Transient Hyperthyroidism Research Articles

Abstract 16468: Low Dose Amiodarone is Safe and Effective in Control of Atrial Fibrillation

Introduction: Amiodarone is the most effective drug for the treatment of atrial fibrillation (AF), but long-term administration of standard doses can have prohibitive side effects. Little data is available for use of lower doses. We sought to determine the lowest effective dose for rhythm control in a single physician practice. Methods: Consecutive AF patients treated with Amiodarone using a down-titration schema were prospectively followed. The goal was the lowest dose providing effective rhythm control defined as less than 1% AF burden in patients with devices (42% of patients) or no symptoms or no AF on ECG at last office visit in non-device patients. Results: 170 patents (89M, 81F) were followed for a mean period of 63 months (range 12-177). 79 of 170 (46%) had devices (6 ILR, 29 PM, 27 ICD, 17 CRT). 5 patients had drug-related transient side effects, including 1 transient hyperthyroidism. No patient had pulmonary fibrosis or death. 130 of 170 patients (76%) had successful control of AF. Table 1 shows the number of patents effectively controlled at each weekly dose level. 51% had success at less than or equal to 400mg per week. Renal disease, systolic heart failure with reduced ejection fraction, and advanced age were common comorbidities. Conclusions: Low-dose Amiodarone is safe and effective for control of AF in most patients if carefully used in a down-titration protocol. Device diagnostics aid in patient management.

Thyroid Crisis and Septic Suspected Sepsis in the First Trimester of Pregnancy

A normal pregnancy with physiological and hormonal changes can change thyroid function, accordingly, there are difficulties to establish the diagnosis of thyroid abnormality. The prevalence of hyperthyroidism in pregnancy is 0.6%. Approximately 1-2% of hyperthyroidism develops into a thyroid crisis. Knowledge of the diagnosis of the thyroid crisis in a pregnant female is very important to avoid complications. The 22-year-old female of thirteen weeks presented with vomiting, since two days before hospitalized, weakness, and decreased consciousness. During treatment, patients had diarrhea, melena, and was irritable. Physical examination showed blood pressure of 136/112 mmHg, pulse of 110 times/minute, respiration of 24 times/minute, and temperature of 38.3oC. Exophthalmos was found at the patient's eyes, but there was no enlargement of the thyroid and the patient often screamed hysterically. Routine urine examination showed proteinuria 1+, blood 3+, leukocytes 1+ in urinalysis, FT4 35.18 pmol/L and TSH <0.05 uIU/mL, leukocytes 15.2 x103/uL, SGOT 245 U/L, SGPT 366 U/L. The final diagnosis of this patient is a thyroid crisis and suspect sepsis in the first trimester of pregnancy. Thyroid Receptor Antibody (TRAb) examination should be performed to assure Graves disease or hyperthyroidism due to pregnancy (transient hyperthyroidism) as the cause.

Massive pulmonary thromboembolism combined with transient thyrotoxicosis in an 18\u2009year old girl

BackgroundPulmonary thromboembolism (PTE) is thought to usually stem from deep vein thrombosis (DVT). However, evidence of DVT could not be found in many cases. Furthermore, transient thyrotoxicosis is a rare but potentially life–threatening emergency involving a systemic hypercoagulable state. We report on an 18 year-old-girl with transient thyrotoxicosis with massive PTE without DVT.Case presentationAn 18-year-old girl was admitted to the hospital with syncope. Patient had no history of trauma, any known underlying disease or oral contraceptives use. Chest computed tomography (CT) showed massive PTE in both central pulmonary arteries and diffuse goiter. However, a low extremity Doppler sonogram did not detect DVT. To manage the PTE, we administered low molecular weight heparin. On the other hands, thyroid function test indicated a state of thyrotoxicosis. In addition, patient had a partial protein S deficiency but no other immunologic abnormality. Therefore, the patient was diagnosed with massive PTE, thyrotoxicosis, and partial protein S deficiency. Patient was discharged with oral warfarin and methimazole. A follow-up echocardiogram obtained 3 months after anticoagulation therapy demonstrated normal dimensions and systolic function. After thyrotoxicosis was treated with methimazole for a month, a euthyroid state was achieved and the goiter decreased to a normal size. The methimazole was gradually tapered off and stopped at 4 months. At a 6-month follow up visit, PTE and pulmonary hypertension had disappeared but the patient still had a partial protein S deficiency. We decided to stop all medication with careful monitoring. During a 4-year follow-up period after the episode, she was asymptomatic without any evidence of recurrent systemic thromboembolism or hyperthyroidism.ConclusionsEarly recognition and appropriate treatment of PTE combined with transient thyrotoxicosis were vital to preventing other complications.

