Risk of autoimmune diseases after post-traumatic stress disorder: a nationwide cohort study

This longitudinal study aimed to investigate the risk of subsequent autoimmune disease in patients with post-traumatic stress disorder (PTSD) in Asian population. Between 2002 and 2009, we enrolled 5273 patients with PTSD and 1:4 matched controls from the National Health Insurance Database of Taiwan, and followed up the patients until December 31, 2011, or death. The investigated autoimmune diseases included thyroiditis, lupus, rheumatic arthritis, inflammatory bowel disease, Sjogren's syndrome, dermatomyositis, and polymyositis. The Cox regression model was used to estimate the risk of developing autoimmune diseases, with adjustment for demographics and psychiatric and medical comorbidities. Furthermore, we examined the psychiatric clinics utility of patients with PTSD indicating the severity of PTSD in association with autoimmune diseases. After adjusting for confounders, patients with PTSD had a 2.26-fold higher risk of developing any autoimmune diseases (reported as hazard ratios with 95% confidence intervals: 1.82-2.80) than the controls. For specific autoimmune diseases, patients with PTSD had a 2.70-fold higher risk (1.98-3.68) of thyroiditis, a 2.95-fold higher risk (1.20-7.30) of lupus, and a 6.32-fold higher risk (3.44-11.60) of Sjogren's syndrome. Moreover, the PTSD severity was associated with the risk of autoimmune diseases in a dose-dependent manner. The patient with the highest psychiatric clinics utility was associated with an 8.23-fold higher risk (6.21-10.90) of any autoimmune diseases than the controls. Patients with PTSD had an increased risk of autoimmune diseases, and such risk was associated with the severity of PTSD in a dose-dependent manner. However, the present study did not provide a direct effect between PTSD and autoimmune diseases, but rather an association. Further studies are warranted to examine the underlying pathophysiological mechanisms.

New and old criteria for diagnosing celiac disease: do they really differ? A retrospective observational study

BACKGROUND

The aim of this study is to compare two groups of celiac patients: the first one, in which diagnosis was based on a "biopsy sparing" approach according to the 2012 ESPGHAN criteria, and the second one, based on the biopsy approach like the one of the 1991 Revised Criteria, in order to find relevant difference for sex, M/F ratio, age at diagnosis, clinical features at the onset, presence and prevalence of concomitant autoimmune disorders.

METHODS

Our study involves 61 patients having the Celiac Disease (CD) onset from February 2013 to February 2020. The 32 patients who received diagnosis according "biopsy sparing" criteria were enrolled in group (1) The 29 patients who received diagnosis by duodenal biopsy were enrolled in group (2) Prevalence of comorbidities was analysed through chi-square test.

RESULTS

In group 1 the prevalence of comorbidities such as Insulin-Dependent Diabetes Mellitus (IDDM) and thyroiditis was of 53%, while in group 2 it was only of 24%. Analysing the IDDM prevalence between the two groups we found a relevant difference. At the same time, the prevalence of thyroiditis was also significantly different. In group 1, male patients, in particular, would seem to have a higher incidence of CD related autoimmune disorders.

CONCLUSIONS

An increased prevalence of IDDM, thyroiditis and juvenile idiopathic arthritis (JIA) in the first group would show that the "biopsy sparing" approach could expose patients to a greater length of disease activity that might be responsible for the onset of such comorbidities. Further studies should be carried out on more numerous samples of patients in order to confirm or not these data.

Langerhans cell histiocytosis of the thyroid mimicking thyroiditis in a boy: a case report and literature review

BACKGROUND

Langerhans cell histiocytosis affecting the thyroid commonly presents with nonspecific clinical and radiological manifestations. Thyroid Langerhans cell histiocytosis is typically characterized by non-enhancing hypodense lesions with an enlarged thyroid on computed tomography medical images. Thyroid involvement in LCH is uncommon and typically encountered in adults, as is salivary gland involvement. Therefore, we present a unique pediatric case featuring simultaneous salivary and thyroid involvement in LCH.

CASE PRESENTATION

A 3-year-old boy with complaints of an anterior neck mass persisting for 1 to 2 months, accompanied by mild pain, dysphagia, and hoarseness. A physical examination revealed a 2.5 cm firm and tender mass in the left anterior neck. Laboratory examinations revealed normal thyroid function test levels. Ultrasonography revealed multiple heterogeneous hypoechoic nodules with unclear and irregular margins in both lobes of the thyroid. Contrast-enhanced neck computed tomography revealed an enlarged thyroid gland and bilateral submandibular glands with non-enhancing hypointense nodular lesions, and multiple confluent thin-walled small (< 1.5 cm) cysts scattered bilaterally in the lungs. Subsequently, a left thyroid excisional biopsy was performed, leading to a histopathological diagnosis of LCH. Immunohistochemical analysis of the specimen demonstrated diffuse positivity for S-100, CD1a, and Langerin and focal positivity for CD68. The patient received standard therapy with vinblastine and steroid, and showed disease regression during regular follow-up of neck ultrasonography.

CONCLUSIONS

Involvement of the thyroid and submandibular gland as initial diagnosis of Langerhans cell histiocytosis is extremely rare. It is important to investigate the involvement of affected systems. A comprehensive survey and biopsy are required to establish a definitive diagnosis.

Effect of Hashimoto's thyroiditis on the dual-energy CT quantitative parameters and performance in diagnosing metastatic cervical lymph nodes in patients with papillary thyroid cancer

BACKGROUND

To evaluate the effect of Hashimoto's thyroiditis (HT) on dual-energy computed tomography (DECT) quantitative parameters of cervical lymph nodes (LNs) in patients with papillary thyroid cancer (PTC), and its effect on the diagnostic performance and threshold of DECT in preoperatively identifying metastatic cervical LNs.

METHODS

A total of 479 LNs from 233 PTC patients were classified into four groups: HT+/LN+, HT+/LN-, HT-/LN + and HT-/LN - group. DECT quantitative parameters including iodine concentration (IC), normalized IC (NIC), effective atomic number (Zeff), and slope of the spectral Hounsfield unit curve (λHU) in the arterial phase (AP) and venous phase were compared. Receiver operating characteristic curve analyses were performed to evaluate DECT parameters' diagnostic performance in differentiating metastatic from nonmetastatic LNs in the HT - and HT + groups.

RESULTS

The HT+/LN + group exhibited lower values of DECT parameters than the HT-/LN + group (all p < 0.05). Conversely, the HT+/LN - group exhibited higher values of DECT parameters than the HT-/LN - group (all p < 0.05). In the HT + group, if an AP-IC of 1.850 mg/mL was used as the threshold value, then the optimal diagnostic performance (area under the curve, 0.757; sensitivity, 69.4%; specificity, 71.0%) could be obtained. The optimal threshold value of AP-IC in the HT - group was 2.050 mg/mL. In contrast, in the HT - group, AP-NIC demonstrated the highest area under the curve of 0.988, when an optimal threshold of 0.243 was used. The optimal threshold value of AP-NIC was 0.188 in the HT + group.

CONCLUSIONS

HT affected DECT quantitative parameters of LNs and subsequent the diagnostic thresholds. When using DECT to diagnose metastatic LNs in patients with PTC, whether HT is coexistent should be clarified considering the different diagnostic thresholds.

Hyperthyroidism: A Review

Importance

Overt hyperthyroidism, defined as suppressed thyrotropin (previously thyroid-stimulating hormone) and high concentration of triiodothyronine (T3) and/or free thyroxine (FT4), affects approximately 0.2% to 1.4% of people worldwide. Subclinical hyperthyroidism, defined as low concentrations of thyrotropin and normal concentrations of T3 and FT4, affects approximately 0.7% to 1.4% of people worldwide. Untreated hyperthyroidism can cause cardiac arrhythmias, heart failure, osteoporosis, and adverse pregnancy outcomes. It may lead to unintentional weight loss and is associated with increased mortality.

