Clinical Hyperthyroidism Research Articles

Associations of maternal iodine status and thyroid function with adverse pregnancy outcomes in Henan Province of China

ObjectiveThe study aimed to explore the effects of maternal iodine status and thyroid diseases on adverse pregnancy outcomes. MethodsA prospective study was conducted on 2347 pregnant women, who provided 2347 urinary samples tested for iodine, 1082 serum samples tested for thyroid function, and 2347 questionnaires about demographic information. Their pregnancy outcomes were recorded and compared between different urinary iodine concentration (UIC) and thyroid function groups. ResultsPregnant women with UIC between 150 and 249 μg/L had lower incidences of preeclampsia (adjusted odds ratio (OR) 0.12, 95% CI: 0.01-0.87), placenta previa (adjusted OR 0.06, 95% CI: 0.01-0.69) and fetal distress (adjusted OR 0.10, 95% CI: 0.02-0.64) than the reference group (UIC < 50 μg/L). Women with UIC between 100 and 149 μg/L had lower risks of abnormal amniotic fluid (adjusted OR 0.32, 95% CI: 0.12-0.87) and fetal distress (adjusted OR 0.08, 95% CI: 0.01-0.82). Women with UIC above 249 μg/L had a significant higher rate of abnormal amniotic fluid (adjusted OR 0.38, 95% CI: 0.16-0.89). Clinical and subclinical hypothyroidism during pregnancy increased the risk of preterm delivery by 4.4 times (P = 0.009) and 3.0 times (P = 0.014), respectively. Isolated hypothyroxinemia had increased odds of having macrosomia (adjusted OR 2.22, 95% CI: 1.13-4.85). Clinical hyperthyroidism was significantly associated with miscarriage (adjusted OR 2.12, 95% CI: 1.92-96.67) and fetal distress (adjusted OR 9.53, 95% CI: 1.05--81.81). Subclinical hyperthyroidism had a significant association with umbilical cord entanglement (adjusted OR 3.82, 95% CI: 1.38-10.58). Isolated hyperthyroxinemia was associated with preterm delivery (adjusted OR 4.73, 95% CI: 1.49-15.05). ConclusionsMaternal iodine status and thyroid diseases during pregnancy were associated with adverse pregnancy outcomes.

Analyzing Thyroid Dysfunction in the Climacteric.

Introduction:Perimenopause and menopause is an integral part of every woman's life constituting about 30% of the Indian female population. Hypothyroidism is a condition that can mimic menopausal symptoms very often. Therefore, routine screening of thyroid function in the climacteric and menopausal period to determine subclinical thyroid disease can be recommended.Materials and Methods:With this background, we conducted a prospective study in our institute, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, to evaluate the abnormal thyroid function tests in perimenopausal and postmenopausal women aged 40–80 years.Results and Observations:Subclinical hypothyroidism status increases from the age group of 40–70 years and hypothyroidism increases in slow frequency from 40 to 70 years after that there is plateauing. Interestingly, the frequency of hyperthyroidism remains same in all the age groups.Conclusion:Looking at the increased risks of thyroid disorders with age, screening of thyroid disorders can be started at the age of 40 years with estimation of serum levels of TSH. This gives us the opportunity to treat both subclinical and clinical hypothyroidism and hyperthyroidism women.

Pancytopenia in an untreated patient with toxic multinodular goiter

Background: Thyroid abnormalities may be the cause of unexplained pancytopenia. Routine hematologic evaluation should be performed before administration of anti-thyroid drugs in cases of clinical hyperthyroidism, to clarify any occurrence of unexplained pancytopenia. Case Presentation: An 82-year-old woman presented to the emergency department with general weakness, palpitations, excessive sweating, and weight loss. A complete work-up suggested the existence of hyperthyroidism due to toxic multinodular goiter with depletion of all three cell lines in peripheral blood count. Abdominal ultrasonogram showed no abnormal findings, including hepatosplenomegaly. Normocellular marrow was noted in bone marrow aspiration and biopsy. Conclusion: A combined drug therapy with methimazole 30 mg/day, parenteral dexamethasone 8 mg/day, beta-blockers, and digoxin was administered to the patient. Free Triiodothyronine (FT3) and Free Thyroxine (FT4) levels decreased gradually and pancytopenia improved within 2 weeks of treatment.

