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Ippolito S, Gallo D, Rossini A, Patera B, Lanzo N, Fazzino GFM, Piantanida E, Tanda ML. SARS-CoV-2 vaccine-associated subacute thyroiditis: insights from a systematic review. J Endocrinol Invest 2022; 45:1189-1200. [PMID: 35094372 PMCID: PMC8800554 DOI: 10.1007/s40618-022-01747-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/13/2022] [Indexed: 12/16/2022]
Abstract
PURPOSE To perform a systematic review on published cases of subacute thyroiditis (SAT) secondary to SARS-CoV-2 vaccination, to highlight main features and increase the awareness of this condition. METHODS Original reports of SAT developed after SARS-CoV-2 vaccination (mRNA, viral vector, or inactivated virus vaccines) were retrieved from a search of electronic databases. Individual patient data on demographics, medical history, type of vaccine, workup and therapies were collected. Wilcoxon rank-sum, Kruskal-Wallis and chi-squared tests were employed for comparisons. RESULTS 30 articles including 48 reports were retrieved, 3 additional cases evaluated by the Authors were described and included for analysis. Of the 51 patients, 38 (74.5%) were women, median age was 39.5 years (IQR 34-47). Patients developed SAT after a median of 10 days (IQR 4-14) after the vaccine shot. Baseline thyroid exams revealed thyrotoxicosis in 88.2% of patients, decreasing at 31.6% at follow-up. Corticosteroids were used in 56.4% of treated patients. Patients undergoing non-mRNA vaccines were most frequently Asian (p = 0.019) and reported more frequently weight loss (p = 0.021). All patients with a previous diagnosis of thyroid disease belonged to the mRNA vaccine group. CONCLUSION SARS-CoV-2 vaccine-associated SAT is a novel entity that should be acknowledged by physicians. Previous history of thyroid disease may predispose to develop SAT after mRNA vaccines, but further studies and larger cohorts are needed to verify this suggestion. SARS-CoV-2 vaccine-associated SAT is usually of mild/moderate severity and could be easily treated in most cases, thus it should not raise any concern regarding the need to be vaccinated.
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Affiliation(s)
- S Ippolito
- Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy.
| | - D Gallo
- Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
| | - A Rossini
- Endocrine and Diabetes Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - B Patera
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - N Lanzo
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - G F M Fazzino
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - E Piantanida
- Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - M L Tanda
- Endocrine Unit, ASST dei Sette Laghi, Viale Borri, 57, 21100, Varese, Italy
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
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Quintanilla-Dieck L, Khalatbari HK, Dinauer CA, Rastatter JC, Chelius DC, Katowitz WR, Shindo ML, Parisi MT, Kazahaya K. Management of Pediatric Graves Disease: A Review. JAMA Otolaryngol Head Neck Surg 2021; 147:1110-1118. [PMID: 34647991 DOI: 10.1001/jamaoto.2021.2715] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The incidence of Graves disease (GD) is rising in children, and adequate care of these patients requires a multidisciplinary approach. Whether patients are seen in the context of endocrinology, nuclear medicine, or surgery, it is important to know the nuances of the therapeutic options in children. Observations Given the rarity of GD in children, it is important to recognize its various clinical presenting signs and symptoms, as well as the tests that may be important for diagnosis. The diagnosis is typically suspected clinically and then confirmed biochemically. Imaging tests, including thyroid ultrasonography and/or nuclear scintigraphy, may also be used as indicated during care. It is important to understand the indications for and interpretation of laboratory and imaging tools so that a diagnosis is made efficiently and unnecessary tests are not ordered. Clinicians should be well-versed in treatment options to appropriately counsel families. There are specific scenarios in which medical therapy, radioactive iodine therapy, or surgery should be offered. Conclusions and Relevance The diagnosis and treatment of pediatric patients with GD requires a multidisciplinary approach, involving pediatric specialists in the fields of endocrinology, ophthalmology, radiology, nuclear medicine, and surgery/otolaryngology. Antithyroid drugs are typically the first-line treatment, but sustained remission rates with medical management are low in the pediatric population. Consequently, definitive treatment is often necessary, either with radioactive iodine or with surgery, ideally performed by experienced, high-volume pediatric experts. Specific clinical characteristics, such as patients younger than 5 years or the presence of a thyroid nodule, may make surgery the optimal treatment for certain patients.
