Síndrome de Wilkie secundario a hipertiroidismo exógeno en una paciente con hipotiroidismo primario autoinmune: reporte de un caso y revisión de la literatura / Wilkie's syndrome caused by exogenous hyperthyroidism in a patient with primary autoimmune hypothyroidism: a case report and literature review

RESUMEN El síndrome de Wilkie o de arteria mesentérica superior es una causa poco común de obstrucción intestinal proximal, relacionada a pérdida de peso reciente. Reportamos el caso de una mujer de 19 años que se presenta a la clínica con pérdida de peso, dolor abdominal, nausea y vomito. Los exámenes de laboratorio reportaron anemia, hipoalbuminemia, hipomagnesemia y una hormona estimulante de la tiroides suprimida secundario al uso con levotiroxina. Se realizó una serie esofagogastroduodenal con datos compatibles con dilatación gástrica severa, gastroparesia y una tomografía axial computada reveló un ángulo aortomesentérico de 11,7°. Se inicio manejo conservador a base de nutrición enteral y parenteral total, siendo este el tratamiento de elección. En casos refractarios, la cirugía es una opción segura y efectiva.

ABSTRACT Wilkie's syndrome or superior mesenteric artery syndrome is an unusual cause of proximal intestinal obstruction, primarily attributed to recent weight loss. We report the case of a 19-year-old woman comes to our clinic and reports weight loss, abdominal pain, nausea, and vomiting. Laboratory tests revealed anemia, hypoalbuminemia, hypomagnesemia, and a suppressed thyroid stimulating hormone secondary to levothyroxine. A barium swallow test showed gastric dilatation, delayed gastric emptying and an axial computed tomography revealed an aortomesenteric angle of 11.7°. Conservative management with total parenteral and enteral nutrition was initiated, being the first-line treatment. In refractory cases surgery is a safe and effective option.

COVID-19 y tiroxicosis / COVID-19 and thyrotoxicosis. Case report

La epidemia por COVID-19, causada por el nuevo coronavirus-2 del síndrome respiratorio agudo severo (SARS-CoV-2) ha enfrentado al equipo de salud a un abanico de presentaciones clínicas y alteraciones de las funciones órganicas a las que diagnosticar y tratar. Dentro de estas se encuentra la disfunción tiroidea.En este reporte se presenta el caso de una paciente con taquicardia persistente luego de pasado el cuadro de COVID-19, que derivó en múltiples consultas hasta que se arribó al diagnóstico de tirotoxicosis de etiología autoinmune.La tirotoxicosis asociada a COVID-19 es infrecuente, pero agrega morbilidad a la convalecencia de los pacientes, por lo que su sospecha clínica y diagnóstico rápido serían beneficiosos

The infection by the new severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has challenged the health care system with a new spectrum of clinical manifestations and organ disfuntions, that require proper diagnosis and treatment.In this case we report a patient with persistent tachycardia after COVID-19 acute illness. This finding led to multiple medical visits until final diagnosis of thyrotoxicosis of autoimmune etiology.Thyrotoxicosis is an unusual complication of COVID-19, that results in higher morbility in patients during the convalescent phase of the disease. Opportune clinical suspicion and early diagnosis seems to be beneficial in terms of clinical outcome

Anticuerpos anti-estreptavidina: Confusión diagnóstica por interferencia bioquímica / Anti-estreptavidin antibodies. Diagnostic confusion by biochemical interference

Se presenta el caso de una paciente que, durante los estudios por búsqueda de fertilidad y posterior embarazo, mostraba un perfil tiroideo alterado con niveles elevados de T4 libre y TSH normal. Luego de descartar un adenoma tirotropo y ante la ausencia de sintomatología clínica de hipertiroidismo, se investigó la posibilidad de interferencias analíticas en los inmunoensayos utilizados para la medición de las hormonas. Se han descrito interferencias causadas por anticuerpos heterófilos, macro TSH, anticuerpos anti-tiroideos, biotina, y en menor medida anticuerpos anti-estreptavidina y anti-rutenio. Los análisis de la paciente se realizaron en autoanalizador cuya plataforma emplea el sistema estreptavidina-biotina que es muy susceptible a varios interferentes. Un algoritmo propuesto incluye una serie de pruebas simples de realizar e interpretar que permiten detectar o descartar la presencia de interferentes. De acuerdo al mismo, se efectuó la comparación con una plataforma analítica diferente (que no utiliza el sistema estreptavidina-biotina), diluciones seriadas, precipitación con polietilenglicol 6000 y tratamiento con micropartículas recubiertas con estreptavidina. Los resultados obtenidos confirmaron la presencia de anticuerpos anti-estreptavidina en el suero de la paciente. Ante discordancias entre las manifestaciones clínicas y los resultados de laboratorio, se debe investigar la posibilidad de interferencias metodológicas para evitar el riesgo iatrogénico potencial que implica una interpretación bioquímica errónea.

