History Of Hypothyroidism Research Articles

Branchial Cleft Remnant Masking as a Thyroid Mass in an Adult Patient

A 53-year-old woman presented with a 4-cm left thyroid mass discovered during physical examination. She reported no history of head or neck radiation and no family history of thyroid carcinoma. However, she had a long history of hypothyroidism, treated with daily 88 mcg levothyroxine. She had no history of weight loss or other systemic symptoms over the past year and denied any compressive symptoms, dysphagia, odynophagia, or hoarseness. Neck ultrasound showed a heterogeneous and atrophic right thyroid lobe measuring 2.2 × 0.4 ×1.1 cm.

Extensive Skin Defect in a Newborn.

A 5-day old boy presents with an extensive skin defect on the scalp, which had been present at birth (Fig 1). He was born at 38 weeks via caesarean delivery due to pre-eclampsia. The mother, with a history of hypothyroidism, was treated with levothyroxine during pregnancy. No other medications, teratogenic exposures or trauma were reported during pregnancy. On physical examination, the infant is well and alert. On the vertex scalp, there is an 8-cm stellate ulcerated plaque with a central escharlike crust. There is no hair collar sign. The remainder of skin examination is normal. The head circumference is 34.7 cm (25th percentile), length is 49.0 cm (32nd percentile), and weight is 2.84 kg (12th percentile). His neurologic examination is normal. A head ultrasound reveals a focal defect in the continuity of the soft tissue overlying the ulcer with no underlying vascular anomalies. A subsequent magnetic resonance imaging of brain illustrates that the underlying dural tissue is preserved with no evidence of intracranial extension or contusion to suggest trauma. A swab for herpes simplex virus is negative. The physical examination suggests the diagnosis.The physical examination and the absence of other findings confirms the diagnosis is aplasia cutis congenita (ACC) without associated anomalies.ACC is a rare disorder with an estimated incidence of 3 per 10,000 births characterized by a localized absence of skin. (1) This disease is characterized by localized or widespread areas with partial or full thickness absence of skin at birth that occurs most commonly on the scalp. (2) The condition is believed to result from the disrupted development or degeneration of skin in utero and was first described by Cordon in 1767. (3)ACC presents as a well-demarcated defect with an overlying translucent, glistening epithelial membrane. It may also present as a nonmembranous irregular erosion or ulcer with an overlying crust. Occasionally, the defect may heal in utero and present as a scarred plaque with overlying alopecia at birth. (4)(5) The anatomic site is important when predicting underlying bony involvement or neural tube defect, with lesions overlying the scalp and spine at greatest risk. Imaging should be utilized when there is suspicion of underlying bony or neural involvement (eg, hair collar sign, membranous lesion, midline vertex location, size >5 cm and associated vascular lesions such as cutis marmorata telangiectatic congenita). (4)(5) A hair collar sign is a ring of dark coarse hair surrounding focus of absent skin or a scalp nodule and is a marker for possible spinal dysraphism. (6) Frieden classified ACC into 9 groups according to the pattern and location, underlying causes, and presence of other anomalies as outlined in Table 1. (3) The comprehensive Frieden classification scheme is beyond the scope of this discussion.Numerous factors have been considered as possible causes of ACC, including placental infarcts and vascular compromise, genetic factors, teratogenic substances, intrauterine infections, trauma, and imperfect neural tube closure. (4) There is no evidence that maternal levothyroxine is associated with ACC. The differential diagnoses may include trauma during birth, neonatal herpes infection, and epidermolysis bullosa. It is important to carefully examine the patient for any associated anomalies before classifying the group of ACC.Treatment for ACC varies depending on the extent of involvement (3)(4) although conservative treatment using a bland emollient is the most popular regimen. The most common complication is infection. The use of prophylactic oral antibiotics is not recommended, but topical antibiotics are often used. Serious complications include limb contractures, meningitis, and venous sinus thrombosis. In cases where underlying structures are exposed, surgical intervention with skin or bone grafts may be required. Parents should be counselled that healing will take weeks to months and generally leads to a scar with overlying alopecia.The patient was followed by dermatology. Initially, he was treated with topical petrolatum ointment and mupirocin for 10 days followed by plain petrolatum ointment and silicone dressings. Due to a foul-smelling discharge, he received a 10-day course of cephalexin. The lesion completely re-epithelialized by 4 months of age (Fig 2). The patient is growing and developing normally. However, there will be no hair growth at the site of aplasia cutis. Patients generally are able to camouflage the area with surrounding hair or by parting their hair differently so that it covers the patch of alopecia.

