Clinical Hyperthyroidism Research Articles

Thyroid Dysfunction in Postmenopausal Women Attending General Health CheckUp at a Tertiary Care Center in Kathmandu: A Cross-Sectional Study

Introduction: Thyroid disorders are increasingly prevalent, with a higher incidence in women, particularly postmenopausal women. Symptoms of menopause, such as irritability, hot flushes, fatigue, and weight gain, often overlap with those of thyroid dysfunction, complicating diagnosis. Identifying thyroid dysfunction in this population is crucial for improving their overall health and preventing complications like cardiovascular diseases, which are associated with untreated thyroid disorders. Methodology: A hospital-based, retrospective, cross-sectional study was conducted involving 170 postmenopausal women attending a general health check-up at a tertiary care center in Kathmandu. Ethical approval was obtained from the IRC, and data were collected on thyroid function, including the incidence of subclinical hypothyroidism, overt hypothyroidism, subclinical hyperthyroidism, and overt hyperthyroidism. Data were analyzed using SPSS, with descriptive and inferential statistics used to assess the prevalence of thyroid dysfunction and its potential impact on cardiovascular risk and overall health. Results: The average age of participants was 60.59 years. Among the study population, clinical thyroid disorders were observed in 3.53% of participants, with clinical hyperthyroidism at 1.18% and clinical hypothyroidism at 2.35%. Subclinical thyroid disorders were more prevalent, with subclinical hypothyroidism affecting 11.76% and subclinical hyperthyroidism 4.12% of the participants. Conclusion: The study highlights the importance of screening for thyroid disorders in postmenopausal women, as 3.53% of participants had clinical thyroid conditions and 15.88% had subclinical disorders. Early detection and treatment of these conditions are crucial for improving patient outcomes and preventing related health complications.

7404 Evaluation Of Cortisol Reserve And Adrenal Imaging In Patients With Graves’ Disease Before And Six Months After Treatment

Abstract Disclosure: P. Sharma: None. S. Mir: None. S. Mohd Patto: None. A.H. Bhat: None. B. Dar: None. M. Bhat: None. Introduction: There is scarcity of data regarding the effect of thyrotoxicosis on cortisol metabolism and adrenal gland size. An increase in cortisol metabolism can deplete the functional reserve of adrenal cortex and lead to adrenocortical insufficiency even when there is no pre-existing Addison's disease. In developing countries patients with Graves’ disease present in advanced states of thyrotoxicosis. Besides they are also exposed to a variety of environmental stresses such as recurrent febrile illnesses, salt, and water loss due to manual labour in hot and humid climates etc., which can precipitate an adrenal crisis in the presence of compromised adrenal reserve. So present study was undertaken to assess cortisol reserve and adrenal gland size in patients with treatment naive Graves' disease. Objectives- The present study, was undertaken to assess cortisol reserve and adrenal imaging in patients with treatment naive Graves' disease. Specific information in this regard would help alert physicians dealing with clinical thyrotoxicosis in developing countries of tropics to the possibility of co-existing adrenal decompensation and adopt appropriate life saving measures promptly. Material & Methods: We examined 38 treatment-naive Graves' Disease patients at GMC, SSH, Srinagar, Kashmir, INDIA. Basal cortisol and cortisol response to ACTH were measured before and after six months of treatment, alongside adrenal CT imaging. Results: In hyperthyroid state, Graves' patients exhibited significantly lower basal cortisol compared to euthyroid and healthy controls (306 vs. 410 vs. 421 nmol/l, p < 0.05). 23.6% patients had subnormal cortisol response to ACTH(250ug). Those with T3 ≥ 400 ng/dl had lower cortisol response (560±133 nmol/l) and delta cortisol response than T3 < 400 ng/dl (724 ± 294 nmol/l, 213+/-73 vs. 428+/-265 nmol/l). After achieving euthyroid state, cortisol levels improved significantly (410±213 nmol/l vs. 306 ± 103 nmol/l, p < 0.05). Adrenal CT scans in 34 patients was done out of which 19 showed statistically significant increases in gland thickness, width, and AP diameter compared to controls (p < 0.01, p < 0.05. Repeat CT in 26 patients demonstrated resolution of hyperplasia (p < 0.05). Conclusion: Treatment-naive Graves' disease patients have compromised adrenocortical reserve and adrenal gland enlargement. Adrenal changes are reversible after achieving euthyroid state. These findings support steroid supplementation in impending thyrotoxic crisis and highlight a unique feature of reversible adrenal gland enlargement in this context. Keywords: Graves’ Disease, Adrenal hyperplasia, Cortisol reserve. Presentation: 6/3/2024

Prevalence of Thyroid Function Abnormalities and Its Association with Physical Fatigue in First-Year Medical Students

