Manifestations Of Hyperthyroidism Research Articles

Gynecomastia as the first manifestation of thyrotoxicosis: an unusual case report

Gynecomastia as the first manifestation of thyrotoxicosis: an unusual case report

FRI506 Severe Dilated Cardiomyopathy As First Manifestation Of Thyrotoxicosis- A Case Report

Abstract Disclosure: Z. Saeed: None. C. Labib: None. W. Althunibat: None. M. Varatharajah: None. Introduction: Hyperthyroidism is a common metabolic disorder with prominent cardiovascular manifestations ranging from palpitations, angina-like chest pain, exercise intolerance and dyspnea to high-output heart failure and dilated cardiomyopathy. Approximately 6% of patients with hyperthyroidism/thyrotoxicosis develop symptoms of heart failure and less than 1% develop dilated cardiomyopathy with reduced left ventricular systolic function. Here we present a case of a 55-year-old man who presented with symptoms of heart failure and was diagnosed with dilated cardiomyopathy due to thyrotoxicosis. CASE PRESENTATION: 55-year-old man with a past medical history of vitiligo and cirrhosis presented to the emergency department with complaint of lower extremity swelling, cough, dyspnea on exertion, chest discomfort, palpitations and lethargy for two weeks. He also had a weight gain of 14 lbs. in this period. In the emergency department he had a heart rate of 118 beats/minute, physical exam revealed bilateral fine hand tremors, bibasilar crackles and a 2/6 holosystolic murmur on chest auscultation as well as hyperactive deep tendon reflexes. EKG showed atrial fibrillation with a rate of 184 beats/min. Initial chest imaging showed cardiomegaly, perihilar congestive changes and small right pleural effusion. CT abdomen & pelvis demonstrated moderate volume ascites. Lab work showed a TSH of 0.00 mIU/L (0.5-5.0. mIU/L), T4 Free 5.3 ng/dL (0.9-2.3 ng/dL), Troponin T 36 ng/L, pro BNP 3150 pg/ml. He was given furosemide, propranolol, hydrocortisone, a bolus of diltiazem and was started on diltiazem and heparin drip and admitted to the hospital. Endocrinology was consulted and he was started on methimazole and methylprednisolone. Transthoracic echocardiogram showed an ejection fraction of 15%. Thyroid ultrasound was negative for any nodules or mass. Cardiac catheterization was done which revealed moderate pulmonary hypertension, non-ischemic dilated cardiomyopathy. Patient was discharged home on methimazole and guideline directed medical therapy for heart failure. He followed outpatient with Endocrinology and Cardiology. Six months after his hospital admission, repeat TSH was 1.71 mIU/L after treatment. Repeat echocardiography showed an improvement in ejection fraction from 15% to 35-40%. DISCUSSION: Prolonged untreated hyperthyroidism leads to high output heart failure characterized by an increase in heart rate, cardiac contractility and cardiac output which in some cases progresses to dilated cardiomyopathy with impaired left ventricular systolic function. Heart failure with reduced ejection fraction is a frequently encountered problem, most commonly due to ischemic cardiomyopathy. Thyrotoxicosis is one of the rare and reversible causes of nonischemic dilated cardiomyopathy which must be promptly diagnosed and treated in order to prevent life threatening complications. Presentation: Friday, June 16, 2023

Thyrotoxic Periodic Paralysis: A Case Report and Discussion of Clinical and Imaging Features

Thyrotoxic Periodic Paralysis (TPP) is a rare manifestation of thyrotoxicosis, resulting in periodic episodes of acute onset muscle weakness in the setting of hypokalemia. The thyrotoxic form of Hypokalemic Periodic Paralysis (HPP) is less studied than the more well-known familial form due to fewer reported cases and smaller prevalence. This case study presents a 30-year-old African American male with multiple episodes of acute lower extremity muscle weakness, tachycardia, and a history of heat intolerance. Abnormal findings on thyroid ultrasound coupled with increased thyroid related immunoglobulins led to a diagnosis of TPP related to exacerbation of newly-found Graves’ disease. The case study will further discuss the importance of imaging in assessing the etiology of TPP with review of relevant literature.

