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Tun Min S, Nordman IIC, Tran HA. Hypercalcaemia due to Sarcoidosis during Treatment with Avelumab for Metastatic Merkel Cell Carcinoma. Case Rep Oncol 2019; 12:639-643. [PMID: 31543781 PMCID: PMC6738145 DOI: 10.1159/000502285] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Accepted: 07/22/2019] [Indexed: 12/17/2022] Open
Abstract
Merkel cell carcinoma is a rare but aggressive skin cancer. Response to chemotherapy is not durable but avelumab, an anti-PD-L1 inhibitor, showed promising ongoing response in a phase II trial. Checkpoint inhibitors including avelumab are known to cause overactivation of the immune system, leading to immune-related adverse events (irAE). We describe the first reported case of hypercalcaemia secondary to reactivation of sarcoidosis in a patient with metastatic Merkel cell carcinoma on avelumab. Hypercalcaemia was managed with corticosteroids to full resolution and avelumab therapy was safely continued.
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Affiliation(s)
- Sandy Tun Min
- Department of Medical Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Ina I C Nordman
- Department of Medical Oncology, Calvary Mater Newcastle, Newcastle, New South Wales, Australia.,University of Newcastle, Newcastle, New South Wales, Australia
| | - Huy A Tran
- University of Newcastle, Newcastle, New South Wales, Australia.,Department of Clinical Chemistry, John Hunter Hospital, Newcastle, New South Wales, Australia
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Affiliation(s)
- Zahrul Ismadi
- From the Department of Clinical Chemistry, NSW Health Pathology; Newcastle, New South Wales, Australia
| | - Amanda J Caswell
- From the Department of Clinical Chemistry, NSW Health Pathology; Newcastle, New South Wales, Australia
| | - Huy A Tran
- From the Department of Clinical Chemistry, NSW Health Pathology; Newcastle, New South Wales, Australia
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Kasherman L, Foy A, Tierney A, Reeves GEM, Tran HA. Primary hypothyroidism masquerading as hepatocellular necrosis. QJM 2015; 108:581-4. [PMID: 23345467 DOI: 10.1093/qjmed/hcs241] [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: 11/13/2022] Open
Affiliation(s)
- L Kasherman
- From the School of Medicine and Population Health, University of Newcastle, Department of General Medicine, Calvary Mater Hospital, Department of Immunopathology, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre and Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia
| | - A Foy
- From the School of Medicine and Population Health, University of Newcastle, Department of General Medicine, Calvary Mater Hospital, Department of Immunopathology, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre and Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia From the School of Medicine and Population Health, University of Newcastle, Department of General Medicine, Calvary Mater Hospital, Department of Immunopathology, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre and Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia
| | - A Tierney
- From the School of Medicine and Population Health, University of Newcastle, Department of General Medicine, Calvary Mater Hospital, Department of Immunopathology, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre and Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia From the School of Medicine and Population Health, University of Newcastle, Department of General Medicine, Calvary Mater Hospital, Department of Immunopathology, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre and Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia
| | - G E M Reeves
- From the School of Medicine and Population Health, University of Newcastle, Department of General Medicine, Calvary Mater Hospital, Department of Immunopathology, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre and Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia From the School of Medicine and Population Health, University of Newcastle, Department of General Medicine, Calvary Mater Hospital, Department of Immunopathology, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre and Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia
| | - H A Tran
- From the School of Medicine and Population Health, University of Newcastle, Department of General Medicine, Calvary Mater Hospital, Department of Immunopathology, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre and Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia From the School of Medicine and Population Health, University of Newcastle, Department of General Medicine, Calvary Mater Hospital, Department of Immunopathology, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre and Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag 1, Hunter Region Mail Centre, Newcastle, NSW 2310, Australia
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Tran HA, Jones TL, Ianna EA, Reeves GEM. THE ABSENCE OF THYROID DISEASE IN AN AUSTRALIAN HEPATITIS C COHORT TREATED WITH TRIPLE COMBINATION THERAPY: A PARADIGM SHIFT. Endocr Pract 2015; 21:1035-9. [PMID: 26121446 DOI: 10.4158/ep14561.or] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To assess the prevalence of thyroid disease in triple combination therapy with interferon (IFN)-α, ribavirin (RBV), and protease inhibitors (boceprevir and telaprevir) for the treatment of chronic hepatitis C virus (HCV) infection in an Australian hepatitis C cohort. Also, to compare with those who received dual RBV and IFN in the past. METHODS A preliminary, retrospective, and nested case control study of thyroid disease in patients who underwent triple combination therapy for chronic HCV infection compared with dual therapy at a major tertiary referral hospital center. Fifty-nine patients were treated with such therapy at the Hunter New England Area Hepatitis C Treatment Center. Of these, 38 were treated with boceprevir and 21 with telaprevir. All had genotype 1 HCV infection. The main outcome measures included (1) the prevalence of thyroid disease (TD), including hyperthyroidism and hypothyroidism, and (2) thyroid outcome comparison with patients who had received dual therapy. RESULTS There was no case of TD detected for the entire duration of therapy with triple anti-HCV therapy. There was a significant absence of TD in the protease inhibitor-treated group. CONCLUSION No case of TD was detected during the treatment of HCV patients with protease inhibitor-based triple therapy. The reasons for this are unclear. Larger studies are necessary to confirm this finding.
