1
|
Moran C, Schoenmakers N, Halsall D, Oddy S, Lyons G, van den Berg S, Gurnell M, Chatterjee K. Approach to the Patient With Raised Thyroid Hormones and Nonsuppressed TSH. J Clin Endocrinol Metab 2024; 109:1094-1108. [PMID: 37988295 PMCID: PMC10940260 DOI: 10.1210/clinem/dgad681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 10/24/2023] [Accepted: 11/20/2023] [Indexed: 11/23/2023]
Abstract
Measurement of free thyroid hormones (THs) and thyrotropin (TSH) using automated immunoassays is central to the diagnosis of thyroid dysfunction. Using illustrative cases, we describe a diagnostic approach to discordant thyroid function tests, focusing on entities causing elevated free thyroxine and/or free triiodothyronine measurements with nonsuppressed TSH levels. Different types of analytical interference (eg, abnormal thyroid hormone binding proteins, antibodies to iodothyronines or TSH, heterophile antibodies, biotin) or disorders (eg, resistance to thyroid hormone β or α, monocarboxylate transporter 8 or selenoprotein deficiency, TSH-secreting pituitary tumor) that can cause this biochemical pattern will be considered. We show that a structured approach, combining clinical assessment with additional laboratory investigations to exclude assay artifact, followed by genetic testing or specialized imaging, can establish a correct diagnosis, potentially preventing unnecessary investigation or inappropriate therapy.
Collapse
Affiliation(s)
- Carla Moran
- Endocrine Section, Beacon Hospital, Dublin, D18 AK68, Ireland
- Endocrine Department, St. Vincent's University Hospital, Dublin, D04 T6F4, Ireland
- School of Medicine, University College Dublin, Dublin, D04 V1W8, Ireland
| | - Nadia Schoenmakers
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK
| | - David Halsall
- Department of Clinical Biochemistry, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Susan Oddy
- Department of Clinical Biochemistry, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Greta Lyons
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Sjoerd van den Berg
- Department of Clinical Chemistry, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
- Department of Internal Medicine, Erasmus Medical Center, 3015 GE Rotterdam, The Netherlands
| | - Mark Gurnell
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK
| | - Krishna Chatterjee
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK
| |
Collapse
|
2
|
Thyrotropin-secreting tumor "TSH-PitNET": From diagnosis to treatment. ANNALES D'ENDOCRINOLOGIE 2023:S0003-4266(23)00024-0. [PMID: 36716819 DOI: 10.1016/j.ando.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Thyrotropic adenomas (TSH-PitNET) are the rarest pituitary tumours. Most TSH-PitNETs are secreting adenoma, with a biological picture of inappropriate TSH secretion (moderately elevated TSH, elevated FT3 and FT4). Patients present most often clinical hyperthyroidism, but with more moderate symptoms than in peripheral hyperthyroidism. Biological diagnosis is not always easy. The main differential diagnoses are interfering antibody assay interactions, dysalbuminemia and thyroid hormone resistance syndrome. Misdiagnosis is common. However, the diagnosis is easier when macroadenomas are involved (80% of cases), with symptoms of optic chiasm compression, headache and signs of hypopituitarism. Treatment is initially based on surgery. In case of failure, somatostatin analogues are very effective in controlling tumor volume and secretion, although there is a risk of thyroid insufficiency, which is usually transient.
