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   Table of Contents - Current issue
Coverpage
January-April 2019
Volume 16 | Issue 1
Page Nos. 1-51

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EDITORIAL  

Glucose metabolism Type 2 diabetes mellitus and the thyroid-so near and yet… Highly accessed article p. 1
Krishna G Seshadri
DOI:10.4103/trp.trp_11_19  
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ORIGINAL ARTICLES Top

Thyroid dysfunction in patients with Type-2 diabetes mellitus in Kerala: A case–control study p. 3
Muhammed Jasim Abdul Jalal, B Riyas, A Pќaveen Kumar
DOI:10.4103/trp.trp_47_18  
Aim: The aim of this study is to establish the relationship between type 2 diabetes mellitus (Type 2 DM) and thyroid dysfunction. Objective: The objective of this study is to study: (1) The prevalence of thyroid dysfunction in Type-2 DM. (2) The spectrum of thyroid dysfunction. Study Design: This was a case-control study. Study Setting: This study was conducted in Family Medicine outpatient clinics in Thrissur, Kerala. Subjects and Methods: A total of 50 cases (diagnosed case of Type 2 DM) and 50 healthy controls were taken into consideration randomly. Thyroid function tests were conducted using the chemiluminescence assay. Then, it was analyzed statistically after tabulation. Statistical Analysis: Statistical analysis was performed using the Chi-square test for categorical variables. Student's t-test was used for finding significance between the means. A “P < 0.05” was considered statistically significant. Results: Thyroid dysfunction was found to be more in type 2 DM (16%) than in healthy controls (4%) which were significant. Among those diabetic patients with thyroid dysfunction, 6 (75%) out of 8 were females. The mean body mass index was high in diabetic patients with thyroid dysfunction. The hemoglobin A1c levels in patients who had thyroid dysfunction were high. Those with thyroid dysfunction had a mean total cholesterol level higher than euthyroid diabetics and controls. Goiter was found to be present in 4% of cases of Type 2 DM. Conclusion: Type 2 DM and thyroid diseases have a significant association. Subclinical hypothyroidism and overt hypothyroidism were the most common thyroid abnormality in Type 2 DM. Thyroid dysfunction was associated with worsening dyslipidemia in Type 2 DM.
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Cryoablation of goiter irrespective of thyroid profile Highly accessed article p. 6
Mohamed S Hamed, Sherif Z Mansour, Mohamed R Halawa, Ahmed M Bahaaeldin, Nesma Ali Ibrahim, Ashraf Z Ghoneim
DOI:10.4103/trp.trp_54_18  
Introduction: Thyroid nodules (TNs) are extremely common and most of them are benign in nature. Cryoablation is used in a variety of clinical applications, and has been applied in focal treatment as a substitute or an adjunct to surgery and other nonoperative modalities. Objectives: The objective is to evaluate the effect of cryoablation on the size and function of TN. Subjects and Methods: This was an interventional therapeutic study, conducted at endocrinology clinic, Ain Shams University Hospitals. Our study sample included 80 participants, aged between 20 and 60 years, having TN diagnosed by ultrasound (US). The participants were divided into two groups: Group 1 (control group) included 40 participants who were not subjected to cryoablation and Group 2 (cases) included 40 participants upon which cryoablation was done. Neck US was done for participants and they were sampled for their thyroid-stimulating hormone (TSH), free triiodothyronine (FT3) and free tetraiodothyronine (FT4) levels at start and after 3 and 6 months. Results: There was a high statistically significant difference between Group 1 and Group 2 regarding nodule size after 6 months (0.87 ± 0.25 cm vs. 0.67 ± 0.21 cm, respectively, P < 0.001), in spite of non-significant difference between both groups at the start of study (0.79 ± 0.29 cm vs. 0.83 ± 0.29 cm, respectively, P = 0.619). The median percentage of change in nodule size from 0 to month 6 in control group was +12.50% (IQR: 0%–22.5%), while in cases was −25.0% (IQR: −50%–−4.17%), P < 0.001. Regarding thyroid function tests, there was no statistically significant difference between both groups all through our study. Conclusions: Cryoablation causes nodule size reduction, while it does not affect thyroid function tests.
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Guwahati thyroid epidemiology study: High prevalence of primary hypothyroidism among the adult population of Guwahati city p. 12
Manash P Baruah, Sarojini Duttachoudhury, Mihir Saikia, Uma K Saikia, Sonali B Bhuyan, Ananya Bhowmick, Anup K Barman, Abha R Bora, Murchana Barkakoti
DOI:10.4103/trp.trp_5_19  
