Serum irisin and apelin levels and markers of atherosclerosis in patients with subclinical hypothyroidism

ABSTRACT Objective: In this study, we aimed to evaluate serum irisin and apelin levels in patients with subclinical hypothyroidism (SCH) when they were subclinical hypothyroid and become euthyroid after levothyroxine therapy and association of these adipokines with markers of atherosclerosis such as serum homocysteine levels and carotid intima-media thickness (IMT). Subjects and methods: The study included 160 patients with newly diagnosed subclinical hypothyroidism due to Hashimoto's thyroiditis and 86 euthyroid healty subjects. Serum glucose and lipid profile, insulin, HOMA, TSH, free T3, free T4, anti-thyroperoxidase and anti-thyroglobulin antibodies, homocysteine, apelin and irisin levels were measured in all study subjects. Thyroid and carotid ultrasound examinations were performed. The subclinical hypothyroid group was reevaluated after 12-weeks of levothyroxine therapy when they became euthyroid. Results: Clinical characteristics of the patient and control group were similar. Glucose, insulin and HOMA levels, lipid parameters and free T3 were similar between the two groups.. Serum homocystein was higher and apelin was lower in patients with SCH, but irisin levels were similar between the two groups. While thyroid volume was lower, carotid IMT was significantly greater in patients with SCH (pCarotidIMT:0,01). After 12-weeks of levothyroxine therapy, all the studied parameters remained unchanged except, serum freeT4, TSH, homocystein and apelin. While homocystein decreased (p: 0,001), apelin increased significantly (p = 0,049). In multivariate analysis, low apelin levels significantly contributed to carotid IMT (p = 0,041). Conclusions: Apelin-APJ system may play a role in vascular and cardiac dysfunction in patients with SCH and treatment of this condition may improve the risk of cardiovascular disease.

Encefalitis autoinmunes: Un nuevo diagnóstico para una antigua enfermedad / Autoimmune encephalitis. New diagnosis for an old condition

Las encefalitis autoinmunes son un nuevo grupo de enfermedades de gran trascendencia clínica y terapéutica debido a la buena respuesta en gran parte de los casos a la terapia inmunomoduladora indicada, con un gran porcentaje de curación, sin secuelas neurológicas importantes (cognitivo, motor, crisis o movimientos involuntarios). En el año 2007 se demostró la presencia de auto anticuerpos neuronales en la patogenia de este grupo de enfermedades, con síntomas psicóticos y de movimientos involuntarios como indicadores de la enfermedad. La presente revisión enfatiza el salto crucial y el cambio de paradigmas suscitados tras el descubrimiento de estas encefalitis asociadas a anticuerpos.

Autoimmune encephalitis is a new group of diseases of great clinical and therapeutic importance due to the good response in most cases to the immunomodulatory therapy indicated, with a large percentage of healing without significant neurological effects (cognitive, motor, seizures or involuntary movements). Since 2007, the presence of neuronal autoantibodies in the pathogenesis of this group of diseases has been demonstrated, with psychotic symptoms and involuntary movements as clinical markers of the disease. The present review emphasizes the crucial leap and change of paradigms arising after the discovery of these encephalitis associated with antibodies.

Encefalopatía respondedora a corticoides asociada a tiroiditis autoinmune (SREAT). Una causa no habitual de compromiso de conciencia en pediatría, reporte de 2 casos / Steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT): an unusual cause of encephalopathy in children, report of two cases

Introduction: steroid responsive encephalopathy associated with autoimmune thyroiditis (SREAT) is a rare condition in children. The pathogenesis and etiology of SREAT has not yet been clearly identified. Clinical features include acute or subacute encephalopathy with neuropsychiatric symptoms, associated with abnormally elevated thyroid antibodies (TA) and symptoms improvement with corticosteroid treatment. Methods and Patients: we present 2 clinical cases; the first a 6 years 8 months male with cephalic myoclonic seizures and behavioral changes, the second a 12 years 10 months female with 4 hospitalizations for encephatlopathy, dystonia and psychomotor agitation. In both patients thyroid function tests and TA were compatible with Hashimoto’s thyroiditis, this associated with neuropsychiatric symptoms did raise the diagnosis of SREAT. Glucocorticoid therapy was started, the first case showed remission of seizures and behavioral improvement, however the second patient had insufficient response, so second line therapy with intravenous immunoglobulin was introduced with good response. This therapy was supplemented by additional long-term glucocorticoids use but when suspended both patients presented relapsing symptoms. Conclusions: Although SREAT is rarely suspected at presentation, it is necessary to consider this diagnosis in patients with encephalopathy, neuropsychiatric symptoms and elevated TA. Further studies are required to elucidate the pathophysiology of this disease and follow-up work to assess comorbidities and long-term complications in pediatric patients.

Clinical, biochemical & cytomorphologic study on Hashimoto’s thyroiditis.

