High Iodine Research Articles

Highly effective selectively removal of carcinogenic dyes and iodine adsorption and release via a metal–organic framework based on multiple helical chains

AbstractA novel porous metal–organic framework Cu‐BCPPy based on a desymmetrized heterofunctional ligand 3,5‐di(4‐carboxyphenyl)pyridine has been successfully synthesized under solvothermal conditions. The framework possesses two sizes of 2D straight channels, which are constructed by one pair and three pairs of helixes, respectively. The distortion of the ligand leads to the structure exhibiting a new type of (3,6)‐connected topology. According to the structural characteristic, Cu‐BCPPy can effectively adsorb large carcinogenic organic dyes sudan III (SD III) and direct black 38 (DB 38) but exclude small molecular dyes. Hence, Cu‐BCPPy exhibits effective and selective adsorption performance for the carcinogenic dye DB 38 on the equal proportional mixture dyes methyl orange (MO) and DB 38, fluorescein and DB 38, and basic red 2 (BR 2) and DB 38 with different sizes. In addition, Cu‐BCPPy can be also provided with the characteristic of high iodine adsorption and release, which indicates that it is a promising candidate material for selectively adsorption and separation of many substances.

Effects of Selenium Supplement on B Lymphocyte Activity in Experimental Autoimmune Thyroiditis Rats.

Methods 45 healthy and adult female SD rats were randomly divided into three groups: normal control group, EAT model group, and selenium yeast supplement EAT group. The EAT model rats were induced by subcutaneous injection of porcine thyroglobulin and fed with high iodine water. The concentrations of serum thyroid-stimulating hormone (TSH), TGAb, TPOAb, and B cell activating factor (BAFF) were detected in each group by enzyme-linked immunosorbent assay (ELISA), and the expression of interleukin-10 (IL-10) in thyroid tissue was detected by immunohistochemistry. B cells and regulatory B cells (Bregs) ratios in the spleen of rats were analyzed by flow cytometry. Results In contrast with the EAT model group, the levels of serum TSH, TGAB, TPOAb, and BAFF were decreased, while IL-10 expression was increased in thyroid tissue, and Bregs ratio was upregulated in the spleen (all p < 0.05) in the selenium yeast supplement EAT group. Conclusion Selenium yeast supplement could partially attenuate immune imbalance in EAT rats, which may be related to the mechanism of modulating B lymphocyte activity.

A study on natural luffa seed oil as a potential source of polymers and bioactive compounds

Luffa seeds are rich in resources, although they are considered as agricultural waste and thus underutilized. The main objective of this study was to investigate the application prospect of luffa seed oil (LSO) in natural polymer composites, cosmetics, functional materials, and other fields. The extraction yield, fatty acid composition, bioactive components, thermal stability, and physicochemical properties of LSO were systematically investigated. The results of extraction yield and gas chromatography–mass spectrometry analysis indicated that the extraction yield of LSO is high (36.24–39.48 %) and is rich in unsaturated fatty acids (70.97–75.03 %). Moreover, LSO is rich in bioactive substances (31 types) such as squalene, (E)-2-decenal, etc. These results indicate that LSO has promising applications in polymer composites and bioactive substance utilization. 1H NMR, 13C NMR, and FTIR spectroscopy analyses showed that LSO contains sufficient chemical reaction sites (e.g. ester groups, unsaturated double bonds, etc.), and the average double bond number of LSO molecules is 2.69–3.29. These results further indicate its greater potential for the development of polymer composites, in particular, more elastic polyurethane foams. Moreover, analysis of the thermogravimetric and physicochemical properties of LSO revealed that LSO has a relatively high iodine value (83.17 g I2/100 g), and high peak degradation temperature (371.89–422.5 °C) and final degradation temperature (490.36–501.80 °C), which is favorable for its thermal polymerization at high temperature for the preparation of polymers.

A Meta-Analysis of the Effect of Iodine Excess on the Intellectual Development of Children in Areas with High Iodine Levels in their Drinking Water.

