Normal T4 Research Articles

SUN-291 17 Year Old Male with Galactorrhea and Elevations in Prolactin and ACTH in the Setting of a Pituitary Microadenoma

Pituitary adenomas are uncommon in children with an incidence of 0.1 per million. Prolactinomas are the most frequent, followed by ACTH-secreting adenomas, whereas TSH-, GH- and non-functioning adenomas are less frequently encountered. Plurihormonal pituitary adenomas, though extremely rare have also been reported, with ACTH/Prolactin and ACTH/GH being the most common. (Lubov B. Mitrofanova, 2017) A 17 year old male presented with bilateral ‘milky’ areolar discharge for the past 2 weeks. He also had a history of chronic headaches and decreased energy for the past 6 months. Initial evaluation at his PCP’s office showed an elevated prolactin of 90.2 ng/mL (4.0-15.2) and normal TSH and free T4. At presentation to endocrinology, physical exam showed weight of 106.8 kg >99%ile, height of 182.8 cm, 85%ile, BMI of 32, 98%ile, and blood pressures 117/50 mmHg, 50th/10th%ile respectively. He was also noted to have circumferential acanthosis nigricans of the neck, gynecomastia, Tanner V pubic hair, and 20 mL testes bilaterally; no striae, nuchal adiposity or areolar discharge was noted. Subsequent biochemical testing at 0900 showed prolactin, 100.7 ng/mL (4.0-15.2), ACTH, 177 pg/mL (<47), cortisol, 21.6 ug/dL (5.3-22.5), FSH 0.8 mU/mL (1.5-12.4), LH 1.5 mU/mL (1.8-10.8), with T4, TSH and IGF-1 within normal limits. An MRI of the brain showed a 3 mm microadenoma in the adenohypophysis. Given elevated prolactin, ACTH and high normal morning cortisol, there were concerns for Cushing’s disease, and midnight salivary cortisols were obtained, which were normal: 0.033, 0.036 and 0.040 ug/dL (<0.259). He was then started on cabergoline, titrated up to 0.5 mg twice a week. After 3 months, he had resolution of the areolar discharge and a decrease in headache frequency as well as improved energy. His repeat labs showed prolactin, 8.4 ng/mL, AM cortisol 17.4 ng/mL, though ACTH was quantity not sufficient. Hyperprolactinemia is most commonly caused by a pituitary adenoma, and symptoms in men include gynecomastia, areolar discharge, fatigue and decreased libido. Plurihormonal adenomas, though a rarity, must be considered when an adenoma is confirmed by imaging, and should trigger screening for other pituitary hormonal abnormalities. Treatment with D2-receptor agonists has been shown to be an effective treatment for some plurihormonal adenomas, likely dependent on D2 receptor expression of the particular adenoma in question (Shalini Kunasegaran, 2017). Lubov B. Mitrofanova, P. V. (2017). Plurihormonal cells of normal anterior pituitary: Facts and conclusions. Oncotarget, 8(17): 29282-29299. Shalini Kunasegaran, M. S. (2017). An unusual case of Cushing's syndrome due to bihormonal ACTH-prolactin secreting pituitary macroadenoma with rapid response to cabergoline. BMJ Case Reports, 10.1136/bcr-2017-219921 .

SUN-LB094 Massive Pericardial Effusion as an Initial Presentation of Hashimoto's Thyroiditis

Background: Pericardial effusion is a known complication of hypothyroidism and usually correlates with the severity and duration of the disease. However, massive pericardial effusion as the primary presenting manifestation of Hashimoto’s thyroiditis is extremely rare. Case: We present a 44-year-old female with a past history of diabetes mellitus who presented to the hospital with complaints of chest pain described as intermittent, sharp, non-radiating, 10/10 intensity ongoing for six days. On physical examination, she appeared lethargic with slow speech, cool dry puffy skin and muffled heart sounds on auscultation. EKG showed sinus rhythm and no significant ST-T wave changes and troponins trended negative. Initial lab-work was significant for a very high TSH of 86.4 (0.35-5.5 uIU/ml) and a low free T4 of 0.54 (0.61-1.12 ng/dl) with a normal free T3 and total T4. CBC, ESR and CRP were within normal limits. The patient did not endorse noticing any of the classical symptoms of hypothyroidism prior to this admission. Chest X-ray and Chest CT were concerning for a large pericardial effusion. Bedside echocardiogram revealed an ejection fraction of 30% and a massive pericardial effusion. No pericardial calcification or thickening was noted. Due to concern for tamponade physiology on echocardiogram, emergent pericardiocentesis was performed and 720 ml of straw-colored fluid was removed. Cardiac catheterization did not show any evidence of coronary artery disease and repeat echo showed trivial pericardial effusion with improvement in ejection fraction to 40-45%. The fluid analysis did not show evidence of mesothelial cells and cultures were negative. Serological markers for viral diseases (Coxsackie virus, EBV, Adenovirus), as well as immunological markers for rheumatoid arthritis (rheumatoid factor) and lupus (double-stranded DNA) were negative. Serum thyroid peroxidase (TPO) antibody was strongly positive: 877 IU/ml (<9IU/ml). Ruling out other common etiologies, pericardial effusion was attributed to severe hypothyroidism. The patient was treated with IV levothyroxine and IV hydrocortisone and her mental status improved over the course of her stay. Conclusion: Hypothyroidism should certainly be considered as a differential diagnosis in patients presenting with unexplained pericardial effusion. The mainstay of treatment for cases with mild to moderate effusions is thyroxine supplementation. Pericardiocentesis is only indicated in patients with massive effusion who are at risk of developing tamponade. Unless otherwise noted, all abstracts presented at ENDO are embargoed until the date and time of presentation. For oral presentations, the abstracts are embargoed until the session begins. s presented at a news conference are embargoed until the date and time of the news conference. The Endocrine Society reserves the right to lift the embargo on specific abstracts that are selected for promotion prior to or during ENDO.