A-63 Non-Alcoholic Wernicke-Korsakoff Syndrome in a Bariatric Surgery Patient

Abstract Objective Wernicke-Korsakoff’s Syndrome (WKS), caused by thiamine deficiency and characterized by altered mental status, amnestic memory loss, confabulation, and lack of awareness, has a global prevalence rate up to 3% and is most commonly observed in alcoholics. Cases of non-alcoholic WKS are exceptionally rare and often go undiagnosed until after the critical treatment period, resulting in permanent brain damage. Despite the paucity of research in this group, there is some evidence that there may be differences in demographic factors, neuroanatomic changes, and cognitive functioning between alcoholic and non-alcoholic WKS patients. Thus, case studies are necessary to understand how non-alcoholic WKS may present and determine whether regular testing in individuals diagnosed with disorders or undergoing medical interventions that can cause thiamine deficiency should be encouraged. Methods Patient is a 65-year-old African American woman with a history of hypothyroidism, obesity, and sleep apnea. She complained of gastrointestinal problems one-month into a pre-bariatric surgery diet. Subsequent medical workups were negative, but she was hospitalized 2–3 months post-symptom onset for thiamine deficiency. Acute neuroimaging was reportedly negative. Results Results from a neuropsychological evaluation indicated temporal disorientation, delusions, and hallucinations. Psychometric testing revealed severe impairments in learning and memory. Some variability was noted in other cognitive domains, but attention, processing speed, executive functioning, language, and visuospatial and motor skills were generally intact. Symptoms of minimal depression and moderate anxiety were endorsed. Conclusion Thiamine deficiency is easily treatable, but different presentations between alcoholic and non-alcoholic cases may complicate diagnosis, delay treatment, and result in WKS. Increased awareness of these differences can inform clinical recommendations.

Gall stones and hypothyroidism: a double jeopardy

Background: Gall stones are one of the frequent biliary pathologies in the biliary system. Gall stones are deposition of bile pigments, cholesterol and calcium salts in the form of hard crystalline mass in the gall bladder. Saturation of bile in gall bladder, bile stasis due to sphincter of Oddi dysfunction, biliary sludge and change in chemical disproportion of bile are all risk factors for gall stone development. Thyroid disorders are also a very common endocrine pathology. On the Oddi sphincter, thyroid hormone receptors are present, and thyroxine has a strong relaxing effect on the sphincter. Hypothyroidism reduces the gall bladder contractility and causes lipid metabolism alteration which leads to biliary stasis. These promote the gall stone formation.Methods: A single centre cross-sectional study, was done among 86 patients diagnosed with cholelithiasis clinically and confirmed by ultrasonography. All patients were subjected to thyroid profile test, liver function test, fasting lipid profile test. Patients with a history of hypothyroidism were excluded from the study.Results: Among 86 study subjects, 29 (33.7%) of study subjects had hypothyroidism, out of which 21 (24.4%) had subclinical hypothyroidism, 8 (9.3%) had clinical hypothyroidism. Of the remaining subjects 4 (4.7%) were hyperthyroid and 53 (61.6%) were Euthyroid. A total of 24 subjects had dyslipidaemia of which (15) 62.5% had clinical and sub clinical hypothyroidism (p<0.001).Conclusions: In the evolution of Gall stones in hypothyroid patients, decreased liver cholesterol metabolism, decreased bile emptying and decreased Oddi relaxation sphincter play a role. In our study there was a strong association between hypothyroidism and gall stones. Hypothyroid patients also had abnormal total cholesterol, triglycerides and ALP levels.