Acute suppurative thyroiditis with transient hyperthyroidism in thalassemia child: an uncommon association in a common disease\u2014a rare case report

BackgroundThyroid infection is rare in paediatric age group in anatomically normal thyroid gland. However, acute suppurative thyroiditis (AST) is common in high-risk cases like thyroglossal duct remnant and thyroglossal pyriform sinus fistula. This may be associated with variable thyroid dysfunctions. Though transient hyperthyroidism is reported in some cases, its association was not documented in thalassemia child.Case presentationWe are reporting an 8-year-old male child with a history of fever, pain, and left neck swelling for 5 days. He was evaluated and empirically started intravenous antibiotics (ceftriaxone, cloxacillin, and amikacin) along with other supportive treatment for localized signs of thyroid infection. Ultrasonography of the neck revealed intercommunicating pockets of collections with internal echoes in the left thyroid lobe. CT neck was done and suggested that the left lobe of the thyroid gland was replaced by hypodense lesions of fluid attenuation without any congenital abnormality of the thyroid gland. His thyroid function tests were suggestive of biochemical hyperthyroidism. He was treated with intravenous antibiotics and ultrasonography-guided fine-needle aspiration of pus. His pus culture showed growth of methicillin resistant Staphylococcus aureus. He also had microcytic hypochromic anaemia which was evaluated and found to have thalassemia trait. His biochemical hyperthyroidism normalized after completion of 2 weeks of treatment and required no intervention.ConclusionAcute suppurative thyroiditis is an uncommon clinical condition in an anatomically normal thyroid gland which could be associated with thyroid dysfunction. Its association in a thalassemia child is also not documented in literature. Clinical evaluation and proper history taking and non-invasive thyroid imaging are the cornerstone for diagnosis. Antibiotics and pus drainage are the mainstay management. Associated biochemical hyperthyroidism is transient and resolves without any specific medication in asymptomatic cases.

Thyroid Disease I: Hyperthyroidism in Pregnancy

Thyroid physiologic adaptations in pregnancy may be confused with pathologic changes. Human chorionic gonadotropin rises early in pregnancy, stimulating thyrotropin secretion and suppressing thyroid stimulating hormone. These chemical changes are often seen in hyperemesis gravidarum and gestational transient thyrotoxicosis. Therefore, mild thyrotoxicosis may be difficult to differentiate from early pregnancy thyroxine stimulation. However, overt hyperthyroidism usually includes classic symptoms seen outside of pregnancy in addition to suppressed TSH and T4 levels. Treatment includes thionamides propylthiouracil and methimazole. Thyroid ablation is contraindicated in pregnancy. Often, in affected women, the fetus is euthyroid, but neonates can develop hyper or hypothyroidism with or without a goiter. Lastly, thyroid storm, though rare, is life threatening. Often presenting as a hypermetabolic state with cardiomyopathy and pulmonary hypertension, it generally results from decompensation from preeclampsia, anemia, sepsis, or surgery. Treatment requires intensive care level management, with initiation of thionamides, iodine, and beta blockers. This review contains 2 figures, 4 tables and 38 references. Keywords: Thyroid-releasing hormong, thyroid-stimulating hormone, thyromegaly, thyroid-stimulating immunoglobulins, thryotoxicosis, thionamides, thyroid storm

Painless thyroiditis in a dupilumab-treated patient.

