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The Indian Journal of Medical Research Jan 2020Thyrotoxic periodic paralysis (TPP) is an endocrine emergency presenting with acute-onset flaccid paralysis in a patient having thyrotoxicosis accompanied by... (Observational Study)
Observational Study
BACKGROUND & OBJECTIVES
Thyrotoxic periodic paralysis (TPP) is an endocrine emergency presenting with acute-onset flaccid paralysis in a patient having thyrotoxicosis accompanied by hypokalaemia. This study was conducted to evaluate the clinical profile of patients with TPP presenting to three centres in India.
METHODS
This retrospective, observational study was conducted at three tertiary care Armed Forces medical centres, located at Lucknow, Kolkata and Delhi. The history, clinical features, treatment details and outcomes were evaluated.
RESULTS
Of the 244 patients with thyrotoxicosis, 15 were diagnosed with TPP and included in the study. These 15 patients (14 male and 1 female) had 32 episodes of TPP which were analyzed. The mean age was 30.2±6.2 yr (range: 21-39), and overt thyrotoxicosis was seen in all patients except one who had subclinical hyperthyroidism. Graves' disease was the most common cause of thyrotoxicosis (13/15) and the remaining two patients had subacute thyroiditis and gestational thyrotoxicosis. Hypokalaemia (serum potassium <3.5 mmol/l) was seen in 12 patients, and the mean serum potassium was 3.2±0.9 mmol/l (range: 2.1-4.9). All patients had flaccid weakness, predominantly involving the lower limb with no bulbar, respiratory or cranial nerve involvement. The average duration of paralysis was 10.6±5.7 h (range: 3-28 h).
INTERPRETATION & CONCLUSIONS
Our study demonstrated an early age of presentation and presence of clinical and biochemical thyrotoxicosis in majority of patients with TPP. Hypokalaemia may not always be evident in patients with TPP.
Topics: Adult; Female; Graves Disease; Humans; Hyperthyroidism; India; Male; Paralysis; Potassium; Thyroid Crisis; Thyroid Diseases; Thyrotoxicosis; Young Adult
PubMed: 32134013
DOI: 10.4103/ijmr.IJMR_335_18 -
Internal Medicine (Tokyo, Japan) Jan 2018We describe a case of amiodarone-induced thyrotoxicosis (AIT) with cardiopulmonary arrest (CPA) in a 49-year-old woman. The patient had been treated with amiodarone for...
We describe a case of amiodarone-induced thyrotoxicosis (AIT) with cardiopulmonary arrest (CPA) in a 49-year-old woman. The patient had been treated with amiodarone for non-sustained ventricular tachycardia. Two weeks prior to her admission, she developed thyrotoxicosis and prednisolone (PSL, 30 mg daily) was administered with the continuation of amiodarone. However, she was admitted to our hospital for CPA. We performed total thyroidectomy to control her thyrotoxicosis and the pathological findings were consistent with type 2 AIT. She gradually improved and was discharged on day 84. This case demonstrates the importance of considering immediate total thyroidectomy for patients with uncontrollable AIT.
Topics: Amiodarone; Anti-Arrhythmia Agents; Female; Heart Arrest; Humans; Middle Aged; Tachycardia, Ventricular; Thyroidectomy; Thyrotoxicosis; Treatment Outcome
PubMed: 29033440
DOI: 10.2169/internalmedicine.9177-17 -
Endocrine Journal Sep 2019Lenvatinib has anti-tumor activity against advanced hepatocellular carcinoma (HCC). Hypothyroidism is also a frequent complication in patients treated with lenvatinib....
