Toxic Multinodular Goiter Research Articles

6472 Methimazole Induced Agranulocytosis: Uncommon Complication of a Common Medication

Abstract Disclosure: R. Kaur: None. L. Kaur: None. A. Sridhar: None. T. Chaudhary: None. N. Patel: None. Methimazole (MMI) induced agranulocytosis is a rare and life threatening adverse effect that usually occurs within 3 months of drug initiation and can rapidly lead to overwhelming infection. It is reported in 0.1 to 0.5 % of patients on treatment with methimazole. MMI is a standard drug used in graves disease and toxic multinodular goiter. We report a case of MMI induced agranulocytosis in an elderly female with recently diagnosed toxic multinodular goiter. A 66 year old female with past medical history of recently diagnosed toxic multinodular goiter for which she was started on methimazole 80mg/day two months ago presented to the emergency department with chief complaint of severe sore throat associated with rapidly increasing pharyngeal pain and fever over the past 24 hours. She was lethargic, febrile with temperature of 102 F, tachycardic with heart rate of 115/minute and hypotensive with blood pressure of 108/64 mm Hg. Physical examination revealed diffuse pharyngeal and tonsillar erythema with bilateral purulent exudate with tender anterior cervical lymphadenopathy. Thyroid was enlarged, firm, irregular and nontender. Pulmonary, cardiac and abdominal exam was unremarkable. Lab work showed severe leukopenia with WBC count of 1,600/mm3, neutropenia with absolute neutrophil count of 0.0 x 1000/ul (normal range 1.8-7.3 x 1000/ul) and erythrocyte sedimentation rate and C reactive protein were both elevated. Blood cultures and fungal cultures showed no growth. Urinalysis and urine culture were both unremarkable. She had an extensive haematological, rheumatological and infectious disease workup for neutropenia, which was largely unrevealing. Rapid streptococcal testing was negative but throat cultures grew beta haemolytic streptococci. Treatment included suspending methimazole, administering antimicrobial therapy with piperacillin - tazobactam, acyclovir and fluconazole. She was also started on a granulocyte colony stimulating factor. Patient presented satisfactory evolution with progressive increase in leukocyte count and remission of symptoms by day 5 of treatment, rendering further bone marrow testing unnecessary. Antibiotics were changed to oral amoxicillin-clavulanic acid after throat culture results were available and the patient was discharged in stable condition. One month after discharge she underwent total thyroidectomy for definitive cure and is currently followed up as an outpatient by endocrinology. The objective of this case report is to present an uncommon case of agranulocytosis secondary to use of methimazole and to increase awareness among the physicians about the need to consider this diagnosis in patients on this medication. It is also advised that these patients be educated about the drugs side effects, a practice that may avert suffering and unnecessary costs. Presentation: 6/3/2024

7588 Coexistent Toxic Nodular Goiter And Primary Hyperparathyroidism (PHPT), A Combo With Diagnostic And Management Implications

Abstract Disclosure: D. Dave: None. A. Bhan: None. S.D. Rao: None. About 17-84% of patients with PHPT have concomitant thyroid disorders, but the prevalence of coexistent hyperthyroidism in PHPT varies 9-14 %. A vast majority had Graves’ disease with only 3 cases of toxic multinodular goiter (MNG) and PHPT reported in the literature as of 2022 ([1]). We present a rare case of coexistent toxic MNG and PHPT. Case Description: A 68y woman presented with recent 23 kg unintended weight loss and palpitations, but no other symptoms. Denied having kidney stones or fractures. On examination she had fine tremors of hands, MNG without exophthalmos. An ultrasound showed multinodular MNG with cystic lesions. A diagnosis of toxic MNG was made. Laboratory results were: TSH (<0.01 uIU/mL), free T4 1,68 ng/dL (normal: 0.61-1.44 ng/ml), high serum Ca (11.0 - 11.4 mg/dl) over 4y, but PTH was unavailable prior to the visit when it was 107 pg/ml and 89 pg/ml after 3 months of antithyroid therapy. Despite clinical and biochemical euthyroidism after 3 months, serum Ca and PTH levels remained high (11.4 mg/dl and 89 pg/ml respectively). Because she had pulmonary embolism a few years ago, we deferred parathyroidectomy until complete remission of hyperthyroidism. Discussion: Hypercalcemia is the biochemical hallmark of PHPT but can occur in 2-10% of patients with hyperthyroidism alone but only 1% of those will have coexistent PHPT. When these two conditions coexist, hypercalcemia is moderate to severe, and an occasional patient may present with hypercalcemic crisis (2). Prior to the availability of PTH assays, it was a challenge to diagnose coexistent PHPT. Hypercalcemia in hyperthyroidism responds to propranolol but not in PHPT, although the response is variable (3). With the availability of sensitive PTH assays, this maneuver is not necessary. In most cases, current PTH assays distinguish hypercalcemia of hyperthyroidism with suppressed PTH from coexistent PHPT in whom PTH level is non-suppressed or elevated. Monitoring serum Ca and PTH levels during therapy of hyperthyroidism would be useful as normalization of serum Ca and PTH has occasionally been reported (4). In our patient, serum Ca and PTH levels remained high with 3-months of methimazole and atenolol. The impact of both conditions on bone and mineral metabolism are profound, with fractures and kidney stones. Since kidney stones are uncommon in hyperthyroidism, presence of kidney stone in a hyperthyroid hypercalcemic patient should alert the possibility of PHPT. Similarly, significant decrease in bone density in such patient also raises the possibility of PHPT. Prompt diagnosis and appropriate treatment of both conditions is necessary to avoid irreversible complications.

