Endocrine Abstracts

Anonymised therapeutic data has been available for all patients in NI across 364 general practices since 2008. The database records age, gender, trusts and postcodes, which allows for spatial deprivation analyses. Patients were categorised in deciles (1-most deprived, 10-least) according to published criteria. We examined carbimazole (CBZ) and propylthiouracil (PTU) prescriptions over 10 years (2010 to 2019). Patients treated definitively with surgery/radioiodine are invariabl...

Purpose: Graves’ disease is an autoimmune condition that can cause hyperthyroidism and thyroid eye disease (TED). Definitive treatment is required in approximately 50% patients. Thyroidectomy remains the least chosen primary treatment (2%-18%) despite it having the highest cure rate (>95%). Our aim was to determine the current relationship between patients’ TED and thyroidectomy in a multidisciplinary specialist eye clinic at a tertiary referral centre.<p cla...

Introduction: Refractory hypothyroidism is associated with significantly increased morbidity and healthcare costs. During the evaluation of refractory disease, a thyroxine absorption test is frequently performed using different protocols. We assessed the usefulness of the supervised rapid thyroxine absorption test in a low-resource setting and formulated a useful model to determine the expected FT4 rise in hypothyroid patients without known malabsorption.<p class="abstext"...

Background and Aim: RAIT has a high success rate in achieving cure of hyperthyroidism but there is unpredictability of thyroid status during the initial post-RAI period, making it difficult to counsel patients or plan medical therapy. We assessed the role of updated TRAB level at the time of RAIT in predicting persistent post-RAI hyperthyroidism.Patients and Methods: We measured TRAB at the time of RAIT (fixed 550MBq dose) in 26 patients with Graves&#146...

Introduction: Lithium is a common pharmacological intervention for the treatment of bipolar affective disorder and is advocated by clinical practice guidelines (NICE 2021). Blood test monitoring is essential for management of lithium treatment and UK NICE guidance recommends 6-monthly serum testing of thyroid function. We here examine conformity to guidance and the consequences of monitoring outside these intervals.Methods: We extracted serum lithium/thy...

Aim: To evaluate thyroid dysfunction in all patients admitted to hospitals in Aneurin Bevan University Health Board (ABUHB) from October 2019 to September 2021.Method: This report is based on a retrospective observational study of the thyroid tests and case notes of 95 patients admitted to all the hospitals under ABUHB for acute concerns (other than thyroid dysfunction) over 2 years.Results: In-Patient scanned notes and pathology r...

Introduction: Persistent symptoms of hypothyroidism or raised levels of thyroid stimulating hormone (TSH) despite adequate levothyroxine replacement (>1.6 µg/kg body weight) suggest treatment-refractory hypothyroidism. Adherence to treatment and conditions that might impair absorption or increase demand for levothyroxine should be explored.Case: A 51-year-old man presented with raised TSH levels despite being on 425 mg daily of levothyroxine. He...

Carbimazole is one of the most commonly prescribed endocrine medications. There are a wide range of side effects associated including bone marrow disorders, severe cutaneous reactions, agranulocytosis and vasculitis. There have been few reports of anti-thyroid associated arthritis, described as migratory arthritis with prompt resolution following medication discontinuation. Side effects reported in British national Formulary and Electronic Medicine Compendium include myopathy ...

Introduction: In rare but severe cases, Hashimoto’s thyroiditis can present with neurological manifestations including stroke-like episodes, cognitive decline, neuropsychiatric symptoms, and coma. This is referred to as Hashimoto’s encephalopathy which is characterized by high titers of antithyroid peroxidase antibodies and is responsive to steroids. Herein, we present a case of a patient with acute onset aphasia, altered mental status with progression to respiratory...

Background: Nottingham University Hospitals (NUH) has a joint endocrine/antenatal clinic to manage autoimmune hyperthyroidism in pregnancy, with the aim of close monitoring and management.Aim: To review service according to NUH standards (Pregnant Women with Thyroid Dysfunction):1. At 20 weeks if thyrotoxic/on antithyroid drugs (ATD)/post radio-iodine or surgery, check thyrotropin receptor autoantibodies (TSHRAb).<p class="abst...

Background: Nice guideline recommends using TSH receptor antibody as a tool for classification of hyperthyroid patients; and considering technetium scanning of the thyroid gland if TRAbs are negative. Early diagnosis of TED is also essential for treatment to be effective. The most common way to assess the severity of TED is to use the Clinical Activity Score (CAS) 7-point scale.Objectives: We aimed to evaluate if hyperthyroid patients are classified corr...