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Affiliation(s)
| | - Hedieh K Khalatbari
- Department of Radiology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle.,Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle
| | - Catherine A Dinauer
- Department of Pediatrics, Section of Pediatric Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey C Rastatter
- Division of Pediatric Otolaryngology-Head and Neck Surgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois.,Department of Otolaryngology-Head and Neck Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Daniel C Chelius
- Department of Otolaryngology-Head and Neck Surgery, Pediatric Thyroid Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston.,Pediatric Head and Neck Tumor Program, Baylor College of Medicine, Texas Children's Hospital, Houston
| | - William R Katowitz
- Department of Ophthalmology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maisie L Shindo
- Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University, Portland
| | - Marguerite T Parisi
- Department of Radiology, University of Washington School of Medicine and Seattle Children's Hospital, Seattle.,Department of Pediatrics, University of Washington School of Medicine and Seattle Children's Hospital, Seattle
| | - Ken Kazahaya
- Division of Pediatric Otolaryngology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Otorhinolaryngology-Head and Neck Surgery, University of Pennsylvania, Philadelphia
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Pizzocaro A, Colombo P, Vena W, Ariano S, Magnoni P, Reggiani F, Favacchio G, Mirani M, Lavezzi E, Voza A, Calatroni M, Mazziotti G, Lania A. Outcome of Sars-COV-2-related thyrotoxicosis in survivors of Covid-19: a prospective study. Endocrine 2021; 73:255-260. [PMID: 34047879 PMCID: PMC8161706 DOI: 10.1007/s12020-021-02758-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 05/06/2021] [Indexed: 01/08/2023]
Abstract
PURPOSE To evaluate the post- coronavirus disease-19 (COVID-19) outcome of thyroid function in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-related thyrotoxicosis. METHODS This was a single-center prospective study involving 29 patients (11 females, 18 males; median age 64 years, range: 43-85) with thyrotoxicosis diagnosed after hospitalization for COVID-19 and then followed-up for a median period of 90 days (range: 30-120) after hospital discharge. At follow-up, patients were evaluated for serum thyrotropin (TSH), free-thyroxine (FT4), free-triiodiothyronine (FT3), TSH receptor antibodies (TRAb), thyroglobulin antibodies (TgAb), thyroperoxidase antibodies (TPOAb) and ultrasonographic thyroid structure. RESULTS After recovery of COVID-19, serum TSH values significantly increased (P < 0.001) and FT4 values significantly decreased (P = 0.001), without significant change in serum FT3 (P = 0.572). At follow-up, 28 subjects (96.6%) became euthyroid whereas overt hypothyroidism developed in one case. At the ultrasound evaluation of thyroid gland, hypoecogenicity was found in 10 patients (34.5%) and in these cases serum TSH values tended to be higher than those without thyroid hypoecogenity (P = 0.066). All subjects resulted to be negative for TgAb, TPOAb and TRAb. CONCLUSION In a short-term follow-up, thyroid function spontaneously normalized in most subjects with SARS-CoV-2-related thyrotoxicosis. However, thyroid hypoecogenicity was found in a remarkable number of them and future longer-term studies are needed to clarify whether this ultrasonographic alteration may predispose to develop late-onset thyroid dysfunction.
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Affiliation(s)
- Alessandro Pizzocaro
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Paolo Colombo
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Walter Vena
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Salvatore Ariano
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Paola Magnoni
- Radiology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Francesco Reggiani
- Medicine Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Giuseppe Favacchio
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Marco Mirani
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Elisabetta Lavezzi
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Antonio Voza
- Emergency Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Marta Calatroni
- Medicine Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
| | - Gherardo Mazziotti
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy.
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy.
| | - Andrea Lania
- Endocrinology, Diabetology and Medical Andrology Unit, IRCCS Humanitas Research Hospital, Rozzano, 20089, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, 20090, Milan, Italy
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4
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Abstract
Amiodarone is a class III antiarrhythmic drug containing 37% iodine by weight, with a structure similar to that of thyroid hormones. Deiodination of amiodarone releases large amounts of iodine that can impair thyroid function, causing either hypothyroidism or thyrotoxicosis in susceptible individuals reflecting ~20% of patients administered the drug. Not only the excess iodine, but also the amiodarone (or its metabolite, desethylamiodarone) itself may cause thyroid dysfunction by direct cytotoxicity on thyroid cells. We present an overview of the epidemiology and pathophysiology of amiodarone-induced thyroid disorders, with a focus on the various forms of clinical presentation and recommendations for personalized management of each form.
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Affiliation(s)
- Dorina Ylli
- Endocrine Section, MedStar Washington Hospital Center, Washington, DC
- Faculty of Medicine, University of Medicine, Tirana, Albania
| | - Leonard Wartofsky
- Endocrine Section, MedStar Washington Hospital Center, Washington, DC
| | - Kenneth D Burman
- Endocrine Section, MedStar Washington Hospital Center, Washington, DC
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5
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Abstract
PURPOSE OF REVIEW Amiodarone-induced thyroid dysfunction is well established and commonly encountered but is associated with several diagnostic and management challenges. The present review discusses recent evidence published related to the effects of amiodarone on the thyroid gland and thyroid function. RECENT FINDINGS Retrospective studies to evaluate amiodarone-induced thyroid dysfunction in children show the occurrence of potential clinically significant changes within 2 weeks of amiodarone initiation that may not be detected if standard adult guidelines for thyroid hormone monitoring are followed. A small study evaluating beta-glucuronidase activity in amiodarone-induced thyrotoxicosis (AIT) demonstrated higher levels in patients with AIT type 2 compared to type 1. New data have suggested the incidence of agranulocytosis may be higher in patients on thionamides with AIT compared to hyperthyroidism because of other causes. In a small study, investigators demonstrated the use of a combination of intravenous and oral steroids to treat refractory AIT which needs to be evaluated in further controlled trials. Finally, recent data demonstrated a possible mortality benefit of surgery over medical therapy for AIT in patients with moderate to severe reduction in left ventricular ejection fraction. SUMMARY Recent research regarding the prevalence, diagnosis, and management of amiodarone-induced thyroid dysfunction were reviewed.
