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   Table of Contents - Current issue
Coverpage
May-August 2017
Volume 14 | Issue 2
Page Nos. 43-91

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EDITORIAL  

The kidney and the thyroid – Together in function and disease p. 43
Krishna G Seshadri
DOI:10.4103/trp.trp_19_17  
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REVIEW ARTICLES Top

Clinical approach to congenital hypothyroidism p. 45
Sunetra Mondal, Pradip Mukhopadhyay, Sujoy Ghosh
DOI:10.4103/trp.trp_5_17  
Congenital hypothyroidism (CH) is a preventable cause of mental retardation. The principal causes include thyroid dysgenesis and dyshormonogenesis. Central CH is rare. Due to absence of overt symptoms at birth, diagnosis is often delayed. There are some known syndromic associations with extrathyroidal anomalies. Neonatal screening programs help in early detection and categorization of cases requiring immediate treatment or close follow-up. Results of screening tests could guide further tests required for confirmation diagnosis and urgency of replacement therapy. A diagnostic protocol starting with an ultrasonography of thyroid and serum thyroglobulin levels can aid identify the probable underlying etiology and dictate the cases requiring scintigraphy or genetic tests. Early initiation of treatment with oral levothyroxine improves neurocognitive outcomes. Some cases might have transient hypothyroidism and reevaluation at 3 years of age may help in further discontinuation of treatment.
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National health programs related to thyroid p. 54
Kanica Kaushal, Sanjay Kalra
DOI:10.4103/trp.trp_17_17  
Identification of health objectives is one of the more visible strategies to direct the activities of the health sector. The government of India and its nodal ministry – Ministry of Health and Family Welfare undoubtedly has the central and primary role in the implementation of the health program. In this article, the authors have tried to review the available national programs for prevention and treatment of thyroid diseases; National Newborn Screening Programme including congenital hypothyroidism, Rashtriya Bal Swasthya Karyakram, National Guidelines for Screening of Hypothyroidism during Pregnancy, National Iodine Deficiency Disorders Control Programme and National Family Health Survey 3 and 4.
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ORIGINAL ARTICLES Top

