Disfunción tiroidea y trastornos del ánimo: revisión del estado del arte / Thyroid dysfunction and mood disorders: review of the state of the art

La relación entre función tiroidea y trastornos del ánimo se ha observado desde hace más de 50 años. Las hormonas tiroideas, actúan en el cerebro modulando génicamente proteínas asociadas a la fisiopatología de los trastornos del ánimo y potenciando los sistemas de neurotransmisión serotoninérgica y noradrenérgica. En el tratamiento de un episodio depresivo, la normalización de hormonas tiroideas es fundamental, y debe realizarse en todo paciente con sintomatología anímica, especialmente en aquellos con respuestas insuficientes a tratamiento, que requieren niveles de hormonas más estrictos que lo recomendado para población general. En pacientes eutiroideos, la potenciación con triyodotironina ha sido probada, pero también se ha utilizado T4 en altas dosis en casos resistentes, en que se postula que pudiese existir un estado de resistencia a hormonas tiroideas, no reflejado en los niveles hormonales periféricos evaluados rutinariamente. Las enzimas deiodasas, el receptor de hormona tiroidea, y el transportador de hormona tiroidea en la barrera hematoencefálica son blancos a investigar. Los objetivos de la presente revisión son ofrecer orientaciones respecto del uso de hormonas tiroideas en pacientes con trastornos del ánimo, una puesta al día sobre la relación entre hormonas tiroídeas y sistema nervioso central, y las interacciones entre psicofármacos y función tiroidea.

The relationship between thyroid function and mood disorders has been observed for more than 50 years. Thyroid hormones act in the brain genetically modulating proteins associated with the pathophysiology of mood disorders and potentiating the serotonergic and noradrenergic neurotransmission systems. In the treatment of a depressive episode, the normalization of thyroid hormones is essential, and should be performed in all patients with mood symptoms, especially in those with insufficient responses to treatment, which require more stringent hormone levels than recommended for the general population. In euthyroid patients, potentiation with triiodothyronine has been proven, but T4 has also been used in high doses in resistant cases, in which it is postulated that there might be a state of resistance to thyroid hormones, not reflected in the peripheral hormonal levels evaluated routinely. The enzymes deiodasas, the thyroid hormone receptor, and the thyroid hormone transporter in the blood brain barrier are white to investigate. The objectives of this review are to provide guidance regarding the use of thyroid hormones in patients with mood disorders, an update on the relationship between thyroid hormones and central nervous system, and the interactions between psychoactive drugs and thyroid function.

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

Selective screening for thyroid dysfunction in pregnant women: How often do low-risk women cease to be treated following the new guidelines of the American Thyroid Association?

ABSTRACT Objective: Universal screening for thyroid dysfunction in pregnant women is not recommended by the American Thyroid Association (ATA) or the American Association of Clinical Endocrinologists (AACE). This study evaluated the frequency of pregnant women that would have an indication for levothyroxine (L-T4) according to the new ATA/AACE guidelines among low-risk women without an indication for screening with TSH. Subjects and methods: The sample consisted of 412 pregnant women ranging in age from 18 to 30 years. These women were considered to be at low risk for thyroid dysfunction according to ATA/AACE and would not be candidates for screening with TSH. Anti-thyroid peroxidase antibodies (TPOAb) and TSH were measured. Women who had TSH > 2.5 mIU/L or TPOAb in the first trimester were submitted to subsequent evaluations in the second and third trimester. Results: In the first trimester, none of the pregnant women would have L-T4 therapy "recommended" and treatment would be "considered" in only two. In the second trimester, pregnant women with positive TPOAb or TSH > 2.5 mIU/L in the first trimester (n = 30) were reevaluated. L-T4 treatment would be "recommended" in only one woman and would be "considered" in two others. The 28 women that were not treated in the second trimester were reevaluated in the third trimester, but none of them would have L-T4 "recommended". Conclusion: The findings of the study suggest that selective screening, recommended by ATA/AACE does not result in a significant loss of pregnant women with an indication for L-T4 treatment.

