Toxic Multinodular Goiter in a Patient with End-stage Renal Disease and Hemodialysis

The management of symptomatic hyperthyroidism in patients with end stage renal disease (ESRD) is challenging because of altered clearance of medications and iodine with dialysis; moreover, many patients meeting these criteria are medically fragile. A 77-year-old man with type 2 diabetes and ESRD requiring hemodialysis, with dilated cardiomyopathy and paroxysmal atrial fibrillation, was found to have subclinical hyperthyroidism. Over a 2-year period he became clinically hyperthyroid with serum TSH level of <0.05 mIU/L and free T4 level of 4.3 ng/dL, attributed to toxic multinodular goiter. Despite antithyroid medication, he developed rapid ventricular rate from his atrial fibrillation that resulted in decompensated heart failure and multiple hospitalizations. His hyperthyroidism was successfully controlled with high dose methimazole and potassium iodide treatment, which were eventually discontinued after prolonged use. Nearly 6 months off medications, his hyperthyroidism recurred but was readily resolved when methimazole was restarted. Hyperthyroidism in the medically fragile ESRD patient may precipitate emergent conditions. Antithyroid medications are effective and should be considered as primary therapy for the treatment of hyperthyroidism in patients with hemodialysis. Moreover, clinical guidelines for the characterization and management of individuals with ESRD and subclinical hyperthyroidism should be developed.     

小剂量碘131辅助抗甲状腺药物治疗甲亢的临床效果观察

目的观察小剂量碘131辅助抗甲状腺药物治疗甲亢的临床效果。方法选取2016年10月至2019年10月我院收治的甲亢患者100例,随机分为实验组(n=50)与对照组(n=50)。两组均采用甲巯咪唑治疗,同时实验组给予小剂量(平均剂量为2.90 MBq/g)碘131治疗,对照组给予常规正常剂量(平均剂量为4.45 MBq/g)碘131治疗,治疗周期均为2个月。比较两组的临床疗效,治疗前后甲状腺肿大率(GR)、甲状腺球蛋白(Tg)水平及治疗后甲状腺功能减退情况。结果实验组治疗总有效率为90.00%,高于对照组的74.00%(P<0.05)。治疗前,两组的GR、Tg水平比较无统计学差异(P>0.05);治疗后,两组的GR、Tg水平均降低,且实验组的GR、Tg水平低于对照组(P<0.05)。治疗后,实验组甲状腺功能减退率为8.00%,低于对照组的24.00%(P<0.05)。结论小剂量碘131辅助抗甲状腺药物治疗甲亢临床效果显著,可有效改善患者甲状腺肿大,降低Tg水平,减少甲状腺功能减退情况,值得临床推广。     

Thyrotoxic crisis in a patient with Graves' disease

A 33-year-old man presented with diarrhoea, dyspnoea, palpitations, fever and shock. One year and a half before admission, Graves'-hyperthyroidism had been diagnosed, for which he was treated with thiamazole and levothyroxine as block-replacement therapy. A diagnosis of thyrotoxic crisis, precipitated by lack of compliance with antithyroid drug therapy and possibly an underlying infection, was made. Euthyroidism was achieved with propylthiouracil, potassium iodide, corticosteroids and propranolol. However, the propylthiouracil had to be stopped due to agranulocytosis, after which hyperthyroidism recurred. An emergency thyroidectomy was then performed; the patient recovered completely. Thyrotoxic crisis is a rare, potentially life-threatening disease in patients with underlying un(der)treated hyperthyroidism. It is characterised by fever, tachycardia, and neurological and gastrointestinal symptoms.     

T3-thyrotoxicosis: incidence, significance and correlation with iodine intake

In a part of patients with thyrotoxicosis the serum triiodothyronine concentration increases only while free thyroxin level remains in the normal range (T3-thyrotoxicosis). This condition occurs in patients with untreated or treated thyrotoxicosis and in some other but rare thyroid disease, respectively. In this study occurrence and importance of T3-thyrotoxicosis were discussed. This form occurred in 11% of untreated thyrotoxicosis (53/480). The majority of patients suffering from T3-thyrotoxicosis have autonomous thyroid function (i.e. toxic uninodular and multinodular goiter: 45/53, 85%). In case of suppressed TSH and normal free thyroxin T3-thyrotoxicosis can be expected in 40% (53/140). The rate of free-triiodothyronin elevation is highest in Graves' disease with autoimmune origin. We consider the possibilities of development of triidothyronine increasing and the importance of iodine deficiency. Our patients are living in an area where mild iodine deficiency can be proved on the basis of decreased iodine excretion in urine. The results show the diagnostic importance of free-T3 determination.     