The purpose of this meta-analysis is to comprehensively investigate the effect of iodine excess on children's intellectual development in areas with high iodine levels in their drinking water. We systematically searched the electronic databases and identified 17 publications (16 in Chinese and 1 in English) on the effect of iodine excess on children's intelligence published between January 31, 1985, and January 31, 2020. This meta-analysis included 14,794 children from 28 studies. The results showed that compared with the control group, the intelligence level of children in the high iodine group reduced significantly by 1.64 points (WMD=-1.64; 95% CI (-3.225, -0.049), Z=2.02, P<0.05). Subgroup analyses were performed according to the water iodine concentration, water iodine concentration of the control group, the intelligence test method, and regions of China (i.e., north and south). We noted that when the water iodine concentration was <300μg/L, 301-600μg/L, 600.1-900μg/L, and >900μg/L, the intelligence level of the high iodine groups decreased by varying degrees, although not statistically significant (all P>0.05). The water iodine concentration of the control group was divided into two groups (<150 μg/L and <100 μg/L) and the heterogeneity analysis showed that the heterogeneity of the control group decreased significantly when the concentration of water iodine was <150 μg/L, I2 = 67.3%, P<0.001, which indicated a potential source of heterogeneity. The analyses by test method showed that among the studies which used the China Joint Raven's test, the intelligence level of children in the high iodine group was 0.86 points lower than in the control group (P>0.05). Conversely, we observed that among the studies which used the China Binet intelligence test and the binaphthalene intelligence test of Tanzhida in Japan to evaluate children's intelligence level, the intelligence level of children in the high iodine groups was significantly lower (3.65 points and 8.0 points, respectively) compared with the control groups (P<0.05). The analysis of the regions of China demonstrated that whereas the reduction in children's intelligence level from excess iodine in the north of China was not statistically significant (WMD=-0.16, 95% CI (-2.18, 1.85), P>0.05), the association was statistically significant in the southern part of China (WMD=-1.86, 95% CI (-3.57, -0.09), P<0.05). This study found that high iodine concentration was statistically significantly associated with a decline in intelligence level in children. Comparatively, the intelligence level of children who were exposed to high iodine concentrations reduced significantly by 1.64 points. These findings have public health implications.

High Iodine Nutrition May Be a Risk Factor for Cervical Lymph Node Metastasis in Papillary Thyroid Cancer Patients

Purpose: The aim of this study was to retrospectively identify the effect of iodine on the papillary thyroid cancer (PTC) process and investigate the risk clinicopathologic characteristics of cervical lymph node metastasis (CLNM) for achieving a better preventive strategy of PTC. Methods: Totally 187 patients with CLNM and 279 without CLNM (NCLNM) were enrolled, and their urinary iodine concentration (UIC) and serum iodine concentration (SIC) were measured. Logistic regressions were used to reveal the effects of iodine nutrition on the CLNM status of PTC. Results: The levels of thyroid-stimulating hormone (TSH) and thyroglobulin (TG) were higher in the CLNM group than in the NCLNM group. UIC and SIC were positively correlated, and both of them were correlated with TSH, free thyroxine, and TG. The proportions of UIC >300 μg/L and of SIC >90 μg/L were higher in the CLNM than in the NCLNM. Logistic analysis showed that SIC >90 μg/L was an independent predictor for CLNM in PTC. Additionally, age ≥45, female, TG, multifocality, and diameter of cancer invasion >1 cm also affected CLNM status in PTC, and their logistic regression model showed a certain diagnostic accuracy (area under the receiver-operating characteristic curve = 0.72). Conclusions: Relatively high iodine nutrition seemed to be a significant risk factor for the occurrence of CLNM in PTC and may promote lymphatic metastasis in PTC.

Functionalized Ionic Porous Organic Polymers Exhibiting High Iodine Uptake from Both the Vapor and Aqueous Medium.

