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   Table of Contents - Current issue
Coverpage
September-December 2018
Volume 15 | Issue 3
Page Nos. 101-148

Online since Thursday, November 15, 2018

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EDITORIAL  

Indian Thyroid Society – Journey so far and path ahead p. 101
KM Prasanna Kumar
DOI:10.4103/trp.trp_50_18  
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COMMENTARY Top

Trimester-specific reference interval for thyroid function test in pregnancy: A review of data from Asia and Africa p. 103
Om J Lakhani, Milind Patil
DOI:10.4103/trp.trp_21_18  
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ORIGINAL ARTICLES Top

Trimester-specific thyroid hormone dynamics, iodine reserve, and pregnancy outcomes: A longitudinal study p. 105
Nikku Yadav, Atul Kathait, Dharmpal S Malik, Madanjeet Kaur Pasricha, Sunil Kumar Mishra, Asha Chandola-Saklani
DOI:10.4103/trp.trp_23_18  
Background: Iodine is an integral constituent of thyroid hormones, and the physiological changes during pregnancy affect its turnover and excretion necessitating increased intake during pregnancy. Understandably, populations with deficient iodine would have a greater prevalence of thyroid dysfunction which would also affect reference-range estimations and hence unreliable diagnosis. Despite this, there is a conspicuous lack of data on the impact of iodine deficiency on thyroid hormone dynamics and reference-intervals during pregnancy. Objective: The aim of this study is to assess thyroid hormone ranges and pregnancy outcome in a mild-iodine-deficient population. Methods: Survey was conducted for goiter and adverse pregnancy outcomes on rural women from 13 Government Primary Health Centers in an iodine-deficient zone. Out of this population, 340 women completed the follow-up for thyroid status (Goiter, thyroid-stimulating hormone [TSH], free thyroxine) and pregnancy outcome. Data on pregnancy outcome for the last 10 years were also retrieved from health center records. Results: Urinary iodine concentration values re-affirmed the mild-iodine-deficient status of this population. TSH indicated relatively higher cutoffs (at 2.5th–97.5th percentile: 1.02–3.70, 1.54-4.83, 2.20–5.74 mIU/L, 1st, 2nd, and 3rd trimester) as compared to that of international guidelines imported in India, yet 98% of the population was found within normal range. Data indicated the possibility of misclassification error following imported guidelines. Survey revealed 1.1% Grade1 goiter, 0.4% miscarriages, 0.68% premature birth, and 1.59% stillbirth. Data retrieved from the past 10 years are comparable. Conclusion: Iodine deficiency appears to enhance the upper cutoffs of TSH. Thyroid function remains unimpaired in continued mild iodine deficiency during pregnancy as a result of efficient homeostasis. The study underscores the need for indigenous population-specific ranges to avoid misclassification errors.
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Postprandial decline in thyroid-stimulating hormone is significant but not its correlation with postprandial change in plasma glucose p. 113
T V S Pradeep, Sree Harsha Varma, Sunanda Tirupati, Vijaya Sarathi, K Dileep Kumar
DOI:10.4103/trp.trp_36_18  
Background: There are limited data on postprandial change in serum thyroid-stimulating hormone (TSH), especially on its correlation with postprandial change in plasma glucose. Hence, we evaluated the postprandial changes in thyroid function tests (TFTs) and their correlation with postprandial changes in plasma glucose. Materials and Methods: This prospective, cross-sectional study was conducted at a tertiary care hospital from South India. The study included 200 participants: 75 healthy volunteers without known thyroid dysfunction (Group A), 65 healthy pregnant women (Group B), and 60 patients who were known hypothyroid (clinical and subclinical hypothyroid) on levothyroxine therapy (Group C). All participants underwent biochemical investigations including plasma glucose and TFTs in fasting and 2-h postprandial states. Results: Serum TSH was significantly lower in the postprandial state than fasting sample in all the three groups, whereas the free triiodothyronine and free thyroxine levels were not significantly different in fasting and postprandial states. There was no significant correlation between change in plasma glucose and the change in TFT in any group. In pregnant women (Group B), the prevalence of hypothyroidism was significantly higher in fasting than postprandial while using a cutoff of 2.5 μIU/ml (41.5% vs. 18.4%, P = 0.004) as well as 4 μIU/ml (12.3% vs. 1.5%, P = 0.03) but not in other groups (Group A and Group C). Conclusion: Our study reports significant TSH decline in the postprandial state but no significant correlation between postprandial changes in plasma glucose and TSH.
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Trimester-specific reference ranges for thyroid function tests in South Indian women p. 117