Collapse
|
3
|
Asif H, Nwachukwu I, Khan A, Rodriguez G, Bahtiyar G. Hyperthyroidism Presenting With Mania and Psychosis: A Case Report. Cureus 2022; 14:e22322. [PMID: 35317040 PMCID: PMC8934034 DOI: 10.7759/cureus.22322] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2022] [Indexed: 11/29/2022] Open
Abstract
Graves' disease accounts for one of the most common causes of thyrotoxicosis. Most patients with Graves' disease present with classic signs and symptoms of hyperthyroidism. Psychosis and mood symptoms secondary to hyperthyroidism are rare. Here we report the case of a 37-year-old male with a history of Graves' disease with poor medication adherence who presented to the emergency department with psychotic features and hyperexcitability. He had excessive agitation, paranoia, and hyperactivity requiring restraints. He also endorsed insomnia and weight loss. He was admitted to the inpatient unit, and laboratory investigations were significant for a low thyroid-stimulating hormone, and elevated T3, T4, thyroid-stimulating antibodies, and thyroid peroxidase antibodies. The initial assessment was a primary psychiatric illness. The patient never had a personal or family history of psychiatric illness. Psychiatry and endocrinology were consulted for further recommendations. The patient was started on methimazole 30 mg, propranolol 100 mg, and hydrocortisone 100 mg, which resolved his symptoms.
Collapse
|
4
|
Mimoto MS, Refetoff S. Clinical recognition and evaluation of patients with inherited serum thyroid hormone-binding protein mutations. J Endocrinol Invest 2020; 43:31-41. [PMID: 31352644 PMCID: PMC6954308 DOI: 10.1007/s40618-019-01084-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/10/2019] [Indexed: 12/16/2022]
Abstract
There are three important thyroid hormone-binding proteins in human serum, thyroxine-binding globulin, transthyretin, and albumin. Genetic variation in these proteins can lead to altered thyroid hormone binding and abnormalities in serum tests of thyroid hormone. Importantly, patients harboring these mutations are euthyroid; thus, the recognition of these conditions is crucial to prevent unnecessary repeated testing and treatment. This article provides an updated overview of serum thyroid hormone transport biology and reviews the underlying genetic alterations, clinical presentation, and appropriate evaluation of patients with suspected mutations in serum thyroid hormone-binding proteins.
Collapse
Affiliation(s)
- M S Mimoto
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of California, San Diego, 9500 Gilman Drive, MC 7381, San Diego, CA, USA
| | - S Refetoff
- Department of Medicine, The University of Chicago MC3090, 5841 South Maryland Avenue, Chicago, IL, 60637, USA.
- Department of Pediatrics, The University of Chicago MC3090, 5841 South Maryland Avenue, Chicago, IL, 60637, USA.
- Committee on Genetics, The University of Chicago MC3090, 5841 South Maryland Avenue, Chicago, IL, 60637, USA.
| |
Collapse
|
5
|
Moura Neto A, Zantut-Wittmann DE. Abnormalities of Thyroid Hormone Metabolism during Systemic Illness: The Low T3 Syndrome in Different Clinical Settings. Int J Endocrinol 2016; 2016:2157583. [PMID: 27803712 PMCID: PMC5075641 DOI: 10.1155/2016/2157583] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Revised: 08/18/2016] [Accepted: 09/15/2016] [Indexed: 12/15/2022] Open
Abstract
Thyroid hormone abnormalities are common in critically ill patients. For over three decades, a mild form of these abnormalities has been described in patients with several diseases under outpatient care. These alterations in thyroid hormone economy are a part of the nonthyroidal illness and keep an important relationship with prognosis in most cases. The main feature of this syndrome is a fall in free triiodothyronine (T3) levels with normal thyrotropin (TSH). Free thyroxin (T4) and reverse T3 levels vary according to the underlying disease. The importance of recognizing this condition in such patients is evident to physicians practicing in a variety of specialties, especially general medicine, to avoid misdiagnosing the much more common primary thyroid dysfunctions and indicating treatments that are often not beneficial. This review focuses on the most common chronic diseases already known to present with alterations in serum thyroid hormone levels. A short review of the common pathophysiology of the nonthyroidal illness is followed by the clinical and laboratorial presentation in each condition. Finally, a clinical case vignette and a brief summary on the evidence about treatment of the nonthyroidal illness and on the future research topics to be addressed are presented.