Large-scale generation of radioactive iodine (129I, 131I) in nuclear power plants pose a critical threat in the event of fallout, thus rendering the development of iodine sequestering materials (from both the vapor and aqueous medium) highly pivotal. Herein, we report two chemically stable ionic polymers containing multiple binding sites, including phenyl rings, imidazolium cations, and bromide anions, which in synergy promote adsorption of iodine/triiodide anions. In brief, exceptional iodine uptake (from the vapor phase) was observed at nuclear fuel reprocessing conditions. Furthermore, the ionic nature propelled removal of >99% of I3- from water within 30 min. Additionally, benchmark uptake capacities, as well as unprecedented selectivity, were observed for I3-anions. The excellent affinity (distribution coefficient, ∼105 mL/g) enabled iodine capture from seawater-spiked samples. Moreover, iodine-loaded compounds showed conductivity (10-4 S/cm, 10-6 S/cm), placing them among the best known conducting porous organic polymers. Lastly, DFT studies unveiled key insights in coherence with the experimental findings.

Effects of iodine excess on serum thyrotropin-releasing hormone levels and type 2 deiodinase in the hypothalamus of Wistar rats.

Iodine is an important element in thyroid hormone biosynthesis. Thyroid function is regulated by the hypothalamic-pituitary-thyroid axis. Excessive iodine leads to elevated thyroid-stimulating hormone (TSH) levels, but the mechanism is not yet clear. Type 2 deiodinase (Dio2) is a Se-containing protease that plays a vital role in thyroid function. The purpose of this study was to explore the role of hypothalamus Dio2 in regulating TSH increase caused by excessive iodine and to determine the effects of iodine excess on thyrotropin-releasing hormone (TRH) levels. Male Wistar rats were randomised into five groups and administered different iodine dosages (folds of physiological dose): normal iodine, 3-fold iodine, 6-fold iodine, 10-fold iodine and 50-fold iodine. Rats were euthanised at 4, 8, 12 or 24 weeks after iodine administration. Serum TRH, TSH, total thyroxine (TT4) and total triiodothyronine (TT3) were determined. Hypothalamus tissues were frozen and sectioned to evaluate the expression of Dio2, Dio2 activity and monocarboxylate transporter 8 (MCT8). Prolonged high iodine intake significantly increased TSH expression (P < 0·05) but did not affect TT3 and TT4 levels. Prolonged high iodine intake decreased serum TRH levels in the hypothalamus (P < 0·05). Dio2 expression and activity in the hypothalamus exhibited an increasing trend compared at each time point with increasing iodine intake (P < 0·05). Hypothalamic MCT8 expression was increased in rats with prolonged high iodine intake (P < 0·05). These results indicate that iodine excess affects the levels of Dio2, TRH and MCT8 in the hypothalamus.

Seaweeds rehydration and boiling: Impact on iodine, sodium, potassium, selenium, and total arsenic contents and health benefits for consumption

Considering the importance of seaweeds for the development of sustainable and innovative food products, this study aimed to characterize the impact of hydrothermal processing on iodine, sodium, potassium, selenium, and arsenic concentrations of four seaweed species (S. latissima, L. digitata, U. pinnatifida, and C. crispus) and on the associated health risks-benefits for consumers. These elements revealed a common pattern for leachable fractions of iodine, total arsenic, and selenium: L. digitata ≥ S. latissima > C. crispus > U. pinnatifida after rehydration and boiling during different periods. The behavior for sodium was: S. latissima > L. digitata > C. crispus > U. pinnatifida, and for potassium: U. pinnatifida > L. digitata > S. latissima > C. crispus. Generally, the species that attained more significant losses were S. latissima and L. digitata. A health-relevant sodium/potassium ratio below 0.7 was found for all species except for U. pinnatifida. In some species, the risk-benefit analysis revealed that high iodine and arsenic levels might promote risks for consumption, even after 20 min boiling, but 5 g of processed U. pinnatifida could contribute to adequate iodine, sodium, potassium, and selenium intakes for all population groups. Standardized processing treatments of seaweeds can open new opportunities for the sector.

