Endocrine Abstracts

Dysfunctional regulation of sodium-iodide symporter (NIS) trafficking can result in ineffective radioiodide uptake in patients with differentiated thyroid cancer. Understanding the trafficking pathways of this key protein can be used to optimise radioiodide therapy. Recently, we identified via HiLo microscopy that the protein ADP-ribosylation Factor 4 (ARF4) helps shuttle NIS to the plasma membrane. To understand how ARF4 interacts with NIS mechanistically, we utilised advance...

Background: Pregnancy is a state where changes in maternal physiology influence thyroid status. In addition, thyroid disease in mother can have substantial adverse outcome on the pregnancy and fetus. The objective of this study was to establish correlation of maternal TSH with PAPP-A, Beta HCG, Inhibin, uE3, AFP and HCG and compare pregnancy outcomes in subclinical hypothyroid pregnant women with euthyroid women.Methodology: 110 out of 150 singleton preg...

Background: Levothyroxine replacement for hypothyroidism is safe and effective but may be associated with reduced quality of life and serious adverse effects if administered inappropriately. We set out to investigate if thyroid hormone profiles in hospitalised patients on levothyroxine are similar to those in inpatients without pre-existing thyroid dysfunction.Methods: We conducted a cross-sectional study in patients admitted for non-endocrine reasons to...

Purpose: There are sporadic reports illustrating more severe TED and complications in those with diabetes mellitus (DM) and from local experience these patients have poorer outcomes as seen in other diseases, such as cardiovascular disease. However, the relationship between glycaemia and clinical activity/severity and disease course are not well described.Methods: A multi-centre retrospective patient-cohort study of 236 patients referred to three TED mul...

Introduction: Screening patients with type 1 diabetes (T1DM) for other autoimmune diseases such as thyroid disorders has been recommended by international guidelines. Data from the Middle East is currently limited. This study aims to identify the pattern and prevalence of thyroid disorders among the UAE population with T1DM.Method: A retrospective cohort study was conducted looking at all adult patients (age ≥16 years) attending Imperial College Lo...

Background: Normal maternal thyroid function is essential for optimal fetal neurological development. However, targeted screening for thyroid dysfunction in the first trimester of pregnancy, together with the criteria that should be applied, remains controversial.Aim: To determine the efficacy of targeted screening for discovering new cases of thyroid dysfunction in pregnancy.Method: All women who delivered their babies at Imperial...

Aim: Anti-thyroid treatment with carbimazole or propylthiouracil is the first-line treatment for autoimmune thyrotoxicosis in the UK. Following 12–18 months treatment there is a significant relapse rate (at least 50%). This study analysed the demographics and clinical features of 100 patients with relapsed thyrotoxicosis to examine which variables are predictive of relapse.Methods: This retrospective study included adult patients identified using ou...

Introduction: Gestational transient thyrotoxicosis (GTT) affects 2–3% or pregnancies of European women and 11% of pregnancies of Asian women and typically resolves within the 2nd trimester. GTT rarely manifests with the typical symptoms of thyrotoxicosis and instead is associated with hyperemesis gravidarum. GTT can be confused with thyrotoxicosis occurring in pregnancy which requires prompt treatment with antithyroid drugs (ATDs) to minimise maternal and foetal risk. Inj...

Background: Thyroid disease in pregnancy can have a profound impact on both mother and fetus. Guidelines on diagnosis and management are lacking in the UK and there is significant variation between European and US guidelines. This survey aimed to gather data on current management by endocrinologists in Scotland.Methods: An online survey was created using Google Forms and emailed to endocrinology trainees and consultants in Scotland (April 2019). The surv...

Introduction: Graves’ disease during pregnancy may cause maternal or neonatal complications, including arrhythmia, thyroid storm, congenital anomalies and neonatal thyroid dysfunction (TD). The optimal timing and frequency of TRAb measurement in pregnant women with a history of TD, and whether fetal monitoring could be limited to those with a strongly positive TRAb, is unclear.Methods: Retrospective case note review of women with elevated TRAb (>1 i...

Introduction: Thyrotoxicosis resistant to the usual treatment is rare, but potentially fatal. In such situations, the optimal next treatment is unclear. Iopanoic acid (IA) was historically used as an oral contrast agent; it’s capacity to treat thyrotoxicosis has been limited in recent years due to its restricted availability.Methods: Retrospective case note review of patients treated with IA for resistant thyrotoxicosis at our institution over the p...

