Chronic Hypothyroidism Research Articles

Autoimmune thyroiditis: an update on treatment possibilities.

Autoimmune thyroiditis (AIT) is due to an autoimmune process that destroys thyrocytes, leading to hormonal disorders. AIT is more common in women, and the aetiology is multifactorial. The destruction of thyroid cells may release free thyroid hormones into the bloodstream, causing hyperthyroid symptoms. With further destruction of thyroid cells, patients develop euthyroidism and eventually chronic hypothyroidism. The diagnosis of AIT is based on clinical symptoms, positive anti-thyroid antibodies, ultrasound, and histological features. The main goal of treatment is correcting hormonal disorders and achieving euthyroidism. Treatment of AIT involves replacing thyroid hormone deficiency with the use of synthetic hormones. Prophylactic levothyroxine (L-T4) treatment of euthyroid patients with AIT may reduce both serological and cellular markers of autoimmunisation. Attention should be paid to the starting dose of L-T4, potential drug interactions, and drug formulation. A follow-up should be planned to determine the optimal dose. The authors highlighted that a healthy lifestyle and supplementing selected vitamins and microelements appropriately are essential. In selected clinical conditions, thyroidectomy should be considered. There are also alternative therapeutic strategies, such as herbal medicine and acupuncture, but their effectiveness has yet to be conclusively confirmed in research studies. Monitoring the thyroid gland enlargement and the possibility of developing nodular goitre is integral to patient care over AIT patients. In conclusion, treating AIT is complex, involving thyroid hormone replacement therapy, taking care of a healthy diet and lifestyle, and proper supplementation. It requires an individual approach. Regular follow-up is necessary to control the disease and minimise its effects.

12393 Myxedema Presenting With Impending Cardiac Tamponade : A Case Report

Abstract Disclosure: A. Hoskote: None. V. Gupta: None. J. Seidenberg: None. The widespread availability of thyroid stimulating hormone (TSH) assays, routine screening and affordable replacement therapy has resulted in decreased prevalence of complications of untreated hypothyroidism. “Myxedema heart” is a rare syndrome that results in bradycardia, cardiomyopathy and pericardial effusion. We present a rare case of cardiac tamponade due to myxedema in a patient with unidentified hypothyroidism. A 49-year-old male was brought to the ER by his family for several weeks of cognitive slowing, weakness and inappropriate behavior involving defecating on himself eating old food and barricading in his room. The patient denied past medical or psychiatric history, medication use or recent physician evaluation. On exam he had macroglossia, was disheveled, forgetful but alert with slow speech, ataxia and muscle wasting. He was afebrile and hemodynamically stable. EKG showed sinus bradycardia. Labs were notable for sodium 133, hemoglobin 8.8g/dL and TSH was incidentally >100U. Levothyroxine was begun. The next day, he was noted to have increased lethargy, bradycardia and hypoglycemia and was transferred to the intensive care unit with concern for myxedema coma. Free T4 was <0.3 ng/dL (0.6-1.6) and free T3 was 1.6pg/mL (2.5-3.9). An echocardiogram revealed a large circumferential pericardial effusion with right atrial and ventricular collapse with tamponade. Treatment with 5 mcg liothyronine, intravenous levothyroxine and stress dose hydrocortisone was begun. A pericardial drain was placed, draining 980mL of sanguineous fluid. After clamping trials, the drain was removed 48 hours later. Labs revealed thyroglobulin <0.1ng/mL (1.6-50), thyroid peroxidase (TPO) antibody 574 IU/mL (<9), thyroglobulin antibody >2500 (<4) and thyroid ultrasound showed a normal sized thyroid gland with heterogenous echogenicity confirming a diagnosis of Hashimoto’s thyroiditis. Serial echocardiograms during the admission and a follow-up two months later showed a stable posterior effusion with no recurrence of the anterior pericardial effusion. Gradually mentation, hemodynamics and electrolyte derangements improved, and he was discharged on oral levothyroxine. TSH values showed sequential improvement to 48U in 15 days and to 11U in 2 months. Myxedema is a manifestation of severe hypothyroidism. The pericardium, a collagen-rich structure, is susceptible to myxedematous infiltration, leading to pericardial effusion. While small pericardial effusions are common with chronic hypothyroidism, a large pericardial effusion with tamponade is a rare life-threatening complication that requires prompt recognition and management. Clinicians must promptly identify myxedema and replace thyroid hormone to prevent progression of pericardial effusion to tamponade, maintaining especially high suspicion in those at risk of poor access to healthcare or inadequate health literacy. Presentation: 6/3/2024

8087 A Case Series on Thyroid Eye Disease Precipitated by the COVID Vaccine in Patients with Long-Standing Primary Hypothyroidism

