Prevalence of hyperthyroidism, hypothyroidism, and euthyroidism in thyroid eye disease: a systematic review of the literature

Association Between HLA-DRB1 Alleles and Graves' Disease in Asian Populations: A Meta-Analysis

Graves' disease (GD) is an autoimmune disease that primarily affects the thyroid gland. It is the most common cause of hyperthyroidism. Genetic studies have shown that human leukocyte antigen (HLA) plays an important role in the development of GD. In this article, we performed a meta-analysis determined to evaluate the relationship between HLA-DRB1 alleles and GD. This meta-analysis included 9 studies (3582 cases in the case group and 23070 cases in the control group) and 27 alleles was performed. The combined results showed that, compared with the control group, GD patients have a significant increase in the frequency of DRB1*1403 (OR=2.50, 95% CI=1.78-3.51, pc<0.0001) and have a significant decrease in frequencies of DRB1* 0101 (OR=0.45, 95% CI=0.34-0.59, pc<0.0001) and DRB1*0701 (OR=0.44, 95% CI=0.35-0.55, pc<0.0001). The meta-analysis indicated that, in Asian populations, DRB1*1403 is a risk allele for GD, and DRB1*0101 and DRB1*0701 are protective against the occurrence of GD. We surprisingly discovered that the susceptibility alleles for GD in Asian populations are completely different from Caucasians and the protective alleles for GD in Asians are quite similar to those of Caucasians. The results of our study may provide new opportunities for gene-targeted therapy for GD in Asian populations.

Racial and Ethnic Disparities in the Diagnosis and Treatment of Thyroid Disease

CONTEXT

There are differences in diagnosis, treatment, and outcomes for thyroid between racial and ethnic groups that contribute to disparities. Identifying these differences and their causes are the key to understanding and reducing disparities in presentation and outcomes in endocrine disorders.

EVIDENCE ACQUISITION

The present study reviews original studies identifying and exploring differences between benign and malignant thyroid diseases. A PubMed, Web of Science, and Scopus search was conducted for English-language studies using the terms "thyroid," "thyroid disease," "thyroid cancer," "race," "ethnicity," and "disparities" from inception to December 31, 2022.

EVIDENCE SYNTHESIS

Many racial and ethnic disparities in the diagnosis, presentation, treatment, and outcomes of thyroid disease were found. Non-White patients are more likely to have a later time to referral, to present with more advanced disease, to have more aggressive forms of thyroid cancer, and are less likely to receive the appropriate treatment than White patients. Overall and disease-specific survival rates are lower in Black and Hispanic populations when compared to White patients.

CONCLUSIONS

Extensive disparities exist in thyroid disease diagnosis, treatment, and outcomes that may have been overlooked. Further work is needed to identify the causes of these disparities to begin to work toward equity in the care of thyroid disease.

Ocular surface and meibomian gland evaluation in euthyroid Graves' ophthalmopathy

PURPOSE

Euthyroid Graves' ophthalmology (EGO) refers to the subgroup of thyroid eye disease patients with distinct clinical presentations. This study evaluated the ocular surface and meibomian gland changes in EGO patients.

METHODS

A cross-sectional study was conducted at The Chinese University of Hong Kong including 34 EGO patients and 34 age-and sex- matched healthy controls. Outcome measures include anterior segment examination, keratographic and meibographic imaging.

RESULTS

Between 34 EGO patients and 34 age and sex-matched healthy controls, EGO was associated with a higher ocular surface disease index (P < 0.01), higher severity of meibomian gland dropout (upper: P < 0.001, lower: P < 0.00001) and higher percentage of partial blinking (P = 0.0036). The worse affected eyes of the EGO patients were associated with corneal staining (P = 0.0019), eyelid telangiectasia (P = 0.0009), eyelid thickening (P = 0.0013), eyelid irregularity (P = 0.0054), meibomian gland plugging (P < 0.00001), expressibility (P < 0.00001), and meibum quality (P < 0.00001). When the two eyes of the same EGO patient were compared, the degree of meibomian gland dropout was higher among the worse affected eyes (upper: P < 0.00001, and lower: P < 0.00001). Tear meniscus height, lipid layer thickness, and noninvasive break-up time were comparable between the two eyes of EGO patients and also between EGO patients and healthy controls. TMH was positively correlated with the degree of exophthalmos (r = 0.383, P < 0.05).

CONCLUSION

EGO patients have more ocular surface complications and meibomian gland dropouts than healthy controls. Almost 60% of them had dry eye symptoms, but aqueous deficiency was not apparent. Further studies are warranted to clarify the mechanism of dry eye in EGO. (249 words).

Understanding the clinical and molecular basis of thyroid orbitopathy: a review of recent evidence

Thyroid eye disease (TED) is an autoimmune orbital inflammatory disease which ranges from mild to severe. Tissue remodeling, fibrosis and fat proliferation cause changes in the orbital tissues which can affect esthetics and visual function. In its severe form, it is sight threatening, debilitating, and disfiguring and may lead to social stigma, the embarrassment about which has an impact on the quality of life of those affected and the family members. The pathogenesis of TED, which is influenced by genetic, immunological, and environmental factors, is complex and not fully elucidated. However, it remains unknown what factors determine the severity of the disease. Recent research has revealed a number of diagnostic and prognostic biomarkers of this disease. In this overview of TED, we focus on new insights and perspectives regarding biological agents that may provide a basis for new treatment modalities.

