Secondary Hyperthyroidism Research Articles

Prevalence of thyroid dysfunction in namakkal district -A hospital based study

Thyroid disorders are most common endocrine disorder in India but the prevalence studies on these dysfunction is limited. All subjects who visited the hospital for a period of four months to have thyroid function tests (TFTs) on their first outpatient visit were included in the study. Thyroid disordrs were present in 22.11 % of the total 2510 subjects . The prevalence rate was higher in females (64.8%) than males (35.2%) with (p=0.0003).The prevalence of hypothyroidism in the study population was 64.32 % (n = 357). In our study those with primary hypothyroidism were predominant (55.18 %, 197 out of 357) and 43.1 % (154 out of 357) were having sub clinical hypothyroidism and 6 of 357 were having secondary hypothyroidism. The prevalence rate of hyperthyroidism was 52.6 % (n-188) . The majority were subclinical hyperthyroidism (65.90 % , 124 out of 188) ,30.8 % (58 out of 188) had primary hyperthyroidism and3% ( 6 out of 188) had secondary hyperthyroidism. In our study thyroid function abnormalities were noted in 15.73 % of all subjects. Thyroid disorders were common in age of >20 years than 20-40 ,40-60 and and >60 year categories. The prevalence of primary hypothyroidism was found to be higher than subclinical hypothyroidism, while in hyperthyroidism subclinical condition was predominant compared to primary hyperthyroidism.

Adenomas hipofisarios y adenomas funcionantes

Functioning pituitary adenomas (FPAs) are the most common pituitary lesions. They represent approximately 15% of all intracranial neoplasms, with prolactinomas accounting for 60% of FPAs. Its clinical manifestations are related to hypersecretion and/or local symptoms due to the tumor's mass effect, such as headache, visual disturbances, and/or hypopituitarism. The main clinical syndromes associated with pituitary hyperfunction include hyperprolactinemia with secondary hypogonadism, acromegaly, Cushing's syndrome, and secondary hyperthyroidism. Diagnosing FPA involves demonstrating an excess in hormone secretion through biochemical tests followed by imaging tests to localize the tumor. Magnetic resonance imaging (MRI) with contrast is the test of choice for this purpose. In regard to treatment, surgery is the first-line option for most FPAs except for prolactinomas, which usually respond well to dopamine agonists.

Biochemical pattern and prevalence of thyroid disorders among adults in a tertiary hospital in North-East Nigeria

Thyroid disorders are a relatively common group of endocrine disorders globally. Thyroid function tests are critical for diagnosing, screening, and prognosticating thyroidal and non-thyroidal diseases, and their accurate interpretation is required for effective and accurate patient management. A retrospective analysis of thyroid function tests - Thyroid Stimulating Hormone (TSH), Free Thyroxine (fT4), and Free Triiodothyronine (fT3) - was carried out at a Nigerian tertiary hospital between January 2017 and January 2024. The tests were conducted using an enzyme-linked fluorescent immunoassay system and interpreted following standard protocols. A preponderance of female patients was investigated for thyroid diseases, with a male-female ratio of 2.2:1. The majority (80.8%) of the analyzed requests showed a euthyroid pattern; primary hyperthyroidism was the most common biochemical pattern of thyroid dysfunction observed, accounting for 10.8% of all the analyzed requests. Secondary hyperthyroidism and hypothyroidism were generally rare. Occasional cases (0.3%) of T3 toxicosis were also observed. Goiters remain a common presentation of thyroid diseases in our environment. Primary hyperthyroidism and primary hypothyroidism are the most common forms of thyroid dysfunction observed.