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Affiliation(s)
- Poorani N Goundan
- Section of Endocrinology, Diabetes and Nutrition, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
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Rago T, Cantisani V, Ianni F, Chiovato L, Garberoglio R, Durante C, Frasoldati A, Spiezia S, Farina R, Vallone G, Pontecorvi A, Vitti P. Thyroid ultrasonography reporting: consensus of Italian Thyroid Association (AIT), Italian Society of Endocrinology (SIE), Italian Society of Ultrasonography in Medicine and Biology (SIUMB) and Ultrasound Chapter of Italian Society of Medical Radiology (SIRM). J Endocrinol Invest 2018; 41:1435-1443. [PMID: 30327945 DOI: 10.1007/s40618-018-0935-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 08/03/2018] [Indexed: 12/27/2022]
Abstract
Thyroid ultrasonography (US) is the gold standard for thyroid imaging and its widespread use is due to an optimal spatial resolution for superficial anatomic structures, a low cost and the lack of health risks. Thyroid US is a pivotal tool for the diagnosis and follow-up of autoimmune thyroid diseases, for assessing nodule size and echostructure and defining the risk of malignancy in thyroid nodules. The main limitation of US is the poor reproducibility, due to the variable experience of the operators and the different performance and settings of the equipments. Aim of this consensus statement is to standardize the report of thyroid US through the definition of common minimum requirements and a correct terminology. US patterns of autoimmune thyroid diseases are defined. US signs of malignancy in thyroid nodules are classified and scored in each nodule. We also propose a simplified nodule risk stratification, based on the predictive value of each US sign, classified and scored according to the strength of association with malignancy, but also to the estimated reproducibility among different operators.
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Affiliation(s)
- T Rago
- Endocrinology Unit, Dept. Clinical and Experimental Medicine, University of Pisa, Via Paradisa, 2, 56124, Pisa, Italy.
| | - V Cantisani
- Dept. of Radiological Science, Policlinico Umberto I, University Sapienza, Viale del Policlinico, 155, Rome, 00161, Italy
| | - F Ianni
- Endocrinology Unit, University Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, Rome, 00168, Italy
| | - L Chiovato
- Internal Medicine and Endocrinology Unit - ICS Maugeri, IRCCS, University of Pavia, Via S. Maugeri, 4, Pavia, 27100, Italy
| | - R Garberoglio
- Endocrinology, Diabetology and Metabolism Unit, Dept. Medical Science, University of Torino, Via Magellano, 1, Turin, 10128, Italy
| | - C Durante
- Dept. of Internal Medicine and Medical Specialties, University Sapienza, Viale del Policlinico, 155, Rome, 00161, Italy
| | - A Frasoldati
- Endocrinology Unit, Arcispedale S. Maria Nuova, IRCCS, Viale Risorgimento, 80, Reggio Emilia, 42123, Italy
| | - S Spiezia
- Endocrine Surgery, Ospedale del Mare, Via Enrico Russo, Naples, 80147, Italy
| | - R Farina
- Dept. of Advanced Biomedical Science, University of Naples Federico II, Corso Umberto I, 40, Naples, 80128, Italy
| | - G Vallone
- Dept. of Advanced Biomedical Science, University of Naples Federico II, Corso Umberto I, 40, Naples, 80128, Italy
| | - A Pontecorvi
- Endocrinology Unit, University Cattolica del Sacro Cuore, Largo Agostino Gemelli, 8, Rome, 00168, Italy
| | - P Vitti
- Endocrinology Unit, Dept. Clinical and Experimental Medicine, University of Pisa, Via Paradisa, 2, 56124, Pisa, Italy
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7
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Kotwal A, Clark J, Lyden M, McKenzie T, Thompson G, Stan MN. Thyroidectomy for Amiodarone-Induced Thyrotoxicosis: Mayo Clinic Experience. J Endocr Soc 2018; 2:1226-1235. [PMID: 30370394 PMCID: PMC6198926 DOI: 10.1210/js.2018-00259] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Accepted: 08/30/2018] [Indexed: 11/19/2022] Open
Abstract