Implementation of thyroid eye disease registry in Iran: rationale and research protocol

BACKGROUND

To describe the implementation of a registry system for patients with thyroid eye disease (TED) in Iran to obtain more information about its nature, prevalence, and annual incidence, as well as extend insight into the etiology, pathogenesis, and eventually make an accurate prognosis of different medical or surgical treatment methods.

METHODS

After receiving approval from the Disease Registry Committee of Iran University of Medical Sciences (IUMS) in 2019 and the Ministry of Health and Medical Education (MOHME) in 2020, the protocol was introduced in three consecutive phases at regional, provincial and national levels. The establishment of a registry committee in Rassoul Akram Hospital, one of the medical centers affiliated to IUMS, was the first step to organizing the registry project's main core. The steering committee included six subgroups of required subject fields. The members are experts in developing a guideline, providing a new dataset, drawing an outline for the next steps, and structuring user-friendly software through several panel discussion meetings. The data is collected from clinical and para-clinical/imaging findings, laboratory evaluations, and their selected treatment strategy, retrospectively and prospectively.

RESULTS

The purpose is to broaden our knowledge about the profile of TED; accordingly, data related to patients' demographics, thyroid gland disease (status, duration, treatments, and function tests), general medical and ocular history, along with visual/ocular exams resulting TED status are collected and recorded in a 2- language software. The web-based software system is accessible at https://orc.iums.ac.ir . To maintain data security, prioritized user access was defined for different members. Furthermore, diverse methods, such as employing trained staff and utilizing software validation rules, were implemented to control data quality in every step of data collection, entry, and registration. Medical records of retrospective subjects were also evaluated and entered after accuracy verification.

CONCLUSION

Iran's TED registry provides practitioners with comprehensive data on natural history and phenotype variations in clinical features and outcomes. It facilitates patient recruitment and, consequently, earlier diagnosis on a large scale which helps improve treatment and quality of life for patients.

Global research on artificial intelligence in thyroid-associated ophthalmopathy: A bibliometric analysis

Purpose

To provide an overview of global publications on artificial intelligence (AI) in thyroid-associated ophthalmopathy (TAO) through bibliometric analysis.

Methods

Publications related to AI in TAO from inception until April 2023 were retrieved from the Web of Science database. The trends of publications and citations, publishing performance, collaboration among countries and institutions, and the funding agencies, relevant research domains, leading journals, hotspots and their evolution were identified.

Results

A total of 55 publications were included for analysis. The number of publications and citations continued to grow since 1998, with a significant acceleration of growth after 2020. China is the most productive country with the highest number of productive institutions, followed by the United States. European countries have the most extensive collaboration. The most relevant research domain was radiology, nuclear medicine & medical imaging. The European Journal of Radiology was one of the most productive journals, with the most influential articles published. "Thyroid-associated ophthalmopathy" and "neural network" maintain hotspots during the entire period. Studies were more focused on clinical features during 1998 and 2016, clinical features and medical data during 2017 and 2020, and medical data and AI techniques during 2021 and 2023.

Conclusions

This study summarized the global research status regarding AI in TAO in terms of trends, countries, institutions, research domains, journals, and key topics. AI has shown great potential in TAO. Sponsored by funding agencies such as NSFC, China has become the most productive country in the field of AI in TAO. Our findings help researchers better understand the development of this field and provide valuable clues for future research directions.

Associations Between Hypothyroidism and Subclinical Atherosclerosis Among Male and Female Patients Without Clinical Disease Referred to Computed Tomography

OBJECTIVES

Hypothyroidism is recognized as a risk factor for coronary artery disease (CAD). However, reports are conflicting when the results are stratified by sex and the underlying risk of CAD. We examine the sex-specific associations of hypothyroidism with coronary calcification and plaques.

METHODS

Retrospective cross-sectional study was conducted among adult patients referred to (64 multidetector spiral) computed tomography. Those with pre-existing CAD were excluded. Hypothyroidism was defined as thyroid-stimulating hormone ≥ 4.5 mU/L. Plaques were determined based on quantification of coronary calcium and coronary computed tomography angiography.

RESULTS

A total of 2499 patients (1544 male and 955 female) were included. The prevalence of hypothyroidism was significantly higher in female than in male patients (18.0% vs 12.9%, P < .001), in all patients and those <65 years. Hypothyroidism in male patients was significantly associated with higher coronary calcium score > 0, higher coronary calcium score groups, and both soft and calcified plaques (P = .027, P = .032, P = .005, and P = .017, respectively). After adjusting for traditional coronary risk factors, the higher risk in male patients remained significant for coronary plaque but not for coronary calcium score >0 (odds ratios and CIs were 1.77, 1.08-2.90, P = .023 and .98, 0.63-1.52, P = .925, respectively). On the other hand, hypothyroidism in female patients was not significantly associated with coronary calcification nor plaques in both univariate and multivariate analyses.

CONCLUSIONS

There are sex-specific differences in the association of hypothyroidism with subclinical atherosclerosis. The higher risk of coronary plaques but not calcification in male patients was independent of traditional coronary risk factors. The lack of associations in female patients may be related to lower underlying risk of CAD.