#1814 Infection associated pancreatitis in peritoneal dialysis, a case report

Abstract Background and Aims Peritoneal dialysis (PD) patients seem to have a higher incidence of acute alithiasic pancreatitis. Though rare and with some suggested triggers described in the literature, this is still a poorly understood and potentially life-threatening complication. We present a 60 years old woman concluding antimicrobial therapy with an icodextrin night-dwell regimen for peritonitis presenting with epigastric pain. This work reviews our approach to cloudy effluent from non-infectious causes during an infection while managing acute pancreatitis in the PD setting. We report diagnostic difficulties and treatment considerations with a positive outcome. Method We present a 60 years old woman on PD for one year presenting to the emergency room in November of 2023 with severe epigastric pain, nausea and emesis. She suffered from stage 5 chronic kidney disease due to autosomal dominant polycystic kidney disease and had disease complications as anemia and secondary hyperthyroidism controlled within targets. She was on automated PD (APD) with glucose based solutions. She was on the 17th of 21 days antibiogram guided treatment (ceftazidime) for a Enterobacter ludwigii PD-related peritonitis with good clinical evolution and peritoneal effluent (PE) leukocyte count per μl from 1258 to 91 in 5 days. In the previous 3 months she had had 2 other infectious episodes. A bacteremic urinary tract infection to E. coli associated with peritonitis treated with antibiogram guided therapy (ceftazidime) followed by C. difficile colitis treated with oral vancomycin. During each infection period she transitioned from APD to continuous ambulatory peritoneal dialysis with an icodextrin night dwell. On admission she presented with normal vital signs, no fever, and abdominal distention with severe epigastric tenderness to palpation without muscular guarding. Her dwell exchange showed blood-tinged cloudy PE. She had hemoglobin of 11.3 g/dl, otherwise normal blood cell counts, and raised amylase (213 UI/l) and lipase (1467 UI/l). There was no elevation of transaminases, cholestatic enzymes, C-reactive protein or procalcitonin and lipidemia or hyperbilirubinemia were normal. PE cell count showed 213/μl leukocytes and 202/μl erythrocytes. Abdominal ultrasound showed no evidence of an obstructive cause. She was admitted in the surgical care unit for a conservative and watchful approach. Results On presentation we accounted for the peritonitis still under treatment, acute pancreatitis, drug therapy and recently introduced icodextrin solution. The acute alithiasic pancreatitis diagnosis was established but there was still a possible causative role of icodextrin or infection and refractory peritonitis could also not be promptly excluded. The literature suggests icodextrin and other drugs as causes for acute pancreatitis in some patients but also mentions the possibility of cloudy or hemorrhagic effluent due to abdominal inflammation processes. Considering the clinical stability, the multiple possible contributing causative agents and the differential diagnosis of refractory peritonitis we closely monitored PE cell count evolution keeping the icodextrin dwell and ceftazidime prescriptions and collected samples for bacterial and fungal culture. The cultures were negative and stability of leukocyte count and mononuclear cell predominance (Fig. 1) helped us exclude the peritonitis hypothesis and attribute the PE changes to the pancreatitis process. Conclusion Inpatient monitoring and identifying all possible causes are essential to ensure good outcomes in PD patients suffering from acute pancreatitis. Full anamnesis, physical examination and close attention to laboratory findings were key in allowing adequate antibiotic therapy and resolution of the abdominal inflammatory process at hand while maintaining an adequate PD prescription.

Case report: nivolumab induced dual hypophysitis and secondary hyperthyroidism

Case report: nivolumab induced dual hypophysitis and secondary hyperthyroidism

FRI476 Asymptomatic Thyrotropin-secreting Pituitary Microadenoma With Biochemical Secondary Hyperthyroidism: A Diagnostic Conundrum

Abstract Disclosure: G. Al-Naqeeb: None. R. Ghosh: None. P. Veeraraghavan: None. C. Cochran: None. J. Klubo-Gwiezdzinska: None. S. Gubbi: None. Background: Thyrotropin (TSH)-secreting pituitary adenomas (TSHAs) are often macroadenomas (>1 cm), and clinically present with secondary hyperthyroidism (SH), but clinically silent microTSHAs (<1 cm) with only biochemical SH pose a diagnostic challenge. Clinical Case: A 49-year-old, healthy male was referred to our center for evaluation of abnormal thyroid function tests (TFTs). Immunoassay (IA) measurements at an outside hospital had identified elevated free T4 (FT4), and an inappropriately normal TSH, and a pituitary magnetic resonance imaging (MRI) had noted an 8mm x 7mm non-invasive adenoma. The patient denied hyperthyroidism symptoms, medication/herbal supplement intake, radiation exposure, headaches, vision changes, and thyroid/pituitary disorders, or abnormal TFTs in relatives. Physical exam revealed no signs and symptoms of hyperthyroidism. No thyromegaly or cervical lymphadenopathy was felt. IA profile at our institute was consistent with an SH pattern [TSH: 3.32 mIU/L (NL: 0.4 - 4.7); FT4: 3 ng/dL (NL: 0.9 - 1.7); total T4: 14.5 mcg/dL (NL: 4.5 - 11.7); triiodothyronine: 266.6 ng/dL (NL: 80 - 200)], with similar values on repeat measurement. Equilibrium dialysis technique also yielded an elevated FT4 value. TSH-receptor, anti-thyroid peroxidase, and anti-thyroglobulin (Tg) antibody (Ab) titers, serum Tg, and thyroid binding globulin levels were normal. Dilution studies ruled out heterophile Ab interference. Familial dysalbuminemic hyperthyroxinemia was unlikely given the elevated FT4 values. Genetic testing revealed a normal THRB gene, thereby ruling out thyroid hormone resistance. THRA gene was not tested due to absence of behavioral or hearing issues. Markers of hyperthyroidism, including angiotensin converting enzyme, carotene, apolipoproteins, and osteocalcin levels were normal, except for an elevated sex hormone binding globulin of 104 nmol/L (NL: 11 - 78). Biochemical evaluation of other pituitary axes was normal. However, an elevated alpha sub-unit fraction (ASF) was noted on two separate measurements. Sonogram revealed a heterogeneous, hypervascular thyroid. Bone densitometry, echocardiogram, and Holter monitor studies were normal. The combination of biochemical SH, elevated ASF, pituitary adenoma, and exclusion of other etiologies causing SH pattern established the diagnosis of TSHA. An active surveillance approach was implemented. A pituitary MRI done 18 months later showed minimal (2mm in one axis) increase in the adenoma size, and the patient continued to demonstrate biochemical SH but remained asymptomatic. Conclusion: MicroTSHAs can present with asymptomatic SH. In this situation, excluding other biochemical SH etiologies is crucial to prevent unnecessary invasive procedures. But once TSHA diagnosis is established, due to the risk of tumor growth leading to symptomatic SH or mass effects, active surveillance is warranted. Presentation: Friday, June 16, 2023