A 42-year-old lady, with a diagnosis of Graves’ disease presented with a day’s history of fever, cough, coryzal symptoms and diarrhoea. Being diagnosed with Graves’ disease in 2015, she had been poorly compliant with ATDs. Prior to this presentation, her last FT4 was 31.4 pmo/l with a suppressed TSH. She was intermittently taking propylthiouracil (was intolerant of carbimazole). She had refused RAI and preferred surgery, but hadn’t been keeping up with her ...

Introduction: Mild hypercalcaemia can occur in patients with Graves’ disease. Postulated mechanisms include increased bone resorption and mobilisation of calcium from the bones in response to increased interleukin-6 and catecholamine levels. The coexistence of primary hyperparathyroidism and Graves’ disease is rare. Hypercalcaemia with suppressed or unsuppressed parathyroid hormone levels should prompt a search for non-parathyroid or parathyroid causes, respectively....

This female patient presented acutely with headache and neck pain associated with vomiting. Neurological examination was normal. Urine pregnancy test prior to imaging was unexpectedly positive. CT head demonstrated a 2.5x1.5 cm hyperattenuating lesion at the left frontoparietal region. Thyroid function tests were in keeping with thyrotoxicosis (TSH <0.01 mU/l, free T4 37.2 pmo/l, free T3 >30.7 pmo/l). Antithyroid medication was commenced and TSH receptor antibody reque...

Background: The prevalence of iodine-based contrast media-induced (ICM-induced) thyroid dysfunction varies (1-15%). Contrast-induced hyperthyroidism is predominantly found in iodine-deficient regions and in patients with underlying nodular goitre or latent Graves’ disease. Beta-blockers are first-line therapy, but anti-thyroid medication are used for severe symptomatic cases.Case Report: A 79-year-old man presented with a 4-day history of bilious vo...

Introduction: Graves’ disease (GD) has a well-known association with thymic hyperplasia caused by TSHR expression in thymus and regresses by approximately 33-90% with treatment. Splenomegaly due to lymphoid hyperplasia has also been linked with GD in about 10% patients. Cerebral venous sinus thrombosis (CVST) linked with GD is documented in literature but is more common occurrence in solid cancers.Case presentation: We report a case of 32-year man a...

40years old lady with 12 months history of hyperthyroidism. Treated with ATD. Referred by her treating physician for RAI therapy due to intolerance to ATD and high dose requirement after 12 months. Patient being treated as Classical Graves’ Hyperthyroidism. She had symptoms of hyperthyroidism at time of presentation but none at time of assessment in our hospital. Main current issue was painful neck swelling: developed slowly over preceding two months. No problems with swa...

The most effective conventional treatment for differentiated thyroid cancer (DTC) still remains total thyroidectomy with subsequent adjuvant therapy with radioiodine ablation (RAI). In case of unsuccessful RAI treatment, an alternative method is the tyrosine kinase inhibitor therapy. However, its usage is related to many side effects and is not well tolerated by patients. Despite the great progress in the clinical management of patients with DTC, the lack of alternative therap...

Introduction: Radioactive iodine (RAI) therapy is a critical component in the post-surgical management of thyroid cancer patients, as well as being a central therapeutic option in the treatment of hyperthyroidism. Previous work suggests that antithyroid drugs hinder the efficacy of RAI therapy in patients. However, the effects of other background medications on RAI treatment efficacy have not been evaluated. Therefore, we performed a systematic review and metanalysis investiga...

Background: Graves’ disease (GD) is an autoimmune condition accounting for up to 80% of thyrotoxicosis cases.1 90% of these patients have TSH receptor antibodies (TRAbs).2 Current NICE guidance recommends testing for TRAbs in adults with confirmed thyrotoxicosis to differentiate between thyrotoxicosis with hyperthyroidism (e.g GD and toxic multinodular goitre) and thyrotoxicosis without hyperthyroidism (e.g thyroiditis).2Objective: To evaluate the n...

Introduction: In cancer patients treated with immune checkpoint-inhibitors (ICI) that target CTLA-4, PD-1 and/or PD-L-1, thyroid dysfunction represents the commonest associated endocrinopathy (1). Patients receiving ICI should be monitored for thyroid dysfunction. A case of PD-1 inhibitor-induced thyroid function test (TFT) interference has been reported (2) and having noted discordant results, we undertook a preliminary assessment of the extent of such ICI-related TFT interfe...