English

BACKGROUND Endometrial cancer (EC) is also the second most common gynaecologic malignancy in developing countries, with an incidence of 5.9 per 100,000 women. Due to the multiple modifiable factors, a better understanding of the prognostic indicators can lead to early detection and treatment. The purpose of this study was to evaluate the frequency and the distribution of various risk factors, epidemiological factors, and histological patterns of patients diagnosed with endometrial carcinoma in a tertiary teaching hospital in south India and compare them with similar studies. The compiled findings of 60 consecutive cases that presented to our tertiary care teaching hospital in Kerala, south India, over oneand-a-half-year period were studied. METHODS This study was essentially an ex post facto retrospective study done on 60 patients for one and half years. Retrospective data collection and compilation were done with previously prepared structured questionnaires in patients with histologically proven endometrial carcinoma. All cases were subjected to hysterectomy with post-surgical histopathology correlation. A study of the risk factors, general epidemiological characteristics, endometrial biopsy findings, and post-surgical histopathology was done. RESULTS The mean age at presentation was 59.83 years. The mean age of menarche was 13.72 years, and menopause was 49.42 years. The majority of patients were married, multiparous, and presented with bleeding per vaginum (77 %). 61.7 % of the patients had a history of hypertension, 31.7 % had a history of hypothyroidism, and 43.3 % had a history of diabetes mellitus in the study population. The most common histopathological type by endometrial biopsy and histopathological correlation was endometrioid adenocarcinoma (88.3 %). CONCLUSIONS Postmenopausal age group, with early menarche and late menopause, high body mass index (BMI), thickened endometrium on ultrasound, and atrophic uterus were some of the features associated with endometrial carcinoma. The most common histological subtype was found to be endometrioid carcinoma KEYWORDS Endometrial Carcinoma, Risk Factors, Prognostic Indicators

Influence of thyroid-stimulating hormone on the recurrence after radiofrequency ablation for atrial fibrillation

Atrial fibrillation is one of the most common sustained disorders of cardiac rhythm and is associated with an increased risk of mortality, morbidity due to thromboembolic complications, and heart failure. It is important to highlight that the causative factors are vast. It is well-known that thyroid dysfunction has a proarrhythmic effect and increases the risk of cardiovascular disease. Hyperthyroidism or thyrotoxicosis is recognized to be a baseline risk factor for the development of atrial fibrillation. However, the role of hypothyroidism in atrial arrhythmogenesis is less recognized and not fully understood. At the moment radiofrequency catheter ablation is actively used in the treatment of atrial fibrillation, which in most cases has high efficiency and persistent effect. Despite that, the recurrence of supraventricular tachyarrhythmia can be observed in some patients even after radiofrequency catheter ablation. Patients with a history of hypothyroidism or even high-normal thyroid-stimulating hormone levels are more likely to have a recurrence of supraventricular tachyarrhythmia after radiofrequency catheter ablation. Therefore, thyroid-stimulating hormone levels should be determined in patients who have undergone radiofrequency catheter ablation of atrial fibrillation, especially paroxysmal atrial fibrillation. Consequently, it should be noted that the assessment and correction of modifying risk factors before radiofrequency catheter ablation may provide opportunities for future prevention of recurrence of supraventricular paroxysmal arrhythmias, improve the prognosis and overall quality of life in patients of this group. We have demonstrated the clinical case and emphasized the association of high-normal thyroid-stimulating hormone levels with supraventricular tachyarrhythmia recurrence after radiofrequency catheter ablation for atrial fibrillation.

Abstract #1002386: A Challenging Case of Severe Bilateral Graves’ Orbitopathy (GO) Involving the Prosthetic Eye, in a Patient with History of Hypothyroidism

Abstract #1002386: A Challenging Case of Severe Bilateral Graves’ Orbitopathy (GO) Involving the Prosthetic Eye, in a Patient with History of Hypothyroidism