SummaryDupilumab an inhibitor of the interleukin (IL)-4R-alpha subunit is used for the treatment of allergic diseases. The patient was a 49-year-old man who received dupilumab for the treatment of severe atopic dermatitis. He presented hyperthyroidism with elevated thyroglobulin and anti-thyroid antibody negativity at 4 months after the initiation of therapy. On scintigraphy, the thyroid radioiodine uptake was low. Ultrasonography showed a diffuse hypoechoic area in the thyroid gland. A pathological study revealed lymphocytic infiltration. The administration of dupilumab was continued because of his atopic dermatitis that showed an excellent response. The patient`s hyperthyroidism changed to hypothyroidism 3 weeks later. Six months later his thyroid function normalized without any treatment. We herein describe the case of a patient with atopic dermatitis who developed painless thyroiditis under treatment with dupilumab. To the best of our knowledge, this is the first report of this event in the literature.Learning points:Dupilumab, a fully human monoclonal antibody that blocks interleukin-4 and interleukin-13, has been shown to be effective in the treatment atopic dermatitis and asthma with eosinophilia.Painless thyroiditis is characterized by transient hyperthyroidism and hypothyroidism and recovery without anti-thyroid treatment.This is the first report of painless thyroiditis as an adverse effect of dupilumab, although conjunctivitis and nasopharyngitis are the main adverse effects of dupilumab.

The relationship between free thyroid hormone index and thyrotoxicosis in pregnancy

Objective: The aim of this study was to evaluate free thyroid hormone index (FTHI) (FT3 index/ FT4 index) as a parameter to use in differential diagnosis of gestational Graves’ disease (GGD) and gestational transient thyrotoxicosis (GTT). GGD and GTT are the most common causes of thyrotoxicosis in early pregnancy and differential diagnosis is important since they are treated differently. Method: Women who applied to our clinic with thyrotoxicosis were evaluated and 51 pregnant women were recruited to the study. Among the 51 women, 36 had GTT, 15 had GGD. The age, gestational age, thyroid stimulating hormone (TSH) levels, and FTHI (FT3 index / FT4 index) of all patients were recorded and compared. FT3/FT3 upper limit of normal (ULN) is referred as FT3 index. FT4 index is also referred as FT4/FT4 ULN. All diagnosis of GGD and GTT was confirmed with TRAb assays. Results: The mean values of FT3, FT3 index, FTHI of the GGD group were found to be statistically significantly higher compared to GTT group (p: 0.002, p: 0.001, 0.001; respectively). No statistically significant difference was found between groups in terms of age, gestational age, FT4, FT4 index and TSH (p:0.999, p:0.730, p:0.620, p:0.570, p:0.291; respectively) FTHI values were above 1 in all patients with GGD while it was below 1 in GTT group. Conclusions: The FTHI values above 1 may be used as a practical, cheap parameter for differential diagnosis between GGD and GTT.

SAT-416 Novel Autoantibodies for Thyroid-Specific Transcriptional Factors in Patients with Immune-Related Adverse Events Involving the Thyroid Gland

Background: Immune-related adverse events by immune checkpoint inhibitors often involve several endocrine-related organs. PD-1 pathway blockade therapy by anti-PD-1 antibodies including nivolumab frequently causes thyroid dysfunction (thyroid irAE). Thyroid irAE seems to be distinctive compared to conventional painless thyroiditis in terms of a clinical course: transient thyrotoxicosis and subsequent persistent hypothyroidism [1]. Our retrospective cohort study regarding nivolumab provided several suggestions [2]. The thyroid irAE (+) group had a longer median overall survival than the thyroid irAE (−) group in patients with lung cancer, but this observation was not seen in patients with malignant melanoma: In addition, 5 of 17 patients tested at the point of thyroid dysfunction development were double negative for TPOAbs and TgAbs, known thyroid autoantibodies. From these findings, we set a hypothesis that antibodies for unknown antigens mediate prognostic effects of thyroid irAEs if tumor tissues express the same antigens. Methods: We performed co-immunoprecipitation using Protein G beads, sera of three patients with thyroid irAEs, and lysates of HEK293T cells overexpressing candidate proteins tagged with FLAG and HiBit (NKX2-1, PAX8, FOXE1, and HHEX). The pellets were analyzed by western blot. Results: FOXE1 bands were augmented in patient 1 with lung cancer, a PAX8 band in patient 2 with malignant melanoma, and bands of FOXE1, PAX8, and HHEX in patient 3 with renal cell carcinoma, compared to a control sample of a normal subject. We performed subcutaneous injections of purified IgG fraction from the serum of patient 3 to C57BL/6 mice every 2 weeks. The mice were sacrificed after 4 weeks, but no significant changes were observed in their thyroid glands and thyroid function. Conclusions: We identified novel autoantibodies for FOXE1, PAX8, and HHEX, thyroid-specific transcriptional factors. In our experiments, the pathogenicity of antibodies were not suggested. Considering our previous observation that the thyroid gland expresses both PD-L1 and PD-L2, ligands of PD-1 receptor [1], PD-1 pathway blockade may particularly disrupt immune tolerance of the thyroid gland, resulting in autoantibody production. Because thyroid irAEs have been revealed to be a prognostic factor, these novel autoantibodies are candidate biomarkers for PD-1 pathway blockade therapy.