Abstract Disclosure: R. Hassan: None. J. Islam: None. Background: Thyroid eye disease (TED) is an autoimmune disease characterized by progressive inflammation and damage to the tissues around the eyes, especially extraocular muscle, connective, and fatty tissue. It is most commonly seen in patients with Graves' disease. Less commonly, TED may occur in patients with hypothyroidism. Case Discussion We are presenting a case series on TED precipitated by the COVID vaccine in three patients with known cases of long-standing hypothyroidism. References ranges:TPO Ab: (Ref range: <9.0 IU/mL)TSI: (Ref range: <=1.3 TSI index)TRAb : (Ref range: 0.00-1.75 IU/L)TSH: (Ref range: 0.450-4.500 uIU/mL)Free T4: (Ref range: 0.82-1.77 ng/dL)T3: (Ref range: 87.00 - 178.00 ng/dL) CASE 1: 59 year-old female patient with 18-year history of primary hypothyroidism on levothyroxine who presented with a 5 month history of progressive ocular symptoms of double vision and “puffy eyes” along with other thyrotoxic symptoms. These occurred after receiving her second COVID-19 vaccine. Labs showed elevated TSI and TRAb (3.0, 6.32). TPO antibody was within normal limits at 0.5. Patient had undetectable TSH and free T4 within normal range (162, 1.08). CASE 2: 70 year-old female patient with 25-year history of primary hypothyroidism on levothyroxine who presented with a 4 month history of eye discomfort, eyelid blistering and ocular swelling after she receiving her first dose of COVID-19 vaccine. She was found to have increased ocular pressure per her ophthalmologist. On lab work, she was found to have elevated TSI and TRAb (7.1, 2.60). TPO antibody was within normal limits at 0.8. TSH was undetectable and free T4 were within normal range (159.76, 1.49). CASE 3: 82 year-old female with 30-year history of primary hypothyroidism on levothyroxine who started developing diplopia and proptosis over a 6 month course after she received her first COVID-19 vaccine.Labs showed elevated TSI and TRAb (5.1, 17). Her TPO antibody was within normal limits at 0.4. Her TSH was undetectable, and free T4 was within normal limits (71.76, 1.32). All three patients were started on low-dose methimazole, prednisone, and completed an eight week infusion course of Teprotumumab (Tepezza) with subsequent improvement of proptosis and diplopia. Conclusion Providers should be aware that patients with long standing hypothyroidism, who suddenly require less to no thyroid hormone replacement along with new onset ocular symptoms could be developing TED. This had previously been thought to be solely associated with Graves’ Disease but now has been seen with an uptick in incidence in patients with chronic hypothyroidism during the COVID pandemic. This is likely related to immune response that been associated with vaccines. Presentation: 6/3/2024

Analysis of factors influencing the dose of levothyroxine treatment in adequately controlled hypothyroid patients of different etiologies

ObjectiveThe mainstay therapy of hypothyroidism is levothyroxine (LT4). In most cases lifelong treatment is warranted, therefore, choosing adequate doses are of paramount significance. The purpose of this study was to assess several factors that have been proposed to influence LT4 therapy including etiology of hypothyroidism, gender, age, bodyweight, BMI, concomitant drug use, disease severity and time since diagnosis in patients with stable, adequately controlled hypothyroidism. MethodsIn this cross-sectional study we analysed past medical history, anthropometric data and biochemical parameters reflecting thyroid function of patients with chronic hypothyroidism who were adequately treated (TSH levels in normal range) with LT4 for at least 6 months. Potential predictors of LT4 requirement were evaluated using uni- and multivariate linear modelling. Results191 individuals were enrolled in this study, who were divided into autoimmune (n = 147) and post-surgery (n = 44) groups. Mean age, time since diagnosis and LT4 dose (1.3 versus 1.1 mcg/kgBW) were significantly lower in the autoimmune group. In the post-surgery group age was the only significant (p = 0.016) predictor of LT4 dose. In the autoimmune group BMI (p = 0.001), time since diagnosis (p = 0.023), as well as their interaction (p = 0.012) turned out to be significant predictors of LT4 requirement. ConclusionsOur results implicate the necessity of differentiating between etiologies of hypothyroidism when starting or changing thyroxine replacement therapy. Patient in both groups required significantly lower doses of LT4 replacement, than previous reports suggest, to maintain stable euthyroidism. Distinctly different factors predicted hormone requirement in the two study groups.

The clinical diversity of primary hypothyroidism presenting as a spontaneous ovarian hyperstimulation syndrome.

Ovarian hyperstimulation syndrome (OHSS) usually occurs in patients undergoing assisted reproduction techniques and ovulation induction. Its variant, spontaneous ovarian hyperstimulation syndrome, a potentially life-threatening disorder, is uncommon and only a few cases have been reported in association with hypothyroidism. This study analysed five patients with untreated chronic hypothyroidism presenting with multicystic ovaries, isosexual precocious puberty, and delayed bone age; subsequently, the follow-up and regression of ovarian pathology was assessed. Two patients had presented to the emergency department with menorrhagia and hypotension, of these, one had ovarian torsion at presentation. Three patients presented to the outpatient department: one for evaluation of short stature, one for premature menarche, and another with polycystic ovaries. They were all diagnosed with long-standing, untreated chronic hypothyroidism. There was regression of the size of the cystic ovaries on subsequent follow-up. In all these patients, long-standing hypothyroidism had resulted in ovarian hyperstimulation syndrome. The potentially life-threatening complications of this syndrome may be prevented by careful screening and a strong index of clinical suspicion at the outset. Long-standing, untreated primary hypothyroidism may result in spontaneous ovarian hyperstimulation syndrome. A high index of suspicion is required for an early and accurate diagnosis. The requirement for interdepartmental collaboration between gynaecology and endocrinology departments is essential for the successful management of this life-threatening but easily treatable disorder.