Observations

The most common cause of hyperthyroidism is Graves disease, with a global prevalence of 2% in women and 0.5% in men. Other causes of hyperthyroidism and thyrotoxicosis include toxic nodules and the thyrotoxic phase of thyroiditis. Common symptoms of thyrotoxicosis include anxiety, insomnia, palpitations, unintentional weight loss, diarrhea, and heat intolerance. Patients with Graves disease may have a diffusely enlarged thyroid gland, stare, or exophthalmos on examination. Patients with toxic nodules (ie, in which thyroid nodules develop autonomous function) may have symptoms from local compression of structures in the neck by the thyroid gland, such as dysphagia, orthopnea, or voice changes. Etiology can typically be established based on clinical presentation, thyroid function tests, and thyrotropin-receptor antibody status. Thyroid scintigraphy is recommended if thyroid nodules are present or the etiology is unclear. Thyrotoxicosis from thyroiditis may be observed if symptomatic or treated with supportive care. Treatment options for overt hyperthyroidism from autonomous thyroid nodules or Graves disease include antithyroid drugs, radioactive iodine ablation, and surgery. Treatment for subclinical hyperthyroidism is recommended for patients at highest risk of osteoporosis and cardiovascular disease, such as those older than 65 years or with persistent serum thyrotropin level less than 0.1 mIU/L.

Conclusions and Relevance

Hyperthyroidism affects 2.5% of adults worldwide and is associated with osteoporosis, heart disease, and increased mortality. First-line treatments are antithyroid drugs, thyroid surgery, and radioactive iodine treatment. Treatment choices should be individualized and patient centered.

Takotsubo cardiomyopathy with left ventricle thrombus caused by subacute thyroiditis

We report a rare case of takotsubo cardiomyopathy caused by subacute thyroiditis in a man in his 50s. He went to the doctor with complaints of loss of appetite, diarrhoea, chills and general malaise. He had consciousness disturbance, thyrotoxicosis and thyroid-stimulating hormone (TSH) suppression. Thyroglobulin and C reactive protein levels in the blood were elevated, but TSH receptor antibody, thyroid-stimulating antibody, antithyroglobulin antibody and antithyroid peroxidase antibody were not. We began treatment with prednisolone and propranolol after he was diagnosed with thyroid storm caused by subacute thyroiditis. The ECG revealed inverted T waves on the fifth day after admission. He was newly diagnosed with takotsubo cardiomyopathy on the day. A large thrombus was detected in the left ventricle, requiring anticoagulation therapy. Thus, even if there are no findings of takotsubo cardiomyopathy or thrombus at the onset of thyroid storm, appropriate monitoring is required because they can develop during the treatment course.

A case of hyperchylomicronemia associated with GPIHBP1 autoantibodies and fluctuating thyroid autoimmune disease

Recent studies have reported that patients with autoimmune hyperchylomicronemia caused by glycosylphosphatidylinositol-anchored high-density lipoprotein binding protein 1 (GPIHBP1) autoantibodies are associated with rheumatoid arthritis, systemic lupus erythematosus, Sjogren's syndrome, Hashimoto's thyroiditis, Basedow's disease, and immune thrombocytopenia. We report a rare case of hyperchylomicronemia due to GPIHBP1 autoantibodies and fluctuating thyroid autoimmune disease. A 28-year-old woman, diagnosed with Hashimoto's thyroiditis at 26 years of age, started taking 50 µg/day of levothyroxine sodium. She had an episode of acute pancreatitis at 27 years of age; her serum triglyceride (TG) level was 1291 mg/dL at that time. The patient was referred to our hospital because her hyperchylomicronemia (hypertriglyceridemia) did not improve on treatment with pemafibrate and eicosapentaenoic acid (EPA). Serum total cholesterol and TG levels were 237 mg/dL and 2535 mg/dL, respectively, while plasma pre-heparin lipoprotein lipase (LPL) mass was 15 ng/mL (26.5-105.5 ng/mL). We diagnosed her as Basedow's disease based on autoimmune antibodies and ultrasound examination. Targeted exome sequencing revealed no pathogenic variants in the LPL or GPIHBP1 genes. The serum GPIHBP1 autoantibody level was 686.0 U/mL (<58.4 U/mL) and GPIHBP1 mass was 301.9 pg/mL (570.6-1625.6 pg/mL). The patient showed hyperchylomicronemia during periods of hypothyroidism and hyperthyroidism, whereas GPIHBP1 autoantibodies were positive during episode of hyperchylomicronemia but negative during periods of normal TG levels. Based on these findings, the patient was diagnosed with hyperchylomicronemia due to GPIHBP1 autoantibodies and treated with rituximab. GPIHBP1 autoantibodies remained undetectable and TG levels were controlled at approximately 200 mg/dL.

Clinical usefulness of thyroid ultrasonography in patients with primary hypothyroidism

BACKGROUND AND OBJECTIVE

Despite the value of ultrasonography in the detection of chronic thyroiditis (CT) as well as in nodular goitre, it is often only indicated in patients with hypothyroidism if a palpable goitre or a thyroid mass is identified. The objective of the study is to evaluate the clinical usefulness of thyroid ultrasonography in patients with primary hypothyroidism without clinical suspicion of nodular goitre. And more specifically, to analyse its value in the aetiological diagnosis of hypothyroidism, and to evaluate its contribution in the detection and characterisation of coexisting subclinical thyroid nodular disease.

PATIENTS AND METHOD

Prospective cross-sectional observational study of 114 patients with primary hypothyroidism of CT or idiopathic aetiology, without symptoms or cervical palpation suspected of nodular goitre, who underwent a thyroid function test, a serological study of antithyroid antibodies, a thyroid ultrasonound and, when appropriate, a cytological study of the nodules found.

RESULTS

Ultrasonound allowed CT to be recognised as the cause of hypothyroidism in 19% of patients who had a negative serological study, and detected nodules larger than 9mm in 22 patients (16 with antithyroid antibodies). A cytological study was performed in 18 of the cases. Five patients underwent surgery, with carcinoma found in two of them.

CONCLUSIONS

Thyroid ultrasound is useful in the aetiological diagnosis of primary hypothyroidism as well as in the detection of a coexisting, unsuspected, but clinically relevant nodular goitre, so this examination should be indicated in the initial study of patients with primary hypothyroidism.

[Thyroiditis]

A thyroiditis is an inflammatory disease of the thyroid whether autoimmune, infectious or drug-induced. Autoimmune thyroid diseases (including Hashimoto's thyroiditis and Graves' disease) are the most frequent of all autoimmune pathologies. The clinical presentation and history are often revealing of the pathology and its etiology. Complementary examinations allow to confirm the diagnosis and to follow the evolution of the disease. Sometimes the disease could have a mixed presentation associating two different causes (like a mixed autoimmunity for Graves and Hashimoto diseases). In these cases, the treatment options are not always straightforward and may need to be adapted with the clinical evolution.

Immune checkpoint inhibitor-related thyroid dysfunction

Immune-related adverse events (irAEs) are caused by immune checkpoint inhibitors in several organs including the endocrine glands. Thyroid dysfunction (thyroid irAEs) is often observed among endocrine irAEs and is induced by blockade of programmed cell death 1 (PD-1), programmed death ligand 1, or PD-1 plus cytotoxic T-lymphocyte antigen 4. Endocrinologically, destructive thyroiditis or hypothyroidism is observed in most cases, whereas hyperthyroidism (Graves' disease) is rare. Most patients who develop destructive thyroiditis or hypothyroidism subsequently require thyroid hormone replacement therapy. Thyroid irAE development is associated with prolonged survival in patients with non-small cell lung carcinoma. The incidence of thyroid irAEs is higher in patients who are positive versus negative for anti-thyroid antibodies at baseline, suggesting that these antibodies can predict thyroid irAE development. Cytotoxic T cells, especially CD4 T cells, are reportedly involved in the development of destructive thyroiditis. In this review, we describe the clinical features, potential biomarkers, and mechanism of thyroid irAEs.