MON-600 Reducing Inappropriate Serum T3 Laboratory Ordering in Patients with Treated Hypothyroidism

Background: Choosing Wisely is a campaign of the American Board of Internal Medicine that aims to promote evidence-based practices to reduce unnecessary ordering of tests or procedures. As part of this campaign, national organizations including the Endocrine Society have identified common tests or procedures that providers should be aware of in their practices. The Endocrine Society advises, “Don’t order a total or free T3 level when assessing levothyroxine (T4) dosing in hypothyroid patients.” This is in line with the co-sponsored American Thyroid Association and American Association of Clinical Endocrinologists clinical practice guidelines for hypothyroidism in adults, which states there is “limited utility” in measuring serum T3 in patients with hypothyroidism, due to typically normal T3 levels (resulting from stimulation of thyroid hormone synthesis by increased TSH) and up-regulation of type 2 iodothyronine deiodinase in these patients. Methods: This study assessed the ordering practices among providers who manage patients with hypothyroidism within our institution, a large urban tertiary/quaternary care academic health system. A best practice advisory (BPA) alert was developed following the collection of baseline data. This BPA consisted of a pop-up window triggered when any type of T3 laboratory test (total and/or free levels) was ordered among patients who have thyroid hormone (both generic and brand-name levothyroxine formulations) listed in the medical record. The BPA alert required user acknowledgement and a clinical decision-making process before the T3 laboratory test order could be placed. Results: Prior to launching the BPA, silent mode testing showed that T3 laboratory tests were inappropriately ordered a mean of 165.8 times per week (standard deviation 17.0). After the BPA alert was actively launched in Sept 2018, inappropriate T3 ordering was triggered a mean of 127.3 times (standard deviation 25.0) in the initial three weeks, dropping to a mean of 115.0 (standard deviation 13.5) in the next three week time period. As a result of the BPA, providers canceled 4.9-12.3% of triggered T3 orders during the six weeks after the BPA launch. The BPA alert currently remains active at our institution. Conclusions: Although national guidelines recommend against ordering serum T3 concentrations during the monitoring of patients with hypothyroidism managed on thyroid hormone replacement therapy, these laboratory tests are inappropriately ordered in many patients. Development of a triggered alert may reduce inappropriate monitoring practices for this common clinical condition, decrease costs, and improve utilization of limited healthcare resources.

OR10-3 Contributions of the Hypothalamus and Pituitary in Expressing the Thyroid Phenotype of SBP2 Deficiency: Other Regulatory Tiers in Addition to the Thyroid Gland

Background: Selenocysteine insertion sequence binding protein 2 (SBP2) is essential for selenoprotein synthesis, including the selenoenzymes deiodinases. Selenoprotein deficiency in individuals with SBP2 deficiency results in a multi-organ syndrome with characteristic thyroid function tests (TFTs) abnormalities of high serum T4, rT3, TSH and low T3. Sbp2 deficient mice (Sbp2 iCKO) replicate most of the TFTs except for normal T3. Previously, we reported the thyroid gland contribution in expressing the thyroid phenotype in Sbp2 iCKO mice with increased thyroid hormone (TH) content and increased synthesis capacity. The decreased expression and activity of selenoenzyme glutathione peroxidase and accumulation of hydrogen peroxide was implicated to promote iodine organification and TH synthesis. Methods: In this study, we evaluated the role of hypothalamus and pituitary in expressing the thyroid phenotype. TH content and gene expression were measured in cerebrum. mRNA expression, TSH content and TRH stimulation test were assessed in pituitary. Results: In the brain, Sbp2 iCKO mice had similar T4 levels compared to WT mice, 9.9 vs 8.4 pg/mg prot, while T3 content was decreased, 12 vs 17 pg/mg prot, discrepant to the respective serum levels. An indicator of local TH status, the expression of TH responsive gene Hr was decreased, 66% of that in WT mice, also indicative of local hypothyroidism. In addition, the expression of TH transporters Mct8 and Oatp1c1 was decreased in cerebrum, 78% and 71% vs WT mice, respectively. While the direct mechanisms for this finding remain elusive, this together with the low deiodinase 2 activity, likely contribute to the low cerebral T3 level. In contrast, at the level of pituitary, which is outside the blood brain barrier, Sbp2 iCKO mice had normal expression of Hr and Tshb gene, indicating adequate local T3. However, pituitary Trhr1 gene expression was increased in Sbp2 iCKO mice, 139% of that in WT, indicative of hypothyroidism at the level of hypothalamus, in line with the aforementioned findings in cerebrum. Although Sbp2 iCKO mice had higher baseline serum TSH, the peak TSH 15 minutes after TRH stimulation was significantly lower, 70% of that in WT mice. This is in part due to the decreased baseline pituitary TSH content by RIA, 71 vs 147 mU/mg prot in Sbp2 iCKO vs WT mice, indicating lower availability of preformed TSH in the pituitary gland. Thus, the observed different T3 availability between brain/hypothalamus and pituitary in Sbp2 deficiency contribute to the characteristic thyroid phenotype through complex regulation of thyrotroph function, dependent on both local and hypothalamic TH status and signaling. Conclusions: In the expression of thyroid phenotype of Sbp2 deficiency, there are contributions not only from the impaired TH metabolism due to deficiency of the deiodinases, but also from each level of the hypothalamic-pituitary-thyroid axis.

