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   Table of Contents - Current issue
Coverpage
May-August 2020
Volume 17 | Issue 2
Page Nos. 51-98

Online since Friday, July 17, 2020

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EDITORIAL  

Could artificial intelligence help in the risk stratification of thyroid nodules? Highly accessed article p. 51
Ambika Gopalakrishnan Unnikrishnan, Sanjay Kalra
DOI:10.4103/trp.trp_53_20  
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REVIEW ARTICLES Top

A 6 Dimensional approach to diagnosing refractory hypothyroidism p. 53
Sanjay Kalra, Prem Narayanan, Ana Soraya P.D.R. Monteiro
DOI:10.4103/trp.trp_14_20  
Refractory hypothyroidism is a commonly encountered clinical challenge despite hypothyroidism being an easy condition to manage. However, truly refractory hypothyroidism accounts for only a small proportion of refractory hypothyroidism, remainder being “pseudo-refractory.” The 6-dimensional tool helps guide physicians to manage poorly controlled hypothyroid individuals better. This tool highlights some important aspects of evaluating such individuals such as dialogue, diagnosis, definition of endpoint, disturbance in assay, drug intake (L-thyroxine and concomitant drug intake), and comorbid disease. Most importantly, this simple reader friendly tool can help differentiate truly refractory from pseudo-refractory hypothyroidism. The latter being easily correctable holds the promise of improving the quality of life in such individuals.
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“Telethyroidology”: Managing thyroid disorders through telemedicine p. 56
Om J Lakhani, Tejal Lathia, Saptarshi Bhattacharya, Altamash Shaikh
DOI:10.4103/trp.trp_20_20  
The recent coronavirus disease 2019 pandemic has brought telemedicine to the forefront in India. Also guidelines by the Board of Governors of the Medical Council of India have paved the way for the practical application of telemedicine. Thyroid disorders in endocrinology are best suited for the use of telemedicine, for which we have coined the term “telethyroidology.” In this review, we discuss the application of telemedicine to specific thyroid disorders such as hypothyroidism (subclinical and overt), thyrotoxicosis, thyroid nodules, thyroid cancer as well as pregnancy-associated thyroid diseases. “Telethyroidology” covers the entire spectrum of the utility of telemedicine diagnosis, multidisciplinary approach with the involvement of teleradiology and telecytopathology, forward triage of patients needing in-person consults, postthyroidectomy care as well as long-term monitoring. Adoption of telethyroidology can reduce the burden of in-person consultation for endocrinologists at the same time ensuring that their expertise is available to all – ultimately improving diagnosis, treatment, and compliance in thyroid disorders.
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Management of thyroid diseases during pandemic: A narrative review p. 62
Mathew John, Vimal Mavila Veetil
DOI:10.4103/trp.trp_35_20  
The COVID-19 pandemic caused by the novel coronavirus (SARS-CoV-2) has caused significant morbidity and mortality across the globe. It has resulted in compromised care for patients with chronic diseases. Thyroid diseases are highly prevalent in the world, both in iodine-deficient and -sufficient areas. Viruses can cause thyroid diseases by the direct invasion of the gland, by triggering immune mechanisms, and by the effects of antiviral drugs on the gland. Although there is no signal of a pathogenic mechanism of thyroid diseases by SARS-CoV-2 to date, the high prevalence of thyroid diseases in people affected by this pandemic makes it prudent to study the association between these diseases and to formulate a management plan in the resource-limited setting. In this brief review, we have tried to discuss the relationship between the virus and diseases of the thyroid gland and the management challenges in patients with hypothyroidism, hyperthyroidism, Graves' orbitopathy, and thyroid nodules including cancer. We have also tried to incorporate the advantages and limitations of telemedicine for thyroid disease in the era of a pandemic.
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ORIGINAL ARTICLES Top

