Can neutrophil/lymphocyte ratio be used as an indicator of inflammation in patients with hyperthyroidism?

Treatment of Graves' Disease Associated With Severe Neutropenia

Severe neutropenia in newly diagnosed hyperthyroidism is a diagnostic and therapeutic dilemma since antithyroid drugs (ATDs) cannot be started if the absolute neutrophil count (ANC) is <1 x 10⁹/L. We report the case of a patient followed for hyperthyroidism associated with severe neutropenia treated with dexamethasone and ATD. The patient was 51 years old and was hospitalized for hyperthyroidism with a thyroid stimulating hormone (TSH) level <0.005 (0.4-4) mUI/L, T4 at 415 (9.3-17.1) ng/L and T3 at 148 (2-4.4) pg/mL on Graves' disease (GD) confirmed by the TSH receptor antibodies at 38 IU/mL and scintigraphy, associated with neutropenia, with ANC at 0.4 x 10⁹/L. He was put on prednisolone 60 mg/day and propranolol 60 mg/day for three weeks without improvement. Faced with the association of hyperthyroidism and severe neutropenia, we could not start the ATD for fear of agranulocytosis; we put the patient on propranolol 60 mg and dexamethasone 6 mg with progressive degression resulting in a spectacular increase of ANC from 0.4 x 10⁹/L to 7.1 x 10⁹/L, which allowed us to start the ATD (carbimazole) at a dose of 30 mg, and then 50 mg, with monitoring of ANC and transaminases every 48 hours. Euthyroidism was achieved after 15 days. A curative treatment with radioactive iodine ablation was administered. Our patient did not respond to prednisolone but responded dramatically to dexamethasone; this leads us to consider using dexamethasone for the rapid preparation for radical treatment of patients with GD.

Neutrophil-to-lymphocyte Ratio is Associated with LV Diastolic Dysfunction in the Overt Hyperthyroid Patients

BACKGROUND

Recent studies have shown that the neutrophil-to-lymphocyte ratio (NLR) has gradually been identified as a more reliable marker of inflammation, with predictive value for the development of many diseases. However, its association with left ventricular (LV) diastolic dysfunction in overt hyperthyroid patients is unclear. Here, we aimed to explore the relationship between NLR and LV diastolic dysfunction in overt hyperthyroid patients.

METHODS

For this study, we retrospected the consecutive medical files of 350 overt hyperthyroid patients. Their medical data and laboratory findings were recorded. According to the presence or absence of LV diastolic dysfunction, the patients with overt hyperthyroidism were divided into two groups. One group with LV diastolic dysfunction included 104 patients and another group with non-LV diastolic dysfunction included 246 patients. The NLR values between the two groups were compared, and the relationship between NLR levels and the prevalence of LV diastolic dysfunction was also explored.

RESULTS

The NLR value in LV diastolic dysfunction group in the overt hyperthyroid subjects was significantly higher than that in non-LV diastolic dysfunction group [1.100 (0.907-1.580) vs 1.000 (0.761-1.405), P=0.016]. The prevalence of LV diastolic dysfunction in Low- (NLR<0.879), Medium- (0.879< NLR<1.287), and High- (NLR >1.287) NLR level groups were 20.9%, 32.5% and 35.7% respectively. Moreover, increased NLR is associated with increased prevalence of LV diastolic dysfunction, and after adjustment for potential associated factors, NLR remained significantly associated with LV diastolic dysfunction. (OR = 11.753, 95%CI = 1.938-71.267, P = 0.007).

CONCLUSIONS

Our findings demonstrated that the NLR was associated with LV diastolic dysfunction in the overt hyperthyroid patients, and the prevalence of LV diastolic dysfunction may be positively correlated with NLR levels.

White blood cell count, its subsets, and their indexes in type 2 diabetes mellitus

Due to the increased prevalence of obesity-related complications, especially type 2 diabetes mellitus (DM2), great attention has been paid to the variety of adipokines and cytokines, i.e. biomarkers, which are secreted by the enlarged visceral adipose tissue. Those pro-inflammatory mediators diminish insulin sensitivity via impairing insulin signalling pathways. If these processes persist, insulin resistance and DM2 occur, with a typical finding of low-grade chronic inflammation. The current review focuses on some hematological indices that reflect the inflammation level, such as white blood cell count, its subsets, and derived indexes. Those parameters are easy to measure, cost-effective, and widely available in a primary care setting. A deeper knowledge of the changes in the mentioned hematological parameters in DM2, in addition to glucoregulation biomarkers, may enable physicians to act promptly when patients with this metabolic disorder are concerned.

Specific impact of cardiovascular risk factors on coronary microcirculation in patients with subclinical hypothyroidism

Background

Although thyroid hormones have significant effect on cardiovascular system, the impact of subtle thyroid dysfunction such as subclinical hypothyroidism (SCH) remains to be determined. We investigated coronary flow reserve (CFR) in patients with subclinical hypothyroidism.

Methods

Thirty two subjects with SCH and eighteen control subjects with normal serum thyroid hormones and thyroid-stimulating hormone (TSH) levels were included in the study. TSH, free thyroxine, free triiodothyronine, glucose, insulin, HbA1c, cholesterol, triglyceride and plasma levels of C-reactive protein were measured. Coronary diastolic peak flow velocities in left anterior descending coronary artery were measured at baseline and after adenosine infusion. CFR was calculated as the ratio of hyperemic to baseline diastolic peak velocity.