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Holliday SM, Tran HA. Death due to intravenous use of α-pyrrolidinopentiophenone. Med J Aust 2015; 202:574. [PMID: 26068687 DOI: 10.5694/mja14.01741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2014] [Accepted: 03/19/2015] [Indexed: 11/17/2022]
Affiliation(s)
| | - Huy A Tran
- Pathology North (Hunter), NSW Health Pathology, Newcastle, NSW, Australia
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Tran HA, Jones TL, Ianna EA, Foy A, Reeves GEM. Thyroid disease in chronic hepatitis C infection treated with combination interferon-α and ribavirin: management strategies and future perspective. Endocr Pract 2013; 19:292-300. [PMID: 23186968 PMCID: PMC4134094 DOI: 10.4158/ep12195.ra] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Hepatitis C virus (HCV) infection is one of the major epidemics afflicting young people in both developed and developing countries. The most common endocrine disorder associated with this infection, especially in conjunction with interferon-α (IFN-α)-based therapy, is thyroid disease (TD). This review examines the development of TD before, during, and after the completion of treatment with combination IFN-α and ribavirin (RBV) for chronic HCV infection. We also summarize the current understanding of the natural history of the condition and propose management and follow-up guidelines. METHODS PubMed was searched up to June 30, 2011 for English-language publications that contained the search terms "hepatitis C virus," "chronic hepatitis C," "HCV," "thyroid disease," "thyroiditis," "autoimmunity," "interferon-alpha," and "ribavirin." Additional publications were identified from the reference lists of identified papers. The included studies were original research publications and included combination IFN-α and RBV use in patients that developed TD. RESULTS The prevalence of TD before combination IFN-α and RBV therapy ranges from 4.6 to 21.3%; during therapy, 1.1 to 21.3%; and after therapy, 6.7 to 21.3%. The most common TD is thyroiditis. Thyroid function testing (TFT) frequency and diagnostic criteria for various thyroid conditions are not standardized, and many of the existing studies are retrospective. CONCLUSION Patients undergoing this therapy should be assessed with a standardized protocol to appropriately detect and manage developed TD. Based on the currently available literature, we recommend that patients receiving combination interferon-α and RBV therapy undergo monthly thyrotropin (TSH) level testing.
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Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry, Hunter Area Pathology Service, Newcastle, New South Wales, Australia.
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Tran HA, Jones TL, Ianna EA, Gibson RA, Reeves GEM. The reduced predictive value of interleukin 28b gene polymorphisms in a cohort of patients with thyroiditis developed during antiviral therapy for chronic hepatitis C: a preliminary study. Hepat Mon 2012; 12:e6036. [PMID: 23087747 PMCID: PMC3475014 DOI: 10.5812/hepatmon.6036] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 05/15/2012] [Accepted: 05/22/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND Single nucleotide polymorphism in the interleukin28B (IL28B) gene was recently shown to be associated with a significant increase in response to interferon-α and ribavirin treatment in patients with chronic hepatitis C. Similarly, thyroid disease (TD) occurring during treatment confer an improved sustained virologic response (SVR). OBJECTIVES To determine the role of IL28B genotypes in a cohort of hepatitis C patients who develop TD during treatment and its relationship to SVR. PATIENTS AND METHODS IL28B gene profiles including rs12979860, rs12980275 and rs 8099917 and their genotypes were determined in a cohort of 23 hepatitis C patients who developed TD during treatment and their relationship to SVR. RESULTS Out of 23 studies cases, 19 has one or more favorable genotypes, of which 15 (78.9%) achieved SVR. Eleven has all three unfavorable genotypes and yet achieved 72.7 % SVR. The presence of more than one favorable genotype only correctly predicts SVR vs. non- SVR in ~50 % of cases, i.e. by chance. CONCLUSIONS Despite the small number of subjects, the presence of one or more unfavorable IL28B genotype does not portend a poor SVR prognostic outcome. This suggests that TD in this clinical context may be a critical factor in the achievement of SVR, probably above that of the genetic predisposition.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, John Hunter Hospital, Newcastle, Australia
- Corresponding author: Huy A Tran, Pathology Service, John Hunter Hospital, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia. Tel.: +61-249214005, Fax: +61-249214440, E-mail:
| | - Tracey L Jones
- Hepatitis C Service, Gastroenterology Department, John Hunter Hospital, Newcastle, Australia
| | - Elizabeth A Ianna
- Hepatitis C Service, Gastroenterology Department, John Hunter Hospital, Newcastle, Australia
| | - Robert A Gibson
- Hepatitis C Service, Gastroenterology Department, John Hunter Hospital, Newcastle, Australia
| | - Glenn E M Reeves
- Hunter Area Pathology Service, John Hunter Hospital, Newcastle, Australia
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Affiliation(s)
- H A Tran
- Hunter Area Pathology Service, John Hunter Hospital, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia.