The surgical treatment of Graves' disease

A man aged 80 and three women aged 66, 26, and 39 years respectively, underwent surgery for Graves' disease. The first woman had pneumonia and experienced thyrotoxic storm. Euthyroidism was restored with antithyroid drugs (ATD) and thyroidectomy was performed as ablative treatment for hyperthyroidism. The man presented with thyrotoxicosis and had severe Graves' ophthalmopathy. After euthyroidism was restored with ATD, he underwent subtotal thyroidectomy. The second woman presented with severe thyrotoxicosis but was allergic to ATD. She was treated with iodine and beta-blockers after which subtotal thyroidectomy was done as an ablative procedure. Medical treatment for hyperthyroidism failed in the last patient and, as she had experienced severe psychological disturbances during a previous relapse, she too chose surgery as a definitive treatment option. In two patients the postoperative course was complicated by early hypocalcaemia and one of these patients experienced temporary recurrent laryngeal nerve paralysis. Surgery has a limited role in the treatment of Graves' disease. In pregnant women with severe ATD-resistant thyrotoxicosis, surgery is the only treatment option, while in patients with Graves' orbitopathy surgery may be preferable because of its neutral and perhaps even beneficial effects on eye symptoms. Large goitre size and thyroid nodules are concomitant reasons for choosing surgery, as are allergy to ATD and patients' preference. Lastly, in patients who have suffered from severe thyrotoxicosis, surgery provides rapid and definitive treatment. Early morbidity following surgery is common and should be discussed with the patient.     

Thyrotoxicosis in Ethiopian patients—a prospective study

Forty-six cases of thyrotoxicosis, 8 males and 38 females, were seen over a period of two years from March 1979. There were 19 cases of toxic multinodular goitre, 22 of Graves' disease, four of toxic adenoma and one of subacute thyroiditis. The median age of those with toxic multinodular goitre was 49 and of those with Graves' disease was 30 years. The five most common symptoms were sweating/heat intolerance (82 · 6%), weight loss (82 · 6%), palpitations (82 · 6%), nervousness and irritability (73 · 9%) and insomnia (69 · 6%). Six of 24 non-pregnant females of child-bearing age had menstrual disturbances. The five most common signs were goitre (97 · 8%), tachycardia (100 · 0%), sweating (84 · 7%), and fine finger and tongue tremors (89 · 1%). Among the 22 cases of Graves' disease, 13 (59 · 1%) had exophthalmos and 4 (18 · 2%) had pretibial myxoedema. Treatment with propylthiouracil or carbimazole was effective in controlling the thyrotoxicosis. Granulocytopenia developed in two cases and skin allergy in one other, necessitating use of alternative treatment. Seven cases had subtotal thyroidectomy after preparation with antithyroid drugs or propranolol and Lugol's iodine.     

Hyperthyroidism

Although the classical presentation of hyperthyroidism is known from the nineteenth century, the mindful evaluation of the clinical symptoms is indispensable for the practitioner physician. The clinical picture depends on the etiology of hyperthyroidism, the gender and age of the patient. The methods for the laboratory diagnosis of hyperthyroidism have outstanding accuracy, the supersensitive TSH, free thyroxine and triiodothyronine determinations are generally available. The etiology of hyperthyroidism was broadened by new diseases: gestational hyperthyroidism caused by human choriogonadotropin and the group of congenital non-autoimmune hyperthyroidism due to TSH receptor mutations were discovered. The iodine-induced hyperthyroidism, which is an everyday problem due to the widespread use of amiodarone treatment, is also better characterized. The role of different treatment modalities in the therapeutic algorithm was established, the part of surgery decreased. The optimal duration and dose of drug treatment in Graves' disease is still questionable in the lack of good evidence, nowadays one and half year of antithyroid treatment is generally recommended. The reduction of relapse rate below 50% after the discontinuation of antithyroid drug was unsuccessful, risk factors are the large goiter, elevated level of the TSH receptor antibodies, in certain studies the male gender and young age. Due to the high relapse rate, the radioiodine treatment is preferred, even as a primary therapy. In case of toxic adenoma, toxic multinodular goiter and congenital non-autoimmune hyperthyroidism the medical treatment cannot result in permanent cure, therefore primary ablative treatment is required. The chances of patients with hyperthyroidism for the complete recovery are excellent, however, long time follow-up is necessary.     

