effects. Additionally, hospitals and other concerned bodies should also avail of TSH tests and methimazole at an affordable cost. Furthermore, community awareness about iodized salt and iodine-rich foods should be enhanced.

Review Article: Present Perspectives of Hyperthyroidism during Pregnancy

Around 80% of the hyperthyroidism cases of women of childbearing age are inflammatory due to Graves' disease. Production and manifestation of other than gestational and early-onset diabetes may be linked to the hormonal modifications in the maternal immune system during birth. Therefore, in addition to the hormonal influences, the pregnancy test will be affected by various anatomical modifications or alterations seen in the body during pregnancy. For the health of a woman and the start of her pregnancy, thyroid hormones are very significant. These hormones are critical in early development and play a vital role in continuing the fetus's growth since conception. Women with untreated or inadequately controlled hyperthyroidism are at risk of giving birth problems. Future diseases, particularly those with IUGRTH producing so many fetuses. The treatment of hyperthyroid pregnant people is so tricky, and medical staff involvement is needed to ensure that it's monitored and treated in various ways. Pregnant women are prescribed antithyroid medications, and it is the medication of preference for most pregnant women (ATDs). Although both of these medications are transmitted to the fetus by the mother's bloodstream, they are significantly efficient in the treatment of maternal hyperthyroidism. Still, they need caution throughout the second half of pregnancy because of the possibility of fetopathy. Except in the first trimesters from weeks 6 to 10 weeks, the most prevalent adverse effect is abnormalities in the fetal; even with that as a caveat, the incidence of birth defects is high during the first trimester with the help of ATDs. The treatment of hyperthyroidism during pregnancy goes into four issues that are currently of major importance to obstetricians: its aetiology, disease occurrence, proper detection, under treatment, complications, and actual or a missed diagnosis and intervention, and finally, the method of dealing with the problem.

The value of [68Ga]Ga-DOTA-TATE PET/CT in diagnosis and management of suspected pituitary tumors

BackgroundGallium 68-tetraazacyclododecane-tetraacetic acid-octreotate ([68Ga]Ga-DOTA-TATE) is a selective somatostatin analogue ligand, which shows increased affinity for somatostatin receptor subtype (SSTR) 2 and has been used routinely for imaging neuroendocrine tumors with PET/CT. We investigated the utility of [68Ga]Ga-DOTA-TATE positron emission tomography/computed tomography (PET/CT) in patients with suspected pituitary pathology. We reviewed imaging for twenty consecutive patients (8 men, 12 women, mean age of 48.2, range 14–78) with suspected pituitary pathology who were referred for [68Ga]Ga-DOTA-TATE PET/CT.ResultsNine patients presented with recurrent Cushing’s syndrome following surgical resection of pituitary adenomas due to recurrent Cushing’s disease (seven patients) and ectopic ACTH secreting tumor (2 patients). All seven patients with recurrent Cushing’s disease showed positive pituitary [68Ga]Ga-DOTA-TATE uptake while both cases of ectopic hormonal secretion had absented pituitary uptake. In 1 of these 2 patients, [68Ga]Ga-DOTA-TATE was able to localize the source of ectopic ACTH tumor.Six patients presented de novo with Cushing’s due to ectopic ACTH secretion; [68Ga]Ga-DOTA-TATE PET/CT was able to localize ectopic tumors in six of eight patients (3 lungs, 2 pancreases, 1 mid-gut)There was high uptake [68Ga]Ga-DOTA-TATE in 3 cases of recurrent central hyperthyroidism (SUVmax 6.6–14.3) and 2 cases of prolactinoma (SUVmax 5.5 and 11.3).ConclusionAbsent [68Ga]Ga-DOTA-TATE activity in the pituitary fossa is useful in excluding pituitary disease in recurrent Cushing’s. Recurrent pituitary thyrotropinomas and prolactinomas showed moderate to high pituitary activity. In addition, in Cushing’s syndrome, [68Ga]Ga-DOTA-TATE is useful for detection of ectopic sources of ACTH production, especially where anatomic imaging is negative.