Bisindole [3]arenes—Indolyl Macrocyclic Arenes Having Significant Iodine Capture Capacity

Bisindole [3]arenes—Indolyl Macrocyclic Arenes Having Significant Iodine Capture Capacity

Comparison of Thyroid Hormone Levels between Women Farmers and Non-Farmers in Banten Indonesia.

Pesticides are suspected of being endocrine disruptors. This cross-sectional study measured serum samples for levels of thyroid hormones including thyroid stimulating hormone (TSH), triiodothyronine (T3), thyroxine (T4), free T3 (FT3), and free T4 (FT4) among Indonesian female farmers (n = 127) and non-farmers (n = 127). A questionnaire was used to collect information on demographics and risk factors including work characteristics and frequency, and the use of home and agricultural pesticides. Results showed that there were no significant differences in the distribution of the clinical categories of thyroid levels between farmers and non-farmers except for FT3 and T4. However, in multivariable regression controlling for confounders, FT3 and T4 were significantly higher for farmers compared to non-farmers. In addition, 32% of farmers had clinically low iodine levels and 49% of non-farmers had clinically high iodine levels. We conclude that pesticide exposure may not be as important as iodine intake in explaining these findings. We recommend counseling by health workers about the importance of using iodized salt for farmers and counseling about high iodine foods that need to be avoided for non-farmers.

A Rare Thyroid Gland Emergency: Thyroid Abscess

Introduction&#x0D; Thyroid abscess is a serious head and neck infection that may easily be overlooked. The thyroid gland is resistant to infections due to its rich blood supply, good lymphatic drainage, high iodine content and a solid capsule. Therefore, thyroid abscess is a rare disease with serious complications when the diagnosis is delayed. In this paper, we present a case of thyroid abscess who presented with fever, fatigue, neck pain and swelling, and rapidly deteriorated general condition.&#x0D; Case Report&#x0D; A 28-year-old female patient had painful swelling and redness on the left side of the neck. She had fever, fatigue, and dysphagia. Laboratory tests revealed leukocytosis, elevated CRP, and sedimentation rate. The patient who was detected to have thyroid abscess on ultra-sonography and computed tomography was discharged with recovery through surgery and appropriate antibio-therapy.&#x0D; Conclusion&#x0D; Thyroid gland abscess is a rare, serious clinical condition with high morbidity and mortality. Thyroid abscess should be kept in mind while performing radiological evaluation in cases presenting with swelling and redness in the neck. In these cases, quite good clinical outcomes may be achieved with early diagnosis and appropriate treatment.

Chemical Activation of &lt;i&gt;Garcinia mangostana&lt;/i&gt; Mangosteen Shell with Acid-Base for Hexavalent Chromium Adsorption

This study investigates the potential for using mangosteen shell which is an agricultural waste to chemically activate using potassium hydroxide (KOH) or phosphoric acid (H3PO4) and then carbonized for 120 min at 673 K, to adsorb hexavalent chromium (Cr6+) from solution. The high iodine number and methylene blue number on the base-activation as a good adsorbent that a high surface area of this activated carbonaceous material is effective in removing Cr6+, with adsorption increasing with temperature, adsorption time, and initial feed concentration. With decreasing solution pH, the maximum of Cr6+ adsorption capacity and removal at a pH of 2.0 was achieved.

Saccharina latissima Cultivated in Northern Norway: Reduction of Potentially Toxic Elements during Processing in Relation to Cultivation Depth.

