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Frontiers in Endocrinology 2024Ectopic thyroid-stimulating hormone (TSH)-secreting tumors are extremely rare, with only 15 reported cases in the literature. Herein, we described a 60-year-old female... (Review)
Review
Ectopic thyroid-stimulating hormone (TSH)-secreting tumors are extremely rare, with only 15 reported cases in the literature. Herein, we described a 60-year-old female patient with thyrotoxicosis and elevated or unsuppressed levels of TSH. Family history and laboratory and genetic tests did not support a diagnosis of resistance to thyroid hormone (RTH). Given the unsuppressed TSH, TSH-secreting tumor was suspected, and magnetic resonance imaging (MRI) of the pituitary gland was performed. Surprisingly, the MRI scans revealed a nodule in the nasopharynx rather than a pituitary tumor in the sella region. Further evaluation using Gallium-68 DOTATATE positron emission tomography/computed tomography (Ga-DOTATATE PET/CT) demonstrated increased DOTATATE uptake in the nasopharyngeal nodule. Additionally, an octreotide suppression test (OST) revealed an obvious reduction in TSH levels, further supporting the suspicion of the nasopharyngeal mass as the cause of inappropriate TSH secretion. To prepare for surgery, the patient received preoperative administration of octreotide, resulting in the normalization of TSH and thyroid hormone levels. The patient subsequently underwent successful surgical removal of the nasopharyngeal mass. Following the procedure, the patient experienced complete resolution of hyperthyroidism symptoms, with TSH declined and thyroid hormone levels returned to normal. Histochemistry analysis of the tumor revealed positive staining for TSH, growth hormone (GH), prolactin (PRL), luteinizing hormone (LH), and somatostatin receptor 2 (SSTR2). We discussed differential diagnosis of hyperthyroidism due to inappropriate TSH secretion, with a particular emphasis on the importance of Ga-DOTATATE PET/CT in combination with OST for identifying ectopic pituitary tumors.
Topics: Female; Humans; Middle Aged; Adenoma; Gallium Radioisotopes; Hyperthyroidism; Octreotide; Pituitary Neoplasms; Positron Emission Tomography Computed Tomography; Thyroid Hormones; Thyroid Neoplasms; Thyrotropin
PubMed: 38516415
DOI: 10.3389/fendo.2024.1301260 -
BMC Endocrine Disorders Mar 2024The prevalence of hyperthyroidism in Pakistan is 2.9%, which is two times higher than in the United States. Most high-quality hyperthyroidism clinical practice...
INTRODUCTION
The prevalence of hyperthyroidism in Pakistan is 2.9%, which is two times higher than in the United States. Most high-quality hyperthyroidism clinical practice guidelines (CPGs) used internationally originate from high-income countries in the West. Local CPGs in Pakistan are not backed by transparent methodologies. We aimed to produce comprehensive, high-quality CPGs for the management of hyperthyroidism in Pakistan.
METHODS
We employed the GRADE-ADOLOPMENT approach utilizing the 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis as the source CPG. Recommendations from the source guideline were either adopted as is, excluded, or adapted according to our local context.
RESULTS
The source guideline included a total of 124 recommendations, out of which 71 were adopted and 49 were excluded. 4 recommendations were carried forward for adaptation via the ETD process, with modifications being made to 2 of these. The first addressed the need for liver function tests (LFTs) amongst patients experiencing symptoms of hepatotoxicity while being treated with anti-thyroid drugs (ATDs). The second pertained to thyroid status testing post-treatment by radioactive iodine (RAI) therapy for Graves' Disease (GD). Both adaptations centered around the judicious use of laboratory investigations to reduce costs of hyperthyroidism management.
CONCLUSION
Our newly developed hyperthyroidism CPGs for Pakistan contain two context-specific modifications that prioritize patients' finances during the course of hyperthyroidism management and to limit the overuse of laboratory testing in a resource-constrained setting. Future research must investigate the cost-effectiveness and risk-benefit ratio of these modified recommendations.