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Tran HA, Reeves GEM, Hetherington FW. Anthony Siew‐Yin Leong. Med J Aust 2012. [DOI: 10.5694/mja11.10964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Tran HA, Jones TL, Gibson R, Reeves GEM. Thyroid disease is a favorable prognostic factor in achieving sustained virologic response in chronic hepatitis C undergoing combination therapy: A nested case control study. BMC Endocr Disord 2011; 11:10. [PMID: 21605462 PMCID: PMC3123561 DOI: 10.1186/1472-6823-11-10] [Citation(s) in RCA: 3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2010] [Accepted: 05/24/2011] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Interferon-α in combination with ribavirin is the current gold standard for treatment of chronic hepatitis C. It is unknown if the development of autoimmune thyroid disease (TD) during treatment confers an improved chance of achieving sustained virologic response. The aim of this study is to assess the chance of achieving sustained virologic response (SVR) in patients who developed TD during treatment when compared with those who did not. METHODS We performed a tertiary hospital-based retrospective nested case-control analysis of 19 patients treated for hepatitis C who developed thyroid disease, and 76 controls (matched for age, weight, gender, cirrhosis and aminotransferase levels) who did not develop TD during treatment. Multivariate logistic-regression models were used to compare cases and controls. RESULTS The development of TD was associated with a high likelihood of achieving SVR (odds ratio, 6.0; 95% confidence interval, 1.5 to 24.6) for the pooled group containing all genotypes. The likelihood of achieving SVR was increased in individuals with genotype 1 HCV infection who developed TD (odds ratio, 5.2; 95% confidence interval, 1.2 to 22.3), and all genotype 3 patients who developed TD achieved SVR. CONCLUSIONS Development of TD during treatment for hepatitis C infection is associated with a significantly increased chance of achieving SVR. The pathophysiogical mechanisms for this observation remain to be determined. TRIAL REGISTRATION The Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRB12610000830099.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service and University of Newcastle, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
| | - Tracey L Jones
- Hepatitis C Service, Gastroenterology Department, John Hunter Hospital and University of Newcastle, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
| | - Robert Gibson
- Hepatitis C Service, Gastroenterology Department, John Hunter Hospital and University of Newcastle, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
| | - Glenn EM Reeves
- Hunter Area Pathology Service and University of Newcastle, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
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Tran HA, Jones TL, Ianna EA, Reeves GE. The natural history of interferon-α induced thyroiditis in chronic hepatitis c patients: a long term study. Thyroid Res 2011; 4:2. [PMID: 21214950 PMCID: PMC3022887 DOI: 10.1186/1756-6614-4-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2010] [Accepted: 01/08/2011] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Autoimmune thyroid disease is a common complication of patients with chronic hepatitis C undergoing combination pegylated interferon-α and ribavirin treatment. A small proportion develops interferon-induced thyroiditis of which the long term natural history is unknown and how it compares with de novo thyroiditis. The aim of the study is to determine the natural history of thyroid disease including antibody profile in this particular setting 36 months from the completion of therapy. METHODS A cohort of 18 hepatitis C patients (mean age 45 ± 8 years (standard deviation)) who developed exclusively thyroiditis in this setting was followed every 12 months after the completion of therapy for 36 months. Investigations included thyrotropin, free tetra-iodothyronine, free tri-iodothyronine levels and thyroid autoantibodies. RESULTS None of the patients developed any long term thyroid disease. Two patients had a prolonged hypothyroid phase of the thyroiditis early after the completion of treatment but recovered fully. The remaining 16 patients remained euthyroid. Similarly, thyroid autoantibodies all declined and returned to reference range. CONCLUSIONS The long term natural history in this small series of interferon induced thyroiditis was benign. If a larger series confirms a similar outcome then there is no long term residual effect on thyroid function and follow-up testing would not be warranted.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service and University of Newcastle, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
