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Kim S, Park S, Moon J, Kim H, Kang S. A novel variant of THRβ and its 4-year clinical course in a Korean boy with resistance to thyroid hormone. Ann Pediatr Endocrinol Metab 2023; 28:219-224. [PMID: 37798897 PMCID: PMC10556442 DOI: 10.6065/apem.2142246.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 01/21/2022] [Accepted: 02/28/2022] [Indexed: 10/07/2023] Open
Abstract
Thyroid hormone resistance (RTH) is characterized by a decreased sensitivity of target tissues to thyroid hormones due to a defect in the THRα- and THRβ-encoded thyroid hormone receptors (THRs). The clinical manifestations range from no symptoms to simple goiter and hypo- or hyperthyroidism, depending on the receptor subtype distribution in the tissues. Here, we report the case of a thyroid hormone-resistant 12-month-old boy carrying a novel THRβ variant who was initially diagnosed with congenital hypothyroidism. An extensive evaluation revealed increased free T4 level and inappropriately increased thyroid-stimulating hormone (TSH) level; a normal lipid profile, sex hormone-binding globulin, and free alpha subunit of TSH; exaggerated TSH response to THR; and no radiological evidence of pituitary adenoma. A targeted next-generation sequencing panel identified a heterozygote c.993T>G (p.Asn331Lys) mutation in the THRβ gene. During the first year of life, a higher dose of levothyroxine was administered to the patient due to uncompensated RTH. Levothyroxine treatment was continued after 3 years to maintain TSH level <5 mIU/mL, but the observed weight gain was poor, height increase was insufficient, and bone development was delayed. However, neither hyperactivity nor developmental delay was observed. Patients with RTH exhibit various clinical features. Due to its heterogeneous nature, genetic test for accurate diagnosis is important to provide proper management.
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Affiliation(s)
- Sejin Kim
- Department of Pediatrics, Keimyung University Dongsan Hospital, Keimyung University school of Medicine, Daegu, Korea
| | - Soyun Park
- Department of Pediatrics, Keimyung University Dongsan Hospital, Keimyung University school of Medicine, Daegu, Korea
| | - Jungeun Moon
- Department of Pediatrics, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Heungsik Kim
- Deparment of Pediatrics, Keimyung University Daegu Dongsan Hospital, Daegu, Korea
| | - Seokjin Kang
- Department of Pediatrics, Keimyung University Dongsan Hospital, Keimyung University school of Medicine, Daegu, Korea
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2
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Feng J, Lin S, Wang W, Chen Q, Wang W, Li J, Wang X. Thyroid hormone resistance resulting from a novel mutation in the THRB gene in a Chinese child: A case report. Medicine (Baltimore) 2023; 102:e33587. [PMID: 37115071 PMCID: PMC10145980 DOI: 10.1097/md.0000000000033587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 03/31/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Thyroid hormone resistance (RTH) (mim # 188570) is a rare autosomal dominant genetic disorder characterized by reduced thyroid hormone response in target tissues. The clinical manifestations of RTH vary from no symptoms to symptoms of thyroid hormone deficiency to symptoms of thyroid hormone excess. PATIENT CONCERN AND CLINICAL FINDINGS A 24-month-old girl presented with growth retardation, tachycardia, and persistently elevated thyroid hormones despite antithyroid treatment. DIAGNOSIS/INTERVENTION/OUTCOMES The patient was diagnosed with RTH, after whole exon gene sequencing, found a de novo missense mutation (c.1375T > G,p.Phe459Val) in a novel locus of the thyroid hormone receptor beta gene. She had only mild growth retardation, so the decision was made to monitor her development without intervention. At her last follow-up at 5 years and 8 months of age, she continued to show growth retardation (-2 standard deviation below age-appropriate levels), in addition to delayed language development. Her comprehension ability and heart rate have remained normal. CONCLUSIONS We report a mild case of RTH caused by a novel thyroid hormone receptor beta gene mutation. RTH should be considered in the differential diagnosis of abnormal serum thyroxine levels during neonatal screening.
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Affiliation(s)
- Jinhua Feng
- Diagnosis and Treatment Center for Children, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Shuangzhu Lin
- Diagnosis and Treatment Center for Children, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Wei Wang
- Diagnosis and Treatment Center for Children, The Affiliated Hospital of Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Qiandui Chen
- College of Integrated Chinese and Western Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Wanqi Wang
- Pediatrics of Traditional Chinese Medicine, College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Jiayi Li
- Pediatrics of Traditional Chinese Medicine, College of Traditional Chinese Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
| | - Xinyao Wang
- College of Integrated Chinese and Western Medicine, Changchun University of Chinese Medicine, Changchun, Jilin Province, China
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3
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Skowrońska-Jóźwiak E, Gach A, Cyniak-Magierska A, Nykel A, Jurkowska M, Lewiński A. Resistance to thyroid hormone due to a novel mutation in the thyroid beta receptor (THRβ) gene coexisting with autoimmune thyroid disease—A case report. Front Genet 2023; 14:1051042. [PMID: 37082196 PMCID: PMC10111252 DOI: 10.3389/fgene.2023.1051042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 02/13/2023] [Indexed: 04/07/2023] Open
Abstract
Resistance to thyroid hormone (RTH) is a syndrome characterized by impaired responsiveness of target tissues to thyroid hormones. The relationship between RTHβ and thyroid autoimmunity has been under research. In this study, we demonstrate a case report of a woman with a novel mutation in THRβ gene coexisting with autoimmune thyroid disease (AITD). The 36-year-old woman has been treated since childhood for a thyroid disease. Based on high levels of thyroid hormones (THs) and elevated concentrations of thyroperoxidase and thyroglobulin antibodies (TPOAb and TgAb, respectively), she received unnecessary long-term treatment with methimazole and finally underwent subtotal thyroidectomy. After the surgery, her TSH level remained significantly elevated, despite the treatment with 150 + 15 µg of thyroxine and triiodothyronine. A sequence analysis of the THRβ gene revealed a novel dinucleotide substitution affecting codon 453, resulting in the replacement of the normal proline with an asparagine (c.1357_1358delinsAA, p.(Pro453Asn)). The mutation has not been described in the literature yet; however, THRβ codon 453 represents a mutational hot spot, frequently altered in the TH receptor ß gene. After establishing the diagnosis of RTH, the patient was treated with 300 µg of thyroxine, which showed clinical improvement and normalization of TSH. The coexistence of RTHβ and AITD may additionally impede establishment of a proper diagnosis, leading to unnecessary therapy and delayed correct treatment. The presented case encourages a closer cooperation between clinical endocrinologists and geneticists.
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Affiliation(s)
- Elżbieta Skowrońska-Jóźwiak
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, Lodz, Poland
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, Lodz, Poland
| | - Agnieszka Gach
- Department of Genetics, Polish Mother’s Memorial Hospital—Research Institute, Lodz, Poland
| | - Anna Cyniak-Magierska
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, Lodz, Poland
| | - Anna Nykel
- Department of Genetics, Polish Mother’s Memorial Hospital—Research Institute, Lodz, Poland
| | | | - Andrzej Lewiński
- Department of Endocrinology and Metabolic Diseases, Medical University of Lodz, Lodz, Poland
- Department of Endocrinology and Metabolic Diseases, Polish Mother’s Memorial Hospital—Research Institute, Lodz, Poland
- *Correspondence: Andrzej Lewiński,
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4
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Rezgani I, Chihaoui M, Oueslati I, Chaker F, Nagi S, Yazidi M. Thyroid hormone resistance syndrome caused by a novel mutation in the thyroid hormone receptor‐beta gene (
THRB
,
GLU457LYS
) treated with methimazole. Clin Case Rep 2022; 10:e6543. [PMID: 36381023 PMCID: PMC9638043 DOI: 10.1002/ccr3.6543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/13/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
A 15‐year‐old girl presented with hyperactivity and behavior disorders. She had tachycardia and no goiter. Thyroid hormones were high and TSH normal. A novel mutation GLU457LYS in THRB gene was observed. Methimazole and propranolol improved clinical symptoms but increased TSH level. Elevated thyroid hormones without a decrease in TSH suggests two diagnoses: thyroid hormone resistance and TSH secreting pituitary adenoma. THRB, GLU457LYS is a novel mutation of the thyroid hormone receptor and was expressed with thyrotoxicosis, short stature with no goiter. Methimazole induced clinical improvement but an increase of TSH level.