Percutaneous ethanol injection versus conservative treatment for benign cystic and mixed thyroid nodules

ABSTRACT Objective To evaluate the efficacy and safety of percutaneous ethanol injection (PEI) in reducing the volume of cystic and mixed thyroid nodules. Materials and methods A total of 36 patients with nodules treated with PEI and 13 individuals who declined PEI and were followed clinically or received other non surgical treatment (control group). Assessments were performed at baseline (immediately before treatment in the PEI group or evaluation of the nodule on ultrasonography in the control group) at short-term (on average 30 days after the last injection in the PEI group), and long-term (on average 14 months after baseline in the PEI group or 26 months after baseline in the control group). Results In the PEI group, the mean baseline volume of 10.4 ± 9.8 cm3 reduced at short-term follow-up to 2.9 ± 3.1 cm3 (67.7 ± 19.9%, p < 0.001) and at long-term follow-up to 2.0 ± 2.5 cm3 (78.2 ± 19.5%, p < 0.01 versus baseline and p = 0.009 versus short-term follow-up). Both types of nodules showed similar degrees of reduction. In the control group, mean volume was 5.8 ± 3.4 cm3 at baseline and 6.2 ± 3.0 cm3 at long-term follow-up (p = 0.507). Compared with the control group, the PEI group showed larger reduction (p < 0.001). Conclusions PEI is effective in reducing the volume of cystic and mixed benign thyroid nodules, with sustained long-term efficacy and better outcome when compared with conservative therapies. Treatment with PEI is a safe alternative, with minimal, transient and self-limited adverse events.

Manejo perioperatorio de pacientes con patología tiroidea y tratamiento crónico con corticoides / Perioperative management in patients with thyroid disorders and chronic glucocorticoid therapy

Abstract Thyroid disorders and chronic use of corticosteroids are common in the surgical population, so is necessary an appropriate perioperative management of these patients. There is no contraindication for elective surgery in patients with asymptomatic hypothyroidism and good control, it is not necessary to maintain thelevothyroxine dose the day of surgery, due to the pharmacokinetic properties of the drug. If hypothyroidpatients are symptomatic and/or have not reached the euthyroid phase, should be treated and compensatedprior to the elective surgical procedure. Patients with hyperthyroidism should keep their antithyroid treatmentincluding the day of surgery. The symptomatic and/or decompensated hyperthyroidism have an increasedrisk of developing a thyroid storm, so no elective surgery is recommended in these patients, which should beconducted once achieved an euthyroid state. A strict monitoring in the postoperative period is key to preventcomplications. Chronic glucocorticoid use is common. In these patients there is risk of developing acute adrenal insufficiency by surgical stress, so before surgery (elective or emergency) it is necessary to supplementwith exogenous corticosteroid dose dependent on the type of surgical procedure performed.

Resumen Los trastornos tiroideos y el uso crónico de corticoides son frecuentes en la población quirúrgica, por lo que es necesario un manejo perioperatorio adecuado en este tipo de pacientes. No existe contraindicación para una cirugía electiva en pacientes con hipotiroidismo asintomáticos y buen control, no siendo necesario mantener la dosis habitual de levotiroxina el día de la cirugía, debido a las características farmacocinéticas del medicamento. Si los pacientes hipotiroideos se encuentran sintomáticos y/o no han alcanzado la fase eutiroidea, deben ser tratados y compensados previo al procedimiento quirúrgico electivo. Los pacientes hipertiroideos deben mantener su tratamiento antitiroideo incluso el día de la cirugía. En el hipertiroidismo sintomático y/o descompensado existe mayor riesgo de desarrollar una tormenta tiroidea, por lo que no se recomiendacirugía electiva en este tipo de pacientes, la cual debe realizarse una vez logrado un estado eutiroideo. Una estricta monitorización en el período postoperatorio es clave para prevenir complicaciones. El uso crónico degluco corticoides es frecuente. En estos pacientes existe riesgo de desarrollar insuficiencia suprarrenal aguda ante el estrés quirúrgico, por lo que antes de una cirugía (electiva o de urgencia) es necesario suplementar concorticoides exógenos, en dosis dependientes del tipo de procedimiento quirúrgico a realizarse.

