Tiroiditis subaguda y tirotoxicosis posterior a vacuna contra SARS-CoV-2: reporte de 2 casos / Subacute thyroiditis and thyrotoxicosis after SARS-CoV-2 vaccine: report of 2 cases

La enfermedad por coronavirus SARS-CoV-2 que surgió en el año 2019 (COVID-19), ha obligado al rápido desarrollo de vacunas para prevenir su propagación e intentar controlar la pandemia. Dentro de las vacunas desarrolladas, las primeras en ser aprobadas con una tecnología nueva en el campo de la vacunación, fueron las vacunas basadas en ARNm (ácido ribonucleico mensajero), que lograron tasas de efectividad cercanas al 95 % para la prevención de la enfermedad COVID-19 grave. Los eventos adversos comunes son reacciones locales leves, pero ha habido varios informes de pacientes que desarrollaron tiroiditis subaguda y disfunción tiroidea después de recibir la vacuna contra SARS-CoV-2. Este artículo presenta dos casos de tiroiditis subaguda poco después de recibir la vacuna contra COVID-19

The SARS-CoV-2 coronavirus disease which emerged in 2019 (COVID-19), has forced the rapid development of vaccines to prevent the spread of infection and attempt to control the pandemic. Among the vaccines developed, one of the first to be approved with a new technology in the field of vaccination, was the mRNA (messenger ribonucleic acid) vaccine, with rates of effectiveness close to 95% for the prevention of severe COVID-19 disease. Common adverse events are mild local reactions, but there have been some reports of patients developing sub-acute thyroiditis and thyroid dysfunction after receiving the SARS-CoV-2 vaccine. This article presents two case reports of subacute thyroiditis shortly after receiving the COVID-19 vaccine

Tireotoxicose induzida pela amiodarona - revisão de literatura e atualização clínica / Amiodarone-induced thyrotoxicosis - literature review & clinical update

Resumo A amiodarona é amplamente utilizada no tratamento de arritmias atriais e ventriculares, porém devido sua alta concentração de iodo, o uso crônico da droga pode induzir distúrbios tireoidianos. A tireotoxicose induzida pela amiodarona (TIA) pode descompensar e exacerbar anormalidades cardíacas subjacentes, provocando aumento da morbidade e mortalidade, principalmente em pacientes com fração de ejeção do ventrículo esquerdo <30%. Os casos de TIA são classificados em dois subtipos que direcionam a conduta terapêutica. Os riscos e benefícios de manter a amiodarona devem ser avaliados de maneira individualizada, e a decisão de continuar ou suspender a droga deve ser tomada conjuntamente por cardiologistas e endocrinologistas. O tratamento de TIA tipo 1 é semelhante ao do hipertireoidismo espontâneo, sendo indicado o uso de drogas antitireoidianas (metimazol e propiltiouracil) em doses elevadas. A TIA tipo 1 mostra-se mais complicada, pois apresenta proporcionalmente maiores números de recorrências ou até mesmo a não remissão do quadro, sendo recomendado o tratamento definitivo (tireoidectomia total ou radioiodo). TIA tipo 2 é geralmente autolimitada, mas devido a elevada mortalidade associada a tireotoxicose em pacientes cardiopatas, o tratamento deve ser instituído para que o eutireoidismo seja atingido mais rapidamente. Em casos bem definidos de TIA tipo 2, o tratamento com corticosteroides é mais efetivo do que o tratamento com drogas antitireoidianas. Em casos graves, independentemente do subtipo, a restauração imediata do eutiroidismo por meio da tireoidectomia total deve ser considerada antes que o paciente evolua com piora clínica excessiva, pois a demora na indicação da cirurgia está associada ao aumento da mortalidade.