SAT216 Multiple Reasons Of Secondary Hyperthyroidism And Unexpected Results

Abstract Disclosure: I. Dzherieva: None. N. Volkova: None. S. Brovkina: None. I. Reshetnikov: None. L. Gritsenko: None. T. Mamedova: None. U. Ismailov: None. Background: Revealing the cause of secondary hyperparathyroidism might be a difficult problem especially if a patient has a few diseases to lead to this condition. Clinical Case: A 52-year-old-man was referred to our service for revealing the cause of weakness which started after COVID 19. When the patient was treated by rivaroxaban there was an unusual feature such as a hemoptysis, so the medicine was canceled. In medical history only the Achilles tendovaginitis was performed. The patient plays football twice a weak regularly, does not smoke, does not use drags. The physical examination showed nothing special. An arterial blood pleasure was 120/80 mm Hg, Body Mass Index was 25,4 kg/m2. Laboratory workup showed high erythrocyte sedimentation rate (ESR)(33mm/hr), leukocytosis (11000mm3) and a normocytic anemia(Hb 115 g/l),hematuria (16650 RBCsper hpf). Creatinine was 163µmol/L, glomerular filtration rate (GFR) was 43 ml/min/1.73m 2 , total serum calcium corrected for the patient's albumin concentration was 2.47 mM/L (2.15-2.50 mM/L), parathyroid hormone (PTH-intact) was 130 pg/mL (10-65 pg/mL),the level of 25-hydroxyvitamin D was 14.4 ng/mL(30.0-100.0 ng/mL). Chest radiograph findings were as follows: bilateral irregular, nodular, and patchy opacities. After vitamin D deficiency correction level of PTH-intact became normal (65 ng/mL). Serological tests : antinuclear antibody [ANA] and double-stranded DNA [dsDNA], ANCA were performed. Antineutrophil cytoplasmic antibody (ANCA) test result revealed perinuclear ANCA related to myeloperoxidase with the level more than 80 IgG. According to this finding Microscopic polyangiitis was diagnosed. Conclusion: This case has shown that sometimes there are two reasons for development of secondary hyperthyroidism and only successive actions help to choose right way for diagnosis. Presentation: Saturday, June 17, 2023

Enhancing the organic solvent resistance of ω-amine transaminase for enantioselective synthesis of (R)-(+)-1(1-naphthyl)-ethylamine.

Biocatalysis in high-concentration organic solvents has been applied to produce various industrial products with many advantages. However, using enzymes in organic solvents often suffers from inactivation or decreased catalytic activity and stability. An R-selective ω-amine transaminase from Aspergillus terreus (AtATA) exhibited activity toward 1-acetylnaphthalene. However, AtATA displayed unsatisfactory organic solvent resistance, which is required to enhance the solubility of the hydrophobic substrate 1-acetylnaphthalene. So, improving the tolerance of enzymes in organic solvents is essential. The method of regional random mutation combined with combinatorial mutation was used to improve the resistance of AtATA in organic solvents. Enzyme surface areas are structural elements that undergo reversible conformational transitions, thus affecting the stability of the enzyme in organic solvents. Herein, three surface areas containing three loops were selected as potential mutation regions. And the "best" mutant T23I/T200K/P260S (M3) was acquired. In different concentrations of dimethyl sulfoxide (DMSO), the catalytic efficiency (kcat /Km ) toward 1-acetylnaphthalene and the stability (half-life t1/2 ) were higher than the wild-type (WT) of AtATA. The results of decreased Root Mean Square Fluctuation (RMSF) values via 20-ns molecular dynamics (MD) simulations under 15%, 25%, 35%, and 45% DMSO revealed that mutant M3 had lower flexibility, acquiring a more stable protein structure and contributing to its organic solvents stability than WT. Furthermore, M3 was applied to convert 1-acetylnaphthalene for synthesizing (R)-(+)-1(1-naphthyl)-ethylamine ((R)-NEA), which was an intermediate of Cinacalcet Hydrochloride for the treatment of secondary hyperthyroidism and hypercalcemia. Moreover, in a 20-mL scale-up experiment, 10mM 1-acetylnaphthalene can be converted to (R)-NEA with 85.2% yield and a strict R-stereoselectivity (enantiomeric excess (e.e.) value>99.5%) within 10h under 25% DMSO. The beneficial mutation sites were identified to tailor AtATA's organic solvents stability via regional random mutation. The "best" mutant T23I/T200K/P260S (M3) holds great potential application for the synthesis of (R)-NEA.