Context Amiodarone-induced thyrotoxicosis (AIT) is a difficult diagnostic and management challenge, especially during severe thyrotoxicosis accompanied by cardiovascular compromise. Objective To evaluate thyroidectomy for the management of AIT. Design Retrospective cohort study of adults with noncongenital heart disease with AIT after >3 months of amiodarone who underwent thyroidectomy from 1 November 2002 to 31 December 2016. Setting Referral center. Patients The group was comprised of 17 patients. Main Outcome Measures Thyroid function, left ventricular ejection fraction (LVEF), and surgical complications were the main outcome measures. Results Patients had median age of 60 years, 82.4% were male, and 47% had systolic heart failure. At diagnosis, median TSH was 0.005 mIU/L, median free T4 was 3.25 ng/dL, and total T3 was 198.5 ng/dL. We classified five patients as type 1 and type 2 and two patients as mixed; five patients remained undefined. The most common surgical indications were medically refractory disease, worsening cardiac status, and severe thyrotoxicosis requiring prompt resolution. Within 1 week post-thyroidectomy, median TSH was 0.565 mIU/L, and free T4 was 1.8 ng/dL. Median LVEF improved by 8% in patients with systolic heart failure. Seven patients had a complication within 30 days postsurgery (rehospitalization, n = 4; cervical hematoma, n = 2; recurrent arrhythmia, n = 2; symptomatic hypocalcemia, n = 1; death, n = 1). A larger thyroid gland was a risk factor for complications. Conclusions Thyroidectomy resulted in rapid resolution of thyrotoxicosis. Its complication rate was higher than for non-AIT indications but lower than previously reported in a similar population of high-risk surgical patients.
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Affiliation(s)
- Anupam Kotwal
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Jennifer Clark
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Melanie Lyden
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | | | | | - Marius N Stan
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
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8
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Ross DS, Burch HB, Cooper DS, Greenlee MC, Laurberg P, Maia AL, Rivkees SA, Samuels M, Sosa JA, Stan MN, Walter MA. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343-1421. [PMID: 27521067 DOI: 10.1089/thy.2016.0229] [Citation(s) in RCA: 1268] [Impact Index Per Article: 158.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Thyrotoxicosis has multiple etiologies, manifestations, and potential therapies. Appropriate treatment requires an accurate diagnosis and is influenced by coexisting medical conditions and patient preference. This document describes evidence-based clinical guidelines for the management of thyrotoxicosis that would be useful to generalist and subspecialty physicians and others providing care for patients with this condition. METHODS The American Thyroid Association (ATA) previously cosponsored guidelines for the management of thyrotoxicosis that were published in 2011. Considerable new literature has been published since then, and the ATA felt updated evidence-based guidelines were needed. The association assembled a task force of expert clinicians who authored this report. They examined relevant literature using a systematic PubMed search supplemented with additional published materials. An evidence-based medicine approach that incorporated the knowledge and experience of the panel was used to update the 2011 text and recommendations. The strength of the recommendations and the quality of evidence supporting them were rated according to the approach recommended by the Grading of Recommendations, Assessment, Development, and Evaluation Group. RESULTS Clinical topics addressed include the initial evaluation and management of thyrotoxicosis; management of Graves' hyperthyroidism using radioactive iodine, antithyroid drugs, or surgery; management of toxic multinodular goiter or toxic adenoma using radioactive iodine or surgery; Graves' disease in children, adolescents, or pregnant patients; subclinical hyperthyroidism; hyperthyroidism in patients with Graves' orbitopathy; and management of other miscellaneous causes of thyrotoxicosis. New paradigms since publication of the 2011 guidelines are presented for the evaluation of the etiology of thyrotoxicosis, the management of Graves' hyperthyroidism with antithyroid drugs, the management of pregnant hyperthyroid patients, and the preparation of patients for thyroid surgery. The sections on less common causes of thyrotoxicosis have been expanded. CONCLUSIONS One hundred twenty-four evidence-based recommendations were developed to aid in the care of patients with thyrotoxicosis and to share what the task force believes is current, rational, and optimal medical practice.