Newborn of mothers with Graves' disease

The most frequent cause of congenital hyperthyroidism is maternal Graves' disease (GD), in which thyroid stimulating hormone (TSH) receptor antibodies (TRAb) cross the placenta and stimulate the fetal and/or neonatal TSH receptor to produce thyroid hormones. Thyroid dys function in these patients is confirmed by increased thyroxine (T4) and triiodothyronine (T3) levels accompanied by suppressed TSH levels. To characterize the clinical and biochemical evo lution of newborns of mothers with GD and to suggest recommendations regarding treatment and follow-up. A literature review using the MEDLINE database was made, iden tifying scientific articles that included more than 30 neonates of mothers with GD and described their evolution. In addition, a review of the topic with an emphasis on the evaluation and management of these patients was included. Nine cohort studies were included, with a total of 790 pregnant women. There was high heterogeneity among the studies. A variable percentage of newborns deve loped neonatal thyrotoxicosis, which was more frequent in those patients whose mothers had high levels of TRAb. The treatment of newborns was initiated according to different criteria. The literature recommends treating cases of clinical hyperthyroidism and considers it in cases of biochemical hy perthyroidism. Children of mothers with GD and high TRAb should be evaluated due to the likelihood of developing neonatal thyrotoxicosis. It is suggested to monitor thyroid function periodically during the first month of life and treat patients with clinical and biochemical hyper thyroidism.

The main autoimmune and nonautoimmune etiologies of endogenous hyperthyroidism do not seem to influence the increased prevalence of morphometric vertebral fractures and osteoporosis in Portuguese men

ObjectivesThe purpose of this study was to evaluate the effects of hyperthyroidism and their etiology on bone mineral density (BMD), on body soft tissue composition, on the prevalence of vertebral fractures detected by vertebral fracture assessment (VFA) and on the trabecular bone score (TBS). MethodsFrom an initial population of 119 Portuguese men (78 with hyperthyroidism [HT]+ 41 controls [CTs]) admitted to the Endocrinology Department we selected 41 men aged over 50 with clinical hyperthyroidism to participate; each one was matched by age and height with a control person. BMD (g/cm2) at the lumbar spine, hip, radius 33% and whole body and the total body masses (kg) were studied by dual-energy X-ray absorptiometry (DXA). VFA with Genant semiquantitative method was used to detect fractures. The TBS was obtained from lumbar spine DXA images. No patient had been treated previously for hyperthyroidism or osteoporosis. Adequate statistical tests were used. ResultsIn the hyperthyroidism group, total lean mass (CT 58.16 ± 7.7 vs. HT 52.3 ± 5.7, P = 0.03) and distal radius BMD (CT 0.769 ± 0.05 vs. HT 0.722 ± 0.08, P = 0.005) were lower; there was a significantly higher prevalence of osteoporosis (CT 9.7% vs. HT 29.3%, P = 0.015) and vertebral fractures (CT 2.4% vs. HT 24.4%, P = 0.007). TBS was similar in both groups (CT 1.328 ± 0.11 vs. HT 1.356 ± 0.11, P = not significant). Comparing patients with Graves' disease with patients with toxic goiter, there were no differences regarding BMD, BMD qualification, prevalence of fractures and TBS and just total lean mass was significantly lower in patients with Graves' disease. ConclusionsThese results suggest that in a group of hyperthyroid men aged over 50 there are significant decreases in cortical bone BMD and lean mass and a higher prevalence of osteoporosis and silent vertebral fractures, but the etiology of the hyperthyroidism does not seem to influence it. Besides the antithyroid drugs, some patients may benefit from bone-directed treatments.

Molar pregnancy and thyroid storm - literature review

Abstract Molar pregnancies results from a tainted fertilization process. Trophoblastic thyroidian hyper function is an unusual complication of a molar pregnancy. The degree of thyroid stimulation and the severity of clinical hyperthyroidism is directly proportional to HCG concentration. Human chorionic gonadotrophin is almost identical with TSH, luteinizing hormone (LH) and follicle-stimulating hormone, this analogy in the structure will cause cross-reactivity with their receptors. Hyperthyroid status can vary from asymptomatic hyper function to thyroid storm. Dilation and curettage represents the treatment for hyperthyroidism in molar pregnancy. Awareness of this condition is important for diagnosis and treatment.