Objective: To estimate prevalence and type of thyroid function abnormalities and explore their associations with physical fatigue in first-year medical students.Methods: This was a cross-sectional observational study comprising of 200 first-year medical students. Demographic details and history of any significant medical illness was asked and noted. Thyroid function tests were conducted on all participants. The prevalence and type of thyroid function abnormalities were documented in all students, and the presence and severity of physical fatigue were assessed on the basis of physical fatigue score. Participants with any kind of thyroid function abnormality were compared with those with normal thyroid function tests for presence and severity of fatigue.Results: Among the 200 students, 144 (72%) were males and 56 (28%) were females, resulting in a male-to-female ratio of 1:0.38. Subclinical hypothyroidism was identified in 9% of students (18 cases), while clinical hypothyroidism was present in 7% (14 cases). Additionally, subclinical hyperthyroidism was detected in 1% of students (2 cases), with no cases of clinical hyperthyroidism reported. Female students were found to be having more thyroid function abnormalities as compared to male students and the difference was found to be statistically significant (p=0.0109). Students with abnormal thyroid function tests (34 cases) had a markedly higher mean FSS score (43.22±4.50) as compared to students with euthyroid (16.85±2.70).Conclusion: Subclinical thyroid abnormalities are prevalent among young individuals, particularly those with physical fatigue. This study revealed a significant link between presence of fatigue and the possibility of thyroid dysfunction.

Hyperthyroidism and hypothyroidism in patients with autoimmune pancreatitis.

The objective of this study is to clarify the clinical features of thyroid dysfunction observed in patients with autoimmune pancreatitis (AIP). We repeatedly examined thyroid function in 74 patients with type 1 AIP (58 males, 16 females; average onset age of AIP 67 years). Clinical and serological findings in patients with thyroid dysfunction were analyzed. During follow-up, clinical and subclinical hypothyroidism were observed in 3 and 17 patients, respectively. Clinical and subclinical hyperthyroidism were observed in 5 and 1 patients, respectively. One patient showed clinical hyperthyroidism followed by subclinical hypothyroidism. All patients with clinical and subclinical hypothyroidism were asymptomatic and required no medical treatment, whereas four patients with clinical hyperthyroidism were symptomatic and received treatment with thiamazole. Frequent hypothyroidism in AIP, which was previously reported, was confirmed. Moreover, in this study, the association between hyperthyroidism and AIP was demonstrated. Hyperthyroidism in AIP may be more clinically significant than hypothyroidism because patients frequently require medical treatment.

Neonatal Hyperthyroidism: Case Report and Literature Review

The onset of Graves' disease during pregnancy exposes the newborn to the risk of neonatal hyperthyroidism due to the transplacental passage of anti-thyroid-stimulating hormone (TSH) receptor antibodies. We report the case of a child whose mother was diagnosed with Graves' disease during pregnancy. Clinical hyperthyroidism appeared only a few days after birth and was confirmed by hormonal tests. Thanks to treatment with synthetic antithyroid drugs, the child's clinical and biological course was favorable. It is essential to systematically screen for neonatal hyperthyroidism in newborns of mothers with Graves' disease, as the absence of immediate clinical signs after birth does not rule out the diagnosis. The pediatrician must be aware of this thyroid condition even in the absence of an identified maternal history, in order to enable rapid therapeutic management.

Effect of Anti-Epileptic Drugs Usage on Thyroid Profile in Egyptian Epileptic Children

Abstract Background AEDs Has been associated with disturbances in thyroid functions. This was studied in adults but there is contradictory data in children especiall newer AEDs. Objective This study aims to compare the effects of conventional and newer AEDs whether mono or polytherapy on thyroid profile in epileptic children. Results This study included 155 children with epilepsy (54.84 % euthyroid, 31.61% hypothyroid, 9.68% subclinical hypothyroid and 3.87 % subclinical hypothyroid) and 78 healthy controls. Epileptic children compliant on AEDS either mono-therapy or poly-therapy are associated with a statistically significant thyroid profile abnormalities (hypothyroidism, sub-clinical hypothyroidism or sub-clinical hyperthyroidism). There was no statistically significant difference between poly-therapy and mono-therapy. Carbamazepine had a statistically significant association with hypothyroidism and valproic acid had a statistically significant association with sub-clinical hypothyroidism. LEV also wa associated with significat thyroid dysfunction. There was no statistically significant difference between those on two AEDS those on three AEDS and those on four or five AEDS. Conclusion AEDs whether older or newer generations can effect thyroid profile. Anti –epileptic drugs whether conventional or new ones are associated with hypothyroidism, sub-clinical hypothyroidism, sub- clinical hyperthyroidism.