6925 A Rare Case of Metastatic Papillary Thyroid Carcinoma Confined to Cervical Lymph Node with No Identifiable Primary Tumor In The Thyroid Gland. A Diagnostic Conundrum

Abstract Disclosure: R. Abdelmasih: None. W. Pan: None. Introduction: Papillary thyroid carcinoma (PTC) is the most common treatable thyroid cancer (TC) with very good prognosis. Metastatic PTC either in the lymph node LN or extra-nodal with no primary thyroid lesion identified is a rare phenomenon referred to as occult thyroid carcinoma (OTC). Despite its rarity, it is reported and constitute a diagnostic conundrum. herein we present a case of metastatic PTC identified in cervical lymph nodes (LN) without a primary tumor in the thyroid gland confirmed with surgical pathology. Case Presentation: A 43-year-old female with history of post-ablative hypothyroidism after treatment of toxic nodular goiter for 10 years, with no family history of thyroid cancer presented with incidentally found left 1.8 Heterogeneous hypoechoic solid nodule with lobulated borders and internal calcifications along with left-sided 0.8 LN without normal fatty hilum on Ultrasound Head and Neck. Fine needle aspiration of the left thyroid nodule and suspicious LN revealed PTC in the left LN though the thyroid nodule sample was non-diagnostic. CT of head and neck showed partially calcified thyroid nodule, Hyperattenuating 8 mm left III LN without fatty hilum, and 9 mm left II calcified LN. Patient underwent total thyroidectomy, central neck, and left lateral neck dissection. Surgical pathology showed no malignancy in thyroid gland or central LNs and 1 out 5 LN of the left neck dissection showed PTC with tumor grading of pT0 pN1b pMNA. patient underwent whole-body thyrogen-stimulated thyroid scan which showed iodine avid tissue in the thyroid bed followed by high-dose I-131 radioactive iodine ablation (RAI). Discussion: OTC refers to impalpable incidental TC less than 10 mm per the WHO. Boucek et al classify OTC into four categories, recently a fifth category was added, in which metastasis is confirmed either in regional LN or distant metastasis though thyroid tissue is confirmed to be benign per pathology and imaging evaluation, our patient falls in the fifth category. Hypothesis of this phenomenon is not well understood, one suggested explanation is missed diagnosis due to not enough sample or if lesion is less than 3 mm. another hypothesis is tumor spontaneous regression, or regression secondary to treatment that was inadequate to treat the systemic process of the tumor, which we believe our patient fits in this hypothesis, given that she underwent RAI ablation many years ago. Tumor regression is very rare and reported to be 1 in 140,000 cases. Another theory suggests that PTC can arise in ectopic thyroid tissue. This case is to shed light on a rare clinical and pathological entity to avoid missed diagnoses. Prognosis depends on the extent of metastasis, with favorable one when it is limited to regional LN and worse with distant metastasis. More cases reports are warranted to help guide further management of such cases due to the lack of available guidance in use of RAI surveillance and ablation. Presentation: 6/1/2024