Thyroid dysfunction in beta thalassemia major patients p. 70
Ankush Singhal, Hema Goyal
DOI:10.4103/trp.trp_4_20  
Background: Endocrinopathies are now amongst the common complications of thalassemia but determining the exact prevalence is difficult because of differences in age of first exposure to chelation therapy and the continuing improvement in survival in well-chelated patients. Hypothyroidism is the second most common endocrine disorder after hypogonadism, having been reported in 5.6% to 17% of patients. Material and Methods: The present study was conducted in Umaid hospital attached to Dr S.N. Medical College, Jodhpur. 112 children were enrolled in the study and thyroid function tests along with serum Ferritin levels were done for all the subjects. Results: Out of a total of 112 children, 82 were Euthyroid (73.2%) and 30 were Hypothyroid (26.8%). The mean serum Ferritin, serum TSH, serum Free T4 and serum Free T3 in Euthyroid children were 1975.4 ± 706.2(ng/ml), 3.23 ± 0.93(μIU/ml), 12.8 ± 2.3(pmol/l) and 6.12 ± 1.4(pmol/l) respectively. Whereas in Hypothyroid children the mean serum Ferritin, serum TSH, serum Free T4 and serum Free T3 were 2842.9 ± 1095.2(ng/ml), 7.05 ± 1.91(μIU/ml), 10.55 ± 2.0(pmol/l) and 4.49 ± 1.2(pmol/l) respectively. Conclusion: Prevalence , severity of thyroid dysfunction in thalassemics is variable and regular follow up is the key. Assessment of thyroid function should be done annually from the age of 9 or earlier if patient is clinically symptomatic.
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Prevalence of thyroid dysfunction and thyroid autoimmunity in polycystic ovary syndrome: A multicenter study from Bangladesh p. 76
A. B. M. Kamrul-Hasan, Fatema Tuz Zahura Aalpona, Marufa Mustari, Farhana Akter, Palash Kumar Chanda, Mohammad Motiur Rahman, Mohammad Imtiaj Mahbub, Shahjada Selim
DOI:10.4103/trp.trp_6_20  
Background: Women with polycystic ovary syndrome (PCOS) have increased risks of thyroid dysfunction and thyroid autoimmunity. Data are limited regarding the prevalence of thyroid dysfunction and thyroid autoimmunity in patients with PCOS. Objective: The objective of this study was to evaluate thyroid function and thyroid autoimmunity in patients with PCOS. Materials and Methods: In this cross-sectional study, 500 women newly-diagnosed with PCOS attending the endocrinology outpatient departments of several tertiary hospitals of Bangladesh were evaluated. Serum thyroid-stimulating hormone (TSH), free thyroxine, and anti-thyroid peroxidase (anti-TPO) were measured in all. Results: The prevalence of thyroid dysfunction was 17% (11% subclinical hypothyroidism, 5.2% overt hypothyroidism, 0.4% subclinical hyperthyroidism, and 0.4% overt hyperthyroidism). Patients with normal and abnormal thyroid function had similar mean age, body mass index, waist circumference, diastolic blood pressure (BP), fasting plasma glucose, plasma glucose 2 h after oral glucose tolerance test, serum total cholesterol, triglyceride, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, total testosterone, and prolactin levels. The frequencies of menstrual irregularities, acne, a first-degree family member with thyroid dysfunction, acanthosis nigricans, biochemical hyperandrogenism, and hyperprolactinemia were also similar. The patients with thyroid dysfunction had lower modified Ferriman–Gallwey score and hirsutism frequency. More patients in the thyroid dysfunction group had a history of weight gain during the course of PCOS onset. Higher rates of subfertility and goiter were also observed in patients with thyroid dysfunction; systolic BP was higher in this group. More than one-fifth (20.6%) of the study participants were positive for the anti-TPO antibody. Conclusions: Thyroid dysfunction and thyroid autoimmunity in Bangladeshi PCOS patients are very common.
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CASE REPORTS Top

