Onset Of Hypothyroidism Research Articles

Association between mood stabilizers and hypothyroidism in patients with bipolar disorders: a nested, matched case‐control study

This study investigated whether lithium, carbamazepine, and valproate increased the risk for hypothyroidism using Taiwan's National Health Insurance Dataset. The sample included 557 bipolar disorder patients with incident hypothyroidism first diagnosed between 1998 and 2004, and 2,228 sex-, age-, and index date-matched bipolar disorder patients without hypothyroidism from 1996-2004. We compared the use of lithium, carbamazepine, and valproate before the onset of hypothyroidism between the two groups using a conditional logistical regression model. Compared with patients who had never used any of the three mood stabilizers, patients were more likely to have hypothyroidism if they only used carbamazepine [odds ratio (OR) = 1.68; 95% confidence interval (CI): 1.07-2.65]; or comedication of lithium and valproate (OR = 2.40; 95% CI: 1.70-3.40), lithium and carbamazepine (OR = 1.52; 95% CI: 1.10-2.08), and three mood stabilizers (OR = 2.34; 95% CI: 1.68-3.25). There was a dose-response relationship between the number of mood stabilizers and risk for hypothyroidism (OR = 1.34, 95% CI: 1.21-1.49) and a significant interaction between lithium and valproate on the risk for hypothyroidism (p = 0.020). Our findings indicate that lithium, carbamazepine, and valproate may increase the risk for hypothyroidism, particularly if combined, and suggest regular monitoring of thyroid function and monotherapy of mood stabilizers for treating patients with bipolar disorders.

Mechanism underlying transient gestational-onset hypothyroidism–induced impairment of posttesticular sperm maturation in adult rats

To understand the mechanism underlying gestational-onset hypothyroidism-induced male infertility. Controlled laboratory study. Research laboratory in a university department of endocrinology. Wistar rat. Pregnant rats were exposed to methimazole from embryonic days 9 to 14, 18, and 21, covering specific fetal periods of differentiation and development of male reproductive tract organs. Fertility of male rats was assessed by testing sperm count, forward motility, and in vivo fertilizing ability. Secretory activity of the epididymis was evaluated by quantifying sialic acid, carnitine, and glycerylphosphorylcholine. Bioavailability of androgens was assessed by quantifying testosterone in serum and testicular interstitial fluid and epididymal 5alpha-reductase activity/mRNA expression. Androgen receptor (AR) status in the epididymis was tested by detecting the expression levels of its mRNA and protein, as well as ligand binding activity. Data were analyzed statistically by one-way analysis of variance. Gestational exposure to methimazole decreased sperm forward motility, in vivo fertilizing ability, bioavailability of androgens, AR status, and secretory activity of the epididymis in adult rats. Transient gestational-onset hypothyroidism affects male fertility by impairing posttesticular sperm maturation process in the epididymis, owing to subnormal androgen(s) bioavailability, AR expression, and AR functional activity.

Feasibility and tolerability of bevacizumab in children with primary CNS tumors

Bevacizumab, an antibody to the vascular endothelial growth factor, has demonstrated anti-cancer activity in a number of solid tumors. Fear of intratumoral hemorrhage, however, has slowed its introduction into the treatment of central nervous system (CNS) tumors. Currently, only a small number of children with gliomas received bevacizumab. We retrospectively analyzed 30 patients who received bevacizumab between January 2007 and August 2009. The median age at start of bevacizumab treatment was 9.9 years (range: 1.5-18). Most patients had recurrent/progressive disease, 25 high-grade and 5 low-grade tumors. The median dose of bevacizumab was 9.5 mg/kg (range 5-15 mg/kg) every 2-3 weeks. In total, 478 courses were administered (median/patient 15.9, range: 2-52). The median duration of bevacizumab treatment was 10.0 months (range: 1.6-30.4). Twenty-nine of 30 patients received additional therapy concomitant to bevacizumab. No bevacizumab related intratumoral hemorrhage occurred in any of our 30 patients. Grade III hypertension was seen in two patients. One patient developed nephrotic syndrome requiring cessation of treatment. Grade III and I proteinuria were observed in one and five patients, respectively. New onset lymphopenia occurred in 12/30 and new onset hypothyroidism in 7/30 patients. Impaired wound healing was manageable. No immediate bevacizumab-related cardiotoxicity was observed as evidenced by echocardiography. Bevacizumab appears to be safe for children with primary CNS tumors. Adverse effects did occur but were manageable. No treatment-related death occurred. Long-term monitoring is advisable to detect lymphopenia and hypothyroidism. Hypertension occurred less frequently than in adult patients. Further prospective studies including more patients are warranted.