7618 Thyroid Nodules, Normal Thyroid Levels, and Chronic Anxiety: A Case for Sub-Clinical Toxic Multinodular Goiter

Abstract Disclosure: C.M. Barrera: None. Introduction: Chronic anxiety and panic disorders, as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), are the most common psychiatric conditions. Hyperthyroidism is a known cause of both chronic anxiety and panic disorder. Case 1: A 36-year-old overweight Latin female is referred for evaluation of multiple thyroid nodules. The thyroid ultrasound was heterogeneous, with multiple bilateral nodules. In her history, the patient has chronic anxiety with panic attacks resulting in frequent emergency room visits. The TSH and T4 levels were TSH 0.59 mIU/L (0.40-4.5) and T4 10.7 mcg/dL (5.1-11.9). An I[1]23- Thyroid Scan showed a hot nodule with mild suppression and an uptake of 31.8% (The top limit is 35%). The patient started methimazole 2.5 mg daily, and after two months, her chronic anxiety and panic attacks resolved. Post-methimazole TSH rose to 1.18 mIU/L, and T4 10.0 mcg/dL and she has weaned off anxiety medications. Case 2: A 49-year-old overweight Latin female is referred for increased thyroid nodules. She complained of six months of tachycardia and anxiety. The TSH and T4 levels were TSH of 0.828 mIU/L (0.40-4.5) and T4 of 7.9 mcg/dl (4.5-12.0). An I[1]23-Thyroid Scan showed no dominant hot or cold nodules, with an uptake of 36.4% (The top limit is 35%, within normal error limits). She started methimazole 5 mg daily, resolving her tachycardia and anxiety within five weeks. Post-methimazole TSH was 1.64 mIU/L (0.45-4.5), and T4 6.7 mcg/dL (4.5-12.0). Case 3: A 60-year-old overweight Latin female is referred for evaluation of multiple thyroid nodules of ten years. She complained of chronic anxiety and panic attacks for two years. The TSH and T4 were normal at TSH 0.36 mIU/L (0.35- 5.50) and T4 9.7 mcg/dL (4.5-10.9). The thyroid ultrasound showed multiple bilateral nodules. An I[1]23-Thyroid Scan showed a suspected hot nodule without appreciable suppression and an uptake of 33% (The top limit is 35%). The patient started methimazole 5 mg daily. After eight weeks, she reported the resolution of most of her chronic anxiety with post-methimazole TSH 2.39 mIU/L and T4 7.1 mcg/dL (4.5-12.0). Discussion: The normal range of TSH, typically from 0.4-4.5 mIU/L, is calculated by measuring the TSH levels among a normal population. The group range then determines the laboratory reference range. This contrasts with individual values, which have a narrower range, suggesting that each person has a unique thyroid level. This suggests that TSH levels at the extremum, associated with hyperfunctioning nodules contributing to a rise in uptake, may not be normal for that patient and may explain the anxiety and other symptoms. Learning Points: Evolving multiple autonomous thyroid nodules lowers TSH levels while raising thyroid uptake. Symptoms of chronic anxiety and panic attacks can predate abnormal thyroid levels and resolve with low-dose methimazole. Presentation: 6/1/2024

The Causes of Thyrotoxicosis, Clinical Features, and Treatment Strategies in a Former Iodine Deficient Area

Thyrotoxicosis is a hypermetabolic condition caused by excess thyroid hormones in the circulation with/without increased production from the thyroid gland. In this prospective study, we aimed to investigate the causes of thyrotoxicosis, clinical features, and treatment strategies in a former iodine-deficient area. Thyroid function tests, antithyroid and antithyroid receptor antibodies, and routine thyroid ultrasonography was obtained, and a thyroid scintigraphy/radioactive iodine uptake test was performed on need. A statistically significant difference was found between toxic multinodular goiter (TMNG) and Graves’ disease (GD) groups when mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), alanine aminotransferase (ALT), and aspartate aminotransferase (AST) values were analyzed. TSH levels were significantly lower in GD patients compared to those in TMNG and TNG patients, but free triiodothyronine (FT3) and free thyroxine (FT4) values were higher. A high level of TSH receptor antibody (TRAb) was observed in patients with normal antithyroid peroxidase (Anti-TPO). TRAb levels were found to be high. Anti-TPO and anti-thyroglobulin (Anti-Tg) levels were observed to be positively correlated with sT3 and sT4 levels. TMNG is the leading cause of thyrotoxicosis; despite sufficient iodide intake in our former iodine-deficient region, TMNG is characteristically seen in older patients with much lower thyroid hormone levels than GD. According to the study results, the diagnosis of patients with thyrotoxicosis, their clinical presentation, the treatment they will receive, early detection of postoperative complications were predicted