Refractory Thyroid Eye Disease Unresponsive to Teprotumumab: A Case Report

Thyroid eye disease (TED) is a complex autoimmune condition that can cause proptosis, ophthalmoplegia, diplopia, optic nerve compression, and vision loss. These clinical findings are caused by a complex pathological mechanism characterized by thyroid-stimulating hormone receptor autoantibodies activating thyroid-stimulating hormone receptors (TSH-Rs). Overexpressed insulin-like growth factor 1 (IGF-1) receptors found in orbital fibroblasts form complexes with these TSH-Rs, leading to the inflammation and expansion of these tissues. Teprotumumab, a human monoclonal antibody sold under the brand name Tepezza, is currently the only FDA-approved immunotherapy for the treatment of TED. Given as an intravenous infusion every three weeks, teprotumumab works by suppressing IGF-1 receptors, thereby interfering with TSH-R and IGF-1 complex-mediated actions in these fibroblasts. The efficacy of teprotumumab was established in randomized, placebo-controlled clinical trials, which demonstrated clinically meaningful improvements in proptosis, inflammation, and diplopia. While teprotumumab has been shown to be efficacious, our patient with TSHRAb-positive euthyroid thyroid-associated ophthalmopathy who presented with diplopia did not have any significant improvement following the standard treatment dose of eight infusions over a 24-week period. This case underscores not only barriers to treatment, such as the high cost of teprotumumab but also highlights the importance of identifying risks for nonresponse.

Investigation of Conjunctival Goblet Cell and Tear MUC5AC Protein in Patients With Graves' Ophthalmopathy

Purpose

The aim of this study was to investigate conjunctival goblet cell density (GCD) and tear mucin-5AC (MUC5AC) protein levels in patients with Graves' ophthalmopathy (GO) and their association with dry eye indicators.

Methods

A total of 99 patients with GO (54 active, 45 inactive) and 40 healthy controls were recruited. Comprehensive ophthalmic examinations, including the external eye, ocular surface, GCD, and tear MUC5AC ELISA, were performed. The GCD examination was performed in temporal bulbar conjunctiva, including IVCM GCD by in vivo confocal microscopy (IVCM) and filled GCD of cytokeratin-7 and MUC5AC-positive co-immunomarkers by impression cytology. Tear MUC5AC protein was detected using samples extracted from Schirmer strips.

Results

The GO group showed a significant decrease in IVCM GCD, filled GCD, and normalized tear MUC5AC protein compared to controls, with the active GO group showing the greatest decrease (all P < 0.05). Tear MUC5AC protein levels in GO correlated with those of IVCM GCD (r = 0.40, P < 0.001) and filled GCD (r = 0.54, P < 0.001, respectively). Higher ocular surface disease index (r = -0.22, P < 0.05; r = -0.20, P < 0.05; r = -0.21, P < 0.05) and lisamine green staining (r = -0.23, P < 0.05; r = -0.38, P < 0.001; r = -0.42, P < 0.001) were associated with lower tear MUC5AC protein levels, IVCM GCD, and filled GCD, respectively, which decreased with increasing clinical activity score (r = -0.24, P < 0.05; r = -0.28, P < 0.01; r = -0.27, P < 0.01) and conjunctival congestion score (r = -0.27, P < 0.01; r = -0.33, P < 0.001; r = -0.42, P < 0.001).

Conclusions

The goblet cell count and tear MUC5AC protein in GO eyes were decreased, possibly due to ocular surface inflammation.

Translational Relevance

This study observed the change of tear film mucin in GO patients.

Interaction Between Dietary Selenium and Zinc Intakes on Hypothyroidism

This study assessed the independent association of dietary selenium and zinc intakes with the risk of hypothyroidism and interaction effect between dietary selenium and zinc intakes with the risk of hypothyroidism in Americans. The data of this cross-sectional study was from the National Health and Nutritional Examination Survey (NHANES) 2007-2012. The outcome was defined as new-onset hypothyroidism. Weighted univariate and multivariate logistic regression and the subgroup analyses based on gender and body mass index (BMI) were conducted to evaluate the association between the dietary selenium and zinc intakes and new-onset hypothyroidism. Odds ratio (OR) and 95% confidence interval (CI) were calculated. A total of 6402 participants were included with 131 (2.05%) developed a hypothyroidism in this study. Compared with participants with high zinc intake, those with low zinc intake had a higher risk of new-onset hypothyroidism (OR = 1.74, 95% CI: 1.05-2.90). Moreover, we also found a significant interaction between dietary selenium level intake and dietary zinc level intake on new-onset hypothyroidism risk (OR = 5.99, 95% CI: 1.77-20.23). There was an interaction between dietary selenium and zinc intakes on the risk of new-onset hypothyroidism, especially the significant effect for adults with women or overweight. The findings indicated that improving the levels of dietary zinc and selenium intake may be beneficial in preventing of new-onset hypothyroidism.

Exposure to pesticides and the risk of hypothyroidism: a systematic review and meta-analysis

BACKGROUND

Knowledge surrounding the association between exposure to pesticides and hypothyroidism is inconsistent and controversial.

