Elementos básicos para el diagnóstico y manejo terapéutico del hipotiroidismo primario en el paciente adulto

Introducción: El hipotiroidismo primario, con frecuencia, es diagnosticado de forma tardía y no siempre las dosis indicadas de levotiroxina son las más convenientes. Urge llamar la atención sobre estos aspectos y actualizar el conocimiento sobre este tema. Objetivo: Describir los elementos básicos para el diagnóstico y manejo terapéutico del hipotiroidismo primario en el paciente adulto, en el primer nivel de atención. Métodos: Se realizó una búsqueda de literatura relevante sobre el tema. Se utilizaron como buscadores de información científica a Pubmed y a Google Académico. La estrategia de búsqueda incluyó los siguientes términos como palabras claves: hipotiroidismo primario; hipotiroidismo subclínico; diagnóstico y tratamiento. Fueron evaluados artículos que, en general, tenían menos de 10 años de publicados, en idioma español e inglés, que hicieran referencia específicamente al tema de estudio a través del título. Fueron excluidos los artículos que no cumplieron con estas condiciones. Esto permitió que 72 fueran referenciados. Conclusiones: Para realizar el diagnóstico del hipotiroidismo primario, es fundamental conocer los factores de riesgo y el cuadro clínico correspondiente. La elevación de la tirotropina en suero es la mejor prueba diagnóstica y casi siempre indica la presencia de hipotiroidismo primario. Se debe tener presente al inicio del tratamiento, la edad del paciente, el tiempo de evolución de la enfermedad, la intensidad del hipotiroidismo, el momento fisiológico y la presencia de enfermedades asociadas. Todos los pacientes con hipotiroidismo primario manifiesto deben ser tratados con levotiroxina sódica, pero aquellos con hipotiroidismo subclínico no siempre se benefician con este tratamiento.

Introduction: Primary hypothyroidism is often diagnosed lately and not always are the indicated doses of levothyroxine the most convenient. It is urgent to draw attention towards these aspects and to update knowledge on this subject. Objective: To describe the basic elements for the diagnosis and therapeutic management of primary hypothyroidism in adult patients at the first level of care. Methods: A search for relevant literature on the subject was carried out. Pubmed and Google Scholar were used as search engines for retrieving scientific information. The search strategy included the following terms as keywords: hipotiroidismo primario [primary hypothyroidism], hipotiroidismo subclínico [subclinical hypothyroidism], diagnóstico y tratamiento [diagnosis and treatment]. Generally speaking, articles within ten years of having been published were assessed, written in Spanish and English and making a specific reference to the subject of the study in their respective titles. Articles not meeting these conditions were excluded. This allowed for 72 articles be referenced. Conclusions: To make the diagnosis of primary hypothyroidism, it is essential to know the risk factors and the corresponding clinical picture. Serum thyrotropin elevation is the best diagnostic test and almost always indicates the presence of primary hypothyroidism. The patient's age, the time of evolution of the disease, the intensity of the hypothyroidism, the physiologic time and the presence of associated diseases should be taken into account at the beginning of treatment. All patients with overt primary hypothyroidism should be treated with levothyroxine sodium, but those with subclinical hypothyroidism do not always benefit from this treatment.

Long-term results of suppressing thyroid-stimulating hormone during radiotherapy to prevent primary hypothyroidism in medulloblastoma/PNET and Hodgkin lymphoma: a prospective cohort study / 医学前沿

Primary hypothyroidism commonly occurs after radiotherapy (RT), and coincides with increased circulating thyroid-stimulating hormone (TSH) levels.We tested therefore the protective effect of suppressing TSH with L-thyroxine during RT for medulloblastoma/PNET and Hodgkin lymphoma (HL) in a prospective cohort study. From1998 to 2001, a total of 37 euthyroid children with medulloblastoma/PNET plus 14 with HL, scheduled for craniospinal irradiation and mediastinum/neck radiotherapy, respectively, underwent thyroid ultrasound and free triiodothyronine (FT3), free thyroxine (FT4), and TSH evaluation at the beginning and end of craniospinal iiradiation. From 14 days before and up to the end of radiotherapy, patients were administered L-thyroxine checking every 3 days TSH to ensure a value < 0.3 μIU/mL. During follow-up, blood tests and ultrasound were repeated; primary hypothyroidism was considered an increased TSH level greater than normal range. Twenty-two/37 patients with medulloblastoma/PNET and all the 14 patients with HL were alive after a median 231 months from radiotherapy with 7/22 and 8/14 having correctly reached TSH levels < 0.3 μIU/mL and well matched for other variables. Twenty years on, hypothyroidism-free survival rates differed significantly, being 60% ± 15% and 15.6% ± 8.2% in TSH-suppressed vs. not-TSH suppressed patients, respectively (P = 0.001). These findings suggest that hypothyroidism could be durably prevented in two populations at risk of late RT sequelae, but it should be confirmed in a larger cohort.