Iodine in Enteral and Parenteral Nutrition

Iodine deficiency (ID) has multiple adverse effects on growth and development due to inadequate thyroid hormone production. Methods for assessment of iodine nutrition in individuals include the urinary iodine concentration (UI), thyroid size and thyroid function tests. The UI measured in several repeat 24-h urine samples can detect inadequate iodine intake in individuals receiving enteral or parenteral nutrition (PN) and allow for iodine supplementation before the onset of hypothyroidism. A daily dose of 1 microg iodine/kg body weight is currently recommended for children receiving PN, but this is far below their requirements. Daily iodine requirements in adults receiving enteral nutrition or PN are estimated to be 70-150 microg, but most PN formulations do not contain iodine. Despite this, ID has been unlikely because absorption from iodine-containing skin antiseptics and other adventitious sources can provide sufficient iodine. However, if chlorhexidine replaces iodine-containing antiseptics for catheter care, ID may occur during long-term PN, and periodic testing of UI and thyroid function may be prudent. Infants may be particularly vulnerable to ID because of their small thyroidal iodine store. In this review, we describe three recent patients (an infant, a child and an adult) who developed ID and thyroid hypofunction during PN.

Changes in mid‐to‐late latency auditory evoked reponses in the chicken during neural maturation

Utilizing the special advantages offered by the protracted maturation of neural circuits in chicken forebrain this study investigates the functional consequence of maturation using auditory evoked response potentials (AERPs) in behaving animals. Repeated measures AERP recordings were undertaken between weeks 1 and 8 posthatch. Quantitative analysis revealed a significant decrease in amplitude of the positive AERP component and a decrease in latency of the negative AERP component with maturation. AERPs were also utilized to investigate perturbed maturation via the induction of chemically induced hypothyroidism. Results from this study showed that the induction of late onset hypothyroidism produces measurable effects on the chicken AERP consistent with perturbation in maturation of neuronal circuits and synapses. This suggests that AERPs may be useful noninvasive functional measures of brain maturation that can be used to study the effects of endogenous or exogenous factors on brain maturation in the chicken. Since human brain also exhibits a protracted maturation period the availability of a well-characterized animal model for protracted brain maturation provides an opportunity to identify molecules, genes and environmental factors that are important in the regulation of maturation. The protracted maturation of neuronal circuits observed in chicken forebrain offers such a model.

Pattern of Thyroid Autoimmunity in Chinese Patients With Pernicious Anemia

BackgroundAutoimmune thyroid disease (AITD) often coexists with pernicious anemia (PA) among whites. The study aimed to determine thyroid autoimmunity in Chinese patients with PA MethodsFrom the data of a hospital-based longitudinal study of Chinese PA patients (1994–2007), those with complete information of antibodies to thyroid peroxidase (TPO), thyroglobulin (Tg), and gastric parietal cell; serum thyroid-stimulating hormone and free thyroxine; gastric mucosal histology; and family history of AITD were analyzed. ResultsAmong 126 Chinese PA patients, 44% had TPO/Tg antibodies and 13.5% AITD. TPO/Tg antibodies occurred in 33% (16 of 49) of male and 52% (40 of 77) of female patients (P=0.034). Graves disease (8 patients) tended to antedate PA and was associated with no or low titers of TPO/Tg antibodies. Primary hypothyroidism (9 patients) developed during follow-up and was associated with high TPO/Tg antibody titers. The TPO/Tg antibodies did not affect the clinical course of PA but was associated with an enhanced risk of developing AITD and vitiligo. Overall, AITD (before and after PA) occurred in 23% (13 of 56) and 5.7% (4 of 70) of PA patients with and without antibodies (P=004). During follow-up (mean duration of 75.24±46.39 months), 10 patients developed AITD—7 new onset of hypothyroidism and 3 progression/relapse of prior AITD. Logistic regression analysis of presenting features of PA revealed 2 independent factors for AITD development during follow-up—presence of thyroid antibodies (odds ratio 20.2, 95% confidence interval 1.8–223) and history of prior AITD (odds ratio 39.8, 95% confidence interval 2.3–679). ConclusionIt is recommended to screen thyroid antibodies and monitor thyroid function during follow-up.