Abstract #1411806: A Case of Thyrotropin Secreting Adenoma and Review of Literature

Elevations of TSH, FT4, and FT3 are a feature of secondary hyperthyroidism which could occur in the setting of resistance of thyroid hormone at the pituitary gland, alteration of certain deiodinase enzymes causing lower T3 at the pituitary or a TSH secreting tumor in the pituitary. Other conditions include pregnancy and the use of drugs (amiodarone, heparin). We present a case of secondary hyperthyroidism that was diagnosed with a TSH-secreting adenoma (TSHoma). A 72-year-old male presented with complaints of chest pain. He had a past medical history of primary hyperaldosteronism, occipital lobe ischemic infarct, osteoporosis with low-intensity rib, wrist, and vertebral fractures, coronary artery disease, and had undergone CABG. He was diagnosed with paroxysmal atrial fibrillation and had thyroid function testing which showed a TSH of 7.72μIU/mL (0.42-4.50), FT3 6.2pg/mL (2.0-4.4) and FT4 1.74ng/dL (0.70-1.48). A subsequent CT Head revealed a sellar mass measuring 1.4 cm craniocaudally with abutment of the optic chiasm. Repeat thyroid testing continued to show an elevated TSH, FT3, and FT4. αsubunit glycoprotein was 4.1ng/mL (< 0.5), IGF-1 by LC/MS was 31ng/mL (32-200), prolactin was 46.5ng/mL (4.0-15.2) and SHBG 131.6nmol/L (13.3-89.5). He was managed with methimazole and underwent trans-sphenoidal resection of the tumor. Pathology showed a 3.5 x 1.8 x 0.3 cm mass that on immunoperoxidase stains demonstrated expression of synaptophysin by many of the neoplastic cells. Some expressed GH, few expressed prolactin while rare neoplastic cells expressed TSH. TSHomas are rare pituitary adenomas with a prevalence of 1-2 cases/million. Up to 30% can be associated with hypersecretion of GH, prolactin, LH and FSH. The cells express TRH, somatostatin, and dopamine receptors. Clinical features include headaches, visual field defects, goiter, signs/symptoms of hyperthyroidism, pressure effects of the adenoma, cardiac manifestations (atrial fibrillation, heart failure, pericardial effusion) and vertebral fractures. αsubunit glycoprotein is elevated and an αsubunit to TSH molar ratio >1 can be used with 90% sensitivity to differentiate it from other causes of elevated TSH, FT3 and FT4. Elevations in SHBG are also found in patients. Resistance to the thyroid hormone at the pituitary level can give rise to a similar presentation. Elevated levels of SHBG and αsubunit glycoprotein seen in TSHoma can aid in differentiation. Dynamic testing such as a T3 suppression test with LT3 fails to suppress TSH production in cases of TSHoma. In addition, a TRH stimulation test fails to increase levels of TSH or αsubunit in TSHomas. Due to the presence of somatostatin receptors, TSH reduction starts to occur within hours after the use of somatostatin analogs. Surgical removal is the cornerstone of management and helps achieve normal TSH levels in more than 75% of patients. Pre-operative treatment with octreotide is shown to reduce TSH levels by up to 50% and cause a reduction in size by 20-50%. Undetectable TSH 1-week post-op has good prognostic value and a reduction in TSH on a T3 suppression test has optimal sensitivity and specificity to demonstrate cure.

The efficacy of combined treatment of secondary hyperthyroidism in pre-dialysis chronic kidney disease patients

Background. It is well known that chronic kidney disease (CKD) patients develop mineral and bone disturbances which lead to the development of renal osteodystrophy and its complications. Secondary hyperthyroidism is the main reason for the development of mineral and bone disoders in these patients. The purpose of the study was to evaluate the efficacy of combined therapy with Alfacalcidol and Quercetin in the treatment of secondary hyperthyroidism in pre-dialysis CKD patients. Materials and methods. 61 patients with CKD 3 and 4 stages aged 20–78 years were included in the study. Patients were divided into 2 groups: 35 patients received combined treatment with Alfacalcidol and Quercetin granules, and 26 patients received standard treatment with calcium carbonate. Indices of calcium, phosphorus, magnesium, and alkaline phosphatase were analyzed by photocolometry method and parathyroid hormone (PTH) by immune assay method. Statistical analysis was performed in the Statistica 5.0 program (StatSoft Inc., USA). Results. It was shown that intake of Alfacalcidol (0,25–0,5 mcg daily) and Quercetin granules 1.0 g three times per day provided normalization of calcium-phosphorous homeostasis, correction of hyperthyroidism but also has pronounced analgesic effect as compared with patients receiving monotherapy with calcium carbonate. Conclusions. Combined treatment with Alfacalcidol and Quercetin granules in predialysis CKD patients with secondary hyperthyroidism leads to calcium and phosphorus metabolism normalization, correction of secondary hyperthyroidism, and has an analgesic effect.