Effect of thyroxine on initial catch-up growth in children with hypothyroidism

Background: Hypothyroidism is a common endocrinal cause of growth retardation in children. Following adequate treatment with thyroxine, growth resumes at an accelerated rate which is known as catch-up growth. There are few observational studies from India on the growth parameters following treatment with thyroxine in children with hypothyroidism.Methods: A retrospective study was done in children aged 2-10 years who were newly diagnosed cases of primary hypothyroidism [Total serum Thyroxine (T4) levels <5 'g/dl and serum Thyroid Stimulating Hormone (TSH) levels ?15 'U/ml] and treated with oral thyroxine to attain euthyroid state. Height measured before starting treatment and at the time of follow up visits was noted, the Height Standard Deviation Scores (HSDS) were calculated. The effect of thyroxine on linear growth was studied.Results: There were 23 children who were diagnosed as having primary hypothyroidism of whom 16(69.6%) were females and 7(30.4%) were males. The mean age of the children studied was 7.3'2.3 years. The mean dose of thyroxine required to maintain euthyroid status was 4.6'2.2 'g/kg/day. Mean duration of follow up was 13.7'2.4 months. The initial HSDS was - 2.31'0.9 which improved to a final value of - 1.7'0.76 (?HSDS0.61, p value <0.0001). Mean height velocity was 8.1 cms/year.Conclusions: Following adequate thyroxine replacement therapy catch-up growth occurs and increased growth velocity leads to partial regain of height deficit in the first couple of years of treatment.

Síndrome de Van Wyk-Grumbach / Van Wyk-Grumbach syndrome

RESUMEN El síndrome de Van Wyk-Grumbach se caracteriza por hipotiroidismo primario de larga duración asociado a pubertad precoz. Se presenta una paciente de 7 años, mestiza, que acude por sangrado vaginal, acompañado de hiperpigmentación de las areolas sin galactorrea, abdomen globuloso, mixedema, hirsutismo, baja talla, astenia y retraso escolar. La química sanguínea mostró anemia, hipercolesterolemia y hipertransaminasemia; los estudios de imágenes constataron derrame pericárdico, retraso marcado de la edad ósea, incremento de las dimensiones de la silla turca y gran quiste del ovario con aparente criterio quirúrgico. Los estudios hormonales confirmaron la sospecha de hipotiroidismo primario asociado a hiperprolactinemia. El tratamiento sustitutivo con levotiroxina sódica revirtió los signos y síntomas de pubertad precoz, lo que evitó la cirugía del quiste de ovario; la recuperación en el ambiente escolar y social fue indiscutible. Reconocer esta entidad evita tratamientos absolutamente contraindicados, como la extirpación de los quistes o el tratamiento quirúrgico de la hiperplasia hipofisaria(AU)

ABSTRACT Van Wyk-Grumbach syndrome is characterized by long-lasting primary hypothyroidism associated with precocious puberty. A case of a 7-year-old female mestizo patient is reported. She came to consultation for vaginal bleeding, accompanied by hyperpigmentation of the areolas without galactorrhea, globular abdomen, myxedema, hirsutism, short stature, asthenia and school delay. Blood chemistry showed anemia, hypercholesterolemia and hypertransaminasemia. Imaging studies showed pericardial effusion, marked delay in bone age, increased dimensions of Turkish chair and large ovarian cyst with apparent surgical criteria. Hormonal studies confirmed the suspicion of primary hypothyroidism associated with hyperprolactinemia. Substitute treatment with levothyroxine sodium reversed the signs and symptoms of precocious puberty, which prevented ovarian cyst surgery; the recovery in the school and social environment was certain. Recognizing this entity avoids absolutely contraindicated treatments, such as the removal of cysts or the surgical treatment of pituitary hyperplasia(AU)

Evaluation of Serum Creatinine, Uric Acid Levels and Urinary Albumin Creatinine Ratio in Patients of Primary Hypothyroidism