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Affiliation(s)
- Imen Rezgani
- Department of Endocrinology, Faculty of medicine of Tunis, University Hospital La Rabta University Tunis El Manar Tunis Tunisia
| | - Melika Chihaoui
- Department of Endocrinology, Faculty of medicine of Tunis, University Hospital La Rabta University Tunis El Manar Tunis Tunisia
| | - Ibtissem Oueslati
- Department of Endocrinology, Faculty of medicine of Tunis, University Hospital La Rabta University Tunis El Manar Tunis Tunisia
| | - Fatma Chaker
- Department of Endocrinology, Faculty of medicine of Tunis, University Hospital La Rabta University Tunis El Manar Tunis Tunisia
| | - Sonia Nagi
- Department of neuroradiology, National Institute of neurology, Faculty of medicine of Tunis University Tunis El Manar Tunis Tunisia
| | - Meriem Yazidi
- Department of Endocrinology, Faculty of medicine of Tunis, University Hospital La Rabta University Tunis El Manar Tunis Tunisia
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5
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Hernandez I, Hayward JJ, Brockman JA, White ME, Mouttham L, Wilcox EA, Garrison S, Castelhano MG, Loftus JP, Gomes FE, Balkman C, Brooks MB, Fiani N, Forman M, Kern T, Kornreich B, Ledbetter EC, Peralta S, Struble AM, Caligiuri L, Corey E, Lin L, Jordan J, Sack D, Boyko AR, Lyons LA, Todhunter RJ. Complex Feline Disease Mapping Using a Dense Genotyping Array. Front Vet Sci 2022; 9:862414. [PMID: 35782544 PMCID: PMC9244801 DOI: 10.3389/fvets.2022.862414] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
The current feline genotyping array of 63 k single nucleotide polymorphisms has proven its utility for mapping within breeds, and its use has led to the identification of variants associated with Mendelian traits in purebred cats. However, compared to single gene disorders, association studies of complex diseases, especially with the inclusion of random bred cats with relatively low linkage disequilibrium, require a denser genotyping array and an increased sample size to provide statistically significant associations. Here, we undertook a multi-breed study of 1,122 cats, most of which were admitted and phenotyped for nine common complex feline diseases at the Cornell University Hospital for Animals. Using a proprietary 340 k single nucleotide polymorphism mapping array, we identified significant genome-wide associations with hyperthyroidism, diabetes mellitus, and eosinophilic keratoconjunctivitis. These results provide genomic locations for variant discovery and candidate gene screening for these important complex feline diseases, which are relevant not only to feline health, but also to the development of disease models for comparative studies.
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Affiliation(s)
- Isabel Hernandez
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Jessica J. Hayward
- Department of Biomedical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
- *Correspondence: Jessica J. Hayward
| | - Jeff A. Brockman
- Pet Nutrition Center, Hill's Pet Nutrition, Topeka, KS, United States
| | - Michelle E. White
- Bioinformatics and Integrative Biology, University of Massachusetts Medical School, Worcester, MA, United States
- Vertebrate Genomics Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, United States
| | - Lara Mouttham
- Cornell Veterinary Biobank, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Elizabeth A. Wilcox
- Cornell Veterinary Biobank, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Susan Garrison
- Cornell Veterinary Biobank, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Marta G. Castelhano
- Cornell Veterinary Biobank, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - John P. Loftus
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Filipe Espinheira Gomes
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Cheryl Balkman
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Marjory B. Brooks
- Department of Population Medicine and Diagnostic Services, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Nadine Fiani
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Marnin Forman
- Cornell University Veterinary Specialists, Stamford, CT, United States
| | - Tom Kern
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Bruce Kornreich
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Eric C. Ledbetter
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Santiago Peralta
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Angela M. Struble
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Lisa Caligiuri
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Elizabeth Corey
- Cornell Veterinary Biobank, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Lin Lin
- Cornell Veterinary Biobank, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Julie Jordan
- Cornell Veterinary Biobank, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Danny Sack
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Adam R. Boyko
- Department of Biomedical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | - Leslie A. Lyons
- Department of Veterinary Medicine and Surgery, College of Veterinary Medicine, University of Missouri, Columbia, MO, United States
| | - Rory J. Todhunter
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
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6
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Külz M, Fellner S, Rocktäschel J, Ceglarek U, Willenberg A, Kratzsch J. Dubiously increased FT4 and FT3 levels in clinically euthyroid patients: clinical finding or analytical pitfall? Clin Chem Lab Med 2022; 60:877-885. [PMID: 35213944 DOI: 10.1515/cclm-2021-1211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 02/13/2022] [Indexed: 01/22/2023]
Abstract
OBJECTIVES We systematically investigated normally or subclinically increased thyroid stimulating hormone (TSH) values associated with unexpectedly increased thyroxine (FT4) and free triiodothyronine (FT3) in findings of patients without any thyroid disease. Moreover, we looked for alternatives to overcome such states with an improved diagnostic procedure and to investigate the pathogenetic background of the respective patients. METHODS Samples with TSH concentrations within the range of 0.4-10 mU/L combined with increased concentrations of FT4 (n=120; Cobas, Roche) were collected over a period of around six years. Cobas FT4 results were compared with measurements from Liaison (DiaSorin) and Architect (Abbott) FT4 assays. For further validation all samples were measured for total thyroxine (TT4) (Cobas, Roche). Finally, FT3 and TT3 as complementary parameters were measured in samples with leftover material. To overcome potential analytical disturbances from stimulating heterophilic antibodies, we used heterophilic blocking tubes (HBTs). RESULTS From the 120 samples with increased FT4 concentrations by Cobas, 51/120 were also increased by Liaison, and 26/120 by Architect. However, the measurement of TT4 indicated only n=10/120 increased values. The number of increased FT3 (n=71) measurements was higher in Architect>Cobas>Liaison (28>27>9). TT3 levels of 70/71 samples were within the reference interval. HBTs were inappropriate to reduce unspecific immunoreactivity in our samples. No clear pathogenetic background could be elucidated in the anamnesis of individual patients. CONCLUSIONS To overcome dubious constellations of TSH, FT4, and FT3, it is helpful to measure TT4 and TT3 for control or to use an immunoassay with an alternative assay design for the respective parameters.
