Síndrome do eutireoidiano doente em pacientes com diabetes mellitus tipo 2: correlação com marcadores inflamatórios, controle glicêmico e relação com doença cardiovascular / Euthyroid sick syndrome in patients with type 2 diabetes mellitus: correlation between inflammatory markers, glycemic control and relationship with cardiovascular disease

A síndrome do eutireoidiano doente (SED) é uma entidade caracterizada pela queda das concentrações sanguíneas de triiodotironina nas formas total e livre e aumento da forma reversa. Ocorre principalmente em pacientes portadores de doenças graves e agudas, particularmente dentre aqueles internados em unidade de terapia intensiva. Há descrição desta síndrome em portadores de Diabetes Mellitus, particularmente sob controle glicêmico inadequado. Objetivos: Avaliar as alterações dos hormônios tireoidianos em portadores de DM sob cuidado ambulatorial e a correlação entre concentrações de hormônios tireoidianos e controle glicêmico, presença de complicações crônicas (neuropatia, nefropatia, retinopatia) e marcadores de inflamação sistêmica subclínica, bem como sua relação com presença de eventos cardiovasculares. Metodologia: Estudo transversal avaliando 52 pacientes com diabetes tipo 2 e 52 indivíduos sem diabetes, entre 40 e 75 anos de idade, pareados por sexo, idade e índice de massa corporal. Avaliaram-se dados clínicos e antropométricos, concentrações séricas de hormônios tireoidianos e proteína C reativa, bem como exames laboratoriais que refletem o perfil lipídico e controle glicêmico. Resultados: Cerca de 73% dos pacientes com diabetes e 40% dos indivíduos sem DM apresentaram concentrações séricas diminuídas de T3 total; 25% dos pacientes e apenas 2% dos indivíduos sem DM apresentaram concentrações diminuídas de T3 livre. As concentrações séricas de T3 total (p<0,001), T3 livre (p<0,001) e T4 total (p=0,006) estavam diminuídas em comparação aos de indivíduos sem diabetes. As concentrações de T3 reverso não apresentaram diferença entre os dois grupos. Pacientes com diabetes apresentaram T4 livre mais elevado (p=0,033).

The non-thyroidal illness is an entity characterized by reduced serum levels of total and free triiodothyronine and a rise in its reverse form. It occurs mainly in critically ill patients. There are descriptions of this syndrome in patients with Diabetes Mellitus, especially those under inadequate glycemic control. Objectives: Evaluate the abnormalities in thyroid hormone levels in individuals with diabetes under standard outpatient care and the correlation of thyroid hormone levels with glycemic control, presence of chronic complications (neuropathy, nephropathy and retinopathy) and subclinical systemic inflammation, as well as its relation with the presence of previous cardiovascular events. Methodology: Cross sectional study involving 52 patients with type 2 diabetes and 52 individuals without the diabetes, between 40 and 75 years of age paired by age, gender and body mass index. We evaluated clinical and anthropometric data, serum levels of thyroid hormones and Creactive protein, as well as laboratory parameters that reflect the lipid profile and glycemic control. Results: Approximately 73% of the patients with diabetes and 40% of individuals without diabetes presented reduced serum levels of total T3. Nearly 25% of the patients and only 2% of the individuals without diabetes presented reduced levels of free T3. The levels of total T3 (p<0.001), free T3 (p<0.001) and total T4 (p=0.006) were lower in patients with diabetes compared with those without diabetes. The levels of reverse T3 did not present any difference between both groups. Patients with diabetes presented higher levels of free T4 (p=0.033). The levels of reverse T3 were significantly different only when comparing individuals with previous cardiovascular events with those without this characteristic (p=0.002 for patients with diabetes and p=0.037 for individuals without diabetes). The prevalence of cardiovascular disease was 25%.

