Endocrine Abstracts

Monitoring patients with thyroid cancer for recurrent disease relies heavily on measuring serum thyroglobulin (Tg). Tg cannot be assessed reliably in the presence of anti-thyroglobulin antibodies for analytical reasons, this being the case in about a third of patients. There has been recent interest in microRNA profiling of fine needle aspiration biopsies of thyroid nodules, with encouraging results. The objective of this pilot was to explore microRNAs in peripheral blood of p...

Thyroid hormones are important regulators of fetal growth, although their mechanism of action remains unclear. This study investigated the effect of hypothyroidism on pancreatic β-cell development in foetal sheep.All procedures were carried out under the UK Animals (Scientific Procedures) Act 1986. Under general anaesthesia between 105 and 110 days of gestation (days; term ~145 days), one twin fetus was thyroidectomised (TX), while the other was sha...

Thyroid hormones increase foetal and adult metabolic rates, and, in adult tissues, increase mitochondrial biogenesis. Foetal tri-iodothyronine (T3) concentrations rise towards term in preparation for the increased postnatal energy demands but whether they affect mitochondrial development remains unknown. This study examined mitochondrial development in skeletal muscle of thyroid hormone deficient sheep foetuses near term.At 105–110 days (...

Background: There is little information regarding the natural history of subclinical hyperthyroidism (SH) due to Graves’ disease (GD). The objectives of this study were to assess the natural course of individuals with SH due to GD over a prolonged period. We also investigated the factors contributing to the progression or remission in these patients.Methods: A prospective analysis of patients with SH due to GD between 2007 and 2013 who had at least ...

Context: Autoimmune polyendocrine syndrome type 1 (APS1) is characterised by multiple autoimmune endocrinopathies and results from mutations in the autoimmune regulator (AIRE) gene. Approximately 80% of patients present with hypoparathyroidism which is suggested to result from autoimmune responses against the parathyroid glands. The calcium-sensing receptor (CaSR), which plays a pivotal role in maintaining calcium homeostasis by sensing blood calcium levels and regula...

Aim: The BTA guidelines published recently suggested an uniform U1–U5 classification of thyroid nodules on ultrasound (US) and organising management and follow-up based on these grades. The aim of our retrospective analysis was to assess the reliability and usefulness of US in assessment of thyroid nodules, in comparison with post-operative histological diagnosis.Methods: All patients who underwent thyroid surgery for thyroid nodules were assessed, ...

Recent guidelines indicate that pregnant women with subclinical hypothyroidism (SCH, TSH above the pregnancy-related reference range where available, or ≧2.5 mU/l) should be treated with thyroxine. We aimed to determine the frequency of overt hypothyroidism (OH; TSH>5 mU/l) and SCH (TSH >2.5 but <5 mU/l) in pregnancy, and to examine how many are diagnosed with thyroid problems after pregnancy. Four thousand three hundred women were recruited between 2007 and...

: In patients with subclinical hypothyroidism, soy protein and isoflavone combination has been shown to increase the risk of developing overt hypothyroidism; however, it is unclear if soy affects thyroid function in those without existing thyroid compromise.Materials and methods: Two double blind randomised trials were undertaken in which thyroid function was performed routinely at the beginning and end as a secondary end point. In both trials soy protei...

Background: Hyperthyroidism often runs an indolent course and may be undiagnosed for prolonged periods. Most patients are treated in the outpatient setting and the effects of hyperthyroidism on hospitalised patients are poorly studied. We set out to determine the prevalence of hyperthyroidism in a large cohort of inpatients and evaluated their comorbidities, reasons for hospitalisation and rehospitalisation rates.Methods: A case-control study was conduct...

Introduction: Hypothyroidism (HypoT)-related polyneuropathy is reported to range between 42 to 72%. However, there is paucity of information regarding the prevalence and clinical course of small fibre neuropathy in HypoT. This prospective study examines small fibre function (SFF) – using the Laser doppler imager flare (LDIFLARE) technique – and structure (SFS) using in-vitro corneal confocal microscopy (IVCCM) in a cohort of HypoT subjects before ...

