Painless thyroiditis complicated by acromegaly

The serum thyroid stimulating hormone (TSH) level is decreased in acromegalic patients. Although this phenomenon is thought to be caused by the enhanced secretion of somatostatin which suppresses TSH production, it has not yet been proven. We describe a 60-year-old woman with acromegaly who showed a low concentration of TSH. We diagnosed her as painless thyroiditis based on an increased level of thyroglobulin, depressed radioactive iodine uptake (RAIU), normal vascularity and mild swelling of the thyroid, and normal T3, T4, free T3 and free T4 levels. To our knowledge, this is the second reported case of acromegaly complicated by painless thyroiditis. The differential diagnosis between central hypothyroidism and painless thyroiditis is so important. Since it is difficult to diagnose precisely based on only the data of a low level of TSH and normal levels of thyroid hormones, we consider that measurement of thyroglobulin and RAIU is necessary when the complication of painless thyroiditis is suspected.

Menstrual disturbances in various thyroid diseases

The prevalence of menstrual disturbances, including secondary amenorrhea, hypomenorrhea, oligomenorrhea, hypermenorrhea, polymenorrhea and irregular menstrual cycle were prospectively examined in 586 patients with hyperthyroidism due to Graves' disease, 111 with hypothyroidism, 558 with euthyroid chronic thyroiditis, 202 with painless thyroiditis and 595 with thyroid tumor. In the overall patient group, the prevalence did not different from that in 105 healthy controls. However, patients with severe hyperthyroidism showed a higher prevalence of secondary amenorrhea (2.5%) and hypomenorrhea (3.7%) than those (0.2% and 0.9%, respectively) with mild or moderate hyperthyroidism. Moreover, patients with severe hypothyroidism had a higher prevalence (34.8%) of menstrual disturbances than mild-moderate cases (10.2%). Menstrual disturbances in thyroid dysfunction were less frequent than previously thought.

An uncommon endocrine cause of pyrexia of unknown origin

We report a previously healthy 43 yr old male who presented with prolonged fever, weight loss and neck pain for 3 weeks. Even after extensive work up for the possible causes of pyrexia, the cause remained elusive. In view of persistent tachycardia and neck pain, possibility of subacute thyroiditis was suspected. Thyroid function test (TFT) revealed thyrotoxicosis, which on further evaluation was found to be secondary to DeQuervains thyroiditis. He was treated with NSAIDs, beta-blockers and steroids. He improved rapidly but went on to develop hypothyroidism on follow-up and required levothyroxine replacement.

A case of Riedel's thyroiditis with pleural and pericardial effusions

Riedel's thyroiditis (RT) is a rare type of chronic thyroiditis of unproven etiology and definite treatment. It can be associated with retroperitoneal, mediastinal, orbital, and hepatic fibrosis. Symptoms arise mainly due to compression of neighboring structures. Surgery is usually required for a definite diagnosis and decompression to relieve the symptoms. Glucocorticoids and tamoxifen are commonly used agents for the pharmacotherapy. We hereby describe the development of pleural and pericardial effusions during the clinical course of an RT case. A 39-year-old woman suffering from neck compression symptoms was admitted to the hospital. After a decompression isthmectomy, RT was diagnosed. She responded well to glucocorticoid therapy after surgery. However, symptoms reoccurred shortly after glucocorticoid withdrawal and the disease process extended to the mediastinum. Tamoxifen was started and the neck and mediastinal mass regressed and her symptoms disappeared considerably for more than 6 months. However, she was readmitted with severe dyspnea and chest pain. Further investigation revealed an exudative pleural and pericardial effusion and mediastinal enlargement. A thorough evaluation of the patient's effusions did not disclose any specific etiological insult. The patient was symptom-free with a considerable reduction of the soft tissue mass and no effusions, and treated successfully with colchicine, azathioprine, and glucocorticoids. To the best of our knowledge, this is the first case reported in the literature as an RT presenting with pleuropericardial effusions.

Reversal of increased whole blood and plasma viscosity after treatment of hypothyroidism in man

Blood and plasma viscosity was measured in 13 patients with hypothyroidism before and during replacement therapy with l-thyroxine. Blood viscosity was measured at natural hematocrit and after adjustment to 40%. The values were compared to those of 12 healthy subjects. Both blood viscosity at hematocrit 40% and plasma viscosity were increased in the hypothyroid state and decreased to the levels of the reference group after treatment. The therapy-induced changes in blood and plasma viscosity were intercorrelated at low but not at high shear rates. The changes in viscosity were not correlated to the reductions in lipoprotein concentrations resulting from therapy. The institution of l-thyroxine replacement therapy was also followed by reductions in erythrocyte sedimentation rate and diastolic blood pressure, both with significant correlations to the decrease in blood viscosity. It is concluded that in hypothyroidism there are changes in both plasma and erythrocytes that increase blood viscosity, with normalization upon treatment with l-thyroxine to euthyroidism.