Title: Case of Hyperthyroidism in a Patient on Anti-PD-1 (Programmed Cell Death Receptor-1 Blocking Antibody) Therapy Caused by Destructive Thyroiditis Followed by Graves’ Disease

Introduction: Immune checkpoint inhibitor (ICI) related thyroid dysfunction such as destructive thyroiditis and hypothyroidism can occur with Anti-PD-1 therapy. Graves’ disease (GD) however is considered rare. We report a case of isolated hyperthyroidism in a patient on Pembrolizumab, Anti-PD-1 presenting initially as destructive thyroiditis and later transitioned to GD. Case: 57 y.o lady was diagnosed with squamous cell carcinoma of cervix, stage 4 in 2016. She was noted to have asymptomatic goiter in 1997. PET scan in 02/2017 showed hypermetabolic activity in the right lobe nodule of 5.6 cm with maximum SUV of 9.8. Baseline TSH was in normal range in 04/2017. US guided fine needle biopsy of the nodule resulted as follicular neoplasm with 15-30%, risk of malignancy. Molecular test showed 40% risk of malignancy. Lobectomy was deferred. Pembrolizumab was initiated for advanced cervical cancer in 07/2018. Repeat PET in 10/2018 showed resolution of metastasis and right thyroid mass was stable. TSH remained in euthyroid range for 4 months until 11/ 2018. In 01/2019, her TSH was low and became undetectable in 03/2019 with high free T4 and total T3. She developed symptoms of hyperthyroidism. TSI was positive and TSHR Ab was negative. RAIU was low. No iodinated contrast study done prior to I123 scan. In 05/2019 to 08/2019, free T4 and total T3 was normal range with detectable but low TSH consistent with transient resolving thyroiditis. In 10/2019, thyroid hormones significantly increased with recurrence of hyperthyroidism. Both TSI and TSHR Ab were elevated confirming diagnosis of GD. Due to overt thyrotoxicosis, Methimazole (MMI) was initiated in 10/2019. She was briefly lost to follow up and stopped MMI. RAIU scan in 12 /2019 showed increased uptake consistent with GD. MMI was resumed in 04/2020. 06/2020 - 09/2020, MMI dose was titrated to achieve euthyroid state. In 09/25/2020, hypothyroidism was noted which improved with MMI dose reduction. Anti- TPO and Anti-Tg were negative. Pembrolizumab was stopped in 07/2020 due to dilated cardiomyopathy. She completed 2-year course of Pembrolizumab with advanced cervical cancer showing excellent response. Discussion: Observed thyroid dysfunction with ICI, is transient destructive thyroiditis followed by hypothyroidism, which can be permanent. Our patient had an initial low RAIU indicating destructive thyroiditis along with, mildly elevated TSI suggestive of superimposed autoimmune process. The elevated TSI predisposed to later occurrence of GD likely precipitated by Pembrolizumab. MMI provided therapeutic benefit. Conclusion: Less than 10 cases of GD with ICI and 5 cases of GD with Anti-PD- 1 have been reported. Our patient is a second case of persistent hyperthyroidism due to GD induced by Pembrolizumab. GD should be considered if hyperthyroidism persists or recurs in patients on ICI with destructive thyroiditis, which is mostly transient.

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

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.