A cross-sectional study to know the prevalence of thyroid dysfunction in systemic lupus erythematosus

Background: Systemic lupus erythematosus (SLE) is a persistent autoimmune disease, the pathogenesis of which remains elusive. Autoimmune factors may be a cause of SLE and thyroid dysfunction. Many studies have revealed that the prevalence of thyroid disorder is higher in SLE patients than in the general population. SLE is a multisystem and hypothyroidism is an organ specific autoimmune disorder and can occur successively or simultaneously. Aims and Objectives: The aim of the study was to study the prevalence of thyroid disorder in patients with SLE. Materials and Methods: Patients admitted with definite clinical features of SLE and Antinuclear Antibodies positive, in medicine ward and healthy blood donors are taken as control. Sample was tested by fully automated analyzer. Results: Subclinical hypothyroidism was found in 24% of study group and 8% of control group which is statistically significant. Central and secondary hyperthyroidism was found in 10% of study group and 12% of control group but it was statistically insignificant. Several studies have documented an association between SLE and other autoimmune diseases such as Sjogren’s syndrome, autoimmune hemolytic anemia, and antiphospholipid syndrome. Subclinical hypothyroidism was higher than another thyroid dysfunction such as primary, central, and subclinical hypothyroidism was found to be higher in frequency, probably depicting the slow destructive process which is pathognomic of autoimmune thyroiditis. Conclusion: Subclinical hypothyroidism was more prevalent in SLE than that of overt hypothyroidism as compared with general population.

Estimation of Prevalence and Patterns of Thyroid Dysfunction in a Tertiary Care Centre in Uttarakhand, India: A Cross-sectional Study

Introduction: Thyroid dysfunction is a common endocrine disorder, defined as the altered serum Thyroid Stimulating Hormone (TSH) levels with normal or altered FT3 and FT4 (triiodothyronine and thyroxine) levels. The spectrum of thyroid disorders includes hypothyroidism, hyperthyroidism, goiter/ iodine deficiency disorders, autoimmune thyroiditis, thyroid cancer, as well as subclinical hypothyroidism or hyperthyroidism. However, further research is required on the spectrum of thyroid disorders, apart from goiter/iodine deficiency disorders in the study population mentioned. Aim: To investigate the prevalence and patterns of thyroid disorders in the clinical biochemistry laboratory of a tertiary care hospital in the hilly region of Uttarakhand, India. Materials and Methods: Present cross-sectional study was conducted in the clinical biochemistry laboratory of Veer Chandra Singh Garhwali (VCSG) Govt. Institute of Medical Science and Research Centre, Srinagar Garhwal, Uttarakhand, India. The study population consisted of 950 subjects who underwent Thyroid Function Test (TFT) panel investigation from January 1, 2018 to December 31, 2020. The collected data were analysed using descriptive statistical tools (mean, frequency, percentage) and correlation analysis of thyroid disorder with age and gender using Spearman’s rank correlation test. Results: Among 950 TFT panel reports, thyroid dysfunction was prevalent in 386 (40.63%) patients, of which 307 (79.53%) were females and 79 (20.47%) were males. The mean age±SD of the 386 patients with thyroid dysfunction was 32.24±8.77 years. Among these 386 thyroid dysfunction patients, the majority, 264 (68.39%) were in the 19-39 years age group. A very weak statistical correlation was observed between thyroid dysfunction with age and with gender among the 386 patients. Out of the total number of patients (950), 156 patients had euthyroid hyperthyroxinaemia (16.42%), 101 had subclinical hypothyroidism (10.63%), 74 had euthyroid sick syndrome (7.78%), 42 had subclinical hyperthyroidism (4.42%), 10 had primary (overt) hypothyroidism (1.05%), one had primary (overt) hyperthyroidism (0.11%), and two had secondary hyperthyroidism (0.21%). Conclusion: The prevalence of thyroid dysfunction in the present study was high, with a greater proportion in females and the 19- 39 years age group. The most common disorders observed were euthyroid hyperthyroxinaemia, subclinical hypothyroidism, and euthyroid sick syndrome.