MO960RENAL TRANSPLANTATION FROM A LIVING DONOR WITH RENAL ARTERY FIBROMUSCULAR DYSPLASIA

Abstract Background and Aims Renal transplantation is considered the most effective and less costly modality of renal replacement therapy in patients with end stage renal disease. The disparity between kidney allografts and recipients has led to a global effort to increase the pool of kidney donors. Accordingly, fibromuscular dysplasia (FMD) is no longer considered an absolute contraindication for kidney donation. The incidence of FMD is about 2.3%-5.8% in potential kidney donors. There are few cases in the literature where renal artery stenosis in allografts with known pre-transplantation FMD became worse after transplantation, indicating the importance of a proper follow up in the recipients. This is a case of a living kidney donor with no history of hypertension, proteinuria or elevated serum creatinine, whose intra-arterial digital subtraction angiography revealed FMD lesions in the left renal artery. Method Case report Results A 54-year-old Caucasian female with medical history of hypothyroidism took the decision to offer her kidney to her 37-year-old son who was diagnosed with end-stage renal disease five years ago secondary to diabetes mellitus type I. She had no history for diabetes, hypertension and renal disease. Her vital signs on admission were heart rate of 78 beats/min and blood pressure of 130/70 mmHg. Urinalysis, biochemical profile and serological evaluations were all within normal ranges. Blood urea was 36 mg/dL and serum creatinine was 0.6 mg/dL (eGFR 97ml/min/1.73m2). The abdominal ultrasound and renogram with Tc-99m DTPA showed no remarkable findings. On intra-arterial digital subtraction angiography an abnormal succession of dilatations and multifocal stenoses of the left renal artery, characteristic of medial FMD, was found. The right renal artery was normal. Apart from a dysfunctional permanent left femoral catheter, the patient had no other vascular access for hemodialysis because of Superior Vena Cava syndrome, so he needed urgent transplantation. Taking all of these into consideration, the patient was offered renal transplantation as the best option. A left open donor nephrectomy was performed; the renal artery was divided distal to the stenotic dysplastic area. The allograft was placed at the right iliac fossa of the recipient with arterial and venous anastomosis to the extrarenal iliac vessels. Post-operatively, the recipient had a delayed graft function lasted 13 days. On renal artery Doppler in the allograft we found increased resistance index (RI) that gradually normalized without any intervention. An immunosuppressive regiment of tacrolimus, mycophenolate and prednisone was administered according to our center protocol. At discharge serum creatinine was 1.7 mg/dL (eGFR: 50ml/min/1.73m2). At the year follow-up, the donor was normotensive and had near normal renal function (Cr:1.3mg/dL, eGFR: 70ml/min/1.73m2). The recipient has a well-controlled blood pressure receiving two antihypertensive drugs and maintains a satisfactory renal function. Conclusion Few cases with FMD in renal allografts from living and deceased donors have been described. In a review of 4 studies the authors concluded that the outcome of transplantation with allografts from living donors with medial FMD was satisfactory and these allografts could be used to increase the donor pool. Furthermore, it is strongly recommended to have a thorough pre-transplantation check of the donor as well as a close monitoring of both the donor and recipient after transplantation. This case shows that allografts harvested from carefully selected donors with renal arterial FMD can be successfully used, particularly in urgent conditions. Detailed pre-tranplantation imaging of donor’s renal arteries, selection of the appropriate screening method, as well as close monitoring of both donor and recipient for early interventions after transplantation is of paramount importance.

Factitious Total Triiodothyronine(T3) Elevation in a Euthyroid Patient With Paraproteinemia

Background: We report a rare case of a patient treated with levothyroxine for hypothyroidism who also had paraproteinemia and was found to have a clinically inconsistent elevation of T3 by RIA. Clinical Case: A 72 Year old African American female with a history of hypothyroidism and IgG kappa Multiple Myeloma (MM) was admitted to the hospital for altered mental status. Her hypothyroidism had been well controlled for years on a stable dose of levothyroxine 0.075mg daily. Review of systems were negative pertinent to thyroid dysfunction. Family history: negative for thyroid disease. On physical exam, an elderly female clinically euthyroid without palpable thyromegaly but was confused and disoriented. Initial Vital signs: BP 117/67, HR 62, RR 14, T 98, SpO2 99% on room air. BMI 19. EKG: normal sinus rhythm, CXR: normal, TSH: 6.27 (0.55-4.78 uIU/mL), total T3: >600 (60-181ng/dL), total T4: 4.5 (3.2-12.6 ug/dL), FT4: 1.22 (0.89-1.76 ng/dL), hemoglobin: 6.6 (12-16 g/dL), hematocrit: 20.9 (38-47 %), Na: 132 (136-145 mmol/L), K: 4.0 (3.5-5.1 mmol/L), Cl: 104 (98-10/ mmol/L), BUN: 45 (20-31 mmol/L), creatinine: 2.8 (0.6-1.0 mg/dL), total protein: 10.1 (5.7-8.2 g/dL), albumin: 1.8 (3.4- 5.0 g/dL), A:G ratio: 0.22 (0.60-1.50 mmol/L). Serum protein electrophoresis revealed Gamma Globulin 5.8 (0.8-1.7 g/dL), Kappa 9270 mg/L (3.3 -19.4 mg/L) Lambda 9.3 (5.7-26.3mg/L), K/L 996.7 (0.26 -1.65), B2 - macroglobulin: 17.9 (ref: <or= 2.51mg/L) which is consistent with an M- spike migrating in the gamma globulin region. Serum TPO, TG, TSI antibodies were negative. Further testing again reported Total T3 >600 with normal reverse T3 21(8-25 ng/dL). Conclusion: Rare cases of factitious elevations of thyroid hormone have been reported in patients with elevated abnormal IgG or IgA proteins having high binding affinity for thyroid hormone.[1] This hypothyroid patient was clinically and biochemically euthyroid except for a dramatic but clinically inconsistent elevated total T3. She also had multiple myeloma with paraproteinemia (IgG Kappa M spike). The few cases reported to date have shown factitious elevation of either or both total T4 and total T3. In our case the factitious elevation was limited to total T3. We alert clinicians to be aware of factitious elevation of thyroid hormones due to high affinity binding to immunoglobulins. In our case this caused spurious elevation of total T3, but not total T4, in a patient with multiple myeloma and an IgG kappa M spike paraprotein. Reference: 1: Marianna Antonopoulou, Arnold Silverberg, “Spurious T3 Thyrotoxicosis Unmasking Multiple Myeloma”, Case Reports in Endocrinology, vol. 2013, Article ID 739302, 3 pages, 2013. https://doi.org/10.1155/2013/739302