Thyroid Storm: A Rare Paraneoplastic Syndrome in an Infant With Hepatoblastoma

Abstract Background: Graves disease (GD) is the most common cause of pediatric hyperthyroidism. Thyroid storm (TS) is a rare initial manifestation of GD and is typically triggered by an underlying stressor such as infection, trauma or surgery in a patient with underlying GD and poorly controlled hyperthyroidism. Clinical Case: A previously healthy 21-month-old Hispanic male presented to our ER due to concerns of acute abdominal pain. He was noted to have diffuse abdominal tenderness, unremitting anxiety and mild exophthalmos. Vital signs revealed tachycardia and hypertension. Initial lab evaluation was suggestive of primary hyperthyroidism (TSH&amp;lt;0.02 mcU/mL, n 0.5-4.5 mcU/mL, and free T4 at 5.8 ng/dL, n 0.8-2 ng/dL). His Burch-Wartofsky point scale score was 45, indicating high likelihood of TS. He was aggressively treated with methimazole, potassium iodide and propranolol. Five days later, there was a significant improvement in symptoms and labs (TSH&amp;lt;0.02 mcU/mL, n 0.5-4.5 mcU/mL, and free T4 2.3 ng/dL, n 0.8-2 ng/dL) and he was discharged home on methimazole and propranolol. Interestingly, all thyroid autoantibodies were negative including TSI, TRAb, anti-thyroglobulin and anti-TPO antibodies. His thyroid function continued to improve and propranolol was discontinued. Three weeks after his initial hospital admission, he developed a diffuse urticarial rash and the methimazole was held and propranolol restarted. Within a few days, he developed persistent fevers for which he was readmitted. His total T4 at that time was elevated at 23 mcg/dL (n 4.5-11 mcg/dL) and because the rash was improving, methimazole was restarted. In the following weeks, the patient continued to have intermittent fevers, diffuse waxing and waning rash, decreased activity, and reduced appetite. He was seen by his pediatrician who noted hepatomegaly. Abdominal CT and ultrasound revealed a liver mass (11 x 10 x 10 cm) and a 7 mm peripherally placed pulmonary nodule in the left lower lobe. The patient was admitted to the hematology/oncology unit for further evaluation. He was found to have an elevated alpha-fetoprotein level (AFP) of 43,051 ng/mL, n&amp;lt;6 ng/mL, which was concerning for hepatoblastoma (HB) that was confirmed by tissue biopsy. He was subsequently initiated on neoadjuvant chemotherapy. Methimazole dose requirements gradually decreased with eventual discontinuation 1 week after initiation of chemotherapy. He has remained clinically euthyroid off methimazole for almost 3 months with normal thyroid function. Conclusion: We report an unusual case of transient hyperthyroidism that initially presented as TS in a 21 month old male who was subsequently diagnosed with HB. Paraneoplastic syndromes (PNS) may occur with any tumor. Hyperthyroidism is occasionally associated with non-seminomatous germ-cell tumors with elevated HCG. We believe this is the first report of pediatric thyroid storm as a PNS in HB.

A Grave Case of COVID-19: SARS-CoV-2 Induced Autoimmune Hyperthyroidism

Background: Autoimmune hyperthyroidism also known as Graves’ disease is the leading cause of hyperthyroidism. The pathogenesis of Graves’ disease is still an area of active research. We present a case of Graves’ disease, which developed following SARS-CoV2 infection. Clinical Case: A 43-year-old man with no prior history of thyroid disease, presented for evaluation due to fatigue palpitations, tremors, and hair loss in June 2020. Earlier that month, he was diagnosed with SARS-CoV2 infection and his thyroid function tests (TFTs) during a visit to the emergency department revealed thyroid stimulating hormone (TSH) level of <0.010 mIU/L (0.35-4.94) with a free T4 (FT4) 1.4 ng/dL (0.7-1.5); consistent with subclinical hyperthyroidism. He continued to report palpitations and tremors and further workup was done. A thyroid ultrasound showed two sub-centimeter nodules. A thyroid uptake scan followed, which showed heterogeneous activity in the thyroid gland, (12% and 32% uptake at 6 and 24 hours respectively) with focal increased uptake in the medial lobes, without cold nodules or hot nodules. Repeat TFTs one month later showed a suppressed TSH <0.010 mIU/L, and a normal FT4 1.3 ng/dL. Given suspicion for Graves’ disease, further labs were ordered. Thyroid stimulating immunoglobulin (TSI) were found to be elevated at 173 % baseline (<=140). Thyroid peroxidase (TPO) antibodies and thyroglobulin antibodies were also elevated at 362 IU/mL H* (<=9) and 2 IU/mL H* (<=1) respectively. The overall picture was consistent with evolving early Graves’ disease. Conclusion: Multiple factors are frequently cited in the pathogenesis of autoimmune hyperthyroidism including viral and bacterial infections1 and there have been several reported cases of autoimmune disease related to SARS-CoV2 infection2. This case is one of several emerging cases of autoimmune hyperthyroidism possibly linked to COVID-19.