There is an increasing interest in the use of Saccharina latissima (sugar kelp) as food, but the high iodine content in raw sugar kelp limits the daily recommended intake to relatively low levels. Processing strategies for iodine reduction are therefore needed. Boiling may reduce the iodine content effectively, but not predictably, since reductions from 38–94% have been reported. Thus, more information on which factors affect the reduction of iodine are needed. In this paper, sugar kelp cultivated at different depths were rinsed and boiled, to assess the effect of cultivation depth on the removal efficacy of potentially toxic elements (PTEs), especially iodine, cadmium, and arsenic, during processing. Raw kelp cultivated at 9 m contained significantly more iodine than kelp cultivated at 1 m, but the difference disappeared after processing. Furthermore, the content of cadmium and arsenic was not significantly affected by cultivation depth. The average reduction during rinsing and boiling was 85% for iodine and 43% for arsenic, but no significant amount of cadmium, lead, or mercury was removed. Cultivation depths determined the relative effect of processing on the iodine content, with a higher reduction for kelp cultivated at 9 m (87%) compared to 1 m (82%). When not taken into consideration, cultivation depth could mask small reductions in iodine content during rinsing or washing. Furthermore, since the final content of PTEs was not dependent on the cultivation depth, the type and extent of processing determines whether cultivation depth should be considered as a factor in cultivation infrastructure design and implementation, or alternatively, in product segmentation.

Korean-specific biokinetic model for iodine in radiological protection

The International Commission on Radiological Protection (ICRP) recently adopted a detailed biokinetic model for systemic iodine with reference transfer coefficients based on typical worldwide dietary intakes of stable iodine. The regional data provided demonstrate that the ICRP reference thyroidal biokinetics may differ substantially across regions with atypically low or high dietary intakes of stable iodine. Importantly, the design of the ICRP model facilitates modifications of reference thyroidal kinetics based on regional dietary iodine intake. The present study extended the ICRP model to the South Korean population, whose dietary iodine intake is much higher than the global mean. The following three transfer coefficients were selected as targets for Korean-specific values: thyroidal uptake rate (λ 1), hormonal secretion rate (λ 4) and leakage rate of thyroidal organic iodine as inorganic iodide (λ 5). The Korean-specific values for λ 1, λ 4 and λ 5 were determined to be 4.48, 0.0086 and 0.0171 d−1, respectively, to yield the measurements of thyroidal iodine and physiological status of Korean adults. The determined λ 1 and λ 5 values differed noticeably from the ICRP values, whereas the λ 4 value was comparable to that of the ICRP. Compared with the ICRP reference model, the Korean model, in which the Korean-specific transfer coefficients were adopted, predicted noticeably lower thyroidal uptake and faster decrease of thyroidal iodine. In addition, the predicted cumulative activities of radioiodine in the thyroid were substantially lower (40–80%) than those predicted by the ICRP model. The Korean model developed in this study demonstrates that the iodine biokinetics for Koreans (i.e. a population with a high iodine consumption) obviously differ from the prediction of the ICRP model. Hence, the Korean model may serve to improve the accuracy of thyroid dose estimation for Koreans and will lead to practical changes in matters concerned with radiological protection.

Radioiodine therapy induced sialadenitis versus chronic idiopathic sialadenitis-Presentation and outcomes.

This study explores the unique characters of high dose radioactive iodine (RAI) induced chronic sialadenitis. A retrospective study of patients having received salivary endoscopy and followed in our outpatient clinic. A total of 100 patients met the inclusion criteria, 75 were diagnosed with chronic idiopathic sialoadenitis and 25 with radio-iodine induced sialoadenitis (RIS). The main complaint in both groups was swelling of the parotid gland. Pain, dysphagia, and xerostomia were observed considerably more in the RIS group. During sialo-endoscopy, fibrosis of the Stensen's duct was more common in the RIS group (p=0.003). RIS patients group generally managed better with interventional endoscopic treatment alone (80% vs. 46%). RIS patients have distinct clinical characteristics. There may be a collateral muscular damage to the masticatory muscles. Fibrosis and parenchymal damage are major findings during sialendoscopy. Sialendoscopy is a safe and efficient treatment for RAI induced sialadenitis.