Thyrotoxicosis among Hanford,Washington, Downwinders: a community-based health survey

Sixty cases of thyrotoxicosis (including hyperthyroidism, Graves' disease, and toxic goiter), an unexpectedly large number compared with general population data, were reported in a voluntary health survey that included a period of approximately 50 yr, with 801 self-defined "Downwinders" who had lived near the Hanford, Washington, nuclear facility. In another self-selected group of medical patients (n = 423) who were examined over the same time period, only 2 cases of thyrotoxicosis were identified. Evidence is presented that suggests that the effects of bias from self-selection likely did not account for the magnitude of the apparent excess of thyrotoxicosis cases in the present study population. The findings are consistent with those of other studies, as well as with the hypothesis of an association of thyrotoxicosis with exposures to radioiodine.     

Thyrotoxicosis among Hanford,Washington, Downwinders: A Community-Based Health Survey

Sixty cases of thyrotoxicosis (including hyperthyroidism, Graves' disease, and toxic goiter), an unexpectedly large number compared with general population data, were reported in a voluntary health survey that included a period of approximately 50 yr, with 801 self-defined “Downwinders” who had lived near the Hanford, Washington, nuclear facility. In another self-selected group of medical patients (n = 423) who were examined over the same time period, only 2 cases of thyrotoxicosis were identified. Evidence is presented that suggests that the effects of bias from self-selection likely did not account for the magnitude of the apparent excess of thyrotoxicosis cases in the present study population. The findings are consistent with those of other studies, as well as with the hypothesis of an association of thyrotoxicosis with exposures to radioiodine.     

Graves' ophthalmopathy: diagnosis and highlights on etiopathogenesis and treatment

It's due to extraocular tissues enlargement: extraocular muscles. Thyroid stimulating receptor antibodies were first incriminated. However, Graves' proptosis can appear several months or years before development of goiter or thyrotoxicosis. Different treatment are possible: glucocorticoids, radiotherapy, surgical orbitary decompression, classical surgery. Treatment of hyperthyroidism has to be undertaken similarly. Classically, surgical or medical treatment with antithyroid drugs were indicated.     

Severe iodine deficiency in southern Albania

Albania does not yet have a national program for control of iodine deficiency and there are no recent data on the severity of the iodine deficiency disorders (IDD) in the country. The aim of the present study was to assess current IDD status in southern Albania. In primary school children in urban and rural areas urinary iodine concentration (UI) and iodine concentration in salt at retail and household levels was measured. Goiter was graded by palpation and thyroid volume determined by ultrasound. Children aged 5-14 yr (n = 826) were sampled at 2 urban and 5 rural primary schools. In the 2 urban schools, the median UI was 45 micrograms/L, the goiter prevalence was 32%, and salt iodine levels were inadequate (< 15 micrograms/g) in 78% of household salt samples. In the rural schools, the median UI was 17 micrograms/L, the goiter prevalence was 95%, and no household salt samples were adequately iodized. Among children in the rural schools, 73% had grade 2 goiter and 20% had nodular changes detected by thyroid ultrasound. In southern Albania, school children in urban areas are moderately iodine deficient and those in rural villages are severely iodine deficient. These findings suggest that regional distribution of oral iodized oil capsules is indicated to control IDD in vulnerable groups until salt iodization is implemented.     

