ABSTRACT
Subclinical hypothyroidism (SCH) is characterized by elevated thyroid-stimulating hormone (TSH) and normal free thyroxine levels. The Korean Thyroid Association recently issued a guideline for managing SCH, which emphasizes Korean-specific TSH diagnostic criteria and highlights the health benefits of levothyroxine (LT4) treatment. A serum TSH level of 6.8 mIU/L is presented as the reference value for diagnosing SCH. SCH can be classified as mild (TSH 6.8 to 10.0 mIU/L) or severe (TSH >10.0 mIU/L), and patients can be categorized as adults (age <70 years) or elderly (age ≥70 years), depending on the health effects of LT4 treatment. An initial increase in serum TSH levels should be reassessed with a subsequent measurement, including a thyroid peroxidase antibody test, preferably 2 to 3 months after the initial assessment. While LT4 treatment is not generally recommended for mild SCH in adults, it is necessary for severe SCH in patients with underlying coronary artery disease or heart failure and it may be considered for those with concurrent dyslipidemia. Conversely, LT4 treatment is generally not recommended for elderly patients, regardless of SCH severity. For those SCH patients who are prescribed LT4 treatment, the dosage should be personalized, and serum TSH levels should be regularly monitored to maintain the optimal LT4 regimen.
ABSTRACT
In elderly Graves’ patients, thyrotoxicosis may have vague or atypical clinical features. It could delay the detection of Graves’ disease itself, and also other combined diseases. Here, we report a case of a 73-year-old Graves’ patient who complained of several atypical symptoms such as chest discomfort, pain in the lower calf, severe agitation, depression, sense of impending doom, myalgia etc. Despite these discomforts, they had previously been ignored as vague clinical features of Graves’ disease. After 4 months with hemoptysis, serious pulmonary embolism was confirmed by computed tomography of the chest, and the patient suddenly died. Clinicians should remember that the atypical symptoms in elderly Graves’ patients can suggest hidden comorbidities. This is especially critical in case of acute cardiovascular diseases such as pulmonary embolism, which can be fatal to elderly patients.
ABSTRACT
Background@#Postoperative thyroid stimulating hormone (TSH) suppression therapy is recommended for patients with intermediate- and high-risk differentiated thyroid cancer to prevent the recurrence of thyroid cancer. With the recent increase in small thyroid cancer cases, the extent of resection during surgery has generally decreased. Therefore, questions have been raised about the efficacy and long-term side effects of TSH suppression therapy in patients who have undergone a lobectomy. @*Methods@#This is a multicenter, prospective, randomized, controlled clinical trial in which 2,986 patients with papillary thyroid cancer are randomized into a high-TSH group (intervention) and a low-TSH group (control) after having undergone a lobectomy. The principle of treatment includes a TSH-lowering regimen aimed at TSH levels between 0.3 and 1.99 μIU/mL in the low-TSH group. The high-TSH group targets TSH levels between 2.0 and 7.99 μIU/mL. The dose of levothyroxine will be adjusted at each visit to maintain the target TSH level. The primary outcome is recurrence-free survival, as assessed by neck ultrasound every 6 to 12 months. Secondary endpoints include disease-free survival, overall survival, success rate in reaching the TSH target range, the proportion of patients with major cardiovascular diseases or bone metabolic disease, the quality of life, and medical costs. The follow-up period is 5 years. @*Conclusion@#The results of this trial will contribute to establishing the optimal indication for TSH suppression therapy in low-risk papillary thyroid cancer patients by evaluating the benefit and harm of lowering TSH levels in terms of recurrence, metabolic complications, costs, and quality of life.
ABSTRACT
Subclinical hypothyroidism (sHypo) is defined as normal serum free thyroid hormone levels coexisting with elevated serum thyroid-stimulating hormone (TSH) levels. sHypo is a common condition observed in clinical practice with several unique features. Its diagnosis should be based on an understanding of geographic and demographic differences in biochemical criteria versus a global reference range for TSH that is based on the 95% confidence interval of a healthy population. During the differential diagnosis, it is important to remember that a considerable proportion of sHypo cases are transient and reversible in nature; the focus is better placed on persistent or progressive forms, which mainly result from chronic autoimmune thyroiditis. Despite significant evidence documenting the health impacts of sHypo, the effects of levothyroxine treatment (LT4-Tx) in patients with sHypo remains controversial, especially in patients with grade 1 sHypo and older adults. Existing evidence suggests that it is reasonable to refrain from immediate LT4-Tx in most patients if they are closely monitored, except in women who are pregnant or in progressive cases. Future research is needed to further characterize the risks and benefits of LT4-Tx in different patient cohorts.