Thyrotoxicosis induced by excessive 3,5,3′-triiodothyronine in a dog

CASE DESCRIPTION A 7-year-old castrated male Havanese was evaluated at a veterinary teaching hospital because of a 12-week history of hyperactivity, aggression, and progressive weight loss despite a healthy appetite. CLINICAL FINDINGS Tachycardia was the only remarkable finding during physical examination. Serum 3,5,3'-triiodothyronine (T3) and free T3 concentrations were markedly increased, and thyroxine (T4), free T4, and thyroid-stimulating hormone concentrations were at or decreased from the respective reference ranges. Thyroid scintigraphy revealed suppressed uptake of sodium pertechnetate Tc 99m by the thyroid gland but no ectopic thyroid tissue, which was indicative of thyrotoxicosis induced by an exogenous source of T3. TREATMENT AND OUTCOME The dog was hospitalized for 24 hours, and its diet was changed, after which the clinical signs rapidly resolved and serum T3 and free T3 concentrations returned to within the respective reference ranges. This raised suspicion of an exogenous source of T3 in the dog's home environment. Analysis of the commercial beef-based canned food the dog was being fed revealed a high concentration of T3 (1.39 μg/g) and an iodine (82.44 μg/g) concentration that exceeded industry recommendations. No other source of T3 was identified in the dog's environment. CLINICAL RELEVANCE To our knowledge, this is the first report of clinical thyrotoxicosis in a dog induced by exogenous T3, although the source of exogenous T3 was not identified. This case highlights the importance of measuring serum T3 and thyroid-stimulating hormone concentrations in addition to T4 and free T4 concentrations when there is incongruity between clinical findings and thyroid function test results.

Evaluation of interrelationships between thyroid function, autoimmunity, insulin resistance and lipid profile in Graves' disease

Introduction: Thyroid hormones modulate the lipoprotein and glucose metabolisms. In hyperthyroidism, insulin resistance is a frequent finding. The aim of our study was to assess the interrelationships between thyroid function, autoimmunity, lipid profile, glucose metabolism and other cardiovascular risk factors in patients with Graves’ disease. Material & Methods: We recorded free T3, free T4, TSH, TSH receptor antibodies, parameters of the lipid profile, glucose metabolism (including insulin resistance markers like homeostasis model assessment for insulin resistance - HOMA-IR), C reactive protein and homocysteine in 126 patients with Graves’ disease in the first cycle of treatment with methimazole (92.9% females, mean age 44.9 ± 15.2 years). Patients were divided in subgroups according to: TSH receptor antibodies [positive (n = 57) or negative (n = 69)] and thyroid function [euthyroidism (n = 74), subclinical (n = 29) or clinical hyperthyroidism (n = 22)]. Spearman correlations, t-tests and Mann-Whitney tests were performed for statistical analysis. Results: Comparing the positive and negative TSH receptor antibodies groups, significantly lower apolipoprotein B (80.3 ± 23.9 vs 89.7 ± 23.8 mg/dL; p = 0.047) and TSH [0.180 (0.002-1.080) vs 1.020 (0.235-2.055) μUI/mL; p < 0.001] were found in the positive TSH receptor antibodies group. Comparing with the normal thyroid function group, patients in the clinical hyperthyroid group presented significantly lower apolipoprotein B (70.9 ± 25.8 vs 89.8 ± 24.0 mg/dL; p = 0.007] and higher fasting glucose (96.0 ± 24.4 vs 86.4 ± 10.0 mg/dL; p = 0.019), insulin [10.4 (6.2-15.8) vs 7.5 (4.8-9.7) μUI/mL; p = 0.021], HOMA-IR [2.09 (1.29-4.53) vs 1.55 (0.96-2.13); p = 0.023] and C reactive protein [0.57 (0.20-0.93) vs 0.20 (0.07-0.38) mg/L; p = 0.005]. No significant differences were found between the subclinical hyperthyroid and the normal groups. There was a negative correlation between TSH and the TSH receptor antibodies (r = -0.386; p < 0.001). Apolipoprotein B was positively correlated with TSH (r = 0.236; p = 0.016), and negatively with the TSH receptor antibodies (r = -0.211; p = 0.030). Both free T3 and free T4 were positively correlated with fasting insulin (r = 0.268; p = 0.008 and r = 0.226; p = 0.025, respectively) and HOMA-IR (r = 0.258; p = 0.010 and r = 0.259; p = 0.010, respectively). Free T4 was also positively correlated with fasting glucose (r = 0.269; p = 0.008). Conclusion: In patients with Graves’ disease, the interrelationships between thyroid function, autoimmunity, insulin resistance and lipid profile may contribute to the increased cardiovascular risk. The lipid profile suggests a hypolipidemic effect.

