Endocrine Abstracts

Local regulation of T3 action in bone and cartilage is a novel mechanism underlying the pathogenesis of osteoarthritis (OA). Accelerated chondrocyte differentiation is a hallmark of OA and T3 regulates this process. The type 1 and 2 deiodinases (D1, D2) convert the pro-hormone T4 to the active hormone T3 whilst D3 inactivates both T3 and T4. D1 contributes to circulating T3 levels and local T3</s...

Context: Pendrin is a transmembrane protein located at the apical end of the thyrocyte where it mediates the efflux of iodide through the thyroid follicular cell. Recently, pendrin was described as a significant antibody target in Japanese patients with Graves’ disease or autoimmune hypothyroidism using an immunoblotting assay. However, a subsequent study failed to verify this in autoimmune thyroid disease patients of Tunisian origin.Objective: The ...

A 44-year-old gentleman with history of intravenous drug abuse, was referred for new onset hyperthyroidism. He was diagnosed with hepatitis C a year prior to presentation. Treatment included pegylated-interferon (IFN-α) 100 μg weekly and Ribavirin 1 g daily. He had early viral response at week 4 of treatment with viral load of <30 IU/ml from 24 089 IU/ml. At week 8, patient complained of lethargy. He was tachycardic, but had no goitre or thyroid eye disease. Thyr...

Background: Overt and subclinical hypothyroidisms are associated with altered cerebral blood flow (CBF) which may be reversed with levothyroxine treatment (T4T). Subclinical hypothyroidism (SCH) is associated with fatigue but it is unclear whether fatigue is related to abnormal CBF and whether T4T has a beneficial impact. We therefore studied fatigued SCH patients before and after T4T and euthyroid non-fatigued healthy controls (HC).Methods: CBF was meas...

Background: Thyroid incidentaloma (TI) is an unsuspected, asymptomatic thyroid lesion discovered on an imaging study performed for unrelated purposes. Reported incidence during 2-(18)(F) fluoro-2-deoxy-D-glucose positron emission tomography (18F-FDG-PET/CT) varies from 0.2 to 8.9%, with a quoted thyroid malignancy prevalence of 8-64%.Method: We reviewed all 18F-FDG-PET/CT scans performed in our institution over 52 mon...

Objective: To investigate vitamin D status in patients with autoimmune hypothyroidism.Methods: The study group consisted of 100 patients with newly diagnosed Hashimato’s thyroiditis and 100 subjects as the control group. Parameters of calcium metabolism, thyroid function tests and 25(OH) vitamin D levels were measured.Results or Case Presentation: Mean age of the study study groups was 33.4±4.8 years with female:male=72:2...

Background: The measurement of thyroglobulin (Tg) is important in the follow-up of patients with differentiated thyroid cancer (DTC), but interpretation is subject to interference by anti-thyroglobulin antibodies (TgAb). National guidelines recommend measurement of TgAb status but no consensus exists on how surveillance should be adapted in cases of TgAb positivity.Aims: To evaluate the impact of TgAbs on clinical management, in a single-centre cohort of...

Thyroid dysfunction is common and the clinical presentation of subjects with abnormal thyroid hormone concentrations varies widely. Whilst acute illness may affect the interpretation of thyroid function tests, delaying diagnosis and treatment of thyroid dysfunction may have significant consequences. We set out to determine the likelihood of thyroid function testing and the factors influencing the probability of serum TSH measurement in hospitalised patients with a recorded dia...

Resistance to thyroid hormone (RTH) is usually due to heterozygous mutations in THRB gene with rare cases being homozygous for receptor defects. We describe an RTH case due to a homozygous TRβ mutation (R243Q).The Proband (male, 8.4 years), was born at term with low birth weight (1.9 kg) to consanguineous parents. He has a prominent nasal bridge, goitre, low body weight (10th centile), recurrent tonsillitis, hyperactivity and has mild hearing impair...

Background: The use of radioactive iodine treatment (RAI) for the definitive treatment of benign hyperthyroid disorders has been well established. This study was conducted to determine the factors predicting the development of hypothyroidism following RAI therapy.Methods: All patients (n=104, 25 men, 79 women) who had RAI for hyperthyroidism between January 2008 and December 2009 were included. In 82.6% of patients antithyroid medications were u...

We have previously shown that the current guidelines for monitoring thyroid function post radioiodine (RI), may not detect hypothyroidism until it has become severe, in a significant proportion of cases (J Endocrinol Invest 2012 35 82–86). An alternative more intense follow-up strategy was used whereby patients had TSH and FT4 measured at 4-week intervals post RI for 6 months. Endocrine specialist nurse-led telephone and nurse-led out-...

Interferon use for the treatment of chronic hepatitis infection, is associated with the side effect of thyroid dysfunction. This is frequent and can be severe, particularly if not recognised. We performed a retrospective analysis of cases of interferon related thyroid dysfunction referred to our tertiary endocrinology centre. Fourteen cases were identified over the last 8 years. An analysis was carried out of demographic features, presentation, treatment and outcomes.<p cl...

