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   2018| January-April  | Volume 15 | Issue 1  
    Online since March 23, 2018

 
 
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ORIGINAL ARTICLES
Vitamin D and primary hypothyroidism: Is there an association?
Jyothi Idiculla, Pooja Prabhu, Rekha Pradeep, Kranti Khadilkar, Subramanian Kannan
January-April 2018, 15(1):34-37
DOI:10.4103/trp.trp_49_17  
Background: Association studies between the vitamin D deficiency (VDD) and hypothyroidism have given mixed results. Because of this controvery and relatively common prevalence of these two conditions, we conducted a case-control study investigating the prevalence of VDD in patients with hypothyroidism (both TPO-Ab positive and negative) and compared it with euthyroid controls. Methodology: This is a single centre cross sectional study. Adults (aged 18 years or more) of both the sexes diagnosed with primary hypothyroidism (TSH >5.1 mIU/L) were included (n = 115) along with age and sex matched euthyroid (TSH <5 mIU/ml) controls (n = 120) chosen from the outpatients' department. Biochemical parameters like Thyroid stimulating hormone (TSH), free T4 (fT4), 25 hydroxy vitamin D (Vit D) and thyroid peroxidase antibody (TPO-Ab) were tested in both the groups. Results: Patients in the hypothyroid group [38 (males) and 77 (females)] had a mean (SD) age 46 (15) years, while the euthyroid control group [24 (males) and 96 (females) had a mean (SD) age of 45 (17) years. In the hypothyroid group, 96% (110/115) had VDD as compared to 90% (108/120) in the control group with a significantly lower mean Vit D level was observed in the hypothyroid group as compared to the euthyroid group (12+8.6 vs 17.49+11.89 ng/ml; P < 0.001). While 27 cases with hypothyroidism had severe VDD (Vit D levels <4.2 ng/ml) only 10 among the control group had severe VDD (OR 2.04, CI: 1.03-4.05, P < 0.05)). The mean level of Vit D in the TPO-Ab positive hypothyroid group was 10.4+7.2 ng/ml in comparison to the TPO-Ab negative group 15.3+10.3 (P = 0.004) (OR 3.39, CI:1.18-9.80; P < 0.05) 3.62). Conclusion: The vitamin D levels in patients with hypothyroidism were significantly lower compared to euthyroid controls.TPO-Ab positive patients had lower levels of vitamin D in comparison with negative
  21,321 574 -
A cross-sectional survey to assess knowledge, attitude, and practices in patients with hypothyroidism in India
Bipin Sethi, Deepak Khandelwal, Upal Vyas
January-April 2018, 15(1):15-22
DOI:10.4103/trp.trp_25_17  
Objective: The objective of this study is to assess the knowledge, attitude, and practices (KAP) in patients with hypothyroidism in India. Methods: This was a questionnaire-based, cross-sectional KAP study conducted in patients with hypothyroidism across 16 centers in India. The questionnaire was validated initially by a panel of experts, followed by 120 patients with primary hypothyroidism. Results: Out of 500 patients enrolled, about three-fourths (72.4%) were women. Most patients had low levels of knowledge (66.6%), were quite concerned (46.6%), and practiced a moderate level of precaution (77.8%). Around 18.4%, 26.2%, 27.8%, and 37.6% of patients had incorrect/no knowledge that weight gain, fatigue, muscle aches/pain, and dry skin were effects of hypothyroidism, respectively. Patients had poor knowledge regarding various risks associated with hypothyroidism such as abnormal menstruation (41.6%), depression (47%), hypercholesterolemia (65.6%), and medications causing hypothyroidism (74.2%). Most patients (91.4%) affirmed the need to consult a physician for or seek medical advice before treatment initiation. However, a small percentage did not agree on testing pregnant women (20.2%) and family members (26.2%) for hypothyroidism. Most patients (93.2% and 92.6%) practiced compliance to frequency and timings for medications; however, one-thirds reported missing doses. There was lack of knowledge-seeking behavior both from online sources (57.4%) and treating doctors (24.2%). Significant associations were found between education and the levels of knowledge, concern, and precautions taken. Conclusion: This study identified significant gaps in the knowledge about the risks associated with hypothyroidism, importance of laboratory investigation, and dietary precautions.