Thyroid Hormone Profile in Children with Sepsis: Does Euthyroid Sick Syndrome Exist?

BACKGROUND:Alterations in peripheral thyroid hormone metabolism play an eminent role in the development of the euthyroid sick syndrome. Altered solvation may also lead to changes in peripheral thyroid hormones. Data on thyroid hormones in critically ill children remain unclear.AIM:This study was aimed to evaluate thyroid hormone profile in children with sepsis as well as to assess the association between thyroid level and sepsis outcome.METHODS:An observational cohort study was conducted in 80 children with sepsis from October 2015 to January 2016 in Haji Adam Malik General Hospital. T3 and T4 level were measured on day 1 and after > 72 hours of sepsis diagnosed.RESULTS:We recorded length of stay in PICU, patient outcome and analysed the relationship with the chi-square test. Level of T3 and T4 were decreased on day 1 in pediatric sepsis. Of 80 subjects, 57 (71.2%) with low-level T3 and 41 (51.2%) with low T4 were found. The relationship between T3 and T4 level on day 1 with the length of stay were not found (P = 0.500; P = 0.987). There were a significant relationship between level of T3 and T4 with outcome (P = 0.0001; OR 24.706; P = 0.014; OR 3.086). Subject with normal T3 and T4 level had 24 and 3 times life chances compare to lower level.CONCLUSION:The Euthyroid Sick Syndrome in children with sepsis does exist. There was a significant relationship between T3 and T4 level on day 1 with patient outcome.

Investigation of T4 and T6 heat treatment on the wear properties of sillimanite reinforced LM30 aluminium alloy composites

In the present work, an attempt has been made to study the effects of heat treatment on the dry sliding wear properties of sillimanite reinforced LM30 aluminium matrix composites. Stir casting process was used for the processing of the composites. Composites with two different particle sizes (fine 1–20 µm and coarse 75–106 µm) and different weight ratio (3–15 wt% in the step size of 3 wt%) were fabricated. Further, the fabricated composites were subjected to the heat treatment as per T4 and T6 process. The composites were heated (at 540 °C), held at that temperature for 0.5–2 h and quenched in water. For T4, the composites were subjected to natural aging of 10–30 days at room temperature and for T6, composites were artificially aged by reheating to a temperature of 150–250 °C, holding there for 1–5 h, followed by air cooling. Hardness testing revealed that the composites subjected to T6 heat treatment exhibited superior hardness in comparison to normal composites and T4 heat treated composites. Further, wear analysis revealed that heat treatment of the composites affected the wear properties of the composites. Maximum improvement in the wear rate was observed for T6 heat treated composites. Also, the coefficient of friction of T6 heat treated composites was lower than other composites. Finally, SEM analysis revealed that the surface damage observed for T6 composites was lesser in comparison to other. In the initial period of wear abrasive wear was dominant and with increase in the sliding distance adhesive/delamination wear mechanism was dominant. Therefore, T6 composites revealed a superior combination of wear properties, and found to be in close comparison to grey cast iron used in the brake drum applications. Hence, 15 wt% reinforced T6 composites can be used as an alternate material for brake drum applications.

Thyroid hormone receptor function in maturing ovine cardiomyocytes.

Plasma thyroid hormone (tri-iodo-l-thyronine; T3 ) concentrations rise near the end of gestation and is known to inhibit proliferation and stimulate maturation of cardiomyocytes before birth. Thyroid hormone receptors are required for the action of thyroid hormone in fetal cardiomyocytes. Loss of thyroid hormone receptor (TR)α1 abolishes T3 signalling via extracellular signal-related kinase and Akt in fetal cardiomyocytes. The expression of TRα1 and TRβ1 in ovine fetal myocardium increases with age, although TRα1 levels always remain higher than those of TRβ1. Near term fetal cardiac myocytes are more sensitive than younger myocytes to thyroid receptor blockade by antagonist, NH3, and to the effects of TRα1/α2 short interfering RNA. Although T3 is known to abrogate ovine cardiomyocyte proliferation stimulated by insulin-like growth factor 1, this effect is mediated via the genomic action of thyroid hormone receptors, with little evidence for non-genomic mechanisms. We have previously shown that the late-term rise in tri-iodo-l-thyronine (T3 ) in fetal sheep leads to the inhibition of proliferation and promotion of maturation in cardiomyocytes. The present study was designed to determine whether these T3 -induced changes are mediated via thyroid hormone receptors (TRs) or by non-genomic mechanisms. Fetal cardiomyocytes were isolated from 102±3 and 135±1days of gestational age (dGA) sheep (n=7 per age; term ∼145dGA). Cells were treated with T3 (1.5nm), insulin-like growth factor (IGF)-1 (1μgmL-1 ) or a combination in the presence of TR antagonist NH3 (100nm) or following short interfering RNA (siRNA) knockdown of TRα1/α2. Proliferation was quantified by 5-bromo-2'-deoxyuridine (BrdU) uptake (10μm). Western blots measured protein levels of extracellular signal-related kinase (ERK), Akt, TRα1/β1 and p21. Age specific levels of TRα1/β1 were measured in normal hearts from fetuses [95dGA (n=8), 135dGA (n=7)], neonates (n=8) and adult ewes (n=7). TRα1 protein levels were consistently >50% more than TRβ1 at each gestational age (P<0.05). T3 reduced IGF-1 stimulated proliferation by ∼50% in 100dGA and by ∼75% in 135dGA cardiomyocytes (P<0.05). NH3 blocked the T3 +IGF-1 reduction of BrdU uptake without altering the phosphorylation of ERK or Akt at both ages. NH3 did not suppress T3 -induced p21 expression in 100dGA cardiomyocytes in 135dGA cardiomyocytes, NH3 alone reduced BrdU uptake (-28%, P<0.05), as well as T3 -induced p21 (-75%, P<0.05). In both ages, siRNA knockdown of TRα1/α2 blocked the T3 +IGF-1 reduction of BrdU uptake and dramatically reduced ERK and Akt signalling in 135dGA cardiomyocytes. In conclusion, TRs are required for normal proliferation and T3 signalling in fetal ovine cardiomyocytes, with the sensitivity to TR blockade being age-dependent.