A Case of HCG-Mediated Hyperthyroidism Related to Metastatic Choriocarcinoma

Introduction: We present a clinical case of a non-seminomatous germ cell choriocarcinoma producing human chorionic gonadotrophin (HCG) and inducing hyperthyroidism. Clinical Case: A 21-year-old male with recently diagnosed metastatic non-seminomatous germ cell choriocarcinoma presented with persistent tachycardia and anxiety. At diagnosis, his β- human chorionic gonadotrophin (β-HCG) was elevated to 6,435 mIU/mL (normal <1 in male) and thyroid-stimulating hormone (TSH) was within normal limits. At presentation, however, his β-HCG increased to 103,229 mIU/mL, TSH was suppressed <0.02 mcIU/mL (normal 0.3-4.7), and free thyroxine was elevated (FT4) 2.6 ng/dL (normal 0.8-1.7). His thyrotoxicosis improved with initiation of methimazole; however, his TSH remained undetectable due to persistently elevated β-HCG levels. His course was complicated by hemorrhagic shock and acute liver injury in the setting of a presumed intraluminal gastric metastasis, necessitating the discontinuation of methimazole. He was continued on steroids to try to minimize T4 to T3 conversion, but ultimately his thyroid hormones uptrended. He became stable enough to tolerate 5 days of chemotherapy, after which his FT4 quickly normalized. Unfortunately, he continued to suffer from vasodilatory shock and ultimately passed away. Discussion: It has been demonstrated that HCG can bind to the TSH receptor and has thyrotropic activity. The development of hyperthyroidism requires HCG levels >200,000 mIU/mL that are sustained for several weeks (1). It is unknown what the prevalence of hyperthyroidism is in choriocarcinoma, but it has been shown to greatly increase when serum HCG levels are greater than >50,000 mIU/mL (2). Conclusion: Hyperthyroidism can be difficult to recognize in patients suffering from cancer as many of the typical symptoms can also be seen with active malignancy. Patients with HCG-secreting tumors should be evaluated for hyperthyroidism and may benefit from treatment until the underlying cause can be managed.

A Million Reasons for Hyperthyroidism. Reporting a Case of Thyrotoxicosis in a Setting of Metastatic Choriocarcinoma

Background: Human chorionic gonadotropin (hCG) induced transient hyperthyroidism is often seen during pregnancy. Other rare causes of beta hCG induced hyperthyroidism include trophoblastic tumors (hydatidiform mole and choriocarcinoma) and in men, germ cell tumors. The mechanism for hCG induced thyrotoxicosis lies in the structural similarity between TSH and hCG molecules leading to the direct stimulation of the TSH receptors. In regard to treatment, while gestational thyrotoxicosis is usually mild, self-limited and does not need medications, the hyperthyroidism of trophoblastic tumors may require antithyroid medications in addition to treating the underlying tumor. Thionamide use is reserved for moderate to severe cases of hyperthyroidism and for presurgical optimization. In our case report, we present a 22-year-old African American female with choriocarcinoma induced thyrotoxicosis requiring thionamide therapy. Clinical Case: A 22-year-old African American female presented to our emergency room after a witnessed generalized tonic-clonic seizure. Her brain CT scan showed a 4 CM mass concerning for AVM malformation with a subsequent brain MRI confirming parenchymal hematoma with surrounding vasogenic edema. Past medical history was significant for molar pregnancy managed with dilation and curettage followed by laparotomy to remove the pelvic mass. Given her history of molar pregnancy, pelvic ultrasound was performed which showed complex heterologous structure of uterine origin concerning for malignancy. Additional imaging studies of the lung, brain, abdomen and pelvis were performed, which showed possible metastasis to the lung, adnexa, and to the brain. Her clinical exam showed heart rate of 130 beats/min with a normal rhythm, fine tremors, aphasia, and a decrease grip strength in her right upper extremity. Her thyroid gland was slightly enlarged with no tenderness. Laboratory tests showed hCG of >1,000,000 mIU/mL, TSH of < 0.01mcU/mL, free T4 of 5.1ng/dL. Her TPO and TSI were negative. With a diagnosis of hyperthyroidism due to trophoblastic disease, she was treated with methimazole and propranolol resulting in rapid clinical and biochemical improvement. Later, left frontal craniotomy and hematoma evacuation was performed with histology confirming the diagnosis of metastatic choriocarcinoma. She was later transferred to a specialized center where she received chemotherapy. Her hCG subsequently dropped down to 699 mIU/mL. Conclusion: We report a rare case of metastatic choriocarcinoma causing symptomatic hyperthyroidism. The diagnosis is made by excluding other common causes of hyperthyroidism and it should be considered in females of childbearing age. Methimazole is an effective agent to control the hyperthyroidism while waiting for treatment of the underlying cancer.