  6,543 610 -
Depression, anxiety, and somatization in patients with clinical and subclinical hypothyroidism: An exploratory study
Kavita Sanjiv Kale, Bharati Baviskar
January-April 2018, 15(1):10-14
DOI:10.4103/trp.trp_42_17  
Background: Hypothyroidism and subclinical hypothyroidism (SCHT) are common disorders seen in clinical practice. A large proportion of patients with these disorders show psychiatric comorbidity. The current study was carried out to assess the prevalence and proportion of depression, anxiety, and somatization symptoms and compare the same between these two groups of patients. Methodology: Patients attending a medical outpatient department were screened for thyroid dysfunction using laboratory parameters, and patients detected with clinical and SCHT were included in the study. The sample consisted of 34 patients with CHT and 36 patients with SCHT. The patients were administered the Hamilton Rating Scale for Depression, Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 Questionnaire, and PHQ-15 for somatization. The data were analyzed statistically using computerized software. Results: The study groups were well matched on sociodemographic profile and basic data. On assessing the severity of depression and anxiety, more cases of mild depression were reported in the subclinical hypothyroid group compared to moderate and severe depression being higher in the clinical hypothyroid group (P = 0.0001). Anxiety was well matched in both groups while somatization was higher in the subclinical hypothyroid group (P = 0.0001). Scores on depression scales were higher in the clinical group (P = 0.0001) and anxiety and somatization scores were higher in the subclinical group (P = 0.0001). Conclusions: Depression is usually seen in CHT while anxiety and somatization may be greater in SCHT. Further studies in larger populations are needed to validate the findings.
  3,478 345 1
CASE REPORTS
Thyroid abscess: A rare case report and review of literature
Balram Sharma, Vijay Kumar Bhavi, Hardeva Ram Nehra, Anshul Kumar, Sanjay Saran, Sandeep Kumar Mathur
January-April 2018, 15(1):49-51
DOI:10.4103/trp.trp_47_17  
Acute suppurative thyroiditis (AST) leading to thyroid abscess is a quite uncommon clinical entity. Both thyroid abscess and AST represent only 0.1%–0.7% of thyroid pathologies which may require surgical management. AST especially affects patients with Hashimoto's thyroiditis or thyroid cancer. In children, AST is associated with the persistence of a canal originating from the 3rd or 4th bronchial pouch that may lead to recurrent thyroid abscess. The left lobe of thyroid gland is more frequently involved. AST can be life threatening if left untreated, resulting in mortality of 12% or higher.
  3,552 246 -
EDITORIAL
The Bethesda system for reporting thyroid cytopathology: A relook
Kaushik Pandit, Ipsita Ghosh
January-April 2018, 15(1):1-2
DOI:10.4103/trp.trp_12_18  
  2,292 358 -
CASE REPORTS
Steroid-responsive encephalopathy in autoimmune thyroiditis: A diagnostic enigma?
Balram Sharma, Vijay Kumar Bhavi, Hardeva Ram Nehra, Anshul Goyal, Sanjay Saran, Sandeep Kumar Mathur
January-April 2018, 15(1):52-55
DOI:10.4103/trp.trp_48_17  
Hashimoto's encephalopathy or steroid-responsive encephalopathy associated with autoimmune thyroiditis is a neuroendocrine disorder of unknown cause associated with thyroid autoimmunity. We report case of a 61-year-old male, previously healthy, who developed a subacute onset of declining higher mental functions. Serologic studies demonstrated the high levels of antithyroid antibodies. Electroencephalographic, cerebrospinal fluid, and magnetic resonance image findings were normal, consistent with Hashimoto's encephalopathy. It is a diagnosis of exclusion once the detailed neurology evaluations were done. This unusual disorder is often underrecognized because of the multiple and protracted neurocognitive manifestations; therefore, it is important to be aware of this clinical manifestations to make a correct diagnosis and favorable outcome.
  2,354 177 1
ORIGINAL ARTICLES
Vitamin D levels in children with Hashimoto's thyroiditis: Before and after L-thyroxine therapy
Navendu Chaudhary, Rakesh Kumar, Naresh Sachdeva, Devi Dayal
January-April 2018, 15(1):23-28
DOI:10.4103/trp.trp_45_17  
Background: Vitamin D deficiency has been associated with Hashimoto's thyroiditis (HT). Hypothyroidism per se can cause poor absorption and metabolism of Vitamin D leading to Vitamin D deficiency. It is unknown that Vitamin D deficiency in HT is a cause or effect of HT. Objectives: To study Vitamin D level in children with newly diagnosed HT and to follow the changes in Vitamin D level after L-thyroxine therapy. Material and Methods: A prospective observational study was conducted on 35 children recently diagnosed with HT who had not received Vitamin D supplementation in the past 6 months. Serum 25 hydroxy Vitamin D levels along with serum calcium profile were estimated before starting L-thyroxine and on follow-up after 3 months. Results: The mean Vitamin D level at diagnosis of HT was significantly low as compared to controls (33.34 ± 16.93 nmol/L vs. 65.13 ± 30.57 nmol/L; P < 0.0001). Out of 22 Vitamin D-deficient patients who were treated, seven (31.8%) remained deficient at follow-up. Thirteen patients (sufficient/insufficient Vitamin D levels) who were not supplemented with Vitamin D had fall in Vitamin D levels in follow-up. Conclusions: Children with HT have low Vitamin D levels at diagnosis, and L-thyroxine therapy can further compromise Vitamin D status. Children with recent diagnosis of HT should be screened and treated or supplemented with Vitamin D.