Adherence to thyroid therapy and depressive status among patients with hypothyroidism in the northern of Jordan: A cross-sectional study.

Hypothyroidism is a chronic and progressive medical condition that requires extreme adherence to medication in order to effectively manage the disease. The aim of this study was to examine patients' adherence to their thyroid therapy and their depressive status and their associated predictors. This is a cross-sectional study that was conducted between April and June 2023 using a sample of chronic hypothyroidism patients visiting the Jordan University of Science and Technology Health Center in Irbid, along with the Family Medicine and Endocrine clinic at King Abdullah University Hospital. The 8-item Morisky Medication Adherence Scale (MMAS-8) and Patient Health Questionnaire (PHQ)-2 were used to examine patients' adherence level and mental status. A total of 296 patients were involved in this study. Around 35.5% of the patients found to have high level of adherence. Around 27.4% of the patients demonstrated a low level of adherence. The mean PHQ-2 score for the study sample was 2.00 (SD: 1.7) out of 6. Using a cutoff point of 3, we identified that 29.7% of the patients are at risk of developing major depressive disorder. Patients aged 31 to 50 years and married patients were identified to have higher adherence level compared to other patients (P < .05). This study observed a notable low to moderate level of adherence among patients diagnosed with hypothyroidism in Jordan with regards to their prescribed therapeutic regimen. Furthermore, a significant part of the individuals had a susceptibility to the development of major depressive disorder.

The role of IL-4 −590 (C&gt;T) Gene as diagnostic biomarker of Hashimoto thyroiditis disease patients in AL-Najaf provenance /Iraq

The study of IL-4 genotyping in Hashimoto patients is considered one of the challenges of sustainable development .Hashimoto disease is an autoimmune disease that causes the immune system to attack the cells of the thyroid gland, causing the death of the cells that produce thyroid hormones, and thus leads to chronic hypothyroidism. The aim of current study is to determine the genotyping of IL-4 -590C&gt;T in the DNA of Hashimoto patients and compared with healthy subjects .A 54 blood samples were collected from people with Hashimoto's disease and 25 samples from healthy people during period from March to September of the year 2022 , DNA was extracted from blood using Favorprep Kit, then, using a specific primers for the C and T alleles of interleukin 4-590 C/T, then doubled using Arms PCR. Then, they were transported in agarose gel with the ethidium bromide dye and detected by the gel documentation system , ultraviolet rays use to determine the type of alleles present in each sample and compared with control group. The current study, which includes 50/54 female and 4/54 male with Hashimoto thyroiditis with ages ranged from 20-59 years old, the results show up that the age group 40-49 years were the most affected, Also the body mass index was had increases among patients. CT genotype present in 74% of Hashimoto patients while 16% of control. C allele was found as high rate in both patients and control with percentage 100% and 96% respectively. in conclusion: The Hashimoto patients have more frequency of CT genotyping of IL-4 -590 C&gt;T than control ,while C Allele was high in both Hashimoto patients and controls. The -590 CC genotype in the IL4 gene may consider to be a strong predictive factor for the development of hypothyroidism in HD.

FRI562 Not JUST Severe Hypothyroidism: Recognizing Autoimmune Polyglandular Syndrome

Abstract Disclosure: S.R. Jafarian-Kerman: None. A. Razzeto: None. G. Saini: None. M. Siddiqui: None. M. Islam: None. D. Behman: None. M. Carson: None. Background: Recognizing Autoimmune Polyglandular Syndrome (AIPS) in a patient who has chronic hypothyroidism, specifically with a non-classic presentation, is challenging. Clinical Case: A woman in her 50’s with hypothyroidism presented with one week of progressive dizziness and weakness. Medications include levothyroxine 125 μg weekly (per the patient, her PCP started this dose 8 months ago based on lab results). On physical examination: BP 101/74 mmHg; HR 56 bpm; T: 98.1 F (36.7 C); RR: 23/min; O2 Sat: 98%. Skin: vitiligo. Lab results demonstrated TSH: 839.6 μIU/mL (0.5-4.5) from 0.28 one year ago, free T4: 0.15 ng/dL (0.4-4.5), phosphorus: 2.3 mg/dL (2.7-4.5), vitamin D: 17.4 ng/dL (&amp;gt;30). She was started on daily levothyroxine 125 μg and intravenous fluids. On day 3 of admission, Rapid Response was called for blood pressure 54/39 mmHg. Myxedema coma was unlikely as she lacked altered mental status, hypothermia, hypoventilation, hyponatremia, or hypoglycemia; CT head was normal. On the same day, hydrocortisone 100 mcg q8h started due to high suspicion of adrenal insufficiency given low normal cortisol [7.1 ug/dL (6-20)] and hypotension. Due to the history of hypothyroidism, vitiligo, and the new diagnosis of adrenal insufficiency, we suspected AIPS. two days later, primary adrenal insufficiency was established by a positive Cosyntropin stimulation test (1 hour cortisol of 14.8 ug/dL; not reaching &amp;gt;18 μg/dL), elevated ACTH 72 pg/mL (6-50), Aldosterone &amp;lt;1 ng/dL (3-16), and low DHEA of 52 ng/dL (345-2030). Other labs were as follow: normal FSH 85.7 mIU/mL (23-116), elevated PTH 153 pg/mL (16-77) which decreased to 62 pg/mL with vitamin D supplementation, normal Vitamin B12, and negative renin and intrinsic factor antibodies. A diagnosis of AIPS was established and she was discharged on levothyroxine, fludrocortisone, and hydrocortisone. Conclusion: AIPS is typically idiopathic and may affect endocrine organ systems either simultaneously or sequentially. The 3 classic patterns are: Type 1 (most common): younger women, presents with candidiasis, hypoparathyroidism, and Addison’s disease. Type 2: middle-aged women, Addison’s disease, autoimmune thyroid disease and/or Type 1 diabetes. Type 3: Type 1 diabetes, pernicious anemia, vitiligo or alopecia, and normal adrenal cortical function. This patient is unique in that she has characteristics of both type 1 and 3 AIPS, but not diabetes. In this case, the combination of hypotension even in the setting of profoundly undertreated hypothyroidism, prompted the expanded evaluation. While isolated hypothyroidism is common among our internal medicine patients, those with additional symptoms, or in this case unexplained hypotension, should be evaluated for AIPS. Presentation: Friday, June 16, 2023