Topics: Humans; Pakistan; Iodine Radioisotopes; Thyroid Neoplasms; Hyperthyroidism; Graves Disease
PubMed: 38509509
DOI: 10.1186/s12902-023-01493-1 -
EBioMedicine Apr 2024Recently, abnormal thyroid function was shown to be common in patients with Takotsubo syndrome (TTS), being classified into "endocrine-type" and "stress-type" responses....
BACKGROUND
Recently, abnormal thyroid function was shown to be common in patients with Takotsubo syndrome (TTS), being classified into "endocrine-type" and "stress-type" responses. The aim of this study was to investigate the association between thyroid homeostasis and TTS in a larger international registry.
METHODS
In total 288 patients with TTS were enrolled through the GEIST multicentre registry from Germany, Italy and Spain. Thyrotropin (TSH), free T4 (FT4) and free T3 (FT3) concentrations were analysed at admission. Data were collected both retrospectively and prospectively from 2017 onwards. Primary endpoints included in-hospital and all-cause fatality, determined by cluster analysis using an unsupervised machine learning algorithm (k-medoids).
FINDINGS
Three clusters were identified, classifying TTS with low (TSLT), high (TSHT) and normal (TSNT) thyroid output, based on TSH and FT4 levels in relation to the median thyroid's secretory capacity (SPINA-GT). Although TSH and FT4 concentrations were similar among survivors and non-survivors, these clusters were significantly associated with patient outcomes. In the longitudinal Kaplan-Meier analysis including in- and out-of-hospital survival, the prognosis related to concentrations of TSH, FT4, and FT3 as well as SPINA-GT, deiodinase activity (SPINA-GD) and clusters. Patients in the TSHT cluster and with cardiogenic shock had a lower initial left ventricular ejection fraction (LVEF).
INTERPRETATION
This study suggests that thyroid hormones may impact the evolution and prognosis of TTS. The findings indicate that thyroid-derived biomarkers may help identify high-risk patients and pave the way for novel personalized and preventive therapeutic options.
FUNDING
This research was not funded by any public, commercial, or not-for-profit agencies.
Topics: Humans; Triiodothyronine; Thyroxine; Takotsubo Cardiomyopathy; Stroke Volume; Retrospective Studies; Ventricular Function, Left; Thyroid Hormones; Thyrotropin; Registries; Cluster Analysis
PubMed: 38502972
DOI: 10.1016/j.ebiom.2024.105063 -
Cureus Feb 2024Thyrotoxicosis is a common clinical condition encountered in endocrine practice. Graves' disease and subacute thyroiditis are the two common causes of thyrotoxicosis and...
BACKGROUND AND OBJECTIVE
Thyrotoxicosis is a common clinical condition encountered in endocrine practice. Graves' disease and subacute thyroiditis are the two common causes of thyrotoxicosis and often have overlapping clinical and biochemical features. 99mTc thyroid scintigraphy is the most commonly used confirmatory test to differentiate the two conditions but is not available in the majority of the second-tier cities of India. However, obtaining thyroid stimulating hormone (TSH) receptor antibodies (TSHrAb), another accurate test to differentiate the two conditions, in second-tier cities by outsourcing to labs in major cities is a feasible option nowadays. However, the data on the performance of TSHrAb to differentiate the two conditions in Indian patients is limited. Hence, we have evaluated the diagnostic accuracy of TSHrAb in the Indian population to differentiate Graves' disease and subacute thyroiditis.
MATERIALS AND METHODS
This prospective study was conducted on 115 consecutive newly diagnosed thyrotoxicosis patients presenting to the Department of Endocrinology at a tertiary health care centre in India. Clinical parameters like throat pain, duration of symptoms, and grade of goitre were noted. Measurement of total tri-iodothyronine (TT3), total thyroxine (TT4), TSH, TSHrAb, and 99mTc thyroid scintigraphy were performed in all participants. All participants were followed up at least for six months after the recruitment. Increased tracer uptake (>4%) and/or increased thyroid to parotid trace uptake ratio (>2.5) were used to diagnose Graves' disease.
