TSH Values Research Articles

A combination of silymarin and garlic extract enhances thyroid hormone activation and body metabolism in orally intoxicated male rats with atrazine: Impact on hepatic iodothyronine deiodinase type 1

Atrazine is a widely applied herbicide to improve crop yield and maintain general health. It has been reported to impair thyroid function and architecture in experimental animals. Alterations in thyroid hormones disrupt normal body function and metabolism. Silymarin, a hepatoprotective flavonolignan, was found to improve thyroid function and body metabolism. Additionally, garlic displays several protective effects on body organs. Therefore, this study explored the prophylactic impact of natural compounds comprising silymarin and garlic extract on disrupted thyroid function, hepatic iodothyronine deiodinase type 1, and metabolic parameters in atrazine-intoxicated male rats. We found that daily pre- and co-treatment of atrazine-intoxicated male rats with silymarin (100 mg/kg, p.o) and/or garlic extract (10 mg/kg, p.o) significantly improved thyroid activation and hepatic functionality as evidenced by the re-establishment of T3, T3/T4, and TSH values as well as ALT and AST activities. Interestingly, individual or concurrent supplementation of the atrazine group with silymarin and garlic extract prevented the down-regulation in hepatic iodothyronine deiodinase type 1. These effects were coupled with the repletion of serum and hepatic antioxidants and the amelioration of lipid peroxidation. In addition, current natural products markedly alleviated weight gain, dyslipidemia, hyperglycemia, glucose intolerance, and insulin resistance. Notably, a cocktail of silymarin and garlic extract exerted superior protection against atrazine-triggered deterioration of thyroid, hepatic, and metabolic functioning to individual treatments. Present findings pinpoint the prophylactic and synergistic influence of silymarin and garlic extract combinatorial regimen on thyroid activation and body metabolism via enhancing antioxidant potential, maintaining hepatic function, and iodothyronine deiodinase type 1.

P-78 Life-threatening fungal infection due to long term glucocorticoid usage in amiadarone thyrotoxicosis

Abstract Introduction Amiadorone-associated thyroiditis (AIT) has 2 subtypes. In type 1, there is usually underlying thyroid disease and thyrotoxicosis occurs due to increased hormone synthesis. In type 2, thyrotoxicosis occurs as a result of T4-T3 release due to destruction(1). Steroid use is recommended in the treatment of AIT. Steroids may cause infections by affecting both innate and acquired immunity. If the patient has other comorbidities, long-term hospitalization, type 2 diabetes mellitus or lymphopenia, these factors may also predispose to infection(2). Clinical Case V.E., age 63, male. The patient was diagnosed atrial fibrillation 4 years ago and was started on amiadorone. After 3 years of amiadorone use, amiadorone was discontinued in January 2023. In April, thyrotoxicosis was detected in an external center where he went with complaint of weight loss. The patient was considered to have amiadorone-associated thyroiditis and methyl prednisolone treatment was started. He used approximately 2 grams of steroid and methimazole 2×15 mg regularly for 2 months. During the period of steroid use, TSH value was always suppressed and T4 value was always 3-4 times the reference value. With the use of methyl prednisolone, severe myopathy developed especially in the proximal muscles and steroid induced diabetes was diagnosed. The patient was admitted to our hospital on 06.07.2023.TSH value was found to be suppressed and T4>100 pmol/liter (reference:11-22). On admission examination, there were diffuse candida plaques in the mouth. On pulmonary examination, rales were heard in the right lung and voriconazole was started because of fungal infection in the right hilar region on tomography. Steroid was discontinued and methimazole was increased to 2×30 mg in the patient who was thought to have fungal infection and had severe myopathy. Cholestyramine was added to his treatment. Voriconazole was discontinued in the patient who had visual hallucinations after 5 days of voriconazole use. During follow-up, the patient developed hypoxia 6 days later and a newly developed cavity in the lower lobe of the right lung was observed in the tomography. The findings were evaluated in favor of fungal pneumonia in the foreground and amphotericin B was started with the recommendation of infectious diseases. Galactomannan, aspergillus and Quantiferon tests were negative. The patient was consulted to pulmonology department because of the newly developed cavity and fiberoptic bronchoscopy was planned. Bronchoscopy showed no appearance suggestive of malignancy. Tuberculosis PCR was negative. T4 values and acute phase reactants completely regressed under treatment and the patient was discharged. Conclusion Steroid treatment is used in AIT type 2 and in cases of indistinguishable AIT, but it should not be ignored that this treatment has its own side effects. Especially, not giving steroids for a long time and trying to reduce the dose as soon as possible will be important in reducing steroid-related side effects.

Predictive factors for the outcome of radioiodine therapy in patients with benign thyroid diseases.