Goitre prevalence and the state of iodine nutrition in the sundarban delta of north 24-parganas in West Benegal

The main objective of this study was to assess the iodine nutritional status among school children (6-12 yrs) of Sundarban delta in North 24-Parganas district of West Bengal in eastern India. A total of 2050 children were clinically examined for goiter and 240 urine samples were analyzed for iodine and thiocyanate respectively; iodine content in 48 water samples and 210 salt samples were also measured. Results indicate that the studied region is clinically severely goiter endemic having goiter prevalence 33.1 % (grade 1: 30.4 %; grade 2: 2.7%),median urinary iodine level 200 mug/l indicating no biochemical iodine deficiency, 65.2 % salt samples contain recommended level of iodine and the iodine content in drinking water is sufficient while mean urinary thiocyanate level was 0.708+/-0.38 mg/dl. In spite of the consumption of adequate iodine, the existing goiter prevalence may be for the consumption of dietary goitrogens/antithyroid substances that possibly come through food and water.     

碘摄入量增加后甲状腺疾病发病率的变化

目的观察食用碘盐应用前后甲状腺疾病谱的变化.方法采用问卷形式自1999年8月中旬至12月底共调查宝钢集团26010人.结果①1990年1月1日至1999年7月31日确诊的甲状腺疾病患者共310例,其中食盐加碘后3年半内新发病183例,较前6年明显增多.②甲状腺疾病谱构成发生了明显改变,主要表现在甲状腺功能亢进(甲亢)、单纯性甲状腺肿大及甲状腺结节(B超检查)患者明显增多.尽管甲状腺结节的发病率仍高居第一位,但甲亢的发病率由补碘前的第五位上升至第二位.③近10年新确诊的甲亢患者55例,其中39例补碘后发病,占70.91%;补碘后甲亢平均发病率为36.87/10万人年±5.40/10万人年,较前增加3倍;补碘后当年甲亢发病率即开始明显升高,1997年最高,以后仍维持在较高水平;补碘后各年甲亢发病相对危险度均有不同程度的升高.结论随着食用碘盐的应用,调查人群甲状腺疾病患者明显增多,甲状腺疾病谱构成也发生了明显改变,尤其是甲亢发病率明显增高,与碘摄入量增多明显相关.但补碘后各种甲状腺疾病发病率变化的最终模式仍有待进一步观察.     

丙硫氧嘧啶联合曲安西龙治疗AITD伴甲状腺功能亢进症的疗效分析

[目的]探讨丙硫氧嘧啶联合曲安西龙治疗AITD伴甲状腺功能亢进症患者的临床疗效。[方法]运用随机数字表法将2006年9月～2011年9月在某院内分泌科住院治疗的86例AITD伴甲状腺功能亢进症患者分为丙硫氧嘧啶组和丙硫氧嘧啶联合曲安西龙组,每组各43例,4月后再次检测AITD伴甲状腺功能亢进症患者的血清游离甲状腺素(FT4)、血清游离三碘甲状腺原氨酸(FT3)、血清促甲状腺激素(TSH)、血清甲状腺过氧化酶抗体(TPOAb)和甲状腺球蛋白抗体(TGAb)的含量评价其临床治疗效果。[结果]治疗前,丙硫氧嘧啶组和丙硫氧嘧啶联合曲安西龙组AITD伴甲状腺功能亢进症患者的血清学指标FT3、FT4、TSH、TPOAb和TGAb差异无统计学意义(P﹥0.05),治疗后,丙硫氧嘧啶联合曲安西龙组AITD伴甲状腺功能亢进症患者的TSH较丙硫氧嘧啶组AITD伴甲状腺功能亢进症患者上升明显,而丙硫氧嘧啶联合曲安西龙组AITD伴甲状腺功能亢进症患者的FT3、FT4、TPOAb和TGAb较丙硫氧嘧啶组AITD伴甲状腺功能亢进症患者下降明显(P﹤0.05)。[结论]丙硫氧嘧啶联合曲安西龙用于治疗AITD伴甲状腺功能亢进症患者,能有效降低AITD伴甲状腺功能亢进症患者的血清FT3、FT4、TPOAb和TGAb的水平,抑制AITD伴甲状腺功能亢进症患者甲状腺的免疫反应,阻止AITD病情的进一步发展,在临床治疗AITD伴甲状腺功能亢进症患者过程中可推广应用该治疗方案。     