Thyroid Toxicity Following Immune Checkpoint Inhibitor Treatment in Advanced Cancer.

Background: Inhibitory antibodies against cytotoxic T lymphocyte antigen-4 (CTLA-4) and programmed cell death-1 (PD-1) have antitumor efficacy and are now standard of care in the management of multiple cancer subtypes. However, the use is complicated by the development of autoimmunity, which can occur in multiple organ systems. Thyroiditis is the most common immune-related adverse event. Summary: Immune checkpoint inhibitor (ICI)-associated thyroiditis affects over 10% of treated patients. PD-1 inhibitors are associated with greater risk of thyroid dysfunction relative to CTLA-4 inhibitors, although the highest risk occurs with combined anti-CTLA-4 and anti-PD-1 treatment. Onset is typically rapid, within weeks to months and both hyperthyroidism and hypothyroidism can occur. The most frequent pattern of thyroid dysfunction is transient hyperthyroidism with evolution to hypothyroidism over four to six weeks. Most cases are asymptomatic and resolve without dedicated treatment. There is no sex or age predominance, and predictive risk factors have not been reliably identified. Thyroid autoantibodies are variably present and are not clearly related to the risk or progression of thyroid dysfunction following treatment with an ICI. Observational data suggest that development of ICI-associated thyroiditis may predict improved survival. Conclusions: ICI-associated thyroiditis is a distinct clinical entity. Mechanisms underlying etiology remain largely unknown. Awareness among health professionals is important to limit morbidity and avoid unnecessary periods of untreated hypothyroidism.

SUN-521 Hyperemesis Gravidarum Resulting in Wernicke’s Encephalopathy and Abnormal Thyroid Function Tests

Background: Wernicke’s encephalopathy (WE) is a potentially fatal consequence of thiamine deficiency that must be considered in patients with poor nutrition and altered mentation. We report a case of a female with hyperemesis gravidarum (HG), nystagmus, clonus, and abnormal thyroid function tests associated with WE. Clinical Case: A 23 year-old healthy G2P0010 woman was admitted for rehydration at 15 weeks gestation after four weeks of intractable vomiting. She denied medications, supplements and alcohol use. Vitals were normal. Exam showed a fatigued ill appearing female with no thyromegaly, tremor, lid lag, or stare. She had a gravid uterus but otherwise normal exam. Fetal heart rate was normal. Laboratory findings included hyponatremia, hypokalemia, elevated creatinine and transaminases, and normocytic anemia. Hepatitis panel, vitamin B12, ammonia, urinalysis and ultrasound of the appendix and gallbladder were unremarkable. She was treated with intravenous fluids and potassium. Electrolyte abnormalities and renal dysfunction resolved. On hospital day three, she became lethargic, tachycardic, unable to follow commands, and exhibited nystagmus and clonus. Thyroid studies showed TSH 0.06 uIU/mL (0.34 - 5.66 µIU/mL), and free T4 3.59 ng/dL (0.52 - 1.21 ng/dL). Methimazole and propranolol were started while awaiting repeat thyroid studies. MRI brain was not obtained due to aspiration risk. EEG showed diffuse slowing but no epileptiform activity. She returned to baseline mentation within hours of intravenous thiamine, with resolution of dysphagia and nystagmus. Thiamine level returned low (51 nmol/l; normal 67–200 nmol/L). Methimazole and propranolol were stopped and thyroid function tests normalized. She was discharged and delivered a healthy baby at term. Conclusion: WE is an acute neuropsychiatric condition caused by thiamine deficiency. Early recognition and treatment are critical to prevent irreversible damage; the classic signs are ataxia, ophthalmoplegia, and encephalopathy. Historically considered in patients with a history of alcohol use, WE is increasingly recognized in other conditions associated with dietary deficiency, since body stores of thiamine last only 18 days. WE has been reported in HG due to prolonged vomiting and increased thiamine requirements in pregnancy. WE has been associated with thyrotoxicosis, possibly due to increased metabolic demands. Both gestational transient thyrotoxicosis and HG are associated with markedly elevated HCG and present in the first 16 weeks of pregnancy. Initial thyroid studies were concerning for thyrotoxicosis, but normal repeat studies argue against that as a contributor. WE is a life threatening complication of poor oral intake, which should be empirically treated with thiamine prior to glucose. WE may be associated with thyrotoxicosis.