ABSTRACT
In elderly Graves’ patients, thyrotoxicosis may have vague or atypical clinical features. It could delay the detection of Graves’ disease itself, and also other combined diseases. Here, we report a case of a 73-year-old Graves’ patient who complained of several atypical symptoms such as chest discomfort, pain in the lower calf, severe agitation, depression, sense of impending doom, myalgia etc. Despite these discomforts, they had previously been ignored as vague clinical features of Graves’ disease. After 4 months with hemoptysis, serious pulmonary embolism was confirmed by computed tomography of the chest, and the patient suddenly died. Clinicians should remember that the atypical symptoms in elderly Graves’ patients can suggest hidden comorbidities. This is especially critical in case of acute cardiovascular diseases such as pulmonary embolism, which can be fatal to elderly patients.
ABSTRACT
Diabetic ketoacidosis (DKA) is an acute complication related to severe hyperglycemia. While the mortality rate for DKA is low with appropriate therapy, several complications may lead to deterioration of the clinical course. Here, we report a case of a 23-year-old patient with DKA who suffered from a rare but hemodynamically unstable cardiac arrhythmia, polymorphic ventricular tachycardia with prolonged QT interval, or Torsades de Pointes. During the recovery phase of DKA, three episodes of Torsades de Pointes suddenly occurred, and were recovered by immediate defibrillation. The patient did not have structural heart disease or a genetic predisposition. To the best of our knowledge, this is the first report of an adult with DKA complicated with QT prolongation related to Torsades de Points after correction of ketosis. To manage DKA, more attention may be needed on changes in the QT interval as well as risk factors for Torsades de Points.
ABSTRACT
Background@#Postoperative thyroid stimulating hormone (TSH) suppression therapy is recommended for patients with intermediate- and high-risk differentiated thyroid cancer to prevent the recurrence of thyroid cancer. With the recent increase in small thyroid cancer cases, the extent of resection during surgery has generally decreased. Therefore, questions have been raised about the efficacy and long-term side effects of TSH suppression therapy in patients who have undergone a lobectomy. @*Methods@#This is a multicenter, prospective, randomized, controlled clinical trial in which 2,986 patients with papillary thyroid cancer are randomized into a high-TSH group (intervention) and a low-TSH group (control) after having undergone a lobectomy. The principle of treatment includes a TSH-lowering regimen aimed at TSH levels between 0.3 and 1.99 μIU/mL in the low-TSH group. The high-TSH group targets TSH levels between 2.0 and 7.99 μIU/mL. The dose of levothyroxine will be adjusted at each visit to maintain the target TSH level. The primary outcome is recurrence-free survival, as assessed by neck ultrasound every 6 to 12 months. Secondary endpoints include disease-free survival, overall survival, success rate in reaching the TSH target range, the proportion of patients with major cardiovascular diseases or bone metabolic disease, the quality of life, and medical costs. The follow-up period is 5 years. @*Conclusion@#The results of this trial will contribute to establishing the optimal indication for TSH suppression therapy in low-risk papillary thyroid cancer patients by evaluating the benefit and harm of lowering TSH levels in terms of recurrence, metabolic complications, costs, and quality of life.
ABSTRACT
Subclinical hypothyroidism (sHypo) is defined as normal serum free thyroid hormone levels coexisting with elevated serum thyroid-stimulating hormone (TSH) levels. sHypo is a common condition observed in clinical practice with several unique features. Its diagnosis should be based on an understanding of geographic and demographic differences in biochemical criteria versus a global reference range for TSH that is based on the 95% confidence interval of a healthy population. During the differential diagnosis, it is important to remember that a considerable proportion of sHypo cases are transient and reversible in nature; the focus is better placed on persistent or progressive forms, which mainly result from chronic autoimmune thyroiditis. Despite significant evidence documenting the health impacts of sHypo, the effects of levothyroxine treatment (LT4-Tx) in patients with sHypo remains controversial, especially in patients with grade 1 sHypo and older adults. Existing evidence suggests that it is reasonable to refrain from immediate LT4-Tx in most patients if they are closely monitored, except in women who are pregnant or in progressive cases. Future research is needed to further characterize the risks and benefits of LT4-Tx in different patient cohorts.
