Transient hyperthyroidism after surgery for secondary hyperparathyroidism: a common problem

Immune Reconstitution After Total Parathyroidectomy and Forearm Transplantation in Chronic Renal Failure

OBJECTIVE

To investigate the immune reconstitution after total parathyroidectomy and forearm transplantation in chronic renal failure.

METHOD

Forty-three patients, accompanied with chronic renal failure and secondary hyperparathyroidism (SHPT) that hospitalized during January 2019 to 2021 and underwent total thyroidectomy and forearm transplantation were enrolled as observation group. Forty hemodialysis patients with chronic renal failure but without SHPT were selected as the hemodialysis group. In addition, fifty volunteers who underwent physical examination within the same period were chosen as a control group. The parathyroid hormone (iPTH), blood phosphorus, blood calcium, th22, Treg cells, and inflammatory factors were detected in the three groups.

RESULTS

The preoperative iPHT, serum phosphorus, and calcium levels in the observation group were higher than those in the control group and hemodialysis group ( P<0.05 ), and the index values of the observation group at each time point after surgery were remarkably lower than those in pre-surgery ( P<0.05 ). The preoperative Th22 and Th22/Treg in the observation group were higher, and Treg was lower than those in the control group and hemodialysis group ( P<0.05 ); The levels of Th22 and Th22/Treg in the observation group at each time point in post-operation were lower than those in pre-operation ( P<0.05 ), whereas Treg cells in observation group at each time point postoperatively were higher than those prior-operation ( P<0.05 ). The preoperative serum TNF-α, IL-6, TGF-β, and IL-22 in the observation group were notably higher than those in the control group and hemodialysis group ( P<0.05 ); And TNF-α, IL-6, TGF-β, and IL-22 in observation group at each time point in post-operation were lower than those in pre-surgery( P<0.05 ).

CONCLUSION

For chronic renal failure patients complicated with SHPT, total parathyroidectomy and forearm transplantation can effectively improve their clinical symptoms, reduce the inflammatory state of the body, and beneficial for immune reconstruction.

Retracting the thyroid matters: Who develops asymptomatic transient thyrotoxicosis after parathyroidectomy

BACKGROUND

Hyperthyroidism after parathyroidectomy is not a well-understood complication. We sought to determine the incidence and risk factors of hyperthyroidism after parathyroidectomy.

MATERIALS AND METHODS

This is a prospective study of 91 patients undergoing parathyroidectomy. Pre- and post-operative thyroid-stimulating hormone(TSH) and free thyroxine(T4) levels at two-week follow-ups were collected. Bivariate analyses were conducted to compare demographics, laboratory results, and intraoperative findings between patients with normal and suppressed post-parathyroidectomy TSH.

RESULTS

Twenty-two(24.2 ​%) patients had suppressed TSH after parathyroidectomy and 2(2.2 ​%) reported symptoms of hyperthyroidism. All hyperthyroidism resolved within 6 weeks. No patients required medical treatment. Compared to the normal TSH group, the suppressed TSH group had significantly more bilateral explorations(91.0 ​% vs. 58.0 ​%, p ​= ​0.006), and superior parathyroid resections(95.5 ​% vs. 65.2 ​%, p ​= ​0.006).

CONCLUSION

Transient hyperthyroidism is common following parathyroidectomy, which is likely associated with intraoperative thyroid manipulation. Gentle retraction of thyroid glands in parathyroidectomy is warranted, especially during superior parathyroid gland resection.

An Adolescent with Transient Hyperthyroxinemia after Blunt Trauma to Head and Neck

Background

Thyroid storm is a well-known complication of surgical procedures in the lower neck, but is rare after a blunt neck trauma. The cases described previously have mainly focussed on adults with pre-existent thyroid disease. In this case report, we describe the disease course of a previously healthy adolescent who had asymptomatic hyperthyroxinemia after a blunt trauma of the jaw and neck. Case Presentation. A 17-year-old girl presented at our emergency department after she fell on her head while roller blading. On physical examination, among other injuries, she had a swelling in the lower neck, which appeared to involve the thyroid gland. Subsequent laboratory analysis was indicative of primary hyperthyroxinemia, with a free T4 of 59 pmol/L (reference range: 12–22) and a TSH of 0.46 mU/L (reference range: 0.5–4.3), but the patient had no symptoms fitting with this. Four weeks after the initial presentation, the patient reported only complaints regarding tenderness in the jaw and neck region. She was no longer hyperthyroidic on biochemical evaluation (with a free T4 level of 15.6 pmol/L and a TSH level of 0.33 mU/L), and antibodies against thyroid peroxidase or TSH receptor were not present.

Conclusions

This case might indicate that hyperthyroxinemia following a neck trauma may go unnoticed if hyperthyroid symptoms are mild or absent and thyroid function tests are not performed.

Clinical study on the status of transient thyrotoxicosis after surgery for secondary hyperparathyroidism patients with end-stage renal disease and normal thyroid function

Objective

Secondary hyperparathyroidism (SHPT) is a common complication of end-stage renal disease (ESRD), and part of SHPT patients need receive parathyroidectomy (PTX). However, as an important postoperative complication of SHPT, thyrotoxicosis has received little attention. Therefore, in this article, we aimed to study the status of transient thyrotoxicosis after PTX for SHPT patients with ESRD and normal thyroid function.