Hypothyroidism in postradiation head and neck cancer patients: incidence, complications, and management

To describe the incidence, risk factors, prevention, and management of hypothyroidism among patients treated with radiation and other modalities for head and neck cancers. Hypothyroidism may occur in up to 48% of patients treated for head and neck malignancies. It has been observed after radiation, surgery, and combined-modality therapies. The onset of hypothyroidism may be as early as 4 weeks and as late as 5 or 10 years after completion of therapy. It has been associated with poor wound healing, bleeding disorders, and a number of other potential complications germane to the practice of head and neck surgery. There is some evidence to suggest a protective role of hypothyroidism with respect to disease control survival in head and neck and other cancers. Hypothyroidism is common after treatment of head and neck cancers. Thyroid function studies should be obtained prior to and at regular intervals after treatment. Prompt recognition and intervention may prevent or reverse adverse physiological outcomes. Further studies are necessary to evaluate the role of permissive hypothyroidism in the context of treated head and neck malignancies.

Age-related learning and memory impairments in adult-onset hypothyroidism in Kunming mice

The memory impairment induced by adult-onset hypothyroidism is a common symptom. However, the exact onset time that will influence on memory function is still an issue of debate. The purpose of this study is to determine the onset effect of hypothyroidism on the memory during adulthood. Three age groups of Kunming (KM) mice were used, including 2, 8, and 15-month-old mice. Adult-onset hypothyroidism was made by adding PTU to drinking water and hypothyroid states were documented by the measurement of serum thyroid hormones level. A battery of tasks, i.e. novel-object recognition, olfactory discrimination, Morris water maze, was used to test mice's memory. The results showed that adult-onset hypothyroidism induced the impairment of odor and spatial memory consolidation whereas it did not affect visual memory encoding or consolidated spatial memory retention. Age at onset of hypothyroidism was an important factor for the memory impairment induced by hypothyroidism. The 2-month-old hypothyroid mice had significantly impaired abilities in both the olfactory discrimination and the spatial cognitive tasks relative to the 2-month-old controls. The 8-month-old hypothyroid mice had only impaired ability in the spatial cognitive task relative to the same age controls. The 15-month-old hypothyroid mice retained these cognitive abilities relative to the same age controls. These results suggested that adult-onset hypothyroidism could induce an age- and task-dependent impairment of memory in female KM mice.

A critical role of CREB in the impairment of late-phase LTP by adult onset hypothyroidism

We have shown previously that adult onset hypothyroidism impairs late-phase long-term potentiation (L-LTP) and reduces the protein levels of mitogen-activated protein kinases (MAPKp44/42 (ERK1/2)) in area CA1 of the hippocampus. In the present study, basal and stimulated levels of signaling molecules essential for the expression of L-LTP were determined in area CA1 of the hippocampus. L-LTP was evoked by multiple train high-frequency stimulation (MHFS) in area CA1 of the hippocampus of thyroidectomized and sham control anesthetized adult rats. Immunoblot analysis showed reduction in the basal protein levels of adenylyl cyclase I (ACI), calcium calmodulin-dependent protein kinase IV (CaMKIV), and cyclic-AMP response element-binding protein (CREB; phosphorylated (P-) and total) in hypothyroid rats. A significant increase in the levels of P-CREB, P-MAPKp44 and P-MAPKp42 was seen 4 h after MHFS in sham-operated control animals, but not in hypothyroid animals. The levels of total CREB, total MAPKp44, total MAPKp42 and CaMKIV were elevated in both groups 4 h after MHFS. Our results suggest that in adult hypothyroid rats, the reduced basal level of CaMKIV, MAPKp44/42 and CREB along with the failure of MHFS to induce MAPKp44/42 and CREB phosphorylation may be responsible for L-LTP impairment in the CA1 area during hypothyroidism.

Onset of acquired autoimmune hypothyroidism in infancy: a presentation of delayed gross-motor development and rhabdomyolysis

We report the case of a 23-month-old girl who presented with poor growth and delayed attainment of gross-motor milestones. Elevated creatine phosphokinase (CPK) indicated rhabdomyolysis, ultimately attributed to severe, acquired autoimmune hypothyroidism. Growth data and bone-age suggest the onset of hypothyroidism occurred at or before 12 months of age. Acquired hypothyroidism is rare before age 3 years, and rhabdomyolysis due to hypothyroidism has not previously been reported as a cause of delayed gross-motor development in toddlerhood. Despite the early onset of hypothyroidism, cognitive function appeared to be unaffected. Adequate thyroid hormone replacement quickly normalized the CPK in our patient, and gross motor development rapidly improved. Although rare, rhabdomyolysis secondary to hypothyroidism should be in the differential diagnosis of delayed gross-motor development in infancy and toddlerhood.