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Affiliation(s)
- Martin Külz
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, (ILM) Leipzig University, Leipzig, Germany
| | - Stephan Fellner
- pes Gesellschaft für medizinische Diagnosesysteme mbH, Markkleeberg, Germany
| | - Jörg Rocktäschel
- pes Gesellschaft für medizinische Diagnosesysteme mbH, Markkleeberg, Germany
| | - Uta Ceglarek
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, (ILM) Leipzig University, Leipzig, Germany
| | - Anja Willenberg
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, (ILM) Leipzig University, Leipzig, Germany
| | - Jürgen Kratzsch
- Institute for Laboratory Medicine, Clinical Chemistry and Molecular Diagnostics, (ILM) Leipzig University, Leipzig, Germany
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7
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Pattan V, Mehra I, Khan SA, Kashyap R. Atypical Thyroid Function Tests and Thyroid Hormone Resistance. Cureus 2021; 13:e16328. [PMID: 34306893 PMCID: PMC8279904 DOI: 10.7759/cureus.16328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2021] [Indexed: 12/05/2022] Open
Abstract
Clinical interpretation of thyroid labs is usually straightforward. However, there are rare instances when the atypical profile of thyroid labs warrants systematic investigation to determine the underlying cause. We report the case of a 90-year-old Caucasian male with a chronic history of atrial fibrillation with chronic pacemaker dependence who presented with significantly elevated free thyroxine level (>7.77 ng/dL) but normal thyroid-stimulating hormone level (2.15 µIU/mL). After ruling out pituitary tumors and artifactual errors due to lab interference, the diagnosis of thyroid hormone resistance was made.
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Affiliation(s)
| | - Ishita Mehra
- Internal Medicine, North Alabama Medical Center, Florence, USA
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8
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Wibowo A, Hastuti P, Susanti V. Polymorphism of Thyroid Hormones Receptor, Angiotensin-Converting Enzyme, and High Blood Pressure in Childbearing Age Women with Hyperthyroidism. Open Access Maced J Med Sci 2021. [DOI: 10.3889/oamjms.2021.6193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM: This study aimed to investigate the association between two polymorphisms of thyroid hormone receptor and renin-angiotensin system (THRA C/T and angiotensin-converting enzyme (ACE) I/D) genes with hypertension in childbearing age women with hypertension.
METHODS: This was a case–control study including 35 cases and 40 matched control subjects. The case group was hyperthyroid women with hypertension while the control group was hyperthyroid women with normotension. The polymorphisms were identified by a classical polymerase chain reaction.
RESULTS: The THRA C/T gene and ACE I/D polymorphisms were not associated with the hypertension while the genotype frequencies in hyperthyroid women with hypertension were as follows: CC genotype was 25.71%, CT genotype was 54.29%, and TT genotype was 20.00%. The ACE I/D genotype frequencies in hyperthyroid women with hypertension were as follows: II genotype was 23.53%, whereas in hyperthyroid women without hypertension, the I/D genotype frequencies were CC: 7.50%, CT: 72.50%, and TT: 20.00%. There were no differences in age, thyroid-stimulating hormone, FT4, systolic blood pressure (SBP), diastolic BP between subgroups in ACE I/D, and at THRA rs-939348. There was a significant difference in the levels of FT4 concentrations in THRA rs-939348. Hypertension groups have higher SBP than controls. Genotype II had higher SBP but it was not statistically significant, while individuals with allele I had SBP higher than D allele.
CONCLUSIONS: The I allele of the ACE gene is involved in susceptibility to hypertension and polymorphism in THRA increasing concentration of FT4. There was no statistically significant difference in blood pressure between hyperthyroid women with or without hypertension.
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Abstract
Thyroid hormones mediate a remarkable range of functions in many tissues and organ systems through the thyroid hormone receptors-THRA and THRB. Tissues and organs are composed of heterogeneous cells of different cell types. These different cell types have varying receptor expression abilities, which lead to variable responses in thyroid hormone regulation. The tissue-specific Thra and Thrb gene expression patterns help us understand the action of thyroid hormones at the tissue level. However, the situation becomes complicated if we wish to focus on tissues more closely to trace the responsive cells, which is a vital step in the process of understanding the molecular mechanism of diseases related to thyroid hormone regulation. Single-cell RNA sequencing technology is a powerful tool used to profile gene expression programs in individual cells. The Tabula Muris Consortium generates a single-cell transcriptomic atlas across the life span of Mus musculus that includes data from 23 tissues and organs. It provides an unprecedented opportunity to understand thyroid hormone regulation at the cell type resolution. We demonstrated the approaches that allow application of the single-cell RNA-Seq data generated by the Tabula Muris Consortium to trace responsive cells in tissues. First, employing the single-cell RNA-Seq data, we calculated the ability of different cell types to express Thra and Thrb, which direct us to the cell types sensitive to thyroid hormone regulation in tissues and organs. Next, using a cell clustering algorithm, we explored the subtypes with low Thra or Thrb expression within the different cell types and identified the potentially responsive cell subtypes. Finally, in the liver tissue treated with thyroid hormones, using the single-cell RNA-Seq data, we successfully traced the responsive cell types. We acknowledge that the computational predictions reported here need to be further validated using wet-lab experiments. However, we believe our results provide powerful information and will be beneficial for wet lab researchers.
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Affiliation(s)
- Liang Hu
- Department of Thyroid Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chao Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
- *Correspondence: Chao Wu,
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10
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Abstract
Congenital hypothyroidism (CH) is the commonest preventable cause of mental retardation in human species. It is so important for clinician to know its etiology epidemiology, clinical manifestation and treatment strategies. Since it is one of the rare serious diseases that should not be diagnosed clinically because late clinical features corresponds to advanced mental retardation, the neonatal screening detection is the best and preferable way of early diagnosis of this congenital disease. Confirmatory laboratory and radiological diagnostic tests should be performed immediately after the positive neonatal screening test. In order to prevent mental defects and to maintain long term clinical as well as biochemical euthyroidism in affected children its diagnosis approach, medical treatment and follow-up should be well established knowledge to all pediatricians during the childhood period and later on to general practitioners when these individuals grow up as adults. Congenital hypothyroidism is a potentially serious disease that we need to emphasize on early detection, using proper diagnostic tools and early and planned therapeutic approach.
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Affiliation(s)
- Mohammad Al-Qahtani
- College of Medicine, Imam Abdulrahman bin Faisal University, Dammam, Kingdom of Saudi Arabia
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11
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Bae JY, Kim DY, Kwon YD, Song YH, Lim HH, Park HD, Lim JW. Thyroid Hormone Resistance in a Preterm Infant with a Novel THRB Mutation. Neonatal Med 2019. [DOI: 10.5385/nm.2019.26.2.111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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12
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Ch'ng TW, Chin VL. Challenging diagnosis of thyroid hormone resistance initially as Hashimoto's thyroiditis. J Pediatr Endocrinol Metab 2019; 32:203-206. [PMID: 30681972 DOI: 10.1515/jpem-2018-0284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Accepted: 12/04/2018] [Indexed: 12/24/2022]
Abstract
Background Resistance to thyroid hormone (RTH) commonly presents with goiter, attention deficit hyperactivity disorder (ADHD), short stature and tachycardia. However, due to its variable presentation with subtle clinical features, a third of the cases are mistreated, typically as hyperthyroidism. Case presentation A 15-year-old female with ADHD and oligomenorrhea was initially diagnosed as Hashimoto's thyroiditis but found to have a rare heterozygous mutation in c803 C>G (p Ala 268 Gly) in the THRβ gene, confirming resistance to thyroid hormone. Conclusions Fluctuating thyroid function tests in addition to thyroid peroxidase antibody (TPO Ab) positivity complicated the diagnosis of RTH, initially diagnosed as Hashimoto's thyroiditis. A high index of suspicion is needed to prevent misdiagnosis and mistreatment.