Screening of hypothyroidism in antenatal mothers and its feto-maternal outcome in tertiary care centre

Introduction: Over the past several years it has been proved that maternal thyroid disorders influence the outcome of mother and fetus, during and also after pregnancy. The most frequent thyroid disorder in pregnancy is maternal hypothyroidism. Overt hypothyroidism (low serum free T4 & high TSH level) complicates from 2 to 3 pregnancies per 1000 whereas subclinical hypothyroidism (high serum TSH but normal free T4 level) is seen in 2.3% cases.2 Endemic iodine deficiency accounts for most hypothyroidism in pregnant women worldwide whereas chronic autoimmune thyroiditis is the most common cause of hypothyroidism in iodine sufficient parts of the world. Objectives: (1) To detect cases of overt or subclinical hypothyroidism in antenatal mothers in early weeks of gestation by screening methods, (2) To start early treatment in positive cases for reduction of deleterious effects on maternal and fetal outcome, (3) To study the maternal complications during antenatal, intranatal and postnatal period in hypothyroid mothers in comparison to euthyroid pregnancy. (4) To note any difference in incidence of low birth weight babies and early neonatal complications in hypothyroid women. Material and Methods: A prospective clinical study was conducted department of Obstetrics and Gynaecology, Calcutta National Medical College and Hospital, Kolkata, Study population included all pregnant mothers attending antenatal clinic in Calcutta National Medical College and Hospital, Study period was one year (June 2012-May 2013), Sample size is 500 in number. Results: Cases (hypothyroid, TSH>2.3 µU/ml) constituted 4.4% of the screening population, in which the incidence of overt hypothyroid (free T44 within normal range) was 4.4%. Controls (euthyroid, TSH Keywords: Hypothyroid, Pregnancy.

SUBCLINICAL HYPOTHYROIDISM;

Objectives: Analysis of thyroid function test, C-reactive protein (CRP) and lipids profile in subclinical hypothyroidism (SCH) as indicators of vascular atherosclerotic disease. Study Design: Cross sectional (case control) study. Place and Duration: Department of Surgery, Liaquat University of Medical and Health Sciences Hospital from January 2016 to July 2017. Materials and Methods: Subjects for this study were selected by inclusion and exclusion criteria. Sampling technique was non-probability purposive sampling. A case of SCH was defined as Thyroid stimulating hormone (TSH) &gt; 6.2 (μIU /ml) with normal T4 and T3 free levels. 5 ml venous blood was collected from peripheral vein. Blood was centrifuged to extract sera for the detection of serum TSH, T4 and T3, and CRP. 12 hours fasting was mandatory for blood lipid detection. Data was analyzed on software SPSS 22.0 (P-value ≤0.05) at 95% confidence interval (P-value ≤0.05). Results: Cases showed high TC, TAG and LDLc with low HDLc compared to controls (P&lt;0.05). Serum TSH was elevated in cases compared to controls (P=0.0001). Serum CRP in controls was noted as 2.75±1.12 ng/ml compared to 9.41±1.58 ng/ml in cases (P=0.0001). Pearson`s correlation shows serum CRP was negative correlated with serum T3 (r= -0.180, P=0.074), and serum T4 (r= -0.2250, P=0.025), but positive correlated with serum TSH (r= 0.626, P=0.0001). Conclusion: Subclinical hypothyroid is associated with dyslipidemia and raised C-reactive protein and both may be interpreted as indicators of vascular atherosclerotic disease.