Late onset hypothyroidism after subtotal thyroidectomy for hyperthyroidism: implications for long term follow-up.

A follow-up register has been used in Aberdeen and Dundee to record early and late onset hypothyroidism occurring in a large population of post-thyroidectomy patients treated for hyperthyroidism. In one centre, in a total of 1170 patients, the prevalence of postoperative hypothyroidism, at the time of entry to the register, was 41 per cent. Of these early cases of hypothyroidism 93 per cent occurred within 18 months of operation. Results are presented from a 12-year prospective study of patients treated in two centres, who were euthyroid when entered on the follow-up register. In one centre, based on 683 patients, the 10-year incidence of late onset hypothyroidism estimated by actuarial methods was 7.4 per cent (95 per cent confidence limits, 3.8-11.1); in the other centre with 156 patients the 5-year incidence was 10.8 per cent (95 per cent confidence limits, 3-18.6). The minimum predicted annual incidence is 1 per cent. Large thyroid remnants do not protect some patients against early or late postoperative hypothyroidism but do lead to an increased risk of recurrent hyperthyroidism. Hypothyroidism after subtotal thyroidectomy for hyperthyroidism shows a bimodal pattern and this study emphasizes the need to maintain life-long follow-up.

Late thyroid toxicity in 153 long-term survivors of allogeneic bone marrow transplantation for acute lymphoblastic leukaemia

The purpose of this study was to identify risk factors for hypothyroidism after bone marrow transplantation (BMT) for high-risk or relapsed acute lymphoblastic leukaemia (ALL) in children. In all, 388 children with acute lymphoblastic leukaemia underwent allogeneic bone marrow transplantation between 1984 and 1994. Overall 5-year survival was 54.6%. Thyroid function was assessed in the 153 patients with more than 5 years of follow-up. In total, 16 patients developed uncompensated hypothyroidism (UH) and 46 compensated hypothyroidism (CH) a median of 2.9 and 2.7 years, respectively, after BMT. Thyroid dysfunction-free survival rates were 73.2% after 5 years and 59.2% after 10 years. Three factors were significantly associated with the onset of hypothyroidism, namely age, bone marrow transplantation in second remission, and single-dose total body irradiation (TBI). Ultrasonography of the thyroid showed nodules in 10 of 35 patients. The median time from BMT to nodule detection was 7.8 years. Cytology (n=5) and surgery (n=4) showed no evidence of thyroid cancer. Four of the 14 patients who received cytoreduction without TBI but with busulphan and cyclophosphamide developed UH (n=2) or CH (n=2). We concluded that children who undergo BMT for ALL are at a high risk of subsequent thyroid dysfunction.

Transient Gestational Hypothyroidism-Induced Changes in the Pituitary Testicular Axis Differ from that of Neonatal Onset Hypothyroidism

Hypogonadism and male infertility associated with congenital hypothyroidism are two important reproductive health problems. Studies emanated from our laboratory and a few others have established thyroid hormone as an important regulator of testicular development, growth, structure and function. Existing literature are centering around the effect of neonatal, prepuberal and puberal onset hypothyroidism on the testis of adult rats.

Retardation of Cochlear Maturation and Impaired Hair Cell Function Caused by Deletion of All Known Thyroid Hormone Receptors

The deafness caused by early onset hypothyroidism indicates that thyroid hormone is essential for the development of hearing. We investigated the underlying roles of the TRalpha1 and TRbeta thyroid hormone receptors in the auditory system using receptor-deficient mice. TRalpha1 and TRbeta, which act as hormone-activated transcription factors, are encoded by the Thra and Thrb genes, respectively, and both are expressed in the developing cochlea. TRbeta is required for hearing because TRbeta-deficient (Thrb(tm1/tm1)) mice have a defective auditory-evoked brainstem response and retarded expression of a potassium current (I(K,f)) in the cochlear inner hair cells. Here, we show that although TRalpha1 is individually dispensable, TRalpha1 and TRbeta synergistically control an extended array of functions in postnatal cochlear development. Compared with Thrb(tm1/tm1) mice, the deletion of all TRs in Thra(tm1/tm1)Thrb(tm1/tm1) mice produces exacerbated and novel phenotypes, including delayed differentiation of the sensory epithelium, malformation of the tectorial membrane, impairment of electromechanical transduction in outer hair cells, and a low endocochlear potential. The induction of I(K,f) in inner hair cells was not markedly more retarded than in Thrb(tm1/tm1) mice, suggesting that this feature of hair cell maturation is primarily TRbeta-dependent. These results indicate that distinct pathways mediated by TRbeta alone or by TRbeta and TRalpha1 together facilitate control over an extended range of functions during the maturation of the cochlea.