We present the case of a patient who, during studies for fertility and subsequent pregnancy, showed an altered thyroid profile with elevated levels of free T4 and normal TSH. After ruling out a thyrotropic adenoma and in the absence of clinical symptoms of hyperthyroidism, the possibility of analytical interference in the immunoassays used to measure hormones was investigated. Interferences caused by heterophile antibodies, macro TSH, anti-thyroid antibodies, biotin, and to a lesser extent anti-streptavidin and anti-ruthenium antibodies have been described. The analysis of the patient was carried out in a self-analyzer whose platform uses the streptavidin-biotin system that is very susceptible to several interferents. A proposed algorithm includes a series of simple tests to perform and interpret that allow detecting or ruling out the presence of interferents. Accordingly, a comparison was made with a different analytical platform (which does not use the streptavidin-biotin system), serial dilutions, precipitation with polyethylene glycol 6000 and treatment with microparticles coated with streptavidin. Results obtained confirmed the presence of anti-streptavidin antibodies in the patient's serum. In the case of disagreements between clinical manifestations and laboratory results, the possibility of methodological interferences should be investigated in order to avoid the potential iatrogenic risk involved in an erroneous biochemical interpretation.

Alternative complement pathway and factor B activities in rats with altered blood levels of thyroid hormone

Evaluating the activity of the complement system under conditions of altered thyroid hormone levels might help elucidate the role of complement in triggering autoimmune processes. Here, we investigated alternative pathway (AP) activity in male Wistar rats (180 ± 10 g) after altering their thyroid hormone levels by treatment with triiodothyronine (T3), propylthiouracil (PTU) or thyroidectomy. T3 and thyroxine (T4) levels were determined by chemiluminescence assays. Hemolytic assays were performed to evaluate the lytic activity of the AP. Factor B activity was evaluated using factor B-deficient serum. An anti-human factor B antibody was used to measure factor B levels in serum by radial immunodiffusion. T3 measurements in thyroidectomized animals or animals treated with PTU demonstrated a significant reduction in hormone levels compared to control. The results showed a reduction in AP lytic activity in rats treated with increasing amounts of T3 (1, 10, or 50 µg). Factor B activity was also decreased in the sera of hyperthyroid rats treated with 1 to 50 µg T3. Additionally, treating rats with 25 µg T3 significantly increased factor B levels in their sera (P < 0.01). In contrast, increased factor B concentration and activity (32 percent) were observed in hypothyroid rats. We conclude that alterations in thyroid hormone levels affect the activity of the AP and factor B, which may in turn affect the roles of AP and factor B in antibody production.

O selênio e a glândula tireóide: um estudo em pacientes portadores de disfunções tireoidianas nos estados de Ceará e São Paulo / The selenium and thyroid gland: a study in patients with thyroid dysfunction in the states of Ceara and Sao Paulo

Introdução: O Selênio é um mineral fundamental para o homem, participa dos mecanismos antioxidantes, influencia o sistema imune e participa ativamente da homeostase da glândula tireóide.Objetivo: Avaliar o estado nutricional relativo ao selênio de pacientes adultos portadores de hipotireoidismo e hipertireoidismo em atendimento ambulatorial no Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo e no Hospital Universitário Walter Cantídio da Universidade Federal do Ceará. Metodologia: Foram avaliados quatro grupos de pacientes com doença de Graves (Graves), Bócio Multinodular Tóxico (BMNT), Hipotireoidismo pós-tireoidectomia (Hipotireoidismo) e tireoidite de Hashimoto (Hashimoto) em dois estados, São Paulo e Ceará e paralelamente dois grupos controle (São Paulo e Ceará). Foram realizadas caracterização antropométrica e clínica. O Se foi analisado no plasma e eritrócitos, foi medida a atividade da GSH-Px, iodúria, MDA plasmático e dosagens de hormônios tireoidianos e Anti-TPO. O consumo alimentar foi estimado utilizando-se a técnica de recordatório 24 horas...