Association between antiretrovirals and thyroid diseases: a cross-sectional study

Objective This study aims to estimate the prevalence of thyroid diseases and anti-TPO status. We searched for an association among presence of immune reconstitution and use of stavudine, didanosine and protease inhibitors with thyroid diseases. Materials and methods A cross-sectional study was performed to analyze the records of 117 HIV-infected patients who had their CD4+ cell count, viral load, anti-TPO, TSH and free T4 levels collected on the same day. Immune reconstitution was considered in those whose T CD4+ count was below 200 cells/mm3, but these values increased above 200 cells/mm3 after the use of antiretrovirals. The odds ratio obtained by a 2x2 contingency table and a chi-square test were used to measure the association between categorical variables. Results The prevalence of thyroid disease was 34.18%; of these, 4.34% were positive for anti-TPO. There was an association of risk between stavudine use and subclinical hypothyroidism (OR = 4.19, 95% CI: 1.29 to 13.59, X2 = 6.37, p = 0.01). Immune reconstitution achieved protection associated with thyroid disease that was near statistical significance OR = 0.45, 95% CI: 0.19 to 1.04, X2 = 3.55, p = 0.059. Conclusion The prevalence of thyroid disease in the sample studied was higher than what had been found in the literature, with a low positive anti-TPO frequency. The historical use of stavudine has an association of risk for the presence of subclinical hypothyroidism, and immune reconstitution has trends towards protection for the presence of thyroid diseases. .

Use of potassium iodide in Dermatology: updates on an old drug / Uso do iodeto de potássio na Dermatologia: considerações atuais de uma droga antiga

Potassium iodide, as a saturated solution, is a valuable drug in the dermatologist's therapeutic arsenal and is useful for the treatment of different diseases due to its immunomodulatory features. However, its prescription has become increasingly less frequent in dermatology practice. Little knowledge about its exact mechanism of action, lack of interest from the pharmaceutical industry, the advent of new drugs, and the toxicity caused by the use of high doses of the drug are some possible explanations for that. Consequently, there are few scientific studies on the pharmacological aspects, dosage and efficacy of this drug. Also, there is no conventional standard on how to manipulate and prescribe the saturated solution of potassium iodide, which leads to unawareness of the exact amount of the salt being delivered in grams to patients. Considering that dosage is directly related to toxicity and the immunomodulatory features of this drug, it is essential to define the amount to be prescribed and to reduce it to a minimum effective dose in order to minimize the risks of intolerance and thus improve treatment adherence. This review is relevant due to the fact that the saturated solution of potassium iodide is often the only therapeutic choice available for the treatment of some infectious, inflammatory and immune-mediated dermatoses, no matter whether the reason is specific indication, failure of a previous therapy or cost-effectiveness.

Iodeto de potássio, sob a forma de solução saturada, é um valioso medicamento no arsenal terapêutico do dermatologista. É usado há mais de um século e útil para doenças de fisiopatologias diversas em virtude de seu caráter imunomodulador. Prescrevê-lo, entretanto, tem se tornado cada vez menos frequente na prática dermatológica. O pouco conhecimento sobre seu exato mecanismo de ação, o desinteresse da indústria farmacêutica com o advento de novos fármacos, além da toxicidade do medicamento pelas altas doses utilizadas são algumas das possíveis justificativas. Dessa forma, os estudos científicos envolvendo seus aspectos farmacológicos, posológicos e de eficácia são relativamente raros. Consequentemente, não se convencionou uma padronização na forma de manipular e prescrever a solução saturada de iodeto de potássio, o que causa um verdadeiro desconhecimento da dose exata em gramas do sal que está sendo fornecida aos pacientes. Ao considerar que a dose está diretamente relacionada toxicidade e o conhecimento da característica imunomoduladora dessa droga, é importante definir a quantidade a ser fornecida, reduzindo-a até a dose mínima eficaz, de forma a diminuir a intolerância e melhorar a adesão ao tratamento. A relevância do tema se deve ao fato da solução saturada de iodeto de potássio ser, muitas vezes, a única escolha na terapêutica disponível para o tratamento de algumas dermatoses de origem infecciosa, inflamatória ou imunomediada, quer por indicação específica, por falha de outro medicamento ou por seu custo acessível.