RESULTS
Eighty-one and 34 patients were diagnosed with Graves' disease and subacute thyroiditis, respectively. TT3/TT4 ratio had low diagnostic accuracy (area under the curve (AUC): 0.6, best cut-off: 15.6, sensitivity: 53.1%, specificity: 79.4%). TSHrAb had the best AUC (0.9) to distinguish Graves' disease from subacute thyroiditis (cut-off: 2.0 IU/L, sensitivity: 97.5%, specificity: 100%). In contrast, the kit manufacturer's reference range (1.75 IU/L) was slightly more sensitive (98.8%), but less specific (94%).
CONCLUSION
The TT3/TT4 ratio is not a good test to differentiate Graves' disease and subacute thyroiditis. TSHrAb is accurate in distinguishing Graves' disease from subacute thyroiditis and a level of 2.0 may be a more accurate cut-off to differentiate the two conditions in the Indian population.
PubMed: 38496158
DOI: 10.7759/cureus.54303 -
Cureus Feb 2024Immune checkpoint inhibitors, specifically programmed death-ligand 1 (PD-LI) inhibitors, are immune modifying medications that increasingly treat specific types of...
Immune checkpoint inhibitors, specifically programmed death-ligand 1 (PD-LI) inhibitors, are immune modifying medications that increasingly treat specific types of cancer. They are known to cause many side effects, including thyroid-related side effects. The use of PD-L1 inhibitors can cause hypothyroidism most commonly, while hyperthyroidism occurs less frequently. This case report describes a patient who developed a toxic thyroid nodule while taking the PD-L1 inhibitor, avelumab, for the treatment of Merkel cell carcinoma. It highlights the need for more research into the specific mechanisms by which these therapies can cause hyperthyroidism. It also raises the question regarding the association between the use of these medications and the development or worsening of thyroid nodules.
PubMed: 38496061
DOI: 10.7759/cureus.54143 -
Case Reports in Endocrinology 2024Thyroid tuberculosis is a rare form of extrapulmonary tuberculosis, even in endemic countries such as Morocco; its precise incidence is not well-defined. The clinical...
Thyroid tuberculosis is a rare form of extrapulmonary tuberculosis, even in endemic countries such as Morocco; its precise incidence is not well-defined. The clinical presentation of thyroid tuberculosis can vary, often being asymptomatic. Consequently, the diagnosis may be overlooked or delayed. Intriguingly, thyroid tuberculosis can manifest alongside thyrotoxicosis due to Graves' disease, an exceptional association. This article reports a distinctive case of thyroid tuberculosis coexisting with Graves' disease, one of the autoimmune thyroid diseases. A 33-year-old female presented symptoms consistent with hyperthyroidism and bilateral exophthalmos. She was subsequently diagnosed with Graves' disease. Despite initially managed medically, recurrences of the disease led to definitive treatment by total thyroidectomy. Histopathological examination revealed concurrent presence of thyroid tuberculosis.
PubMed: 38481612
DOI: 10.1155/2024/3865608 -
Romanian Journal of Internal Medicine =... Mar 2024The frequency of thyrotoxicosis may vary between countries and some laboratory test results may be used in etiology research. This study aimed to evaluate the prevalence...
BACKGROUND
The frequency of thyrotoxicosis may vary between countries and some laboratory test results may be used in etiology research. This study aimed to evaluate the prevalence of thyrotoxicosis diagnoses and laboratory test results.
METHODS
3246 patients with overt thyrotoxicosis were included in this study. Laboratory test results, epicrisis, thyroid ultrasonography, thyroid scintigraphy, and radioactive iodine uptake test reports of the patients were examined in the study.
RESULTS
Thyrotoxicosis was found due to levothyroxine overdose in 58.1% of the patients. When this group was excluded, 36.1% of the patients were diagnosed with toxic multinodular goiter most frequently. TRab levels were 8.5 times higher in Graves' disease than in other diagnostic groups. Anti-TPO levels were found to be the highest in the Graves' disease and Hashitoxicosis groups compared to other diagnostic groups (p<0.001). Anti-Tg levels were found to be highest in Graves' disease, Postpartum thyroiditis, and Hashitoxicosis patients (p<0.001). The free triiodothyronine / free thyroxine ratio was significantly higher, a cut-off value of >2.94 provided a sensitivity of 66% and specificity of 64% in diagnosing Graves' disease.
