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   Table of Contents - Current issue
Coverpage
January-April 2017
Volume 14 | Issue 1
Page Nos. 1-42

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PERSPECTIVE  

Rashtriya Bal Swasthya Karyakram: Bringing thyroid to center-stage p. 1
Naresh Kardwal, Mudita Dhingra, Sanjay Kalra
DOI:10.4103/0973-0354.200562  
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ORIGINAL ARTICLES Top

Study on quantification of drain in intracapsular thyroidectomies p. 3
UP Santosh, KB Prashanth, K Swetha, KR Sumanth
DOI:10.4103/0973-0354.200558  
Introduction: Disease of the thyroid gland is common with prevalence of 4–7% in the general population. The incidence being higher in endemic areas. Thyroidectomy is an important procedure done for majority of thyroid swellings, after which drains are placed. Our study aims to assess the postoperative drain fluid amount in thyroidectomies done using intracapsular dissection technique. Materials and Methods: Retrospective study of 170 patients who underwent hemi/subtotal/total thyroidectomies using intracapsular dissection in Chigateri District Hospital and Bapuji Hospital, Teaching Hospitals, attached to JJM Medical College, Davangere during March 2009 to July 2015. All patients fulfilling inclusive criteria are included in the study. The drain was removed after 48 h of surgery. The amount of drain present was measured before removal of the drain. Results: Total number of 170 cases were analyzed. We found that the drain fluid amount was drastically less when compared with thyroidectomies done using other techniques. Conclusion: Drain fluid amount was minimal with thyroidectomies done using intracapsular dissection technique.
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Spectrum of extrathyroidal congenital malformations in a cohort of North Indian children with permanent primary congenital hypothyroidism p. 8
Devi Dayal, Rajendra Prasad, Savita Bhunwal, Rakesh Kumar, Rohit Manoj Kumar, Kushaljit Singh Sodhi
DOI:10.4103/0973-0354.200559  
Background: Children with permanent primary congenital hypothyroidism (CH) are at increased risk for extrathyroidal congenital malformations (ECMs) as compared to normal child population. A wide variation in the prevalence of ECMs in CH has been reported previously with the reports from Turkey and India indicating a much higher prevalence (48%–59%) as compared to reports from other countries (2.1%–10.5%). Setting and Design: Pediatric Endocrinology Clinic of a large multispecialty hospital located in Northwest India. Retrospective study. Materials and Methods: Children diagnosed as permanent primary CH underwent evaluation for associated ECMs using echocardiography and abdominal and pelvic ultrasonography if clinically indicated. Results: The etiological diagnoses in 106 children (52 girls and 54 boys) with permanent CH were thyroid agenesis in 70 (66%), ectopia in 9 (8.5%), hypoplasia in 6 (5.5%), hypothyroidism with eutopic gland in 5 (4.7%), and dyshormonogenesis in 16 (15%) patients. Seven (7.42%) patients had associated ECMs. The majority (4, 3.7%) of ECMs were cardiac (ventricular septal defect in two patients and patent ductus arteriosus and transposition of great arteries in one each), while skeletal (congenital talipes equinovarus in two and hemivertebra in one patient) and genitourinary (splitting of the pelvicalyceal system in two patients) anomalies were seen in 3 (2.8%) and 2 (1.8%) patients, respectively. Conclusion: The prevalence of ECMs in children with permanent CH was much lower as compared to other cohorts from India. Further studies are needed to determine the underlying genetic and environmental factors to explain the drastic regional differences in the prevalence of ECMs in CH.
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Study of epicardial fat thickness as a marker of visceral adiposity in patients with hypothyroidism p. 12
Ritu Karoli, Nikhil Gupta, Jalees Fatima, Zeba Siddiqi
DOI:10.4103/0973-0354.200561  
Introduction: Hypothyroidism has adverse effects on the cardiovascular system. Visceral adiposity, the fat deposited around the internal organs, is recognized as an important risk factor. Hence, the present study was undertaken to investigate the presence of visceral adiposity, epicardial fat thickness (EFT), and nonalcoholic fatty liver disease (NAFLD) in patients with hypothyroidism as compared to matched euthyroid controls. Materials and Methods: In a case–control hospital-based study, 100 patients of hypothyroidism and equal number of age-, gender-, and body mass index-matched euthyroid controls were enrolled. They were studied for EFT and the presence of NAFLD along with anthropometric and biochemical parameters. Results: Among the hypothyroid patients, 67% had serum thyroid-stimulating hormone (TSH) varying 4.5–10 mIU/L and 33% had serum TSH >10 mIU/L. Patients with hypothyroidism had higher waist circumference (92.4 ± 8.6 cm vs. 84 ± 6.2 cm, P = 0.002) and diastolic blood pressure (88 ± 4 mmHg vs. 72 ± 10 mmHg, P = 0.01) than controls. The hypothyroid patients had significantly higher levels of triglycerides, low-density lipoprotein cholesterol homeostasis model assessment of insulin resistance, and prevalence of metabolic syndrome (22% vs. 8%). Markers of visceral adiposity were significantly higher in hypothyroid patients, and EFT had positive correlation with serum TSH levels. Conclusion: We observed higher EFT in patients with hypothyroidism and a significant correlation between EFT and serum TSH levels. Whether increased epicardial thickness as a marker of visceral adiposity may be associated with the potential cardiovascular adverse effects of hypothyroidism warrants further research.