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Affiliation(s)
- Tong Wooi Ch'ng
- Department of Pediatrics, Division of Pediatric Endocrinology, SUNY Downstate Medical Center, Brooklyn, NY, USA
| | - Vivian L Chin
- Department of Pediatrics, Division of Pediatric Endocrinology, SUNY Downstate Medical Center, Brooklyn, NY, USA
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13
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Yu C, Zhao J, Yao J, Wang H, Shang H, Zhang R, Cui Y, Wang L, Dong J, Liao L. Pituitary resistance to thyroid hormone caused by a novel mutation (H435A) in the thyroid hormone receptor beta: A case report. Medicine (Baltimore) 2018; 97:e10544. [PMID: 29794730 PMCID: PMC6392742 DOI: 10.1097/md.0000000000010544] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
RATIONALE In patients with pituitary thyroid hormone resistance, the ability of the pituitary gland to detect (and down-regulate) the increase of triiodothyronine is selectively impaired, while the periphery remains sensitive to triiodothyronine levels, producing symptoms of peripheral thyrotoxicity. Subsequently, there is no feedback of pituitary production of thyroid-stimulating hormone (TSH), which is responsible for this hyperthyroidism. PATIENT CONCERNS We report a case of a 46-year-old Chinese woman diagnosed with a thyroid nodule, with normal thyroid function. She underwent conventional subtotal thyroidectomy, and replacement therapy (levothyroxine) was used for as convention. However, it was later proven that she had pituitary resistance to thyroid hormone, as supra-physiological doses of levothyroxine were required to normalize TSH levels, which resulted in peripheral thyrotoxicity. DIAGNOSES Based on the patient's symptoms, laboratory tests results, imaging examinations, and genetic analysis (which noted a gene mutation), a diagnosis of pituitary resistance to thyroid hormones was confirmed. INTERVENTIONS The dose of levothyroxine was adjusted periodically and β-adrenergic blocker was used as symptomatic treatment. OUTCOMES The outcome in the reported case has been satisfactory despite the persistence of non-suppressed TSH. LESSONS An inappropriate level of TSH should always be evaluated. We found a new mutation (H435A) of the thyroid hormone receptor beta gene, which allowed for the establishment of a definitive diagnosis.
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Affiliation(s)
- Changzhen Yu
- Division of Endocrinology, Department of Internal Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University of Traditional Chinese Medicine
| | - Junyu Zhao
- Division of Endocrinology, Department of Internal Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University
| | - Jinming Yao
- Division of Endocrinology, Department of Internal Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University
| | - Huanjun Wang
- Division of Endocrinology, Department of Internal Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University
| | - Hongxia Shang
- Division of Endocrinology, Department of Internal Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University
| | - Rui Zhang
- Division of Endocrinology, Department of Internal Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University
| | - Yujiao Cui
- Division of Endocrinology, Department of Internal Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University of Traditional Chinese Medicine
| | - Likang Wang
- Division of Endocrinology, Department of Internal Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University of Traditional Chinese Medicine
| | - Jianjun Dong
- Division of Endocrinology, Department of Internal Medicine, Qilu Hospital of Shandong University, Jinan, China
| | - Lin Liao
- Division of Endocrinology, Department of Internal Medicine, Shandong Provincial Qianfoshan Hospital, Shandong University
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Schneider C, Feller M, Bauer DC, Collet TH, da Costa BR, Auer R, Peeters RP, Brown SJ, Bremner AP, O’Leary PC, Feddema P, Leedman PJ, Aujesky D, Walsh JP, Rodondi N. Initial evaluation of thyroid dysfunction - Are simultaneous TSH and fT4 tests necessary? PLoS One 2018; 13:e0196631. [PMID: 29709030 PMCID: PMC5927436 DOI: 10.1371/journal.pone.0196631] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 04/15/2018] [Indexed: 01/07/2023] Open
Abstract
Objective Guidelines for thyroid function evaluation recommend testing TSH first, then assessing fT4 only if TSH is out of the reference range (two-step), but many clinicians initially request both TSH and fT4 (one-step). Given limitations of previous studies, we aimed to compare the two-step with the one-step approach in an unselected community-dwelling study population, and develop a prediction score based on clinical parameters that could identify at-risk patients for thyroid dysfunction. Design Cross-sectional analysis of the population-based Busselton Health Study. Methods We compared the two-step with the one-step approach, focusing on cases that would be missed by the two-step approach, i.e. those with normal TSH, but out-of-range fT4. We used likelihood ratio tests to identify demographic and clinical parameters associated with thyroid dysfunction and developed a clinical prediction score by using a beta-coefficient based scoring method. Results Following the two-step approach, 93.0% of all 4471 participants had normal TSH and would not need further testing. The two-step approach would have missed 3.8% of all participants (169 of 4471) with a normal TSH, but a fT4 outside the reference range. In 85% (144 of 169) of these cases, fT4 fell within 2 pmol/l of fT4 reference range limits, consistent with healthy outliers. The clinical prediction score that performed best excluded only 22.5% of participants from TSH testing. Conclusion The two-step approach may avoid measuring fT4 in as many as 93% of individuals with a very small risk of missing thyroid dysfunction. Our findings do not support the simultaneous initial measurement of both TSH and fT4.
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Affiliation(s)
- Claudio Schneider
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martin Feller
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Douglas C. Bauer
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco, California, United States
| | - Tinh-Hai Collet
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
| | - Bruno R. da Costa
- Service of Endocrinology, Diabetes and Metabolism, Lausanne University Hospital, Lausanne, Switzerland
- Applied Health Research Centre, Li Ka Shing Knowledge Institute of St Michael's Hospital, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Reto Auer
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
| | - Robin P. Peeters
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Suzanne J. Brown
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Alexandra P. Bremner
- School of Population Health, The University of Western Australia, Crawley, Western Australia, Australia
| | - Peter C. O’Leary
- School of Women's and Infants' Health, The University of Western Australia, Crawley, Western Australia, Australia
| | | | - Peter J. Leedman
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
- UWA Centre for Medical Research, Harry Perkins Institute for Medical Research, Perth, Western Australia, Australia
| | - Drahomir Aujesky
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - John P. Walsh
- Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- Medical School, University of Western Australia, Crawley, Western Australia, Australia
| | - Nicolas Rodondi
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland
- * E-mail:
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15
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Fanibunda SE, Desouza LA, Kapoor R, Vaidya RA, Vaidya VA. Thyroid Hormone Regulation of Adult Neurogenesis. Vitamins and Hormones 2018; 106:211-251. [DOI: 10.1016/bs.vh.2017.04.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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16
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Karakose M, Caliskan M, Arslan MS, Cakal E, Yesilyurt A, Delibasi T. Thyroid hormone resistance in two patients with papillary thyroid microcarcinoma and their BRAFV600E mutation status. Arch Endocrinol Metab 2017; 59:364-6. [PMID: 26331327 DOI: 10.1590/2359-3997000000091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 11/24/2014] [Indexed: 11/21/2022]
Abstract
Resistance to thyroid hormone (RTH) is a rare autosomal dominant hereditary disorder. Here in, we report two patients with RTH in whom differentiated thyroid cancer was diagnosed. Two patients were admitted to our clinic and their laboratory results were elevated thyroid hormone levels with unsuppressed TSH. We considered this situation thyroid hormone resistance in the light of laboratory and clinical datas. Thyroid nodule was palpated on physical examination. Thyroid ultrasonography showed multiple nodules in both lobes. Total thyroidectomy was performed. The pathological findings were consistent with papillary thyroid microcarcinoma. BRAFV600E mutation analysis results were negative. RTH is very rare and might be overlooked. There is no consensus on how to overcome the persistently high TSH in patients with RTH and differentiated thyroid cancer (DTC). Further studies are needed to explain the relationship between RTH and DTC which might be helpful for the treatment of these patients.