A Rare Case of Thyrotropin Secreting Pituitary Macroadenoma Primarily Treated With Somatostatin Analogue

Introduction/Background: Thyrotropin secreting pituitary adenomas (TSH-oma) are a rare cause of hyperthyroidism. They account for <1% of the cases of hyperthyroidism with a reported incidence of 2.8 per 1 million in Sweden. Diagnosis is suspected by the presence of elevated T4 and T3 in the setting of an unsuppressed TSH level. The presence of large pituitary adenoma is highly suggestive of the diagnosis and can be differentiated from thyroid hormone resistance by elevated alpha subunit and SHBG levels. Trans-sphenoidal surgery is the definitive treatment. Peri-operative medical treatment with somatostatin analogues is indicated to achieve euthyroidism and prevent surgical risks and thyroid storm. The use of somatostatin analogues as a primary treatment for TSH-oma is still under investigation. We hereby report a rare case of TSH-oma where somatostatin analogues successfully resulted in normalization of thyroid function and tumor size reduction. Clinical Case: A 61 years old gentleman with a history of hypothyroidism diagnosed three years before presentation to the Pituitary clinic. He was treated with Levothyroxine. On clinical examination, he had mild tremor and warm sweaty palms with no stigmata of Grave’s disease. The thyroid function test showed elevated free T4 of 3.6 ng/dl (0.9-1.7), elevated free T3 of 8.6 pg/ml (2.0-4.4), and a high TSH level of 9.10 μIU/ml (0.27-4.20). His prolactin level was mildly elevated at 24.8 ng/ml(4.0-15.2). Testosterone, IGF-1, and cortisol levels were normal. An MRI of his pituitary gland showed large pituitary macroadenoma with supra-sellar extension and mild compression of the optic nerve. He had an elevated alpha subunit of 5.6 ng/ml (<1.37) and a high SHBG level of 198 nmol/l(10-80). TSH adenoma was diagnosed and he was planned for trans-sphenoidal surgery. Pre-operative treatment with somatostatin analogue Lanerotide 90 mg monthly injection was initiated. Interestingly normal thyroid function was observed approximately 1 month after his first injection. Repeat MRI showed a considerable decrease in the size of the pituitary macroadenoma. The patient opted to hold on to surgery and to continue on medical treatment. His thyroid function remains normal 15 months after initiation of treatment and his MRI continues to show stable pituitary adenoma. Conclusion: Somatostatin analogues can be used as a primary treatment for thyrotropin secreting pituitary adenomas when the patient is unable or unwilling to undergo surgery. It is use is associated with normalization of thyroid function and in some cases with a reduction in the adenoma size.

Use of Lugol’s Solution in the Management of Complex Graves’ Disease-a Small Case Series

Background: There are currently no clear guidelines for the peri-operative use of Lugol’s solution (LS) as an alternative to conventional anti-thyroid drug (ATD) therapy in patients with complex Graves’ thyrotoxicosis. Clinical Cases: Case 1 is a 44- year-old woman who presented with symptoms of hyperthyroidism and a moderately enlarged goiter due to Graves disease. She was treated initially with Methimazole 45 mg, once daily which was reduced to 30 mg once daily after a week. She subsequently presented to the emergency department with severe anxiety, sore throat, and a high fever. A blood panel showed evidence of profound agranulocytosis due to Methimazole. Methimazole was stopped and she was treated with a 10-day course of LS followed by a semi-elective total thyroidectomy.Case 2 is a 54-year-old old woman who presented with thyrotoxicosis due to Graves’ disease. She was started on Propylthiouracil (PTU) to which she developed hepatotoxicity and the decision was made to stop PTU. Methimazole was substituted to which she developed a severe desquamating rash hence it had to be stopped immediately. She was given a 10 day course of LS followed by semi-elective total thyroidectomy. Conclusion: In both cases, hyperthyroidism was successfully treated with Lugol’s solution and their surgeries were uneventful with full recovery. Although beneficial, Lugol’s Solution may result in adverse effects such as severe hypothyroidism, escape hyperthyroidism and death. These cases highlight the need for evidence based treatment guidelines for the use of Lugol’s solution in complex hyperthyroid cases.