ABSTRACT
The novel viral disease COVID-19 is spreading globally, causing countless infected individuals and deaths. There are active discussions and debates on how to manage patients with chronic illnesses in the COVID-19 pandemic era. Since thyroid diseases are chronic and associated with autoimmune diseases as well as high tumors, there is a need to assess the association between thyroid diseases and COVID-19. Recently, the American Thyroid Association and European Thyroid Association published a statement on thyroid disease management during the COVID-19 pandemic. Further, clinical data from COVID-19 patients also indicate that COVID-19 may affect thyroid functions. Therefore, we reviewed published literature on COVID-19 and thyroid diseases and discussed approaches to proper management of thyroid diseases during the COVID-19 pandemic.
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BACKGROUND AND OBJECTIVES: Thyroid scan is a good tool for diagnosis of hyperfunctioning thyroid nodules (HNs), however it has been limited in use in a primary clinical practice, because of its inconvenience and low accessibility. This study aimed to analyze ultrasonographic (US) characteristics of HNs and to predict HNs by US. MATERIALS AND METHODS: We included 114 patients who exhibited results of ‘hot’ nodule in the thyroid scan from 2008 to 2017. Analysis for US characteristics included 73 patients without unclear US images and other inevitable reasons. We compared US characteristics of HNs with cold nodules that showed “cold” in the thyroid scan. Additionally, we compared US characteristics of HNs between suppressed thyroid-stimulating hormone (TSH) (<0.25 uIU/mL) or normal TSH, and analysis receiver operating characteristics (ROC) curve for prediction of suppressed TSH among HNs. RESULTS: The HNs showed more partially cystic nodule, isoechoic echogenicity, hypervascularity and presence of halo in the US finding than the cold nodule. In subgroup analysis of nodules with TSH suppression among HNs, the TSH suppression nodules was lager in max size and volume than the normal TSH nodules. In ROC analyses for prediction of the TSH suppression among HNs, area under receiver operating characteristics curves was 0.736 in max size, 0.761 in volume. CONCLUSION: HNs showed more frequently partially cystic contents, isoechoic echogenicity, hypervascularity, and peripheral halo sign in US finding. Thyroid nodule size and volume were associated with suppressed TSH level of HNs, and optimal cutoff levels for prediction of TSH suppression among HNs were 2.6 cm and 1.13 cm3, respectively.
Subject(s)
Humans , Diagnosis , ROC Curve , Thyroid Gland , Thyroid Nodule , Thyrotropin , UltrasonographyABSTRACT
BACKGROUND: Insulin therapy is the treatment of choice in type 2 diabetes mellitus (T2DM) patients who are not achieving glycemic goals despite triple oral hypoglycemic agent (OHA) combination therapy. However, there is still no additional treatment option for patients who cannot afford insulin therapy or who have various clinical limitations. The purpose of this study was to evaluate the clinical efficacy and safety of four OHA combination therapy in poorly controlled T2DM patients who could not afford insulin therapy. METHODS: Forty-seven T2DM patients were enrolled according to the following criteria: 1) glycosylated hemoglobin [HbA1c] > 8.5%, 2) ongoing treatment with 3 OHA combination therapy (metformin, sulfonylurea, dipeptidyl peptidase-4 inhibitor), or 3) combined limitations for applying insulin therapy. Patients were given the fourth OHA (pioglitazone) in addition to their previous treatment for 12 months. We evaluated changes in HbA1c, body weight, hypoglycemic events, and side effects. RESULTS: At study completion, mean HbA1c and fasting plasma glucose were significantly reduced from 9.6% to 8.04% and from 198.4 mg/dL to 161.5 mg/dL, respectively (P < 0.001). Mean body weight was significantly increased from 66.7 kg to 69.3 kg. Hypoglycemia and side effects were observed 18 times and only 3 cases showed abnormal liver function tests or edema. In addition, subjects with higher initial HbA1c levels and HOMA-beta showed an independent association with a greater reduction in HbA1c. CONCLUSION: The 4 OHA combination therapy is effective and safe when insulin is not feasible.
