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Yamaguchi Y, Okajima F, Sugihara H, Iwabu M, Emoto N. Atypical Clinical Courses of Graves' Disease Confound Differential Diagnosis of Hyperthyroidism. J NIPPON MED SCH 2024; 91:48-58. [PMID: 38072422 DOI: 10.1272/jnms.jnms.2024_91-104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
Abstract
BACKGROUND This study examined the appropriateness of the current paradigm for differential diagnosis of painless thyroiditis and Graves' disease (GD) in patients with thyrotoxicosis. METHODS We retrospectively evaluated the clinical course of 343 consecutive patients with hyperthyroidism diagnosed by Tc-99m pertechnetate thyroid uptake (TcTU) testing at our hospital from January 2011 to December 2017. RESULTS Of the 263 patients with normal or high TcTU levels (≥1.0%), 255 (97%) had unequivocal GD and 5 had spontaneous remission GD or atypical GD. Of the 10 patients with low TcTU levels (<1.0% and ≥0.5%), 7 had GD, while others had subclinical GD, spontaneous remission GD with later relapse, and painless thyroiditis. Of those with very low TcTU levels (<0.5%), most had thyroiditis (painless thyroiditis, 33/67 [49%]; subacute thyroiditis, 29/67 [43%]), and some were positive for anti-TSH receptor antibodies. CONCLUSION Given that atypical GD may confound the diagnosis of thyrotoxicosis, it is essential to follow the patient as a tentative diagnosis, whatever the diagnosis. This is the first report clearly demonstrating that so far there is no gold standard for the diagnosis of GD. It is therefore urgent to establish a consensus on the definition of GD so that the specificity and sensitivity of future diagnostic tests can be determined.
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Affiliation(s)
- Yuji Yamaguchi
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
- Department of Diabetes, Endocrinology and Metabolism, Nippon Medical School Chiba Hokusoh Hospital
| | - Fumitaka Okajima
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
- Department of Diabetes, Endocrinology and Metabolism, Nippon Medical School Chiba Hokusoh Hospital
| | - Hitoshi Sugihara
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
- IVY Clinic
| | - Masato Iwabu
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
| | - Naoya Emoto
- Department of Endocrinology, Metabolism and Nephrology, Graduate School of Medicine, Nippon Medical School
- Department of Diabetes, Endocrinology and Metabolism, Nippon Medical School Chiba Hokusoh Hospital
- Diabetes & Endocrine Clinic, Sakura Chuo Hospital
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2
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Chaker L, Cooper DS, Walsh JP, Peeters RP. Hyperthyroidism. Lancet 2024; 403:768-780. [PMID: 38278171 DOI: 10.1016/s0140-6736(23)02016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 08/07/2023] [Accepted: 09/16/2023] [Indexed: 01/28/2024]
Abstract
Thyrotoxicosis causes a variety of symptoms and adverse health outcomes. Hyperthyroidism refers to increased thyroid hormone synthesis and secretion, most commonly from Graves' disease or toxic nodular goitre, whereas thyroiditis (typically autoimmune, viral, or drug induced) causes thyrotoxicosis without hyperthyroidism. The diagnosis is based on suppressed serum concentrations of thyroid-stimulating hormone (TSH), accompanied by free thyroxine and total or free tri-iodothyronine concentrations, which are raised (overt hyperthyroidism) or within range (subclinical hyperthyroidism). The underlying cause is determined by clinical assessment, detection of TSH-receptor antibodies and, if necessary, radionuclide thyroid scintigraphy. Treatment options for hyperthyroidism include antithyroid drugs, radioactive iodine, and thyroidectomy, whereas thyroiditis is managed symptomatically or with glucocorticoid therapy. In Graves' disease, first-line treatment is a 12-18-month course of antithyroid drugs, whereas for goitre, radioactive iodine or surgery are preferred for toxic nodules or goitres. Evidence also supports long-term treatment with antithyroid drugs as an option for patients with Graves' disease and toxic nodular goitre.
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Affiliation(s)
- Layal Chaker
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - David S Cooper
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P Walsh
- Department of Endocrinology & Diabetes, Sir Charles Gairdner Hospital, Nedlands, WA, Australia; Medical School, University of Western Australia, Crawley, WA, Australia
| | - Robin P Peeters
- Department of Internal Medicine, Erasmus University Medical Center, Rotterdam, Netherlands.