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Affiliation(s)
- Douglas S Ross
- 1 Massachusetts General Hospital , Boston, Massachusetts
| | - Henry B Burch
- 2 Endocrinology - Metabolic Service, Walter Reed National Military Medical Center , Bethesda, Maryland
| | - David S Cooper
- 3 Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine , Baltimore, Maryland
| | | | - Peter Laurberg
- 5 Departments of Clinical Medicine and Endocrinology, Aalborg University and Aalborg University Hospital , Aalborg, Denmark
| | - Ana Luiza Maia
- 6 Thyroid Section, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul , Porto Alegre, Brazil
| | - Scott A Rivkees
- 7 Pediatrics - Chairman's Office, University of Florida College of Medicine , Gainesville, Florida
| | - Mary Samuels
- 8 Division of Endocrinology, Diabetes and Clinical Nutrition, Oregon Health & Science University , Portland, Oregon
| | - Julie Ann Sosa
- 9 Section of Endocrine Surgery, Duke University School of Medicine , Durham, North Carolina
| | - Marius N Stan
- 10 Division of Endocrinology, Mayo Clinic , Rochester, Minnesota
| | - Martin A Walter
- 11 Institute of Nuclear Medicine, University Hospital Bern , Switzerland
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9
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Stan MN, Sathananthan M, Warnes CA, Brennan MD, Thapa P, Bahn RS. Amiodarone-induced thyrotoxicosis in adults with congenital heart disease--clinical presentation and response to therapy. Endocr Pract 2016; 20:33-40. [PMID: 24013980 DOI: 10.4158/ep13059.or] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The development of amiodarone-induced thyrotoxicosis (AIT) can threaten the hemodynamic stability of adult patients with congenital heart disease (CHD). Here, we describe the natural history and treatment response of AIT in this at-risk population. METHODS We studied retrospectively all cases of AIT that occurred in CHD patients at our institution after a minimum of 3 months on amiodarone. Subjects were identified from the cohort of adults with CHD who were treated at the Mayo Clinic Adult CHD clinic between 1987 and 2009. RESULTS We identified 23 cases of AIT: 7 were type 1, 13 were type 2, and 3 were undefined due to insufficient data. Most patients were symptomatic (17 of 23, 74%), with arrhythmia and weight loss as the most common symptoms. The majority (12 of 23, 52%) were initially observed; 10 patients (43%) were treated medically and 1 patient (5%) underwent thyroidectomy. Four patients from the observation group eventually required active treatment and 3 patients from the medical group required surgery. Asymptomatic patients tended to resolve under observation (5 of 7, 71.4%) rather than progress to active treatment (0 of 4) (P = .06). Discontinuation of amiodarone, AIT type, or use of perchlorate did not impact AIT duration. CONCLUSION AIT in CHD patients exhibits a wide range of severity and sensitivity to medical therapy. Asymptomatic patients display a trend toward AIT resolution with observation alone. Amiodarone continuation does not appear to impact management outcome or disease duration. Additional studies in this high-risk population could identify elements of pathophysiology that would point toward better disease prevention and treatment.
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Affiliation(s)
- Marius N Stan
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Carole A Warnes
- Department of Internal Medicine, Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Michael D Brennan
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Prabin Thapa
- Department of Health Sciences Research, Division of Biostatistics, Mayo Clinic, Rochester, Minnesota
| | - Rebecca S Bahn
- Department of Internal Medicine, Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, Minnesota
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10
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Zechmann CM, Haufe SE. [Radiologic and nuclear medicine diagnosis and therapy of thyroid disorders. Part 1: Benign thyroid diseases]. Radiologe 2012; 52:661-76; quiz 677. [PMID: 22801791 DOI: 10.1007/s00117-012-2359-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The thyroid gland is one of the most important endocrine organs. It has multiple influences on physical and mental health. The most important benign diseases are goiter, thyroid adenomas and inflammation. The clinical, imaging and laboratory findings are often pathognomic. The therapy spectrum ranges from follow-up, to medication or definitive therapy by operation or radioiodine therapy.
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Affiliation(s)
- C M Zechmann
- Abteilung Nuklearmedizin, Universität Heidelberg, Im Neuenheimer Feld 400, 69120 , Heidelberg, Deutschland.
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11
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Abstract
Amiodarone-induced thyroid dysfunction occurs in 15-20% of amiodarone-treated patients. Amiodarone-induced hypothyroidism (AIH) does not pose relevant problems, is easily controlled by L-thyroxine replacement, and does not require amiodarone withdrawal. Most frequently AIH develops in patients with chronic autoimmune thyroiditis. Amiodarone- induced thyrotoxicosis (AIT) is most frequently due to destructive thyroiditis (type 2 AIT) causing discharge of thyroid hormones from the damaged, but otherwise substantially normal gland. Less frequently AIT is a form of hyperthyroidism (type 1 AIT) caused by the iodine load in a diseased gland (nodular goiter, Graves' disease). A clearcut differentiation between the two main forms is not always possible, despite recent diagnostic advances. As a matter of fact, mixed or indefinite forms do exist, contributed to by both thyroid damage and increased thyroid hormone synthesis. Treatment of type 1 (and mixed forms) AIT is based on the use of thionamides, a short course of potassium perchlorate and, if treatment is not rapidly effective, oral glucocorticoids. Glucocorticoids are the first-line treatment for type 2 AIT. Amiodarone should be discontinued, if feasible from a cardiac standpoint. Continuation of amiodarone has recently been associated with a delayed restoration of euthyroidism and a higher chance of recurrence after glucocorticoid withdrawal. Whether amiodarone treatment can be safely reinstituted after restoration of euthyroidism is still unknown. In rare cases of AIT resistance to standard treatments, or when a rapid restoration of euthyroidism is advisable, total thyroidectomy represents a valid alternative. Radioiodine treatment is usually not feasible due to the low thyroidal iodine uptake.