Transiently impaired endothelial function during thyroid hormone withdrawal in differentiated thyroid cancer patients.

Endothelial dysfunction, which was associated with chronic hypothyroidism, was an early event in atherosclerosis. Whether short-term hypothyroidism following thyroxine withdrawal during radioiodine (RAI) therapy was associated with endothelial dysfunction in patients with differentiated thyroid cancer (DTC) was unclear. Aim of the study was to assess whether short-term hypothyroidism could impair endothelial function and the accompanied metabolic changes in the whole process of RAI therapy. We recruited fifty-one patients who underwent total thyroidectomy surgery and would accept RAI therapy for DTC. We analyzed thyroid function, endothelial function and serum lipids levels of the patients at three time points: the day before thyroxine withdrawal(P1), the day before 131I administration(P2) and 4-6 weeks after RAI therapy(P3). A high-resolution ultrasound named flow-mediated dilation (FMD) was used to measure endothelial function of the patients. We analyzed the changes of FMD, thyroid function and lipids at three time points. FMD(P2) decreased significantly compared to FMD(P1) (P1vsP2, 8.05 ± 1.55vs 7.26 ± 1.50, p<0.001). There was no significant difference between FMD(P3) and FMD(P1) after restoring TSH (thyroid stimulating hormone) suppression therapy (P1 vs P3, 8.05 ± 1.55 vs 7.79 ± 1.38, p=0.146). Among all parameters, the change of low-density lipoprotein (ΔLDL) was the only factor correlated negatively with the change of FMD (ΔFMD) throughout the RAI therapy process (P1-2, r=-0.326, p=0.020; P2-3, r=-0.306, p=0.029). Endothelial function was transiently impaired in DTC patients at short-term hypothyroidism state during the RAI therapy, and immediately returned to the initial state after restoring TSH suppression therapy.

Case Report on Myxedema Coma Associated with End-Stage Cardiac Disease

Myxedema coma is a critical disorder with high mortality rates. Disruption of the compensatory mechanism for severe and long-term hypothyroidism by various causes leads to serious complications, including hypothermia, respiratory failure, circulatory failure, and central nervous system dysfunction. The most common causes of myxedema coma are thought to include infectious disease, stroke, myocardial infarction, sedative medicines, exposure to the cold and surgery in patients with poorly controlled hypothyroidism. We present a case of an 82-year-old female presented with complaints of loss of speech for 3 days, complaint of easy fatiguability for 3 days, altered sensorium since 1 day, weakness of both upper and lower limbs for 3 days and the patient attenders complaint of that patient is not taking food and difficult in swallowing since 3 days. In spite of the foregoing, patients with decreased mental status who have undergone thyroid surgery or hypothyroidism should be evaluated for myxedema coma. Additionally, this condition may be caused on by chronic hypothyroidism or by experiencing acute precipitating events like sepsis, a cerebrovascular accident, gastrointestinal bleeding, exposure to cold, trauma, or taking certain medications. A high mortality rate was noted, so patients whose myxedema coma is suspected should start receiving treatment right away.

Cardioprotection by Hypothyroidism Is Not Mediated by Favorable Hemodynamics-Role of Canonical Thyroid Hormone Receptor Alpha Signaling.