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3
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Lewandowski KC, Kawalec J, Kusiński M, Dąbrowska K, Matusiak AE, Dudek I, Lewiński A. The Utility of Intravenous Methylprednisolone as an Adjunct Treatment for Drug-Resistant Amiodarone-Induced Thyrotoxicosis. J Clin Med 2024; 13:324. [PMID: 38256458 PMCID: PMC10816408 DOI: 10.3390/jcm13020324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/31/2023] [Accepted: 12/04/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Amiodarone-induced thyrotoxicosis (AIT) may pose treatment challenges. We present a series of patients in which we achieved the normalisation of free T3 (FT3) using intravenous methylprednisolone (ivMP) in AIT refractory to thiamazole and oral prednisone. Namely, in three males (aged 56, 50 and 64, all with a history of AF and/or a low ejection fraction), an addition of ivMP resulted in the normalisation of FT3, which allowed successful thyroidectomy. In another case of a 65-year-old man, we initially succeeded in the normalisation of FT3 using ivMP from FT4 > 7.77 ng/dL (0.93-1.7) to 2.41 ng/dL and in that of FT3 from 14.95 pg/mL (2-4.4) to 2.05 pg/mL), but four weeks after stopping ivMP, despite the continuation of thiamazole and prednisone, there was rebound thyrotoxicosis: FT4 > 7.77 ng/dL and FT3-5.46 pg/mL. Intravenous MP was restated leading to a decline in FT4 to 2.51 ng/dL and in FT3 to 1.92 pg/mL, thus allowing a successful thyroidectomy. Finally, in a 78-year-old man with AF, goitre, and AIT resistant to thiamazole, prednisone and lithium carbonate, we obtained a reduction in FT4 to 1.51 ng/dL and in FT3 to 3.17 pg/mL after seven pulses of ivMP. Oral prednisone was gradually reduced and successfully stopped about six months later. He remained on low-dose thiamazole (5 mg od). CONCLUSIONS Pulse ivMP in addition to oral steroids may be a useful adjunct therapy either for the preparation of a thyroidectomy or as a treatment modality in drug-resistant AIT. Though a total cure is possible, there is a danger of a rebound worsening of thyrotoxicosis after premature discontinuation of ivMP.
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Affiliation(s)
- Krzysztof Cezary Lewandowski
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, 93-338 Lodz, Poland; (K.C.L.); (A.E.M.)
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, 93-338 Lodz, Poland; (J.K.); (K.D.); (I.D.)
| | - Joanna Kawalec
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, 93-338 Lodz, Poland; (J.K.); (K.D.); (I.D.)
| | - Michał Kusiński
- Department of Endocrinological, General and Vascular Surgery, Medical University of Lodz, 93-338 Lodz, Poland;
- Department of Endocrine, General and Oncological Surgery, Mikolaj Kopernik District Hospital, 91-513 Lodz, Poland
| | - Katarzyna Dąbrowska
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, 93-338 Lodz, Poland; (J.K.); (K.D.); (I.D.)
| | - Aleksandra Ewa Matusiak
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, 93-338 Lodz, Poland; (K.C.L.); (A.E.M.)
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, 93-338 Lodz, Poland; (J.K.); (K.D.); (I.D.)
| | - Iga Dudek
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, 93-338 Lodz, Poland; (J.K.); (K.D.); (I.D.)
| | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, 93-338 Lodz, Poland; (J.K.); (K.D.); (I.D.)
- Department of Paediatric Endocrinology, Medical University of Lodz, 93-338 Lodz, Poland
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2024; 149:e1-e156. [PMID: 38033089 PMCID: PMC11095842 DOI: 10.1161/cir.0000000000001193] [Citation(s) in RCA: 76] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines liaison
| | | | | | | | | | - Paul L Hess
- ACC/AHA Joint Committee on Performance Measures liaison
| | | | | | | | | | - Kazuhiko Kido
- American College of Clinical Pharmacy representative
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5
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Sharma P, Sheikh R, Siribaddana N, Sathyanarayanan A, Fernando D, Muraleedharan V. Monitoring thyroid function during amiodarone use. Br J Hosp Med (Lond) 2024; 85:1-5. [PMID: 38300678 DOI: 10.12968/hmed.2023.0214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Amiodarone is an antiarrhythmic drug used to treat cardiac tachyarrhythmias. It has many adverse effects, with thyroid dysfunction one of the most notable. Through various mechanisms, both thyrotoxicosis and hypothyroidism can occur secondary to amiodarone therapy. There are two types of amiodarone-induced thyrotoxicosis: type 1 occurs in those with pre-existing thyroid disease and is treated with thionamide, whereas type 2 occurs in those without and is treated with glucocorticoids. Patients with amiodarone-induced hypothyroidism may be given levothyroxine to replace thyroid hormone, but in some cases, the appropriate management may be cessation of amiodarone.