Radioiodine therapy (RIT) of benign thyroid diseases is an established therapy. This study aimed to identify factors predictive for outcome in patients with non-toxic goiter (NTG), unifocal (UFA), multifocal (MUFA) or diffuse autonomy (DISA) and Graves' disease (GD). Retrospective analysis of 205 patients with benign thyroid disease (54 NTG, 46 MUFA, 24 DISA, 26 UFA, 55 GD) who underwent RIT. Follow up time was 12 months for determining treatment outcome. The type of disease was predictive for volume reduction after 12 months (NTS 66%, DISA 67%, MUFA 58%, UFA 51%, GD 71%, p<0.001) and post-treatment hypothyroidism (NTS 48%, DISA 33%, MUFA 15%, UFA 15%, p=0.006). Initial volume, intra-therapeutic uptake and intra-therapeutic half-life were independent prognostic factors for volume reduction 12 months after RIT. In patients with NTG, UFA, MUFA, DISA post-treatment hypothyroidism was significantly correlated with extent of volume reduction 12 months after RIT, achieved dose, higher pre-therapeutic TSH values and younger age. Two different strategies for pre-therapeutic dosimetry used in MUFA showed no differences regarding the therapeutic outcome. In GD, effective half-life, initial volume and Graves' ophthalmopathy were predictive for treatment failure. Reduction of thyroid volume and the percentage of hypothyroid patients one year after RIT was primarily dependent on the type of disease. In MUFA and DISA we could identify volume reduction after 3 months as a reliable predictor for hypothyroidism while in patients with GD a short intra-therapeutic half-life, a large pre-therapeutic volume and active Graves' ophtalmopathy were relevant predictors for treatment failure suggesting an intensified follow-up scheme in these patients.

Avaliação da mortalidade associada ao status tireoidiano em uma coorte de pessoas idosas eutireoidianas de ambulatório de geriatria em hospital universitário

Abstract Objective To assess the associations between the mean thyrotropin (TSH) and mean free thyroxine (FT4), detected during follow-up, and mortality in a group of older euthyroid patients according to age-specific reference range (as-RR) for TSH. Method Retrospective survival analysis cohort including euthyroid elderly patients who were being monitored at the outpatient clinic of a university hospital from 2010 to 2013. All participants had been assessed for the risk of functional disability as a criterion for admission to this outpatient clinic. Mean TSH and FT4 values were calculated using hormone dosages obtained during the follow-up period. Each as-RR for TSH was divided into four equal parts, considering the lower levels as the main exposure variable (≤1.75 mlU/L for &lt;80, and ≤2.0 mlU/L for ≥80 years). FT4 levels were explored according to two categories (&lt; e ≥1.37 ng/dL). The outcome was time to death. We used Cox proportional hazard regression to estimate the hazard ratio (HR) and 95% confidence interval (CI). Results 285 participants (73% females, mean age =80.4 years) followed by a median of 5.7 years (IQR =3.7–6.4; maximum =7), of which 114 died. After the adjusted final model, mortality was associated with the lowest mean TSH (HR=1.7; CI=1.1–2.7; p=0.016) and with the upper mean of FT4 (HR=2.0; CI=1.0–3.8; p=0.052). Conclusions Higher FT4 and lower TSH mean levels were associated with risk of death in a cohort of euthyroid older adults using an as-RR of TSH.

Heterophilic Interference of Rheumatoid Factor in TSH Immunometric Assay: A Cross-Sectional Observational Study.

Considering the inherent vulnerability of immunoassays for heterophilic interference and the potential of Rheumatoid Factor (RF) to act as a heterophile-like antibody, we conducted this study to investigate if RF leads to any such heterophilic interference in seropositive rheumatoid arthritis (RA) patients. The study was done on the TSH assay as it is a noncompetitive, double antibody sandwich assay, which is known to be vulnerable to heterophilic interference. In this cross-sectional observational study, eighty-four consecutive newly diagnosed RF-positive RA patients underwent TSH, Free T4, and anti-TPO estimation using the chemiluminescence technique (CLIA) on Siemens Immulite 1000 platform. The samples were screened for TSH interference using four methods: 1) analysis on a different platform, 2) assessment of linearity using doubling dilutions, 3) polyethylene glycol (PEG) precipitation, and 4) addition of a commercial blocker. Ten samples had a loss of linearity on serial dilution, indicating potential interference. After heterophile blocker treatment, five cases exhibited interference. One patient had diagnostic interpretation discordance on the second platform. No sample on PEG precipitation suggested the influence of antibodies. It is worth noting that even in cases where interference was suspected, the clinical interpretation was largely unaffected by the correction of TSH values based on mean dilution or measurement after heterophile blocker treatment. RF can cause heterophilic interference in TSH immunoassays used commercially. However, in most cases, this interference does not affect clinical decision-making.

CLINICAL PROFILE OF PATIENTS HAVING SUBCLINICAL AND CLINICAL HYPOTHYROIDISM ATTENDING GENERAL MEDICINE OPD OF A TERTIARY CARE MEDICAL CENTER