K Sandhya Rani, Sunanda Tirupati, Vijaya Sarathi, K Dileep Kumar
DOI:10.4103/trp.trp_24_18  
Background: There are no published data on trimester-specific reference intervals for thyroid function tests (TFTs) in south Indian pregnant women. Hence, this study was conducted to establish trimester-specific reference intervals for TFTs in south Indian pregnant women. Materials and Methods: This is a cross-sectional study conducted at a tertiary health-care center at Coastal region from South India. A total of 235 healthy women of age >18 years with uncomplicated singleton, intrauterine pregnancy who were consuming iodized salt were recruited for the study. Family history of thyroid illness, history of abortion, goiter, antithyroid peroxidase positivity, overt hypothyroidism, and overt hyperthyroidism were present in 11 (4.7%), 27 (11.5%), 50 (21.3%), 15 (6.38%), 1 (0.42%), and 3 (1.28%) had, respectively, and a total of 73 participants having one of these features were excluded from the study. A total of 162 (I trimester: 47, II trimester: 50, and III trimester: 65) women were included in the analysis to derive trimester-specific reference ranges. Results: The reference ranges for the first, second, and third trimester were 0.08–2.24, 0.42–2.84, and 0.40–3.14 μIU/ml for thyroid-stimulating hormone, 0.68–1.44, 0.59–1.21, and 0.53–1.15 ng/dl for free thyroxine 4 (FT4) and 2.08–3.48, 1.81–3.81, and 1.86–3.38 pg/ml for FT3. Conclusion: Our study reports trimester-specific reference ranges for TFTs in south Indian women from a coastal region.
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Clinical spectrum and outcome of patients with hyperthyroidism in Nepal p. 122
Robin Maskey, Jeet Prasad Ghimire, Bickram Pradhan, Vivek Kattel, Prahlad Karki, Madhab Lamsal
DOI:10.4103/trp.trp_19_18  
Context: Thyroid dysfunction is a major public health problem among the Nepalese population. The average prevalence of thyroid disorder was 30% seen in different parts of Nepal. It is important to detect these disorders at the preclinical stage and manage them accordingly. Aims: This study aimed to assess the clinical spectrum and outcome of patients with hyperthyrdoism in BP Koirala Institute of Health Sciences, a tertiary care teaching hospital of Nepal. Settings and Design: This is a prospective observational study. Subjects and Methods: All adult hyperthyroid patients presenting to the Department of Internal Medicine were enrolled for 1 year and evaluated for clinical spectrum and outcome after treatment with antithyroid drugs. Statistical Analysis Used: Descriptive statistics such as frequencies, mean, standard deviation, and proportion for quantitative variable were calculated and association was established using Chi-square test with P values. P < 0.05 was considered statistically significant. Results: Among sixty patients of hyperthyroidism enrolled in the study, common clinical manifestation was palpitations (92.7%), tremulousness, and heat intolerance (70.1%). Similarly, most common clinical sign was warm, moist skin (89.1%), followed by tremors (72.7%). After treatment with antithyroid drugs, 60% became euthyroid within 6 weeks. Conclusions: The most common symptoms of hyperthyroidism were palpitation. Majority of patients improved with antithyroid drugs within 6 weeks of treatment.
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Serum concentrations of interleukin-17A but not interleukin-17F are elevated in children with recent-onset Hashimoto's thyroiditis p. 128
Sandhya Cautha, Devi Dayal, Naresh Sachdeva, Darshan Badal, Savita Verma Attri, Kushaljit Singh Sodhi
DOI:10.4103/trp.trp_22_18  
Background: Recent advances in immunology suggest that T-helper 17 lymphocytes (Th17) have a major role in the disrupted autoimmunity in Hashimoto's thyroiditis (HT). However, there are no data on the Th17 characteristics, especially regarding the dominant interleukins (ILs) that they produce in children with HT. Material and Methods: With an aim to determine the role of two major Th17 cytokines in children with HT, we measured serum concentrations of IL-17A and IL-17F in 40 children with recent-onset HT and 40 age- and sex-matched controls by enzyme-linked immunosorbent assay. Results: Serum IL-17A concentrations were significantly higher in children with HT when compared to controls (3.39 ± 6.93 pg/mL vs. 0.12 ± 0.47 pg/mL, P = 0.00). However, the IL-17F concentrations were similar in patients and the controls (11.12 ± 15.34 pg/mL vs. 9.68 ± 12.87 pg/mL, P = 0.65). Conclusions: The elevated concentrations of IL-17A, one of the major effector cytokines of the Th17 system, suggest its possible role in the pathogenesis of HT in children.
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Thyroid function and autoantibody status in Bangladeshi patients with type 2 diabetes mellitus p. 132
A B. M. Kamrul-Hasan, Farhana Akter, Shahjada Selim, Md Asaduzzaman, Md Habibur Rahman, Palash Kumar Chanda, Marufa Mustari, Md Shah Alam, Md Nazrul Islam Siddiqui
