Endocrine Abstracts

Introduction: Thyroid dysfunctions are relatively common presentations in Endocrine Practice. They are second to diabetes mellitus (DM) among endocrine disorders. However, management often involves the endocrinologists and surgeons.Aims: The aim of this review is to determine the spectrum of thyroid disorders and the pattern of presentation seen in our hospital.Method: It is a five (5) years study (June 2004–April 2009) that l...

Background and objectives: Thyroid function tests (TFT) are expensive in Nigeria. The reliability of the test is sometimes called into question when at variance with clinical findings. The Wayne’s clinical index is an old diagnostic index to facilitate objectivity and improve the accuracy of clinical assessment of thyrotoxicosis. This report highlights the unreliability of a TFT result in a case of thyrotoxicosis and the usefulness of the clinical index.<p class="abst...

A 39-year-old lady with severe primary hypothyroidism was referred to the endocrine clinic. Her past medical history includes intermittent colitis and Irritable Bowel syndrome. There was no history of diarrhoea for the last 1 year. TSH 97.2 mU/l (0.3–5.0) and free thyroxine (T4) was 5.0 pmol/l (10–22). The dose of levothyroxine was increased gradually from 100 to 300 μg/day. Despite this, TSH level remained high at 96.1 and freeT4 was 4.0. ...

Thyroid eye disease (TED) is clinically evident in 25–50% of patients with Graves’ disease and 3–5% of cases develop severe eye disease. We present a case of very aggressive TED.A 46-year-old gentleman developed graves thyrotoxicosis and was blocked and replaced with carbimazole and thyroxine. He continued to smoke 20 cigarettes/day despite several advises.He developed marked exophthalmos (L>R), chemosis, with re...

A 29-year-old pregnant lady known hypothyroid for 5 years, presented with thyroid eye disease (TED). She is a non-smoker. Her TFT in the past years has been stable.Her exophthalmos was noticed at early pregnancy. Her anti-thyroid peroxidise antibodies (TPO-Ab) were >1300 mU/l (ref. range <1.4) and TSH-R antibodies (TRAB) were 18.6 U/l (ref. range <5.0).On presentation she was clinically and biochemically euthyroid with ...

Introduction: The symptoms and signs of thyroid disease can be subtle and non-specific resulting in the indiscriminate use of thyroid function tests (TFT) for diagnosis. The resulting rise in the number of TFTs has raised issues about cost–effectiveness of such a practice. We set out to identify whether using specific clinical indications was an effective way to identify patients with abnormal TFTs and to determine any demographic data that would support unrestricted TFT ...

Background: Radionuclide thyroid scanning using technetium pertechnetate (Tc99m) is a useful aid in the differential diagnosis of benign thyroid disease. It is particularly useful in the differentiation of the causes of a thyrotoxic biochemical picture, e.g. viral thyroiditis, toxic nodular disease or Grave’s disease. This has implications for long-term management plans. However, its cost and exposure to radiation necessitate the need to justify its use in the ...

Aim: To audit if fine needle aspiration of thyroid nodules are done as per the Royal College of Physicians Guidelines.Methods: We selected a list of 25 patients who had FNA of throid nodule over a 6 months period between July 2008 and December 2008 and analysed if the procedure had been done in accordance with current Royal College of Physicians guidelines for FNA Thyroid.Results:1. None of the cytopathology ...

Introduction: Hyperthyroidism may mimic many conditions, and there is potential for under-diagnosis if testing is considered only in patients presenting with classical symptoms.Aim: To describe the range of presentations in patients found to have hyperthyroidism and referred from primary care.Method: Consecutive patients diagnosed with hyperthyroidism and referred to the endocrine clinic between Jan 2009 and Nov 2009 were studied. ...

A 24-year-old female make-up artist presented with a 6 months history of emotional lability, heat intolerance, weight loss and shaking of the hands. She described a deteriorating relationship with her spouse and increasing difficulties performing her professional role. On examination, she demonstrated marked agitation, tremor, sweating and tachycardia. Biochemistry confirmed severe thyrotoxicosis (fT4 84 pmol/l, TSH<0.01 mU/l). Subsequent clinic attendance and c...

Introduction and methods: Controversy exists regarding the optimal dosing regimen of radioactive iodine (RAI) for the treatment of hyperthyroidism. The dose of RAI was individualised, based on the size of the thyroid gland and 24-h RAI uptake. We performed a 10-year retrospective analysis of patients with hyperthyroidism treated with variable dose RAI, with a cure defined as eu- or hypothyroidism.Results: One hundred and forty-nine patients with hyperthy...