Hypothyroidism has been shown to reduce infarct size in rats, but the underlying mechanisms are unclear. We used isolated pressure-constant perfused hearts of control, hypothyroid and hyperthyroid mice and measured infarct size, functional parameters and phosphorylation of key molecules in cardioprotective signaling with matched heart rate. Compared with controls, hypothyroidism was cardioprotective, while hyperthyroidism was detrimental with enlarged infarct size. Next, we asked how thyroid hormone receptor α (TRα) affects ischemia/reperfusion (IR) injury. Thus, canonical and noncanonical TRα signaling was investigated in the hearts of (i) mice lacking TRα (TRα0), (ii) with a mutation in TRα DNA-binding domain (TRαGS) and (iii) in hyperthyroid TRα0 (TRα0hyper) and TRαGS mice (TRαGShyper). TRα0 mouse hearts were protected against IR injury. Furthermore, infarct size was reduced in the hearts of TRαGS mice that lack canonical TRα signaling but maintain noncanonical TRα action. Hyperthyroidism did not increase infarct size in TRα0 and TRαGS mouse hearts. These cardioprotective effects were not associated with increased phosphorylation of key proteins of RISK, SAFE and eNOS pathways. In summary, chronic hypothyroidism and the lack of canonical TRα signaling are cardioprotective in IR injury and protection is not due to favorable changes in hemodynamics.

Abstract #1183674: Fluctuating Graves’s disease and Hashimoto’s thyroiditis: a case report

Graves's disease and Hashimoto's thyroiditis are two distinct autoimmune entities with different pathophysiology and treatment. However, they can fluctuate in the same patient at other times. This study aims to present the case of a patient who converted to hyperthyroidism from chronic hypothyroidism and how she was treated.

Identifying multimorbidity clusters in an unselected population of hospitalised patients

Multimorbidity (multiple coexisting chronic health conditions) is common and increasing worldwide, and makes care challenging for both patients and healthcare systems. To ensure care is patient-centred rather than specialty-centred, it is important to know which conditions commonly occur together and identify the corresponding patient profile. To date, no studies have described multimorbidity clusters within an unselected hospital population. Our aim was to identify and characterise multimorbidity clusters, in a large, unselected hospitalised patient population. Linked inpatient hospital episode data were used to identify adults admitted to hospital in Grampian, Scotland in 2014 who had ≥ 2 of 30 chronic conditions diagnosed in the 5 years prior. Cluster analysis (Gower distance and Partitioning around Medoids) was used to identify groups of patients with similar conditions. Clusters of conditions were defined based on clinical review and assessment of prevalence within patient groups and labelled according to the most prevalent condition. Patient profiles for each group were described by age, sex, admission type, deprivation and urban–rural area of residence. 11,389 of 41,545 hospitalised patients (27%) had ≥ 2 conditions. Ten clusters of conditions were identified: hypertension; asthma; alcohol misuse; chronic kidney disease and diabetes; chronic kidney disease; chronic pain; cancer; chronic heart failure; diabetes; hypothyroidism. Age ranged from 51 (alcohol misuse) to 79 (chronic heart failure). Women were a higher proportion in the chronic pain and hypothyroidism clusters. The proportion of patients from the most deprived quintile of the population ranged from 6% (hypertension) to 14% (alcohol misuse). Identifying clusters of conditions in hospital patients is a first step towards identifying opportunities to target patient-centred care towards people with unmet needs, leading to improved outcomes and increased efficiency. Here we have demonstrated the face validity of cluster analysis as an exploratory method for identifying clusters of conditions in hospitalised patients with multimorbidity.

Assessment of the state of the oxidant-antioxidant system and lipid peroxidation in patients with chronic pancreatitis combined with hypothyroidism

Changes in oxidative-antioxidant homeostasis is one of the pathogenetic links in the onset and progression of many nosologies, including chronic pancreatitis (CP) and hypothyroidism (HТ), however, data on the development of oxidative stress (OS) with a combination of CP and HP are insufficient, therefore, determining the role of these systems with a comorbid course of these pathologies is an urgent issue of our time.The aim of the work is to study the state of the oxidative and antioxidant system in patients with CP and CP combined with HT.Material and methods. 96 people were examined, including 26 patients with chronic pancreatitis (group 1), 24 patients with hypothyroidism (group 2), 26 patients with chronic pancreatitis on the background of hypothyroidism (group 3), 20 almost healthy individuals (group 4). Evaluation of the oxidative-antioxidant system and lipid peroxidation was assessed by determining the content of malonic aldehyde in blood plasma (MA pl.) And erythrocytes (MA er.), The level of reduced glutathione, glutathione peroxidase (GP) and glutathione-S-trans-ion (GT). Enzyme activity was calculated per 1 g of hemoglobin (HB).Research results. The analysis of the obtained results revealed clear patterns of changes in the state of the oxidative-antioxidant system and lipid peroxidation in patients with chronic pancreatitis on the background of hypothyroidism. Namely, violation of lipid peroxidation in patients with comorbid pathology, accompanied by an increase in the content of MA er. by 44.87% and the content of MA in blood plasma by 46.42%; oxidative-antioxidant system: decrease in HF in the blood by 51,61%, combined of a compensatory increase in BP - by 48.03% and HT - by 34.76%.Conclusion. Under the conditions of comorbidity of CP and HT, there is a violation of the oxidative-antioxidant system and the state of lipid peroxidation, which is characterized by a significant increase in MA in erythrocytes and MA in plasma against a decrease in glutathione and which complicates the course of the underlying disease, its diagnosis and treatment.