Newly diagnosed thyrotoxicosis in hospitalized patients: clinical characteristics

BACKGROUND

Thyrotoxicosis is often diagnosed in an outpatient setting. The most common symptoms include irritability, heat intolerance, palpitations and weakness. Sometimes, however, thyrotoxicosis is first diagnosed in the hospital setting. The prevalent symptoms in hospitalized patients with newly diagnosed thyrotoxicosis have not been fully characterized.

AIM

To determine the clinical characteristics of patients with thyrotoxicosis newly diagnosed during hospitalization.

DESIGN

A retrospective computer-based search was undertaken to detect patients that were hospitalized in our medical centre during 1999-2006, and discharged with thyrotoxicosis or thyroiditis as the primary diagnosis.

RESULTS

Fifty-eight patients (36F/22M; mean age 52.1 +/- 17.5 years) were identified. Weakness, weight loss and palpitations were the most common manifestations (50, 40 and 35%, respectively) and were predominantly present in patients with hyperthyroidism. Sore throat was present in 41% of patients with thyroiditis. Sinus tachycardia and atrial fibrillation occurred in 65.5 and 15.5% of the patients, more common in those with hyperthyroidism. The diagnoses on discharge were Graves' disease, subacute thyroiditis and multinodular goiter in 39.7, 34.5 and 8.9%, respectively.

CONCLUSION

Weakness, weight loss and palpitations were the main symptoms in patients diagnosed with thyrotoxicosis during hospitalization. Thyrotoxicosis should be included in the differential diagnosis when patients are admitted to the hospital with those symptoms.

Palpation thyroiditis causing new-onset atrial fibrillation

OBJECTIVE

Surgery-induced thyroiditis can pose a significant clinical problem that is underappreciated. We present a case of new-onset atrial fibrillation as a consequence of palpation thyroiditis in a 70-year-old man who underwent radical right neck dissection for malignant melanoma and review the limited literature on this topic.

DESIGN

Biochemical parameters including thyrotropin, free thyroxine, triiodothyronine, erythrocyte sedimentation rate, C-reactive protein, thyroglobulin, thyroid stimulating immunoglobulins, thyroid binding inhibitory immunoglobulins, thyroid peroxidase, thyroglobulin antibodies, and 24-hour urine iodine were measured. Thyroid ultrasound and technetium-99m pertechnetate scintigraphy with radioactive iodine 131 uptake were employed for diagnostic purposes.

MAIN OUTCOME

Following right neck exploratory dissection, the patient developed hyperthyroidism and atrial fibrillation. Imaging studies were compatible with right lobar thyroiditis. Other etiologies of thyroiditis were excluded. Despite normalization of thyroid function after 2 weeks, atrial fibrillation persisted and required cardioversion.

CONCLUSIONS

Manipulation of the thyroid gland during neck exploratory surgery can result in hyperthyroidism with atrial fibrillation as a consequence. To avoid this complication, careful attention should be paid during surgical procedures or other clinical situations in which the thyroid gland is manipulated.

Serial changes in liver function tests in patients with thyrotoxicosis induced by Graves' disease and painless thyroiditis

CONTEXT

When the liver function tests are aggravated after starting antithyroid drugs (ATDs) in Graves' hyperthyroidism, discontinuation of ATDs is generally considered. However, a question arises whether such aggravation constitutes an adverse effect of the drugs or not.

OBJECTIVE

The aim of this study was to clarify the influence of thyrotoxicosis on liver function tests, comparing the results with those in thyrotoxicosis induced by painless thyroiditis.

DESIGN

We prospectively studied liver biochemical tests in 30 patients with Graves' disease and in 27 patients with painless thyroiditis.

MAIN OUTCOMES

Twenty-three (76.7%) untreated Graves' disease patients and 14 (51.9%) untreated painless thyroiditis patients were found to have at least one liver function test abnormality. One month after starting ATD therapy in patients with Graves' disease, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) elevations from initial values were observed in 16 (53.3%). Similar elevations of AST and ALT from initial values at 1 month were observed in 10 (37.0%) and 7 (25.9%) patients with painless thyroiditis, respectively. Alkaline phosphatase (ALP) increased gradually after starting ATD therapy and maintained an elevated value for 3-5 months in Graves' disease. In painless thyroiditis, ALP also increased gradually, similarly to that in Graves' disease, but changes were mild. Elevation of ALT after 1 month of ATD therapy in Graves' disease was significantly higher in patients whose estimated disease duration was 6 months or more compared to those with duration of less than 6 months. Elevated AST and ALT at 1 month after ATD therapy decreased to normal ranges, even though patients were receiving the same ATDs in Graves' disease.