A study of relationship of hyperuricemia in hypothyroid patients

Introduction: Hypothyroidism is a common metabolic disorder in general population. The prevalence of primary hypothyroidism is 1:100, but it may be 5:100 if patients with subclinical hypothyroidism (normal T4, raised TSH) are included.The degree of severity ranges from mild and unrecognized hypothyroid states to striking myxedema. The thyroid dysfunction increases with age, especially in women.Uric acid has been found to be significantly elevated in primary hypothyroidism in many studies. In comparison to the prevalence reported in the general population, a significant increase of both Hyperuricemia and gout was found in the hypothyroid patients. In hypothyroidism, the hyperuricemia is secondary to a decreased renal plasma flow and impaired glomerular filtrationThis study was designed for evaluation of uric acid levels in hypothyroid patients which might be helpful for clinical management of hypothyroid patients with hyperuricemia. Objective of Study: To find out any relationship between hyperuricemia in hypothyroidism patients. Methods:In our study, out of 100 patients, only 15 were found to have increased serum uric acid levels and only 3 had increased urinary uric acid levels. Out of these 15, 9 were females and 6 males, or can be said out of 70 females in study; only 9 were having increased serum uric acid levels. Results: In our study, the association between hypothyroid function and hyperuricemia seems to be week.No significant correlation was found betweenT3, T4 &amp;TSH and serum uric acid. Conclusion: The correlation between hypothyroidism and gout still remains a matter of debate and more extensive studies need to be done to come to a definitive conclusion.

Sex differences in the association between thyroid-stimulating hormone levels and depressive symptoms among the general population with normal free T4 levels

Background: Overt and subclinical thyroid dysfunction has been reported to be related to depression. Thyroid diseases have been known to occur more frequently in women. However, scarce data are available on effects and sex differences of changes in thyroid-stimulating hormone (TSH) levels, with a normal range of thyroid hormones, on depression. This study aimed to investigate the association between TSH levels and depressive symptoms, according to sex, in individuals from the general population with free thyroxine (fT4) values within the normal range. Methods: Data from the 2014 Korea National Health and Nutritional Examination Survey were used for this study. The study population of 1651 Korean adults was categorized by tertiles of TSH levels. The presence of depressive symptoms was determined using a cut-off score of 5 in the Patient Health Questionnaire-9. Results: The highest TSH tertile group was 1.92 times more likely to have depressive symptoms in men after adjustment for covariates than the lowest TSH tertile (adjusted odds ratio: 1.92, 95% confidence interval: 1.11–3.31, P = 0.019). Contrastingly, the highest TSH tertile was associated with an approximately 35% lower prevalence of depressive symptoms in women (adjusted odds ratio: 0.65, 95% confidence interval: 0.43–0.97, P = 0.034). Limitations: Cross-sectional design and unrecognized confounding factors, are the main limitations of our study. Conclusions: Sex may play a substantial role in the relationship between TSH and depressive symptoms. Sex differences might be associated with differences in thyroid response, TSH blunting, thyroid autoimmunity, and sex hormone levels.

Isovolumetric Relaxation Time (IVRT): An Effective Tool in Management of Subclinical Hypothyroidism

Hypothyroidism is a common condition in which thyroid gland doesn't produce sufficient thyroid hormone. Normal range of TSH is 0.4 to 4 mIU/L. Patients with TSH between 5 and 10 mIU/L, with normal T4 are diagnosed to have subclinical hypothyroidism. Decision to treat, particularly the subclinical hypothyroidism is tailored to individual patients. In our study, isovolumetric relaxation time (IVRT) was used to detect the diastolic function of cardia in hypothyroid patient, with the help of 2D echocardiogram. Normal duration of IVRT is 54 to 65μs and in hypothyroidism it is expected to increase. To assess, whether IVRT is an effective tool in the management of subclinical hypothyroidism. 50 patients attending otorhinolaryngology OPD with TSH level of 5 to 10 mIU/L were selected for the study. All these were sent for 2D echocardiogram, for the measurement of IVRT. These 50 patients were divided into 2 groups. Group A-patients with TSH level 5 to 10 mIU/L and normal IVRT. Group B-patients with TSH level 5 to 10 mIU/L and prolonged IVRT. Patients in Group A were not given thyroxine, and after 3months, they were reviewed with TSH level and IVRT duration. Patients in Group B were started with thyroxine, and after 3months, they were reviewed with TSH level and IVRT duration. The basal and 3months follow up values of TSH and IVRT was analysed on both the groups. The p value of group A was not significant, but p value group B was significant. IVRT as a measuring tool in sub clinical hypothyroidism will definitely bring a major change in the concepts of treatment.

Subclinical Hyperthyroidism, an Under-Recognized Entity

Subclinical Hyperthyroidism, an Under-Recognized Entity Sindhu Igala, Marivette Machado, Britta Neugaard, Philip R Foulis, Joaquin Gomez-Daspet Abstract Purpose: Determine the medical evaluation completed and the clinical progression observed in subjects with Endogenous Subclinical Hyperthyroidism (ESCH).Method: This is a single site retrospective chart review of subjects who visited the Ambulatory Care Clinics at the James A. Haley VA Hospital (JAHVA), Tampa, Florida. Subjects were selected and charts reviewed using the automatic data mining tool. Inclusion criteria encompassed subjects’ low thyroid stimulating hormone (TSH) and normal T4 and T3 levels.Results: 95 subjects met criteria for inclusion. At the end of one year, 48 (51%) had normal thyroid function tests (TFTs), 43 (45%) had persistent ESCH and 4 (4%) had overt hyperthyroidism. A radioiodine thyroid uptake/scan was completed in 32 (33%) subjects. Only 9 (10%) had thyroid stimulating Immunoglobulin (TSI) or anti-thyroid peroxidase antibody (anti-TPO) studies. A bone density study was not completed. Conclusions: Out of the 95 subjects with ESCH, at the end of one year 51% had normal TFTs, 45% had persistent ESCH and 4% had hyperthyroidism. Less than 50% of the subjects received further tests. It is recommended that subjects with ESCH be followed periodically with TFTs and further evaluation may be required to assess cause, severity, risk of complications and need for treatment. Full Text: PDF DOI: 10.15640/ijmp.v7n1a1