Prevention of Iodinated Contrast Media-Induced Hyperthyroidism in Patients with Euthyroid Goiter

Introduction: Iodinated contrast media (ICM)-induced hyperthyroidism is an underestimated, potentially severe condition; however, its prevention has not been sufficiently investigated. The aim of this study was to evaluate the influence of ICM on thyroid status, the advantages of prophylactic therapy for iodine-induced hyperthyroidism (IIH) in patients with euthyroid goiter and cardiovascular comorbidities, and the association between the incidence of IIH and thyroid volume. Methods: Thirty-six euthyroid patients undergoing procedures involving ICM administration were divided into 2 groups: the first group (n = 13) received prophylactic treatment with thiamazole or thiamazole combined with sodium perchlorate during ICM exposure; the second group (n = 23) did not receive prophylaxis. Thyroid-stimulating hormone levels were evaluated before and after ICM, and thyroid hormone levels were assessed after ICM at different points in time. The morphology of the thyroid was evaluated by ultrasonography. Results: Twenty-one patients (58%) developed hyperthyroidism after ICM. Hyperthyroidism was observed more frequently in the group without prophylactic treatment than in the group with prophylaxis (65 vs. 15%, respectively; p = 0.006). No cases of overt hyperthyroidism were observed in the group receiving thiamazole with sodium perchlorate. IIH persisted for a median time of 52.5 days. Larger thyroid volume was associated with a significantly higher occurrence of ICM-induced hyperthyroidism (p = 0.04). Conclusions: Patients with euthyroid goiter receiving ICM are at risk of developing hyperthyroidism. The occurrence of hyperthyroidism after ICM in euthyroid patients with goiter is higher in those with larger thyroid volume. The frequency of ICM-induced hyperthyroidism in euthyroid patients with goiter is lower in those receiving prophylactic therapy with thiamazole in monotherapy or in combination with sodium perchlorate than in those not receiving prophylactic treatment.

IATROGENIC CHANGES IN THYROID GLAND OF PATIENTS WITH ATRIAL FIBRILLATION AFTER THERAPY WITH AMIODARON

Objective of the study: to analyze the frequency of structural and functional changes in the thyroid gland of the patients with atrial fibrillation who took amiodarone for 12 months on regular basis. The study was based on findings obtained by examining 80 patients (28 women and 52 men) with cardiosclerosis (diffuse and postinfarction), atrial fibrillation and heart failure IIA at the age of 63.5 ± 1.3 years and 15 healthy individuals of the relevant age (62,4 ± 2,4 years) and relevant sex proportions. The main inclusion criterion was the euthyroid state of the thyroid gland before the beginning of antiarrhythmic therapy. To assess the functional state of the thyroid gland, we studied the content of free thyroxine, triiodothyronine, and antibodies to thyroid peroxidase. The examination was carried out before the therapy, and in 3, 6, 9 and 12 months after the beginning of the study during the course of antiarrhythmic therapy. To detect structural changes in the thyroid gland, we used ultrasound scanning. Depending on the prescribed treatment, the participants were divided into the following groups: group I included the patients who received amiodarone in a dosage of 200 mg per day and basic therapy (n = 60); control group involved the patients who received the basic therapy with antiarrhythmic drugs, digoxin and bisoprolol (n = 20). Results. The therapy with amiodarone for a year resulted in thyroid dysfunction in 33.3% of the patients. Hypothyroidism (20.0%) is leading in the structure of amiodarone-associated thyroid dysfunctions; this condition is subclinically manifested in 11.7% of the patients. The development of amiodarone-induced thyrotoxicosis was observed in 13.3% of the patients, and the first cases of hyperthyroidism were detected not earlier than six months. Under the effect of amiodarone in the first months of the therapy, serum levels of free thyroxine may increase, while free triiodothyronine may decrease, therefore there may be a tendency to slightly increased levels of thyroid-stimulating hormone in the first weeks of the therapy. The above changes in laboratory parameters are transient and are not accompanied by the deterioration of the antiarrhythmic action of amiodarone.