High iodine adsorption by lignin-based hierarchically porous flower-like carbon nanosheets

Developing an efficient adsorbent for adsorbing and capture radioactive iodine as a fission product in air and aqueous solution during the nuclear disposal process and in the event of a nuclear accident is of great importance. In this work, lignin-based porous flower-like carbon nanosheets have been developed by using lignin as a carbon precursor, MgO as a template coupled with KOH-activation (LFC-K), and KOH/NaOH eutectic activation (LFC-KN), which were tested for the adsorption of iodine molecules in iodine vapor and in solution. The combination of nanosheets structure and abundant pores makes LFC-K, and LFC-KN excellent absorbability for iodine. The LFC-K with both micropores and mesopores had a higher adsorption capacity for I2 vapor (4060 mg g−1); in comparison, LFC-KN with both micropores, mesopores and macropores had a higher adsorption capacity for I2 in water (1295 mg g−1). After several iodine adsorption and release cycles, the two adsorbents still exhibit excellent reusability.

Multi-Step Subcritical Water Extracts of Fucus vesiculosus L. and Codium tomentosum Stackhouse: Composition, Health-Benefits and Safety

Mental health and active aging are two of the main concerns in the 21st century. To search for new neuroprotective compounds, extracts of Codium tomentosum Stackhouse and Fucus vesiculosus L. were obtained through multi-step (four step) subcritical water extraction using a temperature gradient. The safety assessment of the extracts was performed by screening pharmaceutical compounds and pesticides by UHPLC-MS/MS, and iodine and arsenic levels by ICP-MS. Although the extracts were free of pharmaceutical compounds and pesticides, the presence of arsenic and high iodine contents were found in the first two extraction steps. Thus, the health-benefits were only evaluated for the fractions obtained in steps 3 and 4 from the extraction process. These fractions were tested against five brain enzymes implicated in Alzheimer’s, Parkinson’s, and major depression etiology as well as against reactive oxygen and nitrogen species, having been observed a strong enzyme inhibition and radical scavenging activities for the step 4 fractions from both seaweed species. Regarding the variation of the chemical composition during the extraction, step 1 fractions were the richest in phenolic compounds. With the increase in temperature, Maillard reaction, caramelization and thermo-oxidation occurred, and the resulting products positively affected the antioxidant capacity and the neuroprotective effects.

Nanoparticles: Untying the Gordian Knot in Conventional Computed Tomography Imaging

X-ray computed tomography (CT) imaging plays an essential role in disease diagnosis due to its noninvasive, painless mode and superior penetration depth. However, the resolution of the soft tissue ...

Thyroid Abscess Initially Presenting as Destructive Thyroiditis With Subsequent Hypothyroidism

Introduction: Due to its rich vascular supply and high iodine content infection of the thyroid gland is rare and is uncommonly associated with hyperthyroidism. We report a case of a thyroid abscess presenting with hyperthyroidism with subsequent hypothyroidism in an immunocompetent patient. Clinical Case: A 34-year old female with no past medical history presented with an enlarging neck mass associated with worsening, non-radiating throat pain of three-week duration associated with dysphagia. She reports 15-lb weight loss and palpitations. On presentation vital signs were within normal range. Physical examination revealed a diffusely tender anterior neck mass. Her thyroid function tests revealed TSH 0.01 uIU/mL (0.358-3.74), FT4 2.4 ng/dL (0.76-1.46), TSI <0.10 IU/L (0.00-0.55), TPO 12 IU/mL (0-34). Laboratory workup was also significant for leukocytosis, thrombocytosis, and hyponatremia. Thyroid ultrasound revealed a large, irregularly shaped, multiloculated fluid collection involving both lobes measuring 6.4 x 4.8 x 2.0 cm. She was started on Vancomycin and Ampicillin/Sulbactam, Metoprolol, and Methimazole. Needle aspiration of 30 cc of purulent material was performed with culture showing a heavy growth of streptococcus constellatus sensitive to penicillin. After a 4-day inpatient stay, she was discharged with Amoxicillin/Clauvanate as well as Methimazole 10mg BID. Ten days after being discharged, the patient again presented to the emergency department with complaint that the neck mass had increased in size. CT neck showed a 5.1 x 2.8 x 0.8 cm lobulated fluid collection. CT-guided drainage was performed, cytology and wound culture were found to be unremarkable. Thyroid function tests revealed she was hypothyroid with TSH 31.157 uIU/mL and FT4 of 0.72 ng/dL. Upon discharge, Methimazole was discontinued and she was started on Levothyroxine 75 mcg daily. Due to failure of prior antibiotics, she received a 14-day course of IV Ceftriaxone. Outpatient follow-up eight weeks later showed she was euthyroid on Levothyroxine 75 mcg with ultrasound revealing small thyroid gland with resolution of the abscess. Conclusion: Hyperthyroidism in the setting thyroid abscess is secondary to destructive thyroiditis. As there is no increase in thyroid hormone synthesis, there is no role for treatment with antithyroid medication. Symptomatic control with beta-blocker, surgical drainage, and IV antibiotics are recommended for cases of thyroid abscesses. If infection persists or extensive necrosis develops, thyroidectomy may be indicated. Hypothyroidism can be a consequence of destructive thyroiditis as was seen in this patient.