Utility of Measuring TSH Levels in Patients Presenting With Abnormal Uterine Bleeding [34G

INTRODUCTION: Abnormal uterine bleeding (AUB) affects 9 to 14% of reproductive aged women. Previous studies have demonstrated an increased prevalence of menstrual abnormalities in patients with thyroid disease. The American College of Obstetricians and Gynecologists recommends thyroid stimulating hormone (TSH) screening in patients with AUB. There, however, is no published data evaluating the prevalence of thyroid disease among women presenting with AUB. The purpose of this study is to determine the prevalence of thyroid disease in patients with AUB presenting to a gynecology clinic. METHODS: This is a retrospective case series of patients aged 18 to 50 years that presented with AUB to the gynecology clinic. Patients were identified through review of the electronic medical record (EMR) from January 2012 to June 2016. Two hundred and three patients meeting study criteria for inclusion were analyzed and the prevalence of abnormal TSH was calculated. RESULTS: Thirteen patients (6.4%) were identified with abnormal TSH values. These patients were diagnosed though subsequent testing with subclinical hyperthyroidism (3.4%), subclinical hypothyroidism (0.49%), clinical hypothyroidism (0.49%), and clinical hyperthyroidism (0.49%). The majority of these patients did not have an established diagnosis for AUB (AUB-N) in the EMR. Five patients (38.5%) were diagnosed with AUB-O (ovulatory dysfunction). CONCLUSION: In this patient population with AUB, the prevalence of thyroid disorders was not increased as compared to the expected prevalence of thyroid disease in general female population. Routine measurement of TSH identified few patients with clinical thyroid disease.

Thyroid profile and autoantibodies in Type 1 diabetes subjects: A perspective from Eastern India.

Context:There has been a rise in the incidence of type 1 diabetes mellitus (T1DM) in India. The prevalence of thyroid autoantibodies and thyroid dysfunction is common in T1DM.Aims:The aim of this study is to determine the incidence of thyroid dysfunction and thyroid autoantibodies in T1DM subjects, without any history of thyroid disease, and the prevalence of glutamic acid decarboxylase (GAD) antibody, Islet antigen-2 antibody (IA2), thyroid peroxidase (TPO), and thyroglobulin autoantibodies (Tg-AB) in T1DM subjects.Settings and Design:This was a cross-sectional clinical-based study.Subjects and Methods:Fifty subjects (29 males, 31 females) with T1DM and without any history of thyroid dysfunction were included in the study. All subjects were tested for GAD antibody, IA2 antibody, TPO antibody, thyroglobulin antibody, free thyroxine, and thyroid-stimulating hormone.Statistical Analysis Used:A Chi-square/pooled Chi-square test was used to assess the trends in the prevalence of hypothyroidism. A two-tailed P < 0.05 was considered statistically significant.Results:The mean age of the subjects was 23.50 years. 9.8% of subjects were below the age of 12 years, 27.45% of subjects were of age 12–18 years, 37.25% of subjects were of age 19–30 years, and 25.49% of subjects were above 30 years. 78% were positive autoantibody for GAD, 30% for IA-2, 24% for TPO, and 16% were positive for Tg-AB. A total of 6.0% of T1DM subjects had evidence of clinical hypothyroidism, but the prevalence of subclinical hyperthyroidism (SCH) varied from 32% to 68.0% for we considered different definitions of SCH as advocated by different guidelines. All subjects with overt hypothyroidism had positive GAD and thyroid autoantibodies. One (2%) subject had clinical hyperthyroidism with strongly positive GAD, TPO, and Tg-AB.Conclusions:We found a high prevalence of GAD, IA2, TPO, and Tg-AB in our T1DM subjects. A substantial proportion of our subjects had undiagnosed thyroid dysfunction with a preponderance of subclinical hypothyroidism. All T1DM subjects with overt hypothyroidism or hyperthyroidism had positive GAD and thyroid autoantibodies. The high prevalence of undiagnosed thyroid dysfunction highlights the importance of regular thyroid screening in T1DM subjects.