Thyroid status in patients with early stages of cancer of various localization

Purpose of the study. To determine the thyroid status of primary cancer patients in the early stages of uterine body cancer, kidney cancer, breast cancer, skin melanoma and lung cancer without a history of endocrine pathology.Patients and methods. The content levels of thyroid-stimulating hormone (TSH), thyroid hormones (THs) T4 and T3 of total and free forms were determined in the blood serum by RIA method in 132 patients with breast cancer, uterine body cancer, lung cancer, kidney cancer and skin melanoma (average age 55 years). The comparison group consisted of practically healthy donors.Results. Only in skin melanoma, serum TSH levels were reduced by 1.5 times (p < 0.05). The T4 content was reduced by 1.4–1.7 times (p < 0.05) in uterine body cancer and kidney cancer, increased in lung cancer patients and 16 % of breast cancer patients by 1.4–1.7 times though (p < 0.05). A 1.3–1.5‑fold low (p < 0.05) T3 level was found in breast cancer, kidney cancer, and skin melanoma, while an 1.6‑fold increase (p < 0.05) was found in uterine body cancer. The revealed changes in THs by the type of clinical hyperthyroidism are an increase of 1.8 times (p < 0.05) FT3 on the background of low TSH in the blood in patients with skin melanoma, and by the type of hyperthyroxinemia in patients with lung cancer and breast cancer, consisting in increased concentrations of T4 and FT3, and with free and total T3 levels in patients uterine body cancer, as well as FT4, without changes in TSH in the blood serum of patients, may be associated with the features of malignant pathology, since it is known that THs are proliferation stimulants and can build up in tumors.Conclusion. The development of a malignant tumor even in the early stages of the disease is perceived by the body as a threat for homeostasis and the response to the occurrence of neoplasm is the reaction of the hypothalamicpituitary-thyroid regulatory axis. As an outcome, patients develop euthyroid disorder syndrome.

Ocular myasthenia gravis and sub clinical hyperthyroidism- a rare occurrence

Ocular myasthenia gravis and sub clinical hyperthyroidism- a rare occurrence

The association between baseline TPOAb and/or TgAb positivity and thyroid immune-related adverse events in patients with malignancies following treatment with immune checkpoint inhibitors

Objective: To investigate the association between positive anti-thyroid peroxidase antibody (TPOAb) and/or anti-thyroglobulin antibody (TgAb) and the occurrence of thyroid immune-related adverse events (irAEs) in patients with malignant tumors who treated with immune checkpoint inhibitors (ICIs). Methods: A case-control study. A total of 116 patients with malignant tumor who received ICIs treatment and underwent thyroid function evaluation at Peking Union Medical College Hospital from January 2017 to April 2023 were enrolled retrospectively, including 77 males and 39 females, with a median age of (M(Q1, Q3)) 63.0 (55.0, 70.0) years. The patients were divided into the euthyroid group (n=58) and the thyroid irAEs group (n=58) according to whether thyroid irAEs occurred after ICIs treatment. The clinical characteristics and baseline anti-thyroid antibodies associated with the occurrence of thyroid irAEs after ICIs treatment in patients with malignant tumors were evaluated. Variables with statistical significance in univariate analysis were included in multivariate logistic regression model to analyze the risk factors for thyroid irAEs in patients with malignant tumors who received ICIs treatment. Results: In irAEs group, therewore 4 (3.4%) cases of clinical thyrotoxicosis, 23(19.8%) cases of subclinical thyrotoxicosis, 23 (19.8%) cases of clinical hypothyroidism, and 8(6.9%) cases of subclinical hypothyroidism. The positive rate of anti-thyroid antibodies at baseline in the thyrioid irAEs group was higher than that in the euthyroid group［16/58（27.6%）vs 3/58（5.2%），P=0.001］. After at least one course of ICIs treatment, the incidence of thyroid irAEs in patients with positive anti-thyroid antibodies at baseline was 84.2% (16/19), whereas it was 43.3% (42/97) in patients with negative anti-thyroid antibodies(P=0.001). Univariate logistic regression analysis showed that gender (OR=2.812, 95%CI:1.257-6.293), baseline thyroid autoantibodies were positive (OR=6.984, 95%CI: 1.909-25.547), baseline TgAb positivity (OR=8.909, 95%CI: 1.923-41.280), and baseline TPOAb positivity (OR=7.304, 95%CI: 1.555-34.308) were associated with thyroid irAEs (all P<0.05). Multivariate logistic regression analysis indicated that baseline TgAb positivity (OR=7.637, 95%CI: 1.617-36.072) was a risk factor for thyroid irAEs (P=0.01). Conclusions: The incidence of thyroid irAEs is higher in patients who are positive for baseline TPOAb and/or TgAb compared to those who are negative for TPOAb and TgAb. Patients with positive TgAb at baseline are at high risk of developing thyroid irAEs.