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Affiliation(s)
- Priya Sharma
- Department of Diabetes and Endocrinology, King's Mill Hospital, Sutton-in-Ashfield, UK
| | - Riyad Sheikh
- Department of Diabetes and Endocrinology, King's Mill Hospital, Sutton-in-Ashfield, UK
| | - Nipuna Siribaddana
- Department of Diabetes and Endocrinology, King's Mill Hospital, Sutton-in-Ashfield, UK
| | | | - Devaka Fernando
- Department of Diabetes and Endocrinology, King's Mill Hospital, Sutton-in-Ashfield, UK
| | - Vakkat Muraleedharan
- Department of Diabetes and Endocrinology, King's Mill Hospital, Sutton-in-Ashfield, UK
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6
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Joglar JA, Chung MK, Armbruster AL, Benjamin EJ, Chyou JY, Cronin EM, Deswal A, Eckhardt LL, Goldberger ZD, Gopinathannair R, Gorenek B, Hess PL, Hlatky M, Hogan G, Ibeh C, Indik JH, Kido K, Kusumoto F, Link MS, Linta KT, Marcus GM, McCarthy PM, Patel N, Patton KK, Perez MV, Piccini JP, Russo AM, Sanders P, Streur MM, Thomas KL, Times S, Tisdale JE, Valente AM, Van Wagoner DR. 2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Atrial Fibrillation: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2024; 83:109-279. [PMID: 38043043 PMCID: PMC11104284 DOI: 10.1016/j.jacc.2023.08.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2023]
Abstract
AIM The "2023 ACC/AHA/ACCP/HRS Guideline for the Diagnosis and Management of Patients With Atrial Fibrillation" provides recommendations to guide clinicians in the treatment of patients with atrial fibrillation. METHODS A comprehensive literature search was conducted from May 12, 2022, to November 3, 2022, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, the Cochrane Library, the Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline. Additional relevant studies, published through November 2022, during the guideline writing process, were also considered by the writing committee and added to the evidence tables, where appropriate. STRUCTURE Atrial fibrillation is the most sustained common arrhythmia, and its incidence and prevalence are increasing in the United States and globally. Recommendations from the "2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" and the "2019 AHA/ACC/HRS Focused Update of the 2014 AHA/ACC/HRS Guideline for the Management of Patients With Atrial Fibrillation" have been updated with new evidence to guide clinicians. In addition, new recommendations addressing atrial fibrillation and thromboembolic risk assessment, anticoagulation, left atrial appendage occlusion, atrial fibrillation catheter or surgical ablation, and risk factor modification and atrial fibrillation prevention have been developed.
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Yazdaan HE, Jaya F, Sanjna F, Junaid M, Rasool S, Baig A, Natt MZ, Maurya N, Iqbal S, Yeldo BA, Khan AS, Varrassi G, Kumar S, Khatri M, Awan SK. Advances in Thyroid Function Tests: Precision Diagnostics and Clinical Implications. Cureus 2023; 15:e48961. [PMID: 38111456 PMCID: PMC10726078 DOI: 10.7759/cureus.48961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 11/17/2023] [Indexed: 12/20/2023] Open
Abstract
This narrative review explores the evolving field of thyroid function testing, explicitly highlighting the significance of precision diagnostics and their substantial impact on clinical practice. Commencing with a comprehensive examination of the historical progression of thyroid diagnostics, the discourse proceeds to explore recent developments, highlighting the paramount importance of accuracy in testing methods. The primary issue under consideration is the crucial requirement for accuracy in the field of therapeutic practice. The review critically examines the problems related to the interpretation, standardization, and ethical considerations in examining advanced laboratory techniques, novel biomarkers, and state-of-the-art technologies like immunoassays, molecular testing, and automation. The focus on the paradigm shift towards precision diagnostics brings attention to the complex connection between test results and their direct influence on patient care. This investigation expands upon the incorporation of imaging and molecular diagnostics, highlighting the rising significance of precision in customizing treatment strategies. In summary, the study provides a prospective viewpoint, recognizing the persistent obstacles and highlighting the want for dependable, uniform methodologies in thyroid diagnostics. This narrative's primary objective is to guide physicians, researchers, and stakeholders in effectively navigating the intricate nature of contemporary thyroid function tests, with a particular emphasis on resolving the fundamental issue of precision.