Protocolo diagnóstico y terapéutico de las tiroiditis

Thyroiditis refers to an inflammation of the thyroid gland, with a variable impact on its functionality. In this protocol, thyroiditis is classified according to its progression as chronic, subacute, acute, or variable course. The epidemiology, etiology (autoimmune, infectious, traumatic, environmental, pharmacological, etc.), pathophysiology, and clinical course differ among the different types of thyroiditis. Some progress with characteristic pain and others are painless. The diagnosis is generally easy and clinical. A medical record and physical examination are essential as well as a good differential diagnosis between the types of thyroiditis and with other thyroid diseases such as Graves-Basedow disease and toxic multinodular goiter. In most cases, the treatment is simple if a proper diagnostic orientation is performed.

Tirotoxicosis e hipertiroidismo

Thyrotoxicosis is a clinical condition secondary to excess thyroid hormones (TH). It can be caused by increased synthesis and release of TH by the thyroid gland (hyperthyroidism, the most common cause) as well as by thyroid inflammation and destruction, ectopic production, or exogenous administration of TH. The diagnosis is biochemical and based on the determination of thyroid stimulating hormone (TSH) and thyroid hormones (thyroxine and triiodothyronine). To plan effective treatment, it is crucial to identify the underlying cause. Graves-Basedow disease is the most common cause, followed by toxic multinodular goiter and toxic thyroid adenoma. Less frequent, although relevant, are thyroiditis, extrathyroidal TH production, and factitious thyrotoxicosis. Some imaging tests, such as a Doppler ultrasound and thyroid scintigraphy, are helpful in the etiological diagnosis. The goal of treatment is to achieve symptoms control and reduce TH synthesis and secretion through the use of drugs or radical treatments (radioiodine or surgery).

A case of giant toxic nodular goiter with dyspnea by pulmonary hypertension and obstructive symptom

A case of giant toxic nodular goiter with dyspnea by pulmonary hypertension and obstructive symptom

A Lower Prevalence of Central Nervous System and Higher Prevalence of Cardiac Symptoms Characterises Indian Patients with Thyrotoxic Storm: A Retrospective Analysis.

Thyroid storm is an uncommon but life-threatening presentation of thyrotoxicosis with a mortality rate of 10%. Our objective was to study the demographics, clinical and biochemical characteristics, and outcomes of inpatients diagnosed with thyroid storm in the Indian context. This retrospective study was conducted by analysing the institutional electronic medical records (EMR) of all patients admitted with thyroid storm from 2004 to 2020 with a Burch-Wartofsky score (BWS) of ≥45. Thirty-five patients with a BWS ≥45 were included, of whom 71.4% were women, with a mean age of 44.9 ± 10.2 years. 43% did not have any prior history of thyrotoxicosis. Graves' disease was the most common underlying aetiology (71.4%), followed by toxic multinodular goitre (14.3%). Cardiovascular (94.3%) and gastrointestinal-hepatic dysfunction (88.6%) were the most common clinical manifestations. Features of Central nervous system (CNS) dysfunction were seen in only 42.3% of patients diagnosed with a thyroid storm. The Japanese Thyroid Association (JTA) criteria diagnosed only 26 patients (74.3%) with "definite" thyroid storm. The mortality rate was 8.6%, and all three patients expired within 48 hours of admission. Nearly one in every two patients with thyroid storm had previously undiagnosed thyrotoxicosis. Toxic multinodular goitre is a notable aetiology in Indians. Features of CNS dysfunction, considered relatively specific for thyroid storm, were less prominent in our series. The JTA criteria might alter the classification of some patients diagnosed with a thyroid storm, when compared to the BWS score due to fewer CNS features among Indian patients.