METHODS

The aim of present study was, therefore, to review scientific evidence systematically and conduct a meta-analysis into the contribution of exposure to pesticides to hypothyroidism. PubMed, Scopus, Web of Science, and Google Scholar were searched. The findings are presented as OR, HR, PR, IRR, and 95% confidence interval (95%CI). A fixed-effect model using the inverse-variance method and random-effects inverse-variance model with DerSimonian-Laird method were used for estimating the pooled estimates. Cochran Q and I2 tests were used to confirm the heterogeneity of selected studies.

RESULTS

Twelve studies were included in the systematic review, and 9 studies in the meta-analysis. Epidemiological evidence suggested that exposure to insecticides including organochlorines, organophosphates, and pyrethroids increased risk of hypothyroidism (adjusted odds ratio (aOR) = 1.23, 95%CI = 1.14, 1.33 for organochlorines, aOR = 1.12, 95%CI = 1.07, 1.17 for organophosphates, aOR = 1.15, 95%CI = 1.03, 1.28 for pyrethroids). Exposure to herbicides also increased risk of hypothyroidism (aOR = 1.06, 95%CI = 1.02, 1.10). However, exposure to fungicides and fumigants was not found to be associated with hypothyroidism.

CONCLUSION

To increase current knowledge and confirm evidence to date future research needs to center on large-scale longitudinal epidemiological and biological studies, examination of dose-response relationships, the controlling of relevant confounding variables, using standardized and high sensitivity tools, and investigating the effects of environmental exposure.

Do Dietary Supplements Affect Inflammation, Oxidative Stress, and Antioxidant Status in Adults with Hypothyroidism or Hashimoto's Disease?-A Systematic Review of Controlled Trials

This systematic review aims to summarise the results of controlled trials on dietary supplements (DS) usage and inflammation, oxidative stress, antioxidant status, and thyroid parameter improvement in hypothyroidism (HT)/Hashimoto's thyroiditis (AIT) patients. The study protocol was registered with PROSPERO (no. CRD42022365149). A comprehensive search of the PubMed, Scopus, and Web of Science databases resulted in the identification of nineteen randomised controlled trials and three non-randomised studies for the review; three studies examined the effect of supplementation with vitamin D, twelve studies-with selenium, and seven studies-with other DS. Based on very limited evidence, the lack of influence of vitamin D supplementation on inflammatory parameters was found, while no studies have examined oxidative stress and antioxidant status parameters, and only one provided results for a single thyroid parameter after an intervention. Some evidence was found proving that selenium supplementation may decrease inflammation and improve thyroid parameters, but reaching a conclusion about its influence on oxidative stress and antioxidant status is not possible because of the insufficient number of studies. Additionally, due to examining other DS (e.g., multicomponent, Nigella sativa, and genistein) only in single studies, conclusions cannot be drawn. Further long-term, high-quality randomised controlled trials are necessary to better understand the influence of DS on inflammation, oxidative stress, and antioxidant status, as well as their potential to improve thyroid gland function in HT/AIT patients.

A systematic review on artificial intelligence techniques for detecting thyroid diseases

The use of artificial intelligence approaches in health-care systems has grown rapidly over the last few years. In this context, early detection of diseases is the most common area of application. In this scenario, thyroid diseases are an example of illnesses that can be effectively faced if discovered quite early. Detecting thyroid diseases is crucial in order to treat patients effectively and promptly, by saving lives and reducing healthcare costs. This work aims at systematically reviewing and analyzing the literature on various artificial intelligence-related techniques applied to the detection and identification of various diseases related to the thyroid gland. The contributions we reviewed are classified according to different viewpoints and taxonomies in order to highlight pros and cons of the most recent research in the field. After a careful selection process, we selected and reviewed 72 papers, analyzing them according to three main research questions, i.e., which diseases of the thyroid gland are detected by different artificial intelligence techniques, which datasets are used to perform the aforementioned detection, and what types of data are used to perform the detection. The review demonstrates that the majority of the considered papers deal with supervised methods to detect hypo- and hyperthyroidism. The average accuracy of detection is high (96.84%), but the usage of private and outdated datasets with a majority of clinical data is very common. Finally, we discuss the outcomes of the systematic review, pointing out advantages, disadvantages, and future developments in the application of artificial intelligence for thyroid diseases detection.

A Case of Recurrent Thyrotoxicosis in a Thyroglossal Duct Cyst 18 Years Following Thyroid Surgery

Graves' disease (GD) is an immune-mediated condition related to high thyroid-stimulating immunoglobulin levels. Here, we present a rare case of recurrent thyrotoxicosis that developed in a thyroglossal duct cyst (TGDC) and the residual thyroid tissue in a 46-year-old female following subtotal thyroidectomy. In 2005, she was diagnosed with GD causing thyrotoxicosis and treated with subtotal thyroidectomy. In 2022, she was seen at our clinic with a neck swelling gradually growing in size over the last 10 years. On examination, the mass was found to be moving with tongue protrusion. She was on thyroxin 100 mcg daily, and the dose was reduced gradually until she was maintained on no therapy for hypothyroidism and was still thyrotoxic. The combined clinical, laboratory thyroid scintigraphy and ultrasonographic features favored early developing recurrent Graves' disease in the thyroid residual and TGDC. She was started on carbimazole and was referred for surgery. Our case represents a rare occurrence of recurrent GD in the thyroid residual and TGDC.