Subject(s)
Humans , Blood Glucose , Body Weight , Diabetes Mellitus , Diabetes Mellitus, Type 2 , Drug Therapy , Edema , Fasting , Glycated Hemoglobin , Hypoglycemia , Hypoglycemic Agents , Insulin , Liver Function Tests , Treatment OutcomeABSTRACT
It is well known that the long-term prognosis of postpartum thyroiditis (PPT) is excellent except recurrent PPT in subsequent pregnancies and risk of progression to permanent hypothyroidism in some patients. However, the prospective observation of PPT patients who have neither consecutive gestation nor any evidence of hypothyroidism were limited. We describe three patients who have history of PPT and showed repeated painless thyroiditis in the span of more than ten years. The clinical courses of repeated painless thyroiditis were the transient thyrotoxicosis, self-limited, and not related to pregnancy. Based on the clinical courses of our three patients, it is recommended to remember that transient painless thyroiditis could be repeated as a possible long-term course of the patients with history of PPT.
Subject(s)
Humans , Pregnancy , Hypothyroidism , Postpartum Period , Postpartum Thyroiditis , Prognosis , Prospective Studies , Thyroid Gland , Thyroiditis , ThyrotoxicosisABSTRACT
BACKGROUND: Anti-thyroid drug therapy is considered a treatment of choice for Graves' disease; however, treatment response varies among individuals. Although several studies have reported risk factors for relapse after initial treatment, few have assessed responsiveness during the early treatment period. Our study aimed to identify the clinical characteristics for responsiveness to methimazole. METHODS: We included 99 patients diagnosed with Graves' disease for the first time. Drug responsiveness was defined as the correlation coefficients between decreasing rates of free thyroxine level per month and methimazole exposure dose. According to their responsiveness to treatment, the patients were classified into rapid or slow responder groups, and age, sex, free thyroxine level, and thyrotropin binding inhibiting immunoglobulin (TBII) titers were compared between groups. RESULTS: The mean patient age was 44.0±13.5 years and 40 patients were male (40%). The mean TBII titer was 36.6±74.4 IU/L, and the mean free thyroxine concentration was 48.9±21.9 pmol/L. The rapid responder group showed higher TBII titer and free thyroxine level at diagnosis, while age, sex, smoking, and presence of goiter did not differ between the two groups. Logistic regression analyses revealed that high level of serum thyroxine, high titer of TBII, and absence of goiter were significantly associated with a rapid response, while age, sex, and smoking were not significant factors for the prediction of responsiveness. CONCLUSION: In patients with new onset Graves' disease, high level of free thyroxine, high titer of TBII, and absence of goiter were associated with rapid responsiveness to methimazole treatment.
Subject(s)
Humans , Male , Diagnosis , Drug Therapy , Goiter , Graves Disease , Immunoglobulins , Logistic Models , Methimazole , Recurrence , Risk Factors , Smoke , Smoking , Thyrotropin , ThyroxineABSTRACT
We describe here two Graves' patients who have presented with atypical symptoms. Interestingly, both of them had symptoms related to imbalance of body fluid homeostasis. Chief complaint of a 35-year-old woman (case 1) was the ipsilateral edema of upper body. A 33-year-old man (case 2) who had severe polyuria has referred from urology department with impression of diabetes insipidus. Both of them denied any typical symptoms of Graves' disease at presentation. These rare extrathyroid manifestations of Graves' disease were completely subsided after antithyroid drug treatment. We introduce their clinical courses and possible pathophysiological mechanisms of the atypical symptoms of Graves' disease.