Iodine deficiency is the most common cause of preventable mental impairment worldwide. Recent evidence suggests the re-emergence of mild iodine deficiency in the UK. A recent multicentre survey in the UK reported that 68% of school girls were iodine deficient with the lowest levels seen in Northern Ireland (NI). Unlike many countries, the UK does not have a salt or food iodination program. World Health Organisation defines deficiency as follows: mild 50–99 μg/l; mode...

: Recent Phase 3 studies have demonstrated the clinical utility of immunotherapy with inhibitors of PD1 in cancers, including melanoma and non-small cell lung cancer. Autoimmune side effects are common. Both hypothyroidism and hyperthyroidism have been observed in up to 16% of patients. We report for the first time the endocrine evaluation of patients with anti-PD1 induced thyroid dysfunction.Methods: All patients treated in published trials of anti-PD1 ...

Context: Soy phytoestrogens are suggested to have an adverse effect on thyroid function but the contribution to this by soy protein alone when free from isoflavones is unknown.Objective: The primary aim was to determine the effect of isoflavone free soy protein supplementation on thyroid function, with a secondary aim of assessing the effects on cardiovascular risk indices in patients with subclinical hypothyroidism.Design and sett...

Adequate iodine intake during pregnancy is required for the production of thyroid hormones and brain development in the foetus. Recent evidence has suggested re-emergence of mild iodine deficiency in the UK but there are few studies that have specifically looked at iodine intake in pregnant women. Current World Health Organisation recommendation is for 250 mcg/day intake of iodine in pregnancy and the following are good sources of dietary iodine: 1 pint milk (~140–220 mcg...

Introduction: Fine needle aspiration cytology (FNAC) is a valuable and cost-effective pre-operative investigation for thyroid nodules. The British thyroid association (BTA) previously recommended two non-neoplastic results 3–6 months apart in aspirates to exclude neoplasia1. However, in recently updated BTA guidelines, repeat aspirates were recommended when there are clinical or ultrasound suspicions2.Aim: The aim of our study ...

Although the vast majority of thyroid nodules are benign, evaluation by ultrasound-guided fine needle aspiration (FNA) biopsy is usually necessary to exclude underlying malignancy. Partially in recognition of reported variability in FNA sensitivity and specificity, the 2007 British Thyroid Association (BTA) guidelines recommended two benign results 3–6 months apart to exclude neoplasia. The 2014 BTA guidance states that a second FNA is not required for nodules with benign...

Introduction: Amiodarone induced thyrotoxicosis (AIT) remains a diagnostic and therapeutic challenge. Broadly, AIT is classified as type 1 (underlying latent thyroid disorder) or type 2 (destructive thyroiditis). Despite being an on-going clinical conundrum, there is no U.K. wide guidance on management of AIT. We report a retrospective review of recent cases treated within our department as AIT.Methods: Data was collected for all patients referred to our...

Introduction: Despite high rates of recurrence after anti-thyroid drug (ATD) withdrawal, ATD (mainly Carbmazole) remain the first line of treatment for Graves’ disease (GD) in the UK. Limited retrospective observational studies have shown that a low TSH post ATD withdrawal had a positive predictive value of 70% and a negative predictive value of 62% (specificity 85%) for relapse of Graves’ disease.Aim: We wished to determine the relationship be...

Introduction: A breech presentation occurs in 3–5% of all full-term pregnancies and is associated with increased risk of maternal and foetal morbidity. Factors known to increase the risk of breech presentation include prematurity, low birth weight and multiple pregnancies. Recent studies suggest maternal thyroid hormone deficiency in late pregnancy may also be a risk factor. Our study aims to assess if a breech presentation at 36 weeks gestation in a healthy singleton coh...

Introduction: Ultrasound (US) is an extremely sensitive examination for thyroid nodules. Fine needle aspiration (FNA) cytology samples taken with ultrasound guidance, increases accuracy and reduces rates of unsatisfactory samples1. In addition, the immediate assessment of the sample for adequacy by onsite cytopathology is shown to reduce inadequacy rates by most reports2.Aim: The aim of this study was to compare the inadequacy (Thy1...