Background: Thyroid disorders have emerged as a common disease in India. Hence, it is pertinent to search the real reasons behind the high prevalence of thyroid disease in India, post salt iodization phase. Objective: This study was executed to unravel the nature of thyroid disorders and there associations with thyroid autoimmunity in the unexplored North east Indian region. Methods: This community based Cross sectional (pilot) survey involved 8 wards of Guwahati city, implementing the “cluster sampling technique”. Abnormal thyroid parameters were classified as Hypothyroid: serum T4 < 4.6 μg/dL and Thyroid stimulating hormone (TSH) > 4.2) μIU/mL; Subclinical hypothyroidism (SCH): normal serum T4 (4.6-12 μg/dL) and TSH > 4.2 IU/mL, and Anti-TPO antibody positive: titre of ≥ 34 IU/ml. Results: Out of the 209 subjects enrolled, incidence of newly detected SCH, self reported hypothyroidism, and cumulative figure of the hypothyroidism cohort were higher amongst female population (27.84%, 14.43%, and 42.27% respectively). Significant association was found between female sex and hypothyroidism [Relative risk (RR) 1.73 (1.16-2.56), P < 0.01]. Significant association was found between family history of thyroid disease and SCH (RR 2.59), elucidating a direct influence of heredity on pre-disposition towards thyroid disorder. Conclusion: A considerable percentage (33.01%) of the adult population in Guwahati city has some form of thyroid disorder. There is lack of evidence pointing out auto immunity being the major driver for primary hypothyroidism; hence we are left to reflect upon whether dietary iodine deficiency or being geographically located near to the sub-Himalayan goitrogenic belt, or frequent consumption of cyanogenic food stuffs, is cumulatively involved in thyroid disorder development.
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Pattern of ocular manifestations in patients with thyroid disease presenting in Eastern Nepal p. 20
Poonam Lavaju, Badri Prasad Badhu, Robin Maskey
DOI:10.4103/trp.trp_38_18  
Purpose: The purpose of this study was to determine the demographic pattern of patients with thyroid disease and to evaluate the clinical activity score (CAS) of patients with thyroid eye disease (TED). Subjects and Methods: A hospital-based cross-sectional study was conducted in patients diagnosed with thyroid dysfunction attending the Outpatient Department of Ophthalmology, Eastern Nepal, from June 2015 to July 2016. Demographic data, complete ocular examinations, thyroid eye signs, severity score (NOSPECS), and CAS were recorded and analyzed. Results: Of the 201 patients with thyroid dysfunction recruited, 40.8% (n = 82) had TED. Among patients with TED, 46 (56%) were hyperthyroid, 34 (41.4%) hypothyroid, and two (2.32%) euthyroid (P = 0.005). The mean duration of thyroid dysfunction in patients with TED was 2.96, median 2 years (P = 0.007). The mean age of the patient was 41.26 ± 11.01 years, with male:female ratio 1:4.7. Exophthalmos was seen in 39%. Eleven patients had diabetes mellitus, ten had hypertension, two myasthenia gravis, and two had cardiovascular disease. Significant association was seen between thyroid status and mean CAS (P < 0.001) and NOSPECS (P < 0.001). Hyperthyroidism was significantly associated with the severity of CAS and NOSPECS (P = 0.006 and P = 0.004, respectively). In logistic regression analysis, the occurrence of TED was influenced by thyroid status (P = 0.005, odds ratio [OR]: 1.79) and mean CAS (P < 0.001, OR: 49.17), age, glaucoma but not by gender, diabetes mellitus, duration of diabetes, hypertension, and cardiovascular disease. Conclusions: TED was more predominant in female and hyperthyroid. A significant associated was seen between hyperthyroid and severity of CAS and NOSPECS. A close synchronization between endocrinologist and ophthalmologist can decrease ocular morbidity.
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Prevalence and predictors of thyroid dysfunction among patients with type 2 diabetes mellitus attending a tertiary care hospital in an urban area of Bhubaneswar, Odisha p. 26
Tahziba Hussain, Braja Sundar Barik, Alok Ranjan Nayak, Shritam Das, Utkal Kishore Khadanga, VS Yadav, Sanghamitra Pati
DOI:10.4103/trp.trp_48_18  
Background: Type 2 diabetes mellitus (T2DM) and thyroid dysfunction (TD) often present together and complicate each other at many levels. Methodology: In this prospective study, we determined the prevalence of TD among 700 patients with T2DM attending the diabetes clinic of a tertiary care hospital who were recruited. Various sociodemographic factors such as age, gender, marital status, literacy status, and habits and clinical profile were assessed. Results: In all, 68% of male and 31% of female patients were enrolled in this study. About 33.5% of males and 66.4% of females were found with TD. One hundred and fifty-two (21.7%) patients were having TD. Diabetes and TD were more common among females, with advancing age, 45–70 years, sedentary, overweight patients and having familial history. Twenty-five percent of the patients were having prehypertension. About 10.5% of the patients were suffering with hyperthyroidism and 9% were suffering from subclinical hyperthyroidism. Forty-two percent were suffering from hypothyroidism, while 36% had subclinical hypothyroidism. Ten percent had higher T3 hormone levels, 11% had higher T4 hormone levels, and 69% had increased thyroid-stimulating hormone levels. Three percent of patients with diabetes and TD were having cardiovascular diseases. Conclusions: Out of 700 patients with T2DM, 21% were having different kinds of TD. More females with advancing age and sedentary lifestyle were having TD. Screening for TD among diabetes patients could improve case detection and early treatment, indirectly leading to better thyroid-specific treatment outcomes and prevention of DM complications.
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CASE REPORTS Top

