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Year : 2020  |  Volume : 17  |  Issue : 1  |  Page : 27-42

ITSCON 2019 Abstracts

Date of Web Publication24-Apr-2020

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0973-0354.283222

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How to cite this article:
. ITSCON 2019 Abstracts. Thyroid Res Pract 2020;17:27-42

How to cite this URL:
. ITSCON 2019 Abstracts. Thyroid Res Pract [serial online] 2020 [cited 2022 Dec 6];17:27-42. Available from: https://www.thetrp.net/text.asp?2020/17/1/27/283222

  Detecting known driver mutations and levels of long noncoding RNAs in differentiated thyroid cancer Top

Susmita Dutta, Suvrendu Sankar Kar, SohamTarafdar, Debanu De, Saikat Chakraborty, Keya Basu, Nitai P. Bhattacharyya, Sujoy Ghosh

Phd Fellow (Medical), Institute of Post Graduate Medical Education and Research, SSKM Hospital, Kolkata, West Bengal, India

E-mail: [email protected]

Background: Thyroid cancer, commonest endocrine malignancy, is caused by multiple genetic and epigenetic changes leading to alterations in signalling pathways. If diagnosed early and treated surgically prognosis is excellent. However, diagnosis of malignancy and decision of surgical removal guided by Fine-Needle Aspiration Cytology (FNAC) can be problematic due to inconclusive reports as a result of inadequate sample, classification as atypia /follicular lesion of undetermined significance and Follicular neoplasm/ suspicious for follicular neoplasm.

Objective: To detect a panel of known driver mutations and levels of long non-coding RNAs in plasma of suspected patients.

Methodology: Patients attending Nodule clinics of IPGMER presenting with solitary thyroid nodule and provided consent were recruited. Detailed history, clinical examination and ultrasonographic findings following TIRADS were recorded. About 5 ml blood, FNAC samples and surgically removed tissues, whenever available, were collected. Cell free DNA/RNA was isolated from plasma was isolated DNA/RNA from FNAC samples and tissue was isolated using standard in house methods. Hotspot mutations in BRAF, NRAS and HRAS were detected by allele specific PCR primers. Levels of lncRNA PVT1 were detected by reverse transcriptase mediated PCR.

Results: We recruited (62) patients, based on FNAC (15) with malignancy of which (6) tumors were removed surgically. Mutations BRAF (V 600 E), NRAS (Q 61 R) and HRAS (G 12 V) were detected in 3 samples; one of them was in non-diagnostic category; in 2 cases had confirmed malignant diagnosis after surgery. A combination of cytology and molecular testing showed significant improvement in the diagnostic accuracy and allowed better prediction of malignancy in the nodules with indeterminate cytology. Besides, levels of PVT1 in plasma was identified; levels were absent in most of the non-malignant cases.

Conclusions: We established proof of concept that mutation detection in plasma can help making decision for the surgeons.

  Role of color flow Doppler ultrasonography in the diagnosis of thyrotoxicosis Top

Tauseef Nabi

Department of Endocrinology, GMC, Srinagar, Jammu and Kashmir, India

E-mail: [email protected]

Background: Differentiating various etiologies of thyrotoxicosis like Gravesma can help makfromthyroiditis is important in planning the specific treatment. Though 99mTc pertechnetate uptake scan is a frequently used for differentiate, but its limited availability and some contraindications has led to use of other modalities such as color flow doppler (CFD) ultrasonography.

Objective: To assess the usefulness of CFD ultrasonography in the diagnosis of various causes of thyrotoxicosis compared with 99mTc thyroid uptake scan.

Patients and Methods: This was a hospital based prospective study done on consecutive 65 treatment naive thyrotoxic patients attending the Endocrinology. Various clinical, biochemical parameters, Thyroid function test and 99mTc thyroid scanning were obtained. Conventional utrasonography and CFD study were performed by experienced radiologist using a 7.5 MHz broadband linear transducer. Peak systolic velocity (PSV) in the inferior thyroid arteries were obtained on both right and left side.

Results: 46 patients had GD [males 17 (37%), females 29 (63%)] and 19 patients had thyroiditis [males 4(21%), females 15(79%)]. Blood glucose, lipid profile and calcium profile did not differ between GD and thyroiditis. T3/T4 ratio less than 20 was seen in 94% patients with thyroiditis but was also seen in 69% patients with GD. Mean Total T3 and T3/T4 ratio of 20 helped in differentiating two groups (p = 0.037). 99mTc thyroid uptake percentage in patients with GD was 43.052 2 c thyroid uptake percentage in patients with p <

0.001). Mean systolic velocity of inferior thyroid artery (m PSV-ITA), with cut off 30 cm/sec was appropriate to differentiate between GD and thyroiditis with sensitivity and specificity 91% and 89%, respectively. For 99mTcuptake scan, with cut off 7% had sensitivity and specificity of 100% and 89% respectively. Significant correlation between PSV-ITA and serum total T3 levels (r = 0.52; p = 0.001).

Conclusion: CFD ultrasonography is as good as 99mTc nuclear imaging in the differential diagnosis of GD from thyroiditis.

Keywords: 99mTc pertechnetate uptake scan, color flow Doppler, Graves anoiditis, thyroiditis, thyrotoxicosis, ultrasonography

  Robotic assisted breast-axillo insufflation thyroidectomy: A novel approach Top

P. Sandeep Nayak1,2, Abhilasha Sadhoo1,2,G. Bharath1,2

1Department of Surgical Oncology, Fortis Hospital, Gurgaon, Haryana,2MS Surgical (Surgery) MACS Clinic, Jayanagar, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Conventional operations for thyroidectomy adopted trans-cervical scar which was disfiguring and caused postoperative morbidities. Different techniques of scarless thyroidectomies have been described by various authors.[1,2] The advent of surgical robots has provided a newer approach to performing minimally invasive head & neck surgeries.[2],[3],[4]

Materials and Methods: We define a new technique of performing robotic thyroidectomy called robotic assisted breast-axillo insufflation thyroidectomy (RABIT). RABIT involves the use of the da Vinci robotic system with CO2 gas insufflation & using 5 ports. We use single docking to approach both the lobes and lymph nodes dissection when needed.

Results: We have performed 12 cases RABIT till date with excellent cosmetic results and minimal visible or hidden scar in the axilla. Our mean duration of surgery was 118 min, docking time was 38 min & mean blood loss was 22 ml. The oncological outcomes in the postoperative radioiodine scan has been acceptable. The cosmetic results were excellent along with better surgeon comfort and vision quality.

Conclusion: RABIT is a safe and effective technique for patients desiring scar free thyroidectomy. The surgeons have an advantage of better vision and single docking for total thyroidectomy.

Keywords: Robotic, scarless, thyroidectomy

  References Top

  1. Hüscher CS, Chiodini S, Napolitano C, Recher A. Endoscopic right thyroid lobectomy. Surg Endosc 1997;11:877.
  2. Lee J, Chung WY. Robotic thyroidectomy and neck dissection: Past, present, and future. Cancer J 2013;19:151-61.
  3. Chung WY. The evolution of robotic thyroidectomy: From inception to neck dissection. J Robot Surg 2011;5:17-23.
  4. Sung ES, Ji YB, Song CM, Yun BR, Chung WS, Tae K. Robotic thyroidectomy: comparison of a postauricular facelift approach with a gasless unilaterall axillary approach. Otolaryngol Head Neck Surg 2016;154:997-1004.

  Nivolumab induced thyroid dysfunction Top

Lohit Kumbar, S. Chitra, P. Ganavi

Department of Endocrinology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India

E-mail: [email protected]

Nivolumab acts by blocking ligand activation of programmed cell death 1(anti-PD-1) receptor on T cells. Its effects on thyroid gland can result in hypothyroidism (7%), hyperthyroidism (1%), and thyroiditis (<1%), mostly developing around week 12 after start of therapy. We report a case of nivolumab-induced thyroid dysfunction.

Case Report: A 41 year old male came with diagnosis of adenocarcinoma lung with leptomeningeal metastasis. Patient received chemotherapy with nivolumab at 240 mg dose weekly for 4 weeks. Following 4th cycle of nivolumab, patient developed weight loss, progressive fatigue, excessive sweating, palpitations and tremors. On examination tachycardia with tremors and nontender diffuse goitre noted. Investigations revealed TSH <0.005 mcIU/ml, T4 > 24.9 mcg/dl, T3 4.37 ng/ml. Thyroid scintigraphy revealed decreased uptake s/o thyroiditis. Patient was started on propranolol following which symptoms subsided. After 5th cycle of nivolumab patient developed giddiness, easy fatigability, anorexia and reduced alertness. Ankle edema and bradycardia noted with no focal neurological deficits. Investigations revealed TSH 62.32 miu/ml, T4-4.02 mcg/dl. Patient was started on levothyroxine 50 mcg/day. But, patient again presented with similar symptoms after 6 cycles of nivolumab. TSH done was 40.58 and T4-4.86 mcg/dl. An 8 am cortisol was 10.2 mcg/dl. Hence nivolumab induced hypophysitis was ruled out. Levothyroxine dose was increased to 75 mcg/day. Presently patient is better with levothyroxine 75 mcg and TSH 2.69 mciu/ml.

Discussion: Because of high incidence of hypothyroidism in course of anti-PD-1 treatment, monitoring TFTs is of value. Mechanisms underlying immune-related thyroid dysfunction is not fully characterised. This can be ascribed to disinhibition of CTLA-4 and PD-1 which might exacerbate hypothyroidism and/or thyroiditis. Adrenal insufficiency is uncommon with PD-1 antibodies, hence no recommendation for routine monitoring.

Conclusion: Since the number of patients treated with nivolumab is expected to increase in due course of time, our case report creates awareness of this endocrine effect.