Tireoideopatias e gravidez / Diseases of thyroids and pregnancy

As doenças da tireóide têm mais prevalência no sexo feminino e, possivelmente, são secundárias aos efeitos dos esteróides sexuais no sistema imunológico. Daí advém à importância do esclarecimento das tireoidopatias e das maneiras de diagnósticá-las precocemente, a tempo de interferir em seu ciclo patogênico e evitar a ocorrência de danos materno-fetais. É necessário discernir entre o patogênico e as adaptações fisiológicas da gestação, estando necessariamente entre as doenças de rastreamento obrigatório nesse período. Hipotireoidismo é doença bastante freqüente em nosso meio, sendo de origem imunológica ou pela deficiência de iodo. Na gestação, é freqüentemente causado por tireoidite auto-imune ou por destruição da glândula. A doença de Graves é a causa mais freqüente de hipertireoidismo durante e fora do período gestacional. Contudo, apesar de apresentar menos prevalência em gestantes, seus efeitos são graves caso não diagnosticado e tratado em tempo hábil. A tireoidite pós-parto é mais comum em mulheres que têm concentração elevada de anticorpo antiTPO e apresenta gênese auto-imune, sendo influenciada pelo ciclo gravídico-puerperal. A presença de nódulos benignos, malignos e o câncer de tireóide ainda apresentam relação a ser esclarecida com o período gravídico.

The thyroid's diseases have greater prevalence in the female sex and, possibly, they are secondary to the effects of the sexual steroids in the immunological system. From there comes the importance of the clarification of the thyroid's diseases and its precocious diagnosis, in time to intervene in its pathological cycle and prevent damages for the embryo or for the mother. It is necessary to discern between the gestation pathological and physiological adaptations, the thyroid diseases being necessarity among the illnesses of obligatory tracking in this period. Hypothyroidism is frequent enough, due to its immunological origins of iodine deficiency. During gestation it is frequently caused by autoimmunity thyroiditis or gland destruction. Graves' disease is the hyperthyroidism most frequent cause during pregnancy of not. However, although its minor prevalence in pregnancy, its effects might be serious if it is not diagnosed and treated in time. Thyroiditis after-childbirth is more common in women who have high TPO antibodies concentration and presente autoimmunity origin, being influenced by the pregnancy-puerperal cycle. The presence of any kind of nodules and thyroid cancer still present relation with the pregnancy period to be clarified.

study on the relationship between thyroid hormones and adenosine deaminase enzyme activity in patients with auto- immune hyperthyroid disease

Adenosine deaminase ADA catalyzes the deamination of adenosine in purine metabolism. Adenosine deaminase deficiency is an inborn error resulting in immunodeficiency condition. Clinical interest in this enzyme has been revived by the discovery of a syndrome of severe humoral and cellular immunodeficiency associated with deficiency of ADA in somatic erythrocyte cell. The aim of present study is conducted to find the relationship between human hyperthyroid activities and immune etiology in graves disease. Forty individuals with hyperthyroidism autoimmune state were included in this study in comparison with forty normal persons. Thyroid hormones levels were estimated by HPLC and serum ADA specific activity was estimated using spctrophotometric method at 265 nm. Serum protein value was determined by Bradford method. Serum ADA activity was measured for 40 hyperthyroid patients as well as 40 normal individuals. The mean activity of ADA in patients was higher than in the controls. A significant increase in T3/T4 ratio and level of TSH were noticed. A positive correlation between thyroid level and ADA enzyme activity was noticed

Determinación del anticuerpo antirreceptor de TSH: experiencia en pacientes con patología tiroídea y controles / Determination of TSH antireceptor antibody: experience in patients with thyroid pathology and controls