Optimal Thyroid Hormone Replacement Dose in Immune Checkpoint Inhibitor-Associated Hypothyroidism Is Distinct from Hashimoto's Thyroiditis

Background: Immune checkpoint inhibitors (ICI) have revolutionized the treatment of many advanced cancers but are recognized to cause treatment-limiting immune-related adverse events (IrAE). ICI-associated thyroiditis is the most common endocrine IrAE and usually resolves to permanent hypothyroidism. Optimal thyroid hormone replacement in these patients remains unclear. We report the levothyroxine (LT4) dose needed to achieve stable euthyroid state in patients with hypothyroidism from ICI-associated thyroiditis, with comparison to patients with Hashimoto's thyroiditis (HT) and athyreotic state. Methods: We conducted a retrospective study of adults with ICI-associated hypothyroidism treated with LT4 at an academic medical center. Patient data were collected from the electronic medical record. Cases had ICI exposure followed first by hyperthyroidism and then subsequent hypothyroidism. Controls were HT (positive thyroid autoantibodies, requiring LT4) and athyreotic (total thyroidectomy or radioiodine ablation, requiring LT4) patients. Patients with central hypothyroidism, thyroid cancer, pregnancy, gastrointestinal stromal tumors, and use of L-triiodothyronine were excluded. Our primary outcome compared LT4 dose needed to achieve euthyroid state (thyrotropin 0.3-4.7 mIU/L over >6 consecutive weeks) for ICI-associated hypothyroidism, HT, and athyreotic patients, considering the impact of age and possible interfering medications by linear regression modeling. Secondary analysis considered the impact of endocrine specialty care on the time to euthyroid state. Results: One hundred three patients with ICI-associated thyroiditis were identified. Sixty-six of the 103 patients achieved euthyroid state; 2 with intrinsic thyroid gland function recovery and 64 on LT4. The mean LT4 dose achieving stable euthyroid state was 1.45 ± standard deviation (SD) 0.47 mcg/[kg·day] in ICI-associated hypothyroidism, 1.25 ± SD 0.49 mcg/[kg·day] in HT, and 1.54 ± SD 0.38 mcg/[kg·day] in athyreotic patients, using actual body weight. The difference in dose between ICI-associated hypothyroidism and HT was statistically significant (p = 0.0093). Dosing differences were not explained by age or use of interfering medications. Conclusions: ICI-associated thyroiditis represents an increasingly recognized cause of hypothyroidism. Our study demonstrates that patients with ICI-associated hypothyroidism have different thyroid hormone dosing requirements than patients with HT. Based on our findings and prior reports, we recommend that in patients with ICI-associated thyroiditis LT4 therapy be started at an initial weight-based dose of 1.45 mcg/[kg·day] once serum free thyroxine levels fall below the reference range.

[Epidemiology of benign thyroid disorders in the adult population of the Republic of Belarus: analysis of nationwide statistics 2009 to 2019]

BACKGROUND

Nowadays, the Republic of Belarus belongs to the countries with sufficient iodine supply, which made it possible to reduce the incidence of non-toxic goiter and congenital hypothyroidism. However, even a slight change in iodine consumption influences the pattern of thyroid diseases. In addition to iodine deficiency, other environmental conditions, as well as genetic factors, play a significant role in the etiology of thyroid diseases.

AIM

To analyze the dynamics of the main epidemiological indicators of benign thyroid diseases from 2009 to 2019 in the adult population of the Republic of Belarus, using the data of official state statistics.

MATERIALS AND METHODS

The indicators of the incidence and prevalence of benign thyroid diseases were studied on the basis of state statistics for 2009-2019. To analyze the dynamics of the studied indicators, regression analysis was used with the construction of linear and polynomial models.

RESULTS

A decrease in the incidence and prevalence of diffuse euthyroid goiter and an increase in the incidence and prevalence of nodular euthyroid goiter, thyroiditis, acquired hypothyroidism, Graves' disease, as well as the incidence of nodular toxic goiter were revealed.

CONCLUSION

Obtained data indicate, that there is an increase in the prevalence of most of the studied thyroid diseases, despite the adequate iodine supply. The above justifies the need for further study of the causes of the identified trends, as well as the necessity of developing new methods of diagnosis and treatment of thyroid diseases.

Factors in the occurrence and restoration of hypoparathyroidism after total thyroidectomy for thyroid cancer patients with intraoperative parathyroid autotransplantation

INTRODUCTION

Postoperative hypoparathyroidism (POH) is the most common and important complication for thyroid cancer patients who undergo total thyroidectomy. Intraoperative parathyroid autotransplantation has been demonstrated to be essential in maintaining functional parathyroid tissue, and it has clinical significance in identifying essential factors of serum parathyroid hormone (PTH) levels for patients with parathyroid autotransplantation. This retrospective cohort study aimed to comprehensively investigate influential factors in the occurrence and restoration of POH for patients who underwent total thyroidectomy with intraoperative parathyroid autotransplantation (TTIPA).

METHOD

This study was conducted in a tertiary referral hospital, with a total of 525 patients who underwent TTIPA. The postoperative serum PTH levels were collected after six months, and demographic characteristics, clinical features and associated operative information were analyzed.

RESULTS

A total of 66.48% (349/525) of patients who underwent TTIPA were diagnosed with POH. Multivariate logistic regression indicated that Hashimoto's thyroiditis (OR=1.93, 95% CI: 1.09-3.42), P=0.024), the number of transplanted parathyroid glands (OR=2.70, 95% CI: 1.91-3.83, P<0.001) and postoperative blood glucose levels (OR=1.36, 95% CI: 1.06-1.74, P=0.016) were risk factors for POH, and endoscopic surgery (OR=0.39, 95% CI: 0.22-0.68, P=0.001) was a protective factor for POH. Multivariate Cox regression indicated that PTG autotransplantation patients with same-side central lymph node dissection (CLND) (HR=0.50; 95% CI: 0.34-0.73, P<0.001) demonstrated a longer time for increases PTH, and female patients (HR=1.35, 95% CI: 1.00-1.81, P=0.047) were more prone to PTH increases. Additionally, PTG autotransplantation with same-side CLND (HR=0.56, 95% CI: 0.38-0.82, P=0.003) patients had a longer time to PTH restoration, and patients with endoscopic surgery (HR=1.54, 95% CI: 1.04-2.28, P=0.029) were more likely to recover within six months.

CONCLUSION

High postoperative fasting blood glucose levels, a large number of transplanted PTGs, open surgery and Hashimoto's thyroiditis are risk factors for postoperative POH in TTIPA patients. Elevated PTH levels occur earlier in female patients and patients without CLND on the transplant side. PTH returns to normal earlier in patients without CLND and endoscopic surgery on the transplant side.

Case Report: Onset of Type 1 Diabetes Mellitus in a Patient With Ulcerative Colitis and Sjogren's Syndrome Under Euthyroid Hashimoto's Thyroiditis

Type 1 diabetes mellitus (T1DM) is often complicated with some other autoimmune disorders. The complication of various autoimmune disorders is known as autoimmune polyglandular syndrome (APS). Once autoimmune thyroid disease develops, various autoimmune diseases can also occur. Such phenomena are classified as APS types 3A to 3D. In this report, we show the onset of T1DM in a patient with ulcerative colitis (UC) and Sjogren's syndrome. The most important and interesting point in this case is that, if we did not check her thyroid-associated antibodies, we could not have diagnosed her as APS. From the data of this case, we assumed that the patient suffered from APS type 3A, 3B, and 3D variants. This case pointed out very clearly the importance of testing for thyroid-associated antibodies under various autoimmune disease conditions even if the thyroid hormone levels are euthyroid. Moreover, based on the strong linkage between inflammatory bowel disease and T1DM and the compatibility with both T1DM and APS type 3, we think it is possible that Hashimoto's disease is present under complicated conditions together with UC and T1DM. It would be important to repeatedly check for thyroid-associated antibodies even in euthyroid patients, especially under various autoimmune disease conditions.