  2,247 184 -
Spectrum of clinical symptomatology and its resolution following levothyroxine supplementation in primary and subclinical hypothyroidism: An Indian perspective
Sachin Chittawar, Apeksha Nagdeote, Abhinav Nair, Krishna Kumar Kawre, Deep Dutta
January-April 2018, 15(1):29-33
DOI:10.4103/trp.trp_1_18  
Background: Data are scant on the spectrum of features associated with subclinical hypothyroidism (ScH) and overt primary hypothyroidism (OPH). This study aimed was to determine the burden as well as predictors of the lack of resolution of symptoms of hypothyroidism in patients of ScH and OPH following levothyroxine supplementation. Methods: A total of 505 patients were screened, of which 411 consecutive patients with ScH and 94 with OPH were evaluated. Data from 347 patients with ScH and 76 patients with overt OPH, who completed the study, were analyzed. Thyroid symptomatology was evaluated using standardized questionnaire. Results: The median age of participants was 35 (28–41) years; 95.04% being females. Common symptoms in OPH were shortness of breath (72.36%), depression (57.89%), irritability (57.89%), periorbital edema (53.94%), “feeling tired” (51.31%), and swelling of limbs (48.68%). Common symptoms in ScH were “feeling tired” (62.82%), “unhappy with routine” (44.95%), depression (40.92%), irritability (38.90%), and “weight gain with a poor appetite” (36.31%). Goiter was documented in 31.58% OPH and 3.17% in ScH (P < 0.001). Hair loss was observed 31.57% OPH and 29.68% ScH. Median (interquartile range) dose of levothyroxine supplemented was 37.5 (12.5–50) and 100 (75–112.5) mcg, respectively. Resolution of hypothyroidism symptoms was lesser in ScH. Persisting features included goiter, irregular menstruation, “weight gain with poor appetite,” irritability, depression, “feeling tired,” body aches, and depression. Binary logistic regression revealed thyroid stimulating hormone (TSH) to be an independent predictor of symptoms resolution. Every unit increase in TSH was associated with 0.7% greater resolution. Conclusion: Symptoms associated with hypothyroidism are diverse and nonspecific. Resolution of symptoms following levothyroxine supplementation and achieving biochemical euthyroidism is more likely in OPH that ScH.
  2,163 193 -
Clinicopathological features of differentiated thyroid carcinoma referred to radioiodine therapy at Tripoli Medical Center
Hawa Juma El-Shareif
January-April 2018, 15(1):3-9
DOI:10.4103/trp.trp_28_17  
Objectives: The objective of this study is to study the demographic, clinicopathological features, and geographical distribution of differentiated thyroid cancer (DTC) among Libyan patients referred from all parts of the country to the nuclear medicine department, for radioactive iodine (RAI) therapy. Materials and Methods: Retrospective review of medical records of 265 patients with differentiated thyroid carcinoma (DTC) referred to RAI therapy in the Nuclear Medicine Branch-Tripoli Medical Center, in the period from May 2005 to October 2010. The data analyzed included sex, age at the time of diagnosis, the city of residence, pathological diagnosis, the extent of disease, and types of treatment. Results: There were 225 (84.9%) females and 40 (15.1%) males giving a sex ratio of 5.6:1. The mean age of males at diagnosis was 51.2 ± 14.8 (range 24–78) years and the mean age of the females was 44.6 ± 15.6 (range 10–95) years. Two hundred and twenty-three (84.2%) had papillary thyroid cancer (PTC), 31 (11.7%) had follicular thyroid cancer, 3 (1.1%) had Hurthle cell thyroid cancer, and 2 (0.8%) had follicular-insular thyroid cancer. About 43 (16.2%) had a history of multinodular goiter, and 3 (1.1%) Hashimoto's thyroiditis. From data collected, cervical lymph node metastases were found in 45 (17.0%), and distal metastases in 27 (10.2%). Conclusions: PTC was the most common type of DTC. DTC was more common among females. The current study showed that the disease tends to occur at an older age, and with less cervical lymph node metastases than previously reported.