Pregnancy and Autoimmune Thyroid Disease: Alternating Between Hypothyroidism and Hyperthyroidism And The Role of Thyrotropin-Receptor Antibodies

ABSTRACT Objective: To report the case of a female patient with hypothyroidism who spontaneously developed Graves hyperthyroidism during pregnancy and then reverted back to hypothyroidism in a subsequent pregnancy. Methods: The pertinent clinical features, laboratory data, and clinical course of the case are reported, along with a brief literature review. Results: A 30-year-old female with hypothyroidism diagnosed at age 20 years unexpectedly required decreased levothyroxine dosing during her second pregnancy. She was taking levothyroxine 12.5 μg daily when she became pregnant a third time. In the first trimester, levothyroxine was discontinued, and she presented in the third trimester with clinical and biochemical hyperthyroidism and a diffusely enlarged goiter. Propylthiouracil (PTU) was initiated. Thyroid-stimulating hormone–receptor antibodies (TRAbs) were positive. After delivery, her baby developed transient neonatal Graves disease. She was continued on a stable dose of PTU for 10 months postpartum ...

Severe Mitral Regurgitation by Hyperthyroidism in the Absence of Left Ventricular Dilatation

Introduction Graves’ disease (GD) is an autoimmune disease and the most common cause of thyrotoxicosis,, with multisystem involvement, that mainly affects women between 40 and 60 years of age. It is the most prevalent cause of autoimmune hyperthyroidism in pregnancy,, and it can be distinguished from gestational thyrotoxicosis due to the presence of diffuse goiter and previous history of hyperthyroidism. Clinical hyperthyroidism occurs in 0.2% of pregnant women. Heart failure (HF) is a rare manifestation of decompensated GD and it [...]

Indications and contraindications to transoral thyroidectomy.

Patient motivation to avoid neck scarring has been a strong impetus in the development of remote access approaches to the thyroid, including transoral robotic or endoscopic thyroidectomy vestibular approach (TOR/ETVA). TOR/ETVA continues to become more prevalent given its early success in North America and the demonstration of its safety and efficacy in Asia. As more surgeons perform this procedure, it is important that specific and uniform indications and contraindications exist to prevent surgical complications due to poor patient selection. In this article, we review the existing English literature regarding TOR/ETVA and compile the inclusion and exclusion criteria of individual authors for both robotic and endoscopic techniques to date. We then resolve differences in the existing literature to provide recommended indications and contraindications to TOR/ETVA based on both our review and our own experience with TOR/ETVA to date. The following are our resultant recommended indications for TOR/ETVA: patient history of hypertrophic scarring or motivation to avoid a cervical neck incision with a maximal thyroid diameter ≤ 10 cm and dominant nodule ≤6 cm, with one of the following pathologic criteria; benign lesion, multinodular goiter, indeterminate nodule, or suspicious lesions/well-differentiated thyroid carcinomas ≤ 2 cm. Recommended contraindications to TOR/ETVA are as follows: history of head & neck surgery, history of head, neck, or upper mediastinal irradiation, inability to tolerate general anesthesia, evidence of clinical hyperthyroidism, preoperative recurrent laryngeal nerve palsy, lymph node metastasis, extrathyroidal extension including tracheal or esophageal invasion, oral abscesses, substernal thyroidal extension, or failure to meet inclusion criteria as above. Relative contraindications include smoking and other oral pathology, and surgeons should be aware that morbid obesity may make it difficult to raise skin flaps.

Diagnostic and Therapeutic Challenges of De Quervain Thyroiditis in Sub-Saharan Africa: Illustration with Two New Cases in Dakar