Covid-19, the thyroid and the pituitary - the real state of play

Thyroid and pituitary disorders linked to the coronavirus SARS-CoV-2, responsible for the COVID-19 epidemic, are mainly due to direct infection of the endocrine glands by the virus and to cell damage induced by the immune response. The two most frequent thyroid complications of COVID-19 are low T3 syndrome, or “non-thyroidal illness syndrome” (NTIS), and thyroiditis. Studies among in-patients with COVID-19 have shown that between one out of six and half of them have a low TSH level, related to NTIS and thyroiditis, respectively, sometimes found in the same patient. In NTIS, the decrease in free T3 concentration correlates with the severity of the infection and with a poor prognosis. Assessment of thyroid function in patients after a COVID-19 infection, shows normalization of thyroid function tests. Thyroiditis linked to COVID-19 can be divided into two groups, which probably differ in their pathophysiology. One is “destructive” thyroiditis occurring early in infection with SARS-CoV-2, with a severe form of COVID-19, usually observed in men. It is often asymptomatic and associated with lymphopenia. The other is subacute thyroiditis occurring, on average, one month after the COVID-19 episode, usually in clinically symptomatic women and associated with moderate hyperleukocytosis. Post-infection, one quarter to one third of patients remain hypothyroid. An Italian study demonstrated that low TSH in patients hospitalized for COVID-19 was associated with prolonged hospitalization and a higher mortality risk. Pituitary diseases associated with SARS-CoV-2 infection are much rarer and the causal relationship more difficult to ascertain. Several cases of pituitary apoplexy and diabetes insipidus during COVID-19 infection have been reported. Hyponatremia occurs in 20–50% of patients admitted to hospital for COVID-19. The prevalence of the syndrome of inappropriate antidiuretic hormone secretion (SIADH) amongst these hyponatremic cases is difficult to determine. These endocrine complications may influence the prognosis of infection with SARS-CoV-2. Although they rarely require specific treatment, it is important that endocrinologists recognize them to ensure appropriate management, particularly in the acute phase.

Painless Thyroiditis Presenting with Headache

Although headache attributed to hypothyroidism is coded within The International Classification of Headache Disorders, 3rd edition, an association between headache and thyrotoxicosis (hyperthyroidism) is mentioned only in the appendix. Reports on relevant cases are too scarce to establish a causal relationship. A young man with a history of migraine with aura arrived at our headache clinic with a 10-day history of headache and weight loss. Brain MRI revealed normal findings. Blood tests revealed thyrotoxicosis. A test for thyroid-related antibodies was negative. Thus, the patient was diagnosed with painless thyroiditis. The patient's headache resolved as his thyroid hormone levels decreased. To the best of our knowledge, this is the first reported case of headache exaggerated by painless thyrotoxicosis.

68Ga-FAPI Uptake of Thyroiditis in a Patient With Breast Cancer

ABSTRACT

68Ga-fibroblast activation protein-specific inhibitor (FAPI)-04 PET/CT was performed in a 49-year-old woman diagnosed with breast cancer. In PET/CT imaging, intense 68Ga-FAPI uptake was observed in the primary tumor, axillary lymph nodes, and also in the thyroid gland, whereas pathological 18F-FDG uptake was not observed in the thyroid gland. On thyroid ultrasonography, parenchyma was heterogeneous, and an area of focal thyroiditis was observed in the superior part of the right lobe. Biochemical parameters were found to be consistent with thyroiditis. This case shows that FAPI uptake in the thyroid gland may be associated with thyroiditis and should be evaluated clinically.

Hashimoto's thyroiditis as a risk factor for thyroid cancer

PURPOSE OF REVIEW

To summarize the recent developments in considering Hashimoto's thyroiditis as a risk factor for thyroid cancer.

RECENT FINDINGS

Modern approaches to understanding the co-occurrence of Hashimoto's thyroiditis and thyroid cancer have consistently found increased prevalence of both conditions, separately as well as of their coexistence. The inflammatory process in Hashimoto's thyroiditis is understood as a potential risk factor for thyroid cancer development. This has also provided a better understanding of the limitations in the current diagnostic and follow-up armamentarium for both conditions, resulting in international guidelines from the clinical and scientific societies. Other recent developments call for a paradigm shift in guidelines on thyroid carcinomas when lymphocytic infiltration is present, which potentially should always be considered the case at least in areas of sufficient iodine intake.

SUMMARY

The literature of Hashimoto's thyroiditis as a risk factor for thyroid cancer is reviewed over the last year to highlight new developments in the understanding of their association and future clinical implications.

Immune Checkpoint Inhibitor-Induced Thyroiditis Is Associated with Increased Intrathyroidal T Lymphocyte Subpopulations

Background: Immune checkpoint inhibitors (ICIs) frequently cause thyroid dysfunction but their underlying mechanism remains unclear. We have previously demonstrated increased circulating natural killer (NK) cells and human leukocyte antigen (HLA)-DR surface expression on inflammatory intermediate CD14⁺CD16⁺ monocytes in programmed cell death protein-1 (PD-1) inhibitor-treated patients. This study characterizes intrathyroidal and circulating immune cells and class II HLA in ICI-induced thyroiditis. Methods: This is a single-center prospective cohort study of 10 patients with ICI-induced thyroiditis by flow cytometry of thyroid fine needle aspirates (n = 9) and peripheral blood (n = 7) as compared with healthy thyroid samples (n = 5) and healthy volunteer blood samples (n = 44); HLA class II was tested in n = 9. Results: ICI-induced thyroiditis samples demonstrated overall increased T lymphocytes (61.3% vs. 20.1%, p = 0.00006), CD4^-CD8^- T lymphocytes (1.9% vs. 0.7%, p = 0.006), and, as a percent of T lymphocytes, increased CD8⁺T lymphocytes (38.6% vs. 25.7%; p = 0.0259) as compared with healthy thyroid samples. PD-1 inhibitor-induced thyroiditis had increased CD4⁺PD1⁺ T lymphocytes (40.4% vs. 0.8%; p = 0.021) and CD8⁺PD1⁺ T lymphocytes (28.8% vs. 1.5%; p = 0.038) in the thyroid compared with the blood. Circulating NK cells, certain T lymphocytes (CD4⁺CD8⁺, CD4^-CD8^- T, gamma-delta), and intermediate monocytes were increased in ICI-induced thyroiditis. Six patients typed as HLA-DR4-DR53 and three as HLA-DR15. Conclusions: ICI-induced thyroiditis is a T lymphocyte-mediated process with intra-thyroidal predominance of CD8⁺ and CD4^-CD8^- T lymphocytes. The HLA haplotypes may be involved but need further evaluation. These findings expand the limited understanding of ICI-induced thyroiditis, which could be further translated to guide immunomodulatory therapies for advanced thyroid cancer.

[Thyroiditis: What's new in 2019?]

Thyroiditis is a frequent and mostly benign disease that can sometimes disrupt the thyroid balance. Their diagnosis, as well as their aetiology, is a necessary step in the management of the patients. Painful thyroiditis includes acute thyroiditis of infectious origin and subacute thyroiditis. The first one can be treated by antibiotics or antifungals depending on the germ found. The second one will be treated with non-steroidal anti-inflammatory drugs or corticosteroids. In cases of Hashimoto's thyroiditis with overt hypothyroidism, replacement therapy with L-thyroxine will be adapted to the TSH level. As amiodarone treatment provides dysthyroidism, the thyroid status should be monitored regularly. Hypothyroidism will be treated using thyroid replacement therapy. Hyperthyroidism imposes a stop of amiodarone when it is possible. Treatment with synthetic antithyroid drugs (propyl-thio-uracil) or corticosteroids could be used whether there is an underlying thyroid disease or not. Immunotherapies with anti-PD-1/PDL1 or anti-CTLA-4 can also provide dysthyroidism. A monitoring of the thyroid assessment needs to be done in these patients, even if there are no clinical signs, which are not very specific in this context. The treatment of hypothyroidism will be based on thyroid replacement therapy according to the TSH level and the presence or absence of anti-TPO antibodies. Treatment of symptomatic hyperthyroidism may involve a prescription of beta-blockers, or synthetic antithyroid drugs in case of positive anti-TSH receptor antibodies. In all cases, it is desirable to contact an endocrinologist to confirm the diagnosis hypothesis and to decide on a suitable treatment.

Follicle-stimulating Hormone-secreting Pituitary Adenoma Accompanied by Painful Thyroiditis

A 30-year-old woman with multiple ovarian cysts presented with high serum estradiol levels. She had a pituitary adenoma, but the follicle-stimulating hormone (FSH) concentration was within the normal range. The patient complained of neck pain and palpitations during the disease course, and laboratory results revealed thyrotoxicosis and a systemic inflammatory response with negative findings for anti-thyroid stimulating hormone (TSH) receptor antibody and positive findings for anti-thyroglobulin and anti-thyroid peroxidase antibodies. Prednisolone improved the symptoms and the thyroid function and was discontinued after two months. A histological examination of the pituitary tumor confirmed it to be FSH-producing pituitary adenoma, with subsequent normalization of the serum estradiol concentration.