An 83-year-old gentleman was referred to the endocrine clinic with incidentally found abnormal thyroid function tests (TFT): TSH <0.02 (0.2–4.0 mU/l), free T4 20.4 (9–19 pmol/l), and free T3 7.6 (2.5–5.7 pmol/l). His TFT done 6 months previously were normal with TSH 1.21 mU/l and FT4 11.8 pmol/l. His past medical history included BPH, peripheral vascular disease and chronic kidney disease (CKD), and medications were tamsulosi...

Objectives: Transient thyroid hypofunction during the initial 3 months following radioiodine (RAI) therapy is well recognised with a reported incidence of 10–15%. There are no clear diagnostic criteria, often leading to management uncertainty, inappropriate diagnosis of ‘cure’ and institution of life-long thyroxine therapy. The aim of our audit was to assess the incidence and identify predictors for transient euthyroidism or hypothyroidism following administrati...

Background: Iopanoic acid is an iodinated oral cholecystographic contrast agent, which can be used for the rapid blockade of thyroid hormone production in preparation for thyroidectomy, especially in patients who are intolerant of thionamides. However, appropriate timing of thyroid surgery is vital.Project: In this retrospective audit, we identified all patients with thyrotoxicosis who received pre-operative preparation with iopanoic acid from 2006 to 20...

Aim: In the thyrotoxicosis local investigation protocol, Tc99m pertechnetate scintigraphy technetium scan is used to assess the presence of thyroid uptake and both the degree and pattern of uptake. TSH receptor antibodies are used to demonstrate the presence and activity of autoimmune thyroid disease. We audited the utility of these investigations in a series of thyrotoxic patients.Methods: Forty-nine patients (11 men, 38 women, mean age 47.5±38) we...

Audit standard: All patients should receive written and verbal advice about the risk of neutropenia associated with the use of anti-thyroid drugs. Compliance rate 100%.Our Endocrinology Department has a detailed patient information sheet that is provided to the patients at the time of initiation of anti-thyroid drugs.Background: Recently, a patient was admitted with neutropenia secondary to the use of carbimazole. She did not know ...

Differentiated thyroid cancers function less well than normal thyroid tissue but continue to secrete thyroglobulin (Tg) which can be iodinated to form thyroxine (T4) and triiodothyroxine (T3). Functioning metastases causing thyrotoxicosis are rare. The majority of reported cases have large volume, metastatic follicular tumours. A significant proportion develop T3 toxicosis with normal T4 levels. T3 toxicosis is often mild....

Thyroid hormone exerts direct effects on almost every body organ or tissue, and thyroid deficiency produces a wide range of metabolic disturbances. Hypothyroidism is readily recognized in an individual presenting with characteristic clinical signs and symptoms. However involvement of the haematologic and renal systems is less commonly acknowledged making the diagnosis less apparent and, therefore, the initial focus of attention is on a diagnosis other than hypothyroidism.<...

Radioactive iodine (RAI) therapy is the usual treatment of choice for hyperthyroidism. We have demonstrated a success rate of 88% (euthyroidism or hypothyroidism) over a 5-year period. We are very happy to recommend RAI, however patients still express concerns.There is little literature available about patients’ reactions to RAI: to our knowledge, only two studies. We performed a survey of our RAI treated patients. Of 143 patients contacted, 87 repl...

In patients presenting with a diffusely enlarged hard thyroid gland the differential diagnosis lies between thyroid carcinoma, lymphoma, and Riedel’s thyroiditis. We present a case of Riedel’s thyroiditis with multifocal nodular sclerosis, which improved with levothyroxine replacement.A 40-year-old woman presented with a 3 months history of neck swelling, dysphagia and breathlessness on exertion. Examination revealed a hard, fixed, diffuse goit...

A 19-year-old, female of West African descent presented with a 5 months history of thyrotoxicosis. The GP had commenced carbimazole. She had continuing clinical and biochemical thyrotoxicosis TSH <0.01 (0.3–5.5 mU/l), FT4 68.0 (9–20 pmol/l) and FT3 18.9 (3.4–5.6 pmol/l). Thyroid antibodies were present at elevated titre and technetium uptake scanning showed toxic diffuse hyperplasia with an uptake function of 37%, confirming Graves&#146...

A 74-year-old gardener developed progressive dysphagia for solids and liquids over 15 months. He lost five stone in weight and became increasingly weak. There was nothing significant in his past medical and drug histories. He is married, never smoked and drank little alcohol.He had an acute medical admission via A&E in April 2008 for profound dehydration and cachexia. His weight was 41.5 kg. There were no gross neurological deficits but he had hoarse...