Background: Primary hypothyroidism is a clinical conditiondue to deficiency of thyroid hormones. Thyroid hormones haveprofound effect on renal development, renal hemodynamics,glomerular filtration rate, electrolytes and water homeostasis.The aim of this case control prospective study is to evaluatethe effect of primary hypothyroidism on renal functions.Methods: Serum creatinine, blood urea nitrogen, uric acid,urinary albumin creatinine ratio and eGFR levels wereestimated in 75 newly diagnosed and untreated patients ofprimary hypothyroidism in the age group of 20 to 60 years ofeither sex (Study group) and 75 healthy, age and sex matchedindividuals with normal thyroid profile (Control group). Followup of patients in study group was done after 8 weeks ofthyroxine replacement and serum creatinine, uric acid, urinaryalbumin creatinine ratio and eGFR levels were estimated.Results: The mean eGFR level in study group at baseline waslower and mean serum creatinine, blood urea nitrogen, serumuric acid and urinary albumin creatinine ratio (UACR) levelswere higher than control group. After 8 weeks of thyroxinereplacement; the mean serum creatinine, uric acid, bloodurea nitrogen levels were decreased and eGFR levels wereincreased. Also serum TSH shows positive correlation withserum creatinine, blood urea nitrogen, uric acid and urinaryalbumin creatinine ratio but negative correlation with eGFR.Conclusion: Primary hypothyroidism is associated withsignificant alteration in renal function which is reversible onthyroxine replacement.

Hipotiroidismo refractario idiopático: un caso clínico / Idiopathic refractory hypothyroidism: case report

Introducción: El hipotiroidismo constituye una patología frecuente, y su tratamiento habitual es el suplemento de levotiroxina (LT4) oral (VO). Sin embargo, existen casos inhabituales donde no es posible corregir esta condición a pesar de la utilización de LT4 en dosis alta. El hipotiroidismo refractario se define como la persistencia del hipotiroidismo a pesar del uso de LT4 > 1,9 ug/kg/día. La prevalencia del hipotiroidismo refractario no ha sido suficientemente documentada hasta ahora. Descripción del caso: Mujer de 53 años con antecedentes de hipotiroidismo, obesidad, dislipidemia, hipertensión arterial e insulinorresistencia. Fue derivada desde APS a nivel terciario por hipotiroidismo persistente a pesar del uso de LT4 800 ug/día y liotironina 80 ug/día. En forma ambulatoria se descartaron distintas causas, como mala adhesión al tratamiento, pseudo-malabsorción, síndromes de malabsorción; interacciones farmacológicas o interacciones alimentarias. Ante esto, y manteniéndose en su condición, se decide hospitalizar. Durante la hospitalización se prueban distintas fórmulas de administración. Finalmente, se logra respuesta adecuada con LT4 por vía rectal 100 ug/día asociado a 100 ug c/12 horas VO. Discusión: A pesar de no contar con herramientas óptimas para enfrentar este caso, se logró aplicar una estrategia sistemática especializada, que permitió un buen manejo de la paciente. Luego de probar distintas formulaciones de hormonas tiroideas, se logró respuesta mediante la administración por vía rectal, lo cual sugiere que esta paciente presentaba algún trastorno celular/bioquímico intestinal alto, que impedía la absorción óptima de LT4 VO. Conclusiones: La principal fortaleza de este trabajo consiste en la demostración de la utilidad práctica, en un contexto de recursos limitados, de una estrategia de estudio y tratamiento sistemático del hipotiroidismo refractario, lo cual ha sido escasamente publicado en la literatura internacional. Además, se recalca la importancia de una intervención especializada oportuna para evitar los riesgos sistémicos asociados a dosis altas de hormonas tiroideas.

Introduction: Hypothyroidism is a common condition, and its usual treatment is the supplement of oral levothyroxine (po). However, there are unusual cases where it is not possible to correct this condition despite the use of high-dose levothyroxine. Refractory hypothyroidism is defined as the persistence of hypothyroidism despite the use of levothyroxine > 1.9 ug/kg/ day. The prevalence of refractory hypothyroidism has not been sufficiently documented so far. Case description: 53 year old woman with a history of hypothyroidism, obesity, dyslipidemia, hypertension and insulin resistance. She was sent from primary care to tertiary level due to persistent hypothyroidism despite the use of 800 ug/day levothyroxine and liothyronine 80 ug/ day. On an outpatient basis, different causes were excluded as poor adherence to treatment, pseudo-malabsorption, malabsorption syndromes; drug interactions or food interactions. Given this, and staying on her condition, it was decided to hospitalize. Different forms of administration were tested during hospitalization. Finally, got adequate response with levothyroxine rectally 100 ug/day associated with 100 ug po bid. Discussion: Despite not having optimum tools to deal with this case, it was succeeded thanks to the implementation of a specialized systematic strategy. After testing different formulations of thyroid hormones, a positive response by rectal administration was achieved, which suggests that this patient presented any high intestinal cell/biochemist disorder that prevented the optimal absorption of levothyroxine po. Conclusions: The main strength of this work consists in demonstrating the practical utility, in a context of limited resources, of a study and systematic treatment strategy of refractory hypothyroidism, which has barely been published in the international literature. It is also highlighted the importance of an early specialized intervention to prevent the systemic risks associated with high doses of thyroid hormones.