Cognitive Impairment Caused by Isolated Adrenocorticotropic Hormone Deficiency without Other Hypo-adrenalism Signs - Autoimmune Encephalopathy Mimics

Isolated adrenocorticotropic hormone deficiency (IAD) is a cause of adrenal insufficiency (AI), which shows impaired secretion of adrenocorticotropic hormone (ACTH) with the preserved secretion of other anterior pituitary gland hormones. We herein report a case of IAD complicated by chronic thyroiditis presenting with neuropsychiatric symptoms without other signs indicative of AI that showed complete improvement of the cognitive function after the administration of corticosteroids. The clinical features of our case may be confused with autoimmune encephalopathies (AEs); however, IAD should be strictly differentiated from AEs, as it requires permanent hormone replacement without addition of immunosuppressive agents.

A Rare Combination of Gastric Mucosa-associated Lymphoid Tissue Lymphoma, Autoimmune Gastritis, Thyroiditis, Hemolysis, and Systemic Lupus Erythematosus

We herein report a case with the rare combination of mucosa-associated lymphoid tissue lymphoma (MALT lymphoma) of the stomach, autoimmune gastritis (AIG), autoimmune thyroiditis, autoimmune hemolytic anemia (AIHA), and systemic lupus erythematosus. A 68-year-old woman was diagnosed with gastric MALT lymphoma associated with Helicobacter pylori (H. pylori) infection and AIG. Complete remission of the MALT lymphoma was achieved by H. pylori eradication and radiotherapy. Three years after the diagnosis of MALT lymphoma, the patient developed AIHA and anti-nuclear and anti-Smith autoantibody-positive lupus serositis, which were successfully managed with prednisolone administration.

Is there a correlation between thyroiditis and thyroid cancer?

BACKGROUND

In the past few decades, the incidence of thyroid cancer has increased significantly all over the world. In the same period, there also seems to have been an increase in the incidence of Hashimoto's Thyroiditis-the most common inflammatory autoimmune thyroid disease. Several studies have linked thyroiditis to thyroid cancer.

METHODS

In our study, we examined 2304 cases of thyroid surgery collected over a 12-year period starting from 2004. In 2090 cases (90.7%) out of our sample, it has been possible to compare the presence, or lack thereof, of thyroiditis by means of a histological diagnosis post-surgery; 214 (9.3%) cases were excluded from our study due to insufficient data. We then divided the different histological classifications into two groups. Group A included all the benign histological classifications and Group B included all the malignant histological classifications. In each group, we then assessed the presence, or lack thereof, of thyroiditis in order to evaluate if thyroiditis can be linked to a higher incidence of thyroid cancer.

RESULTS

Data analysis showed a higher incidence of thyroiditis in Group B, 36.4% (malignant pathology report), than in Group A, 32.4% (benign pathology report), but no statistically significant difference emerged between those two groups (P > 0.05).

CONCLUSIONS

Our conclusion was that a correlation between thyroiditis and a higher incidence of thyroid cancer is still undefined.

Painless Thyroiditis with Thyrotropin Receptor-blocking and Receptor-stimulating Autoantibodies

We herein report a rare case of a 41-year-old woman with painless thyroiditis who was positive for thyrotropin (TSH) receptor-blocking (TBAbs) and receptor-stimulating autoantibodies (TSAbs) in the thyrotoxic phase. Her serum thyroid hormone levels were high, and TSH was undetectable. The low uptake of ^99mTc led to the diagnosis of painless thyroiditis. M22-TRAb, TBAb and TSAb were detectable in the thyrotoxic phase. Three months later, she became severely hypothyroid. M22-TRAb and TBAb were still strongly positive, although the TSAb levels had decreased to just above the reference range. In this case, TBAb led to hypothyroidism.

Mean peak systolic velocity of superior thyroid artery for the differential diagnosis of thyrotoxicosis: a diagnostic meta-analysis

BACKGROUND

Thyrotoxicosis is often caused by destructive thyroiditis (DT) or Graves' disease (GD), and a prompt and accurate differential diagnosis for thyrotoxicosis is needed as management strategy differs. A meta-analysis of published literature was performed to evaluate the diagnostic accuracy for differentiating GD from DT patients by the measurement of mean peak systolic velocity of superior thyroid artery (STA-PSV) using ultrasonography.

METHODS

The databases of Embase, Pubmed, Cochrane, Web of Science, Wanfang, and CNKI were retrieved without time limit to identify eligible studies. The statistical information and scientific quality were assessed and classified. The data were analyzed using Stata12.0 software.

RESULTS

A total of 11 studies with 1052 cases only from Asia were included. Meta-analysis results showed the pooled sensitivity and pooled specificity of STA-PSV by ultrasonography were 0.86 (95% CI, 0.80-0.90) and 0.93 (95% CI, 0.86-0.97) in distinguishing GD from DT, respectively, with the AUC of 0.94 (95% CI, 0.92-0.96) .

CONCLUSION

STA-PSV by ultrasonography is a useful diagnostic method in differentiating GD from DT. More studies from other countries are needed to further evaluate the accuracy of STA-PSV for the differential diagnosis of thyrotoxicosis.

Gasless Transaxillary Endoscopic Thyroidectomy with Robotic Assistance: A High-Volume Experience in North America

BACKGROUND

Since its introduction nine years ago, gasless transaxillary thyroidectomy with robotic assistance (RT) has achieved a relatively limited application in North America. This study aimed to assess the outcomes of RT in a recent large, diverse North American population.

METHODS

Consenting patients were selected for the RT approach from November 2010 to July 2015 based on patient preference, and their perioperative data were retrospectively reviewed.

RESULTS

Of 301 robotic thyroidectomies completed in 281 patients, 160 were total thyroidectomy and 141 were lobectomy. Women predominated (98.9%), with a mean age of 41 years (range 17-74 years) and a mean follow-up of 24 months (range 3-71 months). The mean body mass index (BMI) was 25.7 kg/m² (range 17-44 kg/m²). However, 33.3% of patients had a BMI 25-29.9 kg/m², 12.4% had a BMI 30-34.9 kg/m², 3.5% had a BMI 35-39.9 kg/m², and 0.7% had a BMI ≥40 kg/m². Excluding 20 completion lobectomy, the indications for surgery were indeterminate cytology (53%), malignant cytology (10%), growth (18%), Graves' disease (12%), and other (5%). The mean size of the largest resected nodule was 2.5 cm (range 0.7-6.4 cm). Mean operating time for robotic lobectomy and total thyroidectomy was 81 and 109 minutes, respectively. One patient was converted to standard cervicotomy for failure to progress endoscopically. Complications included temporary dysphonia (6.0%), permanent recurrent laryngeal nerve deficit (1.3%), hypocalcemia (temporary 8.2%, permanent 1.1%), seroma (0.7%), and hematoma requiring reoperation (0.3%). Complications did not differ in patients with a BMI ≥25 kg/m² compared to those with a BMI <25 kg/m² or with respect to nodules >3 cm or surgery for Graves' thyroiditis. One patient developed grade II arm lymphedema ipsilateral to the axillary incision at two years, which resolved with conservative management. No patient had a surgical site infection or brachial plexopathy. Cancer was present histologically in 133 (48%) patients. Among 91 patients with cancer of the index nodule, 48.4% had papillary, 44.0% follicular variant papillary, 2.2% minimally invasive follicular carcinoma, and 5.5% minimally invasive Hürthle cell carcinoma. One patient had sclerosing variant thyroid paraganglioma. To date, all patients are without evidence of tumor recurrence.

CONCLUSIONS

At a high-volume center, gasless transaxillary endoscopic thyroid surgery done with robotic assistance is a safe, efficient, and effective approach in a diverse North American patient population.