[Unusual thyroid lesion]

The incidence of aspergillosis has increased during the past decade with the widespread use of aggressive chemotherapy and immunosuppressive agents. The lungs are the most common primary site of infection. Thyroid involvement is rare, usually asymptomatic, and difficult to make an ante-mortem diagnosis. Our aim is to discuss the epidemiological characteristics, the diagnosis and the histogenesis of this unusual thyroid lesion. Case report A 13-year-old girl, with a past history of lung disease was hospitalised for cervical pseudo-tumoral lesion. Cervical scintigraphy was taken and showed abnormal uptake in the thyroid. A resected specimen of the thyroid showed an extensive abscess with diffuse aspergillus hyphae infiltration. Treatment with amphotericine B was initiated and the evolution was unfavorable. Aspergillus infection frequently disseminates to a variety of organs, thyroid involvement is rare and its prognosis depends on early diagnosis and prompt initiation of therapeutic measures

Tiroides ectópico sublingual con hipotiroidismo: revisión de la literatura y caso clínico / Sublingual ectopic thyroid gland with hypothyroidism: clinical case and review of the literature

Las ectopias tiroideas son una patología poco frecuente pero de una trascendencia clínica importante por el papel que juegan las hormonas tiroideas en el desarrollo del niño. Por ello tanto el clínico como el médico nuclear y el radiólogo deben estar atentos a la hora de establecer el diagnóstico. El clínico por la necesidad de instaurar un tratamiento precoz, y los dos últimos por la necesidad de ser cautos a la hora de evaluar toda la zona en la que puede encontrarse el tiroides ectópico en un niño, es decir, es básico examinar con cualquiera de las técnicas disponibles desde la boca hasta el mediastino. Exponemos un caso visto en nuestro hospital.

Consenso colombiano para el diagnóstico y manejo de las enfermedades tiroideas

La asociación Colombiana de Endocrinología (ACE) con el ánimo de mejorar la información y práctica clínica relacionada con el doagnóstico y el tratamiento de las enfermedades tiroideas realizó una conferencia de consenso sobre este tema en el marco del XV Congreso Colombiano de Medicina Interna en octubre de 1998. Esta conferencia de consenso se basó en la metodología internacionalmente reconocida para este tipo de reuniones y creada por el Instituto Nacional de Salud de los Estados Unidos (NIH) en 1977 y reproducida luego por muchos otros países. La conferencia de consenso, como método de evaluación, tiene por objeto tratar de resolver un problema frente al cual existen posiciones controvertidas relacionadas con un procedimiento médico que busca mejorar la práctica clínica. Esta metodología se inspira, a su vez, en una reunión científica diseñada según el modelo parlamentario, en la que participan tres tipos de actores: Comité organizador, jurado y expertos. La diferencia sustancial con lo que se ha llamado "reunión de expertos", consiste en la existencia de un grupo de profesionales y algunas veces de pacientes que actuán como "jurado de conciencia" que son los llamados a tomar las decisiones y emitir las recomendaciones finales. Esta Conferencia se realizó de acuerdo con lo estipulado en las recomendaciones internacionales, según las cuales un grupo de expertos, mediante un programa previamente elaborado, presentó a la audiencia y al jurado sus puntos de vista sobre los diferentes tópicos relacionados, los cuales fueron discutidos ampliamente. El jurado eleboró luego las recomendaciones que son las que estamos presentando a la comunidad médica del país. La ACE cumpliendo con las funciones asignadas en sus estatutos, como son las relacionadas con la educaión y la asesoría en el diagnóstico y el manejo de las patologías endocrinológicas y consciente de la importancia que revisten las enfermedades tiroideas dentro del perfil epidemiológico del país, realizó esta conferencia de consenso. Esperamos que esta iniciativa se difunda par el beneficio de nuestros pacientes y de la comunidad en general y que, así mismo, el médico pueda ver facilitada y racionalizada su labor. Dejamos abierta la puerta para que en el futuro se lleven a cabo eventos similares sobre temas más específicos, tanto en patología tiroidea como en otros tópicos de la endocrinología.