Clinical phenotypes of euthyroid, hyperthyroid, and hypothyroid thyroid-associated ophthalmopathy

OBJECTIVE

To compare the demographic and clinical phenotypes of thyroid-associated ophthalmopathy (TAO) with euthyroidism (Eu-TAO), hyperthyroidism (Hr-TAO), and hypothyroidism (Ho-TAO).

METHODS

We enrolled 2158 TAO patients in this retrospective study and assessed their demographics, clinical manifestations, activity, and severity.

RESULTS

Among the enrolled patients, 526 (24.37%) had Eu-TAO, 1544 (71.55%) had Hr-TAO, and 88 (4.08%) had Ho-TAO. Compared to Hr-TAO (2.02) and Ho-TAO (2.52) patients, Eu-TAO (1.57) patients had the lowest female-to-male ratio (p = 0.026). The mean ages of Eu-TAO, Hr-TAO, and Ho-TAO patients were 43.11 ± 12.05, 42.23 ± 13.63, and 47.39 ± 13.28 years, respectively (p = 0.001). Patients with Eu-TAO had more unilateral involvement (50% vs. 14.38% vs. 21.59%, p < 0.001) than Hr-TAO or Ho-TAO patients. Clinically active TAO patients presented 8.56% in euthyroid vs. 13.86% in hyperthyroid vs. 11.36% in hypothyroid (p = 0.006). Regarding the severity of the European Group on Graves' Orbitopathy (EUGOGO) classification among euthyroid, hyperthyroid, and hypothyroid patients, mild TAO was present in 67.68, 54.27, and 72.72% of participants, moderate-to-severe TAO in 31.18, 42.49, and 26.14%, and sight-threatening TAO in 1.14, 3.24, and 1.14%, respectively. Eu-TAO was positively correlated with unilateral involvement (OR = 5.671, p < 0.001) and age (OR = 1.013, p = 0.003) and negatively correlated with the female-to-male ratio (OR = 0.656, p < 0.001) and TAO severity (OR = 0.742, p < 0.01).

CONCLUSIONS

Eu-TAO patients are older and less likely to be female, and show more unilateral and milder clinical phenotypes than hyper/hypothyroid TAO patients.

Hypo vs. hyperthyroid eye disease: is there any difference?

BACKGROUND

Thyroid-eye disease (TED) is the most common extra-thyroidal presentation of graves' disease. We performed this study to compare clinical characteristics of TED in hypothyroid vs. hyperthyroid patients.

METHODS

This was a retrospective analytical cross-sectional study in which we compared demographics, severity (EUGOGO classification) and activity (clinical activity score) of TED, thyroid disease duration, TED duration and clinical signs between hypothyroid eye disease (Ho-TED) and hyperthyroid eye disease (Hr-TED). To minimize the effect of selection bias and potential confounders, 1:1 propensity score matching (PSM) was also performed.

RESULTS

Three hundred and seventy-four patients (341 Hr-TED and 33 Ho-TED) with a female to male ratio of 1.4:1 were identified in our study. Female to male ratio was 1.3:1 in hyperthyroid and 4.5:1 in hypothyroid group (P = 0.005). The duration of thyroid disease was longer in Ho-TED (P = 0.002) while the duration of eye disease was not significantly different between the Hr-TED (mean = 24.33 ± 41.69, median = 8) and Ho-TED (mean = 19.06 ± 33.60, median = 12) (P = 0.923). Most of the patients in hypothyroid group developed eye involvement after thyroid disease (80.0% in hypo vs. 48.1% in hyper, P = 0.003). Severity (P = 0.13) and activity (P = 0.11) was not different between Hr-TED and Ho-TED patients. After PSM analysis, no clinical characteristics were significantly different between the two groups (P > 0.05).

CONCLUSION

The results of our study showed several differences between the Hr/Ho TED patients including sex, duration of thyroid disease and pattern of eye involvement. After matching the two groups with statistical methods, no clinical characteristics were different between Hr-TED and Ho-TED patients.

Clinical Characteristics of Patients with Euthyroid Thyroid-associated Ophthalmopathy

Purpose: To compare clinical features between thyroid-associated ophthalmopathy (TAO) patients with hyperthyroidism and euthyroidism.Methods: Between September 2015 and January 2021, we enrolled 96 TAO patients with euthyroidism (n = 16) or hyperthyroidism (n = 80). We recorded the age, sex, smoking status, presence of hypertension and diabetes, total follow-up period, unilateral involvement, eyelid edema, lid lag and retraction, clinical activity score (CAS), modified NOSPECS score, exophthalmometry, Hess test, area of extraocular muscles on orbital computed tomography (CT), treatment with systemic and subconjunctival steroids and radiotherapy, and serum levels of free thyroxine, thyroid-stimulating hormone (TSH), anti-thyroglobulin antibody (anti-Tg Ab), anti-thyroid peroxidase antibody (anti-TPO Ab), TSH receptor antibody (TSHR Ab), and thyroid stimulating antibody.Results: Unilateral involvement was significantly more common in the euthyroid group, while conjunctival injection, CAS, extraocular muscle movement restriction within 10° on the Hess chart, maximum cross-sectional area of the inferior rectus on orbital CT, and treatment with intravenous high-dose steroid were significantly more common in the hyperthyroid group. Furthermore, the modified NOSPECS score and levels of free thyroxine, anti-Tg Ab, anti-TPO Ab, and TSHR Ab were significantly higher in the hyperthyroid than euthyroid group.Conclusions: Compared to hyperthyroid TAO patients, those with euthyroid TAO were more likely to have unilateral involvement. They also had lower clinical activity and severity, milder enlargement of extraocular muscles (EOMs), and lower rates of EOM movement restriction and treatment with intravenous high-dose steroid. Euthyroid TAO patients had lower levels of free thyroxine, anti-Tg Ab, anti-TPO Ab, and TSHR Ab compared to hyperthyroid TAO patients.