Background: Thyrotoxicosis is a common endocrine disorder in the UK, with a prevalence of 2% in females and 0.2% in men. Endocrine services at Barnet / Chase Farm Hospitals receive ~250 new referrals per year, equating to a local incidence of 50 per 100,000. There is often a significant delay between GP referral and Endocrine clinic review, resulting in delays to commencing anti-thyroid treatment. These delays have been exacerbated by the Covid crisis. A need was identified fo...

Background: Traditional method in Sheffield involved preoperative admission and use of an intensive regimen. The pandemic led to the development and implementation of an outpatient-based protocol (SPROG - ‘Sheffield Peri-operative Rapid Optimisation in Graves’ disease (GD)’) for patients’ intolerant to thionamides and/or with uncontrolled disease requiring thyroidectomy. Control was achieved using sequential addition and dose-escalation of drugs such as Lug...

Background: Spontaneous coronary artery dissection (SCAD) is a rare condition, which is sometimes underdiagnosed in patients with chest pain and presumably normal coronaries. There have been a few case reports of patients with thyroid dysfunction and arterial dissections.Case: We present a 20 year old female with recent diagnosis of Graves’ thyrotoxicosis managed with methimazole. She initially presented in South Korea with shortness of breath on ex...

Primary thyroid lymphoma accounts for <5% of thyroid malignancies. The most common (up to 70%) and clinically aggressive sub-type is non-Hodgkin’s B-cell lymphoma. Mucosa-associated lymphoid tissue (MALT) lymphoma is less common (up to 30%) and clinically more indolent. Females are more frequently affected than males (4-8:1) with onset in 6th and 7th decades. A strong association with Hashimoto’s disease (>90%) is recognised. A 66 year old male presented with...

Hyperthyroidism is not a well-known cause of venous thromboembolism. Hyper-coagulable and hypofibrinolytic states are described in hyperthyroidism. A meta-analysis of 51 studies evaluating the consequence (exogenous and endogenous effect on coagulation, raised thyroid levels were associated with a rise in clotting factor VIII, IX, Von Willebrand factor and fibrinogen. The procoagulant effect noticed in hyperthyroidism facilitated by thyroid hormone receptor beta gene. 40-year-...

Benign Ethnic Neutropenia (BEN) is a common form of neutropenia defined as an absolute blood neutrophil count (ANC) of < 1.5 x 109/l, usually observed in Afro-Caribbeans. These patients are not at increased risk of infection despite their neutropenia, unless they are on medications which can cause neutropenia. Amongst these drugs antithyroid medications are known to cause agranulocytosis defined as ANC of <500/μl. We report a case of 24 years old male w...

Generally, after an initial active phase TED rarely reactivates. However, epidemiological evidence is scant. The following cases highlight the propensity for Graves’ orbitopathy to reactivate many years later.Case 1: A 69-year-old woman had Graves’ disease aged 29, and was reviewed in the TED clinic (ophthalmology, rheumatology and endocrinology), with reactivation of orbitopathy 40 years after initial disease. She was an ex-smoker, had hyperte...

38 year old woman presented with palpitations, chest tightness, dizziness and light headedness. There was no evidence of infection clinically or biochemically. She had a background of Alemtuzumab induced Graves’ thyrotoxicosis, relapsing remitting Multiple Sclerosis. Her regular medications included Carbimazole 20 mg three times a day, Amitriptyline 120 mg daily, Propranolol 40 mg four times a day, Tizanidine 2 mg daily (up to 18 mg), Tramadol 50 mg as required, Senna 7.5...

Thyroid storm is rare and life threatening manifestation of thyroid hormone excess. It has high mortality rate with delayed treatment. As early intervention is associated with improved patient outcome, prompt diagnosis based on clinical grounds is of paramount importance. We present a case of thyroid storm which was different in terms of absence of fever on presentation, presence of thrombocytopenia and deranged cholestatic LFTs which resolved after treatment of thyroid storm....

31 years old lady with no past medical history or family history of thyroid disease had her first dose of Pfizer vaccine and few days later she presented unwell, Febrile with painful swelling in the neck. She was thought to have Covid because of fever. Examination revealed tender thyroid enlargement with positive bruit and Tachycardia. Investigations showed florid thyrotoxicosis with TSH: < 0.02, fT4: 60.0, CRP: 60, rest of investigation: normal, TRab and TPO AB: pending, ...