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Affiliation(s)
- Hamd E Yazdaan
- Internal Medicine, Khyber Medical College, Peshawar, PAK
| | - Fnu Jaya
- Medicine, Ziauddin University, Karachi, PAK
| | - Fnu Sanjna
- Medicine, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
| | - Maha Junaid
- Medicine, Shifa College of Medicine, Islamabad, PAK
| | - Sohaib Rasool
- Medicine, Bakhtawar Amin Medical and Dental College, Multan, PAK
| | - Ahmadullah Baig
- Internal Medicine, Allama Iqbal Medical College/ Jinnah Hospital, Lahore, PAK
| | | | - Nikhil Maurya
- Medicine, Ruxmaniben Deepchand Gardi Medical College (RDGMC), Ujjain, IND
| | - Subhan Iqbal
- Diagnostic Radiology, Dr. Ziauddin Hospital North Nazimabad, Karachi, PAK
| | | | - Alina S Khan
- Medicine and Surgery, Liaquat National Hospital and Medical College, Karachi, PAK
| | | | - Satesh Kumar
- Medicine and Surgery, Shaheed Mohtarma Benazir Bhutto Medical College, Karachi, PAK
| | - Mahima Khatri
- Medicine and Surgery, Dow University of Health Sciences, Karachi, PAK
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8
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Rhee CM, You AS, Narasaki Y, Brent GA, Sim JJ, Kovesdy CP, Kalantar-Zadeh K, Nguyen DV. Development and Validation of a Prediction Model for Incident Hypothyroidism in a National Chronic Kidney Disease Cohort. J Clin Endocrinol Metab 2023; 108:e1374-e1383. [PMID: 37186674 PMCID: PMC11009786 DOI: 10.1210/clinem/dgad261] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 04/15/2023] [Accepted: 05/09/2023] [Indexed: 05/17/2023]
Abstract
CONTEXT Hypothyroidism is a common yet under-recognized condition in patients with chronic kidney disease (CKD), which may lead to end-organ complications if left untreated. OBJECTIVE We developed a prediction tool to identify CKD patients at risk for incident hypothyroidism. METHODS Among 15 642 patients with stages 4 to 5 CKD without evidence of pre-existing thyroid disease, we developed and validated a risk prediction tool for the development of incident hypothyroidism (defined as thyrotropin [TSH] > 5.0 mIU/L) using the Optum Labs Data Warehouse, which contains de-identified administrative claims, including medical and pharmacy claims and enrollment records for commercial and Medicare Advantage enrollees as well as electronic health record data. Patients were divided into a two-thirds development set and a one-third validation set. Prediction models were developed using Cox models to estimate probability of incident hypothyroidism. RESULTS There were 1650 (11%) cases of incident hypothyroidism during a median follow-up of 3.4 years. Characteristics associated with hypothyroidism included older age, White race, higher body mass index, low serum albumin, higher baseline TSH, hypertension, congestive heart failure, exposure to iodinated contrast via angiogram or computed tomography scan, and amiodarone use. Model discrimination was good with similar C-statistics in the development and validation datasets: 0.77 (95% CI 0.75-0.78) and 0.76 (95% CI 0.74-0.78), respectively. Model goodness-of-fit tests showed adequate fit in the overall cohort (P = .47) as well as in a subcohort of patients with stage 5 CKD (P = .33). CONCLUSION In a national cohort of CKD patients, we developed a clinical prediction tool identifying those at risk for incident hypothyroidism to inform prioritized screening, monitoring, and treatment in this population.
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Affiliation(s)
- Connie M Rhee
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
| | - Amy S You
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
| | - Yoko Narasaki
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
| | - Gregory A Brent
- Division of Endocrinology, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA 90095, USA
- Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, CA 90073, USA
| | - John J Sim
- Division of Nephrology, Kaiser Permanente Southern California, Los Angeles, CA 90027, USA
| | - Csaba P Kovesdy
- Division of Nephrology, University of Tennessee Health Science Center, Memphis, TN 38104, USA
- Section of Nephrology, Memphis Veterans Affairs Medical Center, Memphis, TN 38104, USA
| | - Kamyar Kalantar-Zadeh
- Division of Nephrology, Hypertension, and Kidney Transplantation, University of California Irvine, Orange, CA 92868, USA
- Southern California Institute for Research and Education, Tibor Rubin Veterans Affairs Medical Center, Long Beach, CA 90822, USA
- Division of Nephrology and Hypertension, Harbor-UCLA Medical Center, Torrance, CA 90502, USA
| | - Danh V Nguyen
- Division of General Internal Medicine and Primary Care, University of California Irvine, Orange, CA 92868, USA
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Intenzo C, Miller J, Gulati A, Colarossi D, Parekh M. The Role of Nuclear Medicine in Benign Thyroid Disease. Semin Nucl Med 2023; 53:469-474. [PMID: 37142521 DOI: 10.1053/j.semnuclmed.2023.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 03/30/2023] [Accepted: 04/10/2023] [Indexed: 05/06/2023]
Abstract
Since the mid-twentieth century, the radionuclide thyroid scan has been utilized in the management of benign thyroid disorders. In current medical practice, patients with hyperthyroidism are referred for thyroid scintigraphy, while patients with goiters and thyroid nodules are most often evaluated by ultrasound or computed tomography. Since thyroid scintigraphy reflects the functional state of the gland, it provides information that anatomical imaging lacks. Therefore, radionuclide imaging of the thyroid is the imaging modality of choice in the evaluation of the hyperthyroid patient. In addition, patients with so-called subclinical hyperthyroidism often present a diagnostic dilemma to the clinician since the causative factor must be determined for proper patient management. The aim of this manuscript is to illustrate the imaging characteristics of thyroid disorders commonly seen in clinical practice resulting in thyrotoxicosis or pending thyrotoxicosis, so that correlation with clinical presentation and pertinent laboratory data will lead to the correct diagnosis.