Long term thyroid function after (131)I treatment for toxic adenoma

Radioactive iodine is a widely used treatment for hyperthyroidism caused by solitary autonomously functioning thyroid nodule (toxic adenoma). The aim of this retrospective analysis is to report the long term effects of this therapy on the thyroid function of patients with toxic adenoma treated in our department. Between 1968 and 1996, 160 patients received a single dose of (131)I (range 25-40 mCi) for hyperthyroidism caused by toxic adenoma. In 126 of these (110 females, 26 males), follow-up was feasible either in our Endocrine Outpatient Clinic or through correspondence. The mean observation period was 5.3 years (range 1-21 years, median 4.0). Post treatment evaluation revealed that: a) 57 patients became euthyroid and remained free of disease up to the last visit (mean observation period 5.76+/-0.52 years, range 1-21 years, median 5 years), b) 69 patients developed hypothyroidism, all within 1 to 12 months (5.9+/-0.49 months), c) persistence or recurrence of the disease (ie. thyrotoxicosis) was not observed, d) the (131)I dose, or the (131)I pretreatment TSH levels were not different between patients who developed hypothyroidism and those who became and remained euthyroid. CONCLUSION: 131I administration in the above-mentioned dose to patients with toxic adenoma: a) was a safe and very effective therapy, and b) led to hypothyroidism which developed within the first year after (131)I administration in 55% of the patients.     

甲巯咪唑和丙硫氧嘧啶治疗甲亢不良反应临床对比

目的：比较甲硫咪唑与丙硫氧嘧啶治疗甲亢的不良反应发生率和临床安全性。方法：回顾性分析本院收治的36例甲亢患者,随机分为甲硫咪唑治疗组（MMI组）和丙硫氧嘧啶治疗组（PTU组）各18例,观察并比较两组临床安全性和预后不良反应的发生情况。结果：治疗后,MMI组引起的白细胞减少、红细胞减少、血小板减少及皮疹的发生率分别为22．2％、11．1％、5．6％、16．7％,均显著高于PTU组（依次分别为5．6％、0、0、5．6％）（P〈O．05）;MMI组引起的ALT、ALP、TBIL、和DBIL异常发生率为5．6％、0、0、0,均低于PTU组（11．1％、5．6％、5．6％、5．6％）,MMI组肝功能损伤发生率为5．6％,显著低于胛u组（27．8％）（P〈0．05）。结论：在甲亢的治疗过程中,不同药物有不同的副作用,MMI易引起的血细胞减少及皮疹等,而P1’u易引发肝功能损伤。     

One-year follow-up of Graves' disease treatment by four different protocols of radioiodine administration

BACKGROUND: Studies have been performed in order to assess a treatment with 131I able to induce a consistent improvement in Graves' hyperthyroidism. METHODS: Experimental design: For this purpose, four different protocols based on four different doses of radioiodine have been tested in Graves' disease patients. Patients never submitted previously to antithyroid drug treatment were given 1 mCi/10 gm of the estimated thyroid weight (group I; n = 50). Group II (n = 48) included patients not previously treated with antithyroid drugs and who were given doses of iodine based on a formula taking into account the rate of thyroid iodine uptake, i.e. 131I dose = microCi/gm of the estimated thyroid weight x 100/24 hrs 131I uptake (%). Patients previously submitted to antithyroid drug therapy were treated with radioiodine whose dose was calculated according to the formula reported above, but the dose was increased in order to overcome the possible resistance of this kind of patients to the effect of 131I. One group (group III; n = 24) received the calculated dose plus 1 microCi/gm of the estimated thyroid weight. Finally, group IV (n = 27) received the calculated dose plus 0.25 microCi/gm of the estimated thyroid weight. RESULTS: The analysis of the patients one year later demonstrated that groups I and II presented the higher percent of euthyroid patients (60% and 58%, respectively) followed by group IV (37%) and group III (29.2%). The percent of patients still exhibiting hyperthyroidism was 28% in group I, 26% in group IV, 12.5% in group III and 8.3% in group II. The highest number of hypothyroid patients was present in group III (58.3%) followed by group IV (37%), group II (33.3%) and group I (12%). CONCLUSIONS: The data here presented suggest that protocols I and II based on relatively low doses of radioiodine are rather effective in reducing Graves' hyperthyroidism in patients not submitted previously to antithyroid drug therapy. The most satisfactory therapy seems that utilized in protocol II, that in front of a fair amount of euthyroid patients (58.3%) presents a very low number of subjects still hyperthyroid (8.3%). However, the number of patients who became hypothyroid (33.3%) as a consequence of the therapy was too high. Hopefully, a better design of the protocol will reduce this figure. The high incidence of hyperthyroidism observed in groups III and IV submitted to a therapy with 131I doses consistently higher than those utilized in groups I and II seems to confirm the hypothesis that hyperthyroid subjects submitted to a therapy with antithyroid drugs become rather resistant to a radioiodine treatment.     