  Prophylactic central lymph node dissection in the clinically node-negative papillary thyroid carcinoma: Is it beneficial? Top

Girish Mysore Suresh, Ravi Arjunan, Rajshekar Hulkud1, C. Ramachandra, Syed Altaf

Departments of Surgical Oncology and1Head and Neck Oncology, Kidwai Cancer Institute, Bengaluru, Karnataka, India

E-mail: [email protected]

Objective: Surgery is the treatment of choice in Papillary thyroid cancer (PTC) which frequently has metastases in the Central compartment lymph nodes (CLN). There is debate among surgeons whether removing normal appearing lymph nodes in the central neck (prophylactic lymph node dissection) is better than removing only the abnormal appearing lymph nodes. Herein, we review the potential utility of CLN dissection (CLND) on surgical outcome in the Clinically Node-Negative (cN0) PTC and disease-free survival (DFS) of PTC and 7-year overall survival (OS) was analyzed.

Methods: A total of 268 patients from november 2008 to august 2011 who were treated for PTC in our Kidwai Cancer Institution was analyzed retrospectively.141 patients who underwent total thyroidectomy and CLND were assigned to Group -A which was compared with 124 patients who received total thyroidectomy, without CLND who were assigned to Group –B by evaluation of postoperative complications (Recurrent laryngeal nerve damage, hoarseness, hypocalcemia, and hemorrhage rates) and recurrence at 84 months follow up. Pearson chi-square and odds ratio for categorical variables were used in the univariate analyses and Kaplan Meir curve was plotted of the clinical characteristics using SPSS version 22. P value <0.05 was considered as statistically significant.

Results: In the present study Mean DFS was better in Group -A in Male gender (95% Confidence Interval (CI) 43.441- 52.901 mean 48.171 p= 0.04) and age more than 45 years (95% CI 40.222- 46.939 mean 48.171 p= <0001) which was statistically significant but without any impact on OS compared to Group -B. There was a significant postoperative complication in Group A compared to Group B (p= <0.001) with a very minimal recurrence in the central neck (6/124(4.8%) in Group B).

Conclusion: Comparing the significant postoperative complication which overweighs benefit we conclude that for cN0 PTC routine CLND is not necessary.

  Management of tracheal invasion in differentiated thyroid cancer Top

Suraj Manjunath

MS. MCh (SURGICAL), Vikram hospital, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Extrathyroidal extension of differentiated thyroid cancer occurs in 6 to 13 per cent of cases and is a marker of poorer prognosis. The trachea is the third most common organ involved after strap muscles and recurrent laryngeal nerve. Surgery with negative margins is a fundamental goal of treatment.

Objective: Evaluation of various surgical techniques of management of tracheal invasion during thyroidectomy for differentiated thyroid cancer.

Methods: Retrospective case series from October 2006 to December 2018.

Results: Out of a total of eleven evaluable patients, four underwent shave excision, three underwent window resection, and four underwent sleeve (circumferential) resection with primary end to end anastomosis. Two of these patients also underwent tracheostomy. There was no mortality in this series. Clinical presentation, pre-op workup, classification, technique (with operative photographs) and outcomes are discussed.

Conclusion: Management of tracheal invasion should be part of armamentarium of surgeons who operate on patients with thyroid cancer. Surgical approach should be tailored to the individual case.

  Multiple myeloma masquerading as anomalous TFT Top

P. Veechika, S. Chitra

Department of Endocrinology, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Highly sensitive immunoassays are the most commonly employed tests for the diagnosis of thyroid disorders. Though the sensitivity is high the specificity is affected by various antibody interferences. Such antibody interference lead to the diagnosis of multiple myeloma in our case.

Case Presentation: A 52 year old male was referred with a history of weight loss over 10 kg in a month associated with excessive sweating. There was mild pallor, tachycardia with no other signs of thyrotoxicosis. Investigations by his primary care physician revealed a TSH : 4.06 uIU/ml T4 : 5.42 ug/dl T3 : >456 ng/dl performed by one step immunoassay with FT3 : 2.93 pg/ml FT4 : 1.01 ng/dl. He was referred to rule out thyrotoxicosis in view of confusing thyroid function tests and clinical presentation. Considering the causes of euthyroid hyperthyroxinemia, we repeated the TFTs by a different assay method( two-step immunoassay) which revealed a TSH : 1.28 uIU/ml T3 : 41.91 ng/dl, T4 : 5.82 ug/dl FreeT3 : 1.68 pg/ml FreeT4 : 0.8 ng/dl. His routine investigations were significant for a Hb : 8.3 g/dl and globulin : 10.3 g/dl. His serum electrophoresis showed IgG kappa monoclonal gammopathy.

Discussion: Thyroid hormone autoantibodies interfere with thyroid hormone assay and can lead to spuriously high or low levels depending on the method of assay employed. The discordant thyroid hormone values in our case by different assay methods implies the presence of interfering antibodies. Though two step immunoassays are considered to be insensitive to interferences, our case reported a spuriously low T3 in this setting. THAABs are usually polyclonal IgG subclass with occasional cases of monoclonality, as in the setting of multiple myeloma. Our case is the first to report a IgG monoclonal antibody binding preferentially to analogue T3. This case highlights the importance of identifying antibody interference as a cause of euthyroid hyperthyroxinemia and hypothyroxinemia.

  Abstract for Oral Presentation Top

  Serum Fibroblast Growth Factor 21 levels in patients with Hyperthyroidism and its association with body fat percentage Top

Aashish Reddy

DM Senior Resident (Medical), Department of Endocrinology,

M S Ramaiah Medical College, Bengaluru, Karnataka, India

E-mail: [email protected]

Background: Most of the actions of thyroid hormone on body metabolism like maintenance of basal metabolic rate (BMR) and body fat are similar to that of FGF21. We hypothesized that in patients with hyperthyroidism, the pathological changes in the BMR and body fat are mediated by thyroid hormone through FGF21.

Objectives: To study the association of serum FGF21 levels with hyperthyroidism and correlate body fat percentage with serum FGF 21 levels in hyperthyroid patients.

Study design: Case-control prospective follow up study.

Methodology: A total of 68 hyperthyroid patients and 63 age, sex-matched healthy controls who fulfilled the inclusion and exclusion criteria were studied. Among them, 45 cases were followed up at 3 to 6 months after achievement of euthyroidism. Body fat percentage was calculated from Jackson and Pollock 3 site equation and Siri equation. BMR percentage was calculated by Gale formula. Serum FGF21 levels were determined using the ELISA method.

Results: The mean age in years in the cases was similar to that of controls (36.14 ±10.01 vs. 36.57±10.53, p=0.81).The serum FGF 21 levels at baseline were significantly elevated in patients with hyperthyroidism compared to controls [ median 406.6 pg/ml (262.9-655.6) vs 252.3(125.1-341) p <0.001] and declined following treatment with antithyroid drugs [405 (275.5-680.4)vs203.6(154.6-230.6)p<0.001] .Serum FGF21 levels negatively correlated with body fat percentage ( r= -0.268 p=0.002) .After adjusting for various confounding factors, serum FGF21 was independently associated with hyperthyroidism.(OR [95 %CI] 3.78(1.046-13.666)p =0.043).

Conclusion: Serum FGF21 levels were elevated in hyperthyroid patients and decreased following treatment with antithyroid drugs. It is independently associated with hyperthyroidism. FGF21 may be responsible for the pathological increase in BMR percentage and decrease in body fat percentage. So there may be a future therapeutic role of FGF21 inhibition in the reversal of these changes in addition to antithyroid drugs in patients with hyperthyroidism.

  Radio iodine therapy for hyperthyroidism: A single centre retrospective data Top

Aneesh Ghosh

Sr Consultant, Endocrinology and Metabolism (Surgical), Ananthapuri Hospitals and Research Centre, Thiruvananthapuram, Kerala, India

E-mail: [email protected]

Objective: To share our experience with radio-iodine (I-131) therapy for hyperthyroidism focussing on efficacy, safety and the long term outcomes.

Methods: Retrospective single arm cohort study from a tertiary care center in Southern India. Adult patients with hyperthyroidism eligible for I-131 having at least 12 months of medical records post I-131 therapy were included in the data analysis. Descriptive statistics were used for overall analysis.

Results: 50 patients were included in the analysis (females :44) with a mean age of 35.9 years (SD 7.8 years). The mean duration of the disease at the time of presentation was 21.4 months (SD 9.5 months). Eighty-six percentage of patients had received antithyroid drugs (66% Carbimazole and 20% Methimazole) before being considered for I-131 and other patients (14%) received I-131 as the primary mode of therapy due to compelling reasons. Adverse drug reactions (10%), relapse (66%) and failure to achieve remission (10%) were the reasons for I-131 therapy in patients who received prior anti-thyroid drugs. Eighty six percentage of patients were having diffuse goiter and 12% patients were having one or more small ( up to 1 cm) and benign nodules in the ultrasonogram. All patients were having uniform tracer uptake in the Technetium Thyroid (99Tc) scan [range 3% to 8%; mean: 5.9% (SD 1.3%)]. The dose of I-131 was calculated based thyroid volume and99Tc uptake [range 8 mCi to 15 mCi; mean: 12.2 mCi (SD 1.73 mCi)]. Overall 88% of patients achieved cure with the first dose and the rest of the patients did so with a second dose of 16 mCi of I-131.The time to therapeutic response varied [range 6 weeks to 12 weeks; mean: 9.2 weeks (SD 1.4 weeks)]. At one year follow up, 94 % of patients were on thyroxin replacement and rest remained euthyroid without any medications. Neck and throat pain (8%) and dry mouth with altered taste (4%) were the common side-effects.

Conclusions: Radio-iodine therapy is a safe and effective method in the management of hyperthyroidism. Majority of the patients had responded to the first dose with minimum side-effects. Most of the patients were on thyroxin replacement at 1 year follow up.

