|LETTER TO THE EDITOR
|Year : 2015 | Volume
| Issue : 1 | Page : 39-40
Pulmonary koch's unmasked by sick euthyroid state
Babul Reddy Hanmayyagari1, Mounika Guntaka2, Sridhar Batula3, Sreedevi Patnala4
1 Department of Endocrinology, Elite Endocrinology Clinic, Hyderabad, India
2 Department of Biochemistry, Prime Hospital, Kukatpally Housing Board Colony, Hyderabad, India
3 Department of Endocrinology, Mahatma Gandhi Memorial Hospital, Warangal, India
4 Department of Endocrinology, Gandhi Hospital, Secunderabad, Andhra Pradesh, India
|Date of Web Publication||18-Dec-2014|
Dr. Babul Reddy Hanmayyagari
Flat No-A 904, Sri Sai Ram Towers, beside Alwyn Colony, Water Tank, Hafeezpet, Hyderabad - 505 415, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Hanmayyagari BR, Guntaka M, Batula S, Patnala S. Pulmonary koch's unmasked by sick euthyroid state. Thyroid Res Pract 2015;12:39-40
|How to cite this URL:|
Hanmayyagari BR, Guntaka M, Batula S, Patnala S. Pulmonary koch's unmasked by sick euthyroid state. Thyroid Res Pract [serial online] 2015 [cited 2020 Aug 15];12:39-40. Available from: http://www.thetrp.net/text.asp?2015/12/1/39/147293
A 42-year-old female referred to endocrinology outpatient department with low T 3 -0.3 ng/ml (0.6-2.00), normal T (4) -8.0 μg/ml (5-12) and normal thyroid-stimulating hormone (TSH) - 3.2 miU (0.3-5.5). She denies any history of systemic illness, drug usage or psychiatric illness. On examination, her vitals and systemic examination were normal. The patient was asked to come to follow-up thyroid function test after two weeks, but persisting low T 3 was observed repeatedly for the next 3 months. Meanwhile patient developed easy fatigability and lost about 3 kg weight. Investigations: Complete Blood Profile (CBP) - Hemoglobin 10.2 gm% (11-15), red blood cell (RBC) count 4.25 millions/cumm (3.8-4.8), white blood cell (WBC) count 12,600 cells/cumm (4000-11000) with lymhocytosis (45%, platelet count 2.69 lakhs/cumm (1.5-4.0), erythrocyte sedimentation rate (ESR) 1 st hour - 80, blood urea 16.9 mg/dl (12-42), creatinine 0.59 mg/dl (0.6-1.1), random blood sugar (RBS) - 98 mg/dl (80-140). Chest X-ray was showing focal opacity in left-lower lobe. The patient was started on anti-tuberculosis drugs after the failure of empirical two weeks of antibiotic therapy. After six months of antitubercular therapy (ATT), thyroid profile became normal. [T (3) -0.96 ng/ml (0.6-2.00), T (4) -8.4 μg/ml (5-12), TSH 2.57 miU/ml (0.3-5.5)].
The sick euthyroid syndrome can be defined as abnormal findings on thyroid function tests that occur in the setting of a non-thyroidal illness (NTI), without pre-existing hypothalamic-pituitary and thyroid gland dysfunction. After recovery from NTI, the abnormal values of thyroid function test should be completely reversible. The sick euthyroid syndrome can occur in both acute and chronic illnesses. Cytokines play a crucial role in contributing to development of sick euthyriod syndrome.  Among the different cytokines studied, tumor necrosis factor-alpha (TNF-α) is perhaps the most promising and best-studied candidate for a mediator of euthyroid sick syndrome.
Tuberculosis is a common infectious disease in India with widespread occurrence. Tuberculosis can rarely affect the thyriod gland, the manifestations vary from a painless thyroid nodule and lymphadenopathy to a thyroid mass, thyroiditis (painful swelling) or as an acute or cold abscess with or without a discharging sinus. 
The functional thyroid disorders due to tuberculosis are distinctly uncommon, even though both hypothyroidism and thyrotoxicosis were reported, , sick euthyroid syndrome is more common in this category and its prevalence has been described in up to 92% of subjects in one of the series.  About 60% of subjects were reported to have low triiodothyronine (T3) level. Serum T3 levels also predicts mortality in sick euthyroid syndrome. 
So to conclude a persistent sick euthyroid state can be associated with underlying chronic systemic illness, as depicted in our case. Hence, a high index of suspicion and appropriate investigations are warranted in such scenario.
| References|| |
Rasmussen AK. Cytokine actions on the thyroid gland. Dan Med Bull 2000;47:94-114.
Magboo ML, Clark OH. Primary tuberculous thyroid abscess mimicking carcinoma diagnosed by fine needle aspiration biopsy. West J Med 1990;153:657-9.
Kapoor VK, Subramani K, Das SK, Mukhopadhyay AK, Chattopadhayay TK. Tuberculosis of thyroid gland associated with thryotoxicosis. Postgrad Med J 1985;61:339-40.
Khan EM, Haque I, Pandey R, Mishra SK, Sharma AK. Tuberculosis of the thyroid gland: A clinicopathological profile of four cases and review of the literature. Aust N Z J Surg 1993;63:807-10.
Post FA, Soule SG, Willcox PA, Levitt NS. The spectrum of endocrine dysfunction in active pulmonary tuberculosis. Clin Endocrinol (Oxf) 1994;40:367-71.
Chow CC, Mak TW, Chan CH, Cockram CS. Euthyroid sick syndrome in pulmonary tuberculosis before and after treatment. Ann Clin Biochem 1995;32:385-91.