IMPACT OF NEONATAL HYPOTHYROIDISM ON LEYDIG CELL NUMBER, PLASMA, AND TESTICULAR INTERSTITIAL FLUID SEX STEROIDS CONCENTRATION

We have previously demonstrated that neonatal and transient neonatal hypothyroidism modulates Leydig, Sertoli, and germ cell numbers, sex steroids and androgen binding protein concentration. The present study was undertaken to study the effect of neonatal onset hypothyroidism on Leydig and peritubular myoid cell numbers, plasma and testicular interstitial fluid (TIF) sex steroid concentration at different age groups of Wistar rats. Hypothyroidism was induced by giving 0.05% methimazole (MMI) to lactating mothers or directly to the male pups from day 1 postpartum through days 10, 15, 30, 40 and 60 postpartum. To confirm hypothyroidism, plasma thyroid hormones and TSH were assayed. Plasma and TIF testosterone, progesterone, dihydrotestosterone (DHT) and estradiol were assayed by radioimmunoassay. Leydig cell number in hypothyroid rats were less than the age-matched controls. The diameter of Leydig cells in hypothyroid rats was smaller than the controls but 10 days old hypothyroids alone had larger than control rats. A significant decrease of peritubular myoid cell number was observed in 30, 40 and 60 days hypothyroid rats and increased in 10 and 15 days hypothyroidism. Hypothyroid rats had elevated level of plasma LH and decreased GH (except day 10 postpartum). Plasma PRL level was increased in 10 and 15 days hypothyroid rats and an opposite effect was observed in 40 and 60 days hypothyroidism. Plasma testosterone, DHT and estradiol were decreased in all hypothyroid rats. However, plasma progesterone level in hypothyroid rats was significantly higher at days 10, 30, and 40 postpartum and an opposite effect was seen in 15 and 60 days experimental groups. TIF testosterone and progesterone titre showed a consistent decrease in hypothyroid rats irrespective of the duration. In hypothyroid rats, TIF DHT levels decreased significantly in days 10, 40 and 60 postpartum. However, it increased in days 15 and 30 postpartum. Except at day 10 postpartum, the level of TIF estradiol in hypothyroid rats was significantly less than their age matched controls. Our data clearly indicate that neonatal onset hypothyroidism adversely affect Leydig cell proliferation along with impaired steroidogenesis.

Impact of Neonatal Onset Hypothyroidism on Sertoli Cell Number, Plasma and Testicular Interstitial Fluid Androgen Binding Protein Concentration

The impact of neonatal onset hypothyroidism from day 1 postpartum through different postnatal developmental events on rat testis was studied in vivo. Hypothyroidism was induced in neonates by feeding the lactating mother or directly with 0.05% methimazole (MMI) through drinking water from the day of birth and were killed at day 10, 15, 30, 40 and 60 postpartum. Hypothyroidism was confirmed by radioimmunoassay of thyroid hormones and TSH. Sertoli cell number, plasma and testicular interstitial fluid (TIF) androgen binding protein (ABP) concentration was quantified. Sertoli cell number was consistently decreased in all hypothyroid rats. Plasma ABP was also decreased irrespective of the duration of hypothyroidism. Unlike plasma ABP, TIF ABP concentration in hypothyroid rats increased at day 10, and 15 postpartum and decreased in other age groups. Plasma FSH level was increased significantly in all hypothyroid groups. The present investigation points out that suppression of T3 during the critical period of Sertoli cell proliferation affects their number and functional activity.

