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Feldt-Rasmussen U, Effraimidis G, Bliddal S, Klose M. Risks of suboptimal and excessive thyroid hormone replacement across ages. J Endocrinol Invest 2024; 47:1083-1090. [PMID: 38015369 PMCID: PMC11035408 DOI: 10.1007/s40618-023-02229-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/13/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Hypothyroidism is prevalent at all ages and represents a non-communicable disease with preventable consequences. METHOD Narrative review. REVIEW In children and adolescents, the most devastating consequences of undertreatment with levothyroxine (LT4) are poor growth and development. Delayed treatment in congenital hypothyroidism can lead to permanent brain damage. In young to middle-aged adults, symptoms are often overlooked, and treatment delayed by many years. The resulting consequences are also at this age group compromised brain and physical function but less severe and partly reversible with treatment. The under-treated condition often results in a higher risk of, e.g., increased cardiovascular disease burden, obesity, hypertension, poor physical capacity, and poor quality of life. Excessive replacement is at all adult age groups associated with increased risk of cardiac death, osteoporosis, loss of muscle function, psychological instability and poor quality of life. In young fertile women, the consequences of undertreatment with LT4 are subnormal fertility, recurrent pregnancy loss, compromised fetal growth, and neurocognitive development. On the other hand, excessive LT4 treatment has been related to gestational hypertension, preeclampsia and preterm birth. In the elderly, care must be given to avoid confusing a slightly high age-related serum TSH with requirement for LT4 treatment in a truly hypothyroid patient. Excessive LT4 treatment in patients of high age is associated with an increased mortality. CONCLUSION Suboptimal and excessive LT4 replacement of the preventable non-communicable disease hypothyroidism requires more focus from the healthcare system and from the global political systems to prevent the personally devastating and socioeconomically challenging consequences.
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Affiliation(s)
- U Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
- Institute of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark.
- Department of Medical Endocrinology and Metabolism PE 2132, Rigshospitalet, National University Hospital, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - G Effraimidis
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Larissa, Greece
- Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - S Bliddal
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - M Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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2
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Feldt-Rasmussen U, Effraimidis G, Bliddal S, Klose M. Consequences of undertreatment of hypothyroidism. Endocrine 2024; 84:301-308. [PMID: 37556077 PMCID: PMC11076368 DOI: 10.1007/s12020-023-03460-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 07/15/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE To provide an overview of consequences of undertreatment with levothyroxine (LT4) in the common non-communicable disease, hypothyroidism. METHODS Narrative review of the literature. RESULTS Hypothyroidism is globally very prevalent at all age groups and represents a non-communicable disease in which the risks and consequences are preventable. In children and adolescents, the most devastating consequences of undertreatment are poor growth and development. Lack of early treatment in congenital hypothyroidism can lead to permanent damage of brain function. In young to middle-aged adults, consequences are often overlooked, and treatment delayed by many years. The resulting consequences are also at this age group compromised brain and physical functioning but less severe and partly reversible with treatment. The undertreated condition often results in a higher risk of several secondary devastating diseases such as increased cardiovascular disease burden, obesity, hypertension, poor physical capacity, poor quality of life. In young women of fertile age the consequences of undertreatment with LT4 are subnormal fertility, recurrent pregnancy loss, preeclampsia, compromised fetal growth and neurocognitive development. There is a further risk of 30-50% of developing postpartum thyroiditis. In the elderly population care must be given to avoid confusing a slightly high serum TSH as result of physiological age adaptation with a requirement for LT4 treatment in a truly hypothyroid patient. CONCLUSION Undertreatment of the preventable non-communicable disease hypothyroidism requires more focus both from caretakers in the healthcare system, but also from the global political systems in order to prevent the personally devastating and socioeconomically challenging consequences.