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Affiliation(s)
- F Bogazzi
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
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13
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Abstract
Amiodarone, a benzofuranic iodine-rich antiarrhythmic drug, causes thyroid dysfunction in 15-20% of cases. Although amiodarone-induced hypothyroidism poses no particular problem, amiodarone-induced thyrotoxicosis (AIT) is a diagnostic and therapeutic challenge. There are two main forms of AIT: type 1, a form of iodine-induced hyperthyroidism, and type 2, a drug-induced destructive thyroiditis. However, mixed/indefinite forms exist that may be caused by both pathogenic mechanisms. Type 1 AIT usually occurs in abnormal thyroid glands, whereas type 2 AIT develops in apparently normal thyroid glands (or small goiters). Diagnosis of thyrotoxicosis is easy, based on the finding of increased free thyroid hormone concentrations and suppressed TSH levels. Thyroid radioactive iodine (RAI) uptake values are usually very low/suppressed in type 2 AIT, most commonly low or low-normal, but sometimes normal or increased in type 1 AIT despite the iodine load. Color flow Doppler sonography shows absent hypervascularity in type 2 and increased vascularity in type 1 AIT. Mixed/indefinite forms may have features of both AIT types. Thionamides represent the first-line treatment for type 1 AIT, but the iodine-replete gland is not very responsive; potassium perchlorate, by inhibiting thyroid iodine uptake, may increase the response to thionamides. Type 2 AIT is best treated by oral glucocorticoids. The response very much depends on the thyroid volume and the severity of thyrotoxicosis. Mixed/indefinite forms may require a combination of thionamides, potassium perchlorate, and steroids. RAI is usually not feasible in AIT due to low RAI uptake values. Thyroidectomy represents a valid option in cases resistant to medical therapy.
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Affiliation(s)
- Fausto Bogazzi
- Department of Endocrinology, University of Pisa, Ospedale Cisanello, Via Paradisa, 2, 56124 Pisa, Italy
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Abstract
Assessment of TSH and TPO-Ab before starting amiodarone (AM) treatment is recommended. The usefulness of periodic TSH measurement every 6 months during AM treatment is limited by the often sudden explosive onset of AIT, and the spontaneous return of a suppressed TSH to normal values in half of the cases. AM-induced hypothyroidism develops rather early after starting treatment, preferentially in iodine-sufficient areas and in females with TPO-Ab; it is due to failure to escape from the Wolff-Chaikoff effect, resulting in preserved radioiodine uptake. AM-induced thyrotoxicosis (AIT) occurs at any time during treatment, preferentially in iodine-deficient regions and in males. AIT can be classified in type 1 (iodide-induced thyrotoxicosis, best treated by potassium perchlorate in combination with thionamides and discontinuation of AM) and type 2 (destructive thyrotoxicosis, best treated by prednisone; discontinuation of AM may not be necessary). AIT is associated with a higher rate of major adverse cardiovascular events (especially of ventricular arrhythmias). Uncertainty continues to exist with respect to the feasibility of continuation of AM despite AIT, the appropriate methods to distinguish between AIT type 1 and 2 as well as the advantages of AIT classification into subtypes in view of possible mixed cases, and the best policy when AM needs to be restarted.
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Affiliation(s)
- Silvia A Eskes
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, The Netherlands
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Tanda ML, Piantanida E, Lai A, Liparulo L, Sassi L, Bogazzi F, Wiersinga WM, Braverman LE, Martino E, Bartalena L. Diagnosis and management of amiodarone-induced thyrotoxicosis: similarities and differences between North American and European thyroidologists. Clin Endocrinol (Oxf) 2008; 69:812-8. [PMID: 18410546 DOI: 10.1111/j.1365-2265.2008.03268.x] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To investigate how North American thyroidologists assess and treat amiodarone-induced thyrotoxicosis (AIT) and to compare the results with those of the same questionnaire-based survey previously carried out among European thyroidologists. DESIGN Members of the American Thyroid Association (ATA) with clinical interests were sent by e-mail a questionnaire on the diagnosis and management of AIT, 115 responses were received from the United States and Canada, representing about one-third of ATA members with clinical interests. RESULTS The majority of respondents (91%vs. 68% in Europe, P < 0.05) see < 10 new cases of AIT per year, and AIT seems less frequent than amiodarone-induced hypothyroidism (AIH) in North America (34% and 66% of amiodarone-induced thyroid dysfunction, respectively, vs. 75% and 25%, respectively, in Europe, P < 0.001). When