  Thyroid symptom scoring index – An authentic validation of thyroid function tests? - A prospective comparative study from a Government General Hospital in South India Top

Smitha Rao

Resident (Surgery), Department of Endocrine Surgery, Madras Medical College, RGGH, Chennai, India

E-mail: [email protected]

Background: Thyroid disease has myriad manifestations. Thyroid disorders present with multiple symptoms pertaining to hyperthyroidism or hypothyroidism. Various scoring indices have been tried and tested in the past. Thyroid function tests are regarded as the best method of diagnosing biochemical abnormalities in the recent days.

Objective: To validate the Clinical Symptom Scoring Index for thyroid disorders using TSH and FT4.

Methods: The Clinical Symptom Scoring Index was given to 101 patients presenting to our outpatient department with various thyroid-related complaints. They were then subjected to Thyroid function testing(TSH and Free T4) and classified accordingly.

Results: There were 40 hyperthyroid, 20 euthyroid and 41 hypothyroid subjects. The most frequent findings in the biochemically hyperthyroid group were weight loss(75.6%), increased appetite(39%), easy tiredness (90%), palpitations (93%), and tremors(68): in the euthyroid group, easy tiredness (40%), thyroid enlargement (60%), and irritability (10%); in the hypothyroid group, easy tiredness (17.5%), weight gain (25%) and constipation (48%). The Clinical symptom scoring index for thyroid disorders has a sensitivity of 85%, specificity of 89%, and accuracy rate of 87 %, with AUC of 0.865 on ROC analysis for the detection of hyperthyroidism. For detecting hypothyroidism, it has a sensitivity of 65%, specificity of 58%, and accuracy rate of 62%, with AUC 0.565 on ROC analysis.

Conclusion: The Symptom scoring index for thyroid disorders was found to have good sensitivity, specificity and accuracy rate when correlated with TSH and FT4 for the detection of hyperthyroidism. Traditional scores are still valuable inorder to consider patients for thyroid function testing. In the third world countries, with very minimal resources, these score indices can help in choosing the patients for biochemical evaluation, thus reducing the load on referral centres.

  Urinary iodine status among autoimmune and nonautoimmune thyroid disease patients in Costal Odisha Top

Kishore Kumar Behera, Sahu Suchanda1, Sahu Madhusmita, Hota Debasish2

Departments of Endocrinology,1Biochemistery and2Pharmacology, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India

E-mail: [email protected]

Objective: The aim of the present study was to assess the urinary iodine concentrations among the subjects of autoimmune and non-autoimmune thyroid patients.

Methods: The study was conducted in subjects with autoimmune thyroid disorder (AITD; n= 95), subjects with non-autoimmune thyroid disorder (NAITD, n=31). The comparator group was age and sex matched healthy euthyroid volunteers (n=29) attending Endocrinology out patient's department, AIIMS Bhubaneswar. Serum free thyroxine (FT4), thyroid peroxidase antibody (TPO Ab) and thyroid stimulating hormone (TSH) were estimated by chemiluminescent immunoassay (CLIA). The median urinary iodine concentration (UIC) in was estimated by ammonium persulfate digestion method recommended by the WHO.

Results: Median urinary iodine concentration was significantly lower in the AITD group compared to control (42.68 ± 20.06 μg/L vs. 57.55 ± 20.66 μg/L respectively, P<0.001). Comparing the values between AITD and NAITD (23.16 ± 20.16 μg/L), there was significant difference in the urinary iodine concentrations. Between the NAITD and control groups, the median iodine concentration was significantly different (P <0.001). It was also observed that, 64% NAITD patients were severe iodine deficient as compared to 16% in the AITD group. Interestingly, none of the patients in all 3 groups was with optimal iodine levels. According to iodine nutrition status, AITD subjects, 51 (53.68%) were significantly moderate iodine deficient compared to control, 10 (34.48%) p=0.003 and AITD group, 08 (25.80%) p=0.01. NAITD subjects, 20 (64.51%) was observed a statistically significant severely iodine deficit when compared with AITD,15 (15.78%) p=0.01.

Conclusion: None of these three groups were in optimal iodine nutrition state as assessed by UIC. Subjects in the NAITD group were more iodine deficit than the AITD and control groups.

  Role of thyroglobulin antibodies in the long term follow up of differentiated thyroid cancers: A case series Top

S. Chitra, Satinath Mukhopadhyay1

Department of Endocrinology, M. S. Ramaiah Medical College, Bengaluru, Karnataka,1Department of Endocrinology, IPGME and R, Kolkata, West Bengal, India

E-mail: [email protected]

Introduction: Serial estimation of serum Thyroglobulin (Tg) levels is a commonly employed tool to monitor recurrence of differentiated thyroid cancers (DTC), post thyroidectomy and ablation. Measurement of Tg is affected by the presence of thyroglobulin antibodies (TgAb) depending on the assay platform. Since TgAb levels are sensitive to the mass of Tg producing tissue, the trend in TgAb levels itself can be used to detect remission or relapse of DTC. We present three case reports in which TgAb levels were used to identify recurrence in DTC. Patient 1 with papillary thyroid cancer, post total thyroidectomy and radioablation was on levothyroxine treatment. Till year 10, her Tg levels were suppressed while TgAb levels rose progressively (Year 1: 84 IU/ml, Year 3: 1403 IU/ml Year 10: 2931.3 IU/ml, Year 14: 3133 IU/ml). Radioiodine scan showed uptake in the neck nodes, which were resected and the patient radioablated again. TgAb levels fell to 667 IU/ml but started rising over the next two years to 890 IU/ml and 1028 IU/ml respectively. While iodine scan showed no uptake, 'FDG PET scan revealed uptake in mediastinal lymph nodes. Patient 2 had similar history with wide fluctuations in Tg measurements varying (0.01 to 8000 ng/ml) due to assay interference with TgAb. Progressive rise in TgAb levels resulted in detection of cervical lymph node recurrence. Patient 3 was interesting in that the titre of TgAb was not very high albeit showing a rising trend (Year 4: 6.76 IU/ml to Year 6: 13.52 IU/ml). A PET- CT fusion imaging confirmed mediastinal lymph node recurrence.

Conclusions: In patients with DTC being monitored for recurrence, presence of TgAb makes thyroglobulin assays difficult to interpret and follow up. In these patients, serial estimation of TgAb itself can be used to monitor DTC patients for remission or recurrence.

  Accidental levothyroxine ingestion in children: Review of four cases Top

Hanumantha Rao Maddukuri, Pramila Kalra, B. P. Karunakar

Department of Endocrinology, M S Ramaiah Medical College. Bengaluru, Karnataka, India

E-mail: [email protected]

Incidence of accidental levothyroxine ingestion in children has been increasing in the recent times mainly because of increasing prescriptions. We present four such cases, who presented to the paediatrics department in the past year.

Case Report: Four children, aged 2-14 years presented to the emergency department with accidental consumption of levothyroxine tablets, total strength ranging from 1000 to 3000 microgram. All were reported within half an hour to eight hours of consumption. Three of them were asymptomatic at presentation and one had one episode of vomiting. Gastric lavage was done and activated charcoal was given to all. Vitals were normal, except one had tachycardia for which the child received propranolol tablet for one-week duration to control heart rate. Baseline Free T4 was high and TSH was normal in all. They were admitted for observation for 2-6 days and later followed on outpatient basis.

Discussion: Ingestion of large dose of levothyroxine in children typically follows a benign course. Patients may be asymptomatic or have thyrotoxic symptoms and rarely significant complications, including seizures and arrhythmias. The severity of symptoms does not correlate with plasma levels of T4 and the onset of symptoms can be delayed for up to 6-11 days. Asymptomatic children can be monitored at home following gastrointestinal decontamination. In cases with severe symptoms, children should be monitored in the hospital for cardiac or neurological instability. Propranolol is used in the presence of features of toxicity.

Conclusion: Levothyroxine is colourful and palatable that can be attractive to young children. Gastric lavage and activated charcoal is mainstay of treatment in accidental levothyroxine ingestion in children.

  Are the Adrenals “hypothyroid/lazy” in severe hypothyroidism? Top

Swaraj Waddankeri1,2

1Department of Medicine, MR Medical College,2Anugraha Diabetes and Endocrinology Center, Gulbarga, Karnataka, India

E-mail: [email protected]

Background: Primary hypothyroidism is one of the most common endocrine disorder, prevalence is in the ranges of 3.8 - 10.9%. It has been estimated that about 42 million people in India suffer from thyroid diseases. With easier availability of the assays and better affordability we are able to diagnose and treat hypothyroidism much earlier. On the other end, we are seeing patients with TSH>100 at diagnosis, most of them done as a part of routine screening often with no other comorbidities.

Materials and Methods: The present case series is a descriptive and observational case study of 25 consecutive cases diagnosed on routine screening with TSH>100. We assessed the Zulweski clinical score, BMI, goitre grading as a part of the clinical examination. Biochemical evaluation included an 8 AM cortisol, prolactin and T3, T4 TSH. LT4replacement was started in all.

Results: The median age of presentation was 26.76 years and 96% were women. Weight gain was a presenting feature only in less than one third of the cases. The commonest feature of presentation was easy fatigability. Prolactin was elevated in 64% of the cases. 8 AM cortisol levels were normal in two-thirds of the cases. Three (12%) presented within 72 hrs of taking LT4 with fatigue, tiredness, headache and hypotension (all had low cortisol). They were managed with intravenous followed by oral hydrocortisone. On follow up, we could withdraw Hydrocortisone within a period of three months.

Conclusion: In this series, severe primary hypothyroidism was not associated with weight gain in most. Twelve percent of the cases had clinical and biochemical hypoadrenalism after levothyroxine therapy. Routine replacement with steroid is not indicated in all cases of severe hypothyroidism but when dealing with severe primary hypothyroidism as in our cases, a check on Cortisol and serum electrolytes is worth considering along with a careful watch for the clinical symptoms of hypoadrenalism in the first few days after starting levothyroxine treatment. Baseline 8 AM cortisol may help in predicting the precipitation of adrenal failure post levothyroxine.