ODP359 Thyrotropin secreting pituitary microadenoma and lung adenocarcinoma treated with epidermal growth factor receptor (EGFR)-tyrosine kinase inhibitors (TKIs) Erlotinib and Osimertinib: a case report

Abstract Background Thyrotropin secreting pituitary adenoma (TSHoma) of the pituitary specific transcription factor-1 (PIT-1) lineage, is the rarest subtype of pituitary neuroendocrine tumours (pitNETs). TSHomas must be discriminated from primary hyperthyroidism and can cause morbidity through thyrotoxicosis or local mass effect. Serum alpha-subunit level may be used as a marker of tumour activity, as 50-85% of TSHoma patients have high serum alpha-subunit levels. First line treatment is surgical resection of the tumour. Medical therapy with somatostatin analogues or radiotherapy may be used for tumour control. Epidermal growth factor receptor (EGFR) expression has been demonstrated in pitNETs including corticotrophs, gonadotrophs, lactotrophs and somatotrophs. EGFR inhibiting agent, Lapatinib, has been investigated for treatment of prolactinomas and EGFR expression is implicated in tumorigenesis of corticotrophs. EGFR targeting tyrosine kinase inhibitors (TKIs) can be used first line to treat metastatic adenocarcinoma of the lung harbouring activating EGFR mutations. Case Report A non-smoking 53-year-old male of Middle Eastern heritage was seen in clinic with secondary hyperthyroidism on a background of metastatic adenocarcinoma of the lung and hypertension. The patient had no symptoms of hyperthyroidism and had no personal or family history of thyroid dysfunction. No new headaches or visual disturbance were reported. Physical exam showed brisk reflexes, no specific signs of hyperthyroidism or thyromegaly were seen. Thyroid function tests demonstrated a persistently elevated TSH 5.1mIU/L (0.4-4. 0), T4 21.8pmol/L (9-19) and T3 6.4pmol/L (2.6-6. 0) with negative anti- thyroid receptor, thyroperoxidase and thyroglobulin antibodies. Ultrasound of the thyroid was unremarkable. MRI revealed a well-circumscribed left anterior pituitary lesion of 5.4×6.8mm in size. Surgery was deferred as 3 months prior, he was diagnosed with stage 4 intrapulmonary adenocarcinoma of the lung with an exon-19 deletion mutation in the EGFR gene. He received stereotactic radiotherapy and EGFR targeted therapy using 100mg of Erlotinib daily, which increased to 200mg 6 months later. After 1 year of therapy, his adenocarcinoma progressed and he was transitioned to the 3 rd generation EGFR-TKI Osimertinib. Instead of undergoing the risk of pituitary surgery, a trial of EGFR therapy for its pleiotropic pituitary adenoma effects was decided. During the EGFR-TKI treatment period, alpha subunit levels have remained stable and serial MRI imaging at 1 year showed no interval pituitary adenoma growth. Conclusion This is a rare case of TSHoma identified during treatment of lung cancer with EGFR-TKIs. EGFR signalling is implicated in prolactinomas and corticotrophs though there is a paucity of data regarding TSHomas. To date, our patient has achieved radiological and biochemical stability in his TSHoma, with hyperthyroidism control on EGFR-TKI therapy, suggestive of a therapeutic benefit from EGFR signal blockade. Further studies are needed in larger cohorts to quantify EGFR expression in TSHomas and evaluate its possible role in pathogenesis. Presentation: No date and time listed

Real-time intraoperative near-infrared autofluorescence imaging to locate the parathyroid glands: A preliminary report.

Identification and localization of parathyroid glands (PGs) remains a challenge for surgeons. The aim of this study was to evaluate the efficiency of intraoperative near-infrared autofluorescence (NIRAF) imaging to detect PGs in thyroid and parathyroid diseases. Seventy-six patients undergoing surgery for thyroid or parathyroid diseases between July 9, 2020 and August 20, 2021 were retrospectively analyzed. Intraoperative carbon nanoparticle (CN) negative imaging and handheld NIRAF imaging were successively performed for each patient. Of 206 PGs that needed to be identified for surgery, 162 were identified by NIRAF imaging, with a theoretical rate of identification of 78.64%. This was higher than the rate of identification with CN negative imaging, which was 75.73%. The number of PGs identified by NIRAF imaging and CN negative imaging did not differ significantly in either total thyroidectomy or thyroid lobectomy. In addition, the autofluorescence (AF) intensity of secondary parathyroid adenoma was weaker than that of normal PGs. NIRAF imaging is potentially a more efficient tool for identification of PGs than CN negative imaging, with a shorter learning curve and lower risk. It may not be well-suited to secondary hyperthyroidism or adenoma, but it was more efficient at identifying excised specimens than visual identification by a surgeon.

Thyrotropinoma with silent somatotroph and lactotroph adenoma during pregnancy.