| | - Tracey L Jones
- Hepatitis C Service, Gastroenterology Department, John Hunter Hospital and University of Newcastle, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
| | - Elizabeth A Ianna
- Hepatitis C Service, Gastroenterology Department, John Hunter Hospital, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
| | - Glenn Em Reeves
- Hunter Area Pathology Service and University of Newcastle, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
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Tran HA, Reeves GEM, Lyons TJ, Attia JR. Histopathologic findings of autoimmunity in thyroid, pituitary, and adrenal diseases in chronic hepatitis C postmortem cases. Endocr Pract 2010; 16:566-9. [PMID: 20150020 DOI: 10.4158/ep09359.or] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To assess the histologic prevalence of immune-mediated thyroid, pituitary, and adrenal diseases in postmortem cases with hepatitis C. METHODS We reviewed 108 consecutive cases of chronic hepatitis C in patients in whom a complete postmortem examination was performed. All microscopic and histologic slides of the thyroid, pituitary, and adrenal reports were reviewed and assessed for evidence of autoimmune diseases. These were compared with a control group of 100 postmortem cases without hepatitis C. RESULTS In chronic hepatitis C infection, there is a heightened immune response resulting in many autoimmune diseases. The commonest endocrinopathy in association with this chronic infection is thyroid disease, a finding confirmed in our current study. Among the 108 postmortem cases of hepatitis C, there were 14 cases (13%) with evidence of thyroiditis. No cases of pituitary or adrenal disease were found. The mean age of the patients was 52 years (range, 29 to 68). This frequency compared with 7 cases of thyroid disease (7%) in the control group (no significant difference between the 2 groups). CONCLUSION On the basis of our postmortem data, thyroid disease was the only major endocrinopathy associated with hepatitis C infection, with a prevalence of 13%. This was comparable with other serologic and nonhistologic antemortem findings. There was no evidence of pituitary or adrenal involvement.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, Hunter Mail Region Centre, Newcastle, New South Wales, Australia.
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Porter NJ, Tran HA, Reeves GEM. Coeliac genetic testing: prone to misuse. Med J Aust 2010; 192:477-8. [DOI: 10.5694/j.1326-5377.2010.tb03594.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Accepted: 03/02/2010] [Indexed: 11/17/2022]
Affiliation(s)
| | - Huy A Tran
- Hunter Area Pathology Service, John Hunter Hospital, Newcastle, NSW
| | - Glenn E M Reeves
- Hunter Area Pathology Service, John Hunter Hospital, Newcastle, NSW
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Affiliation(s)
- H A Tran
- Hunter Area Pathology Service and Newcastle University, Locked Bag No. 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia.
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Tran HA, Reeves GE. The influence of hepatitis C infection and interferon-alpha therapy on thyrotropin blocking and stimulating autoantibodies in Graves' ophthalmopathy: a case report. Thyroid Res 2009; 2:12. [PMID: 19954547 PMCID: PMC2791747 DOI: 10.1186/1756-6614-2-12] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [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: 08/24/2009] [Accepted: 12/02/2009] [Indexed: 11/16/2022] Open
Abstract
Background Hepatitis C virus is a highly immunogenic pathogen often inducing autoimmune activation changes and this can often be further exacerbated by Interferon therapy. As HCV is lymphocytotropic, it can modulate T cell and B cell antibody responses, affecting many endocrine organs, most commonly the thyroid. Case presentation We hereby describe a case of fluctuating and wavering thyrotropin autoantibodies of both stimulating and blocking nature in the setting of Graves's ophthalmopathy, hepatitis C infection and interferon-α, causing hypo- and subsequently hyper-thyroidism. The autoantibody profile was clearly modified during interferon therapy and settled into a new equilibrium at the completion of treatment. Conclusion The case highlights the possible existence of a dual thyroid autoantibody population associated with hepatitis C, and its modulation by interferon therapy, which further compounds the difficulties in the assessment thyroid disease in this setting.
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Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry and University of Newcastle, Locked Bag 1, Hunter Region Mail Centre, Newcastle, New South Wales 2310, Australia.