Objective: The objective of this study was to analyze and compare the clinical profile of patients having clinical and subclinical hypothyroidism. Methods: This was a comparative observational study in which adult patients with clinically overt and subclinical hypothyroidism were included on the basis of predefined inclusion and exclusion criteria. Written and informed consent was obtained from all the patients. Demographic details such as age gender and occupation were noted. The normal reference values of T3, T4, and TSH for diagnosis of subclinical and clinical hypothyroidism were taken to be 0.8–2 ng/mL, 5.5–12.2 μg/dL, and 0.3–4.5 μIU/mL. The cases were divided into two groups, namely, Group C (clinical hypothyroidism) and Group SC (Subclinical hypothyroidism). Mean T3, T4, and TSH levels and clinical signs and symptoms were compared in both the groups. SSPS 21.0 software was used for statistical analysis and p&lt;0.05 was taken as statistically significant. Results: In cases of clinical hypothyroidism out, there were 42 (70%) females and 18 (30%) males, whereas in cases of subclinical hypothyroidism, there were 38 (63.33%) females and 22 (36.67%) males. There was an overall female preponderance in both the groups. The mean age of patients in group C was found to be 39.48±12.36 whereas the mean of patients in SC group was found to be 42.82±13.46. The mean T3 and T4 were low in clinical hypothyroidism and mean TSH levels were high and the difference was statistically highly significant (p&lt;0.0001). In cases with clinical as well subclinical hypothyroidism, the most common clinical features were dry skin, fatigue, and cold intolerance. The prevalence of fatigue, weight gain, cold intolerance, dry skin, pedal edema, and thyroid swelling was more in patients with clinical hypothyroidism as compared to the patients with subclinical hypothyroidism and the difference was found to be statistically significant. Conclusion: The clinical presentation of clinical as well as subclinical hypothyroidism varies and a high index of suspicion is necessary for the diagnosis particularly in cases of subclinical hypothyroidism so that appropriate interventions can be undertaken.

Pathogenetic and clinical rationale for syntropic pathology based on metabolic syndrome, coronary heart disease and type 2 diabetes mellitus

Pathogenetic and clinical rationale for syntropic pathology based on metabolic syndrome, coronary heart disease and type 2 diabetes mellitus

Is There an Adequate Therapeutic Approach to Thyroid Pathology in Patients with Down Syndrome?

Thyroid dysfunction stands as the most prevalent endocrine disorder in individuals with Down syndrome, particularly showcasing both clinical and subclinical hypothyroidism. TSH and FT4 blood values serve as common diagnostic and treatment adjustment markers. In Down syndrome (DS), hormone values may deviate from those observed in the general population, which may lead to overdiagnosis and consequent iatrogenesis of subclinical hypothyroidism. The objective of this study was to analyze the appropriateness of the replacement therapeutic approach by identifying the TSH and FT4 values that can be considered normal in these patients. Methods: A cross-sectional study was conducted in 503 subjects with DS of both sexes and without age limit drawn from the Health Program for individuals with DS in Valencia (Spain) from February 1993 to November 2021. The exclusion criteria included hyperthyroidism, nodules, tumors, or individuals under treatment with drugs influencing iodine metabolism. The normality of data distribution was assessed using the Shapiro–Wilk test. Outliers were detected using the Reed’s criterion. Hormone values were estimated using quantile regression models for the 2.5th and 97.5th percentiles. Results: The normal values identified were 0.88–11.25 mIU/L for TSH and 0.71–1.63 ng/dL for FT4. The Wald test indicated no significant differences in the reference intervals based on age or sex. Conclusion: The establishment of these values, which, in people with DS, can be considered unique, is of great importance, allowing a watchful waiting attitude to be maintained before starting replacement therapy that is unnecessarily or adjusting medication in diagnosed cases.

Clinical Aspects in Subacute Thyroiditis: A Real-Life Study on 226 Cases in Greece Amid the COVID-19 Pandemic.

This study aimed to evaluate various therapeutic approaches, identify potential predictive factors for the recurrence and development of hypothyroidism, and examine specific clinical and laboratory characteristics of patients with subacute thyroiditis (SAT) due to SARS-CoV-2 infection. We retrospectively analyzed the medical records of 226 patients with confirmed SAT diagnosed from January 2020 to November 2022. The mean age was 48.01 ± 0.75 years, and the F/M ratio was 2.3/1. At the end of the follow-up period, 69 patients (32.1%) had developed hypothyroidism. Treatment duration was significantly shorter with nonsteroidal anti-inflammatory drugs (NSAIDs) (17.40 ± 2.56 days), while time-to-symptom relief was shorter with glucocorticoids (CGs). Recurrence was observed only in those treated with corticosteroid preparations (14.1%). C-reactive protein levels at treatment discontinuation were higher in patients who experienced SAT recurrence, while the coexistence of Hashimoto's thyroiditis was a significant predictive factor for the development of hypothyroidism. The TSH value at the time of treatment withdrawal >4.12 μIU/mL showed optimal sensitivity and specificity for the prediction of permanent hypothyroidism. Regarding COVID-19, 34 patients (15%) experienced related SAT, with similar clinical manifestations of the disease but a higher BMI and shorter time-to-symptom relief. In conclusion, GCs administration alleviated acute symptoms earlier during the onset of SAT, whereas NSAIDs had a shorter treatment duration, and both regimens could not prevent the development of delayed hypothyroidism. The clinical characteristics of SAT due to COVID-19 infections were similar to those of typical SAT disease.

Do elevated thyrotropin levels increase the risk of miscarriages: yes or no?