Results

CFR values were not significantly different between the two groups (SCH 2.76±0.35 vs controls 2.76±0.42). There was a significant correlation of CFR with waist to hip ratio, hypertension, smoking habits, markers of glucose status (glucose level, HbA1c, insulin level, HOMA IR), cholesterol, LDL-cholesterol and triglyceride levels in SCH group, whereas only cholesterol level showed significant correlation with CFR in controls. There was no correlation between CFR and thyroid hormones.

Conclusions

We concluded that there is a different impact of cardiovascular risk factors on CFR in SCH patients compared to healthy control and that these two groups behave differently in the same circumstances under the same risk factors. The basis for this difference could be that the altered thyroid axis "set point" changes the sensitivity of the microvasculature in patients with SCH to known risk factors.

Neutrophil-to-Lymphocyte, Monocyte-to-Lymphocyte and Platelet-to-Lymphocyte Ratios in Relation to Clinical Parameters and Smoking Status in Patients with Graves' Orbitopathy-Novel Insight into Old Tests

Graves' orbitopathy (GO) is an autoimmune disease with a chronic inflammatory background. Smoking behavior is the main environmental factor responsible for the transition of this major extra thyroidal manifestation of Graves' disease (GD) from the subclinical to the overt form. Complete blood count-derived parameters are suggested to be novel inflammatory indices. The aim of this retrospective study was to investigate the association between neutrophil-to-lymphocyte (NLR), monocyte-to-lymphocyte (MLR), and platelet-to-lymphocyte ratios (PLR) with selected clinical parameters and smoking status in 406 GD patients with (n = 168) and without GO (n = 238). The control group consisted of 100 healthy individuals. The activity of GO was graded according to Clinical Activity Score. Significantly higher white blood cells (WBC), neutrophil, and NLR (p < 0.05) values were observed in GD patients with GO compared with those without GO. PLR values were significantly higher in GO patients than in the controls. WBC (6.81 ± 1.56 vs. 5.70 ± 1.23) and neutrophils (3.89 ± 1.06 vs. 3.15 ± 0.95) count was higher in active GO patients than in those with inactive GO. Positive correlation (p < 0.05) between CAS score and WBC, neutrophil and monocyte count, and NLR was found. Smoking was associated with higher WBC (p = 0.040), neutrophil (p = 0.049), PLR (p = 0.032) values. Multivariate analysis revealed that WBC, NLR may be risk factors for GO development. WBC, neutrophil, NLR and PLR values seem to be useful tools in the assessment of inflammation in GD.

High neutrophil-to-lymphocyte ratio is associated with relapse in Graves' disease after antithyroid drug therapy

PURPOSE

Antithyroid drugs (ATDs) are effective in controlling hyperthyroidism due to Graves' disease (GD); however, long-term remission rates are low. The neutrophil-to-lymphocyte ratio (NLR) is a useful prognostic marker in many inflammatory diseases. We aimed to evaluate whether NLR can be used as a prognostic marker for relapse in patients with GD after ATD therapy.

METHODS

This retrospective cohort study included 108 patients with newly diagnosed GD who achieved remission after ATD therapy and were followed-up for >12 months after ATD discontinuation. The primary outcome was relapse-free survival (RFS).

RESULTS

Patients were classified into two groups according to baseline NLR: low NLR group with NLR < 1.14 (n = 59; 55%) and high NLR group with NLR ≥ 1.14 (n = 49; 45%). During the median follow-up of 6.5 years, disease relapse after a year of ATD withdrawal occurred in 23 (21%) patients. The patients with high NLR had poorer RFS than those with low NLR, and RFS curves were significantly different between the two groups (p = 0.002). In multivariate analysis, a high NLR (OR = 4.22, p = 0.016) was an independent prognostic factor for relapse in patients with GD after adjusting for age, sex, goiter, orbitopathy, thyroid hormone levels, thyrotropin binding inhibiting immunoglobulin titer, and the duration of ATD therapy.

CONCLUSIONS

This study showed that NLR can be an early and cost-effective prognostic biomarker for relapse in patients with GD after ATD therapy. Further studies are needed to validate the prognostic role of NLR in GD.

Neutrophil-to-lymphocyte ratio, monocyte-to-lymphocyte ratio, and platelet-tolymphocyte ratio in different etiological causes of thyrotoxicosis

Background/aim

The most common causes of thyrotoxicosis include Graves’ disease (GD), toxic multinodular goiter (TMNG), toxic adenoma (TA), and subacute granulomatous thyroiditis (SAT). In our study, we aimed to see whether neutrophil‐to‐lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet‐to‐lymphocyte ratio (PLR), and mean platelet volume (MPV) may be helpful in the differential diagnosis of these diseases.

Materials and methods

We retrospectively analyzed the hospital records of the Endocrinology Clinic of our hospital between 2016 and 2019. We included data from 66 GD, 37 TA, and 35 SAT patients. We compared the data with those of 35 healthy subjects as controls.

Results

NLR, MLR, and PLR were found to be higher in the SAT group when compared to other groups. The post hoc analysis of comparison of NLR, MLR, and PLR in each group showed that NLR and PLR were significantly different in the SAT group when compared to the GD, TA, and controls groups (P < 0.001, P = 0.003, and P < 0.001 for NLR respectively and P < 0.001 for PLR in all groups). MPV levels were different between groups (P = 0.007). However, the intergroup analysis (Tukey’s test) failed to show a statistically significant difference for any of the groups. In patients with SAT, PLR and NLR were significantly higher than in the GD, TA, and control groups. MLR was also higher in SAT when compared to other groups, but the difference was not statistically significant.

Conclusion

High PLR and NLR may be helpful to differentiate SAT from GD and TA, the other common causes of thyrotoxicosis.