  Thyroid malignancy - A surgical challenge Top

Balan Ashok kumar, S. M. Azeem Mohiyuddin,K. S. Gopinath

Department of Surgery, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India

E-mail: [email protected]

Thyroid malignancy pose a challenge to head and neck surgeon due to various problems like very large size of the tumor, pre existing recurrent laryngeal nerve palsy, retro-sternal extension, infiltration of important structures, multiple lymph node metastasis, stridor, etc. Surgery with post-op radioiodine ablation remains the main stay of treatment. We are presenting a series of 44 patients, 38 of whom had very large thyroid, 3 patients had pre-existing recurrent laryngeal nerve palsy and involvement of various important structures with lymph node metastasis. The problem encountering during surgery, complication and follow-up will be discussed in detail.

Conclusion: Thyroid malignancy presents with various surgical challenges but surgery and radioiodine ablation remain the main stay of treatment. They have excellent long-term prognosis after meticulous surgery.

  Prevalence and pattern of thyroid dysfunction among the tribal population of Kashmir Valley Top

Mohammad Ashraf Ganie, Hilal Bhat, Abid Ali, Madiha Niyaz, Ishfaq Ahmad Wani, Aafiya Rashid, Qaiser Farooq, Syed Mudassar, Sobia Nisar

Department of Endocrinology SKIMS, Srinagar, Jammu and Kashmir, India

E-mail: [email protected]

Introduction: There is scarce data on the incidence & prevalence of thyroid disorders in the tribal population of India. Some small studies among this section of population has depicted higher incidence of hypothyroidism than general population. There has been no attempt at estimating the burden of thyroid diseases among the tribals that comprise 10.9 per cent of population in the state of Jammu & Kashmir.

Objectives: To estimate the prevalence of thyroid dysfunction among tribal population of Kashmir valley and to estimate the urinary iodine concentration (UIC) and auto-antibody (Anti-TPOAb) among these people.

Methods: In a cross-sectional study tribal men and women in the age group of 5 years to 90 years were screened for thyroid dysfunction, antibody status and urinary iodine using health camps in the areas that are inhabited by this section of population. After written consent demographic and anthropometric data was obtained. Samples were collected for biochemistry, thyroid hormones, TPO-antibody and urinary iodine.

Results: The prevalence of subclinical hypothyroidism was 28.9 per cent (15.2 % men and 16.4 % women). The prevalence of overt hypothyroidism was 6.8 per cent (3.6 % men and 3.9 % women). The prevalence of autoimmunity (positivity anti-TPO Ab) was 17.1 % (8.2 % men, and 8.9% women). The mean urinary iodine was 191.25 μg/l in men and 178.86 μg/l in women. 25.7 percent subjects had UIC < 100 μg/l with 27 percent having UIC of 100-200 μg/l and 47.3 percent having > 200 μg/l.

Discussion: There is high prevalence of subclinical hypothyroidism in the tribal population of Kashmir valley although the prevalence of overt hypothyroidism is comparable to general population. This high prevalence of subclinical hypothyroidism may in part be the result high autoimmunity in this section of Kashmiri population which may be partly a result of high iodine intake as shown by there high UIC. Many factors may be responsible for this high iodine intake which include overestimation of iodine loss in transport from source hence delivering high iodine to consumer, high salt intake than general Kashmiri people because of cultural differences in food habits and unknown factors.

  Thyroidectomy in thyroid hormone resistance?? Top

Justin Easow Sam, Chitra Selvan

Department of Endocrinology, Ramaiah Medical College, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Resistance to thyroid hormone is a rare genetic disorder with impaired responsiveness of target tissues to the action of thyroid hormone (TH) associated with an increase in thyroid hormone levels, with non-suppressed thyroid-stimulating hormone (TSH) levels. We report a case of thyroid hormone resistance.

Case Report: 55 yr old gentleman, on tab carbimazole, presented with thyrotoxic symptoms with no eye symptoms and increase in size of neck swelling. The patient has similar symptoms for 10 years and has been on treatment since then with good compliance. He was toxic on examination and had a goitre 15 X 10 cm in size, nodular, non-tender, firm in consistency with retrosternal extension. Investigations showed an elevated TSH, T4, T3, free T4 and free T3. Ultrasound neck showed multinodular goitre. FNAC showed colloid goitre. α subunit, SHBG levels and MRI pituitary were normal suggestive of thyroid hormone resistance. Genetic analysis could not be done due to financial constraints. Due to the presence of large goitre with compressive symptoms, total thyroidectomy was done and the histopathology showed multinodular goitre. Postoperatively patient had remission of symptoms but continued to have non- suppressible TSH requiring a high dosage of levothyroxine supplementation (1.8 mcg/kg/day) with borderline elevated fT4.

Discussion: Thyroid hormone resistance is a rare entity with the usual management being symptomatic. Goitre is the most common presentation occurring in 65-95% of patients which is usually detected on ultrasonography. However, in our patient, the goitre was large enough to cause compressive symptoms and thus total thyroidectomy was advised. This case highlights the rare presentation of thyroid hormone resistance with large goitre.

Conclusion: Thyroid hormone resistance is an extremely uncommon condition which may rarely require thyroidectomy as a treatment in cases of large compressive goitres.

  Neuropsychological correlates of subclinical hypothyroidism Top

Pramila Kalra, D. R. Kumaraswamy1, Ravi Yadav2, Mala Dharmalingam, Jitender Saini3

Departments of Endocrinology and1Neuropsychology, M. S. Ramaiah Medical College, Departments of2Neurology and3Neuroimaging and Interventional Radiology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: There are conflicting studies about the presence of cognitive dysfunction in patients with subclinical hypothyroidism. It is prudent to identify subclinical cognitive abnormalities if any in patients with subclinical hypothyroidism to recommend/choose levothyroxine therapy.

Aims and Objectives: To study the neuropsychological abnormalities in cases with subclinical hypothyroidism and compare them with euthyroid controls.

Methods: Patients between 18 to 45 years of age, diagnosed with subclinical hypothyroidism with thyroid stimulating hormone (TSH) value between 4.5 to 10 mIU/L with normal T4 values were recruited. Controls were healthy age, gender and education matched. All the cases and controls underwent detailed neuropsychological assessment with a battery of validated tests for use in hypothyroid patients and age groups 18 to 60 years.

Results: Thirty nine patients with a mean age 30.28 ± 7.7 years (female: male ratio 13:1) and 23 controls (female: male ratio 21:2) with mean age 33.4±7.1 years (P = 0.2) were enrolled. The mean TSH value in cases was 6.36 ± 1.3 mIU/L and in controls was 2.49 ± 1.03 mIU/L (P < 0.001). Patients were clinically screened for any nutritional deficiencies, and Diabetes mellitus was ruled out by HbA1c testing (values less than 6.5%) in both cases and controls. The visual memory delayed recall which is a function of the right temporal lobe was abnormal in 46.2% (N = 39) cases as compared to 22.7% (N = 5) controls (P = 0.06). The category fluency test was abnormal in 35.9% (14) in patients as compared to 13% (n=3) in controls (p<0.05). The word recognition task was abnormal in 28.2%(n=11) as compared to 4.5% (n=1) in controls (p<0.05).

Conclusion: This study shows that patients with subclinical hypothyroidism have word recognition and category fluency deficits suggestive of dysfunction of the prefrontal cortex.

  Evaluation of thyroid blood flow parameters in differentiation of thyrotoxicosis Top

Swayamsidha Mangaraj

Department of Endocrinology, IMS and SUM Medical College, Bhubaneswar, Odisha, India

E-mail: [email protected]

Objectives: To evaluate the utility of peak systolic velocity of superior thyroid artery (PSV-STA) and a novel parameter (ratio of peak systolic velocity of superior thyroid artery to peak systolic velocity of common carotid artery (STA-PSV/CCA-PSV ratio) in differentiation of Graves' disease and thyroiditis presenting with thyrotoxicosis.

Methods: A total of 111 patients with newly diagnosed thyrotoxicosis without antithyroid medication or β-blockers use and 45 age and sex matched healthy subjects as control were included. Thyroid function tests and thyroid autoantibody titres were done. All subjects underwent a detailed color-flow Doppler ultrasonography of the thyroid gland and spectral flow analysis of thyroid and carotid arteries.

Results: On Doppler study, the mean STA-PSV of patients with Graves' disease was significantly higher than thyroiditis and control group ((92.79±44.95 cm/sec, 37.89±15.33 cm/sec, 20.07±6.77 cm/sec respectively (p<0.001). Similarly, STA-PSV/CCA-PSV ratio was significantly higher in Graves' disease (0.65±0.32) than thyroiditis (0.30±0.11) (p<0.001). STA-PSV greater than 54.275 cm/s had 82.9 % sensitivity and 86.2 % specificity in diagnosing Graves' disease. On the other hand, STA-PSV/CCA-PSV ratio (0.40) had a similar specificity (86.2%) albeit with a slightly lower sensitivity (80.5%) compared to STA-PSV.

Conclusions: The mean STA-PSV and STA-PSV/CCA-PSV ratio have high sensitivity and specificity in differentiating Graves' disease from thyroiditis and should be used routinely in clinical practice.

  Case series - Van Wyk Grumbach syndrome in North Karnataka Top

Meenakshi Waddankeri, Swaraj Waddankeri1,2

Departments of Paediatrics and1Medicine, MR Medical College,2Anugraha Diabetes and Endocrinology Center, Gulbarga, Karnataka, India

E-mail: [email protected]

Background: Juvenile hypothyroidism in young females with precocious puberty and multicystic ovaries was first described by Van Wyk and Grumbach in 1960. The exact prevalence of the syndrome is unknown and only sporadic case reports have been reported in the literature since then.

Materials and Methods: The present case series on this rare syndrome is an observatory and descriptive data of three cases of Van Wyk Grumbach syndrome who were referred to our center for evaluation of precocious puberty.