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

Hormonios tireoidianos: sao ainda uteis no tratamento de bocios, nodulos e cistos de tireoide / Thyroid hormones: are they still usefull in the treatment of goiter, thyroid nodules and cysts

Os hormonios tireoidianos estao entre as drogas mais frequentes prescritas. Alem do tratamento do hipotireoidismo, sao utilizadas tambem em pacientes com bocios, nodulos e cistos tireoidianos. Revisam-se os novos conceitos patogeneticos dos bocios, que fundamentam o tratamento com hormonios tireoidianos. Descrevem-se estudos clinicos preliminares que avaliaram a eficacia terapeutica do emprego de hormonios tireoidianos na reducao de bocios e nodulos, assim como a prevencao de recorrencia de cistos aspirados e bocios operados. Analisam se tambem as evidencias de anormalidades fisiologicas e possiveis complicacoes relacionadas ao uso dos hormonios tireoidianos. Com base nestes dados, sao apresentadas recomendacoes para o uso dos hormonios tireoidianos no tratamento dos bocios, nodulos e cistos de tireoide

Diagnóstico y tratamiento del quiste de la glándula tiroides / Diagnosis and treatment of the cyst of the thyroid gland

Se presenta el resultado del diagnóstico y tratamiento de quistes tiroideos en una serie de 28 pacientes atendidos en las consultas de tiroides del Instituto Nacional de Endocrinología (INEN). El diagnóstico se realizó por ultrasonografís y se corroboró por biopsia aspirativa con aguja fina (BAAF). Los 28 quistes constituyen el 25 % de los nódulos tiroideos estudiados entre septiembre de 1988 y septiembre de 1989. Fueron identificados 16 casos como quistes verdaderos, todos con citología negativa de células neoplásicas (BAAF). De ellos, 4 casos recidivaron después de una segunda evacuación aspirativa y tratamiento con dosis supresivas de hormonas tiroideas. Los 12 casos restantes resultaron quistes complejos. La BAAF fue negativa de células neoplásicas por 2 ocasiones en 11 pacientes. En uno de los del grupo, la citología por segunda intención fue característica de un tumor papilar

Thyroid stimulating hormone receptor antibody in thyroid diseases.

Thyroid stimulating hormone receptor antibody (TRA) was estimated as a measure of TSH binding inhibitory immunoglobulin (TBII) in 48 persons. These included (i) 14 controls; (ii) 23 patients with Graves' disease who were tested for TRA within 3 months of commencing treatment with carbimazole of which 13 were studied serially; (iii) 5 patients with toxic nodular goitre; (iv) 4 with euthyroid exophthalmos; and (v) 2 neonates of thyrotoxic mothers. TRA was measured with an RIA system, while total thyroxine (T4), free thyroxine concentration (FTC) and TSH were also estimated along with TRA. All controls showed undetectable TRA levels; 87 per cent of patients with Graves' disease were TRA positive within 3 months of starting carbimazole therapy. In the serial study, 5 patients with Graves' disease who had undetectable TRA initially remained so while on treatment. Seven out of the remaining 8 patients showed a decline of TRA levels to normal over 3 to 18 months. This decline coincided with clinical and biochemical recovery.