THYROID FUNCTION ABNORMALITIES IN PATIENTS WITH METABOLIC SYNDROME: AN OBSERVATIONAL STUDY

Objective: The objective of the study is to study the presence of thyroid function abnormalities in cases with metabolic syndrome. Methods: This was a prospective observational study done in the department of biochemistry of a tertiary care medical college. 60 patients fulfilling the criteria for metabolic syndrome as per the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria were included in this study. Demographic details of all the patients were noted. A detailed history was taken and thorough clinical examination was done. Thyroid function test was done in all cases. The presence of thyroid function test abnormalities was analyzed. Statistical analysis was done using SSPS 21.0 software and p&lt;0.05 was taken as statistically significant. Results: Out of these 60 cases, there were 37 (61.67%) males and 23 (38.33%) females with a M: F ratio of 1:0.62. The mean age of male and female patients was found to be 47.96±14.78 and 45.78±13.26 years, respectively. The mean age of male and female patients was found to be comparable with no statistically significant difference. Skin changes were present in 23 (38.33%) cases followed by tiredness (36.67%), constipation (25.00%), weight gain (21.67%), and pallor (15%). 29 (48.33%) were euthyroid whereas subclinical and clinical hypothyroidism was present in 18 (30%) and 10 (16.67%), respectively. 3 (5%) patients were found to have subclinical hyperthyroidism whereas there was no patient with clinical hyperthyroidism. Conclusion: Thyroid function abnormalities are common in patients with metabolic syndrome. It is therefore important to screen patients for thyroid function abnormalities so that appropriate interventions can be undertaken if necessary.

Multiparametric ultrasound-based assessment of overt hyperthyroid diffuse thyroid disease.

Hyperthyroidismis a prevalent condition affecting global populations, with an overall prevalence of 1.2%. Our research aimed to establish a systematic diagnostic approach using multiparametric ultrasound (MPUS) to diagnose hyperthyroid diffuse thyroid disease (DTD). We conducted a retrospective study from June 2021 to June 2023 at a specialized endocrinology center in Timisoara, Romania, enrolling subjects presenting with clinical hyperthyroidism. Using the Mach 30 Aixplorer ultrasound equipment, evaluations were performed initially in B-mode US, followed by Color Doppler and Spectral Doppler measurements, and finally, 2D Shear wave elastography (SWE). From the 218 patients analyzed, the diagnosis of DTD with hyperthyroidism was confirmed through biochemical assessment, subgrouping various pathologies such as subacute thyroiditis, Graves' disease, painless thyroiditis, Hashimoto's thyroiditis, iatrogenic, as well as healthy controls. In the first step, B-mode hypoechogenicity had an AUC of 0.951 for DTD detection. In the second step, the peak systolic velocity differentiated Graves' disease with a median of 42.4 cm/s and an AUC of 1. Lastly, the third step consisted of SWE evaluation, revealing a mean elasticity index in the SAT subgroup significantly higher from other subgroups (p<0.001) with an AUC of 1. Our study offers a step-by-step evaluation algorithm for DTD diagnosis, with a very good overall diagnostic performance (AUC of 0.946).

Increased prevalence of thyroid dysfunction in Tehran – HAMRAH study

BackgroundThe aim of the current study is to assess the prevalence of different categories of thyroid dysfunction and their associated risk factors among the modern urban population of Tehran, the capital of Iran.MethodsThe present investigation is a sub-study of the HAMRAH study, a population-based prospective study designed to assess the prevalence of traditional cardiovascular risk factors and their changes through a 10-year follow-up. 2228 (61% female) adults aged between 30 and 75 years old and with no overt cardiovascular diseases were selected through a multistage cluster randomized sampling. Blood levels of thyroid-stimulating hormone (TSH), thyroxin (T4), and triiodothyronine (T3) were measured with the aim of assessing the prevalence of abnormal thyroid function status among the modern urban Iranian population, and in order to report the total prevalence of participants with clinical hypo- or hyperthyroidism, the number of individuals taking thyroid-related drugs were added to the ones with overt thyroid dysfunction. A subgroup analysis was also performed to determine the associated risk factors of thyroid dysfunction.ResultsThe prevalence of thyroid dysfunction among the total population was 7% (95%CI: 5.9 − 8%) and 0.4% (95% CI: 0.1 − 0.6%) for subclinical and overt hypothyroidism, and 1.6% (95% CI: 1 − 2%) and 0.2% (95% CI: 0 − 0.3%) for subclinical and overt hyperthyroidism, respectively. Clinical thyroid dysfunction was detected in 10.3% of the study population (9.4% had clinical hypo- and 0.9% had clinical hyperthyroidism). In the subgroup analysis, thyroid dysfunction was significantly more prevalent among the female participants (P-value = 0.029).ConclusionsIn the current study, the prevalence of different categories of abnormal thyroid status, and also the rate of clinical hypo- and hyperthyroidism was assessed using the data collected from the first phase of the HAMRAH Study. In this study, we detected a higher prevalence of clinical and subclinical hypothyroidism among the Iranian population compared to the previous studies.