SummaryThyrotropinomas are an uncommon cause of hyperthyroidism and are exceedingly rarely identified during pregnancy, with limited evidence to guide management. Most commonly they present as macroadenomas and may cause symptoms of mass effect including headache, visual field defects and hypopituitarism. We present a case of a 35-year-old woman investigated for headaches in whom a 13 mm thyrotropinoma was found. In the lead-up to planned trans-sphenoidal surgery (TSS), she spontaneously conceived and surgery was deferred, as was pharmacotherapy, at her request. The patient was closely monitored through her pregnancy by a multi-disciplinary team and delivered without complication. Pituitary surgery was performed 6 months post-partum. Isolated secondary hypothyroidism was diagnosed postoperatively and replacement thyroxine was commenced. Histopathology showed a double lesion with predominant pituitary transcription factor-1 positive, steroidogenic factor negative plurihormonal adenoma and co-existent mixed thyroid-stimulating hormone, growth hormone, lactotroph and follicle-stimulating hormone staining with a Ki-67 of 1%. This case demonstrates a conservative approach to thyrotropinoma in pregnancy with a successful outcome. This highlights the need to consider the timing of intervention with careful consideration of risks to mother and fetus.Learning pointsThyrotropinomas are a rare cause of secondary hyperthyroidism. Patients may present with hyperthyroidism or symptoms of mass effect, including headaches or visual disturbance.Thyrotropinoma in pregnancy presents a number of pituitary-related risks including pituitary apoplexy and compression of local structures.Hyperthyroidism in pregnancy raises the risk of complications including spontaneous abortion, preeclampsia, low birthweight and premature labour.Timing of medical and surgical therapies must be carefully considered. A conservative approach requires careful monitoring in case emergent intervention is required.

Spectrum of Thyroid Illness in COVID-19

Background: De novo thyroid dysfunction can occur as a result of COVID-1. Patients have diverse manifestations of thyroid illness, ranging from asymptomatic hyperthyroidism to secondary hyperthyroidism. Aim: To evaluate various thyroid diseases and compare them to mortality and clinicopathological features. Methods: After approval from the institutional ethical review board, this observational cross sectional study was carried out at a private sector hospital in Karachi. Patients diagnosed with COVID-19 admitted between December 2020 to May 2021 were recruited using consecutive sampling. Patients who did not give informed consent and had known thyroid disorders or history of thyroidectomy were excluded. To analyse the relationship between thyroid laboratory reports, and clinicopathological features, the Chi-square test and “Fischer's exact test” were utilised. SPSS version 21 was used for statistical analysis. A statistically significant P value of 0.05 was used. Results: Majority of the patients 105(72.9%) had higher FT3 levels and none of them reported with the decreased levels. 88(61.1%) came up with the higher FT4 levels while 9(6.3%) reported with decreased FT4. 9(6.3%) and 6(4.2%) were positive for the anti-thyroperoxidase and anti-thyroglobulin antibodies. The results showed statistical significance for free FT4 (p value 0.018), anti-TG (p-value 0.001) and anti-TP antibodies (p value 0.005). Conclusion: COVID-19 patients had a high frequency of thyroid abnormalities. Thyroid dysfunction appears to fluctuate over time and to recover slowly and naturally. Key words: TSH, Thyroid, COVID-19, Anti-thyroglobulin, Anti-Thyroperoxidase, FT4, FT3

Thyroid Disorders.

Thyroid Disorders.

English

BACKGROUND Thyroid disorder patients are more prone to develop depressive symptoms. Depression is also associated with various thyroid abnormalities.1 Slight change in thyroid hormone levels show symptoms of depression, anxiety, increasing fatigability and psychomotor slowing. The depressive symptoms are more in elderly patients with rapid changes in thyroid hormone levels.1 In depressive disorder patients, 1 % to 4 % have primary (Overt Hypothyroidism) and 4 % to 40 % have subclinical Hypothyroidism.2 Overt thyroid dysfunction is usually mild. Thyroid abnormality is not a causal factor, it is mainly a risk factor for depression.2 We intended to study the thyroid function in various depressive disorder patients of Srikakulam district at Government medical college &amp; General hospital Srikakulam. Srikakulam district has been chosen for this study for its backwardness in the residuary state of Andhra Pradesh. The objectives were to find out thyroid function levels like serum TSH, T3 and T4 in various depressive disorder patients and compare with the severity of clinical score, analyse and correlate with various depressive disorder patients of different age and sex groups, locality (both rural and urban areas). METHODS This observational study of thyroid function was conducted among 61 various depressive disorder patients of both males and females of 21 to 60 years age group who attended OPD and IPD of Psychiatry, Government medical college and general hospital, Srikakulam. We analysed and correlated serum TSH, T3 &amp; T4 levels with various depressive disorders. RESULTS It was observed that subclinical hypothyroidism had a clinical severity of 16.39 %, overt hypothyroidism was 1.63 %, secondary hyperthyroidism was 1.63 % and euthyroidism was 80.33 % of various depressive disorders and was more common in females than in males and equal in distribution in both the rural and urban population. CONCLUSIONS Hypothyroidism was found to have been associated with various depressive disorders, cognitive function and psychosis among female patients and hyperthyroidism was associated with psychosis, anxiety, depression and cognitive impairment. KEY WORDS Depression, Hypothyroidism, Hyperthyroidism, Euthyroidism