The role of autoimmune thyroid disorders in patients with alopecia areata

Objective: The aim of this study was to investigate the association of thyroid autoimmunity with alopecia areata (AA) by examining thyroid stimulating hormone (TSH) and thyroid autoantibody levels. In addition, to compare the epidemiologic data obtained with the data of our country. Methods: Our study was organized as a cross-sectional, retrospective study. The study was performed on patients between the ages of 2-65 years who were admitted to our outpatient clinic between 01.01.2008 and 31.12.2011, who were clinically or histopathological diagnosed with AA, examined for etiology and thyroid autoantibodies were requested. Patients under two years of age and over 65 years of age, patients with no thyroid autoantibodies and pregnant patients were excluded. Results were expressed as mean±standard deviation and median values. Mann-Whitney U test was used to compare TSH, anti-TG antibody (Anti-TG) and anti-TPO (Anti-TPO) antibody values in the variables of nail involvement, psychiatry, comorbidity and family history. Spearman correlation analysis was used to examine the relationships between age and disease duration and TSH, Anti-TPO and Anti-TG variables. Results: In our study, 65 (42.8%) of 152 patients were female and 87 (57.2%) were male. The ages of the patients ranged between 2-65 years and the mean age was 26.5±14.6 years. The mean age of females was 27.5±14.4 and 25.7±14.9 in males. Elevated thyroid autoantibodies were found in a total of 29 patients, 21 of whom were female and 8 of whom were male. Of these 29 patients, 10 had hypothyroidism, 2 had chronic thyroiditis and 3 had toxic multinodular goiter. 14 patients did not return after the examination at the internal medicine outpatient clinic, so the diagnosis of thyroid disease could not be reached. The mean TSH, Anti-TG and Anti-TPO values were 2.27±1.57, 29.2±99 and 71.5±2.2, respectively. When these values were analyzed separately as men and women, they were found to be 2.6±2.02, 41.8±1.23 and 134±2.8 in women and 1.99±1.03, 19.8±75.6 and 24.5±1.32 in men. There was a significant difference between men and women in terms of Anti-TG and Anti-TPO values (p=0.011 and p=0.001, respectively). A significant correlation was found between disease duration and Anti-TPO positivity (p=0.045); however, a similar relationship was not found between disease duration and Anti-TG positivity (p=0.34). Conclusions: As a result of this study, although there was a significant correlation between anti-TPO and duration of AA, the association between thyroid autoimmunity and AA was not found to be statistically significant. This may be due to the fact that humoral autoimmunity plays a role in thyroid autoimmunity and primarily cellular autoimmunity plays a role in AA. In addition, the epidemiologic data of our study were similar to the data of studies conducted in our country.

Long-Term Follow-up of Patients With Autonomous Thyroid Nodules Treated With Radioiodine.

This article aims to describe the presentation of Plummer disease and its evolution after radioiodine treatment and determine factors that may influence treatment efficacy. The sample included retrospective medical records of 165 adult patients with toxic nodular goiter treated with radioiodine between 1997 and 2017, followed up at a single thyroid center. The efficacy of treatment with a single dose of radioiodine was higher than 90%. The mean radioiodine activity was 28.9 ± 3.4 mCi. The mean time between radioiodine performance and hyperthyroidism resolution was 3.6 ± 3.0 months, ranging from 1-12 months. After the first year, 33.9% of the patients were under hypothyroidism, 59.4% under euthyroidism, and 6.7% under hyperthyroidism. Among the nonresponders, the variables that showed statistical difference were the presence of multinodular goiter and the radioiodine activity (mean, 25.5 ± 6.5 mCi; median, 30 [15-30 mCi]). The cumulative rate of hypothyroidism was 48.9% over 20 years of follow-up. Radioiodine therapy is an effective and safe treatment. In Plummer disease, high rates of euthyroidism are expected after the radioiodine treatment. Therapeutic failure was observed mainly in patients with larger multinodular goiters treated with lower doses of radioiodine. The evolution to hypothyroidism was mostly observed in younger patients with larger and uninodular goiters.

Use of a dosimetry-based RAI protocol for treatment of benign hyperthyroidism optimises response while minimising exposure to ionising radiation.