Lenvatinib has anti-tumor activity against advanced hepatocellular carcinoma (HCC). Hypothyroidism is also a frequent complication in patients treated with lenvatinib. However, studies on lenvatinib-induced thyroid toxicity and destructive thyroiditis are limited. Therefore, this study aimed to clarify the frequency and timing of thyroid abnormalities in lenvatinib for unresectable HCC. This retrospective study enrolled 50 patients with advanced HCC treated with lenvatinib. Patients were classified to have euthyroid, subclinical hypothyroidism, overt hypothyroidism, and thyrotoxicosis. The timing of thyroid dysfunction was assessed, and risk factors for incident hypothyroidism or thyrotoxicosis were evaluated using multivariate models. Subclinical hypothyroidism, overt hypothyroidism, and thyrotoxicosis occurred in 7 (14.0%), 26 (52.0%), and 5 (10.0%) patients, respectively. In the 33 patients with hypothyroidism, 27 (84.4%) developed the condition within 2 weeks of starting lenvatinib treatment. Of the 5 patients with thyrotoxicosis, 3 developed the condition within 8 weeks of starting lenvatinib administration. One patient developed thyrotoxicosis in only 1 week of the initiation of treatment. No correlation between the presence of antibodies and the incidence and severity of thyroid dysfunction due to the autoimmune mechanism was observed. The progression-free survival was significantly better in the hypothyroidism group. Lenvatinib treatment for unresectable HCC not only causes hypothyroidism, but also thyrotoxicosis. Moreover, these thyroid conditions develop within the early period of treatment at a higher prevalence. Patients with thyroid dysfunction had better prognosis. Based on these results, in patients administered with lenvatinib, there is need for careful assessment for the possibility of thyroid dysfunction from the onset of treatment.
Topics: Aged; Aged, 80 and over; Carcinoma, Hepatocellular; Female; Follow-Up Studies; Humans; Hypothyroidism; Incidence; Japan; Liver Neoplasms; Male; Middle Aged; Phenylurea Compounds; Quinolines; Retrospective Studies; Thyroid Diseases; Thyroid Function Tests; Thyroid Gland; Thyroiditis; Thyrotoxicosis
PubMed: 31142692
DOI: 10.1507/endocrj.EJ19-0140 -
Journal of Clinical Research in... May 2019To determine the demographic and biochemical features of childhood and juvenile thyrotoxicosis and treatment outcome.
OBJECTIVE
To determine the demographic and biochemical features of childhood and juvenile thyrotoxicosis and treatment outcome.
METHODS
We reviewed the records of children from 22 centers in Turkey who were diagnosed with thyrotoxicosis between 2007 to 2017.
RESULTS
A total of 503 children had been diagnosed with thyrotoxicosis at the centers during the study period. Of these, 375 (74.6%) had been diagnosed with Graves’ disease (GD), 75 (14.9%) with hashitoxicosis and 53 (10.5%) with other less common causes of thyrotoxicosis. The most common presenting features in children with GD or hashitoxicosis were tachycardia and/or palpitations, weight loss and excessive sweating. The cumulative remission rate was 17.6% in 370 patients with GD who had received anti-thyroid drugs (ATDs) for initial treatment. The median (range) treatment period was 22.8 (0.3-127) months. No variables predictive of achieving remission were identified. Twenty-seven received second-line treatment because of poor disease control and/or adverse events associated with ATDs. Total thyroidectomy was performed in 17 patients with no recurrence of thyrotoxicosis and all became hypothyroid. Ten patients received radioiodine and six became hypothyroid, one remained hyperthyroid and restarted ATDs and one patient achieved remission. Two patients were lost to follow up.
CONCLUSION
This study has demonstrated that using ATDs is the generally accepted first-line approach and there seems to be low remission rate with ATDs in pediatric GD patients in Turkey.
Topics: Adolescent; Antithyroid Agents; Child; Child, Preschool; Combined Modality Therapy; Disease Management; Female; Follow-Up Studies; Humans; Infant; Male; Retrospective Studies; Thyroidectomy; Thyrotoxicosis; Treatment Outcome
PubMed: 30488822
DOI: 10.4274/jcrpe.galenos.2018.2018.0210 -
Clinical Endocrinology Oct 2019Atrial fibrillation (AF) is the most common cardiac complication of thyrotoxicosis and is strongly implicated in thromboembolic events. However, the incidence of stroke...
OBJECTIVE
Atrial fibrillation (AF) is the most common cardiac complication of thyrotoxicosis and is strongly implicated in thromboembolic events. However, the incidence of stroke in thyrotoxic AF remains unclear. Herein, we aimed to investigate the risks of mortality and ischaemic stroke between patients with thyrotoxic AF and nonthyrotoxic AF.
DESIGNS AND METHODS
From Taiwan's National Health Insurance Research Database, 1868 patients with the concomitant diagnoses of AF and thyrotoxicosis identified between 2001 and 2010 were compared to 7472 patients with nonthyrotoxic AF using propensity score matching for age, sex and comorbidities.