CONCLUSION

Similar serial changes in liver function tests in both Graves' disease and painless thyroiditis strongly suggest that increases of AST and ALT after starting ATD therapy may not be due to ATD side effects but may be induced by changes in thyroid function.

Symptomatic hypercalcemia due to painless thyroiditis after unilateral adrenalectomy in a patient with Cushing's syndrome

We report a 53-year-old woman with Cushing's syndrome due to an adrenocortical adenoma, who underwent unilateral adrenalectomy and developed symptomatic hypercalcemia during the thyrotoxic period of painless thyroiditis, while tapering off a daily supplemented dose of cortisol. A study of patients with thyrotoxicosis and hypoadrenalism at our institute revealed that mild hypercalcemia was present in 9.9% of those with thyrotoxicosis and 5.0% of those with hypoadrenalism. The present case suggests that the simultaneous occurrence of thyrotoxicosis and hypoadrenalism may lead to overt hypercalcemia due to a synergistic increase in bone resorption and impaired urinary excretion of calcium.

A case of pheochromocytoma complicated with slowly progressive type 1 diabetes mellitus and chronic thyroiditis

This is a case report regarding a 45-year-old woman, who has been undergoing treatment for diabetes mellitus (DM) with chronic thyroiditis (euthyroid state). The patient was admitted to our hospital for the evaluation of a right adrenal tumor (50 x 45 mm) and episodic hypertension. She was diagnosed as having pheochromocytoma based on the increased catecholamine and metabolite concentrations and the result of iodine-131 metaiodobenzyl guanidine ((131)I-MIBG) scintigraphy. Subsequently, the right adrenal tumor was excised. Slowly, progressive type 1 DM (SPIDDM) was confirmed by seropositivity to anti-glutamic acid decarboxylase (1890 U/ml) and the clinical course. After right adrenalectomy, the elevated catecholamine and metabolite concentrations and blood pressure returned to normal, and the dosage of insulin injection was reduced. However, she still needed the insulin injection therapy to control her blood glucose level. This case exhibited an extremely rare combination of pheochromocytoma and SPIDDM with chronic thyroiditis. Although it is common for patients with pheochromocytoma to exhibit glucose intolerance, this case raises the suggestion that measuring the levels of the autoantibody for pancreatic islet cells should be considered if SPIDDM is suspected in a patient with pheochromocytoma.

Evaluation of thyroid hormone action in a case of generalized resistance to thyroid hormone with chronic thyroiditis: discovery of a novel heterozygous missense mutation (G347A)

Resistance to thyroid hormone (RTH) is a dominantly inherited syndrome of variable tissue hyporesponsiveness to thyroid hormone (TH). Its characteristics are a high level of TH and inappropriate lack of TSH suppression. RTH is mainly categorized as generalized RTH (GRTH), pituitary RTH (PRTH), and peripheral tissue RTH (PTRTH). Untreated subjects with GRTH usually achieve a normal metabolic state. We describe a 21-year-old Japanese woman with GRTH and coincidental chronic thyroiditis. Physical examination revealed palpable goiter, congenital alopecia on top of the head, and short stature. She showed elevated levels of free triiodothyronine (FT3) and free thyroxine (FT4), and an inappropriately normal level of TSH. Anti-thyroglobulin and anti-thyroid peroxidase antibodies were positive. A TRH stimulation test showed a normal TSH response. The patient received the standardized diagnostic protocol, administration of incremental doses of liothyronine (L-T3). The peak TSH level after the TRH stimulation test gradually decreased. The patient showed low sensitivity to TH in terms of bone metabolism, protein catabolism, lipid metabolism, and urine magnesium metabolism. Sequence analysis of the TR beta gene was performed with informed consent, and this revealed a novel heterozygous mutation at codon 347 resulting in a GGG (glycine) to GCG (alanine) substitution (G347A). The patient was diagnosed as having GRTH with chronic thyroiditis, and carrying a novel mutation, G347A, of the TR beta gene.

Sunitinib (sutent)-induced thyrotoxicosis due to destructive thyroiditis: a case report

Numerous drugs have been associated with destructive thyroiditis (subacute thyroiditis). Sunitinib, a tyrosine kinase inhibitor employed in renal cell carcinoma and gastrointestinal stromal tumors, has recently been linked to destructive thyroiditis with resultant hypothyroidism. We report a patient with transient overt thyrotoxicosis followed by hypothyroidism, apparently related to sunitinib therapy.