CONCLUSION
The causes of thyrotoxicosis show some differences between countries. Patients using levothyroxine should be informed about drug use and dose titration. The free triiodothyronine / free thyroxine ratio can be used in addition to other tests during diagnosis.
PubMed: 38470338
DOI: 10.2478/rjim-2024-0007 -
Open Heart Mar 2024The wearable cardioverter defibrillator (WCD) is becoming a more and more widely used instrument for the prevention of sudden cardiac death of patients either with a...
The wearable cardioverter defibrillator (WCD) is becoming a more and more widely used instrument for the prevention of sudden cardiac death of patients either with a secondary prevention implantable cardioverter defibrillator indication or with a transient high risk of sudden cardiac death. Although clinical practice has demonstrated a benefit of protecting patients for a period as long as 3-6 months with such devices, the current European guidelines concerning ventricular arrhythmias and sudden cardiac death are still extremely restrictive in the patient selection in part because of the costs derived from such a prevention device, in part because of the lack of robust randomised trials.To illustrate expanded use cases for the WCD, four real-life clinical cases are presented where patients received the device slightly outside the established guidelines. These cases demonstrate the broader utility of WCDs in situations involving acute myocarditis, thyrotoxicosis, pre-excited atrial fibrillation and awaiting staging/prognosis of a lung tumour. The findings prompt expansion of the existing guidelines for WCD use to efficiently protect more patients whose risk of arrhythmic cardiac death is transient or uncertain. This could be achieved by establishing a European register of the patients who receive a WCD for further analysis.
Topics: Humans; Electric Countershock; Defibrillators, Implantable; Death, Sudden, Cardiac; Atrial Fibrillation; Wearable Electronic Devices
PubMed: 38458770
DOI: 10.1136/openhrt-2023-002597 -
Cureus Feb 2024Thyrotoxic periodic paralysis (TPP) is a complication of hyperthyroidism that predominantly affects the Asian population. Episodes of muscle paralysis typically coincide...
Thyrotoxic periodic paralysis (TPP) is a complication of hyperthyroidism that predominantly affects the Asian population. Episodes of muscle paralysis typically coincide with symptoms of hyperthyroidism. However, we present a unique case of TPP in a 32-year-old African American patient where TPP served as the primary manifestation of thyrotoxicosis. The patient was discharged with a resolution of symptoms after correcting electrolyte abnormalities.
PubMed: 38449927
DOI: 10.7759/cureus.53581 -
Cureus Feb 2024Moyamoya syndrome, known as secondary moyamoya disease, is associated with various primary illnesses, such as brain tumor, meningitis, autoimmune disease, and...
Moyamoya syndrome, known as secondary moyamoya disease, is associated with various primary illnesses, such as brain tumor, meningitis, autoimmune disease, and thyrotoxicosis, and their relations are not clear. We report a rare case of moyamoya syndrome in a patient with Graves' disease. An 18-year-old woman was admitted to our hospital due to convulsions. She had symptoms of palpitations and fatiguability for half a year and transient numbness in her left upper extremity and dysarthria for a month. In physical findings, tachycardia and diffuse thyroid swelling were noted. A blood test revealed thyrotoxicosis and antithyroid antibody, and a diagnosis of Graves' disease was obtained. Brain magnetic resonance imaging (MRI) showed bilateral internal carotid artery occlusion. We finally diagnosed the patient with moyamoya syndrome caused by Graves' disease. Moyamoya disease or syndrome can cause symptoms like a stroke, sometimes requiring neurosurgical treatment. In our case, the therapy for Graves' disease resolved the symptoms. When diagnosing moyamoya disease, it is necessary to confirm whether there are any background diseases, such as Graves' disease.
PubMed: 38445131
DOI: 10.7759/cureus.53519