RESULTS
There was no significant difference in either CHA DS -VASc score or anticoagulant usage between the groups. Alternatively, the thyrotoxic group contained more β-blocker/digoxin users, whereas the nonthyrotoxic group contained more statin users. Patients with thyrotoxic AF exhibited lower risks of all-cause mortality (HR: 0.66, CI: 0.59-0.73, P < .0001) and ischaemic stroke (HR: 0.73, CI: 0.64-0.84, P < .0001) than those with nonthyrotoxic AF, especially thyrotoxic patients with CHA DS -VASc scores ≥1. Comorbidities, including diabetes, hyperlipidaemia, hypertension and coronary artery disease, contributed to all-cause mortality in patients with nonthyrotoxic AF; however, this effect was diminished in thyrotoxic AF.
CONCLUSIONS
Patients with thyrotoxicosis and AF have a lower risk of stroke than patients with nonthyrotoxic AF. Treatment for thyrotoxicosis is also crucial as the prescription of anticoagulants based on CHA2DS2-VASc scores.
Topics: Adolescent; Adult; Aged; Atrial Fibrillation; Brain Ischemia; Case-Control Studies; Female; Hemorrhage; Humans; Incidence; Male; Middle Aged; Retrospective Studies; Risk Factors; Severity of Illness Index; Stroke; Thyrotoxicosis; Young Adult
PubMed: 31301252
DOI: 10.1111/cen.14061 -
Thyroid : Official Journal of the... Dec 2020Thyroxine (T4) to triiodothyronine (T3) deiodination in the hypothalamus/pituitary is mediated by deiodinase type-2 (D2) activity. mice show central resistance to...
Thyroxine (T4) to triiodothyronine (T3) deiodination in the hypothalamus/pituitary is mediated by deiodinase type-2 (D2) activity. mice show central resistance to exogenous T4. Patients with resistance to exogenous thyroxine (RETH) have not been described. The aim of this study was to identify hypothyroid patients with thyrotropin (TSH) unresponsiveness to levothyroxine (LT4) and to characterize the clinical, hormonal, and genetic features of human RETH. We investigated hypothyroid patients with elevated TSH under LT4 treatment at doses leading to clinical and/or biochemical hyperthyroidism. TSH and free T4 (fT4) were determined by chemiluminescence, and total T4, T3, and reverse T3 (rT3) by radioimmunoassay. TSH/fT4 ratio at inclusion and T3/T4, rT3/T4, and T3/rT3 ratios at follow-up were compared with those from patients with resistance to thyroid hormone (RTH) due to thyroid hormone receptor-β () mutations. including the Ala92-D2 polymorphism, selenocysteine binding protein 2 (), and were fully sequenced. Eighteen hypothyroid patients (nine of each sex, 3-59 years) treated with LT4 showed elevated TSH (15.5 ± 4.7 mU/L; reference range [RR]: 0.4-4.5), fT4 (20.8 ± 2.4 pM; RR: 9-20.6), and TSH/fT4 ratio (0.74 ± 0.25; RR: 0.03-0.13). Despite increasing LT4 doses from 1.7 ± 1.0 to 2.4 ± 1.7 μg/kg/day, TSH remained elevated (6.9 ± 2.7 mU/L). Due to hyperthyroid symptoms, LT4 doses were reduced, and TSH increased again to 7.9 ± 3.2 mU/L. In the euthyroid/hyperthyrotropinemic state, T3/T4 and T3/rT3 ratios were decreased (9.2 ± 2.4, RR: 11.3-15.3 and 2.5 ± 1.4, RR: 7.5-8.5, respectively) whereas rT3/T4 was increased (0.6 ± 0.2; RR: 0.43-0.49), suggesting reduced T4 to T3 and increased T4 to rT3 conversion. These ratios were serum T4-independent and were not observed in RTH patients. Genetic testing was normal. The Ala92-D2 polymorphism was present in 7 of 18 patients, but the allele dose did not correlate with RETH. Human RETH is characterized by iatrogenic thyrotoxicosis and elevated TSH/fT4 ratio. In the euthyroid/hyperthyrotropinemic state, it is confirmed by decreased T3/T4 and T3/rT3 ratios, and elevated rT3/T4 ratio. This phenotype may guide clinicians to consider combined T4+T3 therapy in a targeted fashion. The absence of germline mutations suggests that aberrant post-translational D2 modifications in pituitary/hypothalamus or defects in other genes regulating the T4 to T3 conversion pathway could be involved in RETH.