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Affiliation(s)
- Charles Intenzo
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA.
| | - Jeffrey Miller
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Aishwarya Gulati
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Daly Colarossi
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
| | - Maansi Parekh
- Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA
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Gontarz-Nowak K, Szklarz M, Szychlińska M, Matuszewski W, Bandurska-Stankiewicz E. A Brief Look at Hashimoto's Disease, Adrenal Incidentalomas, Obesity and Insulin Resistance-Could Endocrine Disruptors Be the Other Side of the Same Coin? MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1234. [PMID: 37512046 PMCID: PMC10385892 DOI: 10.3390/medicina59071234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 06/20/2023] [Accepted: 06/24/2023] [Indexed: 07/30/2023]
Abstract
Hashimoto's disease (HD) is the most common cause of hypothyroidism in developed countries. The exact pathomechanism behind it has not been clearly established; however, an interplay of genetic susceptibility, environmental triggers (including diet) and epigenetic factors seems to be involved. Among the latter, increasingly more attention has been paid to some hormonally active substances, known as endocrine disruptors, which are commonly used worldwide. HD has become a condition widely reported in the media, acting as a culprit for inexplicable weight gain, chronic fatigue or weakness. Nevertheless, the recognition of HD is undeniably increasing and represents a major public health burden. At the same time, improving access to imaging tests has increased the number of incidentally diagnosed adrenal tumors. Above all, the widespread use of chest computed tomography (CT) due to the COVID-19 pandemic has contributed to frequent incidental detection of adrenal lesions. Fortunately, a vast majority of these findings are asymptomatic benign tumors with no excessive hormonal activity, and therefore, they are defined as adrenal incidentalomas (AIs). Interestingly, recent studies have indicated that patients with AIs are more prone to obesity and insulin resistance. Although mutual relationships between the thyroid and the adrenal glands have been studied widely, still, little is known about the possible pathophysiological associations between thyroid autoimmunity and the occurrence of adrenal incidentalomas. This article presents a brief review of the common endocrine disorders with a special focus on the frequently coexisting insulin resistance and/or obesity. Furthermore, in response to the recent growing interest in endocrine disruptors, with their transgenerational epigenetic effects that influence hormonal system function, a concise overview of the topic has also been included.
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Affiliation(s)
- Katarzyna Gontarz-Nowak
- Department of Internal Medicine, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
| | - Michał Szklarz
- Department of Internal Medicine, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
| | - Magdalena Szychlińska
- Department of Internal Medicine, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
| | - Wojciech Matuszewski
- Department of Internal Medicine, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
| | - Elżbieta Bandurska-Stankiewicz
- Department of Internal Medicine, Faculty of Medical Sciences, University of Warmia and Mazury in Olsztyn, 10-719 Olsztyn, Poland
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11
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Alnaeem MM, Suleiman KH, Mansour NH, Alwahsh BS, Nashwan AJ. Amiodarone-Induced Myxedema Coma in Elderly Patients: A Systematic Review of Case Reports. Cureus 2023; 15:e40893. [PMID: 37492810 PMCID: PMC10364664 DOI: 10.7759/cureus.40893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/24/2023] [Indexed: 07/27/2023] Open
Abstract
This systematic review aimed to explore whether elderly patients administered amiodarone were susceptible to developing myxedema coma. Utilizing the Cochrane guidelines, a comprehensive review of databases such as Medline (PubMed), Science Direct, CINAHL Cochrane, and Google Scholar was undertaken to examine case reports on amiodarone-induced myxedema coma. Following stringent criteria for inclusion, 12 pertinent case reports were identified. These findings suggested a high probability of myxedema coma development in patients who had been administered amiodarone. Specifically, patients who received an oral dosage of 100-200 mg of amiodarone were reported to have developed bradycardia and hypothermia alongside elevated thyroid-stimulating hormone (TSH) levels. Upon diagnosis, the majority of patients were treated with a regimen of levothyroxine and hydrocortisone medication. Despite the myriad potential causes of myxedema coma complicating the diagnosis, it was found that through a combination of clinical symptoms and serum TSH measurements, a confirmed diagnosis could be reached. Furthermore, it was observed that amiodarone-induced myxedema coma responded favorably to treatment with levothyroxine and glucocorticoids.
