Diagnosis and Treatment > Medication > Levothyroxine
You are looking at 81 - 86 of 86 items
Search for other papers by Mahmud Abo Salook in
Google Scholar
PubMed
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Search for other papers by Carlos Benbassat in
Google Scholar
PubMed
Search for other papers by Yulia Strenov in
Google Scholar
PubMed
Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
Search for other papers by Amit Tirosh in
Google Scholar
PubMed
Summary
A 55-year-old male, with a positive medical history for hypothyroidism, treated with stable doses for years was admitted with subacute thyroiditis and a feeling of pain and pressure in the neck. Laboratory tests showed decrease in TSH levels, elevated erythrocyte sedimentation rate, and very high antithyroid antibodies. Owing to enlarging goiter and exacerbation in the patient's complaints, he was operated with excision of a fibrotic and enlarged thyroid lobe. Elevated IgG4 plasma levels and high IgG4/IgG plasma cell ratio on immunohistochemistry led to the diagnosis of IgG4-mediated thyroiditis. We concluded that IgG4-thyroiditis and IgG4-related disease should be considered in all patients with an aggressive form of Hashimoto's thyroiditis.
Learning points
-
IgG4-related disease is a systemic disease that includes several syndromes; IgG4-related thyroiditis is one among them.
-
IgG4-thyroiditis should be considered in all patients with an aggressive form of Hashimoto's thyroiditis.
-
Patients with suspected IgG4-thyroiditis should have blood tested for IgG4/IgG ratio and appropriate immunohistochemical staining if possible.
Search for other papers by Despoina Manousaki in
Google Scholar
PubMed
Search for other papers by Cheri Deal in
Google Scholar
PubMed
Search for other papers by Jean Jacques De Bruycker in
Google Scholar
PubMed
Search for other papers by Philippe Ovetchkine in
Google Scholar
PubMed
Search for other papers by Claude Mercier in
Google Scholar
PubMed
Search for other papers by Nathalie Alos in
Google Scholar
PubMed
Summary
Cystic sellar lesions are a rare cause of hypopituitarism and extremely rare in the pediatric age group. The differential diagnosis is large and includes both primary pituitary abscesses and cystic components on pre-existing lesions, such as adenoma, craniopharyngioma, Rathke's cleft cyst, leukemia, granulomatous disease and lymphocytic hypophysitis. In the absence of a definitive diagnosis, treatment can be challenging. We report a case of a 15-year-old female, who presented with headaches, altered consciousness and diplopia after a molar extraction, for which she had received oral antibiotics. Broad-spectrum i.v. antibiotics were given for presumed meningitis. Blood cultures failed to identify pathogens. Cerebral magnetic resonance imaging showed a pituitary cystic lesion. Endocrine studies revealed abnormal pituitary function. In the absence of a therapeutic response, the patient underwent a transsphenoidal biopsy of the pituitary gland, which yielded a purulent liquid, but cultures were negative. Histopathology showed lymphocytic infiltrates but no neutrophils, compatible with an inflammation of autoimmune or infectious origin. High-dose glucocorticoid therapy was started and pursued, along with i.v. antibiotics, for 6 weeks, leading to clinical and radiological improvement but with persistence of endocrine deficits. In conclusion, this is a case of secondary panhypopituitarism due to a cystic pituitary lesion, with a differential diagnosis of lymphocytic hypophysitis vs abscess in a context of decapitated meningitis. Combination therapy with antibiotics and glucocorticoids is a legitimate approach in the face of diagnostic uncertainty, given the morbidity, and even mortality, associated with these lesions.
Learning points
-
It is not always easy to differentiate primary cystic sellar lesions (such as a primary infectious pituitary abscess) from cystic components on pre-existing lesions (such as adenoma, craniopharyngioma, Rathke's cleft cyst, leukemia or lymphocytic hypophysitis).
-
Because of the absence of specific symptoms and of immunohistochemical and serum markers, response to glucocorticoids can be the only way to differentiate lymphocytic hypophysitis from pituitary lesions of another origin. In addition, microbiological cultures are negative in 50% of cases of primary infectious sellar abscesses, thus the response to antibiotic treatment is often the key element to this diagnosis.
-
A short course of high-dose glucocorticoids combined with antibiotics is not harmful in cases where there is no diagnostic certainty as to the origin of a cystic sellar mass, given the morbidity and mortality associated with these lesions.
-
This approach may also diminish inflammation of either infectious or autoimmune origin while ensuring that the most likely pathogens are being targeted.
Search for other papers by Gerald J M Tevaarwerk in
Google Scholar
PubMed
Summary
Low triiodothyronine (T3) concentrations in the presence of normal thyroxine (T4) and TSH levels, referred to as the low T3 syndrome (LT3S), are common. LT3S may be caused by starvation, various non-thyroidal illnesses (NTIs) and some medications. Reverse T3 (rT3) concentrations are elevated in the more severely ill, and they characteristically fail to respond to exogenous levothyroxine (l-T4) therapy. The biochemical abnormalities have been explained on the basis of altered peripheral deiodinase activities. Herein, we report on two patients with hypothyroid symptoms who on testing were found to have LT3S. They were atypical clinically in not having LT3S due to any of the usual causes, had no increased rT3 concentrations, and had a normal negative TSH feedback response to l-T4. One (patient 1) had previously been diagnosed with Hashimoto's autoimmune primary hypothyroidism and was on l-T4 therapy. Both had T4 concentrations in the reference range. TSH levels were elevated in patient 1 and in the reference range in patient 2. Starting or increasing l-T4 doses resulted in no clinical improvement and no increase in T3 levels in spite of a marked increase in T4 levels. It is suggested that in the absence of the usual causes, lack of elevated rT3 levels, response to treatment and intact negative TSH feedback these two patients differ from the usual secondary causes of decreases in deiodinase activity. It is speculated that they may represent primary alterations in deiodinase enzymes possibly due to genetic variations in the deiodinase-encoding genes.