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Affiliation(s)
- Ulla Feldt-Rasmussen
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
- Institute of Clinical Medicine, Faculty of Health and Clinical Sciences, Copenhagen University, Copenhagen, Denmark.
| | - Grigoris Effraimidis
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Sofie Bliddal
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marianne Klose
- Department of Medical Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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3
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Lauffer P, Heinen CA, Goorsenberg AWM, Malekzadeh A, Henneman P, Heijboer AC, Zwaveling-Soonawala N, Boelen A, van Trotsenburg ASP. Analysis of Serum Free Thyroxine Concentrations in Healthy Term Neonates Underlines Need for Local and Laboratory-Specific Reference Interval: A Systematic Review and Meta-Analysis of Individual Participant Data. Thyroid 2024. [PMID: 38563802 DOI: 10.1089/thy.2023.0562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
Background: Initial evaluation of the hypothalamus-pituitary-thyroid axis is done by measuring serum free thyroxine (fT4) and thyrotropin concentrations. For correct interpretation of these measurements, reliable age-specific reference intervals (RIs) are fundamental. Since neonatal fT4 RIs conforming to the Clinical and Laboratory Standards Institute guidelines are not available for all assays, we set out to create literature-based uniform age-specific neonatal fT4 RIs that may be used for every assay. Methods: For meta-analysis of individual participant fT4 concentrations, we systematically searched MEDLINE and Embase (search date December 6, 2023; PROSPERO registration CRD42016041871). We searched for studies reporting fT4 concentrations in healthy term newborns aged 2-27 days, born to mothers without thyroid disease in iodine-sufficient regions. Authors were invited to supply data. Due to standardization differences between assays, data could not be combined for meta-analysis directly, and we attempted to normalize the data using two distinct methods. Results: We obtained 4206 fT4 concentrations from 20 studies that used 13 different assays from 6 manufacturers. First, we set out to normalize fT4 data using the mean and standard deviation of (assay-specific) adult RIs. fT4 concentrations were transformed into Z-scores, assuming a normal distribution. Using a linear mixed-effects model (LMM), we still found a significant difference between fT4 concentration across studies (p < 0.001), after this normalization. As a second approach, we normalized the fT4 concentrations using data from a method/assay comparison study. We used the relationship between the Cobas assay and the other assays as a reference point to convert all values to Cobas values. However, this method also failed to produce consistent results, with significant differences between the normalized data (LMM p < 0.001). Conclusions: We conclude that our attempts at normalizing fT4 assay results were unsuccessful. Confounders related to our unsuccessful analysis may be assay related and/or biological. These findings have significant implications for patient care, since relying on RIs from literature may result in erroneous interpretation of results. Therefore, we strongly recommend to establish local RIs for accurate interpretation of serum fT4 concentrations in neonates.
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Affiliation(s)
- Peter Lauffer
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Charlotte A Heinen
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Annika W M Goorsenberg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Malekzadeh
- Medical Library, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Peter Henneman
- Department of Human Genetics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Annemieke C Heijboer
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Endocrine Laboratory, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Endocrine Laboratory, Amsterdam University Medical Centers, VU University, Amsterdam, The Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anita Boelen
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Endocrine Laboratory, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - A S Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Gastroenterology Endocrinology Metabolism, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
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Lauffer P, Naafs JC, Bikker H, Garrelfs MR, Mooij CF, Boelen A, Zwaveling-Soonawala N, van Trotsenburg AS. Further delineation of central congenital hypothyroidism due to variants in TBL1X and IRS4. Thyroid 2023. [PMID: 36860195 DOI: 10.1089/thy.2022.0675] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Affiliation(s)