The optimal treatment strategy for radioiodine (RAI) treatment protocols for benign hyperthyroidism remains elusive. Although individualised activities are recommended in European Law, many centres continue to provide fixed activities. Our institution implemented a dosimetry protocol in 2016 following years of fixed dosing which facilitates the calculation of individualised activities based on thyroid volume and radioiodine uptake. This was a retrospective study comparing success rates using a dosimetry protocol targeting an absorbed dose of 150 Gy for Graves' disease (GD) and 125 Gy for Toxic Multinodular Goiter (TMNG) with fixed dosing (200MBq for GD and 400MBq for TMNG) among 204 patients with hyperthyroidism. Success was defined as a non-hyperthyroid state at 1 year for both disease states. Results were analysed for disease specific or patient specific modulators of response. This study included 204 patients; 74% (n = 151) received fixed activities and 26% (n = 53) of activities administered were calculated using dosimetry. A dosimetry-based protocol was successful in 80.5% of patients with GD and 100% of patients with TMNG. Differences in success rates and median activity administered between the fixed (204Mbq) and dosimetry (246MBq) cohort were not statistically significant (p = .64) however 44% of patients with GD and 70% of patients with TMNG received lower activities following treatment with dosimetry as opposed to fixed activities. Use of dosimetry resulted in successful treatment and reduced RAI exposure for 36% of patients with GD, 70% of patients with TMNG, and 44% of patients overall. This retrospective clinical study demonstrated that treatment with a dosimetry-based protocol for TMNG and GD achieved comparable success rates to fixed protocols while reducing RAI exposure for over a third of patients with GD and most patients with TMNG. This study also highlighted that RAI can successfully treat hyperthyroidism for some patients with activities lower than commonplace in clinical practise. No patient or disease specific modulators of treatment response were established in this study; however, the data supports a future prospective trial which further scrutinises the individual patient factors governing treatment response to RAI.

Evaluation of the prevalence and laboratory test results of overt thyrotoxicosis cases.

The frequency of thyrotoxicosis may vary between countries and some laboratory test results may be used in etiology research. This study aimed to evaluate the prevalence of thyrotoxicosis diagnoses and laboratory test results. 3246 patients with overt thyrotoxicosis were included in this study. Laboratory test results, epicrisis, thyroid ultrasonography, thyroid scintigraphy, and radioactive iodine uptake test reports of the patients were examined in the study. Thyrotoxicosis was found due to levothyroxine overdose in 58.1% of the patients. When this group was excluded, 36.1% of the patients were diagnosed with toxic multinodular goiter most frequently. TRab levels were 8.5 times higher in Graves' disease than in other diagnostic groups. Anti-TPO levels were found to be the highest in the Graves' disease and Hashitoxicosis groups compared to other diagnostic groups (p<0.001). Anti-Tg levels were found to be highest in Graves' disease, Postpartum thyroiditis, and Hashitoxicosis patients (p<0.001). The free triiodothyronine / free thyroxine ratio was significantly higher, a cut-off value of >2.94 provided a sensitivity of 66% and specificity of 64% in diagnosing Graves' disease. The causes of thyrotoxicosis show some differences between countries. Patients using levothyroxine should be informed about drug use and dose titration. The free triiodothyronine / free thyroxine ratio can be used in addition to other tests during diagnosis.

Primary thyroid lymphoma: a case of postoperative diagnosis in a patient with toxic multinodular goiter.

Primary thyroid lymphoma: a case of postoperative diagnosis in a patient with toxic multinodular goiter.

Hyperthyroidism and the risk of non-thyroid cancer: a Danish register-based long-term follow-up study.

Cancer is the second most common cause of death worldwide. It is currently debated whether thyroid dysfunction is a modifiable cancer risk factor. Our aim was to evaluate the risk of cancer in patients with hyperthyroidism. This is a register-based nationwide cohort study of individuals with a diagnosis of hyperthyroidism. Each hyperthyroid case was matched with four reference individuals according to age and sex. Using Fine and Gray competing risk regression models, we studied the association of hyperthyroidism and subsequent all-cause cancer diagnoses, adjusted for preexisting morbidity. Sub-analyses were stratified for cause of hyperthyroidism (Graves' disease and toxic nodular goiter, age when diagnosed with hyperthyroidism, sex, and cancer localization (lung, prostate, breast, and colorectal cancer)). The cohort consisted of 95,469 patients with hyperthyroidism (followed for a median of 10.9 years (range: 5.2-17.2)), and 364,494 reference individuals (followed for a median of 11.2 years (range: 5.4-17.4)). Hyperthyroidism was associated with increased all-cause cancer risk (sub-distribution hazard ratio (SHR): 1.12; 95% CI: 1.10-1.14), as well as an increased risk of breast (SHR: 1.07; 95% CI: 1.02-1.13), lung (SHR: 1.20; 95% CI: 1.16-1.26), and prostate cancer (SHR: 1.10; 95% CI: 1.02-1.19), but not colorectal cancer (SHR: 1.04; 95% CI: 0.99-1.09). Sub-analyses stratified for age when diagnosed with hyperthyroidism and cause of hyperthyroidism yielded similar results. In this register-based study, patients with hyperthyroidism had an increased risk of cancer, in particular lung, prostate, and breast cancer. Whether a causal link exists remains to be proven.