Anxiety in patients with hyperthyroidism

IntroductionMental symptoms are the first manifestations of hyperthyroidism. They include anxiety, dysphoria, irritability, emotional lability, sleep disorders, intellectual dysfunction, mania or depression. Anxiety is the main symptom and requires more detailed study.ObjectivesThe objective was to determine symptomatology of anxiety in patients with hyperthyroidism and compare with euthyroid patients.MethodsThe study included 56 patients with hyperthyroidism (high free T3 and free T4, suppressed TSH) and 32 euthyroid patients (normal free T3, free T4 and TSH) of the control group. For psychiatric assessment State-Trait Anxiety Inventory [STAI], Hamilton Depression Rating Scale [HAM-D], and Hamilton Anxiety Rating Scale [HAM-A] were used.ResultsTotal scores obtained from STAI, HAM-D and HAM-A were significantly greater in the hyperthyroidism group than that of the euthyroid group (p<0.05). The level of state anxiety in patients with hyperthyroidism was 51.39 ± 0.95 (high level) compared with 41.59 ± 2.41 (moderate level) in the control group. The level of trait anxiety in patients with hyperthyroidism was 46.86 ± 0.69 (high level), and 44.16 ± 2.17 (moderate level) in the control group. Psychomotor agitation (HAM-D # 9), psychic anxiety (HAM-D # 10), insomnia (HAM-A # 4) and weight loss (HAM-D # 16) were typical for patients with hyperthyroidism, while in the control group predominate the feelings of fatigue, weakness and loss of interest in working (HAM-D # 7).ConclusionsThe prevalence of anxiety in patients with hyperthyroidism is significantly more frequent compared to euthyroid patients. Anxiety and other psychiatric symptoms should be considered by both endocrinologists and psychiatrists.DisclosureNo significant relationships.

Cardiovascular Manifestations in Hyperthyroidism: A Cross-Sectional Study in a Tertiary Care Hospital in South India.

BackgroundThe involvement of the heart in hyperthyroidism patients has a considerable prognostic value and causes significant morbidity and mortality. However, very little research, particularly among the Indian population, has addressed the most critical cardiovascular symptoms of hyperthyroidism, so this study aimed to assess the cardiovascular manifestations of hyperthyroidism.MethodThe current cross-sectional investigation involved 140 newly diagnosed and untreated confirmed cases of hyperthyroidism of any etiology for nine months. A structured data collection schedule was used to collect patient-specific and pertinent information during OPD hours or after admission. T4, T3, and TSH were measured in 10 mL of blood from each patient. The information was entered into a Microsoft Excel spreadsheet. All tests were carried out with a 5% level of significance.ResultsThe mean age of study subjects was 43.2 years. Females made up 85.0% of the subjects in the current study, while males made up 15.0%. The etiology of hyperthyroidism was primarily due to Grave’s disease (59.3%). Heat intolerance (67.9%) was the most typical presenting symptom among the patients. The most common cardiac symptom was palpitation among 76.4% of subjects in the present study. Upon clinical examination, 80.7% of subjects had tachycardia. The ECG showed atrial fibrillation (AF) in 17.9% of subjects. The echocardiogram (ECHO) findings revealed systolic dysfunction in 17.8% of subjects.ConclusionSince cardiovascular manifestations are common in patients with thyroid disease and may be the only manifestation of thyroid disease, it is suggested that all patients with thyroid disorders be checked for cardiovascular manifestations. In addition, thyroid function tests should be performed in all patients with unexplained cardiovascular disease.

Manifest hyperthyroidism in patient with autoimmune hepatitis (clinical observation)

Among patients with autoimmune hepatitis concomitant autoimmune diseases occur in 40 % of cases. The most commonly associated autoimmune hepatitis is primary biliary cholangitis, primary sclerosing cholangitis and thyroid disease. With regard to the association of autoimmune liver diseases with each other there is experience in management and this is reflected in the clinical guidelines. Information on the features of comorbidity in autoimmune hepatitis and autoimmune thyroid diseases is very limited. This article presents our own clinical observation of the manifestation of thyrotoxicosis against the background of autoimmune hepatitis.

Unilateral gynecomastia as an initial presentation of hyperthyroid Graves' disease.