Characteristics of serum lipid profiles in patients with primary hypothyroidism / 安徽医科大学学报

Objective To study the changes of serum lipoprotein cholesterol subclass in patients with primary hypothyroidism).Methods 38 cases of primary hypothyroidism were divided into clinical hypothyroidism group (hypothyroidism group,20 cases) and subclinical hypothyroidism group (subclinical hypothyroidism group,18 cases),Another 20 healthy persons (control group) were selected as control group.5 ml of fasting venous blood was extracted,the serum was separated and preserved at-80 ℃.Configuration of density liquid and ultracentrifugation under different background densities was done.Cholesterol oxidase method was used to determine the serum cholesterol,levels of small and low density lipoprotein (sdLDL),high density lipoprotein 2 (HDL2),and HDL3.At the same time,levels of serum triiodothyronine (T3),thyroxine (T4) and thyroid stimulating hormone (TSH) were checked.Statistical analysis of the correlation between the thyroid relevant hormone mentioned above and serum lipoprotein cholesterol subclass was done.Results ① The total cholesterol,triglycerideand LDL cholesterol levels in hypothyroidism group and subclinical hypothyroidism group were higher than that in the control group,However,the HDL level was significantly lower than the control group (P ＜ 0.05);② SdLDL-C in hypothyroidism group and subclinical hypothyroidism group was significantly higher than that in the control group (P ＜ 0.05);serum HDL2-C in hypothyroidism and subclinical hypothyroidism group was significantly lower than that in the control group (P ＜0.05);while the significance of HDL3 was not reached;sdLDL-C,HDL2-C,HDL3-C in hypothyroidism and subclinical hypothyroidism group had no statistical significance;(Primary thyroid dysfunction occurs,the level of sdLDL-C was positively correlated with TSH (r =0.287,P =0.026),and negatively correlated with T4 (r =-0.267,P =0.039);and no correlation with T3;HDL2-C and T3,T4 were positively correlated (r =0.271,0.270,P =0.036,0.037);no significant correlation between HDL3-C and TSH,T3 T4.Conclusion The changes of clinical lipid profile and lipoprotein cholesterol subclass in patients with hypothyroidism are correlated with thyroid function.

An analysis of the changes of serum lipid and liver enzyme content in patients with primary hypothyroidism before and after treatment / 中华地方病学杂志

Objective To observe the changes of serum lipid and liver enzyme after levothyroxine sodium treatment in patients with primary hypothyroidism.Methods Data from 104 patients with primary hypothyroidism together with increased serum lipid and liver enzyme were collected from August 2006 to November 2015.The date were compared of the changes of thyroid three triiodothyronine (T3),thyroxine (T4),free three triiodothyronine (FT3),free thyroxine thyroid (FT4),thyroid stimulating hormone (TSH),total cholesterol (TC),glycerol triester (TG),high density lipoprotein (HDL-C),low density lipoprotein (LDL-C),alanine aminotransferase (ALT),aspartate aminotransferase (AST) before the levothyroxine sodium treatment and after three month of the treatment.Results After three months of levothyroxine sodium treatment,thyroid function (T3,T4,FT3,FT4,TSH) gradually returned to normal levels [(2.02 ± 0.40) vs (0.96 ± 0.24) nmol/L,(95.76 ± 15.23) vs (24.31 ± 9.99) nmol/L,(4.79 ± 0.58) vs (1.96 ±0.57) pmol/L (15.15 ± 1.77) vs (4.70 ± 1.57) pmol/L,(3.05 ± 1.00) vs (82.41 ± 17.18) mU/L,t =-23.57,-44.13,-34.03,-46.48,48.07,P ＜ 0.01],TC,TG,LDL-C,ALT,AST apparently decreased [(4.30 ± 0.67) vs (7.54 ± 1.26) mmol/L,(2.05 ± 0.34) vs (2.14 ± 0.47) mmol/L,(2.35 ± 0.49) vs (4.28 ± 0.88) mmol/L,(23.31 ±3.92) vs (46.27 ± 0.98)U/L,(26.63 ± 4.64) vs (55.33 ± 11.99) U/L,t =33.68,4.24,24.87,29.36,33.83,P ＜0.01],the decrease was less obvious than before treatment in HDL-C [(1.62 ± 0.36) vs (1.63-± 0.38) mmol/L,t =1.49,P ＞ 0.05].Conclusion Levothyroxine sodium treatment in patients with hypothyroidism can effectively reduce blood lipid and liver enzyme content.