Premenopausal Osteoporosis &amp; Perfluoroalkyl Substance Exposure; Is There a Link?

Introduction: Perfluoroalkyl substances (PFAS) like Perflouroctanoate (PFOA) and Perflurooctane sulfonate (PFOS) are ubiquitous environmental contaminants that have been in industrial use for many years. Many known adverse effects include malignancies, reproductive and thyroid dysfunction. However, there is limited literature regarding PFAS causing low bone density. We report a case of a premenopausal woman with a history of exposure to PFAS who was recently diagnosed with osteoporosis.Clinical Case: A 36-year-old lady with a history of hypothyroidism, on levothyroxine, presented to the orthopedics clinic with complaints of sudden onset right foot pain with no trauma. She was found to have a fracture of her right second metatarsal bone. Notably, over a period of five years she had suffered multiple fractures including metatarsal, elbow and a wrist fracture, all with minimal or no trauma. She denied smoking, alcohol, chronic steroid or PPI use, history of malabsorption, celiac disease, kidney stones, malignancy or liver problems. Her menstrual cycles were regular; she was on oral contraceptives in the past for dysmenorrhea. She is on Vitamin D supplementation and consumes adequate dairy products daily. There is no family history of hip fracture or osteoporosis. Labs showed: Calcium 8.9mg/dl, Phosphorus 2.4mg/dl (2.5–4.5mg/dl), intact PTH was 92.7pg/ml (8-97pg/ml), 24-hour urine calcium was undetectable. Vitamin D was 56.6ng/ml (30-100ng/ml). CBC, TSH, FSH, liver & kidney functions were all normal. Anti-endomysial, anti-gliadin and anti-tissue trans glutaminase antibodies were all unremarkable. IgA level was 362mg/dl (8–352 mg/dl). DXA scan revealed the lowest Z-score (-3.1) in the lumbar spine. She reported a history of exposure to PFAS with a blood level of 22.3ng/ml for PFOA and 48.4ng/ml for PFOS in the year 2005. Plan is to initiate bisphosphonate therapy for the treatment of osteoporosis.Discussion: PFAS are known endocrine disruptive agents that have been used widely in making a wide range of consumer products including nonstick and stain-resistant coatings of cookware, food containers. Recent studies suggest that serum PFAS concentrations were associated with lower bone density. There was a higher incidence of lower lumbar spine bone density in patients exposed to PFOS. PFOA is believed to compete with calcitriol at the same binding site on Vitamin D receptor resulting in changes in the osteoblasts thereby decreasing bone mineralization.Conclusion: There needs to be increased awareness about the association of low bone density in patients exposed to PFAS. This is especially important in the evaluation of premenopausal osteoporosis.

Unusual Presentation of Myxedema Coma in Type 1 Diabetes Mellitus With Hyperglycemia and Polysubstance Abuse