Особливості фібринолітичної та протеолітичної активності плазми крові у пацієнтів з хронічним панкреатитом, поєднаним з гіпотиреозом

The purpose of the study is to analyze the state of proteolytic and fibrinolytic activities of blood plasma in patients with chronic pancreatitis combined with hypothyroidism. Materials and methods. 105 people participated in our study, of which group 1 consisted of patients with chronic pancreatitis (n = 27), group 2 – patients with hypothyroidism (n = 30), group 3 – patients with chronic pancreatitis combined with hypothyroidism (n = 28), group 4 – almost healthy individuals (n = 20). The state of fibrinolytic activity of blood plasma was studied by lysis of azofibrin, followed by determination of total fibrinolytic activity, non-enzymatic fibrinolytic activity and enzymatic fibrinolytic activity. Assessment of the state of the proteolysis system was studied by lysis of azoalbumin (breakdown of low molecular weight proteins), azocasein (breakdown of high molecular weight proteins) and azocol (breakdown of collagen). Results. When analyzing the results of the study, we observe a probable increase in lysis of azoalbumin by 1.89, 1.96 and 2.16 times (p &lt;0.05) in groups 1, 2, 3 compared with the group of almost healthy individuals. In patients with chronic pancreatitis and hypothyroidism, the most pronounced degradation of low molecular weight proteins was observed, which was 13.86% and 9.75% (p &lt;0.05) higher than in the first and second groups. Indicators of azocasein lysis by 52.48%, 56.35% and 95.03% (p &lt;0.05) were found in groups 1, 2, 3 compared with almost healthy individuals. Azocasein lysis was higher by 27.89% and 24.73% (p &lt;0.05) in patients with chronic pancreatitis combined with hypothyroidism than in patients in groups 1 and 2. Azocol lysis was significantly higher by 10.85%, 12.05%, 16.87% (p &lt;0.05) in groups 1, 2, 3 compared with almost healthy individuals. In addition, in patients with comorbid pathology there was an increase in lysis of azocol by 5.3% and 4.3% (p &lt;0.05) compared with the first and second groups. The total fibrinolytic activity of blood plasma was 8.3%, 6.7%, 16.26% (p &lt;0.05) lower in patients of groups 1, 2, 3 compared with almost healthy individuals. Non-enzymatic fibrinolytic activity of blood plasma was 44.89%, 49.64%, 66.27% higher in groups 1, 2 and 3 than in almost healthy individuals. Enzymatic fibrinolytic activity of blood plasma was 44.28%, 42.25%, 90.57% (p &lt;0.05) lower in group 1, 2, 3 compared with the group of almost healthy individuals (p &lt;0,05). There was a decrease in the level of enzymatic fibrinolytic activity of blood plasma by 32.07% and 33.96% (p &lt;0.05) in patients with chronic pancreatitis associated with hypothyroidism compared with participants in groups 1 and 2 without comorbid pathology. Conclusion. The most pronounced changes in proteolytic (increased lysis of azoalbumin, azocasein, azocol) and fibrinolytic (decrease in total, non-enzymatic and enzymatic) activities of blood plasma in patients with chronic pancreatitis associated with hypothyroidism were determined

A RARE CASE OF PAPILLARY FIBROELASTOMA IN THE SETTING OF MYXEDEMA COMA: DISEASE ASSOCIATIONS AND MANAGEMENT RECOMMENDATIONS

TOPIC: Cardiovascular Disease TYPE: Fellow Case Reports INTRODUCTION: Papillary fibroelastomas are rare and arise through an overgrowth of intracardiac endothelium; pathogenicity varies based on their size, proximity/adherence to valvular structures and the presence of comorbid diseases. Separately, myxedema coma is a known complication of chronic hypothyroidism and classically manifests with altered mentation, bradycardia and hypothermia. And while each is rare individually, these conditions are likely interconnected. CASE PRESENTATION: A 64 year-old female with a history of hypothyroidism presented to the hospital after being found unresponsive at home. Initial assessment under emergent care demonstrated an intact airway but a generally unresponsive patient; hemodynamics were significant for a heart rate of 57, temperature of 95.7 degrees Fahrenheit and respirations of 11 per minute. Laboratory studies were normal apart from a thyroid-stimulating hormone of 126 with a T4 of <0.25. Suspecting myxedema coma, providers placed the patient empirically on intravenous levothyroxine as well as corticosteroids, which led to an expected TSH down-trend and improved mentation. Seven days later, however, the patient again became altered, prompting magnetic resonance imaging of her brain, which demonstrated embolic strokes affecting multiple vascular territories, suggesting a central source. Subsequent transthoracic echocardiography revealed a dense, mobile structure on the aortic side of the left cusp measuring 0.37 cm, most consistent with a fibroelastoma. Definitive surgical intervention in the form of fibroelastoma resection and resuspension of the AV commissures was performed but the patient declined post-operatively after a Vfib arrest, ultimately prompting the family to pursue comfort measures. DISCUSSION: Although a rare entity, there is data in the available literature to support an association between myxedema coma with papillary fibroelastoma. One group under Suzuki et al. suggested that EMO syndrome, which consists of exophthalmos, myxedema of the pretibial region and osteoarthropathy, may itself contribute to the development of fibroelastoma. Researchers here specifically noted that, on microscopic analysis, Alcian blue-positive mucinous regions were found in both the pretibial soft tissue and resected fibroelastoma of their patient. And again while uncommon clinically, this phenomenon may suggest an infiltrative process into exta-thryoidal soft/cartilagenous tissues in states of systemic thryoid-mediated stress. CONCLUSIONS: The presence of aortic valvulopathy in pre-existing states of hypothyroidism, particularly in myxedema, should at minimum raise suspicion for papillary fibroelastoma. If confirmed, fibroelastomas must be resected while maintaining patient's hemodynamic stability and thyroid hormone metabolism. Tissue from both the tumor and from any suspected extra-thyoroidal sites should also be sampled and cross-compared on histopathology. REFERENCE #1: Gopaldas RR, Atluri PV, Blaustein AS, Bakaeen FG, Huh J, Chu D. Papillary fibroelastoma of the aortic valve: operative approaches upon incidental discovery. Tex Heart Inst J. 2009;36(2):160-163. REFERENCE #2: Suzuki H, Shimura H, Haraguchi K, Harii N, Endo T, Hosaka S, Yoshii S, Tada Y, Onaya T. Exophthalmos, pretibial myxedema, osteoarthropathy syndrome associated with papillary fibroelastoma in the left ventricle. Thyroid. 1999 Dec;9(12):1257-60. doi: 10.1089/thy.1999.9.1257. PMID: 10646668. REFERENCE #3: Kurmann RD, El-Am EA, Sorour AA, Ahmad A, Lee AT, Scott CG, Bois MC, Maleszewski JJ, Klarich KW. Papillary Fibroelastoma Growth: A Retrospective Follow-Up Study of Patients With Pathology-Proven Papillary Fibroelastoma. J Am Coll Cardiol. 2021 Apr 27;77(16):2154-2155. doi: 10.1016/j.jacc.2021.02.027. PMID: 33888255. DISCLOSURES: No relevant relationships by Samuel Reynolds, source=Web Response