Results: The mean age of presentation was 9 year 1 month. Two cases presented with menarche as the main complaint, one with thelarche and menarche. On examination all had short stature (height < 3rd centile, weight < 3rd centile), delay of bone age by more than 3 years with high TSH, low T 3 and T4 at diagnosis. Prepubertal LH with high FSH confirmed the clinical suspicion. USG abdomen showed bilateral multicystic ovaries in two cases and one had only right-sided bulky ovary. One of the patients' MRI showed a Pituitary macroadenoma. MRI wasn't done in the other two cases due to financial constraints.

Conclusions: Precocious puberty, short stature, juvenile primary hypothyroidism and delayed bone age can be taken as a clinical quartet in diagnosing Van Wyk Grumbach and will always remain a diagnosis of exclusion. Levothyroxine is the treatment of choice and it normalizes all the other hormone levels post replacement along with anatomical changes (shrinking of the ovarian cysts and regression of the pituitary macroadenoma). Regular monitoring with thyroid function tests to maintain euthyroidism is of at most importance to provide a good quality of life.

Keywords: Precocious puberty, primary hypothyroidism, Van Wyk Grumbach

  Concordance between the thyroid imaging reporting and data systems ultrasound criteria and Bethesda cytology criteria and the incidence of histological surprises after thyroidectomy Top

Diviya Kariappa

Post Graduate (Medical), St Johns Hospital, Bangalore, Karnataka, India

E-mail: [email protected]

Introduction: Thyroid nodules are a common clinical problem. Epidemiologic studies have shown the prevalence of palpable thyroid nodules to be approximately 5% in women and 1 % is men. Thyroid Ultrasound (US) has considerably increased the number of cases identified. Several ultrasound features have are used to assign probabilities for risk stratification of thyroid nodules called as Thyroid Imaging Reporting and Data Systems (TIRADS).The Bethesda System for Reporting Thyroid Cytopathology is a standardized reporting system for classifying thyroid FNAC results that comprises six diagnostic categories with unique risks of malignancy and recommendations for clinical management. The Bethesda System has been widely adopted. But it is still unclear if each category also predicts the type and extent of malignancy.Although both US and FNAC are widely recommended procedures to study patients with thyroid nodules, the value of the existing concordance between the two methods has not been established. Consequently, the purpose of this study was to assess the existing concordance between the two diagnostic methods (TIRADS and Bethesda systems) and finally confirm the same by a histopathological examination.

Materials and Methods: This is a retrospective study of patients from 2015 to 2018, who presented to St. Johns Hospital, who underwent US imaging, FNAC and then subsequently surgery when required. The overall objective of study was to determine the level of concordance between TIRADS category and BETHESDA, along with the incidence of histological susses after hemi or total Thyroidectomy.

Results: Of the 120 patients who underwent US thyroid, followed by US guided FNAC, and subsequently surgery the incidence TIRADS and Bethesda showed a remarkable concordance.But in about 10 % of cases there was a discordance.

Conclusion: Although TIRADS criteria has a good concordance with the BETHESDA system, we did find histological surprises.

  Medullary cancer thyroid with neurogenic bladder and cholelithiasis: An unusual presentation of Men2b syndrome Top

Ajeet Tiwari

Department of Surgical Oncology, Kidwai Cancer Institute, Bengaluru, Karnataka, India

E-mail: [email protected]

Background and Introduction: Apart from the pathognomic features (Medullary cancer thyroid and pheochromocytoma) of Men2b syndrome less known manifestations associated with this syndrome have rarely been described.

Methods: We describe a case of Men2b syndrome that presented to us with complaints of neck swelling, neurogenic bladder and cholelithiasis.

Results: A 25 year old male was referred to our institute with complaints of neurogenic bladder and anterior neck swelling. He gave history of pain in abdomen since 5 years for which he was evaluated and diagnosed to have neurogenic bladder. Since then he was advised intermittent daily self catheterization at regular intervals. On clinical examination he had marfanoid habitus, extreme flexibility of fingers and upper limbs, neuromas over conjuntiva, anterior tongue, vocal cords and thyroid swelling. FNAC of thyroid swelling revealed features of Medullary carcinoma thyroid with serum Calcitonin levels 1248 pg/ml. MRI abdomen revealed left adrenal mass with raised urinary free metanephrines (confirming pheochromocytoma), cholelithiasis and dural ectasia with large distended urinary bladder and bilateral hydroureteronephrosis. Patient was first posted for pheochromocytoma with cholecystectomy and 2 weeks later for total thyroidectomy with functional neck dissection. Final histopathology confirmed diagnosis of medullary carcinoma and pheochromocytoma with neuromas in gallbladder. Patient has been on regular follow up since a year and is disease free. Patient is also being treated for neurogenic bladder and is currently having acceptable renal parameters.

Conclusions: Patients with Men2b syndrome can harbor microscopic neuromas in gallbladder which can lead to early chlolelithias. Also marfanoid habitus can result in dural ectasia which can lead to neurological problems such a neurogenic bladder which may go completely unrecognised in these patients and hence should always be part of complete clinical workup.

  Pediatric thyroid cancer Top

Darshan Patil

Department of Surgical Oncology, Kidwai Cancer Institute, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Pediatric thyroid cancer is a rare disease. Compared with adults, epithelial-derived differentiated thyroid cancer (DTC), which includes papillary and follicular thyroid cancer, presents at more advanced stages in children and is associated with higher rates of recurrence.

Materials and Methods: 8 yr old male child presented change of voice, stridor on rest, breathlessness on lying down. Diagnosis of Papillary carcinoma of thyroid was made on FNAC of thyroid swelling planned for total thyroidectomy with bilateral functional neck dissection. Investigations showed:

  1. TFT was suggestive of hypothyroidism with TSH of 13.77 mIU / L
  2. Neck X ray AP and lateral view showed tracheal compression
  3. Indirect laryngoscopy showed right sided vocal cord palsy
  4. Ct Scan of Neck and Thorax showed

    1. Nodules in bilateral lobes of thyroid , largest being 12 * 12 mm
    2. Multiple bilateral cervical, pretracheal , superior mediastinal, upper paratracheal nodes present , causing compression and narrowing of trachea at T 1 level
    3. Maximum narrowing at T 1 level – 3.4 mm.

Difficult airway cart was kept ready. As the lesion was adherent to trachea, tracheostomy could not be done. Cricothyrotomy was attempted, but airway could not be accessed. Finally laryngo fissure was done and 6.0 mm cuffed endotracheal tube inserted and bilateral air entry and ventilation confirmed. General anaesthesia with muscle relaxation was instituted and total thyroidectomy and bilateral functional neck dissection was done. Child was shifted to post anaesthesia care unit with tracheostomy tube in situ. Child was administered supplemental oxygen with a T piece. Post operative period was uneventful except for child developing symptomatic hypocalcemia which needed oral and intravenous calcium supplementation.

Discussion: There has been a substantial increase in the number of WDTC cases referred to our institution in recent years with more advanced TNM staging at the time of initial presentation. Despite the advanced disease in some cases, both local regional control and short-term outcomes are excellent with comprehensive thyroidectomy surgery, appropriate therapeutic neck dissections followed by adjuvant therapy.

  Parathyroid hormone assay following total thyroidectomy for early prediction of post-operative hypocalcemia Top

Raxith Sringeri

MCH Post-Graduate (Medical), St Johns Hospital, Bangalore, Karnataka, India

E-mail: [email protected]

Background: Detecting post-operative hypocalcaemia following total thyroidectomy using serum parathyroid hormone levels would help in an earlier and a definitive treatment plan in treating hypocalcaemia.

Methods: This was a prospective interventional study done in a tertiary care teaching hospital. This was mainly done to assess the post-operative hypocalcemia following total thyroidectomy using parathyroid hormone levels and to assess the correlation between the two. With a baseline levels recorded patients underwent a post-operative evaluation of parathyroid hormone 1 hour after total thyroidectomy and serum calcium levels on day 1, 2, 3 and 4 after surgery. The same was statically analyzed to find a correlation between parathyroid hormone levels and the degree of hypocalcemia and evaluated to see if parathyroid hormone was a reliable clinical indicator.

Results: A total of 30 patients were included in the study and the parathyroid hormone levels were assessed following surgery, the same was plotted statistically. Sensitivity of parathyroid hormone drop by 75% in predicting hypocalcaemia was 95%. 50% drop in parathyroid hormone levels was a sensitive predictor of hypocalcaemia. A PTH value of less than 15.1 pg/ml was highly specific and sensitive indicator of hypocalcaemia.

Conclusions: Parathyroid hormone Assay following total thyroidectomy is reliable for early prediction of hypocalcaemia. Patients with a parathyroid hormone level <9 pg/ml or with 75% drop in parathyroid hormone level are at a high risk for hypocalcaemia and would require calcium supplementation.

  Refractory hypoglycemia in an infant with severe primary hypothyroidism Top

Shreya Sharma

Fellowship in Pediatric Endocrinology, Bai Jerbai Wadia Hospital for Children, Mumbai, Maharashtra, India

E-mail: [email protected]

Introduction: Isolated hypothyroidism as a primary cause of hypoglycaemia is not a well known phenomenon. The following case illustrates how isolated severe primary hypothyroidism can lead to symptomatic refractory hypoglycaemia as part of myxoedema crisis complex.

Case Details: 6 months old female infant with undiagnosed congenital athyreosis, presented with pseudo-intestinal obstruction and myxedema crisis i.e. fluid refractory hypotension, hypothermia, relative bradycardia and hypoglycemia. The hypoglycaemia was refractory, requiring high glucose infusion rate, stress dosing of steroids, carbohydrate loading for 72 hours, and inotropes to tide over the crisis. Critical sample revealed an appropriate cortisol and insulin response to hypoglycaemia, and screen for inborn error of metabolism was negative. The hypoglycemia resolved on thyroxine replacement and the child has shown significant catch up in growth and development on 2 years of follow up, with no repeat episode of hypoglycaemia.