- Peter Lauffer
- Amsterdam Universitair Medische Centra, 522567, Emma Children's Hospital/Department of Paediatric Endocrinology, Meibergdreef 9, Amsterdam, Netherlands, 1081 HV;
| | - Jolanda C Naafs
- Amsterdam UMC - Locatie AMC, 26066, Pediatric Endocrinology, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ;
| | - Hennie Bikker
- Amsterdam UMC - Locatie AMC, 26066, Amsterdam, North Holland, Netherlands;
| | - Mark R Garrelfs
- Amsterdam Universitair Medische Centra, 522567, Emma Children's Hospital/Department of Paediatric Endocrinology, Amsterdam, Netherlands;
| | - Christiaan F Mooij
- Amsterdam UMC, 522567, Pediatric Endocrinology, Meibergdreef 9, Amsterdam, Netherlands, 1105 AZ;
| | - Anita Boelen
- Academic Medical Center, 26066, Endocrinology Laboratory, Amsterdam, Netherlands;
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D'Aurizio F, Kratzsch J, Gruson D, Petranović Ovčariček P, Giovanella L. Free thyroxine measurement in clinical practice: how to optimize indications, analytical procedures, and interpretation criteria while waiting for global standardization. Crit Rev Clin Lab Sci 2023; 60:101-140. [PMID: 36227760 DOI: 10.1080/10408363.2022.2121960] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Thyroid dysfunctions are among the most common endocrine disorders and accurate biochemical testing is needed to confirm or rule out a diagnosis. Notably, true hyperthyroidism and hypothyroidism in the setting of a normal thyroid-stimulating hormone level are highly unlikely, making the assessment of free thyroxine (FT4) inappropriate in most new cases. However, FT4 measurement is integral in both the diagnosis and management of relevant central dysfunctions (central hypothyroidism and central hyperthyroidism) as well as for monitoring therapy in hyperthyroid patients treated with anti-thyroid drugs or radioiodine. In such settings, accurate FT4 quantification is required. Global standardization will improve the comparability of the results across laboratories and allow the development of common clinical decision limits in evidence-based guidelines. The International Federation of Clinical Chemistry and Laboratory Medicine Committee for Standardization of Thyroid Function Tests has undertaken FT4 immunoassay method comparison and recalibration studies and developed a reference measurement procedure that is currently being validated. However, technical and implementation challenges, including the establishment of different clinical decision limits for distinct patient groups, still remain. Accordingly, different assays and reference values cannot be interchanged. Two-way communication between the laboratory and clinical specialists is pivotal to properly select a reliable FT4 assay, establish reference intervals, investigate discordant results, and monitor the analytical and clinical performance of the method over time.
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Affiliation(s)
- Federica D'Aurizio
- Department of Laboratory Medicine, University Hospital of Udine, Udine, Italy
| | - Jürgen Kratzsch
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, University Hospital, University of Leipzig, Leipzig, Germany
| | - Damien Gruson
- Department of Clinical Biochemistry, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
| | - Petra Petranović Ovčariček
- Department of Oncology and Nuclear Medicine, University Hospital Center Sestre milosrdnice, Zagreb, Croatia
| | - Luca Giovanella
- Clinic for Nuclear Medicine and Competence Center for Thyroid Diseases, Imaging Institute of Southern Switzerland, Ente Ospedaliero Cantonale, Bellinzona, Switzerland.,Clinic for Nuclear Medicine and Thyroid Center, University and University Hospital of Zurich, Zurich, Switzerland
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6
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Lauffer P, Bikker H, Boelen A, Jöbsis JJ, van Trotsenburg ASP, Zwaveling-Soonawala N. Mild Isolated Congenital Central Hypothyroidism Due to a Novel Homozygous Variant in TSHB: A Case Report. Thyroid 2022; 32:472-474. [PMID: 35102753 DOI: 10.1089/thy.2021.0651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/13/2022]
Abstract
Pathogenic variants in TSHB are known to cause severe isolated central congenital hypothyroidism (CH). In this study, we present the clinical, biochemical, and genetic features of the first patient with a mild central CH phenotype. We identified a novel homozygous variant in TSHB: (Chr1: NM_000549.5):c.290A>G p.(Tyr97Cys) in a newborn girl detected by neonatal CH screening, whose central CH was initially overlooked because of misinterpretation of her plasma-free thyroxine (fT4) concentration. This report adds to the phenotypic spectrum of TSHB variants and underlines the importance of using age-specific fT4 reference intervals to diagnose central CH.