Purpose: There is increasing evidence that a multidisciplinary (MDT) approach optimises diagnosis and management in active Thyroid Eye Disease (TED) and is recommended by current TEAMeD-5 guidelines1. Here we aim to describe the clinical and endocrine characteristics of a large cohorts of patients with TED seen in 3 MDT clinics in London.Methods: A retrospective patient-cohort study of 236 patients with suspected TED referred to these services...

Introduction: The thyroxine absorption test (TAT) is well established to investigate persistently raised TSH in patients on L-thyroxine. We review our experience with this test.Method: Blood was taken for baseline FT4, FT3, TSH measurements and malabsorption screen. A week’s supply of L-thyroxine (1.6 mcg/kg×7) was administered orally under direct supervision and FT4 and TSH measured 2 h later. Patients continued o...

Prior to therapy, patients choosing I131 therapy for the treatment of Grave’s disease were pre treated with carbimazole. Post I131 they have their thyroid function checked monthly in primary care prior to clinic review at 3 months. Carbimazole can be restarted if clinically indicated and treatment with thyroxine was recommended if their TSH was greater than 3.5 mU/l (ref range 0.35–5.5). A previous audit had demonstrated that 24% of patients had an elevated TSH great...

Purpose: To compare effectiveness of different radioiodine activities used for the treatment of benign thyroid disease.Method: We retrospectively reviewed our local radioiodine audit data collected over 7 years duration. Patients with benign thyroid disease and known post-treatment biochemical outcomes were included. Data were analysed for primary diagnosis, activity dose, and biochemical outcomes in 6 and 12 months post-treatment....

Objectives: Hyperthyroidism is associated with a high basal metabolic rate and weight loss is a common symptom. However, it has been observed, that once patients are treated, they gain back the lost weight and may also put on more. Given that weight gain is a health factor, there’s interest in studying the effect that the thyroid levels have on weight gain and potential harmful health consequences.Methods: 79 patients (58 female) with hyperthyroidis...

Introduction: Primary hypothyroidism is most commonly caused by autoimmune hypothyroidism whilst additional causes include post radioactive iodine treatment (RAI) whereas central hypothyroidism is typically associated with pituitary disease. Treatment in primary hypothyroidism aims to maintain the TSH within the reference range whilst treatment of central hypothyroidism is aimed at maintaining free T4 in the upper half of the reference range as established by intern...

Graves’ disease is an autoimmune disorder of the thyroid gland. Patients with type 1 diabetes (T1DM) are at a higher risk of developing autoimmune diseases including thyroid disorders. To our knowledge, diagnosing Graves’ disease at the same time in a monozygotic twin with T1DM is a rare occurrence. We present a case of monozygotic female twin with T1DM, who both developed Graves’ disease at the same time. Type 1 diabetes was diagnosed in one of the twins (twin ...

Background: Severe maternal hypothyroidism during pregnancy may be associated with delayed development and lower IQ in the foetus. BES (2007) and NICE (2011) guidelines recommend maintaining TSH<2.5 mU/l with monitoring of maternal thyroid function test (TFT) 4 weekly, especially in the first trimester.Aim and methods: A retrospective study on all pregnant women with established hypothyroidism attending the Joint Antenatal Clinic (JANC) at Liverpool ...

Background: Primary hypothyroidism affects about 3% of the general population (5.1% women and 0.9% men). The majority of people are treated adequately with levothyroxine. However about 5–10% of hypothyroid patients (representing between 75 000 and 150 000 adults in the UK) continue to experience profound and sometimes disabling symptoms, such as fatigue/depression/impaired cognition, in spite of being adequately replaced biochemically. Before any trial of alternatives to ...

Background: Radioactive Iodine (RAI) is one of the main treatment modalities of hyperthyroidism. Its success rate seems to differs. Lithium efficacy as adjuvant therapy to RAI remains debatable.Objective: To assess the efficacy and safety of lithium carbonate as an adjuvant therapy to RAI in the treatment of hyperthyroidism.Methods: This is 24 weeks prospective study carried out in the Endocrinology Unit, Penang General Hospital. L...