Fine-needle aspiration biopsy (FNAB) is the tool of choice for evaluating thyroid nodules but there is a significant percentage of insufficient or indeterminate aspirates and falsely reassuring results have been reported in up to 6% of cases.We aimed to examine our experience with FNAB among a large cohort of unselected patients with thyroid nodules.239 consecutive patients (211 women) underwent FNA of a thyroid nodule between July...

A 42-year-old man with resistance to thyroid hormone (RTH) and a recognised thyroid hormone receptorβ mutation (R383C) mutation, presented with atrial fibrillation (AF) which was resistant to DC cardioversion until initiation of amiodarone therapy.As expected in RTH, his baseline TFTs were abnormal (FT4 34.6 pmol/l, TSH 2.27 mU/l), but rose further (FT4 45 pmol/l, TSH 0.93 mU/l) following commencement of amiodarone. However, sh...

Background: Anaplastic carcinoma and primary lymphoma (TL) each constitute <2% of thyroid malignancies and are difficult to distinguish clinically. Both typically present with rapidly enlarging anterior neck masses in the elderly. Both may cause pressure symptoms (e.g. dysphagia, stridor and hoarseness). Differentiation is imperative as their treatment and prognoses differ.Case report: A 68-year-old man presented with a rapidly enlarging thyroid mass...

TSH receptor antibodies (TRAB) are now routinely measured in patients with Graves’ disease (GD) to aid diagnosis. Thyroid peroxidase antibodies (TPO) sometimes co-exist in these patients but not always. Some studies have suggested a functional and prognostic role for these antibodies. However, the phenotypic characteristics of the patient with positive TPO (with or without TRAB) and the influence of TPO on the clinical course of GD are not known.A r...

Graves’ disease is an autoimmune condition predominantly affecting middle aged women. It can be difficult to manage and consumes a lot of medical time and resources.In Torbay Hospital, we introduced endocrine nurse specialist (ENS) follow up service to reduce medical burden. This has shifted the work-load of patient care but on the other hand, has resulted in identification of great need for support and increased nurse time.We...

Introduction: Thyroid nodules are very common and elucidating the nature of these thyroid nodules is an important task.Methodology: Patients who had an ultrasound guided fine needle aspiration (FNA) of a thyroid nodule between January 2008 and June 2012 were retrospectively audited and their ultrasonographic and biochemical characteristics where analysed. For those patients who were operated nodule characteristics were correlated with thyroid histology.<...

We report a case of a false positive pentagastrin stimulation test in a patient with a positive family history for medullary thyroid cancer (MTC), but normal histology following total thyroidectomy.An asymptomatic 50-year-old man was referred urgently with an elevated calcitonin level of 19.9 ng/l (reference range<11.8), taken following the diagnosis of his brother with MTC which had been discovered on a routine private medical examination. There was...

The use of anti-thyroid medication is favoured first line therapy in Graves’ disease (GD). However, relapse rates are high (up to 50%) and definitive therapies of either surgery or radioactive Iodine therapy (RAI) are often considered following an informed decision. The definitive choice taken depends on several factors considered during the patient-doctor interaction. The aim of this study was thus to determine the influence of such factors.A cross...

Introduction: Despite being on adequate amounts of levothyroxine (>1.6 μg/kg) some patients still exhibit biochemical evidence of inadequate replacement (serum TSH >4.2 mIU/l±free-thyroxine (FT4) <12 pmol/l). We report the use of a 5-day absorption test for assessing levothyroxine absorption in such a patient.Case: A 35-year-old female with hypothyroidism since 2007 had a serum TSH ranging from 4.48 to 54.9 mIU/l and FT<s...

Thyroid cancer has an annual incidence of 0.2–5 per million children representing 3% of all childhood tumours. We describe the presentation, histopathology and treatment of four patients in a regional paediatric surgical and endocrine unit over the past 15 years.Three of four cases are female with 1 male. Age of diagnosis ranged from 6 to 15 years. All had an elevated thyroglobulin at presentation with normal thyroid function tests. Three underwent ...

Radiation to the neck is known to be associated with the later development of hypothyroidism. The possibility of acute radiation-induced thyrotoxicosis is not generally recognised. We report here a case of acute hyperthyroidism shortly after radiotherapy.A 57-year-old man with poorly differentiated adenocarcinoma of the left parotid underwent parotidectomy with radical neck dissection followed by radiotherapy. He received 65 Gy by intensity modulated rad...

Objective: To evaluate the outcome of fine needle aspiration biopsy (FNAB) of solid thyroid nodules, and the utility of thyroid ultrasound in determining the nature of solid nodules in our practice.Methods: We reviewed the diagnostic outcome of FNAB of solid thyroid nodules in 93 patients from our dedicated thyroid biopsy clinic. In addition we compared the predictive value of sonographic assessment with FNAB in a subset of patients who had undergone bot...

Introduction: Thyroid dermopathy usually takes the form of pre-tibial myxedema, which may rarely be caused by Hashimoto’s thyroiditis. We present an extreme variant of pre-tibial myxedema, called Elephantiasis nostras verruca (ENV), in a hypothyroid patient.Case: A 51-year-old woman presented with a progressively worsening growth on her left leg and reduced mobility, constipation, cold intolerance and severe self-neglect. She was slow to respond to ...