[ON THE ISSUE OF AUTOIMMUNE OVARY DAMAGE DURING PUBERTY]

The aim of the study was to ascertain the influence of AІТ on the formation of autoimmune damage to ovaries by determining the connections between the levels of AOAB, ATPO, gonadotropic and sex hormone levels, and the functional state of the ovaries and thyroid gland. 198 girls age 10-18 were studied: 166 with AIT (AIT+ Group), и 32- without AIT (the AIT- Group). A defined difference between TTH. and ATPO, was revealed, which is explained by the presence of thyroid pathology in the AIT+ Group. Prolactin levels and ovarian volume were notably higher, while Progesterone levels were lower in the AIT+ Group. No discernable differences among levels of AOAB, sex hormones, Estrogen, Testosterone or antral follicules were observed. A direct correlation was revealed between AOAB levels and the girls' age both in the AIT+ and AIT- groups. AOAB data was divided into three tertials in order to study links with various hormonal homeostasis. Analysis of data obtained showed numerous correlative links between ATPO, AOAB, gonadotropins, sex hormones, TTH and ovarian volume in all tertials of both the AIT+ and AIT- groups; correlative links were found, too, between AOAB and ATPO in the III tertial groups AIT+ and AIT-. In adolescents with AIT disbalance occurs at all levels of hormonal homeostasis as well as in ovarian structure. Such changes and the presence of ATPO and AOAB may be associated with emerging autoimmune ovary damage.

Differentiated thyroid carcinomas associated with chronic thyroiditis: biological and clinical properties

AIM

To determine biological and clinical features of papillary and follicular thyroid carcinomas associated or not associated with chronic thyroiditis.

MATERIALS AND METHODS

The study was conducted by retrospective analysis of medical histories of 2,459 patients with thyroid cancer. Tumor size, its category according to the TNM system, multi-focal properties of tumor growth, carcinoma invasiveness, as well as disease stage, rates of relapses and metastasis, and also cumulative survival rates were analyzed.

RESULTS

The tumor size in patients with papillary or follicular carcinoma associated with thyroiditis was smaller compared to the patients without thyroiditis. In the first case, the invasion frequency into extrathyroid structure and into the capsule was also lower. Multi-focal growth of both carcinoma types was registered more frequently in the presence of thyroiditis. The frequency of papillary carcinoma metastasis to lateral cervical lymph nodes was lower in the presence of thyroiditis, the frequency being equal for metastasis into lymph nodes of the VI lymph outflow zone in both groups of patients (with and without thyroiditis). In the presence of thyroiditis, the frequency of distant papillary carcinoma metastasis was decreased, no metastases were detected in patients with follicular carcinoma. In the group of patients with papillary carcinoma there was found no relation between the presence of thyroiditis and disease stage, relapse rates, and mortality levels; however, the risk of follicular carcinoma relapse was significantly lower in patients with thyroiditis.

CONCLUSIONS

The presence of chronic thyroiditis in papillary carcinoma patients showed a certain positive impact on the course of the disease, in particular, primary tumor growth, invasion, and metastasis. Such effect is even more expressed in the patients with follicular thyroid carcinoma.

Benign Thyroid Diseases and Risk of Thyroid Cancer: A Nationwide Cohort Study

CONTEXT

Thyroid nodules, adenomas, and goiter have consistently been associated with thyroid cancer risk. Few studies have assessed whether thyroid dysfunction and thyroid autoimmunity influence this risk.

OBJECTIVE

To examine thyroid cancer risk after diagnoses of a wide range of benign thyroid conditions.

DESIGN

Hospital and cancer registry linkage cohort study for the years 1978 to 2013.

SETTING

Nationwide (Denmark).

PARTICIPANTS

Patients diagnosed with hyperthyroidism (n = 85,169), hypothyroidism (n = 63,143), thyroiditis (n = 12,532), nontoxic nodular goiter (n = 65,782), simple goiter (n = 11,582), other/unspecified goiter (n = 21,953), or adenoma (n = 6,481) among 8,258,807 residents of Denmark during the study period.

MAIN OUTCOME MEASURES

We computed standardized incidence ratios (SIRs) for differentiated thyroid cancer, excluding the first 12 months of follow-up after benign thyroid disease diagnosis.

RESULTS

SIRs were significantly elevated for all benign thyroid diseases apart from hypothyroidism. SIRs were higher for men than women and in the earlier follow-up periods. Elevated SIRs were observed for localized and regional/distant thyroid cancer. After excluding the first 10 years of follow-up, hyperthyroidism [n = 27 thyroid cancer cases; SIR = 2.00; 95% confidence interval (CI): 1.32 to 2.92], nontoxic nodular goiter (n = 83; SIR = 4.91; 95% CI: 3.91 to 6.09), simple goiter (n = 8; SIR = 4.33; 95% CI: 1.87 to 8.53), other/unspecified goiter (n = 20; SIR = 3.94; 95% CI: 2.40 to 6.08), and adenoma (n = 9; SIR = 6.02; 95% CI: 2.76 to 11.5) remained positively associated with thyroid cancer risk.

CONCLUSIONS

We found an unexpected increased risk of differentiated thyroid cancer, including regional/distant disease, following diagnosis of hyperthyroidism and thyroiditis that could not be solely attributed to increased medical surveillance. Hypothyroidism was less clearly associated with thyroid cancer risk.

RAPID EVOLUTION OF THYROID DYSFUNCTION IN PATIENTS TREATED WITH NIVOLUMAB

OBJECTIVE

To describe the evolution of thyroid dysfunction in a series of patients with cancer treated with the immune checkpoint inhibitor anti-programmed cell death protein-1 (PD-1) monoclonal antibody, nivolumab.

METHODS

Cases of thyroid dysfunction after initiation of checkpoint inhibitor treatment were identified from the Division of Endocrinology clinical practice at Mount Sinai Hospital, New York from April 2016 to February 2017. Charts were reviewed to identify patients treated with nivolumab with new onset of thyroid dysfunction.

RESULTS

Nine cases of thyroid function in patients who were treated with nivolumab were identified. There were 4 male and 5 female patients, with a mean age of 66 years (range 50-76 years). Seven patients ultimately developed hypothyroidism. Five of the 7 patients developed abnormal thyroid function tests within the first 90 days of starting therapy (range 21-84 days), 3 of whom had transient hyperthyroidism. Transient hyperthyroidism evolved rapidly to hypothyroidism; elevated thyroid-stimulating hormone (TSH) levels were detected within 16 to 32 days of the last documented low TSH. In the 2 patients without a hyperthyroid phase, TSH levels >50 were found 18 to 28 days after the last normal TSH value.

CONCLUSION

As the use of immune checkpoint inhibitor therapy increases, the need for prompt diagnosis and treatment of drug-induced thyroid disease will become more important. As illustrated in this case series, in contrast to other causes of auto-immune thyroiditis, hypothyroidism can develop rapidly within 3 months of treatment. Close monitoring is necessary to detect the development of thyroid dysfunction and avoid preventable morbidity.

ABBREVIATIONS

Anti-TPO Abs = anti-thyroglobulin antibodies; CT = computed tomography; CTLA-4 = cytotoxic T-lymphocyte-associated protein 4; FDA = U.S. Food & Drug Administration; FDG-PET = fluorodeoxyglucose-positron emission tomography; PD-1 = programmed cell death protein-1; PD-L1 = programmed death-ligand 1; T3 = triiodothyronine; T4 = thyroxine; TG = thyroglobulin; TPO = thyroperoxidase; TSH = thyroid-stimulating hormone.

[Nutrition management in obese patients with type 2 diabetes mellitus after laparoscopic sleeve gastrectomy]

OBJECTIVE

To explore the value of nutrition management in obese patients with type 2 diabetes mellitus(T2DM) after laparoscopic sleeve gastrectomy(LSG).