Thyroid Function Status of Female Nurses Working Night-shift at a Tertiary Care Hospital

Background &amp; objective: Night shift work has well-known adverse effects on health like sleep disturbances and other medical conditions including thyroid diseases. Various studies have revealed that the effect of night shift work on healthis mainly related to its interference with circadian rhythm, which can also influence thyroid hormone levels in accordance with sleep patterns. Therefore, night work can modify thyroid function and increase the risk of thyroid disorders. The present study was therefore conducted to evaluate the impact of the night shift work on the thyroid function status of female nurses in a tertiary care hospital. Methods: This case-control study was conducted in the Department of Physiology, Dhaka Medical College, Dhaka over a period of 1 year from January 2021 to December 2021. All female nurses (in the age range of 25-50 years) working at Dhaka Medical College in different shifts were the study population. Of them, the case group consisted of 90 female nurses who worked the night shift in different wards from 8.00 pm. to 8.00 am and the control group consisted of 90female nurses who worked the morning shift in the Outpatient Department (OPD) from 8.00 am to 2.00 pm. However, nurses with a personal or family history of sleep disorder, taking medications that may interfere with sleep, history of diabetes mellitus, bronchial asthma, or diagnosed with any kind of thyroid disease, such as Hashimoto’s thyroiditis, and pregnant nurses were excluded from the study. While the exposure variable was shift-work, the outcome variable was thyroid function status, evaluated in terms of serum FT4, FT3, and TSH and the presence of thyroid disorders. Results: The cases and controls were almost alike in terms of age, BMI, and blood pressure. The mean age of the case and the control groups were between 34 and 35 years with no significant difference between the groups. While serum levels of free thyroxine (FT4) and free triiodothyronine (FT3) were somewhat reduced in the case group than those in the control group, the serum TSH was significantly elevated in the former group than that in the latter group – a picture typical of subclinical hypothyroidism. Overt hypothyroidism was also higher in the former group than that in the latter group. Subclinical and clinical hyperthyroidism was found in 2(2.2%) and 3(3.3%) subjects of the control group only. Overall, 60% of the cases had some form of thyroid disorders as opposed to 15% of the controls with the risk of having thyroid disorders in night shift nurses being &gt; 8(95% CI = 4.1 – 17.5) times higher than that in morning shift nurses(p &lt; 0.001). Conclusions: The study concluded that night shift nurses may have a higher risk of developing subclinical hypothyroidism due to significantly higher levels of TSH and normal FT3, and FT4 levels. About two-fifths of the nurses working night shifts are at increased risk of having thyroid disorders, primarily subclinical hypothyroidism. Ibrahim Card Med J 2022; 12 (2): 40-45

Evaluation of Ultrasonographic Characteristics and Cytopathological Results of Autonomous (Toxic) Thyroid Nodules

Objective: Thyroid nodules are clinical conditions frequently encountered in the community and known to be associated with malignancy. In this study, it was aimed to determine the frequency of malignancy in patients diagnosed with autonomous (toxic) thyroid nodules (TTN). In addition, the effectiveness of ultrasonography (US) findings and fine needle aspiration (FNA) results in helping the diagnosis of malignancy were investigated.&#x0D; Methods: Autonomous (Toxic) thyroid nodule was diagnosed by presence of nodule on US in the presence of subclinical or clinical hyperthyroidism, and detection of suppression in other parts of the gland with increased activity in scintigraphy performed with Tc‐99m pertechnetate. Fine-needle aspiration was performed on patients who were considered suspicious by ultrasonographic findings. The histopathology results of the patients who were found to need surgical resection were recorded.&#x0D; Results: 125 patients with autonomous (toxic) thyroid nodules were included in the study. Of the patients, 82 (65.60%) were female and 43 (34.40%) were male, with a mean age of 63.55±11.13 years. Ultrasonography revealed that nodules were less frequently located in the isthmus and left upper pole. The presence of microcalcification was detected in 8 (6.4%) patients. Histopathologically, the nodules of 2 (1.6%) patients were found to be malignant. Both patients who were found to be malignant were male and their nodules were seen as hypoechoic on US.&#x0D; Conclusions: Since it has been seen that autonomic (toxic) thyroid nodules may be related to malignancy, careful evaluation of male patients with a hypoechoic image on US was considered appropriate.

Exploring the Association Between Thyroid Function and Oral Microbiome Diversity: An NHANES Analysis.