SUN-517 Methimazole-Induced Neutropenia in Premature Twins with Graves’ Disease

Introduction: Neonatal Graves’ disease (NGD) occurs in approximately 1-5% of infants born to women with Graves’ disease. It is caused by trans-placental crossing of thyroid stimulating immunoglobulin (TSI) antibodies during third trimester. Hyperthyroidism during pregnancy can lead to craniosynostosis, goiter, premature bone maturation, developmental delay or even heart failure in the neonate. Neonatal Hyperthyroidism is usually transient and resolves in few weeks. Treatment consists of beta blockers and Methimazole. Studies in adults recommend discontinuing of Methimazole if patients develop neutropenia. However due to lack of alternatives, we present a case of continued use of Methimazole with neutropenia in newborn twins.Case Report:33 weeks gestational age mono-chorionic/di-amniotic twins born to a 34-year-old woman with poorly controlled hyperthyroidism. Mother diagnosed with Graves’ disease during 2nd trimester with poor control throughout pregnancy. At the time of delivery, maternal TSH was <0.005uIU/mL(0.358-3.74uIU/mL) and FT4 2.18ng/dL(0.76-1.46ng/dL). Antenatal ultrasound at 32 weeks showed homogeneous enlargement of fetal thyroid glands with increased vascularity in both twins. Babies found to have diffuse goiter and exophthalmos at birth. Thyroid tests remained normal for first 3 days of life. By day 3, babies labs showed TSH <0.005uIU/mL, FT4 -8 ug/dL and TSI >700%. Baseline CBC showed ANC of 4.95K/mm3. Babies were started on Methimazole 0.5mg/kg/day and Propranolol 2mg/kg/day. TFTs fluctuated throughout their stay in NICU and they developed neutropenia with ANC 1.23K/mm3 on day 20 of life. Methimazole was initially discontinued then restarted at 0.25 mg/kg/day 3 days later. There is no recommended protocol for restarting Methimazole. Further follow up showed persistent neutropenia despite multiple dose adjustments in Methimazole, including dosing every other day. ANC was maintained around 800-1100K/mm3. At age 2 months, Methimazole was discontinued completely after TSI antibodies decreased to 400%. ANC remained low until 6 months of life, even after discontinuing Methimazole. Both babies ultimately developed central hypothyroidism and were started on l-thyroxine.Discussion:NGD can range anywhere from transient hyperthyroidism to persistent central hypothyroidism. Early diagnosis and treatment is crucial to prevent significant morbidity and mortality. Methimazole is the only approved treatment at this age, and management of Methimazole-induced neutropenia has not been established. Adult studies recommend discontinuing Methimazole in context of neutropenia; we took an approach of decreasing dose gradually. Further studies are needed to establish step-wise approach in managing Methimazole-induced neutropenia.