Perfil dos hormônios tireoidianos nas síndromes coronarianas agudas / Thyroid hormone profile in acute coronary syndromes

OBJETIVO: Descrever o perfil hormonal tireoidiano em pacientes com síndromes coronarianas agudas (SCA), e nos grupos: 1) angina instável e/ou infarto agudo do miocárdio sem supradesnivelamento de segmento ST (AI/IAM sem supra ST); 2) infarto agudo do miocárdio com supradesnivelamento do segmento (IAM com supra ST), e nos pacientes que evoluíram ou não a óbito conforme os grupos. MÉTODOS: Foram estudados prospectivamente setenta pacientes portadores de SCA, internados na unidade coronariana do Hospital dos Servidores do Estado/RJ. As amostras sangüíneas foram coletadas nos primeiro, quarto e sétimo dias de internação. Exame clínico e eletrocardiograma foram realizados no período de internação. RESULTADOS: Dos 70 pacientes admitidos, 13 (18,6 por cento) apresentaram a "síndrome do eutireoidiano doente" (SED), que consiste na queda do hormônio T3 e ou T3 livre, aumento do hormônio T3 reverso (rT3) e inalteração dos hormônios TSH, T4 e T4 livre. Nos pacientes do grupo IAM com supra ST, observaram-se elevação precoce e maiores médias do hormônio tireoidiano T3 reverso (rT3) e menores médias dos hormônios T3 e T3 livre. Nos coronariopatas que evoluíram a óbito, observamos achados hormonais condizentes com os encontrado na SED, com valores médios expressivos dos hormônios rT3 e T3. CONCLUSÃO: Os resultados apresentados neste estudo mostram a importância do reconhecimento da "síndrome do eutireoidiano doente" nos pacientes coronariopatas, sugerindo associação com pior prognóstico nos pacientes com síndrome coronariana aguda.

OBJECTIVE: To describe thyroid hormone profile in patients with acute coronary syndromes (ACS), divided into two groups: 1) unstable angina and/or non-ST-segment elevation acute myocardial infarction (UA/NSTEMI); 2) ST-segment elevation acute myocardial infarction (STEMI), as well as in patients that progressed or not to death, according to the groups. METHODS: Seventy ACS patients admitted to the coronary care unit of the Hospital dos Servidores do Estado, Rio de Janeiro, were prospectively studied. Blood samples were collected on day 1 and on days 4 and 7 following admission. Clinical evaluation and electrocardiograms were performed during hospitalization. RESULTS: Of the 70 patients admitted, 13 (18.6 percent) had "euthyroid sick syndrome" (ESS), a condition characterized by decreased serum T3 and/or free T3, increased serum reverse T3 (rT3), plus normal serum TSH, T4, and free T4. Patients belonging to the STEMI group showed early elevations, in addition to higher mean reverse T3 (rT3) and lower mean T3 and free T3 levels. In coronary heart disease patients that progressed to death, hormonal findings were consistent with those found in the ESS, with more expressive rT3 and T3 mean values. CONCLUSION: Our results show the importance of recognizing the "euthyroid sick syndrome" in coronary heart disease patients, suggesting an association with poorer prognosis in patients with acute coronary syndrome.

Hypothalamic pituitary thyroid axis in critically ill patients

Patient with critical illness has disturbed thyroid function tests sick euthyroid syndrome' in the form of low total and free T 3, T 4 [FT 3, PT 4] and low level of the serum TSH. We investigated the hypothalamic-pituitary-thyroid axis and its relation to the mortality and/or morbidity before and after TRH stimulation. Bas-line serum TSR, free T 3, T 4 and after 200 microgram TRH, stimulated serum TSR, free T 3,and free T 4, were measured in 17 patients presented with acute critical illness, in 24 patients with chronic illness and in 20 healthy control. The results showed significant reduction in baseline and impaired secretion of thyroid hormones [FT 4 and PT 3] as well as TSH level in patients groups compared to control group. In acutely ill patients this reduction is mainly in PT 3, while in chronic patients reduction of both FT 3 and FT 4 were evident. A bolus I.V. injection of TRH in critically ill patients leads to marked increases in the serum TSR without changes in serum FT 3 or FT 4 and outcome of patients. It was found that serum TSH, FT 4 and serum albumin were correlated significantly with the mortality and morbidity of critically ill patients than APACHE II score inspite of its long term used in the prediction of morbidity and mortality in such patients. However follow up measurements of FT 4 and TSH can take it as a marker of recovery of critical illness. The results demonstrated an impairment of the hypothalamic-pituitary-thyroid axis in patients with critical illness and serum levels of FT 4 and TSH can be used in the prediction of morbidity and mortality in such patients