Background: Myxedema coma is a severe manifestation of hypothyroidism that typicallypresents with altered mental status and requires close monitoring in the intensive care unit dueto 30-60% mortality rate. Clinical Case: A 56 year old white male with type 1 diabetes with recurrent DKA, polysubstanceabuse, Bipolar disorder on lithium and post surgical hypothyroidism presented due to change inmental status after being brought in by sister. Patient was found to be lethargic with confusionthat worsened over the last week. The patient was admitted several times in the past monthsecondary to pneumonia, sepsis, and recurrent DKA. On physical examination, he found to have lethargy, macroglossia, hyporeflexia, and periorbitaledema. Patient had acute respiratory failure with metabolic encephalopathy, bradycardia,tachypnea, severe hyperglycemia, hypotension of 77/51, tachypnea of 31 breaths per minuteand hyponatremia. Laboratory findings showed T4 levels 2.87(n=5.28-9.87ug/dL) withundetectable FT4 and elevated TSH (>50, n=0.300-4.500uIU/mL). Electrolyte panel showedhyponatremia (133, n=136-145mmol/L), hyperglycemia up to 532mg/dL and lithium levels werewithin normal limits (n=0.5-1.5 mmol/L). Urine drug screen was positive for cocaine. A CT scanof the head was negative. His myxedema score was diagnostic (>60). The patient wasdiagnosed with myxedema coma and admitted to the ICU. Patient was treated with IV LT4 400mcg, LT3 10mcg and hydrocortisone 100mg and started onIV LT4 100mcg daily, LT3 2.5mcg daily and hydrocortisone 100mg Q8 hours. There was wideglycemic variation from 46-532 mg/dL on POCT. The patient improved clinically, with resolutionof lethargy, confusion, fatigue, improved appetite, and improved lab work of FT3 2.30 (n=2.28-3.96pg/mL), FT4 at 0.76 (n=0.50-1.26ng/dL) and was downgraded from the ICU. On hospitalday four, he was transitioned to oral levothyroxine and discharged home. Conclusion: It is important to diagnose early and promptly manage decompensatedhypothyroidism in the setting of other comorbidities such as hyperglycemia in diabetes andpolysubstance abuse. The cocaine in the system may cause tachypnea and tachycardia. Manyconditions may have altered mental status, but with a history of hypothyroidism, Myxedemacoma should be on the differential due to its high mortality rate.

High-Dose Thyroid Hormone Replacement in Bexarotene-Induced Central Hypothyroidism

Background: Central hypothyroidism is a rare disorder characterized by a defect in thyroid hormone production by an otherwise normal thyroid gland due to decreased stimulation by TSH. Medications are an uncommon cause. Case Presentation: A 72-year-old man was referred for evaluation of a low TSH. He had a long history of hypothyroidism, euthyroid on levothyroxine, and was diagnosed with cutaneous T cell lymphoma (CTCL). Due to disease progression on dapsone, PUVA and TAR baths, he was started on bexarotene. Soon after, he developed recurrent symptoms of hypothyroidism including fatigue, cold intolerance, dry skin, and myalgias. Workup revealed a TSH of <0.01 ulU/mL (0.27-4.20) with a free T4 of 0.6 ng/dl (0.9-1.7). After evaluation, his levothyroxine dose was increased. Repeat labs 3 months later showed a TSH of <:0.01 with a free T4 0.8 ng/dl and T3 43 ng/dl (80-200). Over several months, levothyroxine titration to a supraphysiologic dose of 800 mcg daily was required, despite optimal administration, to normalize FT4. Given persistent hypothyroid symptoms and a low T3 level, liothyronine 5 mcg BID was added and resulted in clinical and biochemical euthyroidism. Clinical Lessons: Unlike in primary thyroid disorders, the TSH assay is unreliable in central hypothyroidism since values can be low, normal, or even mildly elevated; regardless, TSH has subnormal bioactivity. Ineffectual TSH leads to a low T4, which is a required for diagnosis. Bexarotene, a derivative of Vitamin A, is a retinoid X receptor (RXR) selective ligand approved for the treatment of CTCL. The exact mechanism of bexarotene-induced thyroid dysfunction is not clear, although it involves both central and peripheral effects. Bexarotene inhibits TSH gene expression by decreasing the activity of the thyrotropin β subunit gene promoter in a dose-dependent and thyroxine-independent manner; TSH levels drop as early as 4-8 hours after exposure. Bexarotene also directly lowers T4 and T3 levels, even in athyreotic patients, by negatively impacting deiodinase activity and hepatic conjugation. Stopping bexarotene is often not possible given its effectiveness in CTCL. Therefore, thyroid hormone should be initiated with the goal of achieving a normal FT4, although as the current case demonstrates, massively supraphysiologic doses and/or the addition of liothyronine may be necessary to achieve clinical euthyroidism.