SummaryGraves’ disease is an autoimmune condition leading to the activation of and an increase in thyroid hormone secretion. Manifestations of hyperthyroidism in Graves’ disease can vary among people. In this case, we report a 24-year-old Thai man with a rare presentation of unilateral gynecomastia along with symptoms of thyrotoxicosis. Physical examination revealed a 3 cm non-tender palpable glandular tissue beneath and around the left areola without nipple discharge and moderately diffuse thyroid enlargement with thyroid bruit. Thyroid function test showed a typical thyrotoxicosis state with elevated serum-free T4 and decreased serum TSH. His diagnosis of Graves’ disease was confirmed biochemically with a highly elevated anti-TSH receptor antibody. Early treatment with anti-thyroid medication was given first, followed by Radioiodine treatment (RAI) for definitive treatment due to high level of anti-TSH receptor antibody, enlarged thyroid and severe thyrotoxicosis presentation at a young age, which might not resolve by anti-thyroid medication alone. The patient responded well to treatment and achieved complete resolution of unilateral gynecomastia with clinically and biochemically euthyroid within 3 months after treatment. No recurrent gynecomastia was found during the 2-year follow-up.Learning pointsCharacteristic of gynecomastia in hyperthyroidism is usually presented with bilateral progressive gynecomastia; however, unilateral gynecomastia is occasionally found as a presentation of hyperthyroidism.Complete resolution of gynecomastia without recurrence can be achieved within a few months of treatment after thyrotoxicosis is resolved in patients with hyperthyroidism with the recent development of gynecomastia.RAI for definitive treatment is recommended in young adult patients expressing very high anti-TSH antibody level with severe thyrotoxicosis.

Smoothelin-Like Protein 1 Regulates the Thyroid Hormone-Induced Homeostasis and Remodeling of C2C12 Cells via the Modulation of Myosin Phosphatase.

The pathological elevation of the active thyroid hormone (T3) level results in the manifestation of hyperthyroidism, which is associated with alterations in the differentiation and contractile function of skeletal muscle (SKM). Myosin phosphatase (MP) is a major cellular regulator that hydrolyzes the phosphoserine of phosphorylated myosin II light chain. MP consists of an MYPT1/2 regulatory and a protein phosphatase 1 catalytic subunit. Smoothelin-like protein 1 (SMTNL1) is known to inhibit MP by directly binding to MP as well as by suppressing the expression of MYPT1 at the transcriptional level. Supraphysiological vs. physiological concentration of T3 were applied on C2C12 myoblasts and differentiated myotubes in combination with the overexpression of SMTNL1 to assess the role and regulation of MP under these conditions. In non-differentiated myoblasts, MP included MYPT1 in the holoenzyme complex and its expression and activity was regulated by SMTNL1, affecting the phosphorylation level of MLC20 assessed using semi-quantitative Western blot analysis. SMTNL1 negatively influenced the migration and cytoskeletal remodeling of myoblasts measured by high content screening. In contrast, in myotubes, the expression of MYPT2 but not MYPT1 increased in a T3-dependent and SMTNL1-independent manner. T3 treatment combined with SMTNL1 overexpression impeded the activity of MP. In addition, MP interacted with Na+/K+-ATPase and dephosphorylated its inhibitory phosphorylation sites, identifying this protein as a novel MP substrate. These findings may help us gain a better understanding of myopathy, muscle weakness and the disorder of muscle regeneration in hyperthyroid patients.

Thyroid storm in pregnancy

Endocrine emergencies can occur during pregnancy and are associated with the thyroid gland and diabetes. Thyrotoxicosis is a hypermetabolic condition associated with an increase in thyroid hormone in the blood. The manifestations of thyrotoxicosis can range from those without symptoms to a life-threatening condition such as thyroid storm. The diagnosis of thyroid storm can be made based on a history of previous thyroid gland disorders; current signs and symptoms; and laboratory tests of thyroid-stimulating hormone, free thyroxine, and triiodothyronine. The thyroid storm is a rare condition, but the mortality rate on these patients is high. Characteristics of thyroid storms are altered consciousness, hyperpyrexia, tachycardia, and gastrointestinal disturbances. Thyroid storm management focuses on the prevention of thyroid hormone synthesis and its conversion in the periphery, identification, and intervention of the thyroid storm causes and the management of systemic disorders that present during thyroid storm. We present a 24-year-old female who presented with a very high suspicion of thyroid storm based on her Burch and Wartofsky's score criteria had a total score with a very high suspicion of thyroid storm. While pregnancy itself can increase the risk of developing severe thyrotoxicosis, the main management is determined by the presence of emergency manifestations. Our concern was not only for the safety of the mother but also for the fetus. Some drugs need special attention because they cross the blood–placental barrier. Previous patient comorbidities should also receive attention in the management of thyroid storm. The patient was being treated in the intensive care unit and managed to move to a regular ward after 3 days.