CLINICAL NUTRITION PROGRAM IMPROVES CHRONIC FATIGUE AND INTESTINAL PAIN IN 50 YEAR OLD MAN WITH HASHIMOTO’S

Event Abstract Back to Event CLINICAL NUTRITION PROGRAM IMPROVES CHRONIC FATIGUE AND INTESTINAL PAIN IN 50 YEAR OLD MAN WITH HASHIMOTO’S David J. Clark1* 1 Carrick Institute, United States Background: A 50 year old man presented with a history of chronic fatigue, gastrointestinal pain, cramping and gas. Within one hour after eating he experienced pain and gas, and then 3 to 4 hours later, he suffered severe lower intestinal cramping. He also suffered constipation (only one to two bowel movements per week). Frequently, a few hours after waking , he would be so fatigue that he needed to nap. This also occurred after doing any kind of exercising such as cycling. Eight years prior to presentation he was diagnosed with hypothyroidism and prescribed levothyroxine. Three years later he demonstrated elevated thyroid autoantibodies (Hashimoto’s) and was switched to bioidentical thyroid replacement. He followed various interventions including acupuncture, low FODMAPS diet and Small Intestine Bacterial Overgrowth protocol— but with no positive effects on his symptoms. He followed a gluten-free diet at time of presentation. He was taking Armour daily as well as vitamin D. Methods: Blood chemistry revealed high homocysteine (13.9), potassium (5.4), TSH (13.26), TPO antibodies (144) and thyroglobulin antibodies (2), low HDL (39), T4 (4.2), Reverse T3 (6), free T4 (0.7), normal T3 and Free T3, clinically significantly high BUN (25), clinically significantly low B12 (375), vitamin D (35). Urea Breath Test for H. pylori was negative. Urinary Organic Acids testing revealed high Arabinose (36), 4-Hydroxybenzoic (0.90), oxalic (135), 3-Hydroxyglutaric (6.8), Suberic (4.0), and 2-Hydroxyhippuric (1.2) acids. Dried urine testing for hormones revealed low levels of epitestosterone, clinically significantly low levels of beta-pregnanediol, alpha-pregnanediol, DHEA sulfate, androsterone, testosterone, 5-alpha DHT, He was placed on an anti-inflammatory diet and a supplement protocol utilizing turmeric, resveratrol, sublingual vitamin D, high EPA fish oil, broad-spectrum digestive enzyme formula, pregnenolone, a multi-nutrient formula for lowering homocysteine and a multi-multi-nutrient formula for support of normal tissue glucose levels. Results: At 60 day follow up, the patient reported a 60% increase in his energy. He no longer needed to nap in the mornings, nor after exercise. He reported a 50% improvement in the frequency of gastrointestinal pain and cramping. Frequency of bowel movements had increased to four to five times per week. In addition, blood chemistry showed improved B12 (580), vitamin D (68.4), homocysteine (11.1). Conclusion: The author suggests further investigation into clinical nutrition, diet and supplementation in the treatment of chronic fatigue and gastrointestinal complaints in patients with Hashimoto’s. Keywords: Hashimoto's autoimmune thyroiditis, HPA axis (hypothalamus-pituitary-adrenal), supplementation, Anti-inflammatory diet, Clinical Nutrition Conference: International Symposium on Clinical Neuroscience, Orlando, United States, 24 May - 26 May, 2019. Presentation Type: Poster Presentation Topic: Clinical Neuroscience Citation: Clark DJ (2019). CLINICAL NUTRITION PROGRAM IMPROVES CHRONIC FATIGUE AND INTESTINAL PAIN IN 50 YEAR OLD MAN WITH HASHIMOTO’S. Front. Neurol. Conference Abstract: International Symposium on Clinical Neuroscience. doi: 10.3389/conf.fneur.2019.62.00025 Copyright: The abstracts in this collection have not been subject to any Frontiers peer review or checks, and are not endorsed by Frontiers. They are made available through the Frontiers publishing platform as a service to conference organizers and presenters. The copyright in the individual abstracts is owned by the author of each abstract or his/her employer unless otherwise stated. Each abstract, as well as the collection of abstracts, are published under a Creative Commons CC-BY 4.0 (attribution) licence (https://creativecommons.org/licenses/by/4.0/) and may thus be reproduced, translated, adapted and be the subject of derivative works provided the authors and Frontiers are attributed. For Frontiers’ terms and conditions please see https://www.frontiersin.org/legal/terms-and-conditions. Received: 02 Apr 2019; Published Online: 27 Sep 2019. * Correspondence: Mx. David J Clark, Carrick Institute, Cape Canaveral, Florida, 32920, United States, mail@doctordavidclark.com Login Required This action requires you to be registered with Frontiers and logged in. To register or login click here. Abstract Info Abstract The Authors in Frontiers David J Clark Google David J Clark Google Scholar David J Clark PubMed David J Clark Related Article in Frontiers Google Scholar PubMed Abstract Close Back to top Javascript is disabled. Please enable Javascript in your browser settings in order to see all the content on this page.