To investigate the association between thyroid functions and the oral microbiome diversity. Data from the US National Health and Nutrition Examination Survey (NHANES; 2009-2012) were analyzed. Thyroid functions were defined using thyroid hormones and related biomarkers. Oral microbiome was measured using the observed number of amplicon sequence variants (ASVs) and the Bray-Curtis dissimilarity. Linear regression was used to estimate the average change (β) and 95% CI for the number of ASVs against thyroid functions, adjusted for sociodemographic variables, health conditions, urinary iodine status, and periodontitis. Non-metric multidimensional scaling (NMDS) was used to analyze the Bray-Curtis dissimilarity. A total of 2943 participants were analyzed. The observed number of ASVs has a weighted mean of 128.9. Self-reported thyroid disease was associated with reduced number of ASVs (β = -9.2, 95% CI: -17.2, -1.2), if only adjusted for sociodemographic variables and health conditions. In the fully adjusted model, compared to normal thyroid function, both subclinical and clinical hyperthyroidism were associated with reduced number of ASVs (β = -59.6, 95% CI: -73.2, -46.0; β = -28.2, 95% CI: -50.0, -6.5, respectively). Thyroid peroxidase antibody level higher than the reference range was associated with higher observed ASV (β= 9.0, 95% CI: 1.2, 16.9). NMDS analysis suggested significant difference in oral microbiome composition between free triiodothyronine groups (P = .002), between free thyroxine groups (P = .015), and between thyroglobulin groups (P = .035). Hyperthyroidism was associated with reduced oral microbiome diversity. Free triiodothyronine, free thyroxine, and thyroglobulin levels may alter the oral microbiome composition.

FRI238 A Rare Combination Of Thyroiditis And Secondary Adrenal Insufficiency Likely Secondary To Hypophysitis In A Patient Treated With Immune Checkpoint Inhibitors

Abstract Disclosure: S. Patel: None. O.A. Aluko: None. E. Thwe: None. T. Gallagher: None. M. Deshmukh: None. Introduction: Immune checkpoint inhibitors have shown significant improvement in treatment of various cancers. Thyroiditis and hypophysitis are well-known reported adverse effects of immune checkpoint inhibitors. However, the co-existence of thyroiditis and hypophysitis in patients treated with immune checkpoint inhibitors is rare. We hereby report a case of a patient with thyroiditis and secondary adrenal insufficiency secondary likely to hypophysitis who was treated with atezolizumab for hepatocellular carcinoma. Case Report: A 65 year old male with past medical history of type 2 diabetes mellitus, hepatocellular carcinoma status post transcatheter arterial chemoembolization on atezolizumab and bevacizumab, thyrotoxicosis, liver cirrhosis secondary to prior alcohol use presented to the ED for evaluation of intermittent dizziness. Vitals signs showed Temperature 97.7°F, BP 137/64 mmHg, HR 82 beats/min, RR 18 breaths/min, SpO2 98%. During the hospital course, work up revealed AM cortisol level of 0.7 μg/dL (N 4.2-22.4 μg/dL), ACTH 33 pg/dL (N 7.2-63.3 pg/dL), TSH &amp;lt;0.007 uIU/mL (N 0.45-4.5 uIU/mL), free t4 3.57 ng/dL (N 0.76-1.46 ng/dL), free t3 6.84 pg/mL (N 2.3-4.2 pg/mL), TSI &amp;lt;0.1 IU/L (0-0.55 IU/L), TRAb &amp;lt;1.1 IU/L (N 0-1.75 IU/L), anti-microsomal antibody &amp;lt;8 IU/mL (N 0-24 IU/mL), anti-thyroglobulin &amp;lt;1 IU/mL (0-0.9 IU/mL). Nuclear medicine uptake scan showed abnormally low 24 hr uptake indicative of thyroiditis in the setting of clinical and biochemical hyperthyroidism. MRI pituitary with and without contrast revealed normal appearing pituitary gland. Patient was subsequently started on prednisolone 30mg in AM and 10mg in PM to treat for thyroiditis as well as secondary adrenal insufficiency likely secondary to hypophysitis. Patient had improvement in symptoms of dizziness on prednisolone. Conclusion: This case highlights the co-existence of endocrinopathies associated with immune checkpoint inhibitor use. Though thyroiditis and hypophysitis are very well associated with immune checkpoint inhibitor use, co-existence of thyroiditis and hypophysitis is rare. This case illustrates the importance of having high index of suspicion for co-existence of endocrinopathies in patients treated with immune checkpoint inhibitors. Presentation: Friday, June 16, 2023