Abstract 16989: Clinical Outcomes of Atrial Fibrillation With Hyperthyroidism

Introduction: Atrial fibrillation (Afib) is a common cardiac manifestation of hyperthyroidism. The data regarding outcomes of A fib with and without hyperthyroidism are lacking. Hypothesis: We hypothesized that patients with Afib and hyperthyroidism have better clinical outcomes, compared with Afib patients without hyperthyroidism. Methods: We queried National Inpatient Sample database for years 2015 - 2017 using Validated International Classification of Diseases and Clinical Modification (ICD-10-CM) codes for atrial fibrillation and hyperthyroidism. Patients were separated into 2 groups- A fib with hyperthyroidism and A fib without hyperthyroidism. Results: Study was conducted on 68,095,278 pateints. A total of 9,727,295 Afib patients were identified, out of which 90,635(0.9%) had hyperthyroidism. The prevalence of hyperthyroidism was higher in patients with Afib (0.9% vs 0.4%, p value <0.001), compared with patients without A fib. Using multivariate regression analysis after adjusting for various confounding factors, the odds ratio of Afib with hyperthyroidism was 2.08 (CI 2.07 - 2.10 P<.0001). Afib patients with hyperthyroidism were younger, (70.9 vs75.1 years, p<0.0001) and more likely to be female (63.9% vs 47% p<0.0001) as compared with Afib patients without hyperthyroidism. Afib patients with hyperthyroidism had lower prevalence of CAD (36.4% vs 43.8%,p<0.0001), cardiomyopathy(24.1% vs 25.9%,p<0.0001), valvular disease (6.9% vs 7.4%,p<0.0001), hypertension(60.7% vs 64.4%,p<0.0001) , and diabetes mellitus (28.9% vs 31.8%,p<0.0001). Afib with hyperthyroidism group had lower all-cause mortality (3.3% vs 4.8%, p<0.0001), shorter mean length of stay (5.7 ±6.6 vs 5.9±6.6 days,p<0.0001) and hospitalization cost ($14968±21871 vs $15955±22233, p<0.0001). The disposition to home was higher in Afib with hyperthyroidism patients (50.6% vs 41.8 p<0.0001). Conclusions: Presence of hyperthyroidism is associated with Afib in both univariate and multivariate analysis. Afib patients with hyperthyroidism have better clinical outcomes, compared with Afib patients without hyperthyroidism.

Reversible Thyrotoxicosis Dilated Cardiomyopathy

Thyrotoxic cardiomyopathy is a rarely diagnosed disease in patients coming into the hospital with hyperthyroidism for the first time. The objective of this case study is to present the rare case of a patient, who was diagnosed with a thyrotoxic cardiomyopathy for the first time. A 47-year old Saudi male was presented in the King Abdulaziz Medical City in Jeddah, Saudi Arabia in March 2017, with a two-week history of progressive dyspnea, orthopnea, paroxysmal nocturnal dyspnoea, and atrial fibrillation. Following physical examinations and investigations, the diagnosis of thyrotoxicosis was performed. Initially, he was treated with Methimazole, followed by radioactive therapy, which resulted in the patient’s full recovery from cardiomyopathy through the treatment of his thyrotoxicosis. One of the first symptoms, the manifestation of thyrotoxicosis, is thyrotoxic dilated cardiomyopathy. In most cases, it may be completely reversible through the appropriate treatment of the thyrotoxicosis.