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Abstract
Described is a case of triphasic thyroid response in a 53-year-old man while undergoing combination interferon α-2b and ribavirin treatment for chronic hepatitis C infection. He developed the classical biphasic thyroiditis during treatment and was treated expectantly. However, 8 weeks after the completion of therapy, he developed T3-Graves-like thyrotoxicosis, which was confirmed with a diffuse-uptake thyroid scan and positive thyroid stimulating immunoglobulin. He was treated as having Graves' disease arising de novo with thiourea, and he achieved rapid remission. This is thought to be only the second case described, and it offers a unique opportunity to understand the possible pathogenesis of this fascinating condition. This is a relative novel entity and highlights the need for continuing thyroid monitor after treatment. Management also needs to be specific for each particular phase of the condition.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, Clinical Chemistry, Locked Bag 1, HRMC, Newcastle, New South Wales, 2310, Australia
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Tran HA, Reeves GE. Treatment of type B insulin resistance with immunoglobulin: novel use of an old therapy. Med J Aust 2009; 190:168. [PMID: 19203327 DOI: 10.5694/j.1326-5377.2009.tb02335.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2008] [Accepted: 11/13/2008] [Indexed: 11/17/2022]
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Abstract
Hypercalcaemia in infants with Down syndrome is an uncommon condition with only five previous case reports. The patients often present in the toddler years with the classical triad of Down syndrome, biochemical hypercalcaemia, and nephrocalcinosis. We present the sixth case and second male with this condition and further review the clinical details of this under-recognised condition and stratify the diagnostic criteria. The management mandates a reduction in calcium intake as a first step. The natural history of the various aspects of this condition is also considered.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, Clinical Chemistry, Locked Bag 1, HRMC, Newcastle, New South Wales, 2310, Australia
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Tran HA, Reeves GEM, Jones TL. The natural history of interferon-alpha2b-induced thyroiditis and its exclusivity in a cohort of patients with chronic hepatitis C infection. QJM 2009; 102:117-22. [PMID: 19033352 DOI: 10.1093/qjmed/hcn150] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Interferon-alpha2b (IFN-alpha2b) is well known to cause both hyper- and hypo-thyroidism. In the former, the commonest aetiology is thyroiditis. As there is no previous data to fully characterize the entity of IFN-related thyroiditis, the aim of this study is to document in detail its evolution in a cohort of hepatitis C patients treated with pegylated IFN-alpha2b and Ribavirin (RBV). METHODS A prospective observational study was conducted in patients who developed thyroid diseases whilst receiving combination of pegylated IFN-alpha2b and RBV for hepatitis C. The patients were followed with monthly thyrotropin (TSH). Where TSH was undetectable, free tetra- (fT4) and tri-iodothyronine (fT3) were added. Anti-thyroperoxidase (TPO), anti-thyroglobulin (Tg) and thyroid stimulating immunoglobulin (TSI) levels were also performed at diagnosis, during and at the end of IFN therapy. All patients were assessed and followed up closely with monthly TSH, fT4 and fT3 levels until the completion, after 6 and 12 months of treatment. RESULTS There were seven females and four males over a 30-month period. All patients were found to have thyroiditis. On average, the time to the development of thyroid disease was 10 weeks and duration of disease 9 weeks. All patients eventually recovered normal biochemical thyroid function although two required short-term supplementation. CONCLUSION Thyroiditis was found exclusively in our patients. Both the hyper- and hypo-thyroid phase can be short lived, extreme and transient in nature which warrants strict monthly TSH monitoring. Careful follow-up of all patients is mandatory as complete recovery is expected.
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Affiliation(s)
- H A Tran
- Hunter Area Pathology Service, Newcastle University, Newcastle, New South Wales 2310, Australia.
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Tran HA, Song S. Myeloma induced osteolysis and nephromegaly. BMJ Case Rep 2009; 2009:bcr07.2008.0510. [PMID: 21686770 DOI: 10.1136/bcr.07.2008.0510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, Clinical Chemistry, Newcastle, New South Wales, 2310, Australia
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Tran HA, Reeves GEM. The Spectrum of Autoimmune Thyroid Disease in the Short to Medium Term Following Interferon-alpha Therapy for Chronic Hepatitis C. Int J Endocrinol 2009; 2009:241786. [PMID: 19946425 PMCID: PMC2778562 DOI: 10.1155/2009/241786] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [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: 01/11/2009] [Revised: 06/09/2009] [Accepted: 07/15/2009] [Indexed: 11/17/2022] Open
Abstract
Autoimmune thyroid diseases are common manifestations of hepatitis C infection, exacerbated by interferon-based treatment. However, the occurrence and pattern of thyroid disease in the short/medium term following the completion of IFN-based therapy is relatively unknown and there are very few previous reports regarding the specific spectrum of autoimmune thyroid disease that may follow such therapy. We hereby report 3 cases which demonstrate the range of thyroid diseases that may occur following interferon therapy. The hypothesis advanced is that in the pathogenesis of these conditions there must be both triggering and sustaining mechanisms as thyroid diseases occur well outside the immediate effect window of pegylated interferon. This paper suggests the need to continue thyroid surveillance in IFN-treated HCV patients following the completion of therapy, perhaps for the first 6 months.