Message: Thyroid axis must not be neglected in the evaluation of persistent hypoglycemia as isolated severe primary hypothyroidism may precipitate hypoglycemia in the absence of other pituitary or adrenal hormone deficiencies.

Keywords: Hypoglycaemia, hypothyroidism, infant, myxoedema crisis

  Hypothyroidism in the presence of elevated T3 - Significance of transporter proteins Top

C P Patanjali

DM 3rd Year Resident (Medical), St Johns Hospital, Bangalore, Karnataka, India

E-mail: [email protected]

Introduction: Thyroid hormones are essential for normal growth and functioning of all organs and tissues in the human body. They are particularly important for appropriate neuronal development during infancy and early childhood. Thyroid hormones mediates its' action via binding of intra-cellular T3 to the thyroid specific nuclear receptor. Inability to transport T3 into the cell can have detrimental effects in the central nervous system as seen in patients with mono carboxylate transporter 8 (MCT8) deficiency, which is the protein involved in neuronal uptake of T3. This was initially reported in 1944 as part of X-linked mental retardation syndromes and was eponymously named “ Allan-Herndon-Dudley syndrome More Details”.

Case Report: A 25 month old male child was referred to Endocrinology for interpreting thyroid function abnormality detected while being evaluated for global developmental delay (GDD). The patient was extensively evaluated in view of the severe cognitive and motor developmental delay. Routine blood screens including hemogram, renal and liver function tests were normal. Work up for inborn errors of metabolism including organic aciduria were negative. A repeat electroencephalography was done which was also normal. Neuroimaging with MRI scan revealed mild cerebral atrophy with evidence of hypomyelination. Thyroid function tests (TFT) showed slightly elevated TSH, slightly low FT4 levels and elevated FT3 levels. In view of GDD, central hypotonia, peripheral spasticity with hyperreflexia, asthenic built, and persistently elevated T3 levels with low T4 and slightly elevated TSH levels, we suspected the possibility of Allan Herndon Dudley syndrome in our patient. In order to confirm our diagnosis, we analysed the SLC16A2 gene on the X chromosome which codes for the MCT8 protein using next generation sequencing. The genetic test revealed a hemizygous missense variant [c.1468G>A; p.Gly490Arg; rs794727799] in exon 6 of the SLC16A2 gene in the patient.

Conclusion: Males presenting with congenital hypotonia, cognitive impairment with motor delay, and peripheral dystonic movements should be evaluated with TFTs which include TSH, T4 or FT4 and T3 or FT3. The signature pattern of AHDS - elevated T3/FT3, low or low normal T4/FT4, and normal to slightly elevated TSH should prompt further confirmation with a genetic test. Early detection of AHDS enables early treatment initiation which may hold promise for better outcomes.

  An observational study of headache characteristics in Indian patients with primary hypothyroidism Top

Pramila Kalra, Ravi Yadav1

Department of Endocrinology, Ramaiah Medical College and Hospitals,1Department of Neurology, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: There are no studies that have systematically evaluated the headache characteristics in Indian patients with primary hypothyroidism and the existence of “hypothyroidism attributed headache” in Indian patients.

Aims and Objectives: To clinically characterize the headache in patients with primary hypothyroidism. The disorder that is known as “headache attributable to Hypothyroidism” has been included in International headache society diagnostic criteria in International Classification of Headache Disorders (ICHD III).

Methodology: The patients with newly diagnosed primary hypothyroidism were included in the study . A detailed history regarding headache including headache onset, type, severity by visual analogue scale, MIDAS score, site, diurnal variation, exacerbating factors, any associated symptoms, drug history was elicited and recorded.

Results: The total number of patients were 50 and the mean age was 32.2±11.2 years .The mean TSH was 45.5±53.8 mU/L . There were 46 (92%) females and 4(8%) males. Headache was present in 29 (58 % ) subjects .The headache attributable to hypothyroidism was seen in 24(48 % ) subjects. The visual analogue scale for severity of headache was 3.9 ±1.2.The average duration of headache in all subjects and in subjects with headache attributable to hypothyrodism was 156.2±221.6 and 38.6±24.9 days respectively .Forty percent of the patients had daily headache while 26.7% had persistent headache followed by twice a week and twice a month in 13.3% and once a week in about 6.7%.

Conclusion: Headache was seen in about 48 percent of our patients who presented with hypothyroidism and was mild to moderate in severity. The commonest type of headache seen was daily headache and with an average onset duration of 38 days .The patients presenting with headache need to be screened for hypothyroidism.

  Long term anti-thyroid drug use in Graves disease: A questionnaire based study of endocrinologists in Southern India Top

Subramanian Kannan

Endocrinologist, Narayana Health City, Bangalore, Karnataka India

E-mail: [email protected]

Objective: It is generally suggested that after a period of 12-18 months of anti-thyroid drug (ATD) use for Graves Disease (GD), the options of definitive therapy including Radio-iodine ablation (RIA) or surgery (TT) be considered. However continued long term use of ATD is gaining popularity. We proposed to study the clinical characteristics of patients who have been on long term ATD.

Methods: We issued a mobile based e-questionnaire that could be filled up using a web-application called Epicollect to a group of Endocrinologists. The inclusion criteria was patients diagnosed with GD who have been on ATD >12 months and had not received radio-iodine or undergone thyroid surgery. Toxic multinodular goiter and toxic adenoma were excluded.

Results: Data of 100 patients obtained between Feb 2019 to April 2019 from 10 endocrinologists were included in this study. Four patients were excluded as they did not meet the inclusion criteria. The mean (SD) age of the reported patient cohort was 43 (16) with 77% females with a follow up duration ranging upto 17 years. Only a small fraction of the patients were smokers (6%) and 20% had orbitopathy. About 78% were currently on ATD with mean (SD) duration of therapy of 45 (34) months with a mean dose of 8 mg/day of Neomercazole or Carbimazole (Range 2.5 mg to 40mg). No patient was on PTU. About 9% of patients had remission of GD and were euthyroid off ATD with mean ATD use of 37 months (Range:18-52), while 6% had converted spontaneously to hypothyroid state. In those who were on ATD, 75% were euthyroid (TSH 0.5-5), 20% were persistently toxic and 5% were hypothyroid (TSH >5). The mean dose of ATD in those who were persistently thyrotoxic was significantly higher than those who were euthyroid (32mg vs 7.5mg P <0.01). No patients developed any adverse events requiring discontinuation of therapy.

Conclusion: Long term ATD use can be safely used beyond 18 months and the chances of achieving and maintaining a euthyroid state is higher (75%) if the dose of ATD is <10mg/day.

  Pilot data from a cost-effective panel of molecular markers in the evaluation of thyroid nodules at a tertiary referral centre in Southern India Top

Subramanian Kannan

Endocrinologist, Narayana Health City, Bangalore, Karnataka, India

E-mail: [email protected]

Objective: Testing for molecular markers on FNAC material is standard of care in patients with cytologically indeterminate thyroid nodules. The cost of these markers are extremely high in India and thereby increasing the number of incomplete as well as unnecessary thyroid surgeries.

Methods: We chose to develop and study a laboratory developed test (LDT) for the detection of six pathogenic mutations and translocations (BRAFV600E, RAS (N/H/K), TERT, RET-PTC, PAX-8-PPAR-ć). We piloted this test in 45 consecutive patients who underwent FNAC of their thyroid nodules from Nov 2017 to June 2018 at Narayana Health City Bangalore. Sequencing was carried out by multiplex PCR and analyzed by next generation sequencing software.

Results: FNAC samples were collected from 45 patients who were evaluated for thyroid nodules. Out of these, 7 samples were used to optimise the protocol for extraction of DNA and RNA. 2 samples gave inadequate yield of DNA and RNA and hence could not be processed further. The rest 36 samples were processed further and libraries were prepared. Nine patients (25%) had positive results in their molecular testing, out of them 7 had RAS mutations [(NRAS Q61R (n=3), NRAS Q61K (n=2), HRAS Q61R (n=2)], and 2 had BRAF V600E mutation. One patient with NRAS Q61R and one patient with HRAS Q61R had follicular thyroid cancer (FTC) (Bethesda 4 on cytology) while the remaining 5 patients had indeterminate cytology (Bethesda 3) and final histopathology is not available. The two patients with BRAFV600E mutation had locally advanced papillary thyroid cancer (PTC) requiring tracheal reconstruction. Two cases of classic PTC and one case of Medullary thyroid cancer (MTC) all with Bethesda 6 on cytology and one case of benign thyroid nodule on histopathology tested negative for mutations.

Conclusion: While not routinely useful in thyroid cytology, molecular panel might help select cases of cytologically indeterminate nodules (Bethesda 3 & 4) for surgery and help with pre-operative strategy int those with aggressive PTC. More data is required to validate this current set of mutations in the management of thyroid nodules.

  Prevalence and severity of ophthalmic manifestations of Graves disease in tertiary centre of North India Top

Numrah Muqsit, Tauseef Nabi1, Junaid Wani, Hardeep Singh1, Shahnawaz Mir1

Department of Ophthalmology, Government Medical College,1Department of Endocrinology, Division of Internal Medicine, Government Medical College, Srinagar, Jammu and Kashmir, India

E-mail: [email protected]

Background: Thyroid Associated Orbitopathy (TAO) is most common extrathyroidal manifestation of the systemic autoimmune process known as Graves disease (GD). TAO is described as a chronic inflammation of orbital and periorbital tissue.

Objective: To evaluate the ocular manifestations in patients with GD.

Materials and Methods: This was a hospital based prospective study done on consecutive 52 newly diagnosed patients of GD documented by thyroid 99mTechnetium-pertechnetate scan. Patients were subjected to a complete clinical work up, thyroid profile and computed tomography orbit. The diagnosis of TAO was based on the criteria of Bartley and Gorman. Clinical activity score (CAS) and severity was estimated as per European Group on Graves Orbitopathy (EUGOGO).