Hipertiroxinemia con eutiroidismo clínico: análisis a propósito de un caso / Hyperthyroxinemia and clinical euthyroidism: report of one case

The association of hyperthyroxinemia and euthyroidism is frequent and characterized by high plasma thyroxin concentrations, normal TSH values and absence of clinical signs of hyperthyroidism. We report an asymptomatic 28 years old male presenting with a serum total plasma thyroxin of 18.5 µg/dl (N 6.1-12.5), a free thyroxin of 2.9 ng/dl (N 0.8-1.4), a TSH of 3.4 µIU/ml (N 0.5-5), and a triiodothyronine of 128 ng/dl (N 80-180). Laboratory assessment did not find high thyroxin binding globulin, albumin or prealbumin concentrations or antithyroxin antibodies. The thyroxin binding capacity of albumin was elevated to 58.2 µg/dl (N 11.5-34.1). TSH responded normally to TRH stimulus and was suppressed with exogenous triiodothyronine, which caused an hyperthyroid syndrome. We concluded that this patient had a familial dysalbuminemia

Síndrome de eutiroidismo enfermo / Ill euthyroidism syndrome

El síndrome de eutiroidismo enfermo (SEE) o enfermedad sistémica no tiroídea, descrito por primera vez en 1974 y 1975, es un síndrome caracterizado por alteraciones de laboratorio de las pruebas tiroídeas, encontrándose valores inapropiadamente bajos de TSH, junto a bajas concentraciones de tiroxina (T4 y triyodotironina (T3) totales. El SSE es un indicador de mal pronóstico. Pareciera que el tratamiento del estado de T3 disminuido en pacientes con SEE con hormonas tiroídeas es al menos no benéfico, y tal vez, perjudicial, y podría empeorar un mecanismo importante de normalización de la función tiroídea durante la recuperación de la patología de base, al suprimir la fuente de TSH durante este período. Se revisa el fundamento fisiológico de este síndrome, su incidencia, su laboratorio, las bases de su diagnóstico diferencial, sus distintas hipótesis etiológicas y, finalmente, su manejo terapéutico

Diagnostic value of thyroid function tests in the euthyroid sick syndrome

We studied thyroid function tests in a group of non thyroidal illnesses "Euthyroid Sick Syndrome ESS" to find any possible alterations as well as the test most reliable in unraveling the actual state of thyroid function under such conditions. Serum T4, T3, FT4I, FT3I and TSH uere measured in patients with insulin dependent diabetes IDD [10 and 11], chronic renal failure CFR [10 and 9], hematologic malignancy [12 and 15] in an Egyptian and American sample respectively. Seventeen Egyptian patients with hepatosplenic schistosomiasis [HSS] and 17 American patients withacute psychiatric illnesses were also studied. There was a tendency for T3 to decrease in all groups of study and T4 to increase in the group uith acute psychiatric illnesses. TSH used to be the most useful test in all groups of study to diagnose euthroidism. It is to be concluded that thyroid function test my be altered in non thyroidal illnesses. These changes however seem to be minimal and correlate with severity of the underlying illness. TSH is the least likely to change and is the best diagnostic test which reflects the actual euthyroid state in such cases