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Affiliation(s)
- Huy A. Tran
- Hunter Area Pathology Service, Hunter Mail Region Centre, John Hunter Hospital, Locked Bag Number 1, Newcastle, NSW 2310, Australia
- *Huy A. Tran:
| | - Glenn E. M. Reeves
- Hunter Area Pathology Service, Hunter Mail Region Centre, John Hunter Hospital, Locked Bag Number 1, Newcastle, NSW 2310, Australia
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, Clinical Chemistry, Newcastle, New South Wales, 2310, Australia
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Tran HA, Song S, Lojewski RJ, Reeves GE. Exacerbation of hepatitis C induced subclinical hypoadrenalism by Interferon-alpha2beta: A case report. Cases J 2008; 1:157. [PMID: 18801174 PMCID: PMC2556317 DOI: 10.1186/1757-1626-1-157] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2008] [Accepted: 09/18/2008] [Indexed: 11/29/2022]
Abstract
Adrenal disease is an uncommon manifestation of hepatitis C infection and its related treatment regimen. This is a case of subclinical hypoadrenalism, probably induced by hepatitis C infection and further exacerbated by interferon-α2β and Ribavirin therapy. The adrenal deterioration during the treatment course was observed closely with 24-hour salivary profiles and 250 μg adrenocorticotropin stimulation tests using parallel serum and salivary cortisol concentrations. A number of possible pathogenic mechanisms are discussed, and the controversy over its management is emphasized.
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Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry, Hunter Area Pathology Service, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia.
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Hooper AJ, Tran HA, Formby MR, Burnett JR. A novel missense LIPA gene mutation, N98S, in a patient with cholesteryl ester storage disease. Clin Chim Acta 2008; 398:152-4. [PMID: 18775687 DOI: 10.1016/j.cca.2008.08.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 08/06/2008] [Accepted: 08/06/2008] [Indexed: 12/13/2022]
Abstract
Lysosomal acid lipase plays an important role in maintaining cellular cholesterol homeostasis. Complete absence of lysosomal acid lipase activity results in Wolman disease and usually death in infancy, whereas partial deficiency of lysosomal acid lipase results in cholesteryl ester storage disease (CESD). We describe a 26 year-old female with CESD who presented with recurrent right upper quadrant abdominal pain. Abnormal liver function tests and a subsequent liver biopsy revealed features consistent with CESD. Sequencing of the LIPA gene revealed that she was a compound heterozygote for the previously reported exon 8 splice junction mutation and a novel missense mutation (N98S) in exon 4. The splice junction mutation allows some (approximately 3%) normal splicing to occur, and therefore gives rise to residual lysosomal acid lipase activity. Asn98 in lysosomal acid lipase is highly conserved among species and mutation of this residue could influence catalytic activity or accessibility to the active site. In summary, we describe a CESD patient compound heterozygous for the LIPA exon 8 splice junction mutation and a novel missense mutation, N98S.
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Affiliation(s)
- Amanda J Hooper
- Department of Core Clinical Pathology & Biochemistry, PathWest Laboratory Medicine WA, Royal Perth Hospital, Perth, Australia
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Tran HA. Gland handling. Am J Med 2007; 120:948-50. [PMID: 17976420 DOI: 10.1016/j.amjmed.2007.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2007] [Revised: 08/07/2007] [Accepted: 08/07/2007] [Indexed: 12/01/2022]
Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry, Hunter Area Pathology Service, John Hunter Hospital and Newcastle University, New South Wales, Australia
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Tran HA, Myint E. Fulminant Clostridium Septicum myonecrosis in well controlled diabetes: a case report. J Med Case Rep 2007; 1:119. [PMID: 17967202 PMCID: PMC2173901 DOI: 10.1186/1752-1947-1-119] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [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] [Received: 04/19/2007] [Accepted: 10/30/2007] [Indexed: 11/28/2022] Open
Abstract
Diabetic myonecrosis with Clostridium Septicum is uncommon but carries a high mortality rate. This commensal organism is part of the gastrointestinal tract flora and can become extremely virulent, often in the setting of immuno-suppression such as neutropenia, occult malignancy (commonly caecal) and poorly controlled diabetes. The case report is unusual in that there are few risk factors other than very mild neutropenia. This highlights the opportunistic character of the organism and recommends that a high index of suspicion and vigilance be carried out in the presence of fevers and sepsis, even in the well-controlled diabetic population.
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Affiliation(s)
- Huy A Tran
- Division of Clinical Chemistry Hunter Area Pathology Service, John Hunter Hospital, Locked Bag 1, Hunter Region Mail Centre, Newcastle, New South Wales, Australia 2310.