Medullary thyroid carcinoma (MTC) is an aggressive form of malignancy, virtually incurable except by complete surgical resection. With insidious onset and occasional rare clinical variants, it is often diagnosed late in the course of disease and has a poor prognosis. We aimed to evaluate diagnostic efficiency, treatment modalities and outcome in patients admitted to our department between 2004 and 2015, diagnosed with MTC, with emphasis on rare clinical presentations. We ident...

Background: Radioactive iodine (RAI) therapy is well-established in the management of benign thyroid disorders associated with thyrotoxicosis, but the optimal dose remains controversial. Guidelines recommend 500–800 MBq, though it is thought that Graves’ thyrotoxicosis may respond more readily to lower doses (400–600 MBq).Methods: We studied all local cases receiving RAI over four calendar years (2010–2013; n=447). Demographi...

Introduction: Correlation of papillary thyroid cancer and lymphocytic thyroiditis is well documented but the incidence of thyroid malignancies in Graves’ disease especially in the absence of nodular thyroid disease is considered to be uncommon.Method: We conducted a retrospective audit of forty-four patients with established diagnosis of Grave’s thyrotoxicosis treated with total thyroidectomy from 2010-2013 (36 months), in a tertiary care centr...

Aim: The British Thyroid Association published guidelines on the management of differentiated thyroid cancer and medullary thyroid cancer in 2007. The aim of our audit was to assess compliance with these guidelines.Methods: Electronic records of patients operated on and followed up in our hospital from January 2009 to December 2013 were reviewed retrospectively.Results: Forty-nine patients fulfilling these criteria were identified....

Thyroid eye disease (TED) affects some 400 000 people in the United Kingdom. Apart from being problematic and cosmetically distressing to patients it can be occasionally sight threatening. The joint TED clinic was first established at the New Cross Hospital in 2010. At this monthly clinic patients are assessed by both an Endocrinology and Ophthalmology consultant. Full orthoptic evaluation is done and the management plan is facilitated by a patient self-assessment questionnair...

: A family with generalised resistance to thyroid hormone secondary to a missense point mutation in thyroid hormone receptor β (TR-β) gene corresponding to substitution of arginine to histidine at amino acid 438 (R438H) is described in three successive generations.Case 1: (Index case) A 43 year old lady presented with thyrotoxicosis and was initially treated with carbimazole followed by radio-iodine ablation of the thyroid. Thyroxine was commen...

Background: Subclinical hyperthyroidism provides a challenging condition in clinical endocrinology. The debate about who and when to treat has long been discussed. Despite guidelines describing assessment of such patients, there is surprising little data on imaging in this condition and the role of nuclear medicine or ultrasound scans.Aim: To review all patients with subclinical hyperthyroidism referred for imaging studies at a district general hospital ...

Introduction: Thyroid Ultrasound (US) is the recommended first line investigation of suspected thyroid nodules. Specific radiological features, such as micro-calcification, low echogenicity, solid consistency, heterogeneity and ill-defined margins, raise the possibility of underlying malignancy. These findings together with fine needle aspiration cytology guide the management of thyroid nodules. The aim of this audit was to evaluate the quality and adequacy of thyroid US repor...

Overt hyperthyroidism occurs in about 0.1–0.4% of all pregnancies. Propylthiouracil (PTU) is recommended in first trimester due to risk of teratogenicity with Carbimazole (CBZ). CBZ is preferable in rest of the pregnancy and postpartum period due to risk of serious liver disease with PTU. We reviewed our management of hyperthyroidism in pregnancy from 2009 to 2014. Total number of pregnancies =34, mean maternal age 32.6 years. Except one all (33/34) were diagnosed pre- pr...

Several preparations of thyroxine are available nowadays but is a great challenge for every clinician when the oral and intramuscular administration is failing and has to consider long term intravenous administration. This is a 42 years old lady who had a total thyroidectomy for Graves thyrotoxicosis. She commenced on multiple oral preparations of thyroxine and liothyroxine with no biochemical response. This is not a case of pseudomalabsorption as oral absorption studies of hi...