Subject(s)
Adult , Female , Humans , Body Fluids , Diabetes Insipidus , Edema , Graves Disease , Homeostasis , Polyuria , UrologyABSTRACT
We describe here two Graves' patients who have presented with atypical symptoms. Interestingly, both of them had symptoms related to imbalance of body fluid homeostasis. Chief complaint of a 35-year-old woman (case 1) was the ipsilateral edema of upper body. A 33-year-old man (case 2) who had severe polyuria has referred from urology department with impression of diabetes insipidus. Both of them denied any typical symptoms of Graves' disease at presentation. These rare extrathyroid manifestations of Graves' disease were completely subsided after antithyroid drug treatment. We introduce their clinical courses and possible pathophysiological mechanisms of the atypical symptoms of Graves' disease.
Subject(s)
Adult , Female , Humans , Body Fluids , Diabetes Insipidus , Edema , Graves Disease , Homeostasis , Polyuria , UrologyABSTRACT
Autoimmune thyroid disease (AITD) includes hyperthyroid Graves disease, hypothyroid autoimmune thyroiditis, and subtle subclinical thyroid dysfunctions. AITD is caused by interactions between genetic and environmental predisposing factors and results in autoimmune deterioration. Data on polymorphisms in the AITD susceptibility genes, related environmental factors, and dysregulation of autoimmune processes have accumulated over time. Over the last decade, there has been progress in the clinical field of AITD with respect to the available diagnostic and therapeutic methods as well as clinical consensus. The updated clinical guidelines allow practitioners to identify the most reasonable and current approaches for proper management. In this review, we focus on recent advances in understanding the genetic and environmental pathogenic mechanisms underlying AITD and introduce the updated set of clinical guidelines for AITD management. We also discuss other aspects of the disease such as management of subclinical thyroid dysfunction, use of levothyroxine plus levotriiodothyronine in the treatment of autoimmune hypothyroidism, risk assessment of long-standing antithyroid drug therapy in recurrent Graves' hyperthyroidism, and future research needs.
Subject(s)
Causality , Consensus , Drug Therapy , Genes, rel , Graves Disease , Hashimoto Disease , Hyperthyroidism , Hypothyroidism , Risk Assessment , Thyroid Diseases , Thyroid Gland , Thyroiditis, Autoimmune , ThyroxineABSTRACT
Some patients have ascites without having liver disease, so it is important to analyze the cause of these ascites. Tuberculous peritonitis is an infectious disease characterized by lymphocyte-dominant exudative ascites. In contrast, myxedema ascites is a very rare disease characterized by a high serum/ascites albumin gradient (SAAG) with hypothyroidism. We herein report a case involving a 48-year-old woman with both diseases simultaneously. She was hospitalized because of massive ascites, generalized edema, and a puffy face. Hypothyroidism was confirmed by thyroid function tests. Her ascitic fluid had a high SAAG; no other specific findings were identified by cytology, culture, or computed tomography. Three months after initiating drug therapy for the hypothyroidism, the patient's systemic edema improved but the ascites recurred. Accordingly, diagnostic laparoscopy was performed, and tuberculous peritonitis was confirmed. As seen in this case, when myxedema ascites is associated with tuberculous peritonitis, an accurate diagnosis may be challenging.
Subject(s)
Female , Humans , Middle Aged , Ascites , Ascitic Fluid , Communicable Diseases , Diagnosis , Drug Therapy , Edema , Hypothyroidism , Laparoscopy , Liver Diseases , Myxedema , Peritonitis, Tuberculous , Rare Diseases , Thyroid Function TestsABSTRACT
In cases of hyperkalemia with preserved renal function, the differential diagnoses that should be considered are drug-related disorders, primary tubular disease, and hormonal diseases including primary adrenal insufficiency. Addison's disease represents a rare disorder characterized by primary adrenal failure, general weakness, poor appetite, nausea, dizziness, and hyperpigmentation. It may also cause fatal adrenal crisis, involving hypotension, loss of consciousness, hyperkalemia, or hyperkalemic periodic paralysis under stressful conditions. We describe herein the case of a 54-year-old Korean male who developed Addison's disease, due to adrenal tuberculosis, in addition to painless thyroiditis, which led to hyperkalemic periodic paralysis.