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Affiliation(s)
| | | | - Nadeen H Mansour
- School of Nursing, Al-Zaytoonah University of Jordan, Amman, JOR
| | - Bayan S Alwahsh
- School of Nursing, Al-Zaytoonah University of Jordan, Amman, JOR
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12
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Mammen JSR. Thyroid and Aging. Endocrinol Metab Clin North Am 2023; 52:229-243. [PMID: 36948777 DOI: 10.1016/j.ecl.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Older adults are more vulnerable to the negative effects of excess thyroid hormone and may even be protected by lower levels of thyroid hormone. The diagnosis and management of thyroid disease in older adults needs to account for aging-related changes in function and resilliance.
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Affiliation(s)
- Jennifer S R Mammen
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Bayview Medical Center, 5501 Hopkins Bayview Circle, Asthma and Allergy Center, 2A62, Baltimore, MD 21224, USA.
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13
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Tizianel I, Sabbadin C, Censi S, Clausi C, Colpo A, Leahu AI, Iacobone M, Mian C, Scaroni C, Ceccato F. Therapeutic Plasma Exchange for the Treatment of Hyperthyroidism: Approach to the Patient with Thyrotoxicosis or Antithyroid-Drugs Induced Agranulocytosis. J Pers Med 2023; 13:jpm13030517. [PMID: 36983698 PMCID: PMC10056870 DOI: 10.3390/jpm13030517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/01/2023] [Accepted: 03/09/2023] [Indexed: 03/17/2023] Open
Abstract
Primary hyperthyroidism is an endocrine disorder characterized by excessive thyroid hormone synthesis and secretion by the thyroid gland. Clinical manifestations of hyperthyroidism can vary from subclinical to overt forms. In rare cases, hyperthyroidism may represent a clinical emergency, requiring admission to an intensive care unit due to an acute and severe exacerbation of thyrotoxicosis, known as a thyroid storm. First-line treatment of hyperthyroidism is almost always based on medical therapy (with thioamides, beta-adrenergic blocking agents, glucocorticoids), radioactive iodine or total thyroidectomy, tailored to the patient’s diagnosis. In cases of failure/intolerance/adverse events or contraindication to these therapies, as well as in life-threatening situations, including a thyroid storm, it is necessary to consider an alternative treatment with extracorporeal systems, such as therapeutic plasma exchange (TPE). This approach can promptly resolve severe conditions by removing circulating thyroid hormones. Here we described two different applications of TPE in clinical practice: the first case is an example of thyrotoxicosis due to amiodarone treatment, while the second one is an example of a severe adverse event to antithyroid drugs (agranulocytosis induced by methimazole).
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Affiliation(s)
- Irene Tizianel
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Chiara Sabbadin
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Simona Censi
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Cristina Clausi
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Anna Colpo
- Department of Transfusion Medicine, Padua University Hospital, Via Giustiniani 2, 35128 Padova, Italy
| | - Anca Irina Leahu
- Department of Transfusion Medicine, Padua University Hospital, Via Giustiniani 2, 35128 Padova, Italy
| | - Maurizio Iacobone
- Endocrine Surgery Unit, Department of Surgery, Oncology and Gastroenterology (DISCOG), Padua University Hospital, Via Giustiniani 2, 35128 Padova, Italy
| | - Caterina Mian
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Carla Scaroni
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
| | - Filippo Ceccato
- Department of Medicine (DIMED), University of Padova, Via Giustiniani 2, 35128 Padova, Italy
- Endocrinology Unit, Padova University Hospital, Via Ospedale Civile 105, 35128 Padova, Italy
- Correspondence: ; Tel.: +39-049-8211323
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14
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Al Manasra T, Shah SQ, Raj SR, Pollak PT. Amiodarone Thyrotoxicosis: A Case of Pharmacy Error Obscured by Amiodarone Suppression of Symptoms of Highly Elevated Thyroxine Concentration. CJC Open 2023; 5:173-176. [PMID: 36880080 PMCID: PMC9984889 DOI: 10.1016/j.cjco.2022.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Affiliation(s)
- Tariq Al Manasra
- Department of Medicine, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Syed Qutb Shah
- Department of Medicine, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Satish R Raj
- Department of Cardiac Sciences, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - P Timothy Pollak
- Department of Medicine, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Cardiac Sciences, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute, Cummings School of Medicine, University of Calgary, Calgary, Alberta, Canada
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15