AIT is suspected, in North America hormonal assessment is mostly based on serum free T4 (FT4) and TSH measurements, while serum free T3 (FT3) determination is requested less frequently than in Europe; thyroid autoimmunity is included in the initial assessment less than in Europe. Most commonly used additional diagnostic procedures include, as in Europe, thyroid colour-flow Doppler sonography, and to a lesser extent, thyroid radioactive iodine uptake and scan, but Europeans tend to request multiple tests more than North Americans. Withdrawal of amiodarone is more often considered unnecessary by North American thyroidologists (21%vs. 10% in Europe in type 1 AIT, P < 0.05, 34%vs. 20% in type 2 AIT, P < 0.05). In type 1 AIT thionamides represent the treatment of choice for North Americans as well as for Europeans, but the former use them as monotherapy in 65%vs. 51% of Europeans (P < 0.05) who more often consider potassium perchlorate as an useful addition (31%vs. 15% of North Americans, P < 0.01). Glucocorticoids are the selected treatment for type 2 AIT, alone (62%vs. 46% in Europe, P < 0.05) or in association with thionamides (16%vs. 25% in Europe, P = NS). After restoration of euthyroidism, thyroid ablation in the absence of recurrent thyrotoxicosis is recommended in type 1 AIT less frequently by North Americans. If amiodarone therapy needs to be reinstituted, prophylactic thyroid ablation is advised by 76% in type 1 AIT, while a 'wait-and-see' strategy is adopted by 61% in type 2 AIT, similar to behaviour of European thyroidologists. CONCLUSION Similarities and differences exist between expert North American and European thyroidologists concerning the diagnosis and management of AIT. While differences reflect the frequent uncertainty of the underlying mechanism leading to AIT, similarities may represent the basis to refine the diagnostic criteria and to improve the therapeutic outcomes of this challenging clinical situation.
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Affiliation(s)
- Maria Laura Tanda
- Department of Clinical Medicine, University of Insubria, Varese, Italy
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Bogazzi F, Bartalena L, Tomisti L, Dell'Unto E, Cosci C, Sardella C, Tanda ML, Lai A, Gasperi M, Aghini-Lombardi F, Martino E. Potassium perchlorate only temporarily restores euthyroidism in patients with amiodarone-induced hypothyroidism who continue amiodarone therapy. J Endocrinol Invest 2008; 31:515-9. [PMID: 18591883 DOI: 10.1007/bf03346400] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
CONTEXT Amiodarone-induced hypothyroidism (AIH) may occur in patients with or without underlying thyroid disorders. In the latter, restoration of euthyroidism, after amiodarone discontinuation, can be facilitated and accelerated by a short course of potassium perchlorate (KClO4). However, it is unknown whether KClO4 may exert similar effects on thyroid function of AIH patients if amiodarone treatment is continued. OBJECTIVE To evaluate the effects of KClO4 on thyroid function in AIH patients (without underlying thyroid disease) while continuing amiodarone treatment. DESIGN AND PATIENTS An open, prospective study of 10 consecutive AIH patients without underlying thyroid abnormalities referred to a tertiary referral center, and treated with KClO4 (600 mg/day) for a period of 26+/-13 days (range, 15-45 days). An additional, historical group of 12 consecutive patients with subclinical AIH left untreated while continuing or after withdrawing amiodarone was retrospectively evaluated as to the outcome of thyroid function. MEASUREMENT Serum free T4, free T3, and TSH concentrations were measured at booking, during KClO4 treatment and after withdrawing the drug. RESULTS In the prospective study, KClO4 treatment restored euthyroidism in all patients within 28+/-11 days (range, 15-45 days). After KClO4 withdrawal, however, all patients became hypothyroid again after 45+/-15 days (range, 30-60 days). Two patients developed mild leukopenia (1 case) or a slight increase in serum creatinine levels (1 case), which promptly normalized after KClO4 withdrawal. In the historical group, followed for at least 12 months, euthyroidism was spontaneously and stably achieved after an average of 6 months in 5 patients in whom amiodarone could be discontinued, while subclinical hypothyroidism persisted in 7 patients in whom amiodarone had to be continued. CONCLUSIONS KClO4 very effectively restores normal thyroid function in AIH patients without underlying thyroid abnormalities, despite the fact that amiodarone therapy is continued. However, euthyroidism does not persist after KClO4 is withdrawn; in addition, spontaneous recovery of euthyroidism does not seem to occur in this subset of AIH patients, unless amiodarone is discontinued. Therefore, also in view of its potential side-effects, KClO4 cannot be recommended as a first-line treatment for AIH if amiodarone needs to be continued, while LT4 replacement is recommended under these circumstances, with periodical reassessment of thyroid function.