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Affiliation(s)
- Melia Karakose
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, TR
| | - Mustafa Caliskan
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, TR
| | - Muyesser Sayki Arslan
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, TR
| | - Erman Cakal
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, TR
| | - Ahmet Yesilyurt
- Department of Stem Cell and Genetic Diagnostic Center, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, TR
| | - Tuncay Delibasi
- Department of Endocrinology and Metabolism, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, TR
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17
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Jimenez R, Privalsky ML. A resistance to thyroid hormone syndrome mutant operates through the target gene repertoire of the wild-type thyroid hormone receptor. Mol Cell Endocrinol 2017; 447:87-97. [PMID: 28257829 DOI: 10.1016/j.mce.2017.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Revised: 02/26/2017] [Accepted: 02/27/2017] [Indexed: 10/20/2022]
Abstract
Thyroid hormone receptors (TRs) play crucial roles in vertebrates. Wild-type (WT) TRs function primarily as hormone-regulated transcription factors. A human endocrine disease, Resistance to Thyroid Hormone (RTH)-Syndrome, is caused by inheritance of mutant TRs impaired in the proper regulation of target gene expression. To better understand the molecular basis of RTH we compared the target genes regulated by an RTH-TRβ1 mutant (R429Q) to those regulated by WT-TRβ1. With only a few potential exceptions, the vast majority of genes we were able to identify as regulated by the WT-TRβ1, positively or negatively, were also regulated by the RTH-TRβ1 mutant. We conclude that the actions of R429Q-TRβ1 in RTH-Syndrome most likely reflect the reduced hormone affinity observed for this mutant rather than an alteration in target gene repertoire. Our results highlight the importance of target gene specificity in defining the disease phenotype and improve our understanding of how clinical treatments impact RTH-Syndrome.
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Affiliation(s)
- Robyn Jimenez
- Department of Microbiology and Molecular Genetics, College of Biological Sciences, University of California at Davis, USA
| | - Martin L Privalsky
- Department of Microbiology and Molecular Genetics, College of Biological Sciences, University of California at Davis, USA.
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18
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Cheng SY. My journey to unravel complex actions of thyroid hormone: was it fate or destiny? Endocr Relat Cancer 2015; 22:P1-P10. [PMID: 25662575 DOI: 10.1530/erc-15-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Sheue-yann Cheng
- Laboratory of Molecular BiologyCenter for Cancer Research, National Cancer Institute, National Institutes of Health, 37 Convent Drive, Room 5128, Bethesda, Maryland 20892-4264, USA
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19
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Tylki-Szymańska A, Acuna-Hidalgo R, Krajewska-Walasek M, Lecka-Ambroziak A, Steehouwer M, Gilissen C, Brunner HG, Jurecka A, Różdżyńska-Świątkowska A, Hoischen A, Chrzanowska KH. Thyroid hormone resistance syndrome due to mutations in the thyroid hormone receptor α gene (THRA). J Med Genet 2015; 52:312-6. [PMID: 25670821 DOI: 10.1136/jmedgenet-2014-102936] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 01/20/2015] [Indexed: 01/15/2023]
Abstract
BACKGROUND Resistance to thyroid hormone is characterised by a lack of response of peripheral tissues to the active form of thyroid hormone (triiodothyronine, T3). In about 85% of cases, a mutation in THRB, the gene coding for thyroid receptor β (TRβ), is the cause of this disorder. Recently, individual reports described the first patients with thyroid hormone receptor α gene (THRA) defects. METHODS We used longitudinal clinical assessments over a period of 18 years at one hospital setting combined with biochemical and molecular studies to characterise a novel thyroid hormone resistance syndrome in a cohort of six patients from five families. FINDINGS Using whole exome sequencing and subsequent Sanger sequencing, we identified truncating and missense mutations in the THRA gene in five of six individuals and describe a distinct and consistent phenotype of mild hypothyroidism (growth retardation, relatively high birth length and weight, mild-to-moderate mental retardation, mild skeletal dysplasia and constipation), specific facial features (round, somewhat coarse and flat face) and macrocephaly. Laboratory investigations revealed anaemia and slightly elevated cholesterol, while the thyroid profile showed low free thyroxine (fT4) levels coupled with high free T3 (fT3), leading to an altered T4 : T3 ratio, along with normal thyroid-stimulating hormone levels. We observed a genotype-phenotype correlation, with milder outcomes for missense mutations and more severe phenotypical effects for truncating mutations. INTERPRETATION THRA mutations may be more common than expected. In patients with clinical symptoms of mild hypothyreosis without confirmation in endocrine studies, a molecular study of THRA defects is strongly recommended.
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Affiliation(s)
- Anna Tylki-Szymańska
- Department of Pediatrics, Nutrition and Metabolic Diseases, The Children's Memorial Health Institute, Warsaw, Poland
| | - Rocio Acuna-Hidalgo
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute of Molecular Life Sciences, Nijmegen, The Netherlands
| | | | - Agnieszka Lecka-Ambroziak
- Department of Endocrinology and Diabetology, The Children's Memorial Health Institute, Warsaw, Poland
| | - Marloes Steehouwer
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute of Molecular Life Sciences, Nijmegen, The Netherlands
| | - Christian Gilissen
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute of Molecular Life Sciences, Nijmegen, The Netherlands
| | - Han G Brunner
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute of Molecular Life Sciences, Nijmegen, The Netherlands
| | - Agnieszka Jurecka
- Department of Pediatrics, Nutrition and Metabolic Diseases, The Children's Memorial Health Institute, Warsaw, Poland
| | | | - Alexander Hoischen
- Department of Human Genetics, Radboud University Medical Center, Radboud Institute of Molecular Life Sciences, Nijmegen, The Netherlands
| | - Krystyna H Chrzanowska
- Department of Clinical Genetics, The Children's Memorial Health Institute, Warsaw, Poland
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20
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Chen K, Xie Y, Zhao L, Zhao S, He H, Mo Z. A novel mutation of thyroid hormone receptor β in exon 10 in a case of thyroid hormone-resistant non-Hodgkin's lymphoma of the thyroid. Oncol Lett 2015; 9:614-618. [PMID: 25621029 PMCID: PMC4301484 DOI: 10.3892/ol.2014.2715] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2014] [Accepted: 10/29/2014] [Indexed: 01/09/2023] Open
Abstract
Only a few previous studies have demonstrated an association between resistance to thyroid hormone (RTH) and thyroid cancer. The current study presents the case of a 67-year-old female who was referred to the Third Xiangya Hospital of Central South University with an enlargement of the neck that had grown gradually over two years and subsequently, rapidly enlarged over the two months prior to admission, alongside a slight sensation of shortness of breath. Laboratory data revealed a significantly increased level of thyroid-stimulating hormone (TSH), total triiodothyronine, total thyroxine, free triiodothyronine, free thyroxine, thyroprotein and thyroglobulin antibody; however, the levels of thyroperoxidase and TSH receptor antibody were within the normal ranges. A thyroid hormone suppression test revealed a TSH reduction of 32%, Magnetic resonance imaging of the pituitary gland was negative for abnormalities. The patient's thyroid pathology revealed a non-Hodgkin's lymphoma of the thyroid. CHOP + nimustine chemotherapy significantly reduced the clinical symptoms. The genetic analysis revealed a novel point mutation of the thyroid hormone receptor β (THRB) gene in exon 10 (g1680 G to A) in the 3'-untranslated region of the patient. To the best of our knowledge, this is the first case report of RTH with thyroid non-Hodgkin's lymphoma, which involved a mutation (g1680 G to A) in exon 10 of THRB.