Abstract Amiodarone is widely used in treating atrial and ventricular arrhythmias; however, due to its high iodine concentration, the chronic use of the drug can induce thyroid disorders. Amiodarone-induced thyrotoxicosis (AIT) can decompensate and exacerbate underlying cardiac abnormalities, leading to increased morbidity and mortality, especially in patients with left ventricular ejection fraction <30%. AIT cases are classified into two subtypes that guide therapeutic management. The risks and benefits of maintaining the amiodarone must be evaluated individually, and the therapeutic decision should be taken jointly by cardiologists and endocrinologists. Type 1 AIT treatment is similar to that of spontaneous hyperthyroidism, using antithyroid drugs (methimazole and propylthiouracil) at high doses. Type 1 AIT is more complicated since it has proportionally higher recurrences or even non-remission, and definitive treatment is recommended (total thyroidectomy or radioiodine). Type 2 AIT is generally self-limited, yet due to the high mortality associated with thyrotoxicosis in cardiac patients, the treatment should be implemented for faster achievement of euthyroidism. Furthermore, in well-defined cases of type 2 AIT, the treatment with corticosteroids is more effective than treatment with antithyroid drugs. In severe cases, regardless of subtype, immediate restoration of euthyroidism through total thyroidectomy should be considered before the patient progresses to excessive clinical deterioration, as delayed surgery indication is associated with increased mortality.

Reconhecimento da paralisia periódica hipocalêmica tireotóxica na emergência: relato de caso e revisão da literatura / Recognizing thyrotoxic hypokalemic periodic paralysis on emergency settings: a case report and literature revie

A paralisia periódica hipocalêmica tireotóxica é uma complicação inusitada do hipertireoidismo, porém é considerada urgência endocrinológica e ainda frequentemente subdiagnosticada. Sua apresentação clínica consiste na tríade de défice de potássio, tireotoxicose e fraqueza muscular ­ sendo esse último sintoma comum em diversas patologias. Realizamos uma revisão bibliográfica e destacamos, por meio do relato de caso, a importância do diagnóstico precoce dessa doença, possibilitando uma evolução favorável ao paciente, independente de sua etnia, sexo ou região geográfica. Atentamos ainda ao tratamento da doença, que, apesar de sua simplicidade, acarreta muitos equívocos.

The thyrotoxic hypokalemic periodic paralysis is a rare complication of hyperthyroidism, but is considered an endocrinological urgency, and yet frequently underdiagnosed. Its clinical presentation consists of potassium deficit, thyrotoxicosis, and muscular weakness, with the latter symptom being very common in several pathologies. We performed a bibliographic review and highlight, through a case report, the importance of the early diagnosis of this disease to allow favorable progression to the patient, regardless of ethnicity, sex, or geographical region. We also reinforce the importance of the disease treatment which, despite its simplicity, leads to many mistakes.

Acute spontaneous suppurative thyroiditis caused by Eikenella corrodens presented with thyrotoxicosis / Tireoidite supurativa espontânea aguda causada por Eikenella corrodens acompanhada de tireotoxicose

ABSTRACT Acute suppurative thyroiditis is a very rare and life-threatening endocrine emergency. Thyrotoxicosis is a rare condition accompanying acute suppurative thyroiditis. While the majority of the cases in the literature are caused by different reasons, spontaneous development is very rare. We present a patient with acute suppurative thyroiditis who presented to our clinic with thyrotoxic findings, and we compared the case to the literature. A 31-year-old male patient was admitted to our clinic with a complaint of progressive neck pain, swelling and redness on midline neck, fever, and palpitations. On physical examination, swelling, redness and tenderness were detected on the neck region that was consistent with the thyroid location. He presented with tremor on the hands, tachycardia and agitation. Thyroid function tests were compatible with thyrotoxicosis, but there were findings supporting the presence of infection in biochemistry tests. On his radiological evaluations, a heterogeneous lesion divided with small septs was observed, with consolidation areas in the left thyroid lobe. In fine needle aspiration biopsy, 2mL of purulent fluid could be aspirated due to the presence of small, separated consolidation areas. He initiated on antibiotic therapy, propranolol, steroid and symptomatic treatment. Eikenella corrodens was detected on the culture antibiogram. Antibiotic therapy was continued for 14 days due to less symptoms and better biochemical values. After treatment, the patient had normal thyroid function, had relief of fever and redness of the neck, and was followed-up. It should be kept in mind that acute suppurative thyroiditis may develop spontaneously with the findings of thyrotoxicosis, with no risk factors.