Introduction: Hashitoxicosis is the rare case of autoimmune thyroid disease. While transforming from Graves’ disease to spontaneous hypothyroid is well known, development of hyperthyroidism following hypothyroidism is a rare phenomenon which can pose a challenge in management. We report here a case of Hashitoxicosis managed with "Block and Replace Therapy" to maintain her euthyroid while waiting for definitive therapy.Case Report: A 30-year-...

Introduction: Following a National training programme for Endocrinologists to provide RAI treatment for benign thyroid disease, the ESHT NHS Trust started Radioactive iodine (RAI) treatment for benign thyroid disease a couple of years ago. Previously ESHT trust patients were referred to neighbouring trusts for RAI treatment.Data/Results: The data was collected over a 12-18 month period. A total of 34 patients received RAI treatment during this period; 28...

Introduction: Graves’ disease is the commonest cause of thyrotoxicosis; and is usually responsive to radio-iodine therapy. In Nigeria, radio-iodine therapy is becoming a common and cost effective option for treatment of thyrotoxicosis; with the less likelihood of most of the complications associated with thyroidectomy.Case presentation: A 49-year-old Nigerian lady, presented to the endocrinology clinic, at LAUTECH Teaching Hospital, Ogbomoso, 8 year...

A 55 year-old Nepalese lady, previously fit and well, presented to her GP 2 months ago with palpitations and weight loss. She was diagnosed with Graves thyrotoxicosis based on her clinical history and biochemistry, and was started on carbimazole 40 mg daily. She suffered from COVID19 infection a month later and started self-isolating. She continued to feel unwell for three weeks but did not seek urgent medical attention due to the perceived general recommended isolation guidel...

Background and aims: Thyroid peroxidase antibody (TPOAb) positivity is prevalent in women of reproductive age and pre-disposes to thyroid dysfunction, namely hypothyroidism, which has adverse effects on pregnancy. The aim of this study was to report the rate of development of abnormal thyroid function among initially euthyroid TPOAb positive women recruited into TABLET trial. To also identify factors associated with the development of hypothyroidism and to compare outcomes bet...

Graves’ disease (GD) is the most common cause of hyperthyroidism with incidence rates of 20-50 cases per 100,000. Genetic predisposition and environmental factors are known to play a role in its pathogenesis. After perceiving an increase in the number of cases presenting to our thyroid clinic we confirmed a rise in the incidence of GD in North West Wales since the start of the COVID-19 pandemic. The annual incidence of GD was calculated using the number of positive thyroi...

Introduction: Thyroid storm, a life-threatening endocrine emergency, requires prompt intervention and treatment to improve outcomes. The diagnosis is made clinically, based on symptoms including hyperpyrexia, tachycardia, nausea, diarrhoea and altered cognition. The Burch-Wartofsky (BW) score is a symptom-based score recommended to determine the likelihood of thyroid storm. This retrospective study aims to determine use of the BW scale and its effect on management.<p class...

Introduction: 90-95% of patients with primary hypothyroidism respond well to levothyroxine (L-T4) therapy. A minority remain symptomatic despite optimised L-T4 therapy. There is limited evidence supporting the role of liothyronine (L-T3) in this subgroup of patients. By looking at 3- and 6-month trials, we aim to review our practice of L-T4/l-T3 therapy.Method: We reviewed medical and pharmacy records of all patients receiving L-T4/l-T3 therapy from Janu...

Background: Elevated TSH concentration should be assessed and treated with caution because of the possibility of transient thyroid dysfunction, or, in rare cases, measurement interference. We describe a case with a rare cause of elevated TSH level in a 39-year-old mother and her four children.Case Summary: A 39-year-old lady was referred with a long history of high serum TSH ranging between 18.9 to 38.7 (reference interval 0.4-4.0 mU/l) with FT4 concentr...

We report a case of a 57-year-old woman with profound uncontrolled hypothyroidism diagnosed in 1999. At her first Endocrine clinic visit in 2015, her TSH level was 93.4 mU/l with FT4 level of 4.8 pmo/l. Despite increasing her Levothyroxine dose, her TSH level remained persistently above 80 mU/l with a low FT4. She had a gastroscopy and coeliac screening which were non-significant. Triiodothyronine 10 mg was added to Levothyroxine 100 mg once daily in October 2015. However, she...