METHODS

Clinical data of 22 obese T2DM patients undergoing LSG from March 2013 to July 2015 in Fudan University Pudong Medical Center were collected. All the patients strictly followed the specialized instruction by nutritionists: diabetic and low calorie diet 3347.2 to 5020.8 kJ (800 to 1200 kcal) per day before the operation; low calorie liquid diet 2510.4 kJ(600 kcal) per day before operation for promoting gastric emptying; fasting diet before postoperative ventilation; clear liquid diet 1673.6 to 2510.4 kJ (400 to 600 kcal) per day after postoperative ventilation (liquid intake >2000 ml); low fat liquid diet 2928.8 to 3765.6 kJ (700 to 900 kcal) per day (protein 60 g per day at least, 2000 ml liquid) 2 weeks after the operation; semi-liquid diet 1 month after operation and gradually normal diet. All the 22 patients were followed up at 1 week, 1, 3, 6 months after operation on time. Changes of body weight, waist circumference, hip circumference, body mass index(BMI), blood glucose indexes induding fasting blood glucose(FBG), 2-hour postparandial blood glucose(PBG), fasting C-peptide, 2-hour postprandial C-peptide, fasting serum inculin(FINS), 2-hour postprandial inculin(INS), HbAlc, blood pressure and blood lipid indexes were observed and analyzed before and 1 week, 1, 3, 6 months after operation.

RESULTS

The average age of 22 patients (10 men and 12 women) was 38.6 years (18 to 66 years). The duration of diabetes varied from 1 month to 15 years. Comorbidity included 12 patients of high blood pressure, 14 of fatty liver, 1 of coronary heart disease, 1 of gout, 1 of chronic thyroiditis and 1 of menstrual disorder. LSG was performed successfully in all the patients and no severe complications and transference to laparotomy occurred. As compared to pre-operation, at 6 months after operation, the average body weight decreased from (103.9±20.2) kg to (80.9±12.6) kg (t=6.294, P=0.000), waist circumference from (118.6±13.8) cm to (96.4±8.0) cm (t=6.331, P=0.000), hip circumference from (116.9±12.6) cm to (104.0±7.7) cm (t=3.854, P=0.000), BMI from (36.2±5.9) kg/m² to (27.9±3.5) kg/m² (t=5.630, P=0.000), showing a decreasing trend over time. There was no underweight patient after 6 months follow-up. As compared to pre-operation, at 6 months after operation, the average FBG reduced from (7.4±1.4) mmol/L to (6.0±0.9) mmol/L (t=3.172, P=0.003), 2 h PBG from (14.1±4.9) mmol/L to (7.5±2.2) mmol/L (t=7.026, P=0.000), FINS from (160.0±71.9) mIU/L to (43.8±20.8) mIU/L (t=7.259, P=0.000), 2-hour postprandial INS from (437.6±261.4) mIU/L to (140.5±104.6) mIU/L (t=5.858, P=0.000), fasting C-peptide from (1.1±0.6) μg/L to (0.7±0.3) μg/L (t=3.560, P=0.000), 2-hour postprandial C-peptide from (2.5±0.9) μg/L to (1.5±0.7) μg/L (t=3.865, P=0.000), HbAlc from (8.0±1.6)% to (5.9±0.6)% (t=5.953, P=0.000), showing a decreasing trend over time except FBG, 2h postprandial C-peptide and HbAlc(all P<0.05). FBG and 2-hour PBG of 16 patients returned to normal 3 months after the operation. Blood pressure and trigly ceride decreased obviously 6 months after operation compared to pre-operation with significant difference(P<0.05). At 6 months after operation, blood pressure of 8 comorbidity patients with high blood pressure became normal (8/12, 66.7%) and of 4 patients improved(4/12, 33.3%); B ultrasound examination revealed normal in 11 comorbidity patients with fatty liver(11/14,78.6%) and improvement in 3 patients (3/14,15.4%). Blood uric acid of the gout patient and the menstruation of the menstrual disorder patient returned to normal 3 months and 1 month after the operation respectively.

CONCLUSION

As for obese patients with T2DM undergoing LSG, reasonable nutrition management is helpful to decrease body weight, and to obtain an ideal improvement of blood glucose and blood lipid levels.

Endocrine manifestations in celiac disease

Celiac disease (CD) is an autoimmune small intestinal mucosal disorder that often presents with diarrhea, malabsorption and weight loss. Often, one or more associated endocrine disorders may be associated with CD. For this review, methods involved an extensive review of published English-language materials. In children and adolescents, prospective studies have demonstrated a significant relationship to insulin-dependent or type 1 diabetes, whereas in adults, autoimmune forms of thyroid disease, particularly hypothyroidism, may commonly co-exist. In some with CD, multiple glandular endocrinopathies may also occur and complicate the initial presentation of the intestinal disease. In others presenting with an apparent isolated endocrine disorder, serological screening for underlying subclinical CD may prove to be positive, particularly if type 1 diabetes, autoimmune thyroid or other autoimmune endocrine diseases, such as Addison’s disease are first detected. A number of reports have also recorded hypoparathyroidism or hypopituitarism or ovarian failure in CD and these may be improved with a strict gluten-free diet.

The increased risk of globus pharyngeus in patients with chronic thyroiditis: a case control study

OBJECTIVE

A correlation between globus pharyngeus and thyroid gland inflammation has been mentioned in previous studies. However, the potential risk of globus pharyngeus in chronic thyroiditis patients has not been shown so far. The aim of this study is to investigate a possible association between chronic thyroiditis and globus pharyngeus.

PATIENTS AND METHODS

The study was performed in an ultrasound (US) center of a tertiary health care institution. Ninety-two patients who were under examination for suspected thyroid pathologies or undergoing follow-up for a previously diagnosed thyroid disease were enrolled in the study. The patients were divided into two groups according to the existence of globus symptoms. Subsequently, all patients underwent high-resolution thyroid ultrasounds. The patients whose ultrasound findings were suggestive of chronic thyroiditis constituted the second subgroup. The demographic data of the patients and other ultrasound findings including the volume of the thyroid glands and nodules, if any, were noted as well.

RESULTS

Sixty-seven female (73%) and 25 male (27%) patients were enrolled in the study. Thirty-two (35%) of the 92 patients constituted the globus pharyngeus group according to their responses to the questionnaire and the US findings were concordant with chronic thyroiditis in 36 (39%) patients. The correlation between chronic thyroiditis and globus sensation was significant (p = 0.004), and the odds ratio was calculated as 3.7 (95% CI = 1.5-9.11). Other parameters including age, sex, thyroid volume and nodule status were not significantly related to globus pharyngeus in this particular patient series.

CONCLUSIONS

In the presented study, the risk of globus pharyngeus occurrence was calculated as 3.7-fold higher in patients with chronic thyroiditis. Being a preliminary report, it is necessary to confirm this finding and understand the pathophysiological mechanism via further investigations with a larger patient series.

Early Hypoparathyroidism Reversibility with Treatment of Riedel's Thyroiditis

BACKGROUND

Riedel's thyroiditis (RT) is a rare, fibroinflammatory condition which induces gradual thyroid gland destruction and adjacent soft-tissue fibrous infiltration. About one- seventh of RT cases are associated with hypoparathyroidism, necessitating long-term therapy for symptomatic hypocalcemia. The reversibility of the parathyroid hormone deficit has not been fully described.

PATIENT FINDINGS

A 40-year-old woman with no prior history of thyroid disease presented with a six month history of progressive thyroid enlargement complicated by worsening dysphagia and positional dyspnea. Her past medical history was remarkable only for retroperitoneal fibrosis. Physical examination revealed a large, hard, non-mobile goiter. Thyroid indices while maintained on levothyroxine were normal, but marked asymptomatic hypocalcemia with an inappropriately normal parathyroid hormone level was noted. Thyroid imaging and fine needle aspiration were consistent with RT. Isthmectomy and subsequent serial corticosteroid and tamoxifen treatment led to rapid symptom improvement. Serum calcium and parathyroid hormone levels returned to the reference range within three months.

SUMMARY

We describe a case of RT in which hypoparathyroidism resolved after treatment targeted the mechanical compression and the fibroinflammatory milieu of the patient's thyroidal disease.

CONCLUSIONS

RT can be associated with hypoparathyroidism that is clinically silent at presentation. Mechanical decompression of the goiter and immunomodulatory therapy can reverse the fibrosclerotic process and lead to rapid recovery of parathyroid gland function, as in this patient. However, in most cases hypoparathyroidism is persistent and requires continued treatment to prevent symptomatic hypocalcemia.