Thyroid dysfunction in critically ill patients in a tertiary care hospital in Sikkim, India p. 58
M Suresh, Nitin K Srivastava, Amit Kumar Jain, Parvati Nandy
DOI:10.4103/trp.trp_16_16  
Background: During critical illness, patients with no history of thyroid disorders may experience multiple changes in their thyroid hormone levels. Such changes are termed as euthyroid sick syndrome. The extent of change correlates with the severity of the illness and its outcomes in critically ill patients. Objectives: The aim of this study was to identify critically ill patients and grade them clinically according to the Acute Physiology and Chronic Health Evaluation II (APACHE II) severity scale and evaluate the thyroid function tests (TFTs) and to document the outcome and relate the APACHE II severity scale with TFTs. Methods: A descriptive, observational hospital-based study was conducted on critically ill patients admitted to the Intensive Care Unit who fulfilled the inclusion criteria. All data were entered into Microsoft Excel sheet and were analyzed using GraphPad InStat software. Results: The majority of the patients belonged to geriatric age group (49%) and were male (55%). Cardiovascular diseases (43%) constituted the major morbidity. The majority had APACHE II score ≥20 (71%) and succumbed (45%) to their illness within 10 days. The majority of them had a low total triiodothyronine (T3) (49%), and there was a significant inverse correlation (P = 0.0235) between severity of illness and low serum total T3 levels whereas there was no relationship between total thyroxine or thyroid-stimulating hormone levels and severity of illness. Conclusions: Serum T3 has a significant inverse relationship to the severity of critically ill patients.
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Prevalence of hypothyroidism in Assam: A clinic-based observational study p. 63
Anindita Mahanta, Sushmita Choudhury, Sarojini Dutta Choudhury
DOI:10.4103/trp.trp_38_16  
Introduction: Hypothyroidism is a common functional disorder of the thyroid gland. Despite extensive research, data on this subject are lacking from the northeastern part of India, which falls in the Sub-Himalayan goitrogenic belt. Therefore, we decided to study the profile of hypothyroidism in Assam, a northeastern state with the following objectives: to determine the prevalence of hypothyroidism and to describe the various modes of clinical presentation. Materials and Methods: The study was conducted at a clinic-cum-radioimmunoassay laboratory in Guwahati, Assam, from January to November 2011. Two thousand and four hundred fifty-six patients referred to our center from different parts of Assam were evaluated clinically and their thyroid profile was estimated. Antithyroid peroxidase (TPO) antibody was estimated in 1950 patients. Results: The prevalence of overt hypothyroidism was 10.9% (n = 267) and that of subclinical hypothyroidism was 13.1% (n = 321). Male:female ratio was 1:3. Among the cases of overt hypothyroidism, 247 (92.51%) were adult hypothyroids, 15 (5.62%) juvenile hypothyroids, and 5 (1.87%) cretins. The common presenting features of hypothyroidism were weakness (98%), lethargy (95%), dry and coarse skin (87%), and body ache (85%). Uncommon modes of presentation were pleural and pericardial effusion, low body weight, frequent motions, and palpitations. Postthyroidectomy and drug-induced hypothyroidism accounted for 2.38% cases each and postpartum hypothyroidism for 3.74% cases. Thirteen percent cases presented with goiter. The prevalence of anti-TPO antibody in the study population was 8.41%. Conclusion: Hypothyroidsm is no longer a rarity, and Assam is no exception to this phenomenon. A population-based epidemiological study of thyroid disorders in Northeast India is an urgent need.
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Clinicopathologic profile of glomerular diseases associated with autoimmune thyroiditis p. 71
Kunal Gandhi, Karamvir Godara, Dhananjai Agrawal, Vinay Malhotra, Pankaj Beniwal, Amith Dsouza
DOI:10.4103/0973-0354.207133  
Introduction: Thyroid hormones are known to influence renal function, development, and renal hemodynamics. In this study, we aimed to de ne the frequency and characteristics of various glomerular diseases associated with autoimmune thyroiditis. Methods: We reviewed retrospectively 36 patients with autoimmune thyroiditis referred for evaluation of proteinuria, hematuria, and/or renal impairment. Renal biopsy was performed in 32 patients and was examined with light microscopy and immunofluorescence. Six months follow-up data of 22 patients was reviewed. Results: The mean age of study population was 43.6 years. Most of them were females (n = 28). Mean duration of hypothyroidism (HT) was 1.5 years. Hypertension was seen in 16 patients and deranged renal function (estimated glomerular filtration rate <60 ml/min/1.73 m2) in 18 with a mean serum creatinine of 1.28 mg/dl at time of biopsy. 10 patients presented with nephrotic syndrome, 33 presented with isolated proteinuria and 22 presented with hematuria with or without significant proteinuria The most common histopathologic finding was membranous nephropathy (MGN) (n = 16), followed by minimal-change nephropathy (n = 5), focal segmental glomerulosclerosis (n = 5), immunoglobulin A nephropathy (n = 3), amyloidosis (n = 2), and membranoproliferative glomerulonephritis (n = 1). Membranous nephropathy was the most common finding inn patients with the nephrotic syndrome. Conclusion: Glomerular pathologies associated with HT are diverse and similar to those found in the general population; therefore, renal biopsy should be performed in cases with progressive renal failure or urinary abnormalities.
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CASE REPORTS Top