An Atypical Case of TSH-Secreting Pituitary Adenoma in a Patient Presenting With Low Libido and Insomnia

Background: TSH-secreting pituitary adenoma is an incredibly rare cause of hyperthyroidism. Most patients with TSHomas present with clinical hyperthyroidism, but some patients may have atypical signs. Here we present the case of a patient who had been suffering from low libido and insomnia who was found to have secondary hyperthyroidism from a TSH-secreting pituitary adenoma. Clinical Case: A 47-year-old man presented with complaints of progressive headache, fatigue, depression, insomnia, low libido and erectile dysfunction. After questioning, he noted the presence of intentional tremor for more than 5 years. He denied anxiety, palpitations, heat intolerance, hyper defecation, proximal muscle weakness, local compressive symptoms of the neck and ocular symptoms. Physical exam was notable for fine tremor and mild thyromegaly, but otherwise patient had no evidence of anxiety, exophthalmos, hyperreflexia or diaphoresis. The patient was found to have a normal free testosterone (46 pg/mL, n 30-140 pg/mL) but had an elevated TSH (6.302 IU/mL, n 0.4-5 IU/mL), elevated Free T4 (3.6 ng/dL, n 0.6-1.2 ng/dL) and an elevated T3 (422 ng/dL, n 73-178 ng/dL). Further lab work revealed elevated alpha-subunit (4.4 ng/mL, n <0.5 ng/mL) suggestive of TSH-secreting pituitary adenoma. Prolactin and IGF-1 levels were normal. Patient had an MRI pituitary which showed a 2.3 cm sellar mass abutting the optic chiasm without involvement of the cavernous sinus. Patient proceeded to trans-sphenoidal resection. Post-operatively, TSH had dropped from 6.534 to 0.002 IU/mL (n 0.4-5 IU/mL) and Free T4 had dropped from 3.1 to 0.5 ng/dL (n 0.6-1.2 ng/dL). Interestingly, immunohistochemical staining was negative for TSH but the specimen did show histologic features characteristic of TSH-producing adenoma including extensive stromal fibrosis and nuclear pleomorphism. Patient was seen in clinic post-operatively where he noted a dramatic improvement in his headache and insomnia. He did show signs of hypothyroidism including constipation and weight gain. Patient was started on levothyroxine 75 mcg PO daily. Conclusion: This demonstrates the case of a patient with a TSH-secreting pituitary adenoma who presented with minimal thyrotoxic symptoms despite elevated thyroid hormones. Patients with this condition may present with atypical symptoms, thus requiring clinicians to have a high index of suspicion for this rare tumor.

Thyrotropin-Secreting Pituitary Adenoma Successfully Treated With Cabergoline

Background: Thyrotropin secreting pituitary adenomas (TSH-oma) account for less than 1% of pituitary adenomas and are a rare cause of hyperthyroidism. In this case, we describe the safe use of cabergoline with the subsequent achievement of euthyroid levels and the resolution of symptoms. Clinical Case: A 67-year-old female with a presumed history of hypothyroidism for the last 3 years managed with Armour thyroid was referred for fatigue associated with palpitations, intermittent diarrhea, insomnia, and anxiety. Her TSH was noted to be suppressed at that time, and her Amour thyroid was changed to Levothyroxine 25 mcg daily, which was eventually stopped as her symptoms persisted. Follow-up thyroid function tests (TFTs) showed elevated TSH (8.60 µU/mL, reference range 0.340 - 5.600 µU/mL), and elevated free T3 (10.8 pg/mL, reference range 2.7-4.7 pg/mL) and free T4 (2.0 ng/dL, reference range 0.8-1.5 ng/dL) levels. Further laboratory workup including basal prolactin, LH, FSH, hCG α-subunit, IGF-1, and ACTH levels were within the normal range. Physical examination showed diffuse thyroid enlargement. An I-123 thyroid uptake and scan showed uniform uptake throughout the gland with no focal hyperintense areas. A dedicated pituitary MRI was performed and revealed an 8 mm microadenoma in the posterior left adenohypophysis. The patient wanted to avoid any invasive treatment and refused trans-sphenoidal surgery and medical therapy was chosen. Unfortunately, using a somatostatin analog as part of the standard medical treatment was not an option due to the high cost and lack of insurance coverage. For these reasons, a trial of cabergoline was started to suppress TSH secretion. Atenolol 25 mg daily was added temporarily for the management of her sympathetic symptoms. On periodic follow-up, her symptoms gradually subsided, and TFTs remained within normal limits. Treatment was continued for one year. Conclusion: Clinical manifestations of hyperthyroidism with biochemical evidence of elevated thyroid hormone levels and TSH levels should raise a strong suspicion for central or secondary hyperthyroidism due to TSH secreting pituitary adenoma. Cabergoline might represent an effective alternative form of medical treatment for TSH-oma in certain situations where the first line therapeutic options are refractory, contraindicated, or declined.