Prospects for the use of thyroid hormones in patients with heart failure

Thyroid hormone therapy in the setting of heart failure is still an «open book» today. There are several unanswered questions: the regimen, doses and schedule of the use of thyroid hormones, the consequences of such therapy. At the same time, the presence of a comorbid pathology of the thyroid gland, which requires the appointment of levothyroxine, allows one to partially answer these questions. Thyroid hormones affect the diastolic and systolic functions of the myocardium. Ventricular contractile function is also affected by changes in hemodynamic conditions secondary to thyroid hormones and peripheral vascular tone. Thyroid hormone homeostasis maintains a positive ventricular-arterial ratio, resulting in a favorable balance for heart function. Experimental studies in rats have shown that chronic hypothyroidism alone can eventually lead to heart failure. Other studies suggest a decrease in the level of free triiodothyronine in the myocardium after myocardial infarction or with arterial hypertension due to the activation of type 3 deiodinase, which leads to deactivation of triiodothyronine and thyroxine. To address these issues, the researchers propose conducting multicenter, randomized, placebo-controlled trials to evaluate the effects of thyroxine replacement in patients with chronic heart failure. The review highlights the growing body of evidence from animal studies and small clinical trials that suggests that low thyroid activity at the cardiac tissue level can negatively affect the progression of heart failure and that treatment with thyroid hormones can lead to an improved prognosis.

Clinical Characteristics of Patients with Pericardial Effusion

Background: Pericardial effusion (PE) is one of the common pericardial diseases in our population with its associated morbidity and mortality. Our study aims to evaluate the clinical characteristics of patients with PE from eastern region of Nepal.&#x0D; Materials and Methods: A descriptive cross-sectional study carried out in tertiary care center in eastern region of Nepal from March 2019 to February 2020. A total of 45 cases of PE were enrolled by convenient sampling method. Diagnosis was made based on clinical history, examination, and relevant laboratory investigations. Data was entered in Microsoft excel 2007 and converted into IBM SPSS data editor, version 20.&#x0D; Results: Forty five patients were included with mean age of 55.36 ± 16.38 years. Twenty seven patients (60%) were male and 18 (40%) were female. Hypertension was present in 12 (26.7%) and diabetes mellitus in 13 (28.9%). Mean serum hemoglobin was 10.85 ± 2.09 gm/dl. Chronic kidney disease (Uremia), tuberculosis and hypothyroidism were the common causes of PE. Common clinical symptoms were dyspnea, fever, and cough and chest pain. Moderate to large pericardial effusion was noted in 21 (46.7%) of patients. Cardiac tamponade was present in 6 (13.3%). Twenty seven patients (60%) patients underwent pericardiocentesis.&#x0D; Conclusion: Chronic kidney disease, tuberculosis and hypothyroidism were the common causes of PE with male predominance. Dyspnea was the most common presenting symptom. Cardiac tamponade was relatively less common.