Choreic Movements as Manifestation of Hyperthyroidism in an Adolescent at the Onset of Graves’ Disease

Objective; Nervous system dysfunction, including irritability, emotional lability and hyperkinesia are the signs and symptoms frequently observed in hyperthyroidism; chorea and/or choreoathetosis have also been reported in adults and rarely in pediatric age. Case report; We described the case of a 12-year-old boy with bilateral choreiform movements of the arms at the onset of the Graves’ disease. The patient was treated with metimazole and chorea disappeared with euthyroidism. Discussion; Hyperthyroidism is to be considered an unusual cause of chorea in childhood. Every child and adolescent with choreiform movements should be examined also for thyroid function.

Quite uncommon entity: Gynecomastia as an initial manifestation of thyrotoxicosis

Quite uncommon entity: Gynecomastia as an initial manifestation of thyrotoxicosis

SAT-595 Ventricular Fibrillation as a Manifestation of Hyperthyroidism

Background: Thyrotoxicosis is a known cause of atrial arrhythmias however, ventricular arrhythmias in this setting are rare. We report a case of ventricular fibrillation (VF) in a patient with Graves hyperthyroidism in the absence of coronary disease. Clinical Case: A 55-year old woman with hypertension and a self-reported thyroid nodule presented with a two week history of general malaise, palpations, diarrhea and muscle aches. Her mother had a goiter and paternal aunt required a thyroidectomy. Both her father and paternal uncle died at age 58 and 60 respectively of myocardial infarction. She was tachycardic to 125 beats per minute (bpm) and had a firm goiter with no bruit and normal reflexes. TSH was <0.01, free T4 > 6.99 ng/dL (n= 0.7-2.19 ng/dL), total T3 > 7.81 ng/mL (n=0.97 -1.7 ng/mL), thyroid stimulating immunoglobulin 516 % (n= <140%), and thyroid binding inhibitory immunoglobulin was 82.5% (n=<16%). Treatment with dexamethasone, methimazole, and propranolol was initiated. Homogenous increased uptake was seen in the thyroid gland on nuclear medicine scan. On day two of admission, her total T3 remained > 7.81 ng/mL despite therapy but her heart rate was better controlled at 100 bpm. However, that night she suffered a 40- minute cardiac arrest from VF. Spontaneous circulation was restored after multiple shocks, amiodarone and lidocaine, and then temporary pacing for bradycardia. She received a total of 440mg of propranolol and 40mg of methimazole prior to cardiac arrest. Serum potassium was normal pre arrest but rose to 6.9 mmol/L (n=3.5-5.1 mmol/L) after. Given the bradycardia, glucagon was given for possible beta blocker toxicity although this was thought to be unlikely as telemetry did not reveal pre-arrest bradycardia. There was no evidence of a coronary event since admission troponin was negative and post arrest troponin was only mild elevated with a flat trend. No wall motion abnormality was see on echocardiogram and ventricular function was preserved. Cardiac catheterization was deferred due to declining renal function. Subsequent myocardial perfusion imaging displayed only an apical cap artifact and coronary CT angiogram was free from atherosclerosis. She had no further arrhythmias. An implantable cardioverter defibrillator was placed prior to discharge for secondary prevention of ventricular arrhythmias. Conclusion: VF in the absence of underlying coronary disease or heart failure is rare in thyrotoxicosis. Thyroid hormone induced coronary vasospasm and activation of regionally varied beta-adrenergic receptors are proposed mechanisms for VF. Further, some individuals may have genetic predisposition to this in the setting of hyperthyroidism. This case highlights the urgency of achieving a euthyroid state and closely monitoring individuals with a family or personal history of ventricular arrhythmias or sudden cardiac death.

Transient pulmonary hypertension as a manifestation of hyperthyroidism

Transient pulmonary hypertension as a manifestation of hyperthyroidism

Thyroid Storm: Emergency Care for Thyrotoxicosis

Thyroid hormones affect all organ systems and, in excess, can cause increased metabolic rate, heart rate, ventricle contractility, and gastrointestinal motility as well as muscle and central nervous system excitability. Thyroid storm is the extreme manifestation of thyrotoxicosis with an estimated incidence of 0.20 per 100,000 per year among hospitalized patients in Japan. The mortality of thyroid storm without treatment ranges from 80% to 100%; but with treatment, the mortality rate is between 10% and 50%. The diagnostic strategy for thyroid storm may take into consideration Burch–Wartofsky scoring or Akamizu's diagnostic criteria. Multiple treatment aims need to be addressed in managing thyroid storm effectively. This paper puts together all aspects to be considered for the management of hyperthyroidism and thyroid storm during the acute and emergency phase as well as consideration of special populations.