Introduction: Intermediate cytology comprises unclear result form Bethesda III and IV category. This category is still present in the general results of thyroid cytology, with 2–18% AUS/FLUS and 2–5% FN. The attitude after such a results is not standardize, follow up, lobectomy or thyroidectomy being the possible indications to solve such a case. The current paper presents the value of predictive value of ultrasound techniques in the final judgment of these cases.</p...

Objective: To study the effect of alemtuzumab used in Reduced Intensity Conditioning prior to hematopoietic stem cell transplant (HSCT) on thyroid function.Methods: This retrospective case review of 13 patients (9 male, 4 female) who underwent HSCT and had alemtuzumab based conditioning regimen. 5 patients had Acute lymphoblastic leukaemia, 3 severe a plastic anaemia, 1 acute myeloid leukaemia, 1 congenital bone marrow failure, 1 chronic granulomatous di...

Introduction: Limited data is available on Liraglutide as a treatment option for weight regain after bariatric surgery. We aim to report the efficacy of Liraglutide as a treatment for weight regain in UAE population who underwent bariatric surgery.Methods: Retrospective analysis was performed on all patients with weight regain after bariatric surgery who received Liraglutide (dose range 0.6 up to 3.0 mg/day) while attending bariatric clinic of Sheikh Kha...

Context: NICE and BTA agrees that combination L T4 and LT3 can be used in patients with symptoms persisting after adequate use of LT4.Methods: We retrospectively audited the patients coming to the endocrine clinics of ESHT whether they followed the local agreed protocol of LT3 usage. We checked if they had:1. Initiation of LT4 by an endocrine specialist.2. If other causes of tiredness were ruled out.<p cl...

Toxic adenomas nodules rarely harbour cancer. Fine needle aspiration (FNA) is often not done due to the rarity of these lesions being cancer, the difficulty in interpreting cytology in hyperthyroid patients and the rarely reported instance of precipitating thyrotoxicosis. Here, we present two young Caucasian female patients with toxic adenomas, who underwent hemithyroidectomy and the histology unexpectedly revealed differentiated follicular cancer. The first is a 29-year-old p...

Objectives: Post-surgical hypoparathyroidism (PoSH) is a common long-term complication after thyroid surgery. The reported median incidence rates of temporary and permanent PoSH was 27% and 1% respectively.Methods and results: We retrospectively analyzed the files of 552 patients who underwent thyroidectomy in our surgery department between 2015 and 2017 with the aim to assess the prevalence of PoSH and to identify patient and disease related factors ass...

Background and aims: Patients with Graves’ disease should be rendered euthyroid rapidly and euthyroidism subsequently maintained. Studies have shown this can be achieved at 3 months and maintained for the following 9 months in 90% of patients. The aim of this review was to ascertain whether we were achieving this target within our hospital setting.Method: We undertook a retrospective analysis of patients with Graves’ thyrotoxicosis referred to ...

Introduction: Thy3 classification was subdivided into Thy3a and Thy3f to reduce the dilemma and confusion surrounding the management of patients with indeterminate thyroid nodules. Thy3a lesions are often downgraded or upgraded on repeat sampling and in thyroid MDT.Patients and method: A retrospective analysis of the patients who had thy3a diagnosis from January 2015 until December 2018 was recorded. All patients who underwent a second sampling were incl...

27 years old lady with recurrent Graves’ thyrotoxicosis for 5 years delivered her baby uneventfully and her thyrotoxicosis worsened 2 months after pregnancy when her FT4 bounced back up to 38 pmol/l (12–22) so her propylthiouracil (PTU) was increased from 200 to 400 mg. Despite of continuing high dose of PTU for few months she remained thyrotoxic and became neutropenic [Neutrophil 0.67×109 (2–7)], decision was made to proceed with thyroidectomy b...

Introduction: Thyroid Hormone Resistance (THR) is a rare disorder caused by mutations of Thyroid Hormone Receptor characterised by insensitivity of target tissues to thyroid hormone actions. Patients can present with hyperthyroidism or hypothyroidism symptoms.Case report: 49 year lady with recurrent thyrotoxicosis with goitre (1989/1994/1998) treated elsewhere with CBZ/PTU and RAI (2001). She developed post-RAI hypothyroidism and at presentation to our O...