RESUMO A tireoidite supurativa aguda é uma emergência endócrina muito rara e com risco de vida. A tireotoxicose é uma doença rara, que acompanha a tireoidite supurativa aguda. A maioria dos casos descritos na literatura tem diferentes causas, mas o desenvolvimento espontâneo é muito raro. Relatamos o caso de um paciente com tireoidite supurativa aguda, que veio a nossa clínica apresentando achados tireotóxicos, e o comparamos com a literatura. Trata-se de paciente do sexo masculino, 31 anos, que foi internado em nossa clínica com queixa de dor progressiva, edema e vermelhidão na linha média do pescoço, febre e palpitações. Ao exame físico, foram observados edema, vermelhidão e sensibilidade à dor na região do pescoço, consistente com a localização da tireoide. Apresentava tremor de mãos, taquicardia e agitação. Embora os exames de função tireoidiana fossem compatíveis com tireotoxicose, houve achados que sustentavam a presença de infecção nos exames bioquímicos. Nas avaliações radiológicas, observou-se lesão heterogênea dividida por pequenos septos, com áreas de consolidação no lobo tireoidiano esquerdo. Na biópsia por aspiração por agulha fina, foi possível aspirar apenas 2mL de líquido purulento, devido à presença de pequenas áreas de consolidação separadas umas das outras. Iniciaram-se antibioticoterapia, administração de propranolol e esteroides, além de tratamento sintomático. Eikenella corrodens cresceu na cultura do antibiograma. A antibioticoterapia foi estendida por 14 dias devido à melhora nos sintomas e dos valores bioquímicos. Após o tratamento, o paciente se apresentava eutireoideo, com melhora na febre e na vermelhidão no pescoço, sendo então acompanhado. Deve-se ter em mente que a tireoidite supurativa aguda pode se desenvolver espontaneamente com achados de tireotoxicose, sem nenhum fator de risco.

A dúvida: tireotoxicose versus hipertireoidismo descompensado / The doubt: Thyrotoxicosis X Decompensated Hyperthyroidism

Relata-se o caso de paciente do sexo masculino, atendido em um hospital universitário, após quadro duvidoso e arrastado de alteração cardíaca e hipertireoidiana, com a propedêutica sequencial própria para crise tireotóxica. Destaca-se a necessidade de identificação precoce da apresentação clínica, com atendimento de emergência, e a capacidade da realização de diagnósticos diferenciais com alterações cardíacas primárias, evitando-se sequelas e desfechos inesperados.

We report the case of a male patient seen in a University Hospital after a dubious and protracted picture of cardiac and hyperthyroid alteration, with adequate sequential propaedeutic for thyrotoxic crisis. The need for early identification of clinical presentation with emergency care, and the ability to perform differential diagnoses with primary cardiac changes are highlighted, to avoid unexpected sequelae and outcomes.

Mean platelet volume in Graves' disease: a sign of hypermetabolism rather than autoimmunity?

Objective: To evaluate the impact of mean platelet volume [MPV] on predicting disease course among patients with Graves1 disease [GD]

Methods: This retrospective study was performed between 2013-2016 at the Outpatient Endocrinology Clinic of Baskent University Faculty of Medicine, Adana hospital on 65 patients with GD. Among participants, 30 cases experienced thyrotoxicosis again during the first six months after discontinuing anti-thyroid drug [ATD] sessions that had been carried out for at least 12 months prior to stopping [Relapse group]. We also observed 35 patients who exhibited normal thyroid functions within six months following ATD withdrawal [Remission group] MPV levels and thyroid function tests were recorded and total duration of ATD therapy was calculated for all participants

Results: The mean MPV level that was measured at the time of drug withdrawal did not differ between groups, being 8.0+/-1.2 microl in the Relapse group vs. 8.0+/-1.0 microL in the Remission group [p=0.81]. However, we found that the relapse MPV was higher than the withdrawal MPV in the Relapse group [9.2+/-1.3 microL] than it was in the Remission group [8.0+/-1.2 microL, p=0.00]

Conclusions: Higher relapse MPV in Relapse group but similar MPV levels in both groups at ATD withdrawal may be attributed to hypermetabolism or hyperthyroidism rather than autoimmunity of GD

Tiroiditis subaguda con ausencia de captación cintigráfica unilateral inicial / Subacute thyroiditis with initial unilateralabsence of scintigraphic uptake

Subacute thyroiditis is a transient inflammatory process of the thyroid gland and the most common cause of painful thyroiditis. It usually involves the whole thyroid. We present a clinical case of a 45 years old woman developing tachycardia, fever and painful sensation in the left anterior cervical region after an upper respiratory tract infection. In addition the patient presented an enlarged and painful left thyroid lobe. Laboratory analysis demonstrated elevated acute phase reactants, high T4 levels and suppressed thyrotropin with absence of antithyroid antibodies. Thyroid scintigram showed an absent left radioactive iodine uptake. One month later the patient started with malaise, fatigue with an enlarged painful right thyroid lobe. A new scintigram showed complete absence of radioactive iodine uptake. A course of prednisone was initiated with excellent clinical response. Four months later the patient was asymptomatic with normal thyroid function.