Introduction: A joint RAI clinic, led by an endocrinologist and nuclear physicist, was introduced in our centre, in July 2007.Aims: To compare our practice since the introduction of the joint RAI clinic against guidelines from the Royal College of Physicians of London.Methods: A retrospective audit of patients who received RAI, Sept 2007–Oct 2008. Data collected from patients’ case notes and compared to previous audit 200...

Background: The BTA guidelines for the use of thyroid function tests recommend the measurement of TSH receptor antibodies (TRAb) when investigating hyperthyroidism of uncertain aetiology, in suspected Graves’ ophthalmopathy and in pregnant women with Graves’ disease. An in-house TSH receptor autoantibody ELISA assay (TRAb) was introduced in 2008. This study has audited the assay performance and evaluated its clinical usefulness in a tertiary centre.<p class="abst...

Case report: A previously fit 53-year-old lady presented to A&E with abdominal pain and vomiting. The pain has been present for 2 months and associated with weight loss. She neither smoked nor drank alcohol. On admission her BP was 160/85, pulse 70/m regular. Abdominal examination revealed generalized tenderness and a right iliac fossa mass with scanty bowel sounds,. FBC, U&E, LFT, CRP, amylase, bone were normal. AXR revealed gas filled small bowel loops.<p class="...

Historically, the 131I whole body scan played a central role in the assessment of disease status in patients with differentiated thyroid cancer.In 2006, the European Thyroid Cancer Taskforce published a new Consensus Statement. It favoured the use of stimulated serum thyroglobulin measurement and neck ultrasound for follow up of disease activity. The use of diagnostic 131I whole body scan was no longer recommended as a routine test....

Thyroid cancer is the most common endocrine malignancy. However, some aspects of its management remain controversial. The protocols provided by the British, European and American Thyroid Associations have changed recently and continue to evolve.We have audited the management of patients with thyroid cancer in a tertiary referral hospital and compared it with the guidelines from the Consensus Statement published by the European Thyroid Cancer Taskforce in...

Introduction: Radioactive iodine (RAI) is a commonly used treatment modality in Graves’ hyperthyroidism. Patient choice is a major factor in advising radioiodine but there are few data on patient satisfaction following treatment.Method: QuestionnaireAn anonymised questionnaire was distributed to 100 individuals on the thyroid register with RAI treated Graves’ hyperthyroidism. The survey included questions relating to side...

Forty-seven years old lady presented to another hospital with symptoms of diarrhea and sleep disturbance. She was found to have abnormal thyroid function tests (TFTs) with fT4 44 fT3 12 and TSH 3.4. She had no goiter or thyroid eye signs. Thyroid ultrasound showed a multinodular goiter and an uptake scan was consistent with thyrotoxicosis.She was commenced on carbimazole and in 2001 radio-iodine was administered for a presumed diagn...

Temporary hypocalcaemia following total thyroidectomy occurs in around 30% of patients and is usually due to inadvertent damage to the parathyroid glands. Whilst mild cases are easily managed with oral calcium supplementation, there is the potential for severe calcium deficit with the ensuing risks of cardiac dysrhythmias, tetany and in extreme cases death. It is common practice to have a post-surgery protocol to allow the early identification of these patients. Whilst many pr...

An 18-year-old male referred to endocrine department 3 years ago with symptoms of tremor in both hands and query thyrotoxicosis. Presenting TFTs showed raised T3 and T4 levels with normal TSH (FT4 – 45 pmol/l, FT3 – 3.3 pmol/l and TSH of 1.4 mU/l). There was family history of thyroid disease with both the patient’s father and grandmother diagnosed with overactive thyroid. Patient’s TFTs were reproduced with differ...

Aim: The aim of our study was to explore the possibility of using a district-wide laboratory database as a governance tool to ensure the optimum management of patients with biochemical hyperthyroidism.Patients and methods: A complete list of patients on whom TFT were requested over a 3-month period was obtained and patients with unequivocal hyperthyroidism were identified. General practitioners (GP) of patients not referred to the specialist endocrine te...

Background: Resistance to thyroid hormone (RTH) is a rare autosomal dominant condition of altered tissue responsiveness to thyroid hormone (TH) characterised by elevated serum FT4 and FT3 and non-suppressed TSH levels caused by mutation in the thyroid receptor (TR) β gene. Different isoforms of TR are expressed in the heart and regulate genes that encode structural and regulatory proteins. The syndrome is characterised by a variable clinical phenotyp...

We report five cases of hyperthyroidism with complex management issues, which were successfully treated with iopanoic acid prior to thyroidectomy.Three patients (cases 1–3) had Graves’ disease; two developed agranulocytosis on carbimazole and one had uncontrolled severe thyrotoxicosis and poor compliance with treatment. Radioiodine was either declined or contraindicated due to radio-protection issues. All patients were rendered euthyroid with i...