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Affiliation(s)
- Ke Chen
- Department of Endocrinology, Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - Yanhong Xie
- Department of Endocrinology, Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - Liling Zhao
- Department of Endocrinology, Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - Shaoli Zhao
- Department of Endocrinology, Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - Honghui He
- Department of Endocrinology, Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
| | - Zhaohui Mo
- Department of Endocrinology, Third Xiangya Hospital of Central South University, Changsha, Hunan 410013, P.R. China
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21
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Glymph K, Gosmanov AR. Methimazole-Induced Goitrogenesis in an Adult Patient With the Syndrome of Resistance to Thyroid Hormone. J Investig Med High Impact Case Rep 2014; 2:2324709614555768. [PMID: 26425626 PMCID: PMC4528878 DOI: 10.1177/2324709614555768] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with the syndrome of resistance to thyroid hormone (RTH) have clinical (tachycardia and anxiety) and biochemical (elevated thyroid hormones level) features of hyperthyroidism. Based on previous reports in pediatric patients with the RTH, antithyroid treatment in these patients is not indicated. Clinical and biochemical sequel of antithyroid therapy in an adult patient with RTH was not previously reported. A 63-year-old African American female with history of RTH was treated with a therapy consisting of methimazole 15 mg daily and atenolol. Methimazole treatment resulted in reduction in thyroid hormone level while the patient’s TSH increased with a peak of 24.88 mIU/L. Having achieved biochemical euthyroidism, the patient developed thyroid gland enlargement associated with progressive symptoms of dysphagia and dyspnea. Examination demonstrated globally enlarged firm thyroid gland with areas of nodularity in both lobes. A computed tomography of the neck showed enlarged thyroid gland with extension around bilateral sternocleidomastoid muscles and compression onto the trachea. Methimazole therapy was discontinued and patient was treated just on atenolol. Over 12 months following discontinuation of methimazole, the patient experienced marked clinical and radiographic improvement of the goiter size associated with TSH reduction to 1.26 mIU/L and modest free thyroxine increase as expected in RTH. It seems appealing to treat patients with the RTH with antithyroid medications. However, in these patients decrease in thyroid hormone levels will stimulate TSH production, which can, in turn, predispose to goiter formation. Our report supports prior observations in children with RTH that treatment with methimazole is not indicated in adult patients with RTH.
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Affiliation(s)
- Kathleen Glymph
- University of Tennessee Health Science Center, Memphis, TN, USA
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22
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Affiliation(s)
- Julio Leey
- Diabetes and Endocrine Care of Alton, BJC Medical Group, Alton, IL
| | - Philip Cryer
- Division of Endocrinology, Metabolism and Lipid Research, Washington University School of Medicine, St. Louis, MO
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23
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Burris TP, Solt LA, Wang Y, Crumbley C, Banerjee S, Griffett K, Lundasen T, Hughes T, Kojetin DJ. Nuclear receptors and their selective pharmacologic modulators. Pharmacol Rev 2013; 65:710-78. [PMID: 23457206 PMCID: PMC11060414 DOI: 10.1124/pr.112.006833] [Citation(s) in RCA: 180] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Nuclear receptors are ligand-activated transcription factors and include the receptors for steroid hormones, lipophilic vitamins, sterols, and bile acids. These receptors serve as targets for development of myriad drugs that target a range of disorders. Classically defined ligands that bind to the ligand-binding domain of nuclear receptors, whether they are endogenous or synthetic, either activate receptor activity (agonists) or block activation (antagonists) and due to the ability to alter activity of the receptors are often termed receptor "modulators." The complex pharmacology of nuclear receptors has provided a class of ligands distinct from these simple modulators where ligands display agonist/partial agonist/antagonist function in a tissue or gene selective manner. This class of ligands is defined as selective modulators. Here, we review the development and pharmacology of a range of selective nuclear receptor modulators.
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Affiliation(s)
- Thomas P Burris
- The Scripps Research Institute, 130 Scripps Way 2A1, Jupiter, FL 33458, USA.
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24
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Rosen MD, Privalsky ML. Thyroid hormone receptor mutations in cancer and resistance to thyroid hormone: perspective and prognosis. J Thyroid Res 2011; 2011:361304. [PMID: 21760978 PMCID: PMC3134260 DOI: 10.4061/2011/361304] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 03/16/2011] [Indexed: 12/13/2022] Open
Abstract
Thyroid hormone, operating through its receptors, plays crucial roles in the control of normal human physiology and development; deviations from the norm can give rise to disease. Clinical endocrinologists often must confront and correct the consequences of inappropriately high or low thyroid hormone synthesis. Although more rare, disruptions in thyroid hormone endocrinology due to aberrations in the receptor also have severe medical consequences. This review will focus on the afflictions that are caused by, or are closely associated with, mutated thyroid hormone receptors. These include Resistance to Thyroid Hormone Syndrome, erythroleukemia, hepatocellular carcinoma, renal clear cell carcinoma, and thyroid cancer. We will describe current views on the molecular bases of these diseases, and what distinguishes the neoplastic from the non-neoplastic. We will also touch on studies that implicate alterations in receptor expression, and thyroid hormone levels, in certain oncogenic processes.
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Affiliation(s)
- Meghan D Rosen
- Department of Microbiology, University of California-Davis, Davis, CA 95616, USA
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25
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Lee S, Young BM, Wan W, Chan IH, Privalsky ML. A mechanism for pituitary-resistance to thyroid hormone (PRTH) syndrome: a loss in cooperative coactivator contacts by thyroid hormone receptor (TR)beta2. Mol Endocrinol 2011; 25:1111-25. [PMID: 21622532 DOI: 10.1210/me.2010-0448] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Thyroid hormone receptors (TR) are hormone-modulated transcription factors that regulate overall metabolic rate, lipid utilization, heart rate, and development. TR are expressed as a mix of interrelated receptor isoforms. The TRβ2 isoform is expressed in the hypothalamus and pituitary, where it plays an important role in the feedback regulation of thyroid hormone levels. TRβ2 exhibits unique transcriptional properties that parallel the ability of this isoform to bind to certain coactivators cooperatively through multiple contact surfaces. The more peripherally expressed TRβ1 isoform, in contrast, appears to recruit these coactivators through a single contact mechanism. We report here that clusters of charged amino acids in the TR hormone-binding domain are required for this enhanced mode of coactivator recruitment and that mutations in these charge clusters, by disrupting TRβ2 coactivator binding, are a molecular basis for pituitary resistance to thyroid hormone, a disease characterized by inappropriate thyroid hormone feedback regulation. We propose that the charge clusters allow wild-type TRβ2 to assume a conformation compatible with its mode of multiple contact coactivator recruitment, whereas disruption of these charge clusters disrupts normal T(3) homeostasis by reducing TRβ2 to a TRβ1-like, single contact mode of coactivator binding.
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Affiliation(s)
- Sangho Lee
- Department of Microbiology, College of Biological Sciences, University of California at Davis, Davis, California 95616, USA
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26
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Souza PCT, Barra GB, Velasco LFR, Ribeiro ICJ, Simeoni LA, Togashi M, Webb P, Neves FAR, Skaf MS, Martínez L, Polikarpov I. Helix 12 dynamics and thyroid hormone receptor activity: experimental and molecular dynamics studies of Ile280 mutants. J Mol Biol 2011; 412:882-93. [PMID: 21530542 DOI: 10.1016/j.jmb.2011.04.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Revised: 04/06/2011] [Accepted: 04/06/2011] [Indexed: 01/28/2023]
Abstract
Nuclear hormone receptors (NRs) form a family of transcription factors that mediate cellular responses initiated by hormone binding. It is generally recognized that the structure and dynamics of the C-terminal helix 12 (H12) of NRs' ligand binding domain (LBD) are fundamental to the recognition of coactivators and corepressors that modulate receptor function. Here we study the role of three mutations in the I280 residue of H12 of thyroid hormone receptors using site-directed mutagenesis, functional assays, and molecular dynamics simulations. Although residues at position 280 do not interact with coactivators or with the ligand, we show that its mutations can selectively block coactivator and corepressor binding, and affect hormone binding affinity differently. Molecular dynamics simulations suggest that ligand affinity is reduced by indirectly displacing the ligand in the binding pocket, facilitating water penetration and ligand destabilization. Mutations I280R and I280K link H12 to the LBD by forming salt bridges with E457 in H12, stabilizing H12 in a conformation that blocks both corepressor and coactivator recruitment. The I280M mutation, in turn, blocks corepressor binding, but appears to enhance coactivator affinity, suggesting stabilization of H12 in agonist conformation.