FRI518 Good For Hair, Skin, And Nails But Bad For Thyroid Lab Tests

Abstract Disclosure: S. Khan: None. P. Kachhadia: None. S. Aldasouqi: None. A. Abu Limon: None. Introduction: Biotin also known as Vitamin B7 is very commonly used for hair, skin and nail growth. It can cause falsely high levels of free thyroxine (FT4), and free triiodothyronine (FT3) and falsely low thyroid stimulating hormone (TSH) levels. This can lead to a false diagnosis of hyperthyroidism. The ATA has recommended to stop taking biotin at least 2 days prior to lab testing to avoid spurious results. We present a case of a patient with hypothyroidism on a stable dose of levothyroxine who developed abnormal thyroid function tests (TFTs) due to biotin supplements. Case Presentation: A 57 years old female with long-standing hypothyroidism had been a on stable dose of Levothyroxine, 100 mcg daily. She was compliant with treatment. Her TFTs, done on periodic follow ups every 3-6 months were normal. Recently, on semi-annual lab work, thyroid function tests revealed elevated free T4 and T3, but normal TSH values. The patient was clinically euthyroid. Due to the unexpected thyroid function test result which did not portray clinical hyperthyroidism, repeat detailed history was taken which revealed that the patient was taking Biotin 1000 mg twice daily, as a hair-skin-nail beauty product. TFTs were repeated after she was instructed to stop Biotin for 3 days, which resulted in normal values. Patient was well-educated by our team to stop Biotin before labs, in the future. Once again, close to a year later, TFTs showed elevated FT4 and borderline low TSH. When contacted, she admitted forgetting to stop Biotin before labs. Labs off biotin once more showed normalization of FT4. Discussion: A variety of laboratory immunoassay blood tests utilize Biotin (Vitamin B7) in view of its high affinity to Streptavidin. At physiological concentrations, Biotin does not interfere with thyroid function tests. However, excessive Biotin use which is often taken as a beauty supplement is known to interfere with these tests. Typically, excessive Biotin intake will result in falsely elevated T4 and T3 and falsely low TSH. Furthermore, it will result in falsely elevated immunoglobulins that are markers for Graves’ disease. Our patient was taking a total of 2000mcg of biotin daily over the counter. This interference, which is not uncommon in clinical practice, has led to many misdiagnoses with potential for unnecessary workup, and sometimes initiation of inappropriate or potentially harmful treatment regimens. In this case report, though this patient’s thyroid function test results were suggestive of hyperthyroidism, biotin use is what caused in-vitro interference with the Biotin-Streptavidine Immunoassay. For this reason, clinicians should remain attentive to common biotin use in patients and advise them to hold biotin at least 2 days before labwork to avoid such outcomes. Furthermore, lab centers should also be informed of this interference and should avoid lab draw in those patients did that not hold biotin appropriately. Presentation: Friday, June 16, 2023

FRI257 Adrenal Insufficiency Secundary Due Immune Checkpoint Inhibitors Therapy

Abstract Disclosure: S.R. Rivera: None. J. Valencia: None. E. Figueroa: None. J. Calisto: None. Background: Immune checkpoint inhibitors (ICIs) are new anticancer immunotherapies that can trigger a variety of immune related adverse events (irAEs) in different organs, including the endocrine system. Adrenal insufficiency is uncommon with a nonspecific clinical presentation that must be recognized in time due to its potential mortality. Clinical Case: 41 year old man diagnosed with papillary renal cell carcinoma. He underwent surgery, performing a ​​right radical nephrectomy plus bilateral lymphadenectomy. He started chemotherapy in March 2022 with ICIs, Nivolumab and Ipilimumab. Three months later he presents with myalgias, fatigue and 6 kilogram weight loss. Physical exam: in regular conditions, vital signs with blood pressure 70/40 mmHg, heart rate 84 bpm, with no signs of hyperpigmentation or dehydration. No evidence of clinical hyperthyroidism. Lab results: low ACTH levels: 6.4 pg/ml (9 - 69 pg/ml), low cortisol: 0.06 µg/dl ( 6.02-18.4 µg/dl), low TSH: 0.1 µU/ml ( 0.4- 4.2 µU/ml) and normal free T4: 1.01 ng/dl ( 0.93-1.7 ng/dl). Antibody tests were negative: anti thyroglobulin, anti TPO and TRAB. Normal thyroglobulin levels. Sellar MRI was requested: normal, metastasis were ruled out. Thyroid ultrasound: normal thyroid gland. Exclusion of exogenous use of corticosteroids and levothyroxine was done. Case was interpreted as an adrenal insufficiency due to hypophysitis with associated thyrotoxicosis. Treatment with hydrocortisone was started, while thyroid function progression was observed. In the following lab control, elevation of TSH was noted. Two months later, we documented elevation of TSH levels: 5 µU/ml and decline of free T4 levels: 0.58 ng/dl, starting levothyroxine supplementation. Patient had a favorable clinical evolution. Conclusion: Adrenal insufficiency due to hypophysitis is uncommon and is mostly linked to Ipilimumab use. In those cases pituitary gland MRI is often normal most of the time. Thyroid involvement, which is frequently seen with Nivolumab therapy, varies from thyrotoxicosis, hyperthyroidism and hypothyroidism. Usually produces chronic damage and needs permanent treatment. The potentially lethal nature of these events makes it essential for oncologists and endocrinologists to be aware of these manifestations in order to achieve early treatment. Presentation: Friday, June 16, 2023