Prevalence of hypothyroidism in Kannur; a coastal district in Kerala

Background: Hypothyroidism is an emerging health issue in India and worldwide. However, detail data related to the magnitude of the problem is lacking currently. Materials and Methods: A cross-sectional, multicentric study was conducted at four villages in Kannur district of Kerala, to study the prevalence of hypothyroidism among the adult population. Thyroid abnormalities were diagnosed based on laboratory results (free thyroxin [FT4] and thyroid-stimulating hormone [TSH]). Participants with history of hypothyroidism and receiving levothyroxine therapy or those with serum FT4 ≤ 0.78 ng/dL and/or TSH ≥ 4.68 μIU/mL were categorized as hypothyroid. The prevalence of self-reported and undetected hypothyroidism was assessed. Results: A total of 1084 adult male or nonpregnant female participants ≥ 18 years of age were enrolled, of which 508 were evaluated. The overall prevalence of hypothyroidism was 9.6%. 2.1% were already on levothyroxine therapy and is self-reported, whereas 7.48% were previously undetected. Higher proportion of female versus male (8.07 vs. 7.87) was diagnosed with hypothyroidism. Conclusion: The prevalence of hypothyroidism was high, affecting approximately 9.6% of adult in the study population. Female gender (odds ratio = 1.791) were found to have significant association with hypothyroidism.

Severe Menorrhagia and Thrombocytopenia in a Patient with Pseudohypoparathyroidism

A 15-year-old female with a history of hypothyroidism presented with severe anemia and thrombocytopenia in the setting of prolonged menses. After further evaluation, she was diagnosed with pseudohypoparathyroidism Ia (PHPIa). Her symptoms improved after starting medications and receiving a platelet transfusion, but a few weeks later she returned with complaints of bleeding and dizziness and was found to be thrombocytopenic once again. Her platelet counts improved after administration of intravenous immunoglobulin (IVIG), leading us to believe she has a combined immune mediated platelet destruction in addition to platelet dysfunction associated with her PHPIa.

An epidemiological study of the prevalence and determinants of overweight and obesity in women of reproductive age (15 to 49 years) group in an urban slum

Background: After comparing data of NFHS-3 and 4, prevalence of overweight and obesity in women of an urban population almost doubled in 10 yr. So, the causes of increasing prevalence need to be studied as public health concern. Objective of the study is to determine prevalence of overweight and obesity among reproductive age group (15-49 years) of women in an urban slum of Mumbai.Methods: Total 220 women were selected among 11 sectors from A to K by simple random method and data collected by using validated questionnaire. WHO’s classification was used to classify as overweight and obese.Results: Out of 220 women participated in study, 14 (6.36%) were obese, 75 (34.09%) were overweight according to BMI and 17 (7.7%) were found to be obese according to waist to hip ratio. From the present study it was seen that age group of the women, socio economic class, education, history of hypothyroidism, family history of obesity, types of work women do, hours of television watching, calorie and fat intake, had a significant relationship with BMI, whereas physical exercise they used to do and tendency to sleep in the afternoon and hours of sleep in the night had non-significant relationship with BMI.Conclusions: Obesity and overweight is found to be a growing public health problem and can be preventable. Interventional measures include developing healthy eating habits, regular moderate physical exercise, sleeping habits, health camps for screening of overweight and obesity.

IDENTIFICATION OF AUTOIMMUNE POLYGLANDULAR SYNDROME TYPE 3 IN PATIENT WITH HYPOTHYROIDISM : A CASE REPORT

Autoimmune polyglandular syndromes (APS) are characterized by sequential or simultaneous deciencies in the function of several endocrine glands that have a common cause. Etiology is most often autoimmune.We report a case of a 40-year-old female with diabetes who presented with diabetic ketoacidosis (DKA) and was later diagnosed with T1D. The patient has had a history of hypothyroidism. The presence of vitiligo was an incidental nding.Laboratory investigations showed low C peptide level, glutamic acid decarboxylase (GAD) 65 antibodies positive, thyroid peroxidase antibodies (TPO) positive, parietal cell antibody positive, and weakly positive antinuclear antibody (ANA), amid normal corticotropin(ACTH), parathyroid hormone (PTH) , vitamin B 12 levels, and a negative intrinsic factor antibody. The patient had a history of hypothyroidism, subsequently developed T1D, and had vitiligobut was overlooked. The case highlights the notable absence of recognizing the need to investigate this patient who presented with more than two endocrine diseases for measurement of hormone levels, autoantibodies against affected endocrine glands and recognition of related symptoms and signs, and hence the signicance of history taking, observation, and maintaining a high degree of suspicion.