Transoral thyroidectomy, vestibular approach using two ports: A novel technique p. 75
Vivek Aggarwal, Raja Bhanu Kiran, Monika Garg, Deepak Khandelwal
DOI:10.4103/trp.trp_12_17  
Cosmesis is a prime concern for many patients undergoing thyroid surgery. Postthyroidectomy scar-related apprehension among patients has forced the surgeons to develop techniques to reduce the scar or even without scar. We report a case of a young female with thyroid nodule who underwent transoral endoscopic thyroidectomy done through a novel technique (transoral vestibular approach using two ports) at our center as potentially scarless thyroid surgery.
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Distant skeletal muscle metastasis to sternocleidomastoid in the setting of recurrent papillary thyroid carcinoma p. 77
Nitish Virmani, Jyoti Dabholkar
DOI:10.4103/trp.trp_24_16  
Papillary thyroid carcinoma (PTC), the most common form of differentiated thyroid cancer, is characterized by an indolent course and excellent prognosis. Although its spread to regional lymph nodes is well known, distant metastases are seen only in a minority of patients with lungs being the most common site. Skeletal muscle metastases are extremely rare even in follicular thyroid carcinoma, in which hematogenous spread is known to occur. We describe a case of skeletal muscle metastasis to sternocleidomastoid muscle in a case of PTC in the setting of local recurrence.
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Primary hypothyroidism presenting as a pituitary macroadenoma and precocious puberty p. 81
Balram Sharma, Hema Singh, Sanjay Saran, Sandeep Kumar Mathur
DOI:10.4103/trp.trp_6_17  
The association in young females of long-standing primary hypothyroidism, isosexual precocious pseudopuberty, and multicystic enlarged ovaries was first described in 1960 by Van Wyk and Grumbach. In this case study, we report a girl with precocious puberty, poor linear growth, decreased vision, and a large pituitary pseudotumor due to long-standing hypothyroidism with regression of all components following thyroxine (T4) supplementation. This girl aged 12 years and 3 months presented in Endocrinology Department with complaints of early menarche starting at the age of 8 years with normal cycles along with early progressive breast development starting almost simultaneously. On examination, she had a reduced growth for age (<5th centile) with adequate breast development (Tanner Stage 3) but no pubic or axillary hair development. Physical and biochemical examination for blood indices revealed a microcytic hypochromic anemia. Most importantly, she had an elevated thyroid stimulating hormone >150 μIU/ml (0.35–5.5) and a free T4 (FT4) and free triiodothyronine below normal limits suggestive of primary hypothyroidism. Furthermore, serum prolactin levels were elevated along with an elevated serum follicle-stimulating hormone, luteinizing hormone, and estradiol. Multicystic ovaries and a bulky uterus on ultrasound were suggestive of precocious puberty. Magnetic resonance imaging scan of the sella turcica was suggestive of a pituitary macroadenoma. Posttreatment with gluten-free diet, iron supplements, and T4 replacement, her thyroid function, hemoglobin, and prolactin normalized along with a regression in the size of the ovary. Therefore, in patients of this age presenting with a pituitary macroadenoma, anemia, precocious puberty, and primary hypothyroidism, medical management was preferred over neurosurgical intervention so as to avoid permanent hypopituitarism and lifelong hormone replacement therapy.
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A rare presentation of autoimmune thyroid disease in mother and neonate postpartum p. 86
Mythili Ayyagari
DOI:10.4103/trp.trp_15_17  
This is a case of long-standing hypothyroidism on levothyroxine (LT4) replacement developing Graves' disease postpartum and the newborn presenting with transient congenital hypothyroidism. The clinical and laboratory data of the case are reported along with a brief literature review. A 27-year-old female who has hypothyroidism for the past 3 years and gestational diabetes mellitus delivered uneventfully. The thyroid function tests (TFTs) of the newborn showed congenital hypothyroidism which was transient and resolved by 3 months' age. An ultrasound of thyroid showed gland in situ. The diagnosis of the newborn is transient congenital hypothyroidism probably due to thyroid-stimulating hormone receptor-blocking antibodies (TBAbs). The mother who has hypothyroidism for the past 3 years was stable with euthyroidism and was on LT4 100 ug daily. Seven months postpartum, she had lid lag and proptosis of her left eye. Her TFTs revealed thyrotoxicosis and was advised to stop LT4. Magnetic resonance imaging orbits were normal and her TBAbs are elevated at 4.65 IU/L (<1.22). Antimicrosomal antibodies and antithyroid peroxidase antibodies were negative. The orbitopathy resolved over 6 weeks and the mother remains euthyroid without LT4 on a follow-up period of 8 months. Close monitoring of autoimmune thyroid disease (AITD) in pregnancy and postpartum is necessary due to the immune switching in this period and may obviate the need for LT4 therapy. The suspicion of transient congenital hypothyroidism due to TBAb should be high in neonates born to mothers with AITD.
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Hashimoto's encephalopathy in a 10-year-old girl p. 89
V Shobi Anandi, Shaila Bhattacharyya, Bidisha Banerjee
DOI:10.4103/trp.trp_41_16  
Hashimoto's encephalopathy (HE) is a rare but probably an unrecognized and underdiagnosed condition in children. Early diagnosis is critical since these patients respond dramatically to corticosteroid therapy. The diagnosis of HE requires a strong clinical suspicion along with a triad of positive antithyroid antibodies, encephalopathy not explained by another etiology, and a response to corticosteroids. We report the case of a 10-year-old female child with HE and review the literature.
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