  2,043 213 -
Clinicopathological study of medullary carcinoma of thyroid: A single institute experience
Chaithra Gowthuvalli Venkataramana, Radha R Pai, Ranjitha Rao, M Nirupama, Flora D Lobo, Kausalya K Sahoo
January-April 2018, 15(1):38-41
DOI:10.4103/trp.trp_43_17  
Context: Medullary thyroid carcinoma is one of the rare thyroid malignancies representing only about 5%–10%of total thyroid cancers. Aims: To study the age, sex distribution, and various histopathological features of medullary carcinoma of thyroid in our institute over a period of 5 years. Settings and Design: This is a retrospective descriptional study of the cases diagnosed as medullary carcinoma over a period of 5 years in our institute (i.e., from April 01, 2010, to March 31, 2015). Subjects and Methods: The study material obtained from departmental records, gross specimens, paraffin blocks or slides and case files from medical record sections. Histopathologically, tumor was identified according to the classical features as described in the World Health Organization of classification of tumors of endocrine organs. Results: We found 20 cases of medullary carcinoma which accounted for 12% of thyroid malignancies. There was female dominance, and the age group of patients ranged from 20 years to 66 years. Microscopically, tumor cell arrangement was classic in all the cases with some showing pseudopapillary and spindle cell areas. Apoptosis of the tumor cells were seen notably in three cases. Three cases had necrotic areas. One case of micro medullary carcinoma was found incidentally. We had one interesting case where the clinical and cytological features were more in favor of papillary carcinoma. Conclusions: Medullary carcinoma of the thyroid is rare. Identifying the histopathological features and its variations may show light into understanding of the tumor biology with its implications on patient management and prognosis.
  1,929 164 -
CASE REPORTS
Case report: An unusual variation in the course of recurrent laryngeal nerve in relation to the thyroid gland
Anjali Venugopal, Akanksha A Saberwal, Yogesh G Dabholkar
January-April 2018, 15(1):46-48
DOI:10.4103/trp.trp_44_17  
A complete understanding of the anatomic variations of the thyroid gland is necessary for a safe thyroid surgery. Injury to recurrent laryngeal nerve during thyroid surgery remains a significant source of morbidity. We present an uncommon variation in the position of right recurrent laryngeal nerve with the Tubercle of Zuckerkandl in a 40-year-old female who underwent thyroidectomy for a benign multinodular goiter. Identification and meticulous dissection of the Tubercle of Zuckerkandl and recognition of its association with the recurrent laryngeal nerve are essential to maintain the integrity of the nerve and prevent complications during thyroid surgery.
  1,732 130 -
Cytodiagnosis of mucosa-associated lymphoid tissue lymphoma of thyroid gland: An extremely rare presentation in a young female
Indranil Chakrabarti, Nirmalesh Mahata, Vaswati Das, Piyali Mitra
January-April 2018, 15(1):42-45
DOI:10.4103/trp.trp_39_17  
Thyroid lymphoma, a rare tumor, constitutes about 1%–5% of all thyroid malignancies and 1%–2% of all extranodal lymphomas. The thyroid gland contains no native lymphoid tissue and is seen only in various pathological conditions such as primary thyroid lymphoma (PTL). PTL is more common in women than men (3:1 predominance) with a peak incidence in the sixth and seventh decades. Mucosa-associated lymphoid tissue (MALT) lymphoma of thyroid is one of the rare variants. Chronic autoimmune thyroiditis (Hashimoto's disease) has been associated with an increased risk of lymphoma, including MALT lymphoma. Here, we report a case of a 38-year-old female who presented with rapidly progressive swelling on the right side of the neck for previous 3 months. No history suggestive of hypothyroidism or hyperthyroidism was present. Ultrasonography showed enlarged thyroid gland with hypoechoic echotexture and multiple echogenic septations. Fine-needle aspiration cytology revealed features suggestive of MALT lymphoma. The swelling was operated, and subsequent histopathology and immunohistochemistry confirmed the diagnosis. Thereafter, the patient was treated by radiotherapy. However, after 6 months' follow-up, there was a recurrence of the tumor. Then, combination of cyclophosphamide, doxorubicin, vincristine, prednisone regime and rituximab was started, and the patient was free of recurrence at the next 12-month follow-up. Here, we report a very rare case of MALT lymphoma of Thyroid occurring in a young female with no known history of Hashimoto's thyroiditis. The tumor recurred after radiotherapy treatment and was successfully treated with subsequent chemotherapy.
  1,595 128 -
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