In order to measure TSH receptor antibodies (TRAb) we tried to set up a radioreceptor assay using human thyroid membranes. Due to lack of appropriate binding activity of the material obtained, we decided to use a kit which provides solubilized porcine membrane-receptors to TSH instead of human membranes, as well as calibrators that have been standarized in a receptor assay against MRC LATS std B. With these reactives we have measured TRAb in sera from 7 normal controls (C), 54 thyrotoxic patients (43 diffuse goiters [BDH], 8 multinodular goiters [BDH] and 3 subacute Thyroiditis [TSA], 3 patients with Hashimoto's Thyroiditis (TH) and 6 non-hyperthyroid Graves ophtalmopathy patients. Measurement were initially performed using calibrators and the results expressed as U/L; since a very good correlation between the expression U/L and the calculated inhibition Index (I.I.) was found (r=0.99, n=15, p<0,001), results are shown using latter. In C mean ñ SD value for I.I. was 3.4 ñ 2.37 percent so we decided to use, as cut off criteria for differentiating between normal and abnormal results, the figure 11 percent which represents the mean ñ 3 SD. According to this, 93 percent of BDH has elevated TRAb activity while only slightly more than one third of MBH had elevated values, this difference being highly significant (p<0,0001); both TSA and TH patients showed low TRAb activity while all Graves ophtalmopathy pts had elevated values, thus suggesting that they had a latent disease. We concluded that the methodology that is adequate and practical for clinical purposes. Our results show that measurement of TRAb activity is very useful in stablishing the etiology of hyperthyroidism in an individual patient. Also it provides help inthe differential diagnosis of patients with exoftalmus od unknown etiology. Its usefulness remains to be proved in the follow-up of BDH pts after been treated with antithyroid drugs

Autoantibodies against thyroid constituents and CIC in Graves' disease associated with exophthalmos

32 patients [19 female, 13 male]- suffering from Graves' disease with exophthalmus and five without exophthalmus were studied for various autoantibodies including anti-thyroglobulin [ATAB], anti-microsomal antibody [AMAB], anti-parietal antibodies [APAB] and also circulating immune complex [CIC]. 43 normal subjects were tested concurrently. Immunofluorescent technique was employed for autoantibody detection. Frozen sections of human thyroid tissue and rat stomach were utilized as antigen sources for thyroid and parietal CIC estimated by PEG [polyethylene glycol] precipitation method and the specific classes of immunoglobulins were detected by SRID [single radial immunodiffusion]. The results were analyzed statistically. From the point of view of presence of antibodies, there were significant differences between patients and control groups [P= 0.005]. Comparing Graves' with or without exophthalmus, no significant difference was seen between autoantibody levels, but higher titers of CIC were elucidated in the latter group. We will discuss that autoantibodies have an important role in thyroid autoimmune diseases and also that CIC may have a critical role in the pathogenesis of exophthalmus associated with Graves' disease

Detection of autoantibodies against 3,5,3'-triiodothyronine in a hyperthyroid patient (a case report).

A 35-year-old female patient was evaluated for thyroid function and was found to be hyperthyroid clinically and by laboratory tests. During the course of treatment with neomercazole, she developed a bizarre picture with consistently low T3 levels irrespective of her clinical thyroid status and other laboratory tests like serum T4 and TSH levels. The serum of the patient when analysed for the presence of autoantibodies was positive for those against T3. The presence of T3 autoantibodies was confirmed by other laboratory techniques like assessment of blank values in radioimmunoassay, binding of T3-125I to isolated gamma globulin and starch gel electrophoresis. Autoantibodies were found to be present only against T3 and not against. T4 The affinity constant of T3 antibodies was 4 x 10(9) lit. mol-1 as determined by Scatchard plot analysis while total binding capacity was 23 x 10(-11) mol/L.

Influencia del nivel de hormonas tiroideas en las subpoblaciones de linfocitos T / Influence of thyroid hormone levels on T lymphocyte subpopulations

Para precisar si la disfunción tiroidea influye en los trastornos de la inmunidad mediada por células presentes en la enfermedad autoinmune del tiroides, se determinaron los niveles de linfocitos T totales y subpoblaciones de linfocitos T en: grupo I: 15 pacientes hipertiroideos, (ocho antes de recibir tratamiento y después, con drogas antitiroideas durante seis meses); grupo II: ocho pacientes eutiroideas (bocio toxico difuso en remisión) y grupo III: tres pacientes con hipotiroidismo primario no iatrogénico sin tratamiento. Los niveles de linfocitos T totales fueron normales en todos los pacientes. Los linfocitos T formadores de roseta activa estuvieron disminuidos (X=19) en pacientes en fase hipertiroidea, y normales (X=25) cuando se logró el eutiroidismo. La relación T4/T8 estuvo disminuida en pacientes hipotiroideos y aumenta en 2/7 pacientes con bocio tóxico difuso (BTD) en fase tirotóxica. Estos resultados apoyan la hipótesis de que en los trastornos (al menos en el orden cuantitativo) de las subpoblaciones de linfocitos T influyen los niveles de hormonas tiroideas. En este trabajo, además, se informan los resultados iniciales con la aplicación de la técnica de anticuerpos monoclonales para el estudio de las células T