An analysis of the changes of serum lipid and liver enzyme content in patients with primary hypothyroidism before and after treatment / 中华地方病学杂志

Objective To observe the changes of serum lipid and liver enzyme after levothyroxine sodium treatment in patients with primary hypothyroidism.Methods Data from 104 patients with primary hypothyroidism together with increased serum lipid and liver enzyme were collected from August 2006 to November 2015.The date were compared of the changes of thyroid three triiodothyronine (T3),thyroxine (T4),free three triiodothyronine (FT3),free thyroxine thyroid (FT4),thyroid stimulating hormone (TSH),total cholesterol (TC),glycerol triester (TG),high density lipoprotein (HDL-C),low density lipoprotein (LDL-C),alanine aminotransferase (ALT),aspartate aminotransferase (AST) before the levothyroxine sodium treatment and after three month of the treatment.Results After three months of levothyroxine sodium treatment,thyroid function (T3,T4,FT3,FT4,TSH) gradually returned to normal levels [(2.02 ± 0.40) vs (0.96 ± 0.24) nmol/L,(95.76 ± 15.23) vs (24.31 ± 9.99) nmol/L,(4.79 ± 0.58) vs (1.96 ±0.57) pmol/L (15.15 ± 1.77) vs (4.70 ± 1.57) pmol/L,(3.05 ± 1.00) vs (82.41 ± 17.18) mU/L,t =-23.57,-44.13,-34.03,-46.48,48.07,P ＜ 0.01],TC,TG,LDL-C,ALT,AST apparently decreased [(4.30 ± 0.67) vs (7.54 ± 1.26) mmol/L,(2.05 ± 0.34) vs (2.14 ± 0.47) mmol/L,(2.35 ± 0.49) vs (4.28 ± 0.88) mmol/L,(23.31 ±3.92) vs (46.27 ± 0.98)U/L,(26.63 ± 4.64) vs (55.33 ± 11.99) U/L,t =33.68,4.24,24.87,29.36,33.83,P ＜0.01],the decrease was less obvious than before treatment in HDL-C [(1.62 ± 0.36) vs (1.63-± 0.38) mmol/L,t =1.49,P ＞ 0.05].Conclusion Levothyroxine sodium treatment in patients with hypothyroidism can effectively reduce blood lipid and liver enzyme content.

Van Wyk-Grumbach syndrome in children:a case report and literature review / 临床儿科杂志

Objective To explore the early diagnosis and treatment of Van Wyk-Grumbach syndrome (VWGS). Methods The clinical data of a child with VWGS were retrospectively analyzed. The related literatures were reviewed. Results Nine-year-old female presented with growth retardation and obesity for 3 years, combined with breast development for 6 months and vaginal bleeding for 3 month. The level of free thyroxine (FT4) was 0.46 ng/dL and thyrotropin (TSH)>150 mIU/L. The GnRH stimulation test showed that the gonad axis was not activated. The serum prolactin and estradiol were significantly increased. Bone age was delayed. Color Doppler ultrasound showed enlarged uterus and enlarged ovary, and ovarian cyst was seen. Pituitary MRI showed hyperplasia of the pituitary gland. The patient received the treatment of Euthyrox, and 2 months later, thyroid function was back to normal, ovaries were significantly reduced by reexamine of color doppler ultrasound, body weight was reduced by 6 kg, and there was no vaginal bleeding. Three months later, both ovaries returned to normal size, and pituitary MRI showed hyperplasia of adenohypophysis was improved. After 6 months, both of uterus and ovary were turn to normal size, ovarian cyst disappeared, and pituitary MRI showed normal. Conclusions VWGS is a rare complication of severe primary hypothyroidism untreated for long time and it mainly occurs in adolescent girls. Thyroid replacement therapy is effective.

Timing of Levothyroxine in the Treatment of Primary Hypothyroidism.