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Affiliation(s)
- Peter Lauffer
- Department of Pediatric Endocrinology, Emma Children's Hospital; University of Amsterdam, Amsterdam, The Netherlands
| | - Hennie Bikker
- Department of Clinical Genetics; University of Amsterdam, Amsterdam, The Netherlands
| | - Anita Boelen
- Endocrine Laboratory; Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Jasper J Jöbsis
- Department of Pediatrics, OLVG Hospital, Amsterdam, The Netherlands
| | - A S Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital; University of Amsterdam, Amsterdam, The Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Emma Children's Hospital; University of Amsterdam, Amsterdam, The Netherlands
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7
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Hengeveld RCC, Albersen M, Hadders MAH, Hellinga I, Bikker H, Heijboer AC, Paul van Trotsenburg AS, Hillebrand JJ, Boelen A, Zwaveling-Soonawala N. A Newborn Falsely Suspected of Congenital Hypothyroidism due to Mutated Thyroxine-Binding Globulin with Low Binding Affinity. Horm Res Paediatr 2021; 94:76-80. [PMID: 34126618 DOI: 10.1159/000516691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 04/15/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Neonatal screening programs for congenital hypothyroidism (CH) have been implemented worldwide to facilitate early diagnosis and treatment. The Dutch neonatal CH screening is primarily based on the measurement of thyroxine (T4). When T4 is low, an additional thyroxine-binding globulin (TBG) measurement is performed to reduce the number of false-positive screening results due to harmless TBG deficiency. Here, we present a case of a rare functional TBG deficiency leading to a false suspicion of CH. CASE PRESENTATION Neonatal screening in this patient revealed a decreased T4, normal TSH, and normal TBG concentration, suggesting central CH. However, free T4 was normal. DNA sequencing analysis revealed a novel, hemizygous mutation (c.139G>A) in SERPINA7, the gene encoding TBG, resulting in the substitution of the conserved amino acid alanine to threonine at position 27. Crystal structure analyses showed that this substitution has a detrimental effect on binding of T4 to TBG. CONCLUSIONS The novel SERPINA7 variant in this patient led to a false suspicion of central hypothyroidism in the Dutch T4-based neonatal screening program. It is important to recognize patients with such TBG defects to prevent unnecessary additional testing and treatment.
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Affiliation(s)
- Rutger C C Hengeveld
- Department of Clinical Chemistry, Amsterdam UMC, Central Diagnostic Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Monique Albersen
- Department of Clinical Chemistry, Amsterdam UMC, Endocrine Laboratory, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Michael A H Hadders
- Department of Molecular Cancer Research, Oncode Institute, University Medical Center Utrecht, Center for Molecular Medicine, Utrecht, The Netherlands
| | - Ilse Hellinga
- Department of Pediatric Endocrinology, Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Hennie Bikker
- Department of Clinical Genetics, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Annemieke C Heijboer
- Department of Clinical Chemistry, Amsterdam UMC, Central Diagnostic Laboratory, University of Amsterdam, Amsterdam, The Netherlands.,Department of Clinical Chemistry, Amsterdam UMC, Endocrine Laboratory, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - A S Paul van Trotsenburg
- Department of Pediatric Endocrinology, Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
| | - Jacquelien J Hillebrand
- Department of Clinical Chemistry, Amsterdam UMC, Central Diagnostic Laboratory, University of Amsterdam, Amsterdam, The Netherlands.,Department of Clinical Chemistry, Amsterdam UMC, Endocrine Laboratory, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Anita Boelen
- Department of Clinical Chemistry, Amsterdam UMC, Central Diagnostic Laboratory, University of Amsterdam, Amsterdam, The Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Amsterdam UMC, Emma Children's Hospital, University of Amsterdam, Amsterdam, The Netherlands
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8