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Ophthalmic manifestation as adverse factor for cure in radioiodine treatment of Graves' disease p. 18
Yetunde A Onimode, Kayode S Adedapo, Magbagbeola D Dairo
DOI:10.4103/0973-0354.200563  
Context: Figures from several states indicate the prevalence of primary hyperthyroidism as 1.5%–5.4%. Goiters (including Graves' disease [GD]) and diabetes mellitus are the most common presentations at Nigerian endocrine clinics. Aim: This study aims to assess the efficacy of radioactive iodine-131 therapy (RAIT) of GD, evaluate factors affecting its outcome, and to find the impact of ophthalmic symptoms on response of GD to RAIT. Participants and Methods: A retrospective review of RAI-naϊve GD patients treated from 2006 to 2016 was performed. Results: Eighty-one treatments were made in this period to 75 patients; of these, 51 patients had had no prior RAI treatment. Overall, 41 patients (78.8%) were cured by mean time to cure 4.5 ± 2.36 months. Fourteen patients (26.9%) were cured by 3 months, an additional 19 (36.5%) by 6 months, an additional 5 (9.6%) by 9 months, and 1 more by 14 months, and 2 were cured later. Cure comprised euthyroidism in 14 patients (26.9%) and outright hypothyroidism in 27 (51.9%). Graves' ophthalmopathy (GO) is associated with less likelihood of cure (P = 0.025). Those with GO were ten times less likely to be cured than those without GO (odds ratio = 0.105, confidence interval = 0.11–0.979, P = 0.048). Conclusions: Findings suggest that GO is an adverse factor in RAIT for GD (as was found in an earlier study from this center) and also suggest that patients with GO will benefit from larger doses of RAI.
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Study of anemia in primary hypothyroidism p. 22
Ram Prakash Patel, Atishay Jain
DOI:10.4103/0973-0354.200564  
Context: Thyroid hormones directly or indirectly, through erythropoietin, stimulate growth of erythroid colonies. In the deficiency of thyroid hormones, anemia frequently develops and may be normocytic, hypochromic-microcytic, or macrocytic. Aims: In this study, we evaluated the types of anemia and its causes in patients with untreated primary hypothyroidism. Settings and Design: This is an observational study conducted at department of general medicine of a tertiary care center. The duration of study was 1 year, November 2015–October 2016. Subjects and Methods: Four hundred and seventy-two patients of overt hypothyroidism or subclinical hypothyroidism were evaluated for possible inclusion in this study. Out of these 112 participants were recruited for the study after fulfilling inclusion criteria. Statistical Analysis Used: Microsoft Excel® and SPSS® 20 for Windows® were used for data storage and analysis. The qualitative data were expressed in percentages, and quantitative data were expressed as mean ± standard deviation. Student's t-test and Chi-square test were used to determine statistical difference between variables. Results: In our study, anemia frequency was 18% in the subclinical hypothyroid patients and 11% in the overt hypothyroid group. In the subgroup analysis of the hypothyroid patients, anemia of chronic disease was most common anemia in patients with overt and subclinical hypothyroidism. Conclusions: Anemia is a common finding in overt hypothyroidism, but anemia is not listed among the consequences of untreated subclinical hypothyroidism. Type and cause of anemia is also different in overt and subclinical hypothyroid patients. Therefore, anemia in hypothyroidism needs to be properly evaluated because treatment varies with etiology of anemia.
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Histologic pattern of thyroid disorders in Southern Kerala p. 25
Jayasree Geothe, KP Poulose
DOI:10.4103/0973-0354.200566  
Since the implementation of universal salt iodization in 1986, India is said to be in the transition phase from iodine deficiency to iodine sufficiency, and this is expected to change the spectrum of thyroid disorders in the country. Materials and Methods: A retrospective study of 246 biopsy specimens of subtotal/total/hemi thyroidectomy cases done during a period of 6 years from 2007 to 2012 at a tertiary hospital in Trivandrum, Kerala, is analyzed. Results: Thyroidectomy specimens accounted for 3.2% of the total surgical specimens received during the study period. Among the 246 thyroidectomy specimens, nodular colloid goiter (NCG) with or without other associated thyroid lesions outnumbered other disorders accounting for a total of 142 cases (58%) followed by 90 cases of autoimmune thyroiditis (AIT) with or without other thyroid lesions (37%). Dual lesions such as AIT with colloid goiter (7 cases, 3%), AIT with tumors (45 cases, 18%), and NCG with tumors (40 cases 16%) were also noted. The presence of tumors was found in 106 cases (43%). The overall incidence of malignancy was 36%. Forty-one cases of AIT and 36 cases of NCG were associated with papillary thyroid carcinoma (PTC) (46% and 25%, respectively); the difference was statistically significant (P = 0.01). Conclusions: This study showed that the incidence of AIT and associated PTC is high, and the role of iodine or any other goitrogens in triggering or enhancing the onset and development of AIT in this area deserves further study.