Atrial flutter with 1:1 atrioventricular conduction: An uncommon cardiac manifestation of hyperthyroidism

Atrial flutter with 1:1 atrioventricular conduction: An uncommon cardiac manifestation of hyperthyroidism

TSH-secreting pituitary adenoma: late diagnosis and effectiveness of therapy

The modern therapeutic and diagnostic algorithms allow timely detection of pituitary disorder to prescribe adequate treatment. Meanwhile, when interpreting the thyroid status, physicians need to take into account the extremely rare but the actually existing possibility of central thyrotoxicosis. The worldwide practice shows that diagnosis of this condition is rather challenging.&#x0D; We report a clinical case of a TSH-secreting pituitary adenoma in a 47-year-old female who received a long-term thyrostatic therapy for thyrotoxicosis. The patient was diagnosed with Graves’ disease; however, thyrotoxicosis was actually caused by TSH-oma. The key laboratory signs of central thyrotoxicosis included the combination of episodes of normal or elevated TSH level with the high or normal free T4 level. MRI showed a pituitary macroadenoma. The clinical manifestations of thyrotoxicosis made it possible to rule out the thyroid hormone resistance syndrome. The attempted therapy with octreotide eliminated the clinical and laboratory signs of thyrotoxicosis, so the conservative method was selected as first-line therapy. The features of clinical and laboratory signs, as well as the principles of differential diagnosis and modern methods for treating TSH-secreting pituitary adenomas are discussed.

Thyrotoxic hepatitis

In most cases, liver pathology in hyperthyroidism is confined to asymptomatic changes in laboratory indices, while clinical signs are much rarer. Three clinical variants of liver pathology in patients with hyperthyroidism can be differentiated: drug-induced hepatitis that develop in response to administration of thyrostatic agents (mainly propylthiouracil); concomitant autoimmune liver diseases (autoimmune hepatitis, primary biliary cirrhosis), and hepatopathies as a direct manifestation of thyrotoxicosis (thyrotoxic hepatitis). Thyrotoxic hepatitis is a rare condition difficult to diagnose. The variety of etiological factor of liver pathology in hyperthyroidism, universal clinical symptoms, and the lack of specific histological markers make it difficult to make a correct diagnosis.&#x0D; A clinical case of Graves’ disease complicated with severe thyrotoxic hepatitis, the edema-ascites syndrome and hyperbilirubinemia is reported. The patient was diagnosed with thyrotoxic hepatitis after all other reasons for liver pathology have been ruled out. The concomitant thyrogenic myocardiodystrophy, cardiomegaly and atrial fibrillation required ruling out the diagnosis of cardiogenic liver injury and made diagnosing more difficult. Normalization of the thyroid status in patients receiving mercazolyl therapy was accompanied by alleviation of clinical symptoms of hepatitis and the positive dynamics of the indices of liver function tests.&#x0D; A brief review of the data on clinical variants and mechanisms of liver injury in patients with thyrotoxicosis is presented.

A Unique Presentation Of Thyroid Storm And Myopericarditis In A Young Muscular Man

ABSTRACT Objective: Thyroid storm represents the extreme manifestation of thyrotoxicosis and is a medical emergency with a high mortality rate. The clinical manifestations of a severely thyrotoxic state can be devastating, and its most significant effects occur in the cardiovascular system. Cardiac involvement is the leading cause of death in patients with thyroid storm. We report a unique case of thyroid storm precipitated by viral myopericarditis in the setting of exogenous thyroid hormone supplementation. Methods: Case report and review of the literature. Results: We report a case of a previously healthy 26-year-old male with a history of bodybuilding who developed thyroid storm with multi-organ failure, including acute-onset congestive heart failure, leading to cardiogenic shock. Investigations revealed ingestion of exogenous thyroid hormone as the source of his thyrotoxicosis. Initial labs revealed serum thyroid-stimulating hormone 0.015 mU/L, free thyroxine 2.3 ng/dL, free triiodothyronine 8.8 pg/mL...