Introduction: De Quervain’s subacute thyroiditis is an inflammatory granulomatosis with clinical presentation some time atypical leading eventually to misdiagnosis or inadequate treatment. In our area, physician should be aware of this possible etiology in presence of recent and acute features of thyrotoxicosis with or without painful firm goiter. We illustrate this fact with two new observations from Sub-Saharan Africa. Observations: Our first patient is a 70-year-old Guinean woman presenting a painful nodular and hard goiter at palpation. Her history was recent in a context of deterioration of the general state with a sub clinical thyrotoxicosis syndrome. The diagnosis of probable malignant thyroid tumor was evoked initially and a thyroidectomy considered. She presented an important biological inflammatory syndrome and biological peripheral hyperthyroidism. Neck ultrasound examination showed heterogeneous patchy decreased echogenicity. The diagnosis of subacute De Quervain’s thyroiditis was set up. A corticosteroid therapy at a rate of 20 mg/day of prednisone was begun with a fast degression of dose. After 3 weeks of treatment, we noticed total clinical recovery normalization of biological parameters. The second observation was about a 52-year-old Senegalese women living in Bamako. She presented cervical pains evolving for 2 months in a context of flu-like syndrome associated with thyrotoxicosis and marked biological inflammatory syndrome. The thyroid ultrasound showed global heterogeneity with characteristic aspect of “geography map” leading to the diagnosis of subacute thyroiditis. A combination therapy with low dose of prednisone, ß-blockers and tranquillizers. We noticed fast disappearance of clinical and biological signs. At 5 mg per day of prednisone, there were moderate signs of relapse with rapid favorable evolution after few days under increased dose of prednisone up to 10 mg/day. Conclusion: De Quervain’s thyroiditis can appear under misleading features opening out to make wandering diagnosis. A good clinical evaluation coupled with hormonal and ultrasound thyroid examination may help for right management. The use of low dose of corticosteroid had enabled us to obtain a fast control of main clinical and biological abnormalities.

Thyroid function, reduced kidney function and incident chronic kidney disease in a community-based population: the Atherosclerosis Risk in Communities study.

Reduced kidney function is a common public health problem that increases risk for a wide variety of adverse outcomes, making the identification of potentially modifiable factors associated with the development of incident chronic kidney disease (CKD) important. Alterations in the hypothalamic-pituitary-thyroid axis have been linked to reduced kidney function, but the association of thyroid function with the development of incident CKD is largely uncharacterized. Concentrations of thyroid stimulating hormone (TSH), free thyroxine (FT4), triiodothyronine (T3) and thyroid peroxidase antibody (TPOAb) were quantified in 12 785 black and white participants of the ongoing community-based prospective Atherosclerosis Risk in Communities study. Thyroid markers and clinical categories of thyroid dysfunction (euthyroidism, combined subclinical and overt hypothyroidism, combined subclinical and overt hyperthyroidism) were also evaluated for their association with reduced kidney function (estimated glomerular filtration rate <60 mL/min/1.73 m2) at study baseline and with incident CKD over a median follow-up time of 19.6 years. Higher TSH and FT4 as well as lower T3 concentrations were strongly and independently associated with reduced kidney function at study baseline. The clinical entities hypothyroidism and hyperthyroidism were also associated with higher odds of baseline reduced kidney function, but this was not significant. However, none of the markers of thyroid function nor different clinical categories of thyroid dysfunction (hypothyroidism, hyperthyroidism or TPOAb positivity) were associated with incident CKD in adjusted analyses. Elevated TSH, FT4 and reduced T3 concentrations were associated with reduced kidney function cross-sectionally. The lack of association with the development of incident CKD suggests that altered thyroid function in the general population is not causally related to CKD development, but screening for thyroidal status may be especially relevant in persons with reduced kidney function.

Clinical and endocrine characteristics and genetic analysis of Korean children with McCune-Albright syndrome: a retrospective cohort study.

BackgroundMcCune–Albright syndrome (MAS) is a rare disease defined by the triad of fibrous dysplasia (FD), café au lait spots, and peripheral precocious puberty (PP). Because of the rarity of this disease, only a few individuals with MAS have been reported in Korea. We describe the various clinical and endocrine manifestations and genetic analysis of 14 patients with MAS in Korea.MethodsPatients’ clinical data—including peripheral PP, FD, and other endocrine problems—were reviewed retrospectively. In addition, treatment experiences of letrozole in five patients with peripheral PP were described. Mutant enrichment with 3′-modified oligonucleotides - polymerase chain reaction (MEMO-PCR) was performed on eight patients to detect mutation in GNAS using blood. MEMO-PCR is a simple and practical method that enables the nondestructive selection and enrichment of minor mutant alleles in blood.ResultsThe median age at diagnosis was 5 years 2 months (range: 18 months to 16 years). Eleven patients were female, and three were male. Thirteen patients showed FD. All female patients showed peripheral PP at onset, and three patients subsequently developed central PP. There was a significant decrease in estradiol levels after two years of letrozole treatment. However, bone age was advanced in four patients. Two patients had clinical hyperthyroidism, and two patients had growth hormone (GH) excess with pituitary microadenoma. c.602G > A (p.Arg201His) in GNAS was detected in two patients in blood, and c.601C > T (p.Arg201Cys) in GNAS was detected in one patient in pituitary adenoma.ConclusionsThis study described the various clinical manifestations of 14 patients with MAS in a single center in Korea. This study first applied MEMO-PCR on MAS patients to detect GNAS mutation. Because a broad spectrum of endocrine manifestations could be found in MAS, multiple endocrinopathies should be monitored in MAS patients. Better treatment options for peripheral PP with MAS are needed.