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Affiliation(s)
- F Bogazzi
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
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Affiliation(s)
- Erik S Mittra
- Division of Nuclear Medicine and Molecular Imaging Program at Stanford, Department of Radiology, Stanford University Hospital and Clinics, Stanford, California 94305-5281, USA
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Bogazzi F, Bartalena L, Dell'Unto E, Tomisti L, Rossi G, Pepe P, Tanda ML, Grasso L, Macchia E, Aghini-Lombardi F, Pinchera A, Martino E. Proportion of type 1 and type 2 amiodarone-induced thyrotoxicosis has changed over a 27-year period in Italy. Clin Endocrinol (Oxf) 2007; 67:533-7. [PMID: 17561980 DOI: 10.1111/j.1365-2265.2007.02920.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
CONTEXT Two main forms of amiodarone-induced thyrotoxicosis (AIT) exist. Type 1 AIT is a form of iodine-induced hyperthyroidism. Its management is complex and includes thionamides, potassium perchlorate and, occasionally, thyroidectomy. Type 2 AIT is a destructive thyroiditis, responds to glucocorticoids, and usually does not require further thyroid treatment once euthyroidism has been restored. OBJECTIVE To assess retrospectively the prevalence and relative proportion of type 1 and type 2 AIT over a 27-year period at a tertiary referral centre in Italy. PATIENTS Consecutive AIT patients (n = 215) seen at the department of endocrinology of the University of Pisa between 1980 and 2006. RESULTS Type 1 AIT constituted the most frequent AIT form (60%) during the first years covered by this study. The annual mean number of type 1 AIT patients was 3.6 at the beginning of the study period, and 2.5 during the later years. In contrast, the mean annual number of new cases of type 2 AIT progressively increased from 2.4 to 12.5. Likewise, the proportion of type 2 AIT increased in a significant linear manner (P < 0.0001), currently accounting for 89% of AIT cases. Type 2 AIT patients showed a male preponderance, higher serum FT4/FT3 ratio (P < 0.002), lower 3-h and 24-h thyroidal radioactive iodine uptake values (P < 0.0001), and received a higher cumulative dose of amiodarone (P < 0.0001) than type 1 AIT patients. CONCLUSIONS Over a 27-year period, the epidemiology of AIT changed, as the prevalence of type 2 AIT progressively increased and that of type 1 remained constant. Thus, under most circumstances, endocrinologists nowadays deal with type 2 AIT, which is a destructive thyroiditis, generally treated successfully with glucocorticoids. Although no additional treatment is usually required after the destructive process subsides, periodic assessment of thyroid function is warranted, because of the occurrence of hypothyroidism (up to 17%) during long-term follow-up of these patients.
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Affiliation(s)
- Fausto Bogazzi
- Department of Endocrinology and Metabolism, University of Pisa, Pisa, Italy.
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2007. [DOI: 10.1002/pds.1375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Bogazzi F, Bartalena L, Tomisti L, Rossi G, Tanda ML, Dell'Unto E, Aghini-Lombardi F, Martino E. Glucocorticoid response in amiodarone-induced thyrotoxicosis resulting from destructive thyroiditis is predicted by thyroid volume and serum free thyroid hormone concentrations. J Clin Endocrinol Metab 2007; 92:556-62. [PMID: 17148557 DOI: 10.1210/jc.2006-2059] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT Amiodarone-induced thyrotoxicosis (AIT) resulting from destructive thyroiditis (type 2) is commonly treated with glucocorticoids, but time needed to restore euthyroidism may be unacceptable for patients with underlying cardiac disorders. OBJECTIVE The objective of this prospective study was to identify factors affecting the response to glucocorticoids in a large cohort of patients with type 2 AIT followed prospectively. SETTING This study was conducted at university centers. PATIENTS Sixty-six untreated patients with type 2 AIT were enrolled in the study. INTERVENTION All patients were treated with prednisone (initial dose, 0.5 mg/kg.d) as long as needed to restore euthyroidism, defined as cure of AIT. MAIN OUTCOME MEASURE The main outcome measure was cure time. RESULTS The median cure time was 30 d (95% confidence interval, 23-37 d). Serum free T4 concentration (picograms per milliliter) and thyroid volume (milliliters per square meter) (and, to a lesser extent, serum free T3 concentration) at diagnosis were the main determinants of response to glucocorticoids, with a cure hazard ratio of 0.97 (95% confidence interval, 0.95-0.99; P = 0.005) and 0.84 (95% confidence interval, 0.77-0.91; P = 0.000) for unit of increment, respectively. AIT was cured in all patients with a complete follow-up; euthyroidism was reached in 30 d or less in 60% of patients but in more than 90 d in 16%. A prompt control of thyrotoxicosis (<or=30 d of treatment) was more frequent (77%) in patients with serum basal free T4 concentration no greater than 50 pg/ml and thyroid volume (normalized for body surface area) no greater than 12 ml/m2. The cure probability and the mean cure time in an individual patient can be obtained using a formula generated by multiple regression models. CONCLUSIONS Baseline serum thyroid hormone concentrations and thyroid volume help identify patients with type 2 AIT at risk of a delayed response to glucocorticoids.
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Affiliation(s)
- Fausto Bogazzi
- Department of Endocrinology, University of Pisa, Ospedale Cisanello, Via Paradisa, 2, 56124 Pisa, Italy.
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