Amiodarone Induced Thyrotoxicosis: A Case of Refractory Disease Treated With Thyroidectomy

Amiodarone induced thyrotoxicosis (AIT) is a challenging diagnosis that affects 3-5% of patients taking amiodarone in the United States. Type I AIT is seen in patients with preexisting thyroid disease and is generally treated with thionamides while type II AIT represents a destructive thyroiditis that responds to glucocorticoids. A mixed type exists and is associated with higher mortality, especially in older adults with cardiovascular disease. Thyroidectomy is considered a last resort option for patients intolerant or refractory to medical treatment.A 70 year-old male with a history of coronary artery disease, ventricular tachycardia (VT), and heart failure was referred to the endocrine clinic for abnormal thyroid function tests that showed TSH <0.0023 uIU/mL (0.4-4.7), Free T4 2.51 ng/dL (0.7-1.48) and Free T3 5.37 pg/mL (1.71-3.71). He endorsed palpitations, excessive sweating, tremors, and reported taking amiodarone for 3 years prior to presentation. Vitals showed normal pulse and blood pressure. Thyroid autoantibodies including TSI and TBII were within normal limits. Thyroid ultrasound showed mild thyromegaly with normal vascularity and no nodules. AIT was suspected and he was started on methimazole 20 mg daily, prednisone 30 mg daily and continued on his home metoprolol 100 mg daily. Methimazole and prednisone were both up titrated in a week because his labs did not improve. One month later, he presented to the hospital with acute exacerbation of heart failure. His TFTs showed (TSH <0.0021 uIU/mL, FT4 >5.0 ng/dL, FT3 4.61 pg/mL). Thyroid RAIU showed severely decreased uptake secondary to the high iodine content of amiodarone. He remained thyrotoxic despite using higher doses of prednisone (60 mg daily) and methimazole (90 mg daily). He was changed to PTU (900 mg daily) and started on cholestyramine, with no improvement in overall status. Several weeks after admission, a total thyroidectomy was performed. His postoperative course was unremarkable except for hypoparathyroidism. He was clinically and biochemically euthyroid one week after his procedure. At 6 months follow up, he remained stable on levothyroxine 100 mcg/day but continued to require calcitriol and calcium supplementation.We present an interesting case of mixed type AIT refractory to medical therapy associated with cardiovascular compromise. This case highlights the challenges in the diagnosis and management of such patients. Thyroid autoantibodies, thyroid ultrasound and RAIU were more indicative of Type II AIT, however, lack of response to high dose steroids was inconsistent with the diagnosis. While receiving the treatment for both Type I and II AIT, our patient had persistent clinical and biochemical thyrotoxicosis and required thyroidectomy. Although most AIT patients are treated medically, thyroidectomy is reserved for those most severe and refractory cases and is considered a viable option in such patients.