SAT-576 Possible Involvement of Thyroid Function in PCSK9 Inhibitor Therapy

INTRODUCTIONProprotein convertase subtilisin kexin type 9 (PCSK9) inhibition is an effective strategy for lowering plasma LDL-cholesterol and enhancing the LDL-cholesterol lowering ability of statins. PCSK9, a serine protease that binds to the LDL receptor promoting its degradation, is an important regulator of LDL metabolism. In addition, LDL-cholesterol is also controlled by TSH and thyroid hormones via PCSK9. TSH has received increasing attention as being closely associated with increased LDL-cholesterol level and higher atherosclerotic risks. In vitro study, the effects of TSH on hepatic PCSK9 expression in HepG2 cells were reported (1). I here report a case of transient hyperthyroidism secondary to PCSK9 inhibitor therapy. This case highlights the involvement of thyroid function in PCSK9 Inhibitor therapy.CLINICAL CASEA 65-year-old man had a weight loss of 6 kg (13 lbs.) in 4 months, accompanied with fatigue. He had a past history of myocardial infarction and his LDL was 83 mg/dL by 2.5mg of rosuvastatin and heart rate was controlled by 10mg of carvedilol. Six months ago, he started a PCSK9 Inhibitor therapy with 140mg of evolocumab every 2 weeks for 6 weeks. He had no preceding viral illness and denied anterior neck pain or tenderness. His height was 1.53 m, weight 52.6 kg (115 lbs.), and body mass index (BMI) 22.46 kg/m2. His thyroid was not enlarged and non-tender without clear palpable thyroid nodules or neck lymph nodes. Hyperthyroidism was suspected and confirmed by thyroid function tests: TSH was less than 0.0005 μIU/mL (normal 0.35–4.94), and free T4 1.830 ng/dL (0.70–1.48). Graves’ disease was considered, and thyroid antibody tests performed. Thyroid peroxidase (TPO) antibody titer was less than 9 IU/mL (<9), and TSI 141% (<120%). To confirm the diagnosis of this hyperthyroid patient, Technetium-99m uptake and scan was done which showed uptake of 0.8% (0.5–7%). After careful observation for 2 months with 5mg of carvedilol, he turned asymptomatic and free T4 lowered to 1.480 ng/dL and TSH remained less than 0.0005 μIU/mL.CLINICAL LESSONSI here report a case of transient hyperthyroidism secondary to PCSK9 inhibitor therapy. There has been no report of hyperthyroidism induced by PCSK9 inhibitors. Immunological influence of anti-PCSK9 therapy on thyroid is unknown. In this case, the decrease of TSH due to hyperthyroidism was considered to reduce hepatic PCSK9 expression, leading to additive effect to PCSK9 inhibitor. PCSK9 inhibitors may modify the effects of hyperlipidemia treatment by causing changes in thyroid function. When using PCSK9 inhibitors, follow-up of thyroid function should be considered. This case highlights the involvement of thyroid function in PCSK9 inhibitor therapy.Reference(1) Gong, Y., Ma, Y., et al. Thyroid stimulating hormone exhibits the impact on LDLR/LDL-c via up-regulating hepatic PCSK9 expression. Metabolism. 2017;76;32–41

SUN-493 A “Curve Ball” in the Management of an Infertile Hyperthyroid Patient

Introduction: We present the case of a young female patient referred for hyperthyroidism with persistently detectable TSH despite elevated free thyroxine (FT4) levels which, interestingly, failed to normalize following anti-thyroidal treatment. Further testing elucidated the underlying causation for detectable TSH in presence of hyperthyroxinemia to be due to interfering substances in the thyroid function assays. Case: A 35-year-old female is evaluated for hyperthyroidism discovered in preparation for embryo transfer. History includes transient hyperthyroidism two years ago while undergoing in vitro fertilization. Prior workup included negative antibodies and nuclear uptake scan revealing a right-sided autonomously functioning thyroid nodule with 24-hour uptake of 40.7%. She was briefly treated with PTU in first trimester and lost to follow-up. While once again undergoing fertility treatment with clomiphene, the patient developed tremor and heat intolerance. She was found to have TSH 0.3 (0.45-4.12 mU/L) and analog FT4 of 6.4 (0.8-1.8 ng/dL). She denied use of OTC supplements. PTU 50 mg twice daily was initiated with minimal improvement with TSH 0.7 mU/L, FT4 3.7 ng/dL. On evaluation, slight tremor and mild thyroid enlargement were noted. Our differential expanded to include TSH-secreting pituitary adenoma, thyroid hormone resistance (no family history), and assay interference. Both MRI pituitary and an alpha-subunit level (0.36) were normal. Symptoms improved gradually with repeat TSH 1.79 mU/L, FT4 2.4 ng/DL by standard analog methods. We suspected ‘assay interference’ for which FT4 via direct equilibrium dialysis was obtained and was indeed normal at 0.76 ng/dL. Further lab testing verified interference in both in the standard TSH and FT4 assays presumed secondary to heterophile antibodies. Discussion: Interpretation of thyroid studies discordant with the clinical picture or incongruent with each other requires understanding of thyroid physiology and the intricacies of commonly utilized assays. The differential of elevated thyroxine levels with detectable/normal TSH rests between thyroid hormone resistance syndromes, TSH secreting pituitary tumors and interfering substances in the assay. Most commercially available TSH assays are based on a ‘sandwich’ assay which is notoriously interfered with by heterophile antibodies and excess biotin. Determination of FT4 is also challenging as the assay must detect very low concentrations of free hormone relative to excess of protein-bound analyte. When in question, it is important consider utilization of laboratory expertise and retesting by alternative assays.