Subject(s)
Humans , Male , Middle Aged , Addison Disease , Appetite , Diagnosis, Differential , Dizziness , Hyperkalemia , Hyperpigmentation , Hyperthyroidism , Hypotension , Nausea , Paralysis, Hyperkalemic Periodic , Thyroid Gland , Thyroiditis , Tuberculosis , UnconsciousnessABSTRACT
BACKGROUND: Dipeptidyl peptidase-4 (DPP-4) inhibitor add-on therapy is a new option for patients with inadequately controlled type 2 diabetes who are taking combined metformin and sulfonylurea (SU). We evaluated the efficacy and safety of this triple therapy and the characteristics of rapid responders and hypoglycemia-prone patients. METHODS: We included 807 patients with type 2 diabetes who were prescribed a newly added DPP-4 inhibitor to ongoing metformin and SU in 2009 to 2011. Glycemia and other metabolic parameters at baseline, 12, 24, and 52 weeks, as well as episodes of hypoglycemia were analyzed. Rapid responders were defined as patients with > or =25% reduction in glycosylated hemoglobin (HbA1c) within 12 weeks. RESULTS: At baseline, while on the submaximal metformin and SU combination, the mean HbA1c level was 8.4%. Twelve weeks after initiation of DPP-4 inhibitor add-on, 269 patients (34.4%) achieved an HbA1c level < or =7%. Sixty-six patients (8.2%, 47 men) were rapid responders. The duration of diabetes was shorter in rapid responders, and their baseline fasting plasma glucose (FPG), HbA1c, C-peptide, and homeostasis model assessment of insulin resistance were significantly higher. Patients who experienced hypoglycemia after taking DPP-4 inhibitor add-on were more likely to be female, to have a lower body weight and lower triglyceride and FPG levels, and to have higher homeostasis model assessment of beta-cells. CONCLUSION: An oral hypoglycemic triple agent combination including a DPP-4 inhibitor was effective in patients with uncontrolled diabetes. Proactive dose reduction of SU should be considered when a DPP-4 inhibitor is added for rapid responders and hypoglycemia-prone patients.
Subject(s)
Female , Humans , Blood Glucose , Body Weight , C-Peptide , Diabetes Mellitus, Type 2 , Dipeptidyl-Peptidase IV Inhibitors , Fasting , Glycated Hemoglobin , Homeostasis , Hypoglycemia , Insulin Resistance , Metformin , Sulfonylurea Compounds , TriglyceridesABSTRACT
BACKGROUND: Over the past several decades, there has been a rapid worldwide increase in the prevalence of papillary thyroid cancer (PTC) as well as a number of changes in the clinicopathological characteristics of this disease. BRAF(V600E), which is a mutation of the proto-oncogene BRAF, has become the most frequent genetic mutation associated with PTC, particularly in Korea. Thus, the present study investigated whether the prevalence of the BRAF(V600E) mutation has increased over the past two decades in the Korean population and whether various PTC-related clinicopathological characteristics have changed. METHODS: The present study included 2,624 patients who underwent a thyroidectomy for PTC during two preselected periods; 1995 to 2003 and 2009 to 2012. The BRAF(V600E) mutation status of each patient was confirmed using the polymerase chain reaction-restriction fragment length polymorphism method or by the direct sequencing of DNA. RESULTS: The prevalence of the BRAF(V600E) mutation in Korean PTC patients increased from 62.2% to 73.7% (P=0.001) over the last two decades. Additionally, there was a greater degree of extrathyroidal extension (ETE) and lymph node metastasis in 2009 to 2012 patients with the BRAF(V600E) mutation and a higher frequency of thyroiditis and follicular variant-PTC in 2009 to 2012 patients with wild-type BRAF. However, only the frequency of ETE was significantly higher in 1995 to 2003 patients with the BRAF(V600E) mutation (P=0.047). Long-term recurrence rates during a 10-year median follow-up did not differ based on BRAF(V600E) mutation status. CONCLUSION: The BRAF(V600E) mutation rate in Korean PTC patients has been persistently high (approximately 70%) over the past two decades and continues to increase. The present findings demonstrate that BRAF(V600E)-positive PTC was associated with more aggressive clinicopathological features, especially in patients who were recently diagnosed, suggesting that BRAF(V600E) mutation status may be a useful prognostic factor for PTC in patients recently diagnosed with this disease.