Prevalence and distribution of subclinical hypothyroidism in middle aged women attending tertiary care hospital

Background: Thyroid diseases are common worldwide mostly in middle-aged women. India is not an exception with a significant burden of thyroid diseases. Subclinical hypothyroidism is mainly diagnosed by laboratory results. In India, there are only a few studies done in prevalence and patterns of age distributions of subclinical hypothyroidism. Aim & Objective: The present study is aimed to estimate the prevalence and distribution of subclinical hypothyroidism in young and middle-aged women attending the outpatient department of a tertiary care hospital. Materials & Methods: This study is a hospital-based cross-sectional study done at Katuri Medical College Hospital and Research Centre, a tertiary care center, Andhra Pradesh, India. More than 12 years of age group including adolescents, pregnant, older age groups are selected and investigated for subclinical hypothyroid by doing T3, T4, and TSH concentrations. Thyroid function tests were done in the Clinical biochemistry Department on Maglumi 800 fully automated hormone analyzer by Chemiluminescence immunoassay method. Patients with any evidence of medical and surgical disorders were excluded from the study. Approval from the scientific and institutional ethics committee was obtained and patients who gave informed consent were included in the study. Results: Out of 932 patients only 841 samples that met the inclusion were included in the study. Among 841 cases, TSH levels above 6 were 71. Out of 71 TSH cases, 43 had T3 less than 0.86 and the remaining 28 had normal T3 and T4 values. Total subclinical Hypothyroidism cases were 28 (3.32%) out of 841 cases tested for TSH. In the present study, the Average age of subclinical hypothyroidism (SCHT) cases was 28.14 years. In the present, study most of the SCHT cases were seen in the age group of 25-30 years 13 (46.42%) followed by 30-35 years 9(32.14%) and 20-25 years 6 (21.42%). In the present study, the minimum & maximum values of Thyroid hormones were (T3- 0.86 & 1.6; T4- 4.7& 10.6; TSH-6.2 &169). The mean values of thyroid hormones in SCHT were (T3- 0.84±0.22, T4-6.85±1.27 and TSH- 15.80±22.62). Conclusion: The present studies conclude that the prevalence of subclinical hyperthyroidism more in females than the males and distribution of SCHT increase as the age advance.

Prevalence of thyroid dysfunctions in infants and children with Down Syndrome (DS) and the effect of thyroxine treatment on linear growth and weight gain in treated subjects versus DS subjects with normal thyroid function: a controlled study.

Background: Individuals with Down syndrome (DS) are at an increased risk of developing thyroid disease, primarily autoimmune, with a lifetime prevalence ranging from 13% to 63%. Unfortunately, there are few studies systematically examining the frequency of thyroid disease in very young children. Aim of the study: The aim of the present study was to investigate the prevalence of different thyroid dysfunctions (TD) in a cohort of infants and children with DS and the growth parameters in subjects with normal versus abnormal thyroid function, followed for 3 years. Patients and methods: All children (n = 102; 48 males and 54 females, aged 2.3±3 years) with the diagnosis of DS who were seen at the General Pediatric Clinic of Hamad General Hospital in Doha (Qatar) from 2014 to 2018 were enrolled in our study. We recorded thyroid function and linear growth parameters [BMI, length/height SDS (Ht-SDS) and weight gain/day] and divided them into 3 groups according to their thyroid function. Group 1: (n = 36 subjects) with normal free T4 (FT4) and TSH; Group 2 (n = 44 subjects) with high TSH >5 and <12 mIU/L, and normal FT4, and Group 3 (n = 22 subjects) with TSH >12 mIU/L and/or FT4 <9 pmol/L. We also compared linear growth parameters in subjects with DS and thyroid dysfunction versus those with normal thyroid function at diagnosis and after treatment with L- thyroxine, for an average of 3 years. Results: In infants with DS (<1 year of age; n = 47, mean age: 5±3.5 months) we documented a higher prevalence of hypothyroidism (HT) (7/47 = 14.9%), both primary (5/47; 10.6%) and secondary (2/47; 4.3%). Subclinical hypothyroidism and positive thyroid antibodies were found in (13/47; 27.7%) and (9/47;19%, respectively). Before treatment with L-thyroxine, DS infants of Group 3 had significantly lower BMI-SDS but were not significantly shorter compared to other two Groups (p= 0.03 and p =0.14, respectively). After an average of 3 years of treatment the BMI- SDS and Ht-SDS did not differ among the treated and not treated infant groups. In the older group (>1 year; n=55; mean age: 5.5±3.3 years) primary HT was detected in 7/55 (12.7%). Subclinical HT was diagnosed in 20/55 (36.4%) and positive thyroid antibodies were found in 26/55 (47.3%). Before treatment with L-thyroxine, using the CDC growth charts for DS, we found that the groups with high TSH (Groups 2 and 3) were significantly shorter and heavier compared to the group with normal TSH (Group 1). After treatment with L-thyroxine, the Ht-SDS and Wt-SDS did not differ between the two groups. The linear growth of those diagnosed early during the first year of life was compared to growth parameters of children who were diagnosed with thyroid dysfunction later in life. Conclusion: Our data provided more evidence to support the findings that L- thyroxine treatment can improve growth of infants and young DS children with high TSH (>5 mIU/L), especially in those with TSH >12 mIU/L. (www.actabiomedica.it)

Guwahati thyroid epidemiology study: High prevalence of primary hypothyroidism among the adult population of Guwahati city