Icterícia grave e miocardiopatia tireotóxica com trombo atrial / Serious jaundice and thyrotoxic myocardiopathy with atrial thrombus

Icterícia relacionada à tireotoxicose, e não como efeito das drogas antitireoidianas, é uma complicação rara que, em geral, ocorre na presença de insuficiência cardíaca (IC) ou hepatite. Apresentamos o caso de mulher de 54 anos de idade, branca, diagnóstico de hipertireoidismo por doença de Graves com icterícia associada a despeito da suspensão prévia de metimazol. A bilirrubina oscilava em valores elevados entre 30,0 e 52,3 mg/dL, as transaminases eram pouco elevadas com valores de ALT, na admissão, de 46 U/I e AST de 87 U/I; coagulograma e proteínas encontravam-se no limite inferior da normalidade, sendo TAP 68% e albumina = 2,5 g/dL. Sorologias para hepatites foram negativas. Após a primeira dose de radioiodoterapia (RT), a bilirrubina atingiu seu valor máximo, que coincidiu com período de pior exacerbação da IC. A bilirrubina normalizou-se após quatro semanas da segunda dose de RT com a estabilização da IC e a normalização dos hormônios tireoidianos. Discutimos as possíveis etiologias de icterícia severa em pacientes hipertireoideos, assim como a difícil terapia anticoagulante com varfarina.

Jaundice related to thyrotoxicosis and not as an effect of antithyroid drugs is a rare complication that usually occurs in the presence of heart failure (HF) or hepatitis. We report a case of a 54-year-old white woman with hyperthyroidism caused by Graves's disease and jaundice despite methimazole suspension. Bilirubin fluctuated at high values, between 30.0 and 52.3 mg/dL, transaminases were slightly increased, on admission ALT = 46 U/L and AST = 87 U/L; coagulation indices and serum proteins were on the lower limit of the normal range with PT 68% and albumin = 2.5 g/dL. Serology for hepatitis was negative. After the first radioiodine therapy (RT), bilirubin reached its maximum, which coincided with the worst period of HF exacerbation. Bilirubin normalized 4 weeks after the second RT, with the stabilization of HF and normalization of thyroid hormones. We discuss the possible etiologies of severe jaundice in hyperthyroid patients, as well as the difficult anticoagulant therapy with warfarin.

Importance of 99mTc-sestaMIBI thyroid scan in a case of amiodarone-induced thyrotoxicosis / A importância da cintigrafia tiroidea com 99mTc-sestaMIBI num caso de tireotoxicose induzida pela amiodarona

Amiodarone (AM)-induced thyrotoxicosis (AIT) is a condition with uncertainties from the diagnostic and therapeutic standpoints. A 54-year old male was referred to the hospital due to thyrotoxicosis. He had history of atrial fibrillation medicated with AM. No history of pre-existing thyroid disease was present, thyroid palpation revealed no goiter, and there were no signs of Graves' ophthalmopathy. Thyroid autoantibodies and thyroid-stimulating hormone receptor antibodies (TRABs) were negative. Thyroid and Doppler ultrasounds were normal. 99mTc-sestaMIBI thyroid scan (STS) showed uptake with rapid washout. AM therapy was discontinued, and combined therapy was started. After a long course of glucocorticoid and thionamides, the patient became euthyroid. It is necessary to distinguish between the types of AIT to decide whether or not continue AM treatment; after that, the appropriate therapy should be selected. STS was very important in the diagnosis of the type of AIT.