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Tran HA, Attia JR, Jones TL, Batey RG. Pegylated interferon-alpha2beta in combination with ribavirin does not aggravate thyroid dysfunction in comparison to regular interferon-alpha2beta in a hepatitis C population: meta-analysis. J Gastroenterol Hepatol 2007; 22:472-6. [PMID: 17376035 DOI: 10.1111/j.1440-1746.2006.04771.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Interferon (IFN) has been well documented to cause thyroid dysfunction, especially in high risk patients and when combined with ribavirin (RBV). There is very sparse data to assess if pegylated IFN will further aggravate the thyroid disease risk in comparison to regular IFN. The purpose of this study was to assess the risk of developing thyroid disease with pegylated IFN (pIFN) versus regular IFN (rIFN) therapy (in combination with RBV). We also pooled our results with previous studies in a meta-analysis. METHODS An observational study was made retrospectively of 24 patients who underwent a combination of rIFN and RBV therapy for hepatitis C virus (HCV) infection. As these patients failed to obtain an initial satisfactory response, they were retreated using pIFN and RBV. Monthly thyrotropin (TSH) levels were assessed while undergoing both treatment regimens. A meta-analysis was performed using available published data in PubMed. RESULTS No difference in TSH levels was observed when comparing rIFN/RBV with pIFN/RBV. None of the patients developed hypo- or hyperthyroidism. TSH levels fluctuated during the treatment but did not extend outside the reference range. No further investigation was carried out in the absence of clinical and biochemical thyroid disease. The result of the meta-analysis failed to find any excess risk of thyroid dysfunction using pIFN above that of rIFN. CONCLUSIONS The pegylation of IFN, in combination with RBV, did not aggravate thyroid diseases in the hepatitis C population. This finding is reassuring and dictates that no deviation from current practice regarding thyroid surveillance is required whilst undergoing HCV treatment.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, Newcastle, New South Wales, Australia.
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Tran HA. Insulin measurement is also inappropriate in paediatric obesity. Med J Aust 2007; 186:270; author reply 271-2. [PMID: 17391097 DOI: 10.5694/j.1326-5377.2007.tb00892.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2006] [Accepted: 01/17/2007] [Indexed: 11/17/2022]
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Abstract
OBJECTIVE To report a case of resistance to thyroid hormone compounded by autoimmune primary hypothyroidism and to discuss the unusual pattern of results of thyroid function tests. METHODS A clinical case history is presented and illustrated with laboratory findings. The difficulty of monitoring the patient's response to levothyroxine supplement is also discussed, and relevant issues are addressed, including reviews of the literature. RESULTS A 45-year-old woman presented with longstanding and nonspecific symptoms of general anxiety and lethargy. Clinically, she was assessed to be euthyroid with no goiter. Her thyrotropin (thyroid-stimulating hormone or TSH) level was 43.6 (1/4)IU/mL, free thyroxine was 27.6 pmol/L, and free triiodothyronine was 7.8 pmol/L. Her anti-thyroid peroxidase titer was 1:102,400. Primary hypothyroidism was diagnosed, and treatment with 50 (1/4)g of levothyroxine daily was initiated, with progressive dose escalation. The patient, however, had thyrotoxic symptoms when her TSH was rendered "normal." The patient then discontinued her levothyroxine therapy, with a consequent elevation of her TSH level to 170.8 (1/4)IU/mL in conjunction with severe lethargy and lassitude. Biochemical evidence of metabolic disturbances was also present at the time, with hypercholesterolemia and elevated creatine kinase concentration. Rechallenge with levothyroxine resulted in considerable improvement in her biochemical findings and symptoms. CONCLUSION This patient has an interesting combination of autoimmune primary hypothyroidism and resistance to thyroid hormone. Levothyroxine replacement therapy was complicated by the nonspecificity of symptoms and the lack of an established TSH target value in this condition. Consideration should be given to using the affected family members' mean TSH level, when available, as a target guide for replacement therapy.
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Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry, Hunter Area Pathology Service, John Hunter Hospital, New South Wales, Australia
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Affiliation(s)
- H A Tran
- Hunter Area Pathology Service and John Hunter Hospital, Newcastle, NSW, Australia
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Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry, Hunter Area Pathology Service, John Hunter Hospital, Newcastle, New South Wales 2310, Australia.
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Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry, Hunter Area Pathology Service, John Hunter Hospital, Newcastle, New South Wales, Australia
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Tran HA. After the bender. Am J Med 2006; 119:487-90. [PMID: 16750961 DOI: 10.1016/j.amjmed.2006.04.015] [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] [Received: 11/04/2005] [Revised: 04/19/2006] [Accepted: 04/19/2006] [Indexed: 10/24/2022]
Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry, Hunter Area Pathology Service, John Hunter Hospital & Newcastle University, Newcastle, New South Wales, Australia
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Abstract
BACKGROUND The major cause of primary hypothyroidism is autoimmune mediated with progressive and permanent destruction of the thyroid gland resulting in life-long replacement therapy. Treatable and reversible hypothyroidism is unusual and here forth is such a case due to infection of the thyroid gland with Tropheryma whippleii, Whipple disease. CASE PRESENTATION A 45 year-old female presented with symptoms and signs consistent with primary hypothyroidism, which was also confirmed biochemically. Her response to thyroxine replacement therapy was poor however, requiring a significantly elevated amount. Further investigation revealed the presence of Whipple's disease involving the gastrointestinal trace and possibly the thyroid gland. Her thyroxine requirement decreased drastically following appropriate antimicrobial therapy for Whipple's disease to the extent that it was ceased. Thyrotropin releasing hormone testing in the steady state suggested there was diminished thyroid reserve due to Whipple's disease. CONCLUSION This is the first ante-mortem case report studying the possible involvement of the thyroid gland by Whipple's disease. Despite the normalization of her thyroid function test biochemically after antibiotic therapy, there is diminished thyroid reserve thus requiring close and regular monitoring.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, John Hunter Hospital, Locked Bag Number 1, Hunter Mail Region Centre, New South Wales, 2310, Australia.