Subacute Thyroiditis – An Underestimated Diagnosis: Description of a Case Series

Abstract Subacute thyroiditis is a relatively rare thyroid disease that develops after acute viral upper respiratory tract infection and manifests with neck pain, fever and transient hyperthyroidism. The diagnosis is often delayed due to the non-specific presentation and laboratory findings. It is misdiagnosed with upper respiratory tract infections, cervical lymph-adenitis, even with acute pyelonephritis. The authors present a series of 12 patients with subacute thyroiditis and discuss the main steps in the diagnosis, differential diagnosis and treatment of this disease.

Fetal and Maternal Outcomes of Gestational Thyrotoxicosis: Single Center Experience, Retrospective Cohort

Objective: Gestational thyrotoxicosis may lead to adverse maternal and fetal events. In this study, the aim was to compare the gestational thyrotoxicosis cases with the control group in terms of their differential diagnoses, clinical observation and gestational follow-up outcomes. Materials and Methods: Pregnant patients with subclinical or overt thyrotoxicosis who were followed up in endocrinology outpatient clinic between December 2009-September 2019 were included in the study. Patients were grouped according to the diagnosis of gestational transient thyrotoxicosis (GTT), Graves’ disease, toxic nodular goiter (TNG), and intra-group comparisons and comparisons with the control group were made in terms of the presence of maternal and fetal pregnancy complications during the gestational period, delivery week, and infant birthweight. Results: A total of 115 patients were divided into GTT group, which had 50 patients, Graves’ group, which had 14 patients, TNG group, which had 1 patient, and control group, which had 50 patients. The prevalence of hyperemesis gravidarum was the highest in GTT group, with 40%. Eclampsia was found in 2 (14.2%) of the pregnant women with Graves’ disease and was not found in other groups (p=0.01). Neonatal death was found in 3 (21.4%) of the pregnant women with Graves’ disease, and 1 (2%) of the pregnant women with GTT (p=0.01). There was a significant positive correlation between delivery week and TSH (p=0.001, r:0.64), and a significant negative correlation withft3(p=0.04 r:-0.3). A significant positive correlation was detected between infant birthweight and TSH and delivery week (p=0.03 r:0.32 and p<0.001 r:0.41, respectively). Conclusion: Gestational transient thyrotoxicosis does not affect infant birthweight and perinatal complications, whereas the prevalence of low infant birthweight and maternal eclampsia is higher in Graves’ disease.

Clinical study on the status of transient thyrotoxicosis after surgery for secondary hyperparathyroidism patients with end-stage renal disease and normal thyroid function

ObjectiveSecondary hyperparathyroidism (SHPT) is a common complication of end-stage renal disease (ESRD), and part of SHPT patients need receive parathyroidectomy (PTX). However, as an important postoperative complication of SHPT, thyrotoxicosis has received little attention. Therefore, in this article, we aimed to study the status of transient thyrotoxicosis after PTX for SHPT patients with ESRD and normal thyroid function.MethodsA total of 24 SHPT patients with preoperative normal thyroid function, normal thyroglobulin (Tg) and normal thyroid antibodies receiving PTX were enrolled from the Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, from January 2017 to January 2019. Tg, high sensitivity thyrotropin stimulating hormone (sTSH), triiodothyronine (T3), free triiodothyronine (fT3), thyroxine (T4) and free thyroxine (fT4) were evaluated the day before PTX and on day 1, 3 and 5 after PTX. Besides, all enrolled patients were evaluated whether there are symptoms associated with thyrotoxicosis.ResultsAmong the 24 SHPT patients, 1 case (4.2%), 8 cases (33.3%) and 13 cases (54.2%) had suffered thyrotoxicosis at the first, third and fifth day after surgery, respectively. Serum FT4 level increased significantly from pre-operation (0.68 ± 0.15 ng/dl, normal range 0.59–1.25 ng/dl) to the third day after operation (1.91 ± 0.97 ng/dl, p<0.001) and then gradually decline. The frequencies of serum sTSH lower than the normal level gradually increased from the first day (8.3%) to fifth day (66.7%) after surgery.ConclusionTransient thyrotoxicosis is a common postoperative complication of parathyroidectomy for SHPT patients with ESRD and normal thyroid function, and it is necessary for clinicians to evaluate the perioperative thyroid function to make early diagnosis and appropriate prevention and treatment of thyrotoxicosis.