Topics: Adult; Biomarkers; Child, Preschool; Drug Resistance; Female; Humans; Hyperthyroidism; Hypothyroidism; Iatrogenic Disease; Male; Middle Aged; Thyrotoxicosis; Thyrotropin; Thyroxine; Time Factors; Treatment Outcome; Young Adult
PubMed: 32498666
DOI: 10.1089/thy.2019.0825 -
Current Radiopharmaceuticals Nov 2017The use of amiodarone for the treatment of ventricular and supraventricular dysrhythmias brings in organism an increased amount of iodine, interfering with thyroid... (Review)
Review
BACKGROUND AND OBJECTIVE
The use of amiodarone for the treatment of ventricular and supraventricular dysrhythmias brings in organism an increased amount of iodine, interfering with thyroid function. If the treatment needs to be interrupted, iodine remains at abnormal levels for months or even years. The aim of the study was to review the literature regarding the optimal tests for early diagnostic and to analyze the role of nuclear medicine tests in the differential and correct assessment of the amiodarone-induced thyroid pathology.
METHODS
We made a review of available publications in PUBMED referring the amiodaroneinduced thyroid pathology, focusing on the differential diagnosis, made by nuclear medicine tests, of hypothyroidism (AIH) and hyperthyroidism expressed as: type I amiodarone induced thyrotoxicosis (AIT I), type II amiodarone induced thyrotoxicosis (AIT II), and less frequently as a mixt form, type III amiodarone induced thyrotoxicosis (AIT III). We presented cases from the database of a tertiary center in Cluj-Napoca, Romania.
RESULTS
Despite the frequent complication of thyroid function, this pathology is underestimated and diagnosed. There is a limited number of studies and clear protocols, especially in the mixed forms cases. This increase in iodine uptake interferes seriously with thyroid hormone production and release. The nuclear medicine tests are essential in the correct assessment and differential diagnosis of different forms of induced thyroid dysfunction. The destruction of the follicular cells can result in the release of excessive thyroid hormone into the circulation, with potential development of atrial fibrillation, worsening the cardiac disease, so any benefic therapeutic procedure should be known; the use of radioiodine as therapy alternative, despite the known limitations induced by blockade was clear benefic in the case presented. A special attention needs to be addressed to those patients with differentiated thyroid cancer, which will be submitted to radioiodine therapy and are under chronic therapy with amiodarone.
CONCLUSION
The nuclear medicine procedures are essential in the correct assessment and differential diagnosis of different forms of induced thyroid dysfunction. The radioiodine is not recommended in AIT, due to stunning effect induced by iodine excess, but in some special, lifethreatening condition, radioiodine I-131 might be a treatment option.
Topics: Amiodarone; Anti-Arrhythmia Agents; Arrhythmias, Cardiac; Biomarkers; Diagnosis, Differential; Early Diagnosis; Humans; Hypothyroidism; Iodine; Nuclear Medicine; Radiopharmaceuticals; Thyroid Gland; Thyrotoxicosis
PubMed: 28814251
DOI: 10.2174/1874471010666170816125402 -
Expert Opinion on Investigational Drugs Nov 2018Thyrotoxicosis with hyperthyroidism is treated with these classical approaches (i) antithyroid drugs to blockade thyroid hormone release and normalize thyroid hormone... (Review)
Review
INTRODUCTION
Thyrotoxicosis with hyperthyroidism is treated with these classical approaches (i) antithyroid drugs to blockade thyroid hormone release and normalize thyroid hormone production and (ii) destruction of the thyroid using radioiodine or surgical removal of the thyroid. The optimal medical therapy, especially for Graves´ disease, remains a subject of debate and there has been little progress in Graves' disease therapeutics over the last decade.
AREAS COVERED
Novel treatments of thyrotoxicosis with hyperthyroidism. This includes (i) small molecules such as synthetic thyroid hormone receptor antagonists and environmental molecules and (ii) molecules with interaction between thyroid stimulating hormone (TSH) receptor and TSH receptor antibodies such as M22, ANTAG3, org274179-0, 5C9, and K1-70. Other approaches to Graves´ disease treatment includes immunosuppressive treatment, glucocorticosteroids, rituximab, and intrathyroid injection of dexamethasone. Optimal iodine and selenium supplementation can also be considered.