Learning points
-
LT3S is commonly found secondary to starvation, NTIs and use of some medications.
-
Low T3 levels are the result of alterations in the activity of deiodinase enzymes.
-
LT3S without the usual causes may represent a primary disturbance in deiodinase activity.
Search for other papers by Gemma Xifra in
Google Scholar
PubMed
Search for other papers by Silvia Mauri in
Google Scholar
PubMed
Search for other papers by Jordi Gironès in
Google Scholar
PubMed
Search for other papers by José Ignacio Rodríguez Hermosa in
Google Scholar
PubMed
Search for other papers by Josep Oriola in
Google Scholar
PubMed
Search for other papers by Wifredo Ricart in
Google Scholar
PubMed
CIBERobn, pathophysiology of obesity and nutrition, Spain
Search for other papers by José Manuel Fernández-Real in
Google Scholar
PubMed
Summary
Background: Thyroid hormone resistance (RTH) is a rare cause of thyroid dysfunction. High TSH levels, as described in RTH syndrome, are known to be associated with an increased risk of developing thyroid nodules with subsequent growth and malignancy.
Patient findings: In 2006, a 29-year-old Caucasian man presented with a palpable mass in the neck. Increased free thyroxine and triiodothyronine levels were found in the context of unsuppressed TSH levels, despite no signs or symptoms of hyperthyroidism. Ultrasonography revealed a multinodular and enlarged goitre, and fine-needle aspiration cytology revealed suspicious features of malignancy. After excluding pituitary tumour and levothyroxine (l-T4) treatment, the patient was diagnosed with generalized RTH. Screening for all the known mutations in thyroid hormone receptor-β (TR β (THRB)) was negative. Thyroidectomy disclosed five Hürthle adenomas and three hyperplasic nodules. Euthyroidism was achieved after surgery with 6.1 μg/kg per day of l-T4.
Conclusion: RTH may be a risk factor that predisposes to the development of multiple Hürthle cell adenomas. To our knowledge, this is the first case of multiple Hürthle cell adenomas in a patient with RTH.
Learning points
-
High TSH levels, as described in RTH syndrome, are known to be associated with an increased risk of developing thyroid nodules, with subsequent growth and malignancy.
-
The exact role of TR β mutants in thyroid carcinogenesis is still undefined.
-
We report the first case of multiple Hürthle cell adenomas associated with RTH.
Search for other papers by Pramila Dharmshaktu in
Google Scholar
PubMed
Search for other papers by Aditya Kutiyal in
Google Scholar
PubMed
Search for other papers by Dinesh Dhanwal in
Google Scholar
PubMed
Summary
A 21-year-old female patient recently diagnosed with severe hypothyroidism was found to have a large ovarian cyst. In view of the large ovarian cyst, she was advised to undergo elective laparotomy in the gynaecology department. She was further evaluated in our medical out-patient department (OPD), and elective surgery was withheld. She was started on thyroxine replacement therapy, and within a period of 4 months, the size of the cyst regressed significantly, thereby improving the condition of the patient significantly. This case report highlights the rare and often missed association between hypothyroidism and ovarian cysts. Although very rare, profound hypothyroidism that can cause ovarian cysts in an adult should always be kept in the differential diagnosis to avoid unnecessary ovarian surgery.
Learning points
-
Hypothyroidism should be considered in the differential diagnosis of adult females presenting with multicystic ovarian tumours.
-
Adequate thyroid hormone replacement therapy can prevent these patients from undergoing unnecessary and catastrophic ovarian resection.
-
Surgical excision should be considered only when adequate thyroid replacement therapy fails to resolve ovarian enlargement.
-
In younger women with ovarian cysts, it is also desirable to avoid unnecessary surgery so as to not compromise fertility in the future.
Search for other papers by Roghieh Molaei Langroudi in
Google Scholar
PubMed
Search for other papers by Fatemeh Ghazanfari Amlashi in
Google Scholar
PubMed
Search for other papers by Mohammad Hassan Hedayati Emami in
Google Scholar
PubMed
Summary
Background: Spontaneous ovarian hyperstimulation syndrome (sOHSS) can occur following hypothyroidism. Ultrasonography facilitates diagnosis and monitoring of this syndrome. We describe ovarian sonographic changes in a hypothyroid patient with sOHSS after treatment with levothyroxine (l-T4).
Case presentation: A 15-year-old girl presented with abdominal pain and distension for a few months. On examination, she had classical features of hypothyroidism. Abdominal and pelvic ultrasound revealed enlarged ovaries with multiple thin-walled cysts and mild ascitic fluid. On follow-up, abdominal ultrasound showed significant reduction of ovary size after 6 weeks of initiation of l-T4. Normal ovary size with complete regression of ovarian cysts was seen after 4 months.
Conclusion: Serial ultrasound in sOHSS associated with hypothyroidism showed regression of ovarian cysts and ovarian volume after 4 months whereas in other studies, it is reported to happen in various durations, presumably according to its etiology.
Learning points
-
OHSS can rarely occur due to hypothyroidism.
-
This type of OHSS can be simply treated by l-T4 replacement, rather than conservative management or surgery in severe cases.
-
Ultrasound follow-up shows significant regression of ovarian size and cysts within 6 weeks of initiation of l-T4.
-
Ultrasound follow-up shows normal ovarian size with complete resolution of ovarian cysts 4 months after treatment.