Using Bedside Spectral Doppler Ultrasound for the Assessment of Patients With Thyrotoxicosis

ObjectiveTo assess the bedside utility of Spectral Doppler Ultrasound (SDUS) in the initial evaluation of patients presenting with thyrotoxicosis. MethodsThis is a retrospective cross-sectional study of patients diagnosed with thyrotoxicosis at an academic outpatient endocrinology clinic from August 2019 to November 2022. The thyroid arteries' peak systolic velocities (PSV) were measured bilaterally using SDUS. PSV ≥40 cm/s in at least a single thyroid artery was considered a reasonable cut-off for Graves’ disease and PSV of perinodular artery ≥ 25 cm/s for toxic adenoma. ResultsWe identified 73 patients. Mean age ± standard deviation 45.2 ± 16.4 years, 54 (74.0%) were female, 49 (67.1%) were Caucasian, 23 (31.5%) were African American, and 1 (1.4%) was Asian. The confirmed diagnoses were 48 (65.8%) Graves’ disease, 13 (17.8%) thyroiditis, four (5.5%) toxic adenoma, four (5.5%) amiodarone-induced thyroiditis type 2, 1 (1.4%) toxic multinodular goiter, 1 (1.4%) had an unremarkable repeat thyroid function testing, and two (2.7%) were unconfirmed. Diagnosis based on the SDUS initial assessment was accurate in 65 (89.0%) of the patients, and it was conclusive and confirmatory during the initial encounter in 55 (75.3%) of the patients before additional testing. A thyroid scan was obtained in nine (12.3%) patients. Incorrectly diagnosed patients were observed in two patients of each of the following categories: Graves’ disease, thyroiditis, toxic adenoma, and unconfirmed diagnoses. ConclusionsSDUS can be a valuable, efficient, and cost-effective bedside tool in the initial assessment of patients presenting with thyrotoxicosis.

Simultaneous Papillary Thyroid Carcinoma and Primary Hyperparathyroidism: Unusual Presentation

The coexistence of Primary Hyperparathyroidism (PHPT) with Papillary Thyroid Carcinoma (PTC) is a rare clinical occurrence. Thyroid pathology is reported in 20% to 84% of Primary Hyperparathyroidism (PHPT) cases, with malignancies identified in 2% to 20% of instances. We report a case of a 49-year-old woman referred for evaluation of left iliac wing and hip pain with elevated parathyroid hormone levels. Imaging revealed a toxic multinodular goiter with a parathyroid adenoma. The patient underwent total thyroidectomy with parathyroid adenoma excision. Subsequent histological examination unexpectedly identified a papillary thyroid microcarcinoma associated with the parathyroid adenoma. The association between PHPT and PTC is complex, influenced by shared embryological origins and genetic factors. Elevated PTH levels in PHPT may contribute to thyroid cell proliferation, and hypercalcemia is suggested to promote thyroid carcinogenesis. Molecular analyses suggest the involvement of pathways like MAPK and Wnt/β-catenin. The coexistence of PHPT and PTC highlights the necessity for thorough preoperative assessment and the ongoing need for research. While minimally invasive parathyroid surgery is favored, the risks associated with coexisting thyroid pathology should be carefully considered. Routine thyroid ultrasonography in PHPT patients is crucial to exclude nodular thyroid disease, emphasizing the role of research in guiding clinical practices. A balanced approach integrating technical advancements and thoughtful risk assessment is essential in navigating this complex clinical scenario.

Factors predicting remission in hyperthyroid patients after low-dose I-131 therapy: 20years retrospective study from a tertiary care hospital.