EXPERT OPINION
Clinical trials results suggest that novel thyroid treatments involving small molecule therapy, may predict a good future in Graves' disease treatment; however, a greater understanding of these antagonists is needed. Other treatments comprising immunosuppressives have demonstrated a significant reduction of relapse of the disease, but are not recommended by international guidelines.
Topics: Animals; Antithyroid Agents; Drug Design; Drugs, Investigational; Glucocorticoids; Graves Disease; Humans; Hyperthyroidism; Immunosuppressive Agents; Thyroid Hormones; Thyrotoxicosis
PubMed: 30354697
DOI: 10.1080/13543784.2018.1541086 -
International Clinical... Jul 2023The relationship between psychiatric symptoms and thyroid function has been well known and studied since antiquity. The common view is that clinical hypothyroidism is...
The relationship between psychiatric symptoms and thyroid function has been well known and studied since antiquity. The common view is that clinical hypothyroidism is associated with depressive symptoms, whereas the psychiatric manifestations of hyperthyroidism are agitation, emotional lability, hyperexcitability, occasionally accompanied by angry outbursts, and euphoria. The case here reported overturns this conventional medical knowledge. A 73-year-old Italian woman experienced a severe major depressive episode with psychotic and melancholic features during laboratory thyrotoxicosis. No classical clinical signs and symptoms of thyrotoxicosis were present. Psychiatric symptoms improved together with the resolution of the hyperthyroid state. Historically, different cases of so-called 'apathetic hyperthyroidism' have been described. Recent neuroimaging and animal studies provided possible neurobiological explanations, showing how the excess thyroid hormones could affect brain structures involved in the regulation of mood, leading to depression. A direct link between hyperthyroidism and depression seems to be likely. This insight may be relevant in facilitating early diagnosis of thyroid disease and the planning of therapeutic strategies.
Topics: Humans; Depression; Depressive Disorder, Major; Hyperthyroidism; Thyrotoxicosis; Female; Aged
PubMed: 36853810
DOI: 10.1097/YIC.0000000000000438 -
World Neurosurgery Aug 2016Moyamoya disease is a cerebral vasculopathy characterized by stenosis of the terminal internal carotid artery, proximal middle cerebral artery, and anterior cerebral... (Review)
Review
OBJECTIVE
Moyamoya disease is a cerebral vasculopathy characterized by stenosis of the terminal internal carotid artery, proximal middle cerebral artery, and anterior cerebral artery. There is an association between moyamoya vasculopathy and Graves disease, primarily in Asian populations. Here, we present the largest series of non-Asian, predominantly Latino patients with moyamoya vasculopathy in the setting of Graves thyrotoxicosis, as well as the largest review of the literature to date.
METHODS
We retrospectively analyzed patients presenting with stroke in the setting of clinical Graves disease to our institution from 2004 to 2014. Moyamoya vasculopathy was diagnosed by magnetic resonance angiography in all patients.
RESULTS
Eight patients with Graves disease thyrotoxicosis and moyamoya vasculopathy were identified. Six patients were effectively managed with aggressive medical management using antithyroid and antiplatelet medications. No recurrent strokes were noted once thyrotoxicosis was controlled. Intracranial bypass was necessary in 2 patients who failed medical management. Seventy-nine additional cases were reported from the literature. There was no significant difference in clinical improvement between medical therapy alone and medical therapy with neurosurgical prophylaxis (87.0% vs. 88.0%, respectively; P = 0.94).
CONCLUSIONS
Moyamoya vasculopathy associated with Graves disease thyrotoxicosis in non-Asian women may be more common than previously thought. In addition, our series suggests that thyrotoxicosis promotes the progression of vasculopathy. Based on our review, there is no significant difference in clinical improvement between proper medical and surgical therapies. Aggressive medical therapy should be considered first-line treatment for moyamoya vasculopathy with Graves thyrotoxicosis, with neurosurgical rescue reserved for medically refractory cases.
Topics: Female; Graves Disease; Humans; Latin America; Moyamoya Disease; Retrospective Studies; Stroke; Thyrotoxicosis; Women's Health
PubMed: 27163552
DOI: 10.1016/j.wneu.2016.04.122