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Lauffer P, Bikker H, Garrelfs MR, Hillebrand JJG, de Sonnaville MLCS, Zwaveling-Soonawala N, van Trotsenburg ASP. Defective Levothyroxine Response in a Patient with Dyshormonogenic Congenital Hypothyroidism Caused by a Concurrent Pathogenic Variant in Thyroid Hormone Receptor-β. Thyroid 2021; 31:1757-1762. [PMID: 34382419 DOI: 10.1089/thy.2021.0204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Indexed: 11/13/2022]
Abstract
Background: Pituitary resistance to thyroid hormone (PRTH) is often seen in congenital hypothyroidism (CH), presenting as elevated thyrotropin (TSH) values despite (high-)normal thyroid hormone (TH) values achieved by levothyroxine treatment. In this study, we describe a girl with CH who was referred because of difficulties interpreting thyroid function tests. She was thought to have PRTH associated with CH, but genetic studies discovered a pathogenic variant in THRB, causing resistance to TH (RTH-β). Methods: Clinical, genetic, and biochemical data of the proband's family were collected. Results: The 3-year-old girl was diagnosed with CH due to a homozygous pathogenic c.470del p.(Asn157Thrfs*3) SLC5A5 variant in the neonatal period. She needed a notably high levothyroxine dose to normalize TSH, leading to high free thyroxine levels. There were no signs of hyperthyroidism. Sequencing identified a heterozygous pathogenic c.947G>A p.(Arg316His) THRB variant. Conclusions: To our knowledge, this is the first report of concomitant SLC5A5 and THRB variants causing CH and RTH-β.
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Affiliation(s)
- Peter Lauffer
- Department of Paediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Hennie Bikker
- Department of Clinical Genetics, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Mark R Garrelfs
- Department of Paediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Jacquelien J G Hillebrand
- Department of Clinical Chemistry, Endocrine Laboratory, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | | | - Nitash Zwaveling-Soonawala
- Department of Paediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - A S Paul van Trotsenburg
- Department of Paediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Center, Amsterdam, The Netherlands
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9
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Naafs JC, Marchal JP, Verkerk PH, Fliers E, van Trotsenburg ASP, Zwaveling-Soonawala N. Health-Related Quality of Life in Patients With Early-Detected Central Congenital Hypothyroidism. J Clin Endocrinol Metab 2021; 106:e4231-e4241. [PMID: 33780546 PMCID: PMC8475203 DOI: 10.1210/clinem/dgab209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Indexed: 12/18/2022]
Abstract
CONTEXT Central congenital hypothyroidism (CH) requires lifelong medical treatment. The majority of children with central CH have multiple pituitary hormone deficiencies (MPHD), but in some cases central CH is isolated. Most pituitary hormone deficiencies are associated with impaired health-related quality of life (HRQoL). However, studies on HRQoL in central CH are lacking. OBJECTIVE To evaluate HRQoL and fatigue in children and young adults with central CH, as well as parent perspectives. DESIGN Nationwide cross-sectional study comparing HRQoL between early-detected central CH patients and unaffected siblings with the Pediatric Quality of Life inventory (PedsQL™) and PedsQL Multidimensional Fatigue Scale. Participants ≥ 8 years old filled in self-reports; parents of participants aged 3 to 18 years filled in parent reports. Isolated central CH patients, MPHD patients, and siblings were compared using a linear mixed model and Tukey's post hoc test. RESULTS Eighty-eight patients and 52 siblings participated, yielding 98 self-reports and 115 parent reports. Isolated central CH patients (n = 35) and siblings showed similar scores on all subscales, both in the self-reports and parent reports. For MPHD patients (n = 53), self-reported scores were similar to those of siblings. Parent reported total HRQoL and fatigue scores were significantly poorer in MPHD patients compared with siblings (mean differences -10.2 and -9.4 points; P < 0.01), as were scores for physical functioning, social functioning and general fatigue. CONCLUSION Self-reported HRQoL scores in isolated central CH and MPHD patients were similar to siblings. However, parents reported significantly lower HRQoL and fatigue scores for MPHD patients, suggesting a difference in perceived limitations between MPHD patients and their parents.