Collapse
Affiliation(s)
- Arnaldo Moura Neto
- Division of Endocrinology, Department of Clinical Medicine, Faculty of Medical Sciences, University of Campinas, Campinas, SP, Brazil
- *Arnaldo Moura Neto:
| | | |
Collapse
|
6
|
Koulouri O, Moran C, Halsall D, Chatterjee K, Gurnell M. Pitfalls in the measurement and interpretation of thyroid function tests. Best Pract Res Clin Endocrinol Metab 2013; 27:745-62. [PMID: 24275187 PMCID: PMC3857600 DOI: 10.1016/j.beem.2013.10.003] [Citation(s) in RCA: 154] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Thyroid function tests (TFTs) are amongst the most commonly requested laboratory investigations in both primary and secondary care. Fortunately, most TFTs are straightforward to interpret and confirm the clinical impression of euthyroidism, hypothyroidism or hyperthyroidism. However, in an important subgroup of patients the results of TFTs can seem confusing, either by virtue of being discordant with the clinical picture or because they appear incongruent with each other [e.g. raised thyroid hormones (TH), but with non-suppressed thyrotropin (TSH); raised TSH, but with normal TH]. In such cases, it is important first to revisit the clinical context, and to consider potential confounding factors, including alterations in normal physiology (e.g. pregnancy), intercurrent (non-thyroidal) illness, and medication usage (e.g. thyroxine, amiodarone, heparin). Once these have been excluded, laboratory artefacts in commonly used TSH or TH immunoassays should be screened for, thus avoiding unnecessary further investigation and/or treatment in cases where there is assay interference. In the remainder, consideration should be given to screening for rare genetic and acquired disorders of the hypothalamic-pituitary-thyroid (HPT) axis [e.g. resistance to thyroid hormone (RTH), thyrotropinoma (TSHoma)]. Here, we discuss the main pitfalls in the measurement and interpretation of TFTs, and propose a structured algorithm for the investigation and management of patients with anomalous/discordant TFTs.
Collapse
Affiliation(s)
- Olympia Koulouri
- Metabolic Research Laboratories, Wellcome Trust – MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Carla Moran
- Metabolic Research Laboratories, Wellcome Trust – MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - David Halsall
- Department of Clinical Biochemistry, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Krishna Chatterjee
- Metabolic Research Laboratories, Wellcome Trust – MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Mark Gurnell
- Metabolic Research Laboratories, Wellcome Trust – MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
- School of Clinical Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
- Corresponding author. Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Box 289, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK. Tel.: +44 1223 348739; Fax: +44 1223 330598.
| |
Collapse
|
7
|
Abstract
Interpretation of thyroid function tests (TFTs) is generally straightforward. However, in a minority of contexts the results of thyroid hormone and thyrotropin measurements either conflict with the clinical picture or form an unusual pattern. In many such cases, reassessment of the clinical context provides an explanation for the discrepant TFTs; in other instances, interference in one or other laboratory assays can be shown to account for divergent results; uncommonly, genetic defects in the hypothalamic-pituitary-thyroid axis are associated with anomalous TFTs. Failure to recognize these potential 'pitfalls' can lead to misdiagnosis and inappropriate management. Here, focusing particularly on the combination of hyperthyroxinaemia with nonsuppressed thyrotropin, we show how a structured approach to investigation can help make sense of atypical TFTs.
Collapse
Affiliation(s)
- Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
| | | | | |
Collapse
|
8
|
Abstract
Thyroid hormones play a critical role in the metabolic activity of the adult brain, and neuropsychiatric manifestations of thyroid disease have long been recognised. However, it is only recently that methodology such as functional neuroimaging has been available to facilitate investigation of thyroid hormone metabolism. Although the role of thyroid hormones in the adult brain is not yet specified, it is clear that without optimal thyroid function, mood disturbance, cognitive impairment and other psychiatric symptoms can emerge. Additionally, laboratory measurements of peripheral thyroid function may not adequately characterise central thyroid metabolism. Here, we review the relationship between thyroid hormone and neuropsychiatric symptoms in patients with primary thyroid disease and primary mood disorders.