Risk factors for thyroid hormone replacement therapy after hemithyroidectomy and development of a predictive nomogram

PURPOSE

Hemithyroidectomy is a valid operation to retain functional contralateral thyroid lobe that is indicated for a variety of thyroid diseases. This study aimed at determination of the risk factors for thyroid hormone replacement following hemithyroidectomy and to develop a predictive nomogram.

METHODS

Data of patients treated by hemithyroidectomy for benign thyroid disease between January 2015 and January 2020 were retrospectively analyzed. Baseline characteristics, surgery-related variables, and preoperative and postoperative thyroid function of patients were collected from the case records and compared between patients with postoperative euthyroidism and patients with postoperative hypothyroidism. Postoperative euthyroidism patients without thyroid hormone replacement were compared to those who developed postoperative hypothyroidism with thyroid hormone replacement. The factors associated with thyroid hormone replacement were used to construct a binomial logistic-regression model and visualized as a predictive nomogram to evaluate the risk of thyroid hormone replacement following hemithyroidectomy.

RESULTS

Of the 378 patients (74% female) included in the study, 110 (29.1%) developed postoperative hypothyroidism. Preoperative serum thyroid-stimulating hormone (TSH) > 2.172 μIU/mL was identified as an independent risk factor for postoperative hypothyroidism (odds ratio [OR] = 8.02; 95% confidence interval [CI]: 4.87-13.20; P < 0.001). Of 110 patients with postoperative hypothyroidism, 56 (50.9%) received thyroid hormone replacement. Unilateral thyroid nodule and preoperative serum TSH > 2.172 μIU/mL were independent predictors of postoperative thyroid hormone replacement (P = 0.01, and P < 0.001, respectively). Temporary subclinical hypothyroidism occurred in 12 patients; all 12 reverted to euthyroid state without thyroid hormone replacement. The discriminative effect of the binomial regression model was proved reliable by the Hosmer-Lemeshow goodness-of-fit test (P = 0.503), and predictive ability of the nomogram was satisfactory with a C-index of 0.833.

CONCLUSIONS

Hypothyroidism is common after hemithyroidectomy, and almost half of the patients will need thyroid hormone replacement. Elevated preoperative serum TSH level and unilateral thyroid nodule were independent predictors of thyroid hormone replacement following hemithyroidectomy. The predictive nomogram could be a useful tool for clinical practice.

Thyroid eye disease with concurrent orbital lymphoma: a radiological surprise

Summary

Thyroid eye disease (TED) is the most common extra-thyroidal manifestation in Graves' disease (GD). Additional/concurrent/synchronous pathologies may be present, especially in elderly patients who present with atypical features such as non-axial (or eccentric) proptosis, absence of lid lag and restricted superior extra-ocular movements. A 70-year-old female presented with progressive proptosis of her left eye and diplopia. She was diagnosed with GD a year prior and initiated on carbimazole. On examination, she had eccentric proptosis, restricted superior extra-ocular movements and a palpable mass in the supero-temporal quadrant of the left eye. Her T3 (1.33 ng/mL) and T4 (8.85 µg/dL) were normal with carbimazole. Thyroid-stimulating hormone (TSH)-receptor antibody was positive (3.15 IU/L, reference range <1.75). MRI revealed an enhancing lesion infiltrating the left superior rectus, with concurrent characteristic muscle belly involvement bilaterally. Orbital biopsy showed atypical lymphoid cells (CD20+), suggesting marginal zone lymphoma. CT thorax and abdomen, fluorodeoxyglucose-positron emission tomography and bone marrow examination were normal. The patient was administered orbital radiotherapy for her localised lymphoma and carbimazole was continued. TED is the most common cause of orbital involvement overall and in GD. However, additional or alternative pathology may be present which requires evaluation. MRI can be a useful adjunct in these patients. Orbital lymphoma needs to be staged with workup for disseminated disease. Radiotherapy is the treatment of choice for localized disease. The index case provides evidence for synchronous presentation of dual pathology and highlights the importance of astute clinical examination as well as keeps a low threshold for MRI in selected cases.

Learning points

Thyroid eye disease can co-exist with other ocular pathology, especially in elderly individuals. Eccentric proptosis, absent lid lag and restriction of eye movements (suggesting tendon involvement) should alert towards the presence of alternative pathology. Orbital imaging using MRI not only has greater sensitivity in diagnosing radiologically bilateral disease in patients who have unilateral involvement clinically but is also useful to identify concurrent neoplasms.