常州地区食盐加碘对人群甲状腺疾病谱的影响评估

目的以碘缺乏纠正状况和住院甲状腺疾病谱的变化对全民食盐加碘有关影响作出评估。方法对人群作碘营养状况与甲状腺肿调查,甲状腺疾病住院病历采用回顾性研究方法搜集。结果居民合格碘盐食用率达95％以上。社区居民甲状腺疾病年住院率暂时性上升最高达54．5／10万,住院甲状腺疾病占总疾病比重亦呈暂时性上升,女性和≥40岁组是受影响的主要人群,甲状腺功能亢进症占甲状腺疾病的比例由平均13．6％增加到34．7％。结论全民食盐加碘消除碘缺乏病的同时其他影响客观存在,碘缺乏的纠正所产生的效益远远超过其他影响的损失。     

Occupational thyroid disease

Summary A case of thyrotoxicosis due to the occupational exposure to cosmetics in a 35-year-old beautician is reported. The hormonal pattern was consistent with exogenous thyroid hormone administration, but not with iodine hyperthyroidism. The patient denied she was using thyroid hormones; also, she lacked the typical features of patients with thyrotoxicosis factitia. Her occupational history was carefully reviewed: A heavy exposure of the unprotected skin to cosmetic creams containing iodine, thyroid hormones, and thyroid extracts had occurred in the previous months. The patient was advised to refrain from the exposure, and a persistent remission of thyrotoxicosis was observed thereafter. This case suggests that percutaneous absorption of thyromimetic substances though never described before, may occur in an occupational setting. We advise that such cosmetics be handled with care, not only by patients with thyroid disease but by euthyroid subjects as well; close medical surveillance over the use of such preparations seems appropriate.     

Factors affecting sustainable iodine deficiency elimination in Pakistan: A global perspective

Iodine deficiency remains a considerable challenge worldwide, even after decades of efforts to address the problem. The aim of this review is to present the current situation in historically iodine-deficient Pakistan regarding iodine nutritional status and place it in a global perspective. We collected relevant articles from online bibliographic databases and websites of concerned organizations that addressed prevalence of goiter/iodine deficiency and barriers to sustainable control. We divided the studies into pre- and post-1994, a landmark year when Pakistan formally adopted the universal salt iodization (USI) programme. Overall, 56 studies reported goiter/iodine deficiency prevalence in Pakistan. Before 1994, six studies (30%) reported a goiter prevalence ≥70%, while nine studies (45%) reported a goiter prevalence between 30% and 70%. Only five studies (25%) found a goiter prevalence less than 30%, of which only two studies reported prevalence <10%. From 1994 onwards, 15 studies (41.7%) reported a goiter/iodine deficiency (ID) prevalence ≥50%, of which seven studies reported prevalence ≥70%, while three studies (8.3%) found a goiter prevalence of 30%–49%, nine studies (25%) found a goiter prevalence of 10%–29%, and five studies (13.9%) reported prevalence of <10%. Four studies (11.1%) reported lower goiter prevalence but higher prevalence of iodine deficiency. The efforts in the past two decades resulted in up to a 50% decline in iodine deficiency disorders (IDD). Variable remaining factors and the recent results, however, indicate that this decline may be non-uniform and even over-estimated. Coordinated and regionally adopted efforts for eradication of IDD from all stakeholders should be pursued. Policy makers should take steps to protect future generations and alert concerned organizations about the importance of careful assessments and estimates of iodine nutritional status.