Background To examine correlation between elevated levels of thyrotropin with the frequency of miscarriages. Methods A cross-sectional study was conducted on the 380 respondents and it investigated TSH (thyrotropin), thyroid peroxidase antibody(anti-TPO) and free thyroxine (FT4) in pregnant women who had a miscarriage (N = 179) and pregnant women with normal pregnancies (N = 201). Results The incidence of subclinical hypothyroidism in the miscarriages group was higher than in control group (61.4% vrs 15.79% (p < 0.001). In the miscarriages group with hypothyroidism (first trimester) mean value of TSH was significantly higher 4.31 ± 2.55 mIU/L compared to the control group 1.95 ± 0.86mIU/L (p < 0.001). Logistic multivariate regression revealed that TSH and body mass index (BMI) have a significant influence on the miscarriage; TSH level has a higher odds ratio (OR) 1.47 CI (95% 1.22–1.78) than BMI (OR) 1.14 CI (95% 1.06–1.23)) (p < 0.001). The combination of thyroid autoimmunity and TSH > 2.5mIU/L increase the risk of miscarriage (65.75%) compared to positive anti-TPO antibodies and TSH < 2.5mIU/L(14.15%)(p < 0.001). Conclusions Higher TSH levels correspond with obesity during early pregnancy and may be a sign of maternal thyroid dysfunction. Physiological thyroid function in the first trimester of pregnancy is important for perinatal outcome.

A study on thyroid function assessment in patients with chronic kidney disease: An investigative analysis

Background: Chronic Kidney Disease (CKD) and thyroid dysfunction often coexist, and understanding their relationship is crucial for diagnosis and management. Aims and Objectives: This study aimed to explore the prevalence, clinical significance, and implications of thyroid function abnormalities in CKD patients, providing valuable insights for improving patient care and outcomes. Methods: This observational cross-sectional study included 46 CKD patients undergoing conservative management at Aditya Hospitals and Diagnostics, Dibrugarh, from July 2021 to July 2022. Participants met predefined inclusion criteria and provided informed consent. Exclusion criteria encompassed active treatment with dialysis or kidney transplantation, nephrotic-range proteinuria, hypoalbuminemia, acute illness, diabetes mellitus, recent surgery, trauma, burns, liver diseases, and medications affecting thyroid function. Results: The study involved 31 male (67.39%) and 15 female (32.60%) CKD patients aged 19 to 69 years. CKD symptoms' duration ranged from 4 to 30 months (mean 9.8 months). Serum T3 levels ranged from 0.2 to 2.0 ng/ml (mean 0.67 ng/ml), T4 levels from 0.9 to 8.5 μg/dl (mean 5.7 μg/dl), and TSH levels from 0.6 to 38 μIU/ml (mean 6.5 μIU/ml). Hypothyroidism symptoms were observed in 31 patients (67%). Low T3 syndrome was found in 27 patients, low T4 syndrome in 11 patients, and hypothyroidism in 3 patients. Conclusion: The study revealed that the incidence of low T3 syndrome increased with age and CKD severity. Patients with lower GFR exhibited decreased serum T3 levels. Interestingly, in patients with low T3 syndrome, TSH values remained within the normal range and did not correlate with GFR. The findings suggest that low T3 levels in CKD may play a protective role in protein conservation. This investigation sheds light on the complex relationship between thyroid function and CKD, emphasizing the need for regular thyroid assessments in CKD patients for better management and improved clinical outcomes. Early identification and appropriate intervention for thyroid abnormalities in CKD may contribute to optimizing patient care and overall well-being.

Serum Levels of Thyroid Hormones in Infertile and Fertile Women Attending a Tertiary Care Hospital in North-Central Nigeria: A Comparative Reproductive Medicine Study

Thyroid hormones have profound effects on reproduction. Normal thyroid function is necessary to maintain reproductive physiology, but its functional abnormalities may cause infertility manifesting as menstrual cycle irregularities. Aim of this research was to determine the serum levels of thyroid hormones in infertile and fertile women attending a tertiary care hospital in North-Central Nigeria. This comparative, reproductive medicine, cross-sectional study was carried out among one hundred and six (106) women attending the Gynecology Clinic of the Department of Obstetrics and Gynecology and the Family Planning Clinic of a tertiary care hospital in North-Central Nigeria. Women with a history suggestive of either primary or secondary infertility and the control women with no history of infertility were evenly grouped. Venous blood samples were collected and analyzed using Enzyme-Linked Immunosorbent Assay (ELISA) technique to determine fT3, fT4 and TSH levels. Data obtained were entered and analyzed using Statistical Package for Social Sciences (SPSS) version 23, and the level of statistical significance was set at p&lt;0.05 and at a confidence interval of 95% for all inferential statistics. Majority (90.6%) of the 106 participants were euthyroid. However, most of the thyroid disorders (80%) were noticed in the infertile women, as 15.1% of them had one form of thyroid disorder. The mean TSH, fT3 and fT4 levels were higher in the infertile patients than in the control group, but the values were still within normal reference range. Mean values of TSH, fT3 and fT4 for the patients and controls were 1.35±1.65 versus 0.85±1.08 mIU/mL, 2.79±1.51 versus 2.19±1.15 pg/mL, and 1.15±0.33 versus 0.99 ± 0.29 ng/dL respectively. Median for TSH, fT3 and fT4 in the patients and controls were as follows: 0.80 (0.40–1.55) versus 0.60 (0.40-0.85) mIU/mL, 2.40 (1.45-4.20) versus 1.70 (1.35-2.95) pg/mL, and 1.10 (1.00-1.30) versus 1.00 (0.90- 1.10) ng/dL respectively. The differences in the median between the patients and controls were statistically significant for fT3 and fT4 with p-values of 0.031 and 0.002 respectively. Subclinical hypothyroidism was the most prevalent (7.5%) thyroid disorder identified in the infertile women. Serum levels of thyroid hormones and prevalence of thyroid disorders were significantly higher in the infertile patients compared to the fertile women, although the overall prevalence of thyroid disorders was quite low.