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Affiliation(s)
- Jolanda C Naafs
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, department of Pediatric Endocrinology, Amsterdam, the Netherlands
- Amsterdam UMC, University of Amsterdam, department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - Jan Pieter Marchal
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Pediatric Psychosocial department, Amsterdam, the Netherlands
| | - Paul H Verkerk
- TNO, Department of Child Health, Leiden, The Netherlands
| | - Eric Fliers
- Amsterdam UMC, University of Amsterdam, department of Endocrinology and Metabolism, Amsterdam Gastroenterology Endocrinology & Metabolism, Amsterdam, the Netherlands
| | - A S Paul van Trotsenburg
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, department of Pediatric Endocrinology, Amsterdam, the Netherlands
| | - Nitash Zwaveling-Soonawala
- Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, department of Pediatric Endocrinology, Amsterdam, the Netherlands
- Correspondence: Nitash Zwaveling-Soonawala, MD, PhD, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Department of Pediatric Endocrinology, Amsterdam, the Netherlands.
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10
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Lauffer P, Zwaveling-Soonawala N, Naafs JC, Boelen A, van Trotsenburg ASP. Diagnosis and Management of Central Congenital Hypothyroidism. Front Endocrinol (Lausanne) 2021; 12:686317. [PMID: 34566885 PMCID: PMC8458656 DOI: 10.3389/fendo.2021.686317] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 03/26/2021] [Accepted: 07/13/2021] [Indexed: 11/21/2022] Open
Abstract
Central congenital hypothyroidism (CH) is defined as thyroid hormone (TH) deficiency at birth due to insufficient stimulation by the pituitary of the thyroid gland. The incidence of central CH is currently estimated at around 1:13,000. Central CH may occur in isolation, but in the majority of cases (60%) it is part of combined pituitary hormone deficiencies (CPHD). In recent years several novel genetic causes of isolated central CH have been discovered (IGSF1, TBL1X, IRS4), and up to 90% of isolated central CH cases can be genetically explained. For CPHD the etiology usually remains unknown, although pituitary stalk interruption syndrome does seem to be the most common anatomic pituitary malformation associated with CPHD. Recent studies have shown that central CH is a more severe condition than previously thought, and that early detection and treatment leads to good neurodevelopmental outcome. However, in the neonatal period the clinical diagnosis is often missed despite hospital admission because of feeding problems, hypoglycemia and prolonged jaundice. This review provides an update on the etiology and prognosis of central CH, and a practical approach to diagnosis and management of this intriguing condition.
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Affiliation(s)
- Peter Lauffer
- Emma Children’s Hospital, Amsterdam University Medical Centers (UMC), Department of Pediatric Endocrinology, University of Amsterdam, Amsterdam, Netherlands
| | - Nitash Zwaveling-Soonawala
- Emma Children’s Hospital, Amsterdam University Medical Centers (UMC), Department of Pediatric Endocrinology, University of Amsterdam, Amsterdam, Netherlands
| | - Jolanda C. Naafs
- Emma Children’s Hospital, Amsterdam University Medical Centers (UMC), Department of Pediatric Endocrinology, University of Amsterdam, Amsterdam, Netherlands
| | - Anita Boelen
- Endocrine Laboratory, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - A. S. Paul van Trotsenburg
- Emma Children’s Hospital, Amsterdam University Medical Centers (UMC), Department of Pediatric Endocrinology, University of Amsterdam, Amsterdam, Netherlands
- *Correspondence: A. S. Paul van Trotsenburg,