Directly Observed Therapy (DOT) is the World Health Organization standard used for tuberculosis treatment, where a trained health worker watches the patient swallow every dose. It can be used for patients receiving doses of Levothyroxine of more than 2 μg/kg with persistently increased TSH levels as they are considered to have thyroid deficiency refractory to treatment. Poor adherence is the most common cause of failure of therapy and if this is suspected, a supervised te...

A 39 year-old man was referred with weight loss and lethargy in 2011. On examination tremor, goitre and mild orbital oedema were present. His past medical history consisted of hypertension (ongoing treatment). Investigations: fT4: 37 pmol/l (9–21), TSH: 0.00 mU/l (0.20–4.50), Anti Thyroid Peroxidase: 242.6 U/ml (0–50) and TRAbs: 11.2 iu/l (0–1.6). Graves’ thyrotoxicosis with moderately active eye disease was diagnosed and he started on carbimazole and ...

Background: Despite relevant evidence that the absorption and/or action of L-thyroxine is compromised by various factors including the diet, until 2014 the British National Formula (BNF) recommended that L-thyroxine be taken ‘preferably before breakfast’ only, with no further clarifications. To follow is one of the cases where untimely food intake in hypothyroid patients manifested with severe hypothyroidism due to L-thyro...

Objective: Most hypothyroid patients require an optimal dose of 1.6–1.8 μg/body weight (kg) of L-thyroxine to restore a normal TSH. Poor response to treatment can be due to malabsorption, drugs interaction and poor compliance. We conducted a test to determine the likely cause of persistent hypothyroidism in a coeliac patient despite taking supraphysiological doses of L-thyroxine (>1000 μg OD).Case...

Resistance to thyroid hormone is a rare genetic disorder which is usually inherited in an autosomal dominant manner. In this disorder, tissues become resistant to thyroid hormones due to the mutations in thyroid hormone receptor beta gene resulting in compensatory rise in hormone levels. Patients are largely asymptomatic apart from goitre, though some can develop symptoms. Estimated rate of occurrence is in the region of 1 in 40 000 live births.We descri...

Introduction: Unilateral proptosis may be due to thyroid eye disease (TED) or retro-orbital tumours. TED is an autoimmune process affecting orbital and periorbital tissue, and generally occurs in patients with Graves thyrotoxicosis. A small subset of patients with TED (5%) have normal thyroid function, but TED is rarer in hypothyroid patients.Case report: We report the case of a 57-year-old lady who initially presented to ophthalmology with diplopia. She...

Hypothyroidism is a common endocrine condition and if untreated can have serious consequences in pregnant women. Generally, TSH receptor antibodies (TRAb) is performed in hyperthyroid pregnant women as high titres can cause foetal hyperthyroidism Neonatal thyrotoxicosis develops in 1% of infants born to thyrotoxic mothers due to placental transfer of TRAb.As part of management of hypothyroid pregnant women, TRAb are checked routinely in our hospital in k...

Introduction: Interferon and Ribavarin-based Hepatitis C therapy can induce or exacerbate autoimmune thyroid dysfunction with variable clinical presentation. Being female, having prior thyroid dysfunction and raised anti-thyroid peroxidase (anti-TPO) antibodies are risk factors. We have a protocol for managing thyroid dysfunction that occurs during hepatitis C antiviral therapy. We present four cases.Case 1: A 48 year old man diagnosed with hepatitis C i...

We report a rare case of propylthiouracil (PTU) induced ANCA-associated-vasculitis (AAV). This young lady with recurrent thyrotoxicosis and positive Thyroid peroxidase and TSH receptor antibodies since 2004 was treated with Carbimazole but was changed to PTU 100 mg daily during pregnancy in 2012.She was admitted to our hospital in January 2015 with sore throat, feeling unwell and neutropenia 1.2 (normal range (NR): 1.6–7.5) 10×9/l. Thyroid func...

Case report: A 29-year old Caucasian male was referred to our Endocrinology Outpatient Clinic following a recent admission after an episode of collapse when he was noted to have abnormal thyroid function tests: fT4 32.6 (7.5–21.1) pmol/l, TSH 6.41 (0.34–5.6) mU/l. These were repeated and again showed elevated fT4 26.9 pmol/l and normal TSH 2.29 mU/l. He reported some tremor of both hands but denied palpitations. He was clinically euthyroid but p...