A tireotoxicose induzida por amiodarona (AIT) é uma condição incerta do ponto de vista de diagnóstico e tratamento. Um homem de 54 anos de idade foi encaminhado ao hospital devido à tireotoxicose. Ele apresentou um histórico de fibrilação atrial medicada com amiodarona (AM). Não havia histórico de doença da tiroide preexistente, a palpação da tiroide não revelou bócio e não havia sinais de oftalmopatia de Graves. Os autoanticorpos contra a tireoide e anticorpos para os receptores de hormônio estimulante da tireoide (TRABs) foram negativos. Os resultados do ultrassom da tiroide e do exame de Doppler foram normais. A cintigrafia da tiroide com 99mTc-sestaMIBI mostrou captação com rápida eliminação. O tratamento com AM foi descontinuado, e se iniciou a terapia combinada. Após um longo tratamento com glicocorticoides e tionaminas, o paciente se tornou eutiroide. É necessário distinguir entre os tipos de AIT para se determinar a continuação ou interrupção do tratamento com AM. Depois disso, o tratamento apropriado deve ser selecionado. A STS é muito importante no diagnóstico do tipo de AIT.

[Diagnosis and treatment of thyrotoxicosis during pregnancy and Lactation]

Poorly treated or untreated maternal overt hyperthyroidism may affect pregnancy outcome. Thyroid dysfunction and hyperthyroidism is present in about 0.3% and 2-3% of pregnancies respectively. Thyroid hyperfunction and hypofunction are more prevalent and usually go unrecognized. If thyroid dysfunction remained undiagnosed and has not been treated appropriately, would result in serious adverse pregnancy outcomes and treat both mother and her fetus. The aim of this review is to mention many aspects of hyperthyroidism in pregnancy and lactation in depth. Literature review was performed using MEDLINE between years 1960 and 2010, with the terms [Hyperthyroidism and pregnancy], [Anti-thyroid drug and pregnancy], [Radioiodine and pregnancy], [Hyperthyroidism and lactation], [Anti-thyroid drug and lactation], both separately and in conjunction with the terms [fetus], [neonate] and [maternal]. We selected proper study design of survey, case control and cohort studies, and clinical trials and review papers if the authors had at least four articles of their own in the list of references of review paper. The strategy used to search for articles was developed with the assistance of a research librarian. Antithyroid drugs are the main therapy of maternal hyperthyroidism during the lactation. All forms of antithyroid drugs can be used in pregnancy. As there are some reports regarding teratogenicity of methimazole [MMI], Propylthiouracil [PTU] is preferred in the first trimester and should be replaced by MMI after this trimester. Radioiodine is absolutely contraindicated for treatment of hyperthyroidism in pregnancy. Subtotal thyroidectomy in second trimester is indicated if hyperthyroidism is uncontrolled. MMI is the mainstay of the treatment of postpartum hyperthyroidism, in particular during lactation. Management of hyperthyroidism during pregnancy requires special considerations because maternal thyroid disease could have adverse effects on the mother, fetus and neonate

Bloqueo auriculo-ventricular de primer grado en tirotoxicosis aguda / First degree atrio-ventricular block in acute thyrotoxicosis

El cuadro clínico de la tirotoxicosis incluye síntomas cardiovasculares variados. La taquicardia sinusal es el trastorno electrocardiográfico más frecuente y los trastornos de conducción son extremadamente raros como modo de presentación. Comunicamos un caso de bloqueo aurículo-ventricular de primer grado en una paciente con hipertiroidismo recién diagnosticado y que comenzó días antes de la consulta con un cuadro general inespecífico. Su evaluación ulterior demostró que se trataba de una tirotoxicosis aguda autoinmune, y su tratamiento con metimazol corrigió el trastorno totalmente. Se discuten los mecanismos fisiopatológicos involucrados y las implicancias clínicas desde el punto de vista del internista.

Surgery versus pharmacotherapy of benign thyroid diseases

Surgical management of benign thyroid diseases [BTDs] has been a topic of interest and confusion for many years. Almost 80% of thyroidectomies at an average endocrine surgical unit are carried out for BTDs. Resistance to surgical intervention in BTDs has been based on the belief that increased complication rate is inherent in its use, this is despite the potential advantages in terms of confirming the benign nature of the lesion, controlling the disease, and relieving local symptoms of large neck mass. Benign thyroid diseases are more likely to occur in middle-aged women living in iodine deficient areas, or have a family history of goiter, or in patients taking iodine-containing drugs, like amoidarone, or in patients with previous history of x-ray exposure. However, the physician must be careful in making the diagnosis of BTDs in patients at the extremes of age or in the presence of positive history of radiation, or in patients with family history of thyroid or colon cancer. In this article we will review the etiology, epidemiology, diagnostic methodologies and the recent trends in the surgical and medical management of BTDs