AYURVEDA TREATMENT PROTOCOL IN FEMALE INFERTILITY DUE TO PCOS &amp; HYPOTHYROIDISM

Infertility is a global problem in one among six couples who wishes to conceive. In Ayurveda Infertility is termed as ‘Vandyatwa’ and is explained in detail. Polycystic Ovarian Syndrome (PCOS) is becoming very common in females of reproductive age and Ovulatory Dysfuction due to PCOS is one of the main reasons for female infertility. The factor for a healthy conception, pregnancy and delivery is mentioned as “Garbha Sambhava Samagri” (factors essential for conception). Acarya Susruta explained it as Rtu (ovulation), Ksetra (healthy uterus and associated structures), Ambu (proper nourishment) and Beeja (healthy sperm &amp; ovum). Sukla (sperm) &amp; Arthava (ovum) are considered as “Anthima Dhatus” (final tissues) therefore proper metabolism is essential for the formation of healthy ovum and sperm. Considering the present case the patient had the history of hypothyroidism and bilateral PCOS, both results in improper metabolism which further results in inadequate development of follicles and anovulatory cycles leading to infertility. In this case evidences of defective Dhathuparinama (process of tissue formation) can be visualized like irregular cycles, Thin Endometrium, Infertility and Increased blood sugar level. Ayurveda treatment including Sodhana (purificatory therapies) and Samana (pacification treatments) is adopted to regularise her cycles, improve the quality of ovum, to reduce the blood sugar level and thereby enhancing the chance of conception. After our treatment the patient conceived soon and now, she completed 28 weeks successfully.

Idiopathic intracranial hypertension, PCOS &amp; hypothyroidism in adolescent

An 18-year old Obese female with a history of hypothyroidism &amp; PCOS presented with complains of headache for 5 days associated with nausea and double vision for 2 days. Her neurological examination together with Cranial Nerves was Normal except for bilateral restriction of abduction, suggestive of bilateral abucens nerve involvement. Fundus findings revealed bilateral grade III disc edema. Lumbar puncture indicated increased opening pressure and MRI was normal, which further ruled out the other Causes for Raised Intracranial Pressure. Patient was treated with IV mannitol and then switched over to oral acetazolamide. Patient improved over 1 week. Patient was further followed with serial visual field tests.

A RARE CASE REPORT ON MYXOEDEMA COMA

Myxoedema coma is a sporadic life-threatening complication of severe hypothyroidism with high mortality. Altered mental status and hypothermia are the main symptoms of myxoedema coma. Apart from that, hypoxia, bradycardia, hypotension, anemia, and hyponatremia would be present. Few patients present comatose with severe myxoedema. Presenting coma may mislead the diagnosis of this condition. A female patient presented with fever, breathlessness, and disorientation was admitted. First diagnosed to have electrolyte imbalance and treatment was started accordingly. The patient did not show much of an improvement, and it took a day to identify the presence of severe hypothyroidism. Treating hypothyroidism resulted in an advance in the patient condition. Patients’ previous history of hypothyroidism was not informed during admission. It is always tough to diagnose myxoedema coma when the patients’ previous history of hypothyroidism is unknown. Hence, it is still essential to have hypothyroidism in mind while treating patients with comatose. This case has been reported to alert physicians in diagnosing myxoedema coma patients and to proceed with the treatment at the earliest.

Severe primary hypothyroidism in an apparently asymptomatic 19-year-old woman: a case report

BackgroundHypothyroidism is diagnosed on the basis of laboratory tests because of the lack of specificity of the typical clinical manifestations. There is conflicting evidence on screening for hypothyroidism.Case presentationWe report a case of an apparently healthy 19-year-old Kuwaiti woman referred to our clinic with an incidental finding of extremely high thyroid-stimulating hormone (TSH), tested at the patient’s insistence as she had a strong family history of hypothyroidism. Despite no stated complaints, the patient presented typical symptoms and signs of hypothyroidism on evaluation. Thyroid function testing was repeated by using different assays, with similar results; ultrasound imaging of the thyroid showed a typical picture of thyroiditis. Treatment with levothyroxine alleviated symptoms and the patient later became biochemically euthyroid on treatment.ConclusionThere is controversy regarding screening asymptomatic individuals for hypothyroidism; therefore, it is important to maintain a high index of suspicion when presented with mild signs and symptoms of hypothyroidism especially with certain ethnic groups, as they may be free of the classical symptoms of disease.