To assess the therapeutic outcome and factors predicting remission in hyperthyroid patients treated with low-dose I-131 (radioactive iodine) from a tertiary care hospital in South India. This 20-year single-institutional retrospective study was carried out on 3891 hyperthyroid adult patients. Only those patients with complete clinical records were audited. Selection criteria were based on patients with scintigraphic diagnosis of either Graves' disease (GD), toxic multinodular goitre (TMNG) or autonomous toxic nodule (ATN) and the records of those who received low-dose I-131 therapy (LDT) between March 2000 and 2020 at Amrita Institute, Cochin were analysed. SPSS 10 software was used for statistical analysis. The records of 3891 hyperthyroid predominantly female patients were analysed. 65% patients had GD, 33% had TMNG and 3% were ATN. High rates of remission as early as 12 weeks (in 61% patients) was observed with a single dose of LDT while on strict iodine-free diet for 3-4weeks prior to LDT. Study reveals that those with lower free T4 (fT4), small goitre (thyroid volume < 25cm3), < 15% thyroid trapping function, shorter time duration from onset of hyperthyroidism to LDT, and treatment-naïve patients were factors determining high remission rates. Mann Whitney U test and Chi-square test was used to correlate variables in the remission and relapse groups. We found a positive correlation between fT4, thyroid volume (r = 0.35, p < 0.01) and trapping function (r = 0.34, p < 0.01), which were independent of age, sex, body mass index and TSH levels in our study. High therapeutic outcome was observed with a single dose of LDT while on iodine-free diet. Remission with single dose of LDT occurred in 90% patients by 5th month. Of them 56% patients were treatment naive prior to LDT. LDT is thus a safe and effective therapy in hyperthyroid patients and can be recommended as a primary modality of management.

Effect of Radioiodine Treatment on Quality of Life in Patients with Subclinical Hyperthyroidism: A Prospective Controlled Study.

Study aim was to evaluate thyroid-related QoL in patients with subclinical hyperthyroidism mostly due to toxic nodular goitre undergoing RIT, compared to a control group of euthyroid subjects. Study design was monocentric, prospective, controlled. Fifty control subjects were enrolled and 51 RIT patients. Most subjects were examined at least twice at an interval of 6 months, with visits immediately before and 6 months after treatment in the RIT group. QoL was estimated with the ThyPRO questionnaire, using its composite scale as primary outcome. Treatment effect was the mean adjusted difference (MAD) between groups over time, using repeated? measures mixed? effects models. TSH concentrations were lower in the RIT group prior to treatment and recovered thereafter slightly above the level of the control group. Correspondingly, QoL improved significantly after 6 months from a worse level in the RIT group, compared to controls (MAD -10.3 [95% CI -14.9, -5.7], p<0.001). QoL improvements were strong for general items, but less pronounced for the hyperthyroid domain. Compared to controls, thyroid volume, thyroid functional capacity (SPINA-GT) and deiodinase activity (SPINA-GD) were significantly reduced in the RIT group. Patients with subclinical hyperthyroidism improve both biochemically and in their QoL after RIT, compared to controls. QoL assessment should have a wider role in clinical practice to complement biochemical tests and help with treatment decisions.

Are there any indicative signs in colour Doppler imaging of de novo development thyroid orbitopathy after radioiodine treatment

Aims/Purpose: The aim of this study was to identify indicative signs in doppler flow parameters in the central retinal artery (CRA) and ophthalmic artery (OA) which might be associated with de novo development of thyroid‐associated orbitopathy in the early period after radioiodine treatment in patients with Graves disease.Methods: 82 patients with hyperthyroidism were enrolled: 44 with Graves disease and 38 with toxic nodular goitre. In both groups, blood flow parameters in the CRA and OA were analysed before and 2 and 4 weeks after radioiodine administration. The peak systolic velocity (PSV) and end‐diastolic velocity (EDV) were evaluated, and the resistive index (RI) was calculated.Results: There were no statistically significant differences in the PSV, EDV or RI between groups at baseline and 4 weeks after radioiodine administration. Two weeks after radioiodine administration, the RI in the CRA and EDV in the OA were significantly lower, and the EDV in the CRA was higher in patients with Graves disease than in patients with toxic nodular goitre. There was an inverse correlation between baseline thyrotropin receptor autoantibody (TRAb) levels and the difference between the RI at weeks 4 and 2 (RI3‐RI2) in the CRA and a positive correlation between the baseline anti‐thyroid peroxidase antibody concentration and RI3‐RI2 in the OA.Conclusions: Administration of radioiodine results in more prominent features of hyperkinetic circulation. Patients with Graves disease and high TRAb titers have a lower sensitivity to radioiodine treatment. High TRAb titers suggest higher disease activity and a weaker therapeutic effect of radioiodine.