Results: Age of patients ranged from 15-68 years with mean age of 42.1±11.49 years. The male to female ratio was 0.6:1. Eyelid retraction was the most common presentation (78%). Conjunctival redness was seen in 61.5% patients followed by eyelid erythema (44.2%), eyelid swelling (32.7%), plical swelling (23.1%). Almost half of the study group (51.9%) had proptosis of >20mm. Majority of patients had mild orbitopathy (65.4%) followed by moderate to severe in (34.6%) and none of the patients showed any signs of a sight threatening disease. CAS was inactive in 55.8% of the study group and active in 44.2%.

Conclusion: TAO was present in about 2/3rd of patients of GD. Majority of patients had mild orbitopathy (65.4%) and none of the patients had sight threatening disease. CAS was active in 44.2% of patients.

Keywords: Clinical activity score, Graves disease, thyroid associated ophthalmopathy

  Prevalence of thyroid dysfunction in type 2 diabetes mellitus patients from South-Coastal Andhra Pradesh Top

Nishitha Reddy Desu, T. V. S. Pradeep, Sunanda Tirupati, Vijaya Sarathi, K. Dileep Kumar

Department of Endocrinology, Narayana Medical College, Nellore, Andhra Pradesh, India

E-mail: [email protected]

Objectives: To study the prevalence of thyroid disorders and their association with glycaemic parameters and microvascular complications among adult T2DM patients from south-coastal region of Andhra Pradesh, India.

Methods: This cross-sectional study was conducted in the Department of Endocrinology, Narayana Medical College and Hospital, Nellore, between October 2013 and September 2015. Pregnant and lactating women, patients on drugs interfering with thyroid function known patients with thyroid disorders or acute illness were excluded from the study.

Results: A total of 500 T2DM subjects were included in the study. Thyroid disorders were observed in 98 (19.6%) subjects. Subclinical hypothyroidism (n=66, 13.2%) was the most common thyroid disorder whereas overt hypothyroidism (n=24, 4.8%) and thyrotoxicosis (n=8, 1.6%) were less common. None of the thyroid disorders were associated with age, gender, glycemic control or diabetes duration. Subclinical hypothyroidism was more frequent in obese patients (16.2%) vs 7.6%, p=0.007) whereas overt hypothyroidism (45.8% vs 2.9%, p< 0.0001) was more frequent among patients with family history of thyroid disease. Subclinical hypothyroidism (9.6% vs 18.7%, p=0.0044) was less frequent among metformin users. Diabetic neuropathy was the most common microvascular complication but did not differ between the groups. Diabetic retinopathy (27.3% vs 8.9%, p < 0.001) was significantly more frequent whereas diabetic nephropathy (22.7% vs 13.9%, p=0.06) tended to be more frequent among patients with subclinical hypothyroidism than euthyroid T2DM patients.

Conclusion: We report high prevalence of thyroid disorders among T2DM patients from south-coastal region of Andhra Pradesh. Subclinical hypothyroidism was the most common thyroid dysfunction, was more frequent among obese and nonmetformin users and was associated with more frequent occurrence of diabetic retinopathy.

  Prevalence of thyroid disorders in Indian patients with type 2 diabetes mellitus: a meta-analysis Top

Gayathri Sabinkar, Sunanda Tirupati, Vijaya Sarathi, K. Dileep Kumar

Department of Endocrinology, Narayana Medical College, Nellore, Andhra Pradesh, India

E-mail: [email protected]

Objective: Prevalence of thyroid disorders is high among Indian patients with type 2 diabetes mellitus (T2DM). However, the reported prevalence rates vary widely. Hence, we have estimated the pooled prevalence of various thyroid disorders among Indian adult T2DM patients.

Methods: MEDLINE, EMBASE, PubMed and Google Scholar were searched. Studies through April 2019 reporting the prevalence of at least one thyroid disorder (hypothyroidism or hyperthyroidism) in adult Indian T2DM were included with full texts available were included. Smaller studies (T2DM participants < 120), studies with high publication bias, studies including selected population (eg. geriatric population), studies reported in grey literature alone and low-quality studies were excluded based on the discretion of the reviewers. Data were extracted independently by two reviewers. Meta-analysis was performed using MedCalc statistical software version 16.4.3, MedCalc software bvba, Ostend, Belgium. Both random and fixed effects models were used for pooled analysis.

Results: A total of 23, 25, 21 and 22 studies were included for the meta-analyses on the prevalence of thyroid dysfunction, total hypothyroidism, subclinical hypothyroidism and thyrotoxicosis respectively. The pooled prevalence rates of thyroid dysfunction, total hypothyroidism, subclinical hypothyroidism and thyrotoxicosis using random effect model were 23.607% (95% CI: 21.043% to 26.271%), 19.02% (95% CI: 16.691% to 21.463%), 10.155% (95% CI: 8.109% to 12.402%) and 4.115% (CI: 2.935% to 5.485%) respectively. I2was > 70% for analyses of all the disorders suggesting considerable heterogeneity between the studies.

Conclusions: Thyroid dysfunction is common among Indian type 2 diabetes mellitus patients affecting at least one in five.

  High malignancy risk among south Indian patients with Bethedsa II thyroid nodules Top

Anudeep Reddy, Pradeep Puthenveetil, Sunanda Tirupati1, Vijaya Sarathi, K. Dileep Kumar

Departments of Endocrinology and1Endocrine Surgery, Narayana Medical College, Nellore, Andhra Pradesh, India

E-mail: [email protected]

Objectives: To study the prevalence of malignancy among south Indian patients with Bethedsa II nodules.

Methods: This retrospective study was conducted in Narayana Medical College and Hospital, Nellore. Patients with thyroid nodule who underwent surgery between January 2008 and September 2015 and a preoperative fine needle aspiration cytology report of Bethedsa II were included in the study. Age, gender, family history of thyroid malignancy, size of the biggest nodule on ultrasound, evidence of calcification or neck nodes on ultrasound were noted from the case records. Patients with inadequate data were excluded from the study.

Results: A total of 563 patients were included in the study. A total of 48 (8.5%) patients had malignancy including papillary thyroid carcinoma (n=39), follicular thyroid carcinoma (n=5), anaplastic thyroid carcinoma (n=1) and encapsulated follicular variant of PTC (n=3). Age, gender and maximum nodule size were not associated with malignancy. Multinodularity, thyroid calcification or neck lymph nodes with loss of hilar architecture on ultrasound were positively associated with malignancy whereas presence of thyrotoxicosis was negatively associated with malignancy.

Conclusion: We report high prevalence of malignancy among south Indian patients with Bethedsa II thyroid nodules. Bethedsa II thyroid nodule patients with thyroid calcification or neck lymph nodes with altered hilar architecture on ultrasound should be considered as high risk for malignancy.

  Resistance to thyroid hormone Top

Sphoorti P. Pai, Patanjali, Ganapathi Bantwal, Vageesh Ayyar, Belinda George, L. P. Nandhini, Nalini Wagmode

Department of Endocrinology, St. Johns Medical College, Bengaluru, Karnataka, India

E-mail: [email protected]

Introduction: Resistance to thyroid hormone Resistance to thyroid hormone (RTH), first described in 1967 and characterized by elevated circulating TH (T4, T3) and nonsuppressed thyroid-stimulating hormone (TSH) levels together with variable tissue refractoriness to hormone action, is mediated by defects in thyroid hormone receptor β. It is a rare syndrome with usually elevated levels of TSH, T4 and T3. Here we present a case where TSH was normal and was referred for hyperthyroidism , but the unusual clinical picture suggested something more.

Case Report: A 6 year 7 month old boy was referred with diagnosis of thyrotoxicosis. He was born out of non -consanguineous marriage by normal vaginal delivery, pre term baby at 7 months, appropriate for gestational age. There was no history of antenatal complications. However gross developmental delay was there and had history of poor scholastic performance. On examination, his height was 100cm, Ht SD Score being -3.6, weight was 15 kg , arm span of 101 cm and an upper segment by lower segment ratio of 1.12. He had mild exophthalmos, goitre, without any bruit. He had tachycardia with a heart rate of 126/min and other systemic examination being normal. His height age was 3y 9m, weight age was 3y 6m and bone age was 3y 6m suggestive of attenuated growth pattern. Thyroid function tests showed TSH - 1.71, T3 – 214 (60 – 200) ng/dl and T4 - 12.47 (4.5 - 12) mcg/dl . Other laboratory work up for short stature was normal. Clinical features of short stature, developmental delay were suggestive of hypothyroidism whereas tachycardia, exophthalmos and goitre were suggestive of hyperthyroidism. TSH was normal , however T3 and T4 Differential diagnoses of drugs like levothyroxine , amiodarone were ruled out by history. Differentials of thyroid hormone transporter defect and resistance to thyroid hormone were considered. To confirm the diagnosis Werner's test was done which showed an elevation in the SHBG levels after 7days of 50mcg T3 orally from 71.4 to 100.7nmol/L. Hence the diagnosis of resistance to thyroid hormone was confirmed. He was started on T3 supplementation, showed a gain of 9.5cm in height which further supported diagnosis of resistance to thyroid hormone.

Conclusions: Resistance to thyroid hormone is a diagnosis which should be considered even when TSH is normal and not elevated , when clinical features of both hypothyroidism and hyperthyroidism are present. In such scenarios, it is very important to note even the mildest abnormalities of thyroid function tests.

  A study on lipid abnormalities in hyperthyroidism and their response to antithyroid drugs Top

Moomin Hussain Bhat, Amer Hussain, Mir Iftikhar Bashir

Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

E-mail: [email protected]

Introduction: Changes in profile of lipids have been reported in patients with thyroid dysfunction. But the evidence is controversial.

Objective: The present study aimed to explore the relationships between hyperthyroidism and the lipid profile of patients and the response to antithyroid drugs.

Methods: A cross-sectional study was conducted in 57 newly diagnosed hyperthyroid patients (Grave's Disease), and 57 control subjects. Apart from thyroid stimulating hormone (TFT), lipid profile was done in all the patients and controls. Repeat lipid profile was done in all the patients once they achieved the euthyroid state.