[Clinicopathologic characteristics of familial versus sporadic papillary thyroid carcinoma]

OBJECTIVE

To investigated the clinicopathologic features of familial papillary thyroid carcinoma (PTC) compared to sporadic PTC.

METHODS

Between January 2008 and August 2014, 20 patients who underwent surgery at Liaoning Cancer Hospital and Institute were diagnosed with familial PTC. We compared the clinicopathologic characteristics between familial PTC and sporadic PTC.

RESULTS

The prevalence of familial PTC was 1.3% (20/1 587). The median age of patients at diagnosis was 37 years and there were 12 females and 8 males. Thirty percent of the familial PTC cases exhibited a parent-offspring relationship, and 70% exhibited a sibling relationship. There were significant differences between familial PTC and sporadic PTC in terms of concomitant chronic thyroiditis (P < 0.01), nodular goiter (P = 0.04), tumor multicentricity (P < 0.01), bilaterality (P < 0.01), histological subtype (P < 0.01), and central lymph node metastasis (P = 0.02). When familial PTC patients were classified based on parent-child and sibling relationship, there were significant differences in preoperative TSH level (P = 0.02) and concomitant chronic thyroiditis (P = 0.01) between the two categories.

CONCLUSIONS

There are significant differences in clinicopathologic features between familial PTC and sporadic PTC and between familial PTC with parent-child and those with sibling relationship. Familial PTC appears more aggressive than sporadic carcinoma. Optimal treatment for familial PTC is not yet established, but improved awareness and screening will permit earlier detection, more timely intervention, and improved outcomes for patients and their families.

Ultrasound and thyroiditis in patient candidates for thyroidectomy

AIM

Thyroiditis is often associated with nodules based on the Bethesda classification system, and the presence of thyroiditis can make thyroid surgery difficult using both conventional techniques and minimally invasive videoassisted approaches (MIVAT).

METHODS

We analyzed 326 patients who underwent total thyroidectomy in 2012. We collected all data in dedicated database. The patients were divided in 4 groups: group 1 no affected by thyroiditis, group 2 affected by thyroiditis, group 3 only histological diagnosis of thyroiditis, group 4all patients affected by thyroiditis.

RESULTS

Group 1 included 201 cases, group 2 included 64 patients, group 3 included 61 patients. No statistically significant difference between group 2 and 3 about Ultrasound (US) examination. Statistically significant difference in incidence of "THYR 3-4" between group 1 and group 4. No differences in MIVAT vs. Conventional group.

CONCLUSION

US examination of the thyroid is essential for the diagnostic study of the gland also in the selection of a surgical approach. Thyroiditis is a relative contraindication to MIVAT but the experience of the endocrine surgeon is the most important factor to reduce intra and postoperative complications together a correct collaboration in multidisciplinart endocrinological team.

Serum human chorionic gonadotropin levels and thyroid hormone levels in gestational transient thyrotoxicosis: Is the serum hCG level useful for differentiating between active Graves' disease and GTT?

Gestational transient thyrotoxicosis (GTT) is defined as transient thyrotoxicosis caused by the stimulating effect of human chorionic gonadotropin (hCG) during pregnancy. We attempted to identify the serum hCG level that causes GTT, and we compared the serum hCG levels and thyroid hormone levels of GTT patients according to whether they had a background of thyroid disease. We also evaluated serum hCG as a parameter for differentiating between active Graves' disease (GD) and GTT. We reviewed the 135 cases of pregnant women who came to our hospital to be evaluated for thyrotoxicosis during their 7th to 14th week of pregnancy, and their serum hCG level was measured at that time. Among the 135 pregnant women with thyrotoxicosis; 103 of the women had GTT, and the other 32 women had active GD. There were no correlations between their serum hCG levels and free thyroid hormone levels. There were no significant differences in thyroid hormone levels or hCG levels among the GTT groups with different thyroid disease backgrounds; i.e., the GTT group without thyroid disease, GTT group with chronic thyroiditis, GTT group with non-functioning thyroid nodules, and GTT group with GD in remission. The serum hCG level of the GTT group was significantly higher than in the active GD group, but it was not a good parameter for differentiating between the two groups. The FT3/FT4 ratio of the active GD was significantly higher than in GTT group, and was a better parameter for differentiation.

Minimal-access video-assisted thyroidectomy for benign disease: a retrospective analysis of risk factors for postoperative complications

BACKGROUND

Minimal-access video-assisted thyroidectomy (MIVAT) has now become a widespread technique in the treatment of benign thyroid disease. No studies systematically investigate risk factors for postoperative complications. The aim of our study was to investigate possible risk factors for postoperative complications in MIVAT in patients with benign disease.

METHODS

One-hundred eighty-nine patients who underwent MIVAT for benign disease were retrospectively identified in a prospectively-maintained institutional register of thyroid surgery. Exclusion criteria were: (1) thyroid volume>45 mL; (2) malignant disease; (3) prior neck surgery; (4) prior neck irradiation; (5) nodule size>3 cm; (6) intrathoracic component; (7) follow-up<1 year. Age, sex, comorbidities, body mass index, existence of symptoms, duration of disease evolution, thyroid volume, hyperthyroidism, thyroiditis, and the duration of surgery were analyzed as risk factors for complications. We applied both bivariate and multivariate logistic regression analyses in order to identify risk factors associated with postoperative complications.

RESULTS

Complications were presented by 28 patients (14.8%). The variables associated as independent risk factors with these complications were hyperthyroidism (OR = 4.31; P = 0.003) and thyroiditis (OR = 3.59; P = 0.035). Age, sex and thyroid volume up to 45 mL do not seem to be independent risk factors.

CONCLUSIONS

In endocrine surgery units, two independent risk factors for postoperative complications could be identified in MIVAT patients: hyperthyroidism and thyroiditis. Surgeons operating on patients presenting these factors should be aware of the potential augmented risk in order to correctly adapt intraoperative and postoperative care.

Tubercular thyroiditis with multinodular goitre with adenomatous hyperplasia: a rare coexistence

A 32-year-old Indian woman presented with swelling in the anterior part of the neck for the last 3 years. Clinical and radiological examination and fine needle aspiration cytology suggested the diagnosis of multinodular goitre. A subtotal thyroidectomy was performed by the surgeon and the specimen was submitted for the final diagnosis. Histological examination of the specimen revealed multiple caseating tubercular granulomas coexistent with multinodular goitre and adenomatous hyperplasia. The sections demonstrated acid-fast tubercle bacteria, confirming the diagnosis of tubercular thyroiditis. This case emphasises that tubercular thyroiditis should always be considered in patients with thyroid swelling or nodule, in countries where the prevalence of tuberculosis is high.

Thyroid profiles in a patient with resistance to thyroid hormone and episodes of thyrotoxicosis, including repeated painless thyroiditis

BACKGROUND

Thyrotoxic disease can be difficult to recognize in patients with resistance to thyroid hormone (RTH) because the clinical symptoms of thyrotoxicosis cannot be observed, and thyrotropin (TSH) may not be suppressed because of hormone resistance. Painless thyroiditis is a relatively common cause of thyrotoxicosis, but its occurrence in RTH has not been reported. We assessed the thyroid profile in a patient with RTH and episodes of thyrotoxicosis who experienced repeated painless thyroiditis.

PATIENT FINDINGS

A 44-year-old Japanese woman with RTH, which was confirmed by the presence of a P453A mutation in the thyroid hormone receptor β (TRβ) gene, showed a slight elevation of the basal levels of thyroid hormones, which indicated that her pituitary RTH was mild. She experienced a slight exacerbation of hyperthyroxinemia concomitant with TSH suppression. A diagnosis of painless thyroiditis was made because of the absence of TSH receptor antibodies, low Tc-99m pertechnetate uptake by the thyroid gland, and transient suppression followed by a slight elevation of TSH following the elevation of thyroid hormones. The patient's complaints of general malaise and occasional palpitations did not change throughout the course of painless thyroiditis. Three years later, painless thyroiditis occurred again without any deterioration of the clinical manifestations.

CONCLUSIONS

Mild pituitary RTH can be overcome by slight exacerbation of hyperthyroxinemia during mild thyrotoxicosis. When pituitary resistance is severe and TSH is not suppressed, thyrotoxicosis may be overlooked.