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Affiliation(s)
- Huy A Tran
- Department of Clinical Chemistry, Hunter Area Pathology Service, New South Wales, Australia.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Services, Newcastle, New South Wales, Australia.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, John Hunter Hospital, New South Wales, Australia
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Tran HA, Jones TL, Batey RG. The spectrum of thyroid dysfunction in an Australian hepatitis C population treated with combination Interferon-alpha2beta and Ribavirin. BMC Endocr Disord 2005; 5:8. [PMID: 16219106 PMCID: PMC1266361 DOI: 10.1186/1472-6823-5-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [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: 05/13/2005] [Accepted: 10/12/2005] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The study aims to assess the pattern of thyroid response to combination Interferon-alpha2beta (IFN-alpha) and Ribavirin (RBV) anti-viral therapy in an Australian hepatitis C cohort. These include the prevalence of thyroid dysfunction (TD) including hyperthyroidism and hypothyroidism and their possible predictors, the common overall pattern of thyroid function tests whilst receiving therapy and TD outcomes, and the correlation with HCV status outcome. METHODS A retrospective analysis of all medical records was performed to assess thyroid function in Hepatitis C Virus (HCV) patients who were treated at the Hunter Area hepatitis C treatment center between 1995 and March 2004. The centre is part of the John Hunter hospital, a major tertiary referral centre in New South Wales, Australia. RESULTS There were 272 cases available for review. The prevalence of TD is 6.7 percent and is made up predominantly of females (80 percent). There were 3 (1.1 percent) cases of hyperthyroidism with 2 (67 percent) females. Thirteen out of fifteen (80 percent) cases of hypothyroidism were females with the overall prevalence of 5.5 percent. The majority of hypothyroid patients still required Thyroxine supplement at the end of follow up. CONCLUSION Ninety three percent of HCV treated patients have intact thyroid function at the end of treatment. The predominant TD is hypothyroidism. The predominant pattern of thyrotoxicosis (TTX) is that of thyroiditis although the number is small. Graves' like disease was not observed. People with pre-existing thyroid auto-antibodies should be closely monitored for thyroid dysfunction, particularly hypothyroidism.
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Affiliation(s)
- Huy A Tran
- Hunter Area Pathology Service, John Hunter Hospital, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
| | - Tracey L Jones
- Hepatitis C Service, Gastroenterology Department, John Hunter Hospital, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
| | - Robert G Batey
- Drug And Alcohol Unit, Hunter Area Health Service, John Hunter Hospital, Locked Bag Number 1, Hunter Mail Region Centre, Newcastle, New South Wales 2310, Australia
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Tran HA. Continuous inappropriate use of serum tumour markers. Intern Med J 2005; 35:640-1; author reply 641. [PMID: 16207270 DOI: 10.1111/j.1445-5994.2005.00938.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Hyperkalemia is a potentially fatal condition and is defined by a serum potassium level (K+) of greater than 5.5 mmol/L. The associated prevalence of cardiac arrhythmia increases directly with the degree of hyperkalemia. The danger in the majority of hyperkalemia cases is cardiac dysrhythmia, and often ventricular fibrillation or asystole is the terminating event. Although there are many previous reports addressing this threatening problem and associated therapeutic maneuvers, there have not been many previous reports citing the fatal concentration of hyperkalemia irrespective of the causes. However, it is uniformly accepted that a K+ concentration greater than 10.0 mmol/L is fatal unless urgent treatment is instituted. This report describes a case of nonfatal hyperkalemia of 14 mmol/L with intact survival and complete recovery. Potassium homeostasis is revisited, and some explanations are proffered regarding the protective mechanism against hyperkalemia, including transcellular flux, renal tubular function, and endocrine responses.
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Affiliation(s)
- H A Tran
- Hunter Area Pathology Service, John Hunter Hospital, Locked Bag Number 1, Hunter Mail Region Centre, New South Wales 2310, Australia.
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