Relationship between subclinical hypothyroidism and distal-symmetric diabetic polyneuropathy in type 2 diabetes mellitus referred to Kosar Hospital in Semnan and related indicators in 2019–2020

Introduction:

Diabetes is one of the most common metabolic diseases and one of its important complications is diabetic neuropathy. Due to the relationship between diabetes and thyroid disorders, the present study was performed to determine the association between subclinical hypothyroidism and end-stage diabetic polyneuropathy in patients with type 2 diabetes.

Materials and Methods:

In this descriptive, analytical study, 154 patients with type 2 diabetes referred to Kosar Hospital in Semnan were evaluated. After recording their demographic information, samples were received for biochemical testing. The patients’ neuropathy was then evaluated based on the United Kingdom screening test (UKST). The results were recorded in the data collection form and then analyzed using SPSS Statistics 22 software.

Results:

In this study, 154 patients were studied, including 49 with subclinical hypothyroidism and 105 with euthyroid. The results of the present study showed that the mean age of patients in the subclinical hypothyroid group was 60.08 years and in the euthyroid group was 60.77 years. Mean ± standard deviation (SD) of the patients’ age, blood pressure, duration of diabetes, body mass index, fasting blood sugar (FBS) and Glucose, and 2-hour post prandial (2HPP) were not statistically significant between the two groups. The frequency of neuropathy severity based on clinical signs during examination and symptoms mentioned by the patients in the two groups was statistically significant (P = 0.005 and P = 0.001, respectively). The severity of neuropathy was not significantly associated with thyroid-stimulating hormone (TSH) levels (P > 0.05).

Conclusion:

From the results of the present study, it can be concluded that the severity of neuropathy based on the clinical signs during examination and the symptoms mentioned by the patient in diabetic patients is related to subclinical hypothyroidism. Further studies are recommended.

Thyroid eye disease or Graves' orbitopathy: What name to use, and why it matters

There is currently no universally accepted name for inflammatory disease of the eye and orbit associated with thyroid autoimmune disease. Variability in terminology impedes the evaluation of scientific literature and clinical collaboration and can affect patients' understanding of a disease process. The goals of this perspective article are 1. To compare the frequency of different terms used for eye disease associated with autoimmune thyroid disease in the scientific literature between 2000, 2010 and 2020 publications; 2. To investigate potential associations of terminology with author and journal specialty, and multidisciplinary vs. mono-disciplinary author teams; 3. To determine preferential terms used by professional societies; and 4. To propose standardized terminology based on our data analysis. The methods for this study included review of all English language articles listed in PubMed, with publication dates in the years 2000, 2010 and 2020, that included one of 6 terms currently used to describe eye disease associated with autoimmune thyroid disease. Characteristics pertaining to authors, journals, and article type were recorded. Results showed that the most used term in the 2000 literature was Graves' Ophthalmopathy (61%). In the 2010 literature, Graves' Orbitopathy (31%) became most common, followed by Graves' Ophthalmopathy (30%). Between 2010 and 2020, thyroid eye disease (37%) became the most common term, followed by Graves' Orbitopathy (35%). This perspective article proposes "thyroid eye disease" (TED) as the preferred name for this entity and discusses supporting terminology patterns and trends over time in scientific literature and in professional societies.

Decreased Bell's phenomenon after inferior and medial orbital wall decompression in thyroid-associated ophthalmopathy: a double-edged sword in management of the patients

PURPOSE

To evaluate the changes in Bell's phenomenon after inferior and medial orbital wall decompression in patients with thyroid-associated ophthalmopathy (TAO).

METHODS

This prospective interventional study included patients with moderate to severe non-active TAO, who underwent inferior and medial wall orbital decompression. Bell's phenomenon and adjusted Bell's phenomenon were evaluated at baseline and six months after surgery. Bell's phenomenon was assessed by holding the upper lid open during forced eyelid closure. Afterwards, the upward excursion, the distance between lower eyelid margin and lower corneal limbus, was measured. Adjusted Bell's phenomenon distance is defined as the difference between margin reflex distance two (MRD2) and Bell's phenomenon distance.

RESULTS

Thirty TAO patients, including 15 males (50%), with a mean age of 43.6 ± 11.6 years, were enrolled. The distance of Bell's phenomenon significantly decreased after surgery by an average of 3.25 ± 1.57 mm (P < 0.001). In addition, the difference between pre- and post-operative distance of adjusted Bell's phenomenon was - 1.58 ± 2.13 (P < 0.001) corresponding to the worsening in the adjusted Bell's phenomenon.

CONCLUSION

The result of our study demonstrated that Bell's phenomenon decreases significantly after inferior and medial wall decompression, which could be considered a complication of this form of orbital wall decompression in TAO.

Complications, treatments, and visual prognosis of choroidal osteomas

PURPOSE

This study aims to report complications, treatments, and visual prognosis of choroidal osteoma.

METHODS

We retrospectively reviewed electronic medical records and multimodal images of 41 patients with choroidal osteoma.