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Affiliation(s)
- Paulo C T Souza
- Institute of Chemistry, State University of Campinas, Campinas, SP, Brazil
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Abstract
Congenital hypothyroidism (CH) occurs in approximately 1:2,000 to 1:4,000 newborns. The clinical manifestations are often subtle or not present at birth. This likely is due to trans-placental passage of some maternal thyroid hormone, while many infants have some thyroid production of their own. Common symptoms include decreased activity and increased sleep, feeding difficulty, constipation, and prolonged jaundice. On examination, common signs include myxedematous facies, large fontanels, macroglossia, a distended abdomen with umbilical hernia, and hypotonia. CH is classified into permanent and transient forms, which in turn can be divided into primary, secondary, or peripheral etiologies. Thyroid dysgenesis accounts for 85% of permanent, primary CH, while inborn errors of thyroid hormone biosynthesis (dyshormonogeneses) account for 10-15% of cases. Secondary or central CH may occur with isolated TSH deficiency, but more commonly it is associated with congenital hypopitiutarism. Transient CH most commonly occurs in preterm infants born in areas of endemic iodine deficiency. In countries with newborn screening programs in place, infants with CH are diagnosed after detection by screening tests. The diagnosis should be confirmed by finding an elevated serum TSH and low T4 or free T4 level. Other diagnostic tests, such as thyroid radionuclide uptake and scan, thyroid sonography, or serum thyroglobulin determination may help pinpoint the underlying etiology, although treatment may be started without these tests. Levothyroxine is the treatment of choice; the recommended starting dose is 10 to 15 mcg/kg/day. The immediate goals of treatment are to rapidly raise the serum T4 above 130 nmol/L (10 ug/dL) and normalize serum TSH levels. Frequent laboratory monitoring in infancy is essential to ensure optimal neurocognitive outcome. Serum TSH and free T4 should be measured every 1-2 months in the first 6 months of life and every 3-4 months thereafter. In general, the prognosis of infants detected by screening and started on treatment early is excellent, with IQs similar to sibling or classmate controls. Studies show that a lower neurocognitive outcome may occur in those infants started at a later age (> 30 days of age), on lower l-thyroxine doses than currently recommended, and in those infants with more severe hypothyroidism.
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Affiliation(s)
- Maynika V Rastogi
- Department of Pediatrics, Division of Endocrinology, Oregon Health & Science University, 707 SW Gaines Street, Portland, OR, USA
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28
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Abstract
BACKGROUND Resistance to thyroid hormone (RTH) is a rare disorder in which an abnormality in the binding domain of the thyroid hormone receptor results in end-organ insensitivity to the actions of thyroid hormones. This disorder is sometimes misdiagnosed as Graves' disease due to the presence of a goiter with high Iodine-123 thyroid uptake and high levels of total and free thyroid hormones. Additionally, some patients with RTH may experience palpitations or tachycardia. There is a previous report of a patient with pituitary RTH and concurrent Graves' disease. SUMMARY We describe a patient who was found to have a goiter with signs and symptoms of hyperthyroidism by his primary care physician. Work-up revealed a low thyroid stimulating hormone (TSH), high thyroid-stimulating immunoglobulins, high Iodine-123 thyroid uptake, as well as increased homogenous activity in both thyroid glands on nuclear scan and a suppressed TSH. Diagnosis of Graves' disease was made, and the patient underwent radioactive ablation of the thyroid gland. The patient subsequently developed hypothyroidism and required a much higher dose of levothyroxine than his weight-based estimate of a full replacement dose to maintain euthyroidism. On 325 micog of daily levothyroxine the patient was clinically euthyroid and had a normal TSH although his levels of T3 and T4 were high. Work-up revealed a mutation in the thyroid hormone beta-receptor gene, consistent with diagnosis of RTH. CONCLUSIONS RTH is often misdiagnosed as Graves' disease. However, these disorders can coexist, and the concurrent presence of both disorders in a patient can present diagnostic challenges. A previous report of a patient with Graves' disease associated with RTH was published before gene sequencing could be used to confirm diagnosis of RTH. We present a patient with Graves' disease and concurrent RTH that was confirmed by gene sequencing, showing a mutation in the thyroid hormone receptor beta gene.
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Affiliation(s)
- Tharsan Sivakumar
- Section of Endocrinology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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29
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Opherk IV, Gutt B, Volz S, Siegmund T, Schumm-Draeger PM. [A 46-year-old patient with atrial fibrillation, elevated thyroid hormones and normal thyrotropine]. Internist (Berl) 2010; 51:397-8, 400-1. [PMID: 19902155 DOI: 10.1007/s00108-009-2462-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
We report on a 46 year old patient with a history of paroxysmal atrial fibrillation who presented to our emergency room. Diagnostic evaluation showed elevated free peripheral thyroid hormone levels and thyrotropine (TSH) hormone within normal limits. Ultrasound of the thyroid was normal, and thyroid autoantibodies were found in the normal range. There was a positive family history for thyroid dysfunction. TSH-producing adenoma (TSHoma) of the pituitary gland - the main differential diagnosis - was excluded by cranial MRI and laboratory tests. Familial thyroid hormone resistance (Refetoff syndrome) was suspected and could be confirmed by detection of a pathogenic mutation within the beta-thyroidhormone receptor gene. After spontaneous conversion to sinusrhythm the patient was treated with a beta(1)-selective betareceptor blocker. Up to now, no specific treatment is available to correct the defective beta-thyroidhormone receptor.
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30
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Abstract
UNLABELLED Resistance to thyroid hormone (RTH) syndrome is caused by thyroid hormone beta receptor (TRbeta) mutations. Goiter, learning disabilities, psychological abnormalities, sinus tachycardia, hearing deficits, short stature, and growth delay are among the most common symptoms in patients with RTH. Alopecia areata (AA) is an autoimmune disease of the hair follicle, frequently associated with other autoimmune disorders. In some cases local alopecia of different genetic backgrounds could be misdiagnosed as AA. We describe here clinical, biochemical and genetic features of a family having RTH syndrome, caused by a novel TRbeta mutation, coexistent with alopecia. Mutational analyses of the TRbeta gene and the hairless gene (HR) in genomic DNA were performed. The index patient is a 9-4/12 year-old boy with RTH due to a novel heterozygous missense mutation of the TRbeta gene (I353V), and diffuse, patchy alopecia without autoimmune thyroid disease. This mutation was also detected in his father and elder brother, who also have local alopecia. One of his paternal aunts and paternal grandmother have local alopecia and they have previously been operated for goiter. Although they refused any genetic analysis, the pre-operative medical report of the paternal aunt was compatible with RTH. A second paternal aunt has alopecia totalis universalis but has no RTH mutation in genomic DNA. Genomic DNA sequence of the HR gene of the family (index patient, two brothers, father, mother and second paternal aunt) was normal as well. CONCLUSION We speculate that RTH due to a novel I353V TRbeta mutation could be causally related to different phenotypic expressions of alopecia in this family, either by a direct effect of unresponsiveness to T3 of the hair follicle or by the modulated action of the HR gene.