Collapse
Affiliation(s)
- M Bauer
- Department of Psychiatry and Psychotherapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany.
| | | | | | | |
Collapse
|
9
|
Constantinou C, Bolaris S, Valcana T, Margarity M. Diazepam affects the nuclear thyroid hormone receptor density and their expression levels in adult rat brain. Neurosci Res 2005; 52:269-75. [PMID: 15927726 DOI: 10.1016/j.neures.2005.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2005] [Revised: 03/23/2005] [Accepted: 03/25/2005] [Indexed: 11/18/2022]
Abstract
Thyroid hormones (THs) are involved in the occurrence of anxiety and affective disorders; however, the effects following an anxiolytic benzodiazepine treatment, such as diazepam administration, on the mechanism of action of thyroid hormones has not yet been investigated. The effect of diazepam on the in vitro nuclear T3 binding, on the relative expression of the TH receptors (TRs) and on the synaptosomal TH availability were examined in adult rat cerebral hemispheres 24 h after a single intraperitoneal dose (5 mg/kg BW) of this tranquillizer. Although, diazepam did not affect the availability of TH either in blood circulation or in the synaptosomal fraction, it decreased (33%) the nuclear T3 maximal binding density (B(max)). No differences were observed in the equilibrium dissociation constant (K(d)). The TRalpha2 variant (non-T3-binding) mRNA levels were increased by 33%, whereas no changes in the relative expression of the T3-binding isoforms of TRs (TRalpha1, TRbeta1) were observed. This study shows that a single intraperitoneal injection of diazepam affects within 24 h, the density of the nuclear TRs and their expression pattern. The latest effect occurs in an isoform-specific manner involving specifically the TRalpha2 mRNA levels in adult rat brain.
Collapse
Affiliation(s)
- Caterina Constantinou
- Laboratory of Human and Animal Physiology, Department of Biology, University of Patras, Patras 265 00, Greece
| | | | | | | |
Collapse
|
10
|
Abstract
The introduction of sensitive thyrotropin assays and free thyroid hormone measurements has simplified the interpretation of thyroid function tests. However, important pitfalls and difficult cases still exist. In this review, thyroid function test results are grouped into six different patterns. We propose that if assays for thyrotropin, free T3, and free T4 are all done, knowledge of these patterns coupled with clinical details and simple additional tests allow a diagnosis to be made in almost all cases.
Collapse
Affiliation(s)
- C M Dayan
- University Department of Medicine, Bristol Royal Infirmary, UK.
| |
Collapse
|
11
|
Abstract
Because of its ability to cause the release of thyrotropin (TSH), prolactin (PRL), and, under particular circumstances, also of other adenohypopyseal hormones, from the pituitary, thyrotropin-releasing hormone (TRH) has been widely used as a diagnostic tool for about 30 years. The recent introduction of an ultrasensitive TSH assay, able to clearly distinguish suppressed from unsuppressed TSH levels, has rendered the use of the TRH test obsolete in the diagnosis of classic hyperthyroidism. On the contrary, the TRH test is still extremely useful in hyperthyroid patients with inappropriate secretion of thyrotropin, allowing the distinction between TSH-secreting pituitary tumors (usually unresponsive) and the pituitary variant of resistance to thyroid hormone (PRTH) syndrome (always responsive). In hypothyroidism, the TRH test is still of value in patients with preclinical primary hypothyroidism, as they show exaggerated TSH response, and in those with central hypothyroidism, allowing the differentiation between pituitary (secondary) and hypothalamic (tertiary) hypothyroidism. The availability of high-resolution imaging techniques such as magnetic resonance has rendered the use of the TRH test obsolete, to distinguish microprolactionomas from functional hyperprolactinemia. The TRH test still has great clinical value in the follow-up of patients with pituitary tumors (in particular somatotropinomas and clinically nonfunctioning pituitary adenomas) showing abnormal responses of anterior pituitary hormones other than TSH.
Collapse
Affiliation(s)
- G Faglia
- Institute of Endocrine Sciences, University of Milan, Ospedale Maggiore IRCCS, Italy
| |
Collapse
|