Fifteen Years of Iodine Prophylaxis in Italy: Results of a Nationwide Surveillance (Period 2015-2019).

In 2005, a nationwide program of iodine prophylaxis on a voluntary basis was implemented in Italy by law. However, recent data on iodine status are lacking. The aim of this study was to evaluate efficiency, effectiveness, and possible adverse effects (increased occurrence of thyroid autoimmunity and hyperthyroidism) of the Italian iodine prophylaxis program. From 2015 to 2019, a nationwide survey was performed. The use of iodized salt was evaluated in a sample of 164 593 adults and in 998 school canteens. A sample of 4233 schoolchildren (aged 11-13 years) was recruited to assess urinary iodine concentration, prevalence of goiter, and thyroid hypoechogenicity on ultrasound, with the latter being an indirect indicator of thyroid autoimmunity. Neonatal TSH values of 197 677 infants screened in regions representative of Northern, Central, and Southern Italy were analyzed to investigate the percentage of TSH values >5.0 mIU/L. Data on methimazole prescriptions were analyzed as indirect indicators of new cases of hyperthyroidism. The prevalence of the use of iodized salt was 71.5% in adult population and 78% in school canteens. A median urinary iodine concentration of 124 μg/L, a prevalence of goiter of 2.2%, and a prevalence of thyroid hypoechogenicity of 5.7% were observed in schoolchildren. The percentage of neonatal TSH values >5.0 mIU/L resulted still higher (5.1%) than the World Health Organization threshold of 3.0%, whereas the prescriptions of methimazole showed a reduction of 13.5%. Fifteen years of iodine prophylaxis have led to iodine sufficiency in Italy, although there still is concern about iodine nutritional status during pregnancy.

THU096 When TSH Alone Is Not Enough

Abstract Disclosure: S.S. Awasty: None. L. Ghalib: None. Background: A Thyrotropinoma or TSHoma is the rarest of all pituitary adenomas approximately 1-2%. TSHomas are often only found due to symptoms from co-secreting tumors with TSHomas or routine laboratory testing. Misinterpretation of laboratory values can cause misdiagnosis and inappropriate treatment. Clinical Case: A 45-year-old female presented to her primary care physician for a routine appointment. The patient reported concerns regarding weight and a TSH was ordered, TSH 7.00 uIU/mL (0.49 - 4.67) with no other thyroid function values. The physician prescribed levothyroxine 50mcg treating for primary hypothyroidism and over the next 37 months the patient was prescribed increasing doses of levothyroxine based on TSH values. This patient was eventually referred to Endocrinology. At the initial Endocrinology visit TSH 7.59 uIU/mL (0.27 - 4.2 uIU/mL) and fT4 3.2 ng/dL (0.7 - 1.7) on levothyroxine 125mcg. Levothyroxine was discontinued and labs were repeated 6 weeks later TSH 5.9 uIU/mL (0.27 - 4.2), fT4 4.8 ng/dL (0.7 - 1.7), fT3 2.1 pg/mL (2 - 4.4), and alpha-subunit 1.5ng/mL (&amp;lt;=1.2 premenopausal female, &amp;lt;=1.8 postmenopausal female). A pituitary macroadenoma was discovered on MRI. The patient was referred to Pituitary Clinic and noted to have a prolactin of 53.8 ng/mL (non-pregnant females 2.8-29.2) and IGF-1 291.6 ng/mL (60.0 - 240.0). The patient underwent transsphenoidal pituitary surgery; pathology reported a plurihormonal subtype pituitary adenoma which stained positive for Prolactin, HGH, and TSH. One week after removal of the TSHoma, TSH 0.014 uIU/mL (0.550 - 4.780) fT4 0.65 ng/dL (0.89 - 1.76), and levothyroxine replacement was initiated with plans for continued outpatient monitoring to assess need for levothyroxine replacement. Conclusion: This case primarily demonstrates the importance of evaluating TSH levels in conjunction with free T4 levels to effectively interpret central versus primary causes of thyroid dysfunction. The high molar ratio of the alpha-subunit to the TSH level lends itself to a TSHoma differentiating it from a diagnosis of syndrome of resistance to thyroid hormone. While rare missing a TSHoma diagnosis could have devastating consequences. Checking other pituitary hormones pre-operatively even without symptoms also gave the indication that this was a co-secreting tumor. After adenoma removal rechecking pituitary hormones is of great importance as exemplified by pituitary-thyroid axis suppression noted post-operatively in this case. Presentation: Thursday, June 15, 2023

SAT475 Levothyroxine and Liothyronine Treated Myxedema Coma with Irreversible Cardiopulmonary Failure: A Rare Phenomenon