Background: Thyroid disorders have emerged as a common disease in India. Hence, it is pertinent to search the real reasons behind the high prevalence of thyroid disease in India, post salt iodization phase. Objective: This study was executed to unravel the nature of thyroid disorders and there associations with thyroid autoimmunity in the unexplored North east Indian region. Methods: This community based Cross sectional (pilot) survey involved 8 wards of Guwahati city, implementing the “cluster sampling technique”. Abnormal thyroid parameters were classified as Hypothyroid: serum T4 4.2) μIU/mL; Subclinical hypothyroidism (SCH): normal serum T4 (4.6-12 μg/dL) and TSH > 4.2 IU/mL, and Anti-TPO antibody positive: titre of ≥ 34 IU/ml. Results: Out of the 209 subjects enrolled, incidence of newly detected SCH, self reported hypothyroidism, and cumulative figure of the hypothyroidism cohort were higher amongst female population (27.84%, 14.43%, and 42.27% respectively). Significant association was found between female sex and hypothyroidism [Relative risk (RR) 1.73 (1.16-2.56), P Conclusion: A considerable percentage (33.01%) of the adult population in Guwahati city has some form of thyroid disorder. There is lack of evidence pointing out auto immunity being the major driver for primary hypothyroidism; hence we are left to reflect upon whether dietary iodine deficiency or being geographically located near to the sub-Himalayan goitrogenic belt, or frequent consumption of cyanogenic food stuffs, is cumulatively involved in thyroid disorder development.

Considerations for Thyroidectomy as Treatment for Graves Disease.

Hyperthyroidism is a clinical state that results from abnormally elevated thyroid hormones. Thyroid gland affects many organ systems; therefore, patients usually present with multiple clinical manifestations that involve many organ systems such as the nervous, cardiovascular, muscular, and endocrine system as well as skin manifestations. Hyperthyroidism is most commonly caused by Graves disease, which is caused by autoantibodies to the thyrotropin receptor (TRAb). Other causes of hyperthyroidism include toxic multinodular goiter, toxic single adenoma, and thyroiditis. Diagnosis of hyperthyroidism can be established by measurement of thyroid-stimulating hormone (TSH), which will be suppressed with either elevated free T4 and/or T3 (overt hyperthyroidism) or normal free T3 and T4 (subclinical hyperthyroidism). Hyperthyroidism can be treated with antithyroid drugs (ATDs), radioactive iodine (RAI), or thyroidectomy. ATDs have a higher replacement rate when compared with RAI or thyroidectomy. Recent evidence has shown that thyroidectomy is a very effective, safe treatment modality for hyperthyroidism and can be performed as an outpatient procedure. This review article provides some of the most recent evidence on diagnosing and treating patients with hyperthyroidism.

Metabolic effects caused by sodium levothyroxine in subclinical hypothyroidism patients with low HDL

IntroductionSubclinical hypothyroidism (SH) is an autoimmune thyroid disorder characterized by elevated TSH with values of T3, T4, free T3 and free T4 within the reference range. High TSH levels are associated with lipid alteration. MethodA total of 21 patients aged between 18 and 80 years were recruited. The sample was composed of 17 females and 4 males, all of whom had TSH values ranging from 5.0 to 9.9 (mlU/L) and normal free T4 levels. They were followed up for 26 months while undergoing sodium levothyroxine replacement therapy (12.5–25 mcg/day). Throughout this period, TSH, free T4 HDL, LDL, triglyceride, total cholesterol and glucose levels were evaluated. ResultsA significant improvement in HDL cholesterol levels was observed. There was also a decrease in fasting glucose. No significant changes were seen in triglyceride levels. ConclusionAs observed throughout this study, SH patients with low HDL under therapy showed a significant increase in HDL levels after TSH levels were normalized. Therefore, it is quite clear that thyroid hormones affect lipid metabolism, and, as a result, metabolic syndrome components.

Coagulation parameters in hyperthyroid cats before and after radioiodine treatment compared with healthy controls.

The aim of the study was to describe the coagulatory state of hyperthyroid cats before and after successful radioiodine therapy (RIT) compared with healthy age-matched controls, using classical coagulation parameters and thromboelastogram (TEG) as a global assessment method. The differences in coagulation activity after RIT, depending on the thyroid hormone (normal vs low total thyroxine [T4]) state, were also evaluated. Fifteen hyperthyroid cats and 10 healthy age-matched controls were recruited. Hyperthyroid cats that remained hyperthyroid 14 days after RIT were excluded. Haematology, biochemistry, T4, prothrombin time (PT), activated partial thromboplastin time (aPTT), fibrinogen and TEG were assessed in control cats and hyperthyroid cats before and 7 and 14 days after RIT. Two weeks after successful RIT, further comparisons were made between cats with normal T4 vs those with low T4. Fourteen days after successful RIT, 7/15 cats had normal T4 and 8/15 had low T4. Thrombocytosis was noted in 6/15 cats after treatment. Fibrinogen was significantly higher (P <0.001) and PT shorter (P <0.01) in the hyperthyroid cats compared with the healthy controls and these changes persisted after RIT. Persistent increases in fibrinogen, PT, TEG maximal amplitude and TEG clot rigidity, reflecting clot stability, after RIT primarily occurred in the cats with normal T4. TEG-K (time until preset amplitude of 20 mm is reached) and alpha (α) angle reflected impaired fibrin cross-linking ability prior to RIT, which significantly increased after therapy (P <0.05). Based on some of the coagulation parameters, cats with hyperthyroidism showed hypercoagulable tendencies, which were mildly increased after RIT, possibly due to transient radiation-induced thyroiditis.