Hipertiroidismo y su tratamiento / Hyperthyroidism and its treatment

El hipertiroidismo afecta el 0,5 a 1,0 por ciento de la población general, siendo 10 veces más frecuente en la mujer que en el hombre. El 85 por ciento de los casos corresponde a enfermedad de Basedow-Graves de naturaleza autoinmune. El 15 por ciento restante se debe a bocio multinodular y adenoma tóxico, tiroiditis de Quervain, etc. Hay casos iatrogénicos tales como los debido a administración de amiodarona. El cuadro clínico es una combinación de manifestaciones de tirotoxicosis, bocio y oculopatía y de compromiso muscular y cardíaco. El tratamiento consiste en administración de drogas antitiroídeas (propiltiouracilo); yodo radioactivo y/o resección quirúrgica según los casos

Tratamiento del hipertiroidismo por enfermedad de Basedow-Graves: visión retrospectiva al cabo de 30 años / Treatment of Basedow-Graves hyperthyroidism: retrospective analysis after 30 years

Background: It is still debated which is the best treatment for Basedow-Graves' hyperthyroidism (BGH). We reviewed 195 patients treated and followed-up during the past 30 years: 88 treated with propylthiouracil (PTU), 70 with 131I and 37 thyroidectomized Aim: to analyze the efficacy of each therapy in terms of achieving euthyroidism and the search of possible indexes for success. Surgery attained euthyroidism in 70.2 percent but has disadvantages; 131I accounted for the highest hypothyroid rate (72.1percent) irrespective of the dose administered; PTU alone was successful in only 26.4 percent but combined with T4, success rose to 62.5 percent (p < 0.025). Suppression test and/or TRAb measurements after 6 mo PTU therapy were used to decide if therapy continued or was changed to other form of treatment. Using this criteria, 87.5 percent of pts with positive results achieved longstanding euthyroidism. Pretreatment predictive indexes were goiter size, T4 levels and 24 h/RAI uptake. Conclusions: As 131I induces hypothyroidism in over 2/3 of pts and surgery besides its cost is not devoid of serious complications, we advocate for the use of PTU as first line therapy; combined treatment (PTU + T4) seems promising. If after 6 mo on PTU, TRAb or Suppression test do not improve, we recommend 131I or surgery

Disfunción tiroidea subclínica / Subclinical thyroid dysfunction

Con el advenimiento de técnicas ultrasensibles para medir la hormona tiroestimulante (TSH) es posible reconocer alteraciones subclínicas antes que desciendan o aumenten los niveles sanguíneos de hormonas tiroideas. Se revisan los conceptos actuales y la significación clínica tanto del hipotiroidismo como de la tirotoxicosis subclínica, así como su manejo terapéutico

Tratamiento de la tirotoxicosis / Treatment of thyrotoxicosis

En una serie de 53 pacientes operados por tirotoxicosis en los últimos ocho años se analizaron retrospectivamente: etiología, duración del tratamiento preoperatorio, indicaciones del tratamiento quirúrgico, operaciones más frecuentemente realizadas, complicaciones posoperatorias (sobre todo hipoparatiroidismo y parálisis de las cuerdas vocales), seguimiento con especial énfasis en las recidivas y el hipotiroidismo y por último la mortalidad. Se compararon estos datos con los suministrados por la bibliografía internacional. Se concluye en nuestra serie: 1. excesiva duración del tratamiento médico preoperatorio; 2. ausencia de recidivas de la tirotoxicosis pero alto porcentaje (72,7 por ciento) de hipotiroidismo en la cirugía de la enfermdad de Graves-Basedow; 3. morbilidad: hipoparatiroidismo 0, parálisis de una cuerda vocal 3,7 por ciento, 4. mortalidad 0

Lithium carbonate therapy for induction of euthyroid state in thyrotoxicosis. A preliminary study.

Lithium carbonate was tried in 27 patients with Graves' disease to induce euthyroid state. Each patient received 1200 mg of lithium carbonate in three divided doses. The study protocol included monthly monitoring of serum lithium, total serum T3, T4 and T3/T4 ratio, and a repeat radioactive iodine uptake (RAIU) at the end of three months. Twenty three patients completed the study. Of these, only 9 (39.1%) achieved euthyroid state, with a significant reduction in serum T3 and T4 but not in T3/T4 ratio and RAIU, suggesting a major effect of lithium on thyroid hormone release. No significant correlation was observed between serum lithium and circulating T3 and T4.