Fluorodeoxyglucose-avid thyroid incidentaloma p. 82
Deepanjan Mitra, Sujoy Ghosh
DOI:10.4103/trp.trp_45_19  
Positron emission tomography–computed tomography (PET-CT) has become a standard investigation oncology workup.18F-fluorodeoxyglucose (18F-FDG) is the main radiopharmaceuticals for most of the studies. Since malignant cells overexpress glucose transporter receptors, they internalize FDG, and FDG undergoes the first rate-limiting step of glycolysis to form FDG-6-phosphate. In a whole-body PET-CT study, a lot of incidental findings are noticed and often bear significant clinical relevance. A normal thyroid gland does not show any demonstrable FDG uptake. However, sometimes, a normal-looking thyroid gland shows up increased FDG uptake in a diffuse manner in both lobes without any obvious focal FDG-avid lesion. This is attributed to autoimmune lymphocytic thyroid diseases and hypothyroidism. A hyperthyroid gland may appear diffusely enlarged with intense FDG uptake throughout the gland suggesting the hyperfunctioning of its follicular cells. However, any focal FDG uptake in either lobe of the thyroid needs an evaluation, particularly if there is any hypodense nodule on corresponding CT study. It is observed that FDG-avid thyroid nodules can harbor malignancy in almost 33% of cases. Hence, any FDG-avid incidentaloma needs an image-guided fine-needle aspiration cytology to rule out occult malignancy.
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Intrathyroidal parathyroid adenoma: A perplexing entity p. 86
Mohit Gupta, Deepak Khandelwal, Vivek Aggarwal, Nishikant Avinash Damle, Monika Garg
DOI:10.4103/trp.trp_18_20  
Intrathyroidal parathyroid adenoma (IPA) can be a cause of failed cervical exploration for primary hyperparathyroidism (PHPT). There is a lot of controversy regarding the correct approach and extent of exploration in such cases. Herein, we report the case of a 37-year-old female who was managed for PHPT with right-sided IPA after correlating preoperative ultrasonography and99mTc-sestamibi scan. A high index of suspicion, preoperative identification, and planning is very important to avoid unnecessary dissection and failure to remove the diseased gland in such cases.
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Parathyromatosis in a patient with parathyroid carcinoma and hypercalcemic crisis: Findings on MIBI scan and 4D CT p. 89
Sneha Prakash, Nishikant Avinash Damle, Devasenathipathy Kandasamy, Yashdeep Gupta, Chitresh Kumar, Shipra Agarwal, Rajni Yadav, Hiya Boro, Sarah Alam, Divya Yadav
DOI:10.4103/trp.trp_21_20  
Parathyroid carcinoma is a rare tumor associated with significantly high levels of parathyroid hormone (PTH) and primary hyperparathyroidism (HPT) and is difficult to distinguish from parathyroid adenoma, which is a much more common cause of HPT. Parathyromatosis is a rare condition in which several nodules of hyperfunctioning parathyroid tissue form in the neck and mediastinum, and it presents as recurrent hyperparathyroidism. We describe the case of a 44-year-old woman with recurrent hyperparathyroidism who presented with hypercalcemic crisis and biochemical investigations showed a severely raised serum intact parathyroid hormone (iPTH) level of 2513 pg/ml and serum calcium level of 17 mg/dl. A four-dimensional computed tomography (4D CT) of the neck was done, which showed few arterially enhancing nodular lesions in the right paratracheal and retrotracheal location at the level of thoracic inlet showing washout in delayed images suggestive of recurrent/residual parathyroid lesions. A technetium-99 m methoxyisobutylisonitrile (Tc-99 m MIBI) scan was done, and the planar neck anterior early images showed an area of increased radiotracer uptake in the right lower neck region with persistent uptake in the delayed images. Single photon emission computed tomography/ computed tomography (SPECT/CT) images showed a soft-tissue lesion in the right paratracheal region at the level of C7 vertebra showing increased radiotracer uptake suggestive of a recurrent/residual parathyroid lesion. Exploration and excision of the recurrent parathyroid mass was planned, and the right paratracheal mass with nodes above the aortic arch along with the subcutaneous and intramuscular lesions were excised. Postoperative serum calcium was 7.8 mg/dl, and serum iPTH was 135 pg/ml. Histopathological examination of the excised tissue showed the features of parathyroid carcinoma. Thus, Tc-99 m MIBI scan and 4D CT were critical in evaluating this case of parathyroid carcinoma with recurrent hyperparathyroidism and planning its management.
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LETTERS TO THE EDITOR Top

A unique presentation of Hashimoto's encephalopathy p. 94
Abhishek Juneja, Kuljeet Anand, Arpit Agrawal
DOI:10.4103/trp.trp_24_20  
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Giant visible parathyroid adenoma presenting with severe hypercalcemia p. 95
Aman Kumar, Deepak Khandelwal, Atul Dhingra, Vivek Aggarwal, Nishikant Avinash Damle, Monika Garg
DOI:10.4103/trp.trp_26_20  
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COVID-19 and thyroid p. 97
Karthik Balachandran, Vikram Singh Chauhan, Mohan Shenoy
DOI:10.4103/trp.trp_15_20  
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