Thyroid Disorders in Pregnancy: Role of Routine Antenatal Thyroid Screening

Background &amp; objective:Thyroid disorders are among the common endocrine problems during pregnancy with well-known adverse effects on both mother and fetus. Many of these adverse effects could be prevented or ameliorated by early detection and appropriate treatment of conditions, provided routine antenatal thyroid screening is done. Considering this view, the present study was aimed to find the prevalence of thyroid disorders and their spectrum in pregnancy in order to justify the necessity of routine antenatal thyroid screening.&#x0D; Methods: This cross-sectional study was conducted in the Department of Obstetrics &amp; Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka over a period 1 year from July 2012 to June 2013 on pregnant women to screen for the thyroid disorders in pregnancy. Based on predefined eligibility criteria, a total of 246 pregnant women up to 36 weeks of gestation were consecutively included in the study. A short history with brief physical examination was done followed by collection of blood samples. Thyroid function was assessed by measuring serum levels of thyroid stimulating hormone (TSH). Serum free thyroxin (FT4) level was estimated in 71 cases, where TSH value was deranged. Trimester specific reference range of serum TSH was used to define hypothyroid, euthyroid and hyperthyroid cases. The suspected risk factors were then compared between abnormal and euthyroid groups to find their association with thyroid disorders.&#x0D; Result: The results of the study showed that the overall prevalence of abnormal thyroid function status was 30.9% (hypothyroidism 29.7% and hyperthyroidism 1.2%) based on normal range of serum TSH in different trimesters of pregnancy. Pregnant women with thyroid disorders were generally older than their euthyroid counterparts (p = 0.039). Hypothyroid state was fairly common with advancing gestation (21.3%, 30.3% and 34% in the 1st, 2nd, and 3rd, trimesters respectively). Pregnant women with personal or family history of thyroid disease in the past exhibited a higher prevalence of abnormal thyroid function than those who did not have such history (p = 0.041 and p = 0.044 respectively). Past menstrual irregularity, past history of subfertility or abortion were significantly associated with thyroid disorders (p = 0.042, p = 0.004 and p &lt; 0.001 respectively). Presence of goitre (21.1%) in current pregnancy also showed significant association with thyroid dysfunction (p = 0.001). The risk of developing abnormal thyroid function was observed to be 3.6(95% CI = 1.9 – 6.4) times higher in those who had at least one risk factor than those who did not have any risk factors (p &lt; 0.001). However, a sizable portion (27.6%) of pregnant women without any risk factors developed abnormal thyroid function.&#x0D; Conclusion: The study concluded that one in every three women may have thyroid disorder during pregnancy, primarily hypothyroidism. Adopting risk factor-based screening for thyroid disorders in pregnancy, there is every chance that a substantial number of cases with thyroid dysfunction may be missed. Therefore, routine antenatal thyroid screening is recommended.&#x0D; Ibrahim Card Med J 2020; 10 (1&amp;2): 74-83

Enfermedades tiroideas y embarazo en una unidad de cuidados intensivos. Experiencia 2014-2019

IntroductionPregnant women with thyroid diseases have a high risk of severe complications. Intensive care may improve results. ObjectiveTo determine maternal and perinatal outcomes in patients with thyroid diseases managed in the intensive care unit (ICU). Material and methodsCross-sectional study in 50 pregnant women with thyroid diseases admitted into the ICU between the years 2014 and 2019. Clinical files were consulted for general characteristics, as well as maternal and perinatal outcomes. Statistical analysis: descriptive analysis, Student t test. ResultsTwo groups were identified: patients with hypothyroidism 66% (n=33) and with hyperthyroidism 34% (n=17). When admitted to ICU, 33.33% (11 cases) had uncontrolled hypothyroidism and 76.47% (13 cases) uncontrolled hyperthyroidism, including one case of thyrotoxicosis. The reasons for admission in the group with hypothyroidism were preeclampsia (32%), uncontrolled thyroid disease (10%), and chronic hypertension (8%). In the group with hyperthyroidism, it was preeclampsia (10%), uncontrolled thyroid disease (10%), and chronic hypertension (2%). Differences were found in gestational age (hypothyroidism 31.07±7.47 vs hyperthyroidism 24.52±9.42 weeks, P=.015), and in the time of hospital admission until termination of pregnancy (hypothyroidism 2.30±1.45 vs hyperthyroidism 12.97±3.39 days, P=.033). The children of patients with hyperthyroidism had lower gestational age (P=.015), lower birth weight (P=.011), higher frequency of prematurity (30.76%), need for intensive care (11.54%), and higher birth mortality (11.54%). ConclusionsMaternal and perinatal outcomes of patients with hypothyroidism were satisfactory, but not so in those with hyperthyroidism.