An uncommon presentation of a common disorder: Van Wyk–Grumbach syndrome p. 36
Beatrice Anne, Vidyasagar Simhadri, Vamsi Krishna Yerramneni, D Neusha
DOI:10.4103/trp.trp_3_19  
Van Wyk–Grumbach syndrome (VWGS) is characterized by juvenile hypothyroidism, delayed bone age, and isosexual precocious puberty. We report the case of a 7-year-old girl who presented with premature menarche, short stature, and isosexual precocity. She had delayed bone age and multicystic ovaries. High circulating levels of thyroid-stimulating hormone (TSH) with prepubertal luteinizing hormone confirmed the diagnosis of VWGS. High circulating levels of TSH acting directly on follicle-stimulating hormone receptors could be the mediators of precocity. VWGS syndrome is quite rare and needs to be suspected for prompt treatment and resolution and avoidance of unnecessary surgery.
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Nonrecurrent laryngeal nerve: A rare but predictable variation p. 39
Deepak Janardhan, Shirish Patil, Shaji Thomas, Sandeep Suresh
DOI:10.4103/trp.trp_56_18  
A 40-year-old female was evaluated for left thyroid swelling and, after left hemithyroidectomy (p T2 N0M0) with intermediate risk as per the American Thyroid Association Guidelines, was referred for completion thyroidectomy as the final histology was papillary carcinoma. A contrast-enhanced computed tomography evaluation of the neck was done, which revealed a suspicious nodule in the right lower pole of the thyroid gland, and a mention of anomalous right subclavian artery was reported. Intraoperative findings were confirmed.
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Hoffmann syndrome: A rare and reversible case of hypothyroid myopathy p. 42
Deepali Sharma, Aanchal Arora, Manasa Mudalagiri, Yogesh Chandra Porwal
DOI:10.4103/trp.trp_33_18  
Hoffmann syndrome is a rare and reversible neurological manifestation of primary hypothyroidism presenting as proximal myopathy and hypertrophy of muscles. It usually presents late in the course of the disease. We hereby present the case of a young male who presented with long-standing weakness and fatigue in the lower limb. He was diagnosed to have proximal muscle weakness and pseudohypertrophy of calf muscles due to primary hypothyroidism. The muscle hypertrophy and muscle weakness receded following hormone replacement therapy with thyroid hormones. Such presentation can raise diagnostic dilemmas for us as clinicians. Hence, this case report emphasizes on simple screening of patients for hypothyroidism who present with symptoms of myopathy.
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Down syndrome with Graves' disease: A lesser thyroid association p. 45
Sonali Sahani, Deepa Kulkarni, Pratishtha Mishra, Namrata Gupta, Madhukar Mittal
DOI:10.4103/trp.trp_40_18  
Down syndrome is a common cause of mental retardation in pediatric population. These individuals also have increased prevalence of both endocrine and nonendocrine autoimmune disorders with thyroid disorder being the most common endocrine disorder reported. Autoimmune disorders in these patients are associated with early presentation. Hypothyroidism is the most common autoimmune thyroid disease while Graves' disease is rare in patients of Down syndrome. We hereby present a case of Graves' disease in a patient with Down syndrome that clinically presented with symptoms of hyperthyroidism. Early definitive treatment is recommended in view of challenges of compliance to treatment in these mentally challenged individuals.
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Follicular variant of papillary carcinoma thyroid occurring in struma ovarii p. 48
Averilicia Passah, Nishikant Avinash Damle, Saurabh Arora, Ritesh Kumar, Chitresh Kumar Sharma, Prashant Ramteke, Chandrasekhar Bal, Madhavi Tripathi
DOI:10.4103/trp.trp_41_18  
We present the case of a 35-year-old female who presented with abdominal pain and irregular menstrual bleeding. The patient was found to have a left adnexal lesion on ultrasonography and contrast-enhanced computed tomography. Based on the preoperative imaging and biochemical workup, a left ovarian cystectomy was done. Histopathology (HPE) revealed follicular variant of papillary carcinoma thyroid in a background of struma ovarii. The patient then underwent total thyroidectomy. HPE showed no malignancy in the thyroid gland. After achieving the desired level of thyroid-stimulating hormone, postoperatively, the patient underwent a diagnostic I-131 whole-body scan (WBS) which revealed remnant thyroid tissue in the neck only. The patient's remnant thyroid tissue was ablated with I-131. Follow-up at 6-month interval revealed normal ultrasound pelvis, no abnormal uptake in diagnostic I-131 WBS and serum thyroglobulin (Tg), and anti-Tg antibody levels within normal range.
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LETTER TO THE EDITOR Top

Trimester-specific reference ranges for thyroid function tests in South Indian women p. 51
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/trp.trp_52_18  
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