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Diagnostic accuracy of ultrasound imaging in Hashimoto's thyroiditis p. 28
Anuradha Kapali, Jaipal Beerappa, P Raghuram, Ravindra Bangar
DOI:10.4103/0973-0354.200567  
Context: There are studies describing the ultrasound (USG) features of Hashimoto's thyroiditis in literature; however, we have not come across studies determining the accuracy of USG in diagnosing Hashimoto's thyroiditis. Aims: We evaluated the cases referred to our institute with suspected thyroid abnormalities and studied in them the accuracy of USG in diagnosing Hashimoto's thyroiditis and also studied the associated malignancies and their USG characteristics. Settings and Design: The patients referred to our department with suspected thyroid abnormalities were included in the prospective study. The study period was of 1 year; we included 28 patients with Hashimoto's thyroiditis. Materials and Methods: We evaluated the USG features of the cases namely echogenicity, echotexture, micronodules, and increased vascularity and followed them up for final diagnosis by fine needle aspiration cytology, histopathology, or antithyroglobulin and thyroid peroxidase tests, other 60 cases were used as a control. The results were analyzed. Statistical Analysis Used: Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Results: Hashimoto's thyroiditis was present in 28 patients. The most sensitive parameter in diagnosing Hashimoto's thyroiditis was hypoechogenicity and increased vascularity. The most specific parameter was micronodules. Nodules were seen in 13 patients, out of which malignant nodules was present in six patients. Microcalcification, thick halo, and internal vascularity increase the likelihood of nodules being malignant. Conclusions: The most sensitive parameter in diagnosing Hashimoto's thyroiditis was hypoechogenicity and increased vascularity. The most specific parameter was micronodules. Coarsened echo texture had an intermediate sensitivity and specificity. The USG is a specific modality for diagnosing Hashimoto's thyroiditis with a good sensitivity. Microcalcification, thick halo, and internal vascularity also increase the likelihood of nodules being malignant in the background of Hashimoto's thyroiditis. Hence, these nodules must be subject to FNA.
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Thyroid dysfunction in patients of ischemic cerebrovascular accidents p. 32
Apurva Pande, Vijay Kumar Goel, Amit Rastogi, Abhinav Gupta
DOI:10.4103/0973-0354.200568  
Introduction: Thyroid dysfunction has been associated with cerebrovascular accidents (CVAs) and is an area of active research in the present times. Materials and Methods: In the present study we tried to establish a relation between the variation in thyroid profile and ischemic CVAs in 75 patients who were admitted to our hospital within 48 hours of the event. Results: Of the 75 patients, 43 had nonthyroidal illness syndrome (NTIS), 13 were euthyroid, 6 were hyperthyroid, 9 were subclinical hypothyroid, and 4 were hypothyroid. Conclusion: In ischemic cases, high mortality rates were observed in euthyroid patients followed by patients with NTIS. A low FT3 level was associated with unfavorable outcome as accessed by the Glasgow Coma Scale and the Scandinavian Stroke Scale scoring.
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CASE REPORT Top

Encephalopathy associated with autoimmune thyroid disease in an 11-year-old girl, a rare clinical presentation p. 38
Meenakshi Cheripady Nayanar, Shakil Vadalivala, Tabrez Noorani, Hiral Shah
DOI:10.4103/0973-0354.200560  
Encephalopathy associated with autoimmune thyroid disease (EAATD) is a rare clinical presentation in pediatric age group whose exact prevalence has not been precisely elucidated. EAATD is characterized by neurological and psychiatric symptoms, high levels of antithyroid antibodies, increased cerebrospinal fluid (CSF) protein concentration, nonspecific electroencephalogram abnormalities, and responsiveness to the corticosteroid treatment. We present a case of an 11-year-old female patient who presented with acute history of fever, irritability, double vision, altered behavior, and unsteady gait which progressed to altered sensorium with drowsiness, tremors, and ataxia. The child had exophthalmos which was long standing in view of which thyroid profile was sent. Preliminary work-up, CSF analysis, and neuroimaging with magnetic resonance imaging of the brain proved normal. Thyroid profile was high with positive thyroperoxidase antibody. Thus, we came to the diagnosis of EAATD. EAATD still requires a better definition of its pathophysiology, the diagnostic criteria, and the most appropriate management including the long-term follow-up of patients.
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LETTER TO THE EDITOR