DOI:10.4103/trp.trp_26_18  
Background: Thyroid dysfunction is common in patients with type 2 diabetes mellitus (T2DM), and data on thyroid autoimmunity in T2DM are scarce. This study was designed to observe the frequency of thyroid dysfunction and autoimmune thyroid disease in Bangladeshi T2DM patients. Materials and Methods: In this cross-sectional study, we investigated 1056 T2DM patients with unknown thyroid function status throughout the country. Serum thyroid stimulating hormone (TSH) and free T4 (FT4) and antithyroid antibodies (antithyroid peroxidase or antimicrosomal) were measured. Statistical analysis was done using IBM SPSS Statistics for Windows, version 23.0 software. P ≤ 0.05 was considered statistically significant. Results: The observed frequency of thyroid dysfunction in our study was 21.9% (subclinical hypothyroid 14.1%, primary hypothyroid 4%, subclinical hyperthyroid 1.9%, overt hyperthyroid 1%, and secondary hypothyroid 0.9%). 32.9% of the participants were positive for thyroid autoantibodies. The patients with thyroid dysfunction had a higher body mass index (BMI), higher TSH, lower FT4, and higher thyroid autoantibody titer than euthyroid ones. Thyroid dysfunction was more common in females and autoantibody-positive individuals. TSH had an inverse negative correlation with FT4 in both euthyroid and thyroid dysfunction groups and had a positive correlation with age in the euthyroid group only. FT4 had an inverse correlation with age and duration of diabetes in both groups and with BMI in euthyroid diabetic patients. Conclusion: Thyroid dysfunction and autoimmunity are common in Bangladeshi T2DM patients. Thyroid dysfunction was more common in females and autoantibody-positive diabetic patients.
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Incipient iron deficiency in primary hypothyroidism p. 138
Tanveer Hassan Banday, Sadaf Bashir Bhat, Sabreen Bashir Bhat, Shahnawaz Bashir, Shah Naveed
DOI:10.4103/0973-0354.245563  
Background: Hypothyroidism affects around 1% of general population. Anemia in association with hypothyroidism has been studied since 1881. Iron deficiency has multiple adverse affects on thyroid metabolism. It decreases circulating thyroid hormone concentration, blunts thyrotropic response to thyrotropin-releasing hormone (TRH) and decreases serum triiodothyronine (T3). Objectives: To find the prevalence of iron deficiency in primary hypothyroids. Material and Methods: In our study, 70 patients were selected, out of which 50 were females and 20 were males, who were suffering from hypothyroidism. Iron deficiency in the study group was confirmed at baseline using multiple iron status indicators (serum ferritin, serum iron, total iron-binding capacity and percentage saturation). These patients were between age group 18–65 years. Results: In our study, only 14 patients (20%) manifested with anemia (which was defined as HB < 12 gm/dl), whereas the prevalence of iron deficiency (with or without anemia) was 34.2%), in which 28.5% were females and 5.70% were males, thus showing that prevalence of iron deficiency (with or without anemia) can be higher than iron deficiency anemia itself, which is supported by literature. Conclusion: Iron deficiency was present in a significant portion of patients with primary hypothyroidism. It also concluded that frequency of iron deficiency (with or without anemia) was higher than iron-deficiency anemia.
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CASE REPORT Top

A rare incidental case of an occult breast carcinoma micrometastasis in papillary thyroid carcinoma: A view within a view p. 142
Jasmine Kaur, Sonam Sharma, Tejinder Singh Bhasin, Ranjan Agarwal, Rahul Mannan
DOI:10.4103/trp.trp_29_18  
Metastasis to thyroid gland is rare, accounting for only 2%–3% of malignant lesions of thyroid and if present, is associated with a poor prognosis. Herein, we describe a case of a 42-year-old female who presented initially with papillary carcinoma of the thyroid and a synchronous malignancy was pointed toward on the basis of a secondary population of atypical cells in intrathyroidal as well as perithyroidal blood vessels emboli. Immunohistochemistry and systematic review of the patient later proved the micrometastasis to be that of carcinoma breast for which the patient was operated 6 years ago. The present case is worth reporting because it documents the presence of two different cancers in a single-organ system (a rare presentation of breast ductal cancer metastasizing to the papillary thyroid carcinoma) by the means of an important yet overlooked lymphovascular compartment, by the identification of the metastatic tumor emboli.
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LETTER TO THE EDITOR Top

Somatization, anxiety, and depression triad in hypothyroidism p. 147
Samir Kumar Praharaj
DOI:10.4103/trp.trp_31_18  
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