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Cappellani D, Marconcini G, Manetti L, Bartalena L, Bogazzi F. Real-life data on the impact of medical therapy for amiodarone-induced thyrotoxicosis on CV events and hospitalizations. J Clin Endocrinol Metab 2022; 108:1298-1307. [PMID: 36585895 DOI: 10.1210/clinem/dgac756] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 12/09/2022] [Accepted: 12/28/2022] [Indexed: 01/01/2023]
Abstract
CONTEXT Patients with amiodarone-induced thyrotoxicosis (AIT) often receive the initial therapy for thyrotoxicosis in several different medical settings before admission to a referral center. Whether the first-line medical therapy (i.e. therapies for thyrotoxicosis at first diagnosis of AIT) affects the outcome of AIT patients is unknown. STUDY DESIGN Single-center historical-prospective cohort study of 313 AIT patients. METHODS Clinical and biochemical data were collected at first diagnosis, at a referral center, and during the course of AIT. Primary outcomes were cardiovascular events and hospitalizations. First-line therapies were considered appropriate when they included glucocorticoids for type 2 AIT and methimazole for type 1 AIT at the approved dosage, either alone (optimal medical therapy, OMT) or in combination (right-dose combination therapy, RCT). Other therapies were considered not appropriate, including no therapy. Duration of exposure to thyrotoxicosis was the time from first diagnosis of AIT to its remission. RESULTS 34.5% patients received appropriate therapies (28.1% OMT, 6.4% RCT), whereas the remaining (65.5%) received non-appropriate therapies. Cardiovascular events, and hospitalizations were more frequent in patients who received non-appropriate therapies (33.2% vs 4.5%, and 24.9% vs 6.5%, respectively; p<0.0001 for both). Appropriate therapies reduced serum thyroid hormone concentrations (p=0.018) from first diagnosis to referral, unlike the non-appropriate therapies. The duration of exposure to thyrotoxicosis was longer in patients receiving non-appropriate therapies and was a risk factor for arrhythmias (HR 1.004, p=0.0008), MACEs (HR 1.004, p=0.020) and hospitalizations (HR 1.006, p<.0001). CONCLUSIONS The first medical therapy of AIT influences the exposure time to thyrotoxicosis and the occurrence of cardiovascular events and hospitalizations.
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Affiliation(s)
- Daniele Cappellani
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Giulia Marconcini
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luca Manetti
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Luigi Bartalena
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Fausto Bogazzi
- Unit of Endocrinology, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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16
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Karbownik-Lewińska M, Stępniak J, Iwan P, Lewiński A. Iodine as a potential endocrine disruptor-a role of oxidative stress. Endocrine 2022; 78:219-240. [PMID: 35726078 PMCID: PMC9584999 DOI: 10.1007/s12020-022-03107-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/02/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE Iodine is an essential micronutrient required for thyroid hormone biosynthesis. However, overtreatment with iodine can unfavorably affect thyroid physiology. The aim of this review is to present the evidence that iodine-when in excess-can interfere with thyroid hormone synthesis and, therefore, can act as a potential endocrine-disrupting chemical (EDC), and that this action, as well as other abnormalities in the thyroid, occurs-at least partially-via oxidative stress. METHODS We reviewed published studies on iodine as a potential EDC, with particular emphasis on the phenomenon of oxidative stress. RESULTS This paper summarizes current knowledge on iodine excess in the context of its properties as an EDC and its effects on oxidative processes. CONCLUSION Iodine does fulfill the criteria of an EDC because it is an exogenous chemical that interferes-when in excess-with thyroid hormone synthesis. However, this statement cannot change general rules regarding iodine supply, which means that iodine deficiency should be still eliminated worldwide and, at the same time, iodine excess should be avoided. Universal awareness that iodine is a potential EDC would make consumers more careful regarding their diet and what they supplement in tablets, and-what is of great importance-it would make caregivers choose iodine-containing medications (or other chemicals) more prudently. It should be stressed that compared to iodine deficiency, iodine in excess (acting either as a potential EDC or via other mechanisms) is much less harmful in such a sense that it affects only a small percentage of sensitive individuals, whereas the former affects whole populations; therefore, it causes endemic consequences.
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Affiliation(s)
- Małgorzata Karbownik-Lewińska
- Department of Oncological Endocrinology, Medical University of Lodz, 90-752, Lodz, Poland.