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Affiliation(s)
- Tulay Guran
- Department of Pediatric Endocrinology and Diabetes, Marmara University Hospital, Istanbul.
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31
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Gómez JJL, Pomar MDB, Casariego AV, Rodríguez IC. [Selective pituitary resistance to thyroid hormone in a patient treated with amiodarone]. Endocrinol Nutr 2009; 56:418-421. [PMID: 19959152 DOI: 10.1016/s1575-0922(09)72712-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 09/02/2009] [Indexed: 05/28/2023]
Abstract
Selective pituitary resistance to thyroid hormones is a syndrome that involves inadequate response of thyroid-stimulating hormone to changes in thyroid hormones. Unlike generalized resistance syndromes, this entity produces central hyperthyroidism and clinical thyrotoxicosis. Sometimes the disease may not be properly diagnosed and is treated with drugs with harmful effects on the thyroid, such as amiodarone, hampering diagnosis and possibly exacerbating the disorder. The treatment of this condition can be symptomatic, based on control of tachycardia and anxiety, or etiological, acting on the pituitary to regulate thyrotropin secretion or on the thyroid gland to control thyroid hormone production. We report the case of a patient with pituitary resistance to thyroid hormone, who was treated with amiodarone to control paroxysmal atrial fibrillation.
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32
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Abstract
OBJECTIVE Resistance to thyroid hormone (RTH) is associated with a varied clinical presentation. The cardiac effects of RTH have been described but vascular function has yet to be fully evaluated in this condition. We have measured the arterial function of those with RTH to assess any vascular changes. DESIGN An observational study. PATIENTS Twelve RTH patients were recruited from the thyroid clinic (mean value +/- SD), age 40.8 +/- 18.7 years; BMI 27.2 +/- 4.2 kg/m(2) and compared with 12 healthy, euthyroid, age-matched controls (age 41.4 +/- 19.3; BMI 24.8 +/- 4.4 kg/m(2)) with no history of cardiovascular disease. No interventional measures were instituted. MEASUREMENTS Arterial stiffness was measured using pulse wave analysis at the radial artery. Thyroid function, fasting lipids and glucose were also measured on the same occasion in both patients and controls. Results The corrected augmentation index, a surrogate marker of arterial stiffness was significantly higher in patients compared with controls (21.0% +/- 14.1%vs. 5.4% +/- 18.2%, P < 0.03). Low density lipoprotein cholesterol (LDL-cholesterol) levels were also significantly elevated in patients compared with controls (3.0 +/- 0.6 vs. 2.1 +/- 0.5 mmol/l; P < 0.002). CONCLUSION RTH patients show evidence in this study of increased augmentation index consistent with an increase in arterial stiffness compared with euthyroid controls. They also demonstrate elevated LDL-cholesterol levels. Both these measures may lead to increased cardiovascular risk.
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Affiliation(s)
- P J D Owen
- Centre for Endocrine and Diabetes Sciences, University Hospital of Wales, Cardiff, UK.
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33
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Abstract
Resistance to thyroid hormone (RTH) is a rare disease characterized by non-suppressed TSH in spite of high free thyroid hormone levels. Up to date, in the literature, there are more than 600 RTH cases, but co-incidental hypophyseal adenoma was reported in only 1 case. In the literature, despite reported cases with thyrotropinoma accompanying RTH, we could not find a case with somatotropinoma accompanying RTH. Here, we report a 34-yr-old male patient, who was admitted to the hospital with complaints of dyspnea, chest pain, and palpitation in 2003. His alpha- subunit value was normal and the alpha-subunit/TSH molar ratio was <1. His response to TRH stimulation test was normal. His TSH level was suppressed in the T3 suppression test. Hypophyseal magnetic resonance imaging showed a 6-mm hypophyseal microadenoma. Levels of all anterior hypophyseal hormones, including GH and IGF-I, were normal. Oral glucose tolerance test (OGTT)-GH suppression test was normal. The patient was followed with the diagnosis of RTH and incidental hypophyseal adenoma. After 3 yr, because of high levels of IGF-I: 901 ng/ml (68-324), the OGTT-GH suppression test was reported and no suppression was detected. Thus, the patient was referred to surgery with the pre-diagnosis of RTH and acromegaly. Immunohistochemistry was showed as strong GH staining with low Ki 67 index while TSH and other anterior hypophyseal hormones stainings were negative. Post-operative thyroid hormones were still high.
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Affiliation(s)
- D Berker
- Endocrinology and Metabolism Department, Ankara Numune Education and Research Hospital, Ankara, Turkey.
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34
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Abstract
Selective pituitary resistance to thyroid hormones (SPRTH) is a non-neoplastic form of inappropriate secretion of thyrotropin (TSH). The etiology of this hormonal resistance is linked to inactivating mutations in the thyroid hormone receptor beta (TR-beta) gene. These mutations affect critical portions of the receptor's triiodothyronine (T3)-binding domain. Clinically, SPRTH is characterized by hyperthyroidism with goiter and absence of pituitary mass in the morphologic study. Laboratory data show an elevation of free T3 and free thyroxine concentrations without suppression of TSH, with normal molar subunit alpha/TSH ratio. At this time, there is no specific therapy for SPRHT. Beta blockers, such as atenolol, and benzodiazepines have been used as a symptomatic therapy. Among the drugs with the capacity for reducing TSH secretion are TR agonists, such as triiodothyroacetic acid, D-thyroxine, triiodothyropropionic acid, and L-T3.
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Affiliation(s)
- Pedro Iglesias
- Servicio de Endocrinología, Hospital General, Segovia, España.
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35
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Affiliation(s)
- Erik S Mittra
- Division of Nuclear Medicine and Molecular Imaging Program at Stanford, Department of Radiology, Stanford University Hospital and Clinics, Stanford, California 94305-5281, USA
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36
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Abstract
Thyrotoxicosis is a condition resulting from elevated levels of thyroid hormone. In this article, the authors review the presentation, diagnosis, and management of various causes of thyrotoxicosis.
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Affiliation(s)
- Bindu Nayak
- Division of Endocrinology and Metabolism, Georgetown University Hospital, 4000 Reservoir Road, Building D, Suite 232, Washington, DC 20007, USA.
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37
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Abstract
The molecular genetic events underlying thyroid carcinogenesis are not well understood. Mice harboring a dominant-negative mutant thyroid hormone receptor-beta (TRbeta(PV/PV) mice) spontaneously develop follicular thyroid carcinoma similar to human cancer. The present study aimed to elucidate the role of the steroid receptor coactivator-3 (SRC-3) in thyroid carcinogenesis in vivo by using the offspring from the cross of TRbeta(PV/PV) and SRC-3(-/-) mice. TRbeta(PV/PV) mice deficient in SRC-3 (TRbeta(PV/PV)SRC-3(-/-) mice) had significantly increased survival, decreased thyroid tumor growth, delayed tumor progression and lower incidence of distant metastasis as compared with TRbeta(PV/PV) mice with SRC-3 (TRbeta(PV/PV)SRC-3(+/+) mice). Further, in vivo and in vitro analyses of multiple signaling pathways indicated that SRC-3 deficiency could lead to (1) inhibition of cell cycle progression at the G(1)/S transition via controlling the expression of cell cycle regulators, such as E2F1; (2) induction of apoptosis by controlling the expression of the Bcl-2 and caspase-3 genes and (3) suppression of neovascularization and metastasis, at least in part, through modulating the vascular endothelial growth factor gene expression. Taken together, SRC-3 could play important roles through regulating multiple target genes and signaling pathways during thyroid carcinogenesis, understanding of which should direct future therapeutic options for thyroid cancer.
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Affiliation(s)
- H Ying
- Laboratory of Molecular Biology, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892-4264, USA
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