Aim: Timing of levothyroxine (L-thyroxine) administration seems beneficial for early obtaining thyroid state. The present study aimed at investigating the best time of L-thyroxine administration that can achieve earlier normalization of thyroid stimulating hormone (TSH) and free thyroxine (FT4) levels in patients with primary hypothyroidism. Study Design: Eighty two patients with primary hypothyroidism were recruited between November 2012 and July 2013 during their consultation to Al-Faiha Specialized Diabetes, Endocrine and Metabolism Center, Basrah, Iraq. The patients were divided into two equal groups; group A were receiving L-thyroxine daily, one hour before breakfast, group B: the dose of L-thyroxine was given at the evening. TSH, FT4, Body mass index (BMI), blood pressure, lipid profile were measured before, 30, 60 and 90 days after treatment with L-thyroxine. Results: The mean reduction in TSH from baseline for the evening treatment was 13.6±22.2 mIU/ml which was slightly and insignificantly higher than the value of the morning treatment (11.3±22.5 mIU/ml), P = .63, df = 80, 95% CI: -12.17, 7.5). The mean increase in FT4 from baseline for the evening treatment was 5.7±4.9 pmol/l which was lower than 7.6±6 pmol/l in the morning treatment, (P = .12, df = 80, 95% CI: - 0.5, 4.3). There was no effect of treatment timing on lipid profile, blood pressure, and BMI. Conclusions: There were no differences between the morning and evening treatment with L-thyroxine on early normalization of TSH and FT4.

Severe Hypernatremia Caused by Acute Exogenous Salt Intake Combined with Primary Hypothyroidism

This report describes a case of severe hypernatremia with a serum sodium concentration of 188.1mmol/L caused by exogenous salt intake. A 26-year-old man diagnosed with Crohn's disease 5 years previously visited our clinic due to generalized edema and personality changes, with aggressive behavior. He had compulsively consumed salts, ingesting approximately 154 g of salt over the last 4 days. Despite careful fluid management that included not only hypotonic fluid therapy for 8 hours but also hypertonic saline administration, his serum sodium level decreased sharply at 40.6 mmol/L; however, it returned to normal within 72-hour of treatment without any neurological deficits. Primary hypothyroidism was also diagnosed. He was discharged after 9 days from admission, with a stable serum sodium level. We have described the possibility of successful treatment in a patient with hypernatremia caused by acute salt intoxication without sustained hypotonic fluid therapy.

Hipotireoidismo / Hypothyroidism

O hipotireoidismo é uma das principais doenças da Endocrinologia. É frequente no cotidiano de qualquer médico, independente da sua especialidade, sendo necessário ter conceitos atualizados de diagnóstico e de tratamento. Este artigo traz, de maneira objetiva, novas informações e dados de cunho prático que permitem evitar erros cotidianos (alterações hormonais, anticorpos), fazendo uma breve revisão com tabelas. Discute as principais causas de hipotireoidismo, com ênfase em hipotireoidismo primário (maior prevalência). Apresenta a avaliação prática dos principais exames complementares. Aborda tratamento, mostrando suas peculiaridades e relembra como conduzir o coma mixedematoso.

Individualized therapy for patients with primary hypothyroidism / 中华内分泌代谢杂志

Levothyroxine monotherapy for primary hypothyroidism has gratifying effects.Doctor should recommend the optimal timing of taking levothyroxine to patients for individualized therapy according to the medical history,the pharmacokinetic characteristics of levothyroxine,and various factors affecting its absorption.After reaching the therapeutic goal,most of patients could live,study,work,marry,and bear as healthy subjects.

Primary Thyroid Lymphoma Associated with Dyspnea in an Old Age Patient: A Case Report / 대한갑상선학회지

Primary thyroid lymphoma is a rare tumor which patients usually present an enlarging neck mass, often causing local obstructive symptoms. Hypothyroidism is seen in 30-40% of the patients with primary thyroid lymphoma. We report a 77-year-old man with history of hypothyroidism, presenting enlarging anterior neck mass which pathologically confirmed as thyroid lymphoma with literature review.