Results: Mean age of patients was 34.7±10.93 years and that of controls 32.3±10.75 years (p=0.239). The mean duration of symptoms in Grave's patients was 9.81±13.95 months. Hyperthyroid patients presented with significantly lower serum levels of total cholesterol, TC (125±29.7 mg/dl), low-density lipoprotein cholesterol, LDLC (74.7 ± 19.43 mg/dl), high -density lipoprotein cholesterol, HDLC (37 ± 7.87 mg/dl), triglycerides, TG (123.2 ± 64.5 mg/dl ) and very low-density lipoprotein cholesterol, VLDL-C (24.6 ± 12.91 mg/dl ) than the control subjects-174.6 ± 34.68 mg/dl, 109.3 ± 23.44 mg/dl, 41.35 ± 7.56 mg/dl, 157.2 ± 86.21 mg/dl and 31.4 ± 17.28 mg/dl respectively (p<0.05). All the patients were treated with carbimazole-mean dose of carbimazole at start of treatment was 33.2 ± 6.59 mg/day. More than two-third (77%) of the patients achieved euthyroidism within twenty weeks of the treatment. Post-treatment, after achieving the euthyroidism, the mean levels of TC, LDL, HDL, TG, VLDL of the patients was 170.8±28.6 mg/dl, 107.5±19.1 mg/dl, 41.8±4.97 mg/dl, 147.7±44.78 and 29.4±8.87 respectively, all statistically significant (p<0.05). By Pearson's correlation, significant negative correlation was documented, between thyroxine (T4) levels and LDL (p<0.04) and TSH and HDL (p<0.001), once patients achieved control of thyrotoxicosis.

Conclusion: There is significant decrease in lipid parameters in hyperthyroid state which show improvement after achieving control of thyrotoxicosis with carbimazole (antithyroid drugs).

Keywords: Antithyroid drugs, Graves disease, lipid profile

  Goitre and thyroid disorder prevelence in healthy school children of Kashmir Valley Top

Mona Sood, Shariq Rashid Masoodi, M. Ashraf Ganie, Moomin Hussain Bhat

Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

E-mail: [email protected]

Background: There has been a gradual transition among pattern and prevalence of thyroid dysfunction in pediatric population in post iodisation era. Kashmir valley, once considered to be endemic zone for iodine deficiency disorders has shown marked improvement in overall iodine nutrition in recent surveys.

Objective: To study prevalence of goitre and thyroid dysfunction among healthy school children of Kashmir valley.

Methods: A multi-staged, cross sectional survey covering 666 school children, aged 6–18 years was conducted. Goitre examination by palpation method was graded as per WHO/UNICEF/ICCIDD classification. Thyroid function tests (TFT) were measured by DXI 800, Beckman Coulter Chemiluminescence Random access analyzer and urinary iodine excretion (UIE) was measured by ammonium persulfate digestion method, based on Sandell–Kolthoff reaction and was estimated in 35 subsampled children.

Results: Thyroid dysfunction (goitre and/or thyroid function abnormalities) were seen in 7.8% (95% CI:5.9-10.1%) of the children; 9.3% (95% CI 2.9-8.9%) girls and 5.3% (95%CI 6.7-12.4%) boys. The overall prevalence of goitre in the present study was 2.4 % with significant difference observed between girls and boys (2.4% vs 0.00%; p< 0.00). Abnormal TFT was found in 6.7% children including 4.26% with subclinical hypothyroidism, 1.6% with overt hypothyroidism and 0.7% with overt thyrotoxicosis. UIE ranged from 71.68 to 558 ug/gm of creatinine (median 150).

Conclusions: Overall there has been gradual improvement in iodine nutrition in Kashmir Valley as prevalence of goitre has reduced from 3.8% as reported in 2013 survey from our centre to 2.6% in present survey. Subclinical hypothyroidism emerged as most common thyroid abnormality which need to be managed judiciously to avoid long term unwanted therapeutic burden on apparently healthy paediatric population.

Keywords: Goitre, school children, thyroid disorders

  Pattern and predictors of thyroid dysfunction in children at a tertiary care hospital in Northern India Top

Mona Sood, Shariq Rashid Masoodi, M. Ashraf Ganie, Moomin Hussain Bhat

Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India

E-mail: [email protected]

Background: The profile of thyroid disorders encountered in pediatric and adolescent age groups has shown dramatic change post optimisation of iodine status. Frequent thyroid function testing for nonspecific symptoms has led to increase in prevalence of milder entity of thyroid dysfunction that do not warrant therapy.

Objective: To evaluate pattern of abnormal thyroid function among children referred to tertiary care centre and to ascertain historical, clinical, and laboratory characteristics that influence treatment decisions in these children.

Methods: A prospective, hospital based, observational study was conducted at a tertiary care hospital in Northen India. All assenting children aged 18 years or less, referred to clinic for suspected thyroid disorder were recruited for this study. Demographic data, clinical features of the recruited children were noted along with family history and iodine status. Thyroid profile, consisting of TT3, TT4, TSH, antiTPO and antiTG antibodies were tested in all . Investigations were also carried out to look for the cause and complications of various thyroid disorders. These children were also followed up for 1 year with appropriate therapy to look for response of therapy and complications to the same.

Results: 241 children were included in the study with an overall goitre prevalence of 36.5%. 73% of subjects were hypothyroid (54.5% subclinical hypothyroidism (SCH)), 18.7% congenital hypothyroid, 5% had hyperthyroidism and 3.3% were euthyroid. Overt hypothyroid had significantly higher prevalence of anti-TPO and antiTG antibody than SCH group. All subjects in the overt hypothyroid group and 76% subjects in SCH group were treated with L-thyroxine with mean dose requirement of 2.31±1.12ug/kg/day vs 1.76±1.07ug/kg/day(p=0.002) in either group. A major independent predictor of treatment in SCH was initial TSH which was significantly higher in the treated group (11.65+3.80 uIU/ml vs 9.24+1.31 uIU/ml; p<0.001). Congenital hypothyroid presented at a mean age of 6 months (18 days to 2 years) with most common aetiology being thyroid hypoplasia and dyshormonogenesis. Overall 85.5% of all refereed subjects were treated and in follow up after one-year management was found to be adequate in 81% subjects.

Conclusions: Primary hypothyroidism constituted the most common aetiology of thyroid disorders with 55% having subclinical hypothyroidism. Such children generally need a close follow up as treating these children strain out stretched health resources. Delayed presentation of congenital hypothyroidism in our study warrants active surveillance of children at birth to avoid long term adverse effects on mental development.

Keywords: Goitre, subclinical hypothyroidism, thyroid disorders

  Thyroid nodule with normal thyroid-stimulating hormone: Who needs evaluation? Top

Girish Mysore Suresh, Ravi Arjunan, Rajshekar Hulkud1, C. Ramachandra, Syed Altaf

Departments of Surgical Oncology and1Head and Neck Oncology, Kidwai Cancer Institute, Bengaluru, Karnataka, India

E-mail: [email protected]

Objectives: Thyroid diseases are, arguably, among the commonest endocrine disorders worldwide. The Indian Council of Medical Research established the National Cancer Registry Program (NCRP), and during the study periods 1984 and 1993 nationwide relative frequency of thyroid cancer among all the cancer cases was 0.1–0.2%. There are no epidemiological data outlining the prevalence of cancer in thyroid nodules, nor previous analysis of ultra-sonographic features correlating with thyroid malignancy in the south Indian population. This study aimed to estimate the prevalence of thyroid malignancy in patients with thyroid nodules and to describe the ultra-sonographic characteristics of thyroid nodules harboring malignancy.

Methods: A retrospective data from 2013-2015 of all thyroid nodules in patients (aged 18 to 60 years) with normal thyroid-stimulating hormone (TSH) levels, who underwent ultrasound guided fine needle aspiration cytology (UG-FNA) was analyzed using age (18 to 60 years), gender, FNA, SIZE(1-2, 2-4), presence or absence of lymph node, USG finding ( calfication and echogenicity) using SPSS 21 version software. Pearson Chi-square(x2) and odds ratio was used for categorical variables. P-value (Probability that the result is true) of <0.05 was considered as statistically significant after assuming all the rules of statistical tests.

Results: 98 patients with normal TSH underwent UG guided -FNA cytological examination of thyroid nodules (n= 103). Prevalence of nodule male vs female was 69% vs 31% and was thyroid cancer of male (31) to female (67) was 49% compared to 30% respectively, in the age group 20-39 years was most common with nodule prevalence with 49%; but most common malignancy was found to be in 40-59 years around 60%. 2-4 cm size was most common with 60% with malignant potential of 60.1%. Bethesda 2 (56%) was most common FNAC classification but with malignant potential was most common in 4 and 5. lymph node was found in 30.6% and malignancy being in 8%. On ultrasonography of the neck course feature was present in 5% and calcification in 23.5% and malignancy found in 2 and 4% respectively. Around 71% did not had calcification out of which 78% had malignancy, Iso echoic followed by hypoechoic features with 55.1 vs 25.3% were found with malignancy in 51% vs 37%. Bethesda classification and (Chi-Square Tests = 54.913; P= <0.001) echogenicity (Chi-Square Tests =8.616; P= 0.048) found to be statistically significant. Rest of the variables could not achieve statistical significance.

Conclusion: Patients with thyroid nodules in patients with normal thyroid-stimulating hormone (TSH) levels with iso and hypoechoic feature on UG needs further workup with UG-FNAC. Rest of the patient's stratification on the risk and can be followed up.

This article has been cited by
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Kaushik Mandal,Damilola Ashorobi,Alice Lee,Huijuan Liao,Salini C. Kumar,David S. Rosenthal,Mihail A. Boyanov
Case Reports in Endocrinology. 2021; 2021: 1
[Pubmed] | [DOI]


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