Hyperthyroidism

Thyrotoxicosis is a condition resulting from elevated levels of thyroid hormone. In this article, the authors review the presentation, diagnosis, and management of various causes of thyrotoxicosis.

A Variant of Thyrotoxicosis Associated with Chronic Thyroiditis Characterized by Prolonged Fever, Absence of Anti-Thyroidal Antibodies, and Favorable Response to Naproxen

An unusual form of thyrotoxicosis due to chronic thyroiditis is described. A 78-year-old debilitated woman was admitted because of fever to 38 degrees C persisting for the previous 16 months, for which the antipyretic effect of diclofenac sodium and pranoprofen had been insufficient or transient. Intense accumulation of gallium-67 citrate in the thyroid gland provided an initial clue to the diagnosis of masked thyrotoxicosis as a cause of the fever, and naproxen (300 mg/d) eliminated the fever and flaring of thyrotoxicosis. Despite the absence of autoantibodies related to chronic thyroiditis, needle biopsy revealed destructive thyroiditis due to chronic lymphocytic thyroiditis. This case suggests a previously unrecognized variant of thyrotoxicosis due to chronic thyroiditis, that is, neither painless thyroiditis nor acute exacerbation of Hashimoto thyroiditis, and instead characterized by prolonged fever, nontender thyroid, absence of antibodies associated with autoimmune thyroiditis, and excellent response to naproxen.

Ectopic lesions as potential pitfalls in fine needle aspiration cytology: a report of 3 cases derived from the thyroid, endometrium and breast

BACKGROUND

Ectopic lesions are rarely encountered. Those that are derived from thyroid, breast, endometrium and salivary glands present with palpable masses that can mimic malignancy. Fine needle aspiration cytology (FNAC) is a practical procedure for the differential diagnosis of such lesions but can reveal surprising images for a cytopathologist.

CASES

Three cases of discrete, ectopic lesions at different locations occurred. Case 1 was a 27-year-old woman. Upon diagnosis of a submandibular mass with a diameter of 1 cm, FNAC was performed. The smears showed crowded thyroid follicular cells comprising papillary clusters. A cytologic diagnosis of papillary thyroid lesion was rendered, Histopathology revealed that this lesion was ectopic thyroid tissue with focal chronic thyroiditis. Case 2 was a 38-year-old woman who presented with a painful mass with a diameter of 2.5 cm in the abdominal wall. The patient had undergone cesarean section 3 years earlier. The case was diagnosed on FNAC as low grade malignancy in which an adenocarcinoma/mesenchymal tumor distinction could not be made. The pathologic examination revealed endometriosis. Case 3 was a 31-year old woman who presented with a palpable nodule in the axillary region with a diameter of 1 cm. The patient had given birth 1 month earlier and was nursing. An FNAC diagnosis of lactation ectopic breast tissue was made. The mass disappeared by the end of lactation.

CONCLUSION

FNAC of ectopic lesions may prove to be a diagnostic pitfall for cytopathologists. A cytopathologist who encounters a cellularpicturefrom a lesion that is outside the normal anatomic location must use a cautious diagnostic approach. Unless there are clear findings, the cytopathologist must refrain from a diagnosis of malignancy.

[Management of subclinical hyperthyroidism]

Management of subclinical hyperthyroidism (low TSH and normal thyroid hormones) is controversial. Knowledge of its causes, clinical context and associated morbidity is required. It is recommended to follow six steps in exploration and treatment: 1) confirmation, 2) estimation of severity, 3) cause assessment, 4) study of complications, 5) balance whether treatment is needed and 6) if necessary, choice of the most appropriate form. In its management, the same treatments are used as in overt hyperthyroidism.

[Hyperthyroidism in pregnancy]

Thyroid disorders constitute one of the commonest endocrine problems found in pregnant women. They are usually treatable but may affect mother and foetus adversely if they are not evaluated relatively early and managed appropriately. The diagnosis of hyperthyroidism in pregnancy may be often challenging due to the fact that its symptoms mimic many of normal pregnancy complaints. Moreover, some forms of hyperthyroidism occur exclusively during this period. The goal of this article is to summarize the present state of knowledge on the etiology, clinical presentation, recognition and management of the various types of hyperthyroidism in pregnancy. On the basis of numerous studies, carried out mainly in the recent years, we provide some practical guidelines for clinical endocrinologists dealing with treatment of pregnant women.