The characteristics of cognitive impairment in patients with primary hypothyroidism / 中华行为医学与脑科学杂志

Objective To observe the characteristics of cognitive impairment in patients with primary hypothyroidism.Methods A total of 90 primary hypothyroidism patients untreated with thyroid hormone were selected.All the 90 patients were divided into subclinical hypothyroidism group,mild or moderate hypothyroidism group and serious hypothyroidism group,and 30 patients in each group.The other 30 healthy volunteers were selected as controls.Mini-Mental State Examination (MMSE) and Montreal Cognitive Assessment (MoCA) were used for the testing their orientation,immediate memory,attention and calculation,delayed recalling,linguistic competence,visual space and execution,naming ability and abstracting power.One-way analysis of variance was performed to determine significant differences among four groups.Results The MMSE scores in subclinical hypothyroidism group,mild or moderate hypothyroidism group and serious hypothyroidism group((27.53 ± 2.16),(26.90±1.88) and (24.80 ± 2.10) respectively) were lower than those of the control (28.23 ± 1.33).The MoCA scores of the above hypothyroidism groups ((23.57 ± 3.33),(2 1.60 ± 2.81) and (20.53 ± 3.03) respectively) were also lower than that of the control (26.63 ± 2.31) (P ＜ 0.05).Except for orientation and immediate memory,statistical significances of the other cognitive function were existed between hypothyroidism groups and the healthy controls (P＜ 0.05).With the increase in severity of hypothyroidism,the abnormality of attention,calculation,linguistic competence,visual space and executive ability,naming ability and abstracting power were appearing gradually in hypothyroidism groups (P ＜ 0.05),and the scores were low(P＜ 0.05).Conclusion Defects of attention and calculation,delayed recalling,linguistic competence,visual space and execution,naming ability and abstracting power are existed in primary hypothyroidism patients.

Avaliação terapêutica e posológica da levotiroxina sódica em cães com hipotiroidismo primário adquirido / L-levothyroxine therapeutic dosage evaluation in dogs with primary hypothyroidism

O hipotireoidismo primário adquirido é uma endocrinopatia frequentemente diagnosticada na espécie canina. A terapia consiste na suplementação oral com levotiroxina sódica (L-tiroxina), no entanto vários protocolos terapêuticos têm sido propostos pela literatura, com doses variando 11 a 44µg/kg uma a duas vezes ao dia, visto à grande variabilidade de absorção e meia-vida plasmática do fármaco. Foram estudados 30 cães com hipotiroidismo primário adquirido (13 machos e 17 fêmeas, idade média de 7,9±1,9 anos e peso médio de 19,1±12,6 kg) atendidos no Hospital Veterinário da Universidade Guarulhos (UnG) e no Serviço de Endocrinologia de duas clínicas particulares da cidade de São Paulo (2009-2011), com o objetivo de avaliar a posologia e a frequência de administração da L-tiroxina, mais frequentemente utilizada, capaz de garantir um controle terapêutico satisfatório, avaliado através dos sinais clínicos e do teste pós-tiroxina, além de correlacionar a dose de tiroxina empregada com o peso dos animais. A dose média de tiroxina utilizada em nossa casuística foi de 16,9±3,1µg/kg, sendo a frequência de administração a cada 12 horas em 50% dos casos. Para se investigar uma possível correlação entre o peso e a dosagem de tiroxina utilizada, uma vez que cães de pequeno porte apresentam maior taxa metabólica que cães de grande porte, os animais foram agrupados em grupo A, cães com peso <10 Kg (n=12/30; 7,7±2,1 kg) e grupo B, cães com peso >10 kg (n=18/30, 26,8±10,7 kg). A dose média de tiroxina empregada nos grupos A e B não apresentaram diferença estatística e foram, respectivamente, 16±3µg/kg e 17±3µg/kg. A frequência de administração foi 50% a cada 24 horas e 50% a cada 12 horas para ambos os grupos. Dessa forma, a dose de tiroxina não parece se correlacionar com o peso do animal, sendo imprevisível quem deverá receber dose e frequência máxima da medicação. O protocolo deve ser individualizado e o paciente devidamente monitorado.