- Polish Mother's Memorial Hospital-Research Institute, 93-338, Lodz, Poland.
| | - Jan Stępniak
- Department of Oncological Endocrinology, Medical University of Lodz, 90-752, Lodz, Poland
| | - Paulina Iwan
- Department of Oncological Endocrinology, Medical University of Lodz, 90-752, Lodz, Poland
| | - Andrzej Lewiński
- Polish Mother's Memorial Hospital-Research Institute, 93-338, Lodz, Poland
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, 93-338, Lodz, Poland
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17
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Fonseca M, Ferreira M, Paulo J, Neves Z. A Refractory Case of Amiodarone Thyrotoxicosis. Cureus 2022; 14:e28527. [PMID: 36185869 PMCID: PMC9516872 DOI: 10.7759/cureus.28527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 11/05/2022] Open
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18
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Protective Role of Amiodarone on Reperfusion Arrhythmia in Patients of Acute Myocardial Infarction with Percutaneous Coronary Intervention Treatment. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:2597173. [PMID: 36065272 PMCID: PMC9440625 DOI: 10.1155/2022/2597173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/29/2022] [Indexed: 11/18/2022]
Abstract
With the development and popularity of percutaneous coronary intervention (PCI), ischemia-reperfusion injury (IRI) has attracted more and more clinical attention. Reperfusion arrhythmia (RA), one of the common manifestations during and after PCI, can affect the postoperative cardiac function of patients with acute myocardial infarction (AMI). Therefore, effective intervention on RA has important clinical significance. This study observed the effect of amiodarone on reperfusion arrhythmia (RA) after percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI) and explored its possible mechanism. The results showed that amiodarone had good clinical efficacy in the prevention of RA in patients with AMI after PCI, and it could reduce the levels of serum IL-6, hs-CRP, CK-MB, and cTnI in patients and reduce the damage caused by reperfusion, thereby reducing the occurrence of RA.
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19
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Grußendorf M. [Thyrotoxicosis]. MMW Fortschr Med 2021; 163:50-59. [PMID: 34595648 DOI: 10.1007/s15006-021-0261-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
PURPOSE OF REVIEW Amiodarone-induced thyroid dysfunction is well established. The present review discusses recent literature related to the effects of amiodarone on the thyroid gland and thyroid function in pediatrics. RECENT FINDINGS Current guidelines in adults treated with amiodarone recommend baseline thyroid function testing followed by initiation of thyroid hormone monitoring after 3 months on therapy. Two retrospective studies to evaluate amiodarone-induced thyroid dysfunction in children and young adults reveal thyroid dysfunction as soon as 2 weeks after amiodarone initiation with a greater percentage of pediatric patients developing amiodarone-induced hypothyroidism rather than thyrotoxicosis. Although additional studies are needed to determine if AIH is associated with negative impact on growth and neurocognitive development, what is clear is that in both adults and pediatrics, there is low compliance with recommended side effect-monitoring guidelines. SUMMARY Pediatric patients are at similarly high risk to develop amiodarone-induced thyroid dysfunction as are adults. It is hoped that through improved education of providers and patients further research into the incidence, the potential risks of amiodarone therapy and the potential benefits of thyroid hormone replacement therapy in patients with AIH will be investigated and reported.
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Affiliation(s)
- Brett Barrett
- Division of Pediatric Endocrinology, Advocate Children's Hospital, Oak Lawn, Illinois
| | - Andrew J Bauer
- Division of Pediatric Endocrinology and Diabetes, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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21
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Ylli D, Wartofsky L, Burman KD. Response to Letter to the Editor from Sukor et al.: "Evaluation and Treatment of Amiodarone-induced Thyroid Disorders". J Clin Endocrinol Metab 2021; 106:e2839-e2840. [PMID: 33624808 PMCID: PMC8208675 DOI: 10.1210/clinem/dgab105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Dorina Ylli
- Endocrine Section, MedStar Washington Hospital Center and MedStar Health Research Institute, Washington, DC, USA
- Faculty of Medicine, University of Medicine, Tirana, Albania
| | - Leonard Wartofsky
- Endocrine Section, MedStar Washington Hospital Center and MedStar Health Research Institute, Washington, DC, USA
| | - Kenneth D Burman
- Endocrine Section, MedStar Washington Hospital Center and MedStar Health Research Institute, Washington, DC, USA
- Correspondence: Kenneth D. Burman, Room 2A72, MedStar Washington Hospital Center, 110 Irving Street Northwest, Washington, DC 20010, USA.
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22
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Sukor N, Lachumanan D, Kamaruddin NA. Letter to the Editor from Sukor et al: "Evaluation and Treatment of Amiodarone-Induced Thyroid Disorders". J Clin Endocrinol Metab 2021; 106:e2457-e2458. [PMID: 33624762 DOI: 10.1210/clinem/dgab104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Indexed: 11/19/2022]
Affiliation(s)
- Norlela Sukor
- Endocrine Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Deviga Lachumanan
- Endocrine Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Nor Azmi Kamaruddin
- Endocrine Unit, Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
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