Background & objectives: Despite, the extensive salt iodization programmes implemented in India, the prevalence of goiter has not reduced much in our country. The most frequent cause of hypothyroidism and goiter in iodine sufficient areas is Hashimoto’s thyroiditis (HT). This study records the clinical presentation, biochemical status, ultrasonographic picture and cytological appearance of this disease in a coastal endemic zone for goiter. Methods: Case records of patients with cytological diagnosis of HT were studied in detail, with reference to their symptoms, presence of goiter, thyroid function status, antibody levels and ultrasound picture. Detailed cytological study was conducted in selected patients. Results: A total of 144 patients with cytological proven HT/lymphocytic thyroiditis were studied. Ninety per cent of the patients were females and most of them presented within five years of onset of symptoms. Sixty eight per cent patients had diffuse goiter, 69 per cent were clinically euthyroid and 46 per cent were biochemically mildly hypothyroid. Antibody levels were elevated in 92.3 per cent cases. In majority of patients the sonographic picture showed heterogeneous echotexture with increased vascularity. Cytological changes were characteristic. Interpretation & conclusions: our study showed predominance of females in the study population in 21-40 yr age group with diffuse goiter. We suggest that in an endemic zone for goiter, all women of the child bearing age should be screened for HT.

Hashimoto encephalopathy: a rare intricate syndrome

Recently, several patients have been reported with various signs of encephalopathy and high thyroid antibody levels together with good responsiveness to glucocorticoid therapy. Despite the various clinical presentations, these cases have been termed "Hashimoto encephalopathy" [HE]. Although all of the pathogenic components have not yet been clearly elucidated, it is believed that brain vasculitis and autoimmunity directed against common brain-thyroid antigens represent the most likely etiologic pathway. The most common clinical signs include unexplained or epilepsy-like seizures resistant to anticonvulsive treatment, confusion, headaches, hallucinations, stroke-like episodes, coma, impairment of cognitive function, behavioral and mood disturbance, focal neurological deficits, disturbance of consciousness, ataxia, and presenile dementia, together with the presence of high thyroid antibody levels, especially against thyroperoxidase [TPOab]. In most cases, the thyroid function is normal or decreased; the thyroid function is rarely increased. The examination of the cerebrospinal fluid, EEG, MRI, SPECT, and neuropsychological examinations are primarily used as diagnostic tools. Most cases showed neural symptoms for months before the acute onset; in some cases, a dramatic acute onset was described. Once the diagnosis is made, corticosteroid treatment usually provides a dramatic recovery. The authors also present a short review of literary cases reported in last decade

Esquizofrenia y tiroiditis de Hashimoto: descripción de un caso clínico / Schizophrenia and Hashimoto’s thyroiditis: a clinical case

Se muestra la asociación entre trastornos psiquiátricos y disfunción tiroídea, mediante el estudio de un adolescente con esquizofrenia y tiroiditis de Hashimoto. Se trata de un varón de 15 años de edad, con bajo rendimiento escolar y desinterés por actividades sociales y académicas. Inicialmente cumple criterios DSM IV para trastorno depresivo y se inicia tratamiento antidepresivo. El cuadro empeora apareciendo sintomatología psicótica donde prima el empobrecimiento afectivo y social, presencia de un juicio de realidad alterado y conducta escindida y autista. Se indica Risperidona lo que tiene un efecto moderado sobre la sintomatología, por lo que se agrega Aripiprazol. Las pruebas tiroídeas inicialmente fueron normales, sin embargo la evaluación endocrinológica confirma una Tiroiditis de Hashimoto iniciándose tratamiento con tiroxina (T4). Posteriormente la sintomatología remite. Queda la duda del papel jugado por la disfunción tiroídea en este caso y se destaca la necesidad de una evaluación cuidadosa de la tiroides en pacientes psiquiátricos.

The following work intends to show the association between psychiatric disorders and thyroid dysfunction through a study of a teenager with schizophrenia disorder and Hashimoto thyroiditis. We present the case of a young male, fifteen years of age, with complaints of low performance at school, and loss of interest in social activities and academic affairs. At the beginning, the symptoms observed in the patient coincided with the DSM-IV criteria for Depression, and treatment with antidepressants was begun. However, the illness soon worsened, with the appearance of different psychotic symptoms, with diminished social interactions and affects, and also the presence of an altered judgment as well as an autistic and split behavior. Risperidone is then indicated having moderate effect on symptoms, so Aripiprazol was added to the treatment. Initially, thyroid tests were normal, but further endocrine evaluation confirms Hashimoto´s thyroiditis diagnosis, indicating thyroxine (T4) treatment, after which the symptoms subside. There remains the question of the role of thyroid dysfunction in this particular case and the necessity to a careful thyroid evaluation in psychotic patients.