Iodine Status and Prevalence of Thyroid Disorders After Introduction of Mandatory Universal Salt Iodization for 16 Years in China: A Cross-Sectional Study in 10 Cities.

The goal of eliminating iodine deficiency worldwide was successfully achieved in China after the implementation of a mandatory universal salt iodization program for the last 16 years. Thus, China has been assessed as a country with more than adequate iodine levels. This survey aimed to investigate the current iodine status in China and the effects of an increased iodine intake on the spectrum and prevalence of thyroid disorders. A total of 15,008 adult subjects from 10 cities in eastern and central China were investigated. Serum thyrotropin (TSH), thyroid peroxidase antibodies (TPOAb), thyroglobulin antibodies (TgAb), and urine iodine concentration (UIC) were measured, and an ultrasonography of the thyroid was performed in all subjects. Free thyroxine (fT4) and free triiodothyronine (fT3) levels were only measured if the serum TSH was outside the normal range. The median UIC values were 197 μg/L in school-age children (SAC) and 205 μg/L in a cohort population. Six cities were classified as regions with adequate iodine intake (AII), and four cities as regions with more than adequate iodine intake (MTAII), according to median SAC UIC. The prevalence of clinical hypothyroidism, subclinical hypothyroidism, and positive thyroid antibodies was significantly higher in MTAII cities than it was in AII cities. Moreover, the prevalence of clinical hyperthyroidism (1.1% vs. 0.8%, p = 0.033) and Graves' disease (0.8% vs. 0.5%, p = 0.019) also significantly increased in MTAII cities. Compared with a five-year prospective study conducted in 1999, the prevalence of goiter significantly decreased (2.9% vs. 5.02%, p = 0.001), but there was a significant increase in thyroid nodules (12.8% vs. 2.78%, p = 0.001). The prevalence of subclinical hypothyroidism (16.7% vs. 3.22%), positive TPOAb (11.5% vs. 9.81%), and positive TgAb (12.6% vs. 9.09%) significantly increased, while no changes were seen in clinical hyperthyroidism, subclinical hyperthyroidism, or Graves' disease. The goal of eliminating iodine deficiency has been successfully achieved in China. However, the prevalence and spectrum of thyroid disorders has increased, reflecting possible adverse effects of increased iodine intake.

Thyroid antibody-negative euthyroid Graves' ophthalmopathy.

SummaryTSH receptor antibodies (TRAbs) are the pathological hallmark of Graves’ disease, present in nearly all patients with the disease. Euthyroid Graves’ ophthalmopathy (EGO) is a well-recognized clinical entity, but its occurrence in patients with negative TRAbs is a potential source of diagnostic confusion. A 66-year-old female presented to our endocrinology clinic with right eye pain and diplopia in the absence of thyroid dysfunction. TRAbs were negative, as measured with a highly sensitive third-generation thyrotropin-binding inhibitory immunoglobulin (TBII) ELISA assay. CT and MRI scans of the orbit showed asymmetrical thickening of the inferior rectus muscles but no other inflammatory or malignant orbital pathology. Graves’ ophthalmopathy (GO) was diagnosed on the basis of the clinical and radiological features, and she underwent surgical recession of the inferior rectus muscle with complete resolution of the diplopia and orbital pain. She remained euthyroid over the course of follow-up but ultimately developed overt clinical and biochemical hyperthyroidism, 24 months after the initial presentation. By this time, she had developed positive TRAb as well as thyroid peroxidase antibodies. She responded to treatment with thionamides and remains euthyroid. This case highlights the potential for negative thyroid-specific autoantibodies in the presentation of EGO and underscores the variable temporal relationship between the clinical expression of thyroid dysfunction and orbital disease in the natural evolution of Graves’ disease.Learning pointsEuthyroid Graves’ ophthalmopathy can present initially with negative thyroid-specific autoantibodies.Patients with suggestive symptoms of ophthalmopathy should be carefully evaluated for GO with imaging studies even when thyroid function and autoantibodies are normal.Patients with EGO can develop thyroid dysfunction within 4 years of follow-up underpinning the need for long-term follow-up and continued patient and physician vigilance in patients who have been treated for EGO.