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Boelen A, van Trotsenburg ASP, Fliers E. Congenital isolated central hypothyroidism: Novel mutations and their functional implications. Handb Clin Neurol 2021; 180:161-169. [PMID: 34225927 DOI: 10.1016/b978-0-12-820107-7.00010-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Congenital hypothyroidism is the most frequent endocrine disorder in newborns, occurring in 1 per 3000-4000 newborns. In the Netherlands, the neonatal screening program is based primarily on heel prick thyroxine (T4). In contrast to thyroid-stimulating hormone-based programs, this approach allows for the detection of both primary and central congenital hypothyroidism. Over the past decade, the identification of families with isolated congenital central hypothyroidism enabled the identification of novel genetic causes of this condition, in addition to mutations in the TSHβ-subunit gene and thyrotropin-releasing hormone receptor gene reported earlier. In 2012, loss-of-function mutations in the immunoglobulin superfamily, member 1 (IGSF1) gene, were reported as a genetic cause of a syndrome including X-linked congenital central hypothyroidism and adult macroorchidism. IGSF1 encodes a hypothalamic plasma membrane glycoprotein. Mutations in IGSF1 represent the most prevalent genetic cause of isolated central hypothyroidism to date. In 2016, mutations in the transducin β-like 1X (TBL1X) gene were identified in patients with a combination of mild central hypothyroidism and sensorineural hearing loss. TBL1X is an essential subunit of the NCoR/SMRT corepressor complex and expressed in many tissues including the human hypothalamus and pituitary. In 2018, mutations in the insulin receptor substrate 4 (IRS4) gene were reported in cases of familial isolated central hypothyroidism. IRS4 encodes a hypothalamic protein that is part of the insulin and leptin signaling cascade. These recent developments will broaden our understanding of the role of the hypothalamus in hypothalamus-pituitary-thyroid axis regulation and will help to improve diagnosis and treatment of isolated central hypothyroidism.
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Affiliation(s)
- Anita Boelen
- Laboratory of Endocrinology, Department of Clinical Chemistry, Amsterdam Gastroenterology, Endocrinology, and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - A S Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Eric Fliers
- Department of Endocrinology and Metabolism, Amsterdam Gastroenterology, Endocrinology, and Metabolism, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands.
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Lauffer P, van Trotsenburg ASP, Zwaveling-Soonawala N. Low free thyroxine and normal thyroid-stimulating hormone in infants and children: possible causes and diagnostic work-up. Eur J Pediatr 2021; 180:2333-2338. [PMID: 33585976 PMCID: PMC8195777 DOI: 10.1007/s00431-021-03976-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/20/2020] [Revised: 01/09/2021] [Accepted: 02/02/2021] [Indexed: 11/28/2022]
Abstract
Screening for hypo- or hyperthyroidism in adults is generally done by measuring the serum thyrotropin (thyroid-stimulating hormone, TSH) concentration. This is an efficient approach in case of suspected acquired thyroid disease. However, in infants and children, congenital hypothalamus-pituitary-thyroid (HPT) axis disorders also need to be considered, including primary and central congenital hypothyroidism, and even rarer thyroid hormone receptor and transporter defects. In primary congenital hypothyroidism, TSH will be elevated, but in the other congenital HPT axis disorders, TSH is usually within the normal range. Free thyroxine (FT4) assessment is essential for the diagnosis in these conditions.Conclusion: Here we discuss a number of rare congenital HPT axis disorders in which TSH is normal, but FT4 is low, and provide a clinical algorithm to distinguish between these disorders. What is Known: • A single thyroid-stimulating hormone (TSH) measurement is an appropriate screening method for primary hypothyroidism. • For central hypothyroidism and rare thyroid hormone receptor and transporter defects a free thyroxine (FT4) measurement is essential for the diagnosis because TSH is usually normal. What is New: • Here we present a new problem-oriented clinical algorithm including a diagnostic flow-chart for low FT4 and normal TSH in infants and children.
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Affiliation(s)
- Peter Lauffer
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - A. S. Paul van Trotsenburg
- Department of Pediatric Endocrinology, Emma Children’s Hospital, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Nitash Zwaveling-Soonawala
- Department of Pediatric Endocrinology, Emma Children's Hospital, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, 1105, AZ, Amsterdam, The Netherlands.
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