A-052 The Importance of Thyroid-stimulating Immunoglobulin (TSI) in the Diagnosis and Follow-up of Marine-Lenhart Syndrome

Abstract Introduction Marine-Lenhart syndrome is a rare cause of hyperthyroidism, occurring in 0.8%–2.7% of patients with Graves’ disease (GD). In this syndrome, GD, which is an autoimmune disease, coexists with one or more hyperfunctioning nodules—Toxic nodular goiter (TNG), or toxic multinodular goiter (TMNG)—which are usually thyroid adenomas. Both induce clinical hyperthyroidism, with suppressed thyroid-stimulating hormone (TSH) and elevated thyroid hormones (TH). Radioactive iodine uptake and thyroid scintigraphy are indicated when there is a nodule on ultrasonography (US) with suppressed TSH, for the differential diagnosis between GD and toxic nodules. However, in this syndrome, scintigraphy does not always define the diagnosis, as the aspects observed do not show the usual pattern. In these cases, it is necessary that a reliable autoimmune thyroid disease marker be performed in order to prove the concomitant autoimmunity. Objectives The aim of this study was to demonstrate the usefulness of thyroid-stimulating immunoglobulin (TSI) for diagnosing hyperthyroidism due to Marine-Lenhart syndrome. Methods The authors prospectively followed 19 patients with suspected Marine-Lenhart syndrome between 2018 and 2020. TSH and TH were measured by Electrochemiluminescence, Roche Diagnostics, and TSI was measured by Chemiluminescence, Siemens Diagnostics. Results All patients had TSH ≤ 0.01 mIU/L, free thyroxine (FT4) was 3.1 ± 0.9 ng/dL, and triiodothyronine (TT3) 312 ± 42.1 ng/dL. All of them had increased radioactive iodine uptake, but the scintigraphy showed nodules sometimes with increased, normo, or low uptake in relation to the adjacent tissue, a finding that is explained by the fact that, both, the nodule and the rest of the thyroid tissue, uptake the radioidine in excess and the pattern varies according to the activity of the DG and nodules in the period in which the test was performed. TSI was 3.98 ± 0.9 IU/L (Negative if &amp;lt;0.55). All patients had positive TSI, confirming concomitant GD with TNG/TMNG. During treatment monitoring, in 14 cases the hyperfunctioning nodules were treated by local sclerosis procedure, with percutaneous injection of ethanol. Despite complete nodular sclerosis, with normal TH but still suppressed TSH, the TSI still remained elevated. This demonstrated that, despite the successful treatment of the nodule, the underlying GD was still active, requiring complementary treatment with antithyroid drugs until TSI was negative, after 18 ± 4 months of treatment. Conclusion In atypical cases of hyperthyroidism, the TSI measurement is decisive for the diagnosis, as in the rare Marine-Lenhart syndrome. This contributes in a relevant way to the definition of the treatment, which can be different between the two causes that occur concomitantly. Likewise, during treatment follow-up, the TSI was essential in defining the need to maintain clinical treatment, even if the nodule had been already adequately treated.

TSH and FT4 Reference Interval Recommendations and Prevalence of Gestational Thyroid Dysfunction: Quantification of Current Diagnostic Approaches.

Guidelines recommend use of population- and trimester-specific thyroid-stimulating hormone (TSH) and free thyroxine (FT4) reference intervals (RIs) in pregnancy. Since these are often unavailable, clinicians frequently rely on alternative diagnostic strategies. We sought to quantify the diagnostic consequences of current recommendations. We included cohorts participating in the Consortium on Thyroid and Pregnancy. Different approaches were used to define RIs: a TSH fixed upper limit of 4.0 mU/L (fixed limit approach), a fixed subtraction from the upper limit for TSH of 0.5 mU/L (subtraction approach) and using nonpregnancy RIs. Outcome measures were sensitivity and false discovery rate (FDR) of women for whom levothyroxine treatment was indicated and those for whom treatment would be considered according to international guidelines. The study population comprised 52 496 participants from 18 cohorts. Compared with the use of trimester-specific RIs, alternative approaches had a low sensitivity (0.63-0.82) and high FDR (0.11-0.35) to detect women with a treatment indication or consideration. Sensitivity and FDR to detect a treatment indication in the first trimester were similar between the fixed limit, subtraction, and nonpregnancy approach (0.77-0.11 vs 0.74-0.16 vs 0.60-0.11). The diagnostic performance to detect overt hypothyroidism, isolated hypothyroxinemia, and (sub)clinical hyperthyroidism mainly varied between FT4 RI approaches, while the diagnostic performance to detect subclinical hypothyroidism varied between the applied TSH RI approaches. Alternative approaches to define RIs for TSH and FT4 in pregnancy result in considerable overdiagnosis and underdiagnosis compared with population- and trimester-specific RIs. Additional strategies need to be explored to optimize identification of thyroid dysfunction during pregnancy.