Abstract Disclosure: T. Menon: None. Y. Xie: None. A. Wang: None. Introduction: We describe a case of myxedema coma associated with irreversible cardiogenic shock and the challenges in optimal management. Case Presentation: A previously healthy 23-year-old man with a history of untreated hypothyroidism (TSH 100 uIU/mL six months prior) presented to the hospital for abdominal pain, shortness of breath, and cough. He soon had two cardiac arrests with successful resuscitation and was stabilized via mechanical ventilation and vasopressors. Physical exam showed peripheral and facial edema with mild jaundice. Laboratory results showed elevated creatinine 1.73 (0.5-1.30 mg/dL), AST 440 (10-40 U/L), ALT 353 (10-45 U/L), and total bilirubin 3.6 (0.2-1.2 mg/dL). Thyroid function tests showed TSH 857 (0.27-4.20 uIU/mL), FT4 &amp;lt;0.1 (0.9-1.8 ng/dL), and TT3 &amp;lt; 20 (80-200 ng/dL), and negative thyroglobulin and TPO antibodies. A thyroid ultrasound showed a small thyroid gland. Echocardiogram revealed severe bi-ventricular failure, with an ejection fraction of 10-15%, dilated chambers, pulmonary hypertension, and moderate pericardial effusion. The patient was initiated on VA-ECMO and treated medically for cardiogenic shock. Myxedema coma treatment was started with IV levothyroxine (LT4) 400 mcg, IV Liothyronine (LT3) 10 mcg, and IV hydrocortisone 100 mg every eight hours. The patient subsequently received IV LT4 100 mcg daily and IV LT3 10-30 mcg daily based on levels of daily FT4 and TT3. Hydrocortisone was tapered down as free cortisol levels prior to steroid administration were elevated at 4.6 (0.2-1.8 ug/dL). Despite significant improvements in TSH values (from 857 to 67 uIU/L), FT4 (from &amp;lt;0.1 to 1.2 ng/dL), and TT3 (from &amp;lt; 20 to 60 ng/dL), the patient’s cardiac function did not improve and he underwent successful orthotopic heart transplantation two weeks after initial presentation. A cardiac biopsy demonstrated cardiomegaly with left ventricular hypertrophy, subendocardial fibrosis, and patent arteries, without other etiologies of heart failure. The patient recovered and was discharged on oral LT4 137 mcg daily, LT3 5 mcg twice daily, and prednisone per cardiac transplantation protocol. Discussion: Several cases describe myxedema coma with reversible heart failure in 4 to 5 days with appropriate hypothyroidism treatment. This case, however, describes irreversible cardiomyopathy despite optimal medical therapy, eventually requiring heart transplantation. Because the cardiac myocyte is dependent on plasma T3 due to lack of intracellular deiodinase, T3 administration may improve cardiac function in myxedema coma induced heart failure. Consensus regarding the use, optimal dose, and duration of LT3 in these situations requires further investigation. Conclusion: We report an unusual case of irreversible cardiomyopathy due to myxedema coma in a young, healthy patient, highlighting the need for rapid correction of hypothyroidism with both IV LT4 and LT3. Presentation Date: Saturday, June 17, 2023

FRI487 Oral Liquid L- Thyroxine (L-T4) Is More Effective In Controlling Hypothyroidism, Than L-T4 Tablet, In Patients Submitted To Total Thyroidectomy

Abstract Disclosure: P. Fallahi: None. S. Ferrari: None. F. Ragusa: None. G. Elia: None. G. Materazzi: None. S. Paparo: None. A. Patrizio: None. V. Mazzi: None. P. Miccoli: None. A. Antonelli: None. Objectives: Our aim is to investigate the efficacy of levothyroxine (L-T4) in liquid formulation in patients recently subjected to total thyroidectomy (without malabsorption or drug interference), with respect to L-T4 tablets. Methods: We enrolled two hundred and twenty-five patients of whom 75 received L-T4 in tablets, and 150 were treated with liquid L-T4 at the same dosage (1.5 mcg/kg/day). The therapy started the day after thyroidectomy, and the drugs were assumed every day 30 min before breakfast. The thyroid profile was assessed by evaluating serum thyrotropic hormone (TSH), free thyroxine (FT4), and free triiodothyronine (FT3) in a first control after 6 weeks, then in a second control after 12 weeks. Results: Our results showed that the prevalence of patients in the hypothyroid range (TSH&amp;gt;3.6 mcU/ml) was significantly higher in the L-T4 tablet group. Moreover, TSH values were significantly lower in the liquid L-T4 group, than in the tablet L-T4 group both at the first (P &amp;lt; 0.05), and at the second control (P &amp;lt; 0.01), while FT4 and FT3 levels were not significantly different. Conclusions: Our data showes that thyroidectomized patients, not reporting issues of malabsorption, gastric disorders, or drug interference, have a better control of TSH levels under a liquid L-T4 therapy. Presentation: Friday, June 16, 2023