Methods

A total of 24 SHPT patients with preoperative normal thyroid function, normal thyroglobulin (Tg) and normal thyroid antibodies receiving PTX were enrolled from the Department of Endocrine and Breast Surgery, the First Affiliated Hospital of Chongqing Medical University, from January 2017 to January 2019. Tg, high sensitivity thyrotropin stimulating hormone (sTSH), triiodothyronine (T3), free triiodothyronine (fT3), thyroxine (T4) and free thyroxine (fT4) were evaluated the day before PTX and on day 1, 3 and 5 after PTX. Besides, all enrolled patients were evaluated whether there are symptoms associated with thyrotoxicosis.

Results

Among the 24 SHPT patients, 1 case (4.2%), 8 cases (33.3%) and 13 cases (54.2%) had suffered thyrotoxicosis at the first, third and fifth day after surgery, respectively. Serum FT4 level increased significantly from pre-operation (0.68 ± 0.15 ng/dl, normal range 0.59–1.25 ng/dl) to the third day after operation (1.91 ± 0.97 ng/dl, p<0.001) and then gradually decline. The frequencies of serum sTSH lower than the normal level gradually increased from the first day (8.3%) to fifth day (66.7%) after surgery.

Conclusion

Transient thyrotoxicosis is a common postoperative complication of parathyroidectomy for SHPT patients with ESRD and normal thyroid function, and it is necessary for clinicians to evaluate the perioperative thyroid function to make early diagnosis and appropriate prevention and treatment of thyrotoxicosis.

Transient Hyperthyroidism Induced by Thyroid Ultrasound

OBJECTIVES

Transient hyperthyroidism has been documented following surgical manipulation or direct trauma to the normal thyroid gland. This has best been studied in patients following parathyroidectomy and also reported following trauma to the neck, strangulation, and vigorous palpation of the thyroid gland. It has not previously been reported following a thyroid ultrasound.

METHODS

We report the case of a 58-year-old euthyroid woman with a large nontoxic multinodular goiter who developed transient hyperthyroidism following an ultrasound of the thyroid gland. She was not treated with anti-thyroid medications.

RESULTS

Two weeks later, her free T3 and free T4 were normal, and 11 weeks after the ultrasound, all thyroid tests, including her TSH, were within the reference range.

CONCLUSIONS

We believe this is the first report of a euthyroid individual who developed hyperthyroidism caused by thyroid ultrasonography. We hypothesize that pressure from the ultrasound probe during the examination compressed her large nodules, releasing stored hormone.

Palpation thyroiditis following subtotal parathyroidectomy for hyperparathyroidism

Thyrotoxicosis is an under-recognised but clinically important complication of parathyroidectomy. We report a case of a 37-year-old man with tertiary hyperparathyroidism who initially developed unexplained anxiety, diaphoresis, tachycardia, tremor and hyperreflexia one day after subtotal parathyroidectomy. Thyroid biochemistry revealed suppressed thyroid stimulating hormone and elevated serum free T₄ and free T₃ levels. Technetium-99m scintigraphy scan confirmed diffusely decreased radiotracer uptake consistent with thyroiditis. The patient was diagnosed with thyrotoxicosis resulting from palpation thyroiditis. Administration of oral beta-adrenergic antagonists alleviated his symptoms and there was biochemical evidence of resolution fourteen days later. This case illustrates the need to counsel patients about thyroiditis as one of the potential risks of parathyroid surgery. It also emphasises the need for biochemical surveillance in patients with unexplained symptoms in the post-operative period and may help to minimise further invasive investigations for diagnostic clarification.

[Surgical treatment of secondary hyperparathyroidism: a systematic review of the literature]

Secondary hyperparathyroidism (HPT) has a high prevalence in renal patients. Secondary HPT results from disturbances in mineral homeostasis, particularly calcium, which stimulates the parathyroid glands, increasing the secretion of parathyroid hormone (PTH). Prolonged stimulation can lead to autonomy in parathyroid function. Initial treatment is clinical, but parathyroidectomy (PTx) may be required. PTx can be subtotal or total followed or not followed by parathyroid tissue autograft. We compared the indications and results of these strategies as shown in the literature through a systematic literature review on surgical treatment of secondary HPT presented in MedLine and LILACS from January 2008 to March 2014. The search terms were: hyperparathyroidism; secondary hyperparathyroidism; parathyroidectomy and parathyroid glands, restricted to research only in humans, articles available in electronic media, published in Portuguese, Spanish, English or French. We selected 49 articles. Subtotal and total PTx followed by parathyroid tissue autograft were the most used techniques, without consensus on the most effective surgical procedure, although there was a preference for the latter. The choice depends on surgeon's experience. There was consensus on the need to identify all parathyroid glands and cryopreservation of parathyroid tissue whenever possible to graft if hypoparathyroidism arise. Imaging studies may be useful, especially in recurrences. Alternative treatments of secondary HPT, both interventional and conservative, require further study.