RESULTS

Visually significant complications included choroidal neovascularization (CNV) in 21 (47.7%) eyes and subretinal fluid (SRF) without CNV in 14 (31.8%) eyes. The most common treatment was intravitreal anti-vascular endothelial growth factor (VEGF) injection: 13 (61.9%) eyes with CNV received an average of 6.3 injections, and 6 (42.9%) eyes with SRF but without CNV received 1.8 injections. As the first-line treatment, intravitreal anti-VEGF injection induced complete or partial remission in 93.4% of eyes with CNV and 57.1% of eyes with SRF. The probability of legally low vision estimated at 3 and at 5 years was 29.1% and 34.2%, respectively. The presence of CNV and outer retinal tubulation (ORT) was independent risk factors for vision loss (adjusted odds ratio, 8.08 and 6.94, respectively).

CONCLUSIONS

The development of CNV and ORT was strong risk factors for visual impairment. Due to the frequent recurrence of complications and poor visual prognosis, regular check-ups and appropriate treatment choices are warranted.

A systematic review of euthyroid Graves' disease (Review)

Euthyroid Graves' Disease (EGD) is a challenging pathology, due to its atypical clinical manifestations and the absence of abnormal thyroid function. Typically, thyroid ophthalmopathy is associated with elevated thyroid hormone levels and with the presence of thyrotropin receptor antibodies (TRAb) but a low percentage of patients remain euthyroid without developing hyperthyroidism during long-term follow-up periods. Although it is considered a different pathology, it shares a lot of similarities with Graves' disease, rendering the diagnosis more difficult. It is also important to note that ophthalmopathy may be the first clinical manifestation of Graves' disease and that thyroid function examinations do not present abnormalities over a long period. Treatment choices for euthyroid disease do not differ from those described in Graves' ophthalmopathy. However, it is considered that since euthyroid patients develop milder ophthalmic symptoms and their clinical activity score is lower, they tend to have better responses to treatment. Moreover, atypical sight-threatening cases such as exposure keratopathy and dysthyroid optic neuropathy with variable responses to therapy also exist. Disease management consists of a favorable collaboration between ophthalmologists and endocrinologists because patients with EGD can develop thyroid abnormalities over time. In conclusion, the diagnosis of EGD is difficult, clinical manifestations and evolution are variables depending on several factors, including the heterogeneity of TRAb. This review aimed to identify the characteristics of this disease by reviewing the clinical studies and case reports published in previous years.

Carotid Cavernous Sinus Fistula with Contralateral Feed Not Diagnosed by Virtual Assessment or by Non-Invasive Vascular Imaging

A 67-year-old woman had delayed initial diagnosis of her right low flow carotid cavernous fistula (CCF) during the coronavirus disease (COVID-19) pandemic due to difficulty detecting ocular signs via online virtual examinations. Her right eye conjunctival erythema and proptosis with medial rectus enlargement on computed tomography scan was initially misdiagnosed as euthyroid thyroid-associated orbitopathy without lid retraction. She developed vision loss, and increasing episcleral venous congestion and CCF was suspected. Computed tomographic angiography did not show an obvious fistula. Digital subtraction angiography revealed the right-sided low flow CCF, which was fed from vessels from the contralateral side.

Association of Polygenetic Risk Scores Related to Immunity and Inflammation with Hyperthyroidism Risk and Interactions between the Polygenetic Scores and Dietary Factors in a Large Cohort

Graves's disease and thyroiditis induce hyperthyroidism, the causes of which remain unclear, although they are involved with genetic and environmental factors. We aimed to evaluate polygenetic variants for hyperthyroidism risk and their interaction with metabolic parameters and nutritional intakes in an urban hospital-based cohort. A genome-wide association study (GWAS) of participants with (cases; n = 842) and without (controls, n = 38,799) hyperthyroidism was used to identify and select genetic variants. In clinical and lifestyle interaction with PRS, 312 participants cured of hyperthyroidism were excluded. Single nucleotide polymorphisms (SNPs) associated with gene-gene interactions were selected by hyperthyroidism generalized multifactor dimensionality reduction. Polygenic risk scores (PRSs) were generated by summing the numbers of selected SNP risk alleles. The best gene-gene interaction model included tumor-necrosis factor (TNF)_rs1800610, mucin 22 (MUC22)_rs1304322089, tribbles pseudokinase 2 (TRIB2)_rs1881145, cytotoxic T-lymphocyte-associated antigen 4 (CTLA4)_rs231775, lipoma-preferred partner (LPP)_rs6780858, and human leukocyte antigen (HLA)-J_ rs767861647. The PRS of the best model was positively associated with hyperthyroidism risk by 1.939-fold (1.317-2.854) after adjusting for covariates. PRSs interacted with age, metabolic syndrome, and dietary inflammatory index (DII), while hyperthyroidism risk interacted with energy, calcium, seaweed, milk, and coffee intake (P < 0.05). The PRS impact on hyperthyroidism risk was observed in younger (<55 years) participants and adults without metabolic syndrome. PRSs were positively associated with hyperthyroidism risk in participants with low dietary intakes of energy (OR = 2.74), calcium (OR = 2.84), seaweed (OR = 3.43), milk (OR = 2.91), coffee (OR = 2.44), and DII (OR = 3.45). In conclusion, adults with high PRS involved in inflammation and immunity had a high hyperthyroidism risk exacerbated under low intakes of energy, calcium, seaweed, milk, or coffee. These results can be applied to personalized nutrition in a clinical setting.