Acute Exacerbation of Type 1 Diabetes and Transient Thyrotoxicosis Around the Same Time After Anti-PD-1 Antibody Administration in a Lung Cancer Patient

Acute Exacerbation of Type 1 Diabetes and Transient Thyrotoxicosis Around the Same Time After Anti-PD-1 Antibody Administration in a Lung Cancer Patient

A literature review of selection of appropriate antiseptics when inserting intravenous catheters in premature infants: The challenge in neonatal intensive care unit

Background: Reducing or preventing bloodstream infection caused by invasive intravenous catheterization, emphasizes the use of an effective topical antiseptics agent; however, because of the flaw in the evidence available regarding the choice of safe antiseptic to use on infants' skin under 2 months this issue remains controversial. The aim of this study was to investigate the types of antiseptics commonly used in neonatal intensive care units, consumption criteria and side effects of consumption and the effects of using antiseptics in premature infants. Methods: In this review, the total number of articles in PubMed, Scopus and ScienceDirect databases since 2010 were searched; titles and abstracts to identify relevant articles have been identified and 14 of the 48 searched articles were finally reviewed. Results: The review articles showed that different antiseptic-including chlorhexidine (CHG) 2% with alcohol base, pure CHG (in different density - 0.05%–2%), povidone-iodine 10%, isopropyl alcohol, 70% alcohol are used when inserting intravenous catheters in premature infants. Cutaneous side effect, systemic absorption and transient hyperthyroidism were reported as common side effects. Weight or age was criteria reported for antiseptic use. Various studies have been conducted to compare the effects of antiseptic with each other and different results have been reported. Conclusion: There is a paucity of evidence-based consensus guidelines for the use of appropriate antiseptic for preparing the skin before placing the intravenous catheter in preterm babies. Further research and publications are required, which will help reduce the risk of line related hospital-acquired infections.

Hematological and serum biochemical profile in cattle experimentally infected with foot-and-mouth disease virus.

Background and Aim:Foot-and-mouth disease (FMD) is an acute viral infection affecting cloven-hoofed animals causing vesicular erosions in the oral cavity and interdigital space. The present study was undertaken to ascertain the time-dependent changes in clinical, hematological, and biochemical profiles in different breeds of cattle following experimental infection.Materials and Methods:The animals were inoculated with 1.0×104 50% bovine tongue infectious dose (BTID50) by intradermolingual route. Clinical signs were observed, and blood/serum samples were collected at different time intervals.Results:The white blood cell count declined sharply on days 7-13 and recovered on day 14 post-FMD infection. Biochemical analysis of serum markers for vital organ profile revealed no marked damage. However, a significant increase in blood urea nitrogen (BUN) value indicated pre-renal azotemia. Transient hyperthyroidism was indicated by the rise in T3 and T4 that can be correlated with a decrease in triglyceride and total cholesterol levels. In the cardiac damage assessment study, a distinct breed difference was observed wherein Malnad Gidda calves showed no cardiac damage.Conclusion:Except thyroid profile, BUN, and creatine kinase-myocardial band, all other serum biochemical parameters showed no significant abnormalities, whereas lymphopenia is the only hematological change and it is suggested that effective ameliorative measures should be targeted mainly on the feed/water intake, thyroid gland, and the level of lymphocytes.

A Male Patient with Acute Hepatitis E Showing Asymptomatic and Transient Hyperthyroidism Due To Autoimmune Thyroiditis

A Male Patient with Acute Hepatitis E Showing Asymptomatic and Transient Hyperthyroidism Due To Autoimmune Thyroiditis