Hypothyroidism is common condition with a strong female preponderance and a UK prevalence of ~2%. It is normally treated with replacement oral levothyroxine.Morbid obesity is a costly public health issue with a prevalence in England of ~3% with two-thirds of sufferers being female. Weight loss surgery is increasingly employed as a successful and cost effective intervention for super-morbidly obese patients (BMI >40 kg/m2) in accordance wit...

Introduction: Thyrotoxicosis is a common condition referred to endocrine clinics. However, not all of them needed treatment with antithyroid medications. We report a case of thyroid hormone resistance due to a novel TSHRβ mutation who has been treated with subtotal thyroidectomy and antithyroid medications due to raised T4 levels.Case report: A 38-year-old south Asian woman was seen in orthopaedic clinic for elective right foot scarf oste...

Background: Differentiated thyroid cancers are reported to present with synchronous distant metastases in 1–9% of cases. The most common single sites of synchronous metastases are lung (45%) and bone (39%) with dual site involvement (12%). Other single sites of metastases are rare (4%). Pleural metastases are very unusual, accounting for < 0.6% of cases.Case: A 55-year-old male smoker presented with cough, weight loss and thoracic back pain. Exa...

Background: Elevated TSH with raised free T4 (fT4) presents a diagnostic challenge. Symptomatically they vary across the spectrum of thyroid status. We report cases with these dilemmas.Case 1: Seventy four year old was referred with 5 years of TSH ranging between 4.9–7.9 mIU/l (0.2–4.0), fT4 18.5–27 pmol/l (9.0–19) and free T3 (fT3) 4.5–12 pmol/l (2.5–5.7). Thyroid perox...

A 64-year-old man was referred with an incidental finding of multiple bilateral thyroid cysts following CT scanning for abdominal pain. He had originally presented with an acute episode of left upper quadrant pain. CT scan of the abdomen demonstrated multiple lesions in the liver compatible with simple cysts. There were also multiple bilateral renal cysts, of which the largest was 10 cm. A small amount of retroperitoneal fluid was seen, probably as a result of a ruptured cyst....

Background: Untreated hypothyroidism may be associated with cutaneous signs including coarse, dry skin and hair loss. Myxoedema (also known as thyroid dermopathy) is usually associated with Graves’ thyrotoxicosis but has been reported in patients with hypothyroidism. We describe an unusual skin disorder in a patient with autoimmune hypothyroidism, initially misdiagnosed as myxoedema.Case: A 41-year-old female with an extensive medical history includ...

A 59-year-old female presented with apathy and 6 kg weight gain. Investigations revealed primary hypothyroidism (TSH >100 μIU/ml). Thyroxine (L-T4) was started and titrated up to 75 μg, o.d., with clinical improvement. Other investigations revealed high titres of anti-thyroid peroxidase and anti-thyroglobulin antibodies. After three months, there was a fall in TSH to 12.74 μIU/ml, however, with unexpectedly high free T4 (...

A 35-year lady with Grave’s disease and brittle asthma presented to the Endocrinology team with symptoms and signs of thyrotoxic crisis. She was not on any anti-thyroid medication as she had previous suffered a severe rash in response to carbimazole, and profound gastrointestinal disturbance with propylthiouracil. It was suggested that she consider radioiodine to control her condition, but as a single parent with young children she was not prepared to undergo the isolatio...

Audit was performed to identify outcomes of patients from our department referred for RAI for thyrotoxicosis over 14 month period. Follow-up data of atleast 6 months was required for inclusion. Forty-eight patients were identified; four were excluded due to insufficient follow-up. Diagnoses were: Graves’ disease (n=35; 79.5%), multinodular disease (MND) (n=8; 18.2%) and Amiodarone induced thyrotoxicosis (AIT) (n=1; 0.02%)....

We present two thyroid antibody positive euthyroid women with history of recurrent miscarriage who had successful pregnancy outcome when treated with levothyroxine.A 31-year-old Caucasian lady was referred to our endocrine services with a history of three previous miscarriages. She had strongly positive thyroid peroxidise antibodies (TPO) with normal thyroid function tests.We commenced her on 25 μg of levothyroxine. Within two...

Thyrotoxicosis is a common disorder especially in women. Most of the patients tolerate antithyroid medications very well with very few developing life threatening side effects. We describe a 64 years old gentleman who was diagnosed with hyperthyroidism secondary to Grave’s disease (autoimmune). He was treated with Carbimazole 20 mg daily. With in a month, he presented with malaise and reduced oral intake. Laboratory investigations showed acute cholestatic hepatitis with r...

Myxedema coma has very high mortality and should be suspected in an acutely unwell patient presenting with depressed mental status who is hypothermic, bradycardic and or hypotensive. Myxedema coma may be the first presentation of people with undiagnosed hypothyroidism. Definitive management is with thyroid hormone but supportive measures, identification and treatment of precipitating factors in an appropriately safe environment are vital. There is no consensus about preferred ...