Thyroid storm, clouds and silver linings

J Oral Med Oral Surg 2021;27:35 Letter to the Editor Thyroid storm, clouds and silver linings John Laszlo* London, UK * Correspondence: jonlaszlo@hotmail.com Received: 9 April 2021 Accepted: 13 April 2021 Dear Editor, In addition to the use of personal protective equipment (PPE), significant interest has developed recommending topical application of Povidone Iodine (PVP-I) for pre-exposure prophylaxis (PEP) against COVID-19 transmission. PVP-I is safe, demonstrating a 99.9% reduction in MERS and SARS activity, far greater than chlorhexidine or benzalkonium-chloride [1]. As oral and nasal fluids contain greater than 107 COVID-19 viruses per mL, PVP-I is a theoretically useful PEP adjunct with PPE. However, the evidence for using PVP-I as PEP, is neither clear nor clinical, extrapolations were made assuming Covid-19 will be just as susceptible to PVP-I in-vivo, as MERS and SARS were in-vitro [1]. Placing those concerns aside, 15% of the population with Thyroid disease are excluded from PVP-I use, but a similar proportion, who are as yet undiagnosed for thyroid disease remain at physiological risk from inadvertent exposure to iodine in PVP-I [2]. In healthy patients, iodine exposure initiates the Wolff-Chaikoff effect;transiently reducing thyroid hormone levels and this is a valuable response to control hypermetabolic morbidity and mortality from the thyroid storm [3]. However, for patients with unrecognised thyroid dysfunction, iodine exposure can either lead to chronic hypothyroidism with no adaptation to Wolff-Chaikoff down-regulation, or it can lead to the Jos-Basedow phenomenon and critical thyroid storm initiation from a loss of negative feedback [3]. Therefore the 15% of patients excluded from PVP-I use are not placed at risk but those patients undiagnosed as yet not recognised as having a thyroid dysfunction will be placed at risk if exposed to PVP-I. If the bidirectional relationship between thyroid disease and kidney function is considered with regard to renal drug excretion;the association of cardiovascular and psychiatric illness with underlying and undiagnosed thyroid disease is problematic. With such patients, the risk of adverse pharmacokinetic drug interactions demands even closer attention if we are to use PVP-I for any patient. Given the positive relationship of thyroid function with RAAS (renin-angiotensin-aldosterone-system), the potential to amplify ACE 2 expression with PVP-Iodine exposure could increase COVID-19 infection risk as more ACE 2 receptors become activated and the potential for viral cellular entry increases [4]. Thyroid disease exhibits a 10:1 female to male predisposition [2], whereas the morbidity and mortality from COVID-19, with equal infectivity is predominantly male. Using PVP-I as PEP may be intuitive, but paradoxically counter-productive;as a greater risk of infection arises in patients more at risk from the effects of COVID-19 by using PVP-I. With 37 isotopes and as many molecular formulations, iodine has many benefits, for example;Silver-Iodide can precipitate rainfall and disinfect surfaces, but there are environmental and medical risks too. To realise the full PEP potential of PVP-I against COVID-19, the theoretical concerns outlined above require further analysis. Thyroid patients are not at increased risk of morbidity and mortality from COVID-19 [5] and this silver lining in a nebulous cloud of PEP should be recognised when considering measures that could potentially do more harm than good.

PREVALENCE OF ASYMPTOMATIC BACTERIURIA AMONG WOMEN WITH DIABETES MELLITUS - A PROSPECTIVE CROSS-SECTIONAL STUDY

Background: There are many studies demonstrating the risk factors of asymptomatic bacteriuria (ASBU) in diabetic women. ASBU is a well-established risk factor for frequent urinary tract infections (UTIs) in women, and the risk factors that predispose diabetic women to ASBU has to be further evaluated. Aim: To estimate the prevalence of asymptomatic bacteriuria among women with diabetes mellitus .To verify if there is a correlation between bacteriuria and the duration of diabetes and also the correlation between bacteriuria with the metabolic control of diabetes. Materials And Methods: Patients who were admitted in Sree Mookambika Institute of Medical Sciences, Kulasekharam from February 2019 to November, 2020 were included in our study. Two hundred women with diabetes mellitus were enrolled in the study. A control group of 75 healthy women were randomly selected without diabetes was also evaluated in the same period.All relevant clinical information, data was collected. Patients were categorised into variables and mean, SD, Levene’s test of homogeneity of variance, linear regression was calculated. Results: 200 diabetic women were included in our study and 75 healthy women were selected as control. 150 patients were included in the study out of which 95 were males and 55 were females 40% had unstable Angina, 7% had NSTEMI and 53% had STEMI. prevalence of anaemia was 50% of the study population. Anaemia varied according to gender and was more in women 70.9% when compared to men 27.3%. Anaemia was also found to be higher in higher age groups and was more in patients with associated co morbidities such as chronic kidney disease,hypothyroidism and diabetes . Anaemia patients were also found to have more incidence of unstable angina when compared to other forms of ACS. The most common anaemia found was Microcytic hypochromic iron deficiency anaemia 32%. Out of those with iron deficiency, upper GI bleed was the most common cause in our patients. Triple Vessel Disease (TVD) patients were also found to have more incidence of anaemia than those with DVD and SVD. Conclusion: Urinary tract infection is one of the major disease burden for many patients having diabetes mellitus. Asymptomatic bacteriuria (ASB) is several-fold more common among diabetic women than healthy women. The risk of asymptomatic bacteriuria increases with increasing age. The duration of diabetes mellitus has significant correlation with development of asymptomatic bacteriuria among diabetic women. A significant impairment of metabolic control of diabetes shows an overall increase in the risk of developing asymptomatic bacteriuria. Keywords: Asymptomatic Bacteriuria, Diabetic Women, UTI