We report a case of familial clustering of familial hypocalciuric hypercalcemia (FHH) associated with and papillary thyroid carcinoma (PTC). The first presentation in our clinic of one of the patients, female patient, was for severe hypercalcemia. The diagnostic workout for hypercalcemia revealed primary hyperparathyroidism (PHPT) due to a left inferior parathyroid adenoma and undergo surgery. The pathologic report described closely packed chief cells arranged in uniform sheet...

A 30-year-old teacher with no past medical history presented with a 3 month history of muscle weakness, pain and spasms together with cold intolerance, weight gain and fatigue. She had a baby 4 months prior to this and 2 months after delivery noticed palpitations, insomnia and tiredness which resolved spontaneously. She was a non-smoker who did not consume alcohol. She was not on any medication. There was no family history of endocrinopathy. Clinical examination revealed proxi...

Graves’ disease is one of the reversible causes of pulmonary hypertension (PAH). The association was first reported in 1980. Studies have suggested an elevated pulmonary artery systolic pressure in about 36% of patients with Graves’ disease by Doppler echocardiography. We report a case of Graves disease associated with pulmonary hypertension in a young female.Case report: A 41 year old female presented with history of worsening breathless and p...

Introduction: Hypothyroid patients with failure to take/absorb oral levothyroxine might require intravenous levothyroxine. IV levothyroxine is neither licensed nor available in UK. It has to be imported (with special request), and is unexpectedly costly. IV liothyronine has shorter duration of action, need 2–3 injections/day, and exhibits sudden surges increasing risk of angina/arrhythmia. Moreover, IV liothyronine is much more expensive than IV levothyroxine.<p class...

Myxoedema coma is a rare Endocrine emergency.Case report: 28 year old Polish woman, recently travelled to the UK, presented to the A&E with 3 week history of breathlessness and bilateral leg swelling. She had a history of Trisomy 21, was not taking any medications. She had amenorrhoea for 4 months and orthopnoea with periorbital oedema with conjunctival congestion. Saturation 70% on air, 96% on 15 l of oxygen, heart rate 42, blood pressure 103/61, te...

Graves’ disease (GD) is the most common cause of hyperthyroidism1 and is caused by stimulating autoantibodies to the TSH receptor (TRAb).2 TRAb assays have 98% sensitivity and 99% specificity 3 for GD and are recommended as the first-line cost-effective investigation to diagnosis the aetiology of hyperthyroidism and determine the risk of thyroid eye disease.4,5 In TRAb antibody negative patients, radionuclide imaging may be help...

Introduction: Iododerma is a hypersensitive skin reaction that occurs after exposure to Iodine. It is a well-known adverse reaction after intravenous iodine-containing contrast medium, but cases occurring after oral exposure are rare. A six-year follow-up study in one centre looking for any skin lesions occurring after oral radioiodine therapy for thyrotoxicosis, noted an incidence rate of 2.1% in 141 patients. The skin lesions can be acneiform, erythematous, urticarial, hemor...

A 41-year old lady with hypothyroidism for 20 years attended the endocrinology clinic for persistently raised TSH levels despite high dose levothyroxine. Past medical problems – depression, psoriasis, obesity, cholecystectomy. Her hypothyroidism was well-controlled until 2016 but since then, her TSH concentration had risen significantly to >100 mU/l with normal free T4. Levothyroxine had been increased in steps to 200 mcg/day. Despite the increased dose, the TSH concentra...

Introduction: Thyroid nodules have a prevalence of 50% in the adult population in the UK. The risk of cancer is significantly lower if the nodules are a part of multi-nodular goitre. Fine needle aspiration and cytology (FNAC) is an important tool to assess the risk of malignancy in thyroid nodules.Method: We audited the safety and efficacy of management of thyroid nodules at Bolton in accordance with British Thyroid Association and Royal College of Patho...

77 year old gentleman was referred to endocrine clinic at Manchester Royal Infirmary in June 2017 due thyrotoxicosis with TSH 0.10 mu/l, free T4 24.3 pmol/l, and free T3 15.7 pmol/l. He was presented at that time with symptoms of tiredness, fatigue and tremor. He was initially treated with antithyroid drugs from June 2018 till May 2018 with radioactive iodine 579 MBq in May 2018. Subsequently, he developed symptoms of excessive tiredness, lack of energy, weight gain and cold i...