FRI496 A Rare Case Of Thyroid Hormone Resistance Beta

Abstract Disclosure: H.K. Rai: None. R.M. Pradhan: None. A. Chaudhuri: None. Background: Genetic mutation in the thyroid hormone receptor leads to the reduced affinity of hormone binding; thus, causing thyroid hormone resistance. It is characterized by a wide range of phenotypic variations and subsequent diagnostic and treatment challenges. Here, we present a case of resistance to the thyroid hormone Beta, with a rare genetic abnormality, that was misdiagnosed as hyperthyroidism. Case: A 46-year-old woman diagnosed with hyperthyroidism s/p RAIA resulting in hypothyroidism on levothyroxine therapy (112mcg daily, weight: 55kg), presented with ten pounds of weight gain, constipation, and cold intolerance for the past six months. TFTs were as follows: TSH: 6.493 mcUnits/ml (normal: 0.400-5.00 mcUnits/ml), and free T4: 1.83 ng/dL (normal: 0.80-1.80 ng/dL). The patient was clinically hypothyroid despite having an elevated FT4 and TSH level. She was also on metoprolol succinate 25 mg daily for sinus tachycardia for the past 1 year. Upon inquiring about further details, the patient informed that at the age of 22, she had significant weight loss, palpitations, and anxiety, but also reported dry skin. The patient was seen by multiple endocrinologists and was provided with contradictory diagnoses. She had RAI scan which was significant for increased uptake and subsequently underwent RAIA. The patient was seen by multiple physicians in the past, levothyroxine dose was adjusted on various occasions but her TFTs never normalized. Post-ablation, she continued to require a higher than the weight-based dose of levothyroxine. Upon review of family history, the patient reported that her father, sister, and daughter had a similar pattern of TFTs with elevated FT4 and TSH values. All of them had palpitations and anxiety that were not severe enough to seek medical care. Family history was also significant for ADHD and hyperlipidemia present in the daughter and father. All affected family members have short stature. The levothyroxine dose was slowly titrated based on the clinical presentation. She was euthyroid with 150 mcg daily of levothyroxine with TSH of 4.869 mcUnits/ml and free T4: 1.85 ng/dl. Given her presentation and suspicion of thyroid hormone resistance, we decided to proceed with genetic testing. The result was positive for the THRB (Resistance to thyroid hormone beta) variant c.904A&amp;gt;G.p.(IIe302Val), which is classified as a variant of uncertain significance, as there is currently insufficient evidence to support its disease-causing role. However, there is a strong association between the gene and the patient's phenotype. Conclusion: The distinctive feature of RTH beta is high levels of free T4 while TSH concentration is normal or elevated, with a combination of hypothyroid and hyperthyroid symptoms. Such patients are often misdiagnosed. We herein describe a novel pathogenic RTH beta gene variant causing thyroid hormone resistance that needs to be further explored. Presentation: Friday, June 16, 2023

SAT495 Persistent Euthyroid State in a Patient with Biochemical and Imaging Evidence of Graves' Disease

Abstract Disclosure: M. Antony: None. S. Gundlapally: None. M. Joglekar: None. B. Fritz: None. S. Patel: None. V. Verma: None. R. Kant: None. INTRODUCTION: Elevated TSI antibody and/or diffuse uptake on radioactive Iodine-123 scan is diagnostic of Graves’ disease. Thyromegaly with increased blood flow on color doppler seen on thyroid USG can also aid in the diagnosis. Rare presence of positive TSI antibody without hyperthyroidism has been reported1. Rare co-existence of both Graves’ disease and Hashimoto’s thyroiditis in a patient causing a challenging clinical course has been reported2. Presence of a neutralizing or blocking antibody against the TSH receptor1 or a false positive TSI have been implicated in such rare cases. CLINICAL CASE: A 37-year-old Caucasian Female was seen at our endocrinology clinic for further evaluation of thyroid disorder. Patient initially experienced goiter during 1st pregnancy at age 18, followed by hypothyroidism during last pregnancy needing levothyroxine treatment. Due to goiter history, patient underwent work-up by her primary physician in 2021. Thyroid ultrasound (usg) showed bilateral hyperemia, heterogeneous echotexture, and 0.2 cm cystic nodule in the right upper lobe. Labs showed normal TSH 1.33 uIU/ml (0.3-4.0 uIU/ml), normal Free T4 0.99 ng/dl (0.8-1.8 ng/dl), normal total T3 140 ng/dl (71-180 ng/dl). Patient underwent further work-up by endocrinology in 2022. Thyroid ultrasound again revealed bilateral hyperemia with other similar findings. Labs showed normal TSH 2.02uUI/ml, normal free T4 0.93 ng/dl, normal total T3 138 ng/dl. Interestingly, TSI antibody and TPO antibody were significantly elevated at 66.70 IU/L (0.0-0.55 IU/L) and 517 IU/ml (0-34 IU/ml), respectively. Repeat labs in April 2022, again showed normal TSH 1.77 uIU/ml, normal free T4 0.90 ng/dl and normal free T3 2.94 (2.0-4.40 pg/ml). Thyroid uptake scan was not performed due to persistently normal TSH values. Patient denied the use of biotin supplementation. Patient continues to remain clinically and biochemically euthyroid without treatment. CONCLUSION: Our case supports the rare presence of TSI antibody without hyperthyroidism. Close monitoring is warranted due to possibility of future progression to overt hyperthyroidism. REFERENCE: 1. Alvin Mathew A, Papaly R, Maliakal A, et al.(November 10, 2021)Elevated Graves’ Disease-Specific Thyroid-Stimulating Immunoglobulin and Thyroid Stimulating Hormone Receptor Antibody in a Patient With Subacute Thyroiditis. Cureus 13(11): e19448. doi:10.7759/cureus.194482. Vipin Verma, MD, Mc Anto Antony, MD, PSAT346 Persistent Fluctuation Between Hypothyroidism and Hyperthyroidism in a Patient with Both Hashimoto's Thyroiditis and Graves’ Disease: Challenges in Diagnosis and Treatment Approach, Journal of the Endocrine Society, Volume 6, Issue Supplement_1, November-December 2022, Page A833, https://doi.org/10.1210/jendso/bvac150.1723 Presentation Date: Saturday, June 17, 2023