Case-1: Nineteen years old nursing student with primary hypothyroidism, despite thyroxine (T4) at 200 μg/day and subsequent trial of T4+T3, remained significantly symptomatically hypothyroid. Over 4 years worsening hypothyroidism was evident (TSH: 19.1 to >200 and fT4 2.1–6.8) despite dose/regime changes. Investigations for malabsorption: normal coeliac screen, B12, ferritin, FBC, kidney and liver function, autoimmune p...

Background: Although hypocalcemia is common post thyroidectomy, no national guidelines pertain to its management.Long-term treatment with calcium and vitamin D replacement predispose patients to nephrocalcinosis and should be avoided in the absence of a clear indication.Aim: To identify the incidence and management of post-operative hypocalcemia following thyroidectomy in a UK teaching hospital with view to formulating management g...

Introduction: Anti-TSH-receptor binding antibodies can cross the placenta and can stimulate or inhibit the fetal thyroid, causing fetal and neonatal thyroid dysfunction. We test for these antibodies in all pregnant women with a history of thyroid disease using a TSH binding inhibitor immunoglobulin (TBII) assay. Our aims were to audit our management of TBII positive pregnancies and to review pregnancy outcomes.Methods: Serum TBII concentration was measur...

Radioactive iodine is a common and effective treatment for hyperthyroidism. Post radio-iodine hypothyroidism is a frequent complication occurring in ~80% of radioiodine treated patients. This can be diagnosed clinically (by monitoring free T4 and TSH levels) but, in our centre, a 123I uptake scan 6 weeks after therapy is sometimes used to help predict the likelihood of future hypothyroidism. In these situations, thyroxine therapy can be started if radioio...

Sunitinib, a tyrosine kinase inhibitor, inhibits VEGF-mediated tumour angiogenesis. Following NICE approval, it is increasingly used in the treatment of metastatic renal cell carcinoma.Hypothyroidism in sunitinib-treated individuals was first described in 2005. The aetiology remains uncertain and possibly reflects a destructive thyroiditis. Incidence rates of hypothyroidism from case series vary between 36 and 85%. We report a retrospective analysis of t...

Introduction: Maternal hypothyroidism is the most common disorder of thyroid function in pregnancy and may influence the outcome of mother and fetus at all stages.Aim: To evaluate screening and management of all high risk pregnant women for thyroid dysfunction.Method: A retrospective audit as carried out between January 2005 and December 2006. Our local standards were TSH<3 mIU/l for screening and TSH<2 mIU/l for treatment....

Background: TSH-receptor stimulating antibodies are implicated in the pathophysiology of Graves’ disease (GD). The detection of TSH-receptor antibodies (TSHR-Abs) is routinely performed by assays measuring thyrotropin-binding inhibitor immunoglobulin and new generation assays are reported to have high sensitivity and specificity in GD. The differentiation of hyperthyroidism (GD or toxic multinodular goiter (TMG) or toxic adenoma (TA)) is important for planning the therapy...

Introduction: Current guidelines recommend that thyroid nodules classified as Thy 3 following fine needle aspiration (FNA) should be managed surgically. This results in over-treatment of benign disease. The purpose of this study was to review multi-disciplinary team (MDT) management of Thy 3 FNAs at our institution.Patients and methods: A total of 109 FNAs were performed between April 2008 and October 2009; 31 were reported as Thy 3. The management of al...

The administration of radioactive iodine (131I) is widely used in the treatment of patients with hyperthyroidism. We have previously reported better cure rates in patients receiving a single dose of 600 MBq 131I compared with those treated with lower doses. We set out to evaluate if baseline patient characteristics predict which patients require multiple doses of radioiodine to induce cure. We compared 42 subjects requiring ≥3 doses with 290 patient...

Genome wide association screening (GWAS) has proved invaluable in determining otherwise undetected genetic effects for several common endocrine diseases. The largest GWAS performed in Graves’ disease (GD), to date, has not only confirmed association of several known gene regions, including the HLA region, TSHR and FCRL3, but has also identified several other possible regions of association with GD. As GD shares several susceptibility loci with other endocrin...

The hypothalamo-pituitary–thyroid (HPT) axis serves to maintain appropriate systemic levels of thyroid hormone (TH) through a negative feedback pathway via the hypothalamic arcuate and paraventricular nuclei. However, the effects of TH in other hypothalamic regions are poorly understood. Triiodothyronine (T3) administration to the hypothalamic ventromedial nucleus (VMN) induces a potent hyperphagic response, although it is unclear whether this is part of a nove...