The acquired primary hypothyroidism is a frequently diagnosed endocrinopathy in dogs. The therapy constitutes in oral supplementation with sodium levothyroxine (L-thyroxine), however various therapeutic protocols have been proposed in the literature, with doses ranging from11 to 44mg/kg once or twice a day, since L-thyroxine has a great variability of absorption and plasma half life. We studied 30 dogs with primary hypothyroidism (13 males and 17 females, mean age 7.9±1.9 years and mean weight of 19.1±12.6 kg), in order to evaluate the dose and frequency of administration of L-thyroxine used more often able to secure a satisfactory therapeutic control as measured by clinical signs and test post-pill, and to correlate the amount of thyroxine employed with the animals' weight. The mean dose of thyroxine used in our study was 16.9±3.1mg/kg, and the frequency of administration every 12 hours in 50% of cases. To investigate a possible correlation between weight and dose of thyroxine used, since small dogs have a higher metabolic rate than large dogs, the animals were grouped in Group A, dogs weighing <10 kg (n=12/30, 7.7±2.1 kg) and group B, dogs weighing> 10 kg (n=18/30, 26.8±10.7 kg). The mean dose of thyroxine used in groups A and B did not differ significantly and were respectively 16±3mg/kg and 17±3mg/kg. The frequency of administration was 50% every 24 hours and 50% every 12 hours for both groups. Thus, the dose of thyroxine does not seem to correlate with the weight of the animal being unpredictable who should receive the highest dose and frequency of the medication. The protocol should be individualized and the patient adequately monitored.

Approach to the patient with primary hypothyroidism accompanied by pituitary hyperplasia and increased serum creatine kinase level / 中华内分泌代谢杂志

Pituitary hyperplasia may be found in patients with primary hypothyroidism as the decreased thyroid hormone level attenuates negative feedback effect.Sometimes the enlarged pituitary may be misdiagnosed as a pituitary tumor.Patients with long term untreated hypothyroidism often have extremely high level of serum creatine kinase and thus may be misdiagnosed as suffering from myositis.In order to increase the awareness of the nonspecific symptoms of primary hypothyroidism,this article introduces the diagnosis and treatment of a patient with primary hypothyroidism with raised serum creatine kinase level and pituitary hyperplasia.

Pituitary Hyperplasia in Children with Short Stature and Primary Hypothyroidism.

We present eight cases with short stature, pituitary hyperplasia, and hypothyroidism. Pituitary hyperplasia due to primary hypothyroidism was diagnosed on the basis of clinical manifestations, endocrine examination and MRI. After 2 to 6 months of L-thyroxine replacement therapy, the signs of hypothyroidism disappeared; free triiodothyronine, free thyroxine, thyrotropin and prolactin became normal; and pituitary enlargement regressed. In two children, the growth rate remained low when treated with L-thyroxine, but with additional recombinant human growth hormone (rhGH), the height increased by 11 cm per year. No recurrence of lesions was found on follow-up.

De Morsier syndrome associated with periventricular nodular heterotopia: case reporte

INTRODUCTION: Septo-optic dysplasia (De Morsier syndrome) is defined as the association between optic nerve hypoplasia, midline central nervous system malformations and pituitary dysfunction. CASE REPORT: Third child born to nonconsanguineous parents, female, adequate pre-natal medical care, cesarean term delivery due to breech presentation, Apgar score 3 at the first minute and 8 at 5 minutes, symptomatic hypoglycemia at 18 hours. Neurological follow-up identified a delay in acquisition of motor and language developmental milestones. Epileptic generalized seizures began at 12 months and were controlled with phenobarbital. EEG was normal. MRI revealed agenesis of the pituitary stalk, hypoplasia of the optic chiasm and periventricular nodular heterotopia. Ophthalmologic evaluation showed bilateral optic disk hypoplasia. Endocrine function laboratory tests revealed primary hypothyroidism and hyperprolactinemia. CONCLUSION: The relevance of this case report relies on its uniqueness, since periventricular heterotopia had not been described in association with septo-optic dysplasia until 2006.

INTRODUÇÃO: Displasia septo-óptica (síndrome de De Morsier) é definida como a associação entre hipoplasia do nervo óptico, malformações de linha média do sistema nervoso central e disfunção pituitária. RELATO DE CASO: Terceiro filho, pais não consangüíneos, sexo feminino, pré-natal adequado, parto cesário a termo por apresentação pélvica, Apgar 3 no primeiro minuto e 8 no quinto minuto, hipoglicemia sintomática com 18 horas de vida. Durante o acompanhamento neurológico identificou-se atraso na aquisição dos marcos de desenvolvimento motor e linguagem. Crises epilépticas generalizadas iniciaram com 12 meses de vida sendo controladas com fenobarbital. EEG era normal. Ressonância magnética revelou agenesia de haste pituitária, hipoplasia de quiasma óptico e heterotopia nodular periventricular. Avaliação oftalmológica demonstrou hipoplasia bilateral de disco óptico. Investigação da função endócrina revelou hipotireoidismo primário e hiperprolactinemia. CONCLUSÃO: A relevância deste relato reside em seu ineditismo, já que heterotopia periventricular não havia sido descrita em associação com displasia septo-óptica até 2006.