Onset of hypothyroidism with polymyositis-like clinical features in elderly patients

Impaired muscle function may be a predominant aspect of hypothyroidism and is virtually present in all patients with overt thyroid failure. Less common is the onset of hypothyroidism with clinical features mimicking a polymyositis. We have observed 3 patients, whose age ranged 63-68 years, presenting with muscle aches, cramps, proximal weakness and stiffness. Two patients had dysphagia. Serum creatine kinase (CK) and electromyography (EMC) were altered in two patients. Muscle biopsy showed type II atrophy, sporadic type I and type II grouping, "core-like" areas, and some myopathic changes such as central nuclei and muscle necrosis. No inflammatory changes were present. Immunohistochemistry of several muscle cytoskeletal proteins revealed increased desmin in "corelike" areas. Detection of serum thyroid hormone levels revealed very low triiodo-L-thyronine (T3) and thyroxine (T4), whereas thyroid-stimulating hormone (TSH) was greatly increased as well as serum anti-thyroglobulin, anti-peroxidase and anti-microsome antibodies. The patients were diagnosed having a hypothyroid myopathy due to Hashimoto thyroiditis. L-thyroxine treatment normalized clinical and hormone levels, but serum antibodies remained elevated. Muscle biopsy was fundamental to establish the correct diagnosis in our patients. Presence of over-expression of desmin in cores, as described in target lesions in neurogenic diseases, may suggest a nerve-mediated pathogenesis of hypothyroid myopathy.

Reversion of thyrotoxic atrial fibrillation in hypothyroid state after radioiodine treatment.

Twenty patients with thyrotoxic Basedow's disease complicated by atrial fibrillation lasting more than one month despite treatment with antithyroidal drugs were treated with radioiodine supplemented with an antithyroidal drug or inorganic iodine. We classified the 20 patients on the basis of atrial fibrillation reversion into two groups, one with reversion (group I) and the other without reversion (group II). In all 12 patients in group I, T4 and T3 decreased to hypothyroid levels in 3.2 +/- 1.3 months, and one month later all patients had their sinus rhythm restored while T4 and T3 remained below normal (2.6 +/- 1.1 micrograms/dl and 77.9 +/- 34.4 ng/dl, respectively). Although T4 and T3 also decreased within 3.5 +/- 1.8 months in all 8 patients in group II, one month later, atrial fibrillation persisted while T4 and T3 (10.4 +/- 5.3 micrograms/dl and 157.7 +/- 67.5 ng/dl, respectively) rose significantly compared to those in group I (P less than 0.001 and P less than 0.01, respectively). For reversion of atrial fibrillation it is important that the onset of hypothyroidism is rapidly induced by radioiodine and that hypothyroidism continues for at least one month.

Neuroleptic Malignant Syndrome Possibly Caused by Molindone Hydrochloride

The case of a patient who developed neuroleptic malignant syndrome (NMS) on three separate occasions is presented. Her third bout of this syndrome possibly was caused by molindone hydrochloride. This medication has been reported only once previously to cause NMS. The pharmacology of molindone is reviewed and a complicating factor in this case--the recent onset of hypothyroidism--is discussed together with its implication in the development of the clinical manifestations of this syndrome.

Onset of Subacute Aggravation of Chronic Thyroiditis Followed Immediately by Transient Hypothyroidism during Antithyroid Drug Therapy for Graves’ Hyperthyroidism

A 56-year-old man presented with clinical and biochemical hyperthyroidism with high thyroid 99mTc uptake, positive result for antimicrosomal antibody (MCHA; 1:8,100) and markedly high activities of thyrotropin-binding inhibitory immunoglobulin (TBII; 90.0%) and thyroid-stimulating antibody (TSAb; 2,400%). Fifty days after the initiation of antithyroid drug therapy, he developed a painful tender enlarged thyroid and an accelerated erythrocyte sedimentation rate (ESR), which were followed immediately by hypothyroidism with a transient increase in MCHA titer (peak; 1:218,700) despite of maintenance of high TBII and TSAb activities. Two and a half months after the recovery from hypothyroidism, recurrent hyperfunction was observed with further elevation of TSAb activity (4,643%). After about 2 weeks, recurrences of a painful tender enlarged thyroid and an accelerated ESR, which were followed by abrupt progression to hypothyroidism, were found. Specimens obtained when he had still slightly tender goiter after the first and second episodes of neck pain showed microscopically extremely extended interstitial fibrosis with collapsed follicles and moderate lymphocytic infiltration. Thyroid-stimulation-blocking antibody was not detected at either onset of hypothyroidism. Thus, it is possible that Graves' disease, subacute aggravation of chronic thyroiditis and hypothyroidism coexist in the same individual. In such patients, thyroid status may be determined by the degree of each of the stimulating factors (TSH, TSAb and/or unknown factors) and suppressive or destructive factors (humoral and/or cellular) and may be changed in a very short interval.