2016 AAFP Guidelines for the Management of Feline Hyperthyroidism.

Since 1979 and 1980 when the first reports of clinical feline hyperthyroidism (FHT) appeared in the literature, our understanding of the disease has evolved tremendously. Initially, FHT was a disease that only referral clinicians treated. Now it is a disease that primary clinicians routinely manage. Inclusion of the measurement of total thyroxine concentration in senior wellness panels, as well as in diagnostic work-ups for sick cats, now enables diagnosis of the condition long before the cat becomes the classic scrawny, unkempt, agitated patient with a bulge in its neck. However, earlier recognition of the problem has given rise to several related questions: how to recognize the health significance of the early presentations of the disease; how early to treat the disease; whether to treat FHT when comorbid conditions are present; and how to manage comorbid conditions such as chronic kidney disease and cardiac disease with treatment of FHT. The 2016 AAFP Guidelines for the Management of Feline Hyperthyroidism (hereafter referred to as the Guidelines) will shed light on these questions for the general practitioner and suggest when referral may benefit the cat. The Guidelines explain FHT as a primary disease process with compounding factors, and provide a concise explanation of what we know to be true about the etiology and pathogenesis of the disease.The Guidelines also:Distill the current research literature into simple recommendations for testing sequences that will avoid misdiagnosis and separate an FHT diagnosis into six clinical categories with associated management strategies.Emphasize the importance of treating all hyperthyroid cats, regardless of comorbidities, and outline the currently available treatments for the disease.Explain how to monitor the treated cat to help avoid exacerbating comorbid diseases.Dispel some of the myths surrounding certain aspects of FHT and replace them with an evidence-based narrative that veterinarians and their practice teams can apply to feline patients and communicate to their owners. To help ensure better case outcomes, the Guidelines reflect currently available, evidenced-based knowledge. If research is lacking, or if a consensus does not exist, the expert panel of authors has made recommendations based on their extensive, cumulative clinical experience.

Serum Cobalamin and Methylmalonic Acid Concentrations in Hyperthyroid Cats Before and After Radioiodine Treatment.

BackgroundHyperthyroidism, the most common endocrine disorder in cats, has been associated with low serum cobalamin concentrations. Whether this is a functional cobalamin deficiency of clinical importance has not been assessed.Hypothesis/ObjectivesCats with hyperthyroidism experience a functional cobalamin deficiency which correlates with their clinical catabolic state and is reversible with return of the euthyroid state.AnimalsThirty‐nine client‐owned hyperthyroid cats.MethodsProspective observational study. Serum cobalamin, methylmalonic acid, and clinical scores were determined in each hyperthyroid cat at enrollment and when euthyroid (60 days after radioiodine treatment).ResultsFive of the 39 hyperthyroid cats (13%) had a low serum cobalamin concentration ranging from <150 to 290 ng/L. Serum cobalamin concentrations normalized to >350 ng/L in 2 of the hypocobalaminemic cats once euthyroid. None of the hyperthyroid/hypocobalaminemic cats had increased serum methylmalonic acid concentrations (175–601 nmol/L). In cats with clinical and biochemical hyperthyroidism, there was no correlation between serum cobalamin concentrations with total T4 concentration (P = .12) or clinical scores including body weight (P = .11) and BCS (P = .54).Conclusions and Clinical ImportanceIn this population of hyperthyroid cats, the prevalence of hypocobalaminemia was low. Specifically, hyperthyroid cats, in which concurrent gastrointestinal disease is unlikely. Hypocobalaminemia is not a functional deficiency requiring supplementation in hyperthyroid cats without gastrointestinal disease.