This case illustrates a decision paradox on investigations (to exclude secondary hypercalcaemia) and treatment options (in unresponsive thyrotoxicosis despite supra-normal doses of carbimazole). A 56-year-old lady, who was referred with hyperthyroid symptoms and evidence of biochemical thyrotoxicosis, was also found to have symptomatic hypercalcaemia (constipation & polyuria). Investigations were as follows: FT4 >100 pmol/l, TSH <0.02 mU/l, TRAb positive, Ca 3.0 mmol/l...

Cardiac failure is a rare manifestation of thyrotoxicosis in patients without heart disease. However, patients with prior cardiac failure are at high risk of decompensation with thyrotoxicosis. Amiodarone is a widely used antiarrhythmic agent and amiodarone induced thyrotoxicosis (AIT) is not an uncommon complication. We present a case. A 48-year old male with intermittent atrial flutter, dilated cardiomyopathy, myocardial infarction and stroke was referred for severe thyrotox...

A 38-year male with background history of Tetralogy of Fallot which had been surgically corrected, presented with symptomatic supraventricular tachycardia in July 2015. This required amiodarone therapy. Thyroid function was normal prior to starting amiodarone. Amiodarone therapy was discontinued in July 2017 when he converted to sinus rhythm. Seven months after stopping treatment, he presented to A&E with signs and symptoms of hyperthyroidism. His TSH was <0.03 mU/l (0...

Aim: To determine the current practice of radioiodine dose treatment provided in Hull and East Yorkshire NHS Trust, in line with the recommended guidelines of the Royal College of Physicians and published data.Methods: The medical records of the patients who received more than one dose of radioactive iodine for the treatment of thyrotoxicosis in Hull and East Yorkshire NHS Trust between 2006 and 2018 were reviewed retrospectively. The level of the bioche...

Graves’ disease is a common autoimmune disease causing hyperthyroidism. Thyroid has a catabolic effect on carbohydrate metabolism especially in the hyperthyroid state. We describe a rare complication of thyrotoxicosis in a patient with type II diabetes on insulin, with no previous thyroid history. An 83 year old woman with type 2 diabetes on biphasic insulin presented with symptoms of polyuria, polydipsia and fatigue. She was tachycardic and tachypneic but normotensive an...

A 54 years old gentleman was admitted to cardiology ward from echocardiography department in view of findings on the scan. He was referred to cardiology clinic on outpatient basis 3 months earlier by his GP for his shortness of breath, ankle swelling and a murmur heard on auscultation by his GP. His transthoracic echocardiography was being conducted prior to attendance at cardiology clinic. The result showed a large global pericardial effusion, max 4.9 cm in size. There was se...

Thyroiditis can often lead to initial thyrotoxicosis and it is important to differentiate among the causes as many cases do not require antithyroid drugs. We present a case report of a 48 year old lady who presented with 10 days history of fever, fatigue, myalgia and a painful goitre after returning from a cruise at Caribbean. Examinations showed pyrexia of 38 C but no localising signs of infection. She had a smooth tender goitre and no signs of thyrotoxicosis. Investigations ...

C-terminal derivatives of hormones commonly have secondary actions. This is a well-established phenomenon, seen in the case of oxytocin, parathyroid hormone and alpha-melanotropin. Such derivatives can either complement or antagonise the action of the parent hormone. Thyroid-releasing-hormone (TRH) undergoes cleavage and cyclisation to form the C-terminal derivative histidinyl-proline-diketopiperazine (His-Pro-DKP). Despite conventional function via the endocrine HPT axis, the...

Although it is well known that aplastic anemia and agranulocytosis are potential lethal adverse reactions of antithyroid treatment, we present a case of methimazole administration in a patient with bone marrow transplant for multiple myeloma, with favorable evolution. We present the case of a 43 y.o. male, known with Grave’s disease since 2010 (on ATS treatment for only 6 months), vitiligo, systemic sclerosis and type 1 diabetes, diagnosed with multiple mieloma Ig G Tipe,...

Hyperthyroidism commonly affects women of child-bearing age. Use of carbimazole in the first trimester of pregnancy has been shown to be associated with certain congenital abnormalities, such as aplasia cutis, choanal atresia, dysmorphic facial features, abdominal wall and gastrointestinal tract defects, in up to 2% of cases. The MHRA issued a Drug Safety Alert in February 2019, recommending to strengthen the advice on contraception given to women of child-bearing age who need...