Introduction: Thyrotropin-secreting adenomas are a rare cause of hyperthyroidism. Preferred treatment is pituitary neurosurgery.Case report: A 35 year old lady was first noted to have abnormal thyroid function when presenting with an AV-nodal re-entry tachycardia in 2011. She had tremors, sweating and irritability. FT4 was 35 pmol/l (10-20 pmol/l) with a non-suppressed TSH level of 7.5 U/l (02–6 U/l). Previous meningococcal meninigitis ag...

Introduction: Hyperparathyroidism is the most common cause of hypercalcemia. We present another endocrine cause for hypercalcemia.Case report: A 49 year old Afro Caribbean man, previously healthy, was admitted with abdominal pain. He had been complaining of a 2 week history of epigastric pain, loose stools, sweating and shortness of breath. On examination, the patient was unwell, afebrile with epigastric tenderness. Bloods results showed anaemia, Haemogl...

Background: Thyroid storm is a rare but dangerous condition which can lead to multi-organ failure if not treated aggressively. Currently accepted treatment is with anti-thyroid medications to convert patients to a euthyroid state before definitive treatment with thyroidectomy is performed 10–14 days later. We present a case that was managed medically for several months due to a delay in surgery for clinical reasons. At present there are few such cases in the literature.</...

Various haematological abnormalities have been reported to be associated with treatment of hyperthyroidism. The Association between neutropenia and untreated hyperthyroidism has been described although the aetiology is unknown, but thought to be related to autoimmunity.Case: A 41 year old Nepalese lady presented with a three month history of poor sleep and loss of weight. She was found to be thyrotocxic with T4 of 64 mol/l (10–24), T...

Riedel thyroiditis, an uncommon form of chronic thyroiditis in which the thyroid gland is replaced by fibrous tissue, is difficult to differentiate from the fibrous variant of Hashimoto thyroiditis or lymphoma. We report a patient illustrating this. A 54 year old lady with a long standing goitre and 3 year history of stable hypothyroidism was referred for progressive thyroid gland enlargement over several months, dysphagia and an increasing thyroxine requirement. Clinically, s...

Thyroid abscess is a rare condition because of the thyroid gland anatomical and biochemical nature. We report a rare case of a rapidly developed thyroid abscess in the background of follicular thyroid nodule.A 77 years old lady admitted for elective right thyroidectomy. She had a history of goiter with normal TFTs. FNA cytology revealed Thy3, Hurthle cell neoplasia. The pre-operation CT scan showed right thyroid large nodule with heterogonous enhancement...

Introduction: Hyperthyroidism is a common endocrine disorder in pregnancy, with potentially significant foeto-maternal consequences.Description of the case: 25 year old lady with auto-immune hyperthyroidism (TRAb>400) was treated with Propranolol and Carbimazole and referred to the Endocrine clinic. She was started on Block and replace therapy. She was soon moved over to Carbimazole as she was contemplating pregnancy. She became hypothyroid in 3 mont...

Background: Serum thyroglobulin (Tg) is a reliable tumor marker in patients with differentiated thyroid carcinoma (DTC). Distant metastases of DTC, particularly in the lung, normally presents with higher levels of Tg, which is useful to follow the disease evolution. We describe a patient with DTC with lung metastases, with undetectable Tg and Tg-antibodies (TgAb).Clinical case: A 52-year-old woman underwent a subtotal thyroidectomy in 1993 because of a g...

A 54 years old female with no significant past medical history was referred by her GP with thyrotoxic symptoms which were not improving on Carbimazole 40 mg daily over the last 3 months in spite of good compliance with the drug. Her initial FT4 was 49.0 pmol/l with TSH suppressed to <0.01 and she was started on Carbimazole 20 mg which a month later was increased to 40 mg/day when there was no improvement in her TFTs. Her TFTs at this point showed FT4 ...

Background: Steroid-responsive encephalopathy associated with autoimmune thyroiditis (SREAT) also known as Hashimoto’s encephalopathy (HE), is a rare immune-mediated complication independent of functional status of thyroid, which leads to either stroke-like symptoms, or presents as diffuse progressive symptoms of altered mental status, seizures, and cognitive dysfunction. Here we present a case of SREAT in a female with recurrent episodes.Case histo...

Introduction: We present a case which highlights the complexities of managing hyperthyroidism.Case report: An 81 year old man complained of irritability, insomnia, diarrhoea, shortness of breath and weight loss. Past medical history includes type II diabetes, atrial fibrillation (AF), hypertension, gallstone pancreatitis requiring cholecystectomy (2005). Clinically, he was in fast AF and right heart failure. On examination he had a tremor; normal sized t...

Introduction: Radioiodine is a safe and effective treatment for benign thyroid disease. It aims to treat hyperthyroidism and achieve a euthyroid state. Radioiodine is indicated in cases of hyperthyroidism caused by Graves’ disease or toxic goitre (solitary toxic adenomas or multi-nodular goitre). In practice there has been concerns about long term safety, worsening of eye disease and weight gain with this treatment.Aims: To audit outcome, management...

A 71 year old lady presented to MAU with a recent onset of generalised weakness and a history of facial and periorbital swelling developing over seven years. She had also noticed hoarsening of her voice, cold intolerance, weight gain, constipation and reduced appetite. Admission blood tests showed marked hyponatremia of 113 mmol/l with severe hypothyroidism (TSH 45.24 mIU/l, fT4 1.1 pmol/l and TPO antibody 358 IU/ml). Subsequent tests confirmed SIADH (serum osmolali...

Resistance to thyroid hormones (RTH) is a genetic syndrome characterized by reduced responsiveness of target tissues to thyroid hormones (TH) and accompanied by normal or slightly high TSH values with high serum concentrations of fT4 or fT3. We present two cases of RTH, one pituitary and one generalised resistance.Case 1: A 31 y.o. male presented with thyrotoxicosis symptoms and a biochemical profile showing increased serum fT4...

Armour thyroid is desiccated porcine extract which is a historical treatment for hypothyroidism. It contains both L-thyroxine and liothyronine. Each grain (60 mg) contains 38 μg of L-thyroxine and 9 μg liothyronine. Since the 1960’s its use has been superseded by L-thyroxine. Due to limited clinical effectiveness studies, it is not licensed for use in the United Kingdom. We present a case of Armour thyroid use in preg...

A 21 year old Caucasian female with no known personal or family history of thyroid disease presented with several years history of anxiety and was found to have abnormal thyroid function tests. Results showed TSH: 1.8 mu/l (0.3–5.5), T4: 73 pmol/l (10–22), T3 12.3 pmol/l (3.1–6.8). Past medical history included chronic anxiety with no regular medications or nutritional supplements. There was no history of recent iodinated contrast administr...

We present a case of a 50 year old patient with sepsis and a significant and symptomatic hypercalcaemia of 3.38 mmol/l with a background of MS. The infection responded to treatment however the hypercalcaemia persisted despite appropriate measures. Further investigation showed a suppressed PTH, normal ACE level, electrophoresis and 25(OH) vitamin D level, but found her to be thyrotoxic with TSH suppressed at <0.01, free T4 – 37.2 nmol/l, free T3 – 212 nmol/l. She ...

Introduction: Myxodedema coma comprises a complex endocrinological emergency whereby there is severe clinical hypothyroid state. It is a life threatening yet a potentially reversible condition that may prove rather difficult to recognise due to the complex symptomatology. Very few articles report the specific therapy for myxoedema coma.The case: Here we present an elderly lady with previous total thyroidectomy, who despite receiving oral thyroxin tablets...

Introduction: Preoperative ultrasonography or Sestamibi scanning (or both) of the parathyroid glands could facilitate a focused or minimally invasive surgical approach. In this audit, we wanted to find out whether one form of imaging is superior to the other in correctly identifying a parathyroid adenoma, later confirmed on histology.Methods: Data were collected from consecutive patients who underwent parathyroidectomy for primary hyperparathyroidism, co...