Tiroiditis crónica de Hashimoto: Serie clínica / Hashimoto chronic thyroiditis: Retrospective analysis of 228 patients

Background: Chronic Hashimoto Thyroiditis (CHT) is the main cause of hypothyroidism. Aim: To report a series of patients with CHT. Material and Methods: Retrospective analysis of a series of 27 men aged 38 ± 14 years and 201 women aged 37 ± 16 years, evaluated in the private offces of two of the authors. Results: Fifty six percent of patients only had unspecifc symptoms at the moment of consultation, 50 percent had a family history of thyroid diseases and only 21 percent of women had a previous history of goiter. Eighty one percent of patients had clinical or subclinical hypothyroidism, 62 percent had both antithyroglobulin and antithyroid peroxidase positive antibodies and 13 percent had both antibodies negative. Only 1.4 percent of patients had a normal thyroid ultrasound examination. Patients were treated with levothyroxine at a mean dosage of 75 µg/day and 53 percent achieved an adequate TSH level. Six of ten patients operated due to nodules had a papillary carcinoma. Conclusions: CHT should be sought in the general population, especially those with a family history of thyroid disease. Thyroid ultrasound is seldom normal in patients with CHT. Thyroid substitution should be monitored periodically to achieve adequate TSH levels.

[Autoimmune thyroid disease. Clinical and biological correlations]

In this article, we analyze the clinical and biological data concerning the autoimmune thyroid diseases in patients recruited in an endocrinology clinic at the university hospital center of Hotel-Dieu de France between March 2005 and November 2005. We studied 121 patients [51 with Basedow disease and 70 with Hashimoto thyroiditis], between 13 and 68 years old, with a BMI of 24.68 kg/m[2] and with a female predominance [105 women]. Symptoms of hyperthyroidism represented the most frequent cause of consultation. The distribution of patients regarding their thyroid disease showed that 42.1% of patients had hyperthyroidism [only one patient had subclinical hyperthyroidism], 21.5% had a subclinical hypothy-roidism, 28.1% had clinical hypothyroidism and 83% had euthyroid goiter. Half of the patients had at least a member of their family whith a thyroid disease. The autoimmune thyroid diseases are strongly associated to other autoimmune diseases and to repetitive spontaneous abortion. Thus, 39% of the married women had had at least one spontaneous abortion and 26.4% of the patients had one or more autoimmune disease associated to their thyroid disease; diabetes mellitus type 1 representing the most frequent one. Concerning the treatment, we remarked a remission of 30 patients [66.7%] with Basedow disease after 18 months of anti-thyroid drug treatment of 45 patients. In Hashimoto thyroiditis, we remarked a frequent evolution of patients with subciinical hypothyroidism to overt hypothyroidism when medical treatment was not initiated

Hashimoto's encephalopathy [a review article]

Hashimoto's encephalopathy [HE] known as Steroid Responsive Encephalopathy associated with Autoimmune Thyroditis [SREAT] is a rare nervous system disease. HE was originally described by Brain, et. al. in 1966, however its cause still remains unknown after about 40 years. Autoimmune vasculitis of CNS, brain edema, and anti-thyroid antibodies are considered some of the etiologies for HE. It is certain that HE is an autoimmune disease and not a thyroid system disease. HE patients may or may not have goiter. Some of the most common neurological manifestations of HE include: Confusion with altered consciousness, seizures, myoloclonus, and cognitive problems. Presence of high titers of anti-thyroid antibodies in blood serum and CSF of HE patients is considered the most common laboratory test for diagnosis of HE. EEG abnormalities such as diffuse slowing and atypical tri-phasic brain waves are the most common findings in about HE patients. Brain CT-Scan is normal in majority of HE patients. Global or local hypo perfusion may be seen in SPECT scanning of the brain. MRI findings are abnormal in about 40% of HE patients. Patients with sub acute or acute onset of confusion, seizure, myoloclonus, stroke-like episodes and amnesia whose laboratory serum and CSF tests indicate presence of high titers of anti- thyroid antibodies should be considered for having HE. Vascular myelopathies, CJD, HSP, Myelinoclastic disease like PML, SSPE, ADE, MS and DNL are some of the differential diagnosis of HE. Adrenal corticosteroids are the first line treatment for HE. Recurrent or steroid resistant HE cases may be treated by addition of other immunosuppressant drugs such as Azathioprine, Cyclophosphamide, or Methotrexate to the 1st line therapy

Hipotiroidismo autoimune refratário a altas doses de levotiroxina e hipocalcemia grave / Autoimmune hypothyroidism nonresponsive to high doses of levothyroxine and severe hypocalcemia

Os fatores que dificultam a normalização do TSH no hipotiroidismo merecem atenção especial já que muitos pacientes em reposição de levotiroxina (LT4) encontram-se com TSH fora da faixa normal. Apresentamos uma paciente de 50 anos com quadro de hipotireoidismo autoimune de difícil compensação, associado à anemia, hipocalcemia severa, hipomagnesemia, alterações psíquicas e perda ponderal importante. Após a compensação do hipotiroidismo somente após 325æg/dia de levotiroxina, levantou-se a hipótese de alguma síndrome disabsortiva. Confirmado diagnóstico de doença celíaca através de dosagem de anticorpo anti-gliadina. Com instituição de dieta sem glúten houve melhora dos sintomas relacionados à disabsorção, assim como diminuição da necessidade de levotiroxina para 125æg/dia. Baseando-se em estudos que comprovam a maior prevalência de doença celíaca entre pacientes com desordens autoimunes da tiróide, tem sido proposto por vários autores a realização rotineira de screening para doença celíaca nesse grupo de pacientes.