OR14-03 The Thyroid Hormone Receptor Beta Genotype Of The Fetus Influences The Maternal Thyroid Function During Pregnancy

Abstract Disclosure: F. Salas Lucia: None. X. Liao: None. H. Jiang: None. A.M. Dumitrescu: None. S. Refetoff: None. J. Anselmo: None. When women with resistance to thyroid hormone beta (RTHβ) are pregnant, their high serum thyroid hormone (TH) levels are perceived as normal by affected fetuses (AfFe) carrying the same THRB mutation as their mothers. On the contrary, normal fetuses (NlFe) that do not carry the maternal THRB mutation are exposed to supraphysiologic TH levels and have unfavorable outcomes. This shows the impact maternal TH levels have on the fetus. However, whether the fetus might influence the maternal thyroid function remains unknown. To explore this possibility, we studied the maternal thyroid function tests (TFT) TSH, FT3, and FT4 throughout the pregnancies from 8 women harboring the R243Q THRB mutation (AfMo) during a total of 10 pregnancies: 6 carrying AfFe and 4 NlFe fetuses. Cord blood TFT from 3 of the NlFe and 3 AfFe at birth were also obtained. In addition, 8 pregnancies from 7 normal mothers (NlMo) carrying 4 AfFe who inherited the THRB mutation from the father and 4 NlFe were also evaluated for TFT. Cord blood from these pregnancies was not available. Results were compared to those in pregnancies of normal WT women. In all RTHβpregnancies, the maternal TSH values were within the range of pregnancies in WT women (0.35-4.94 mU/L) with an hCG-mediated nadir at the end of the first trimester. Maternal FT4 and FT3 values in RTHβpregnancies were above the upper limit of normal (ULN) of 100, peaking during weeks 5-16 (150±20% and 175±15% ULN, respectively) and progressively decreasing afterward. We found differences in maternal TFTdepending on the THRB genotype of the fetus. From weeks 25-32, the AfMo carrying an AfFe exhibited lower FT4 than when carrying a NlFe (96±2 vs. 108±5.3% ULN; p&amp;lt;0.05). Similarly, from weeks 25-40, the AfMo carrying an AfFe exhibited lower FT3 values than when carrying a NlFe ULN (110±11 vs. 134±13% ULN; p&amp;lt;0.05). While gestational age at delivery was similar in all RTHβ pregnancies, the NlFe had a lower birth body weight than the AfFe (2.3±0.1 vs. 3.1±0.2 kg; p&amp;lt;0.01). Cord blood TSH in NlFe was undetectable (&amp;lt;0.1 mU/L) but was 9.51 mU/L (2.2-10; range in normal neonates) in AfFe, which indicates that the thyroid function in NlFe could be restricted during pregnancy, but not in AfFe. Cord blood FT4 levels were similar in NlFe and AfFe (98.4±16.4 vs. 89.5±9.4% ULN). However, FT3 levels were significantly higher in NlFe than in AfFe (67.7±3.0 vs. 42.0±9.6% ULN; p&amp;lt;0.05) and represented ∼68, and ∼42% of the serum maternal FT3 level at birth, respectively. NlMo carrying either AfFe or NlFe showed similar TSH and FT3 levels during pregnancies. However, from weeks 33 to 40, FT4 levels were lower when carrying an AfFe than when carrying a NlFe (51.8±2.8 vs. 62.5±3.2% ULN; p&amp;lt;0.001). Our findings indicate that maternal thyroid function are influenced by THRB genotype of the fetus. The quantitation of placental and fetal TH transporters, deiodinases, and TH metabolites could provide insights into the mechanisms involved. Presentation: Friday, June 16, 2023

Thyroid Profile and Serum Lipid Level in Women with Normal Pregnancy

Objective: To evaluate the changes in thyroid profile and serum lipid level in normal pregnancy.Methods: This observational study was conducted at the Department of Biochemistry of Santosh Medical College, Ghaziabad, UP, India, from June 2021 to February 2022. In this study, 200 average pregnant women were enrolled. The thyroid profile was estimated using the ELISA method, and the lipid profile was measured using the enzymatic kit method. All data were expressed as means and standard deviations, and SPSS version 17 was used for statistical analysis.Results: This observational study observed that the mean T3, T4, and TSH levels increased significantly in the second trimester compared to the first trimester. In contrast, the mean value of T3, T4, and TSH decreased in the third trimester as compared to the second trimester. The mean levels of total cholesterol, triglyceride, and LDL-cholesterol increased significantly, while the mean value of HDL-cholesterol decreased significantly in the second and third trimesters when compared to the first trimester.Conclusion: This study demonstrated abnormal lipid and thyroid metabolism. Changes in thyroid profile may be associated with adverse obstetric outcomes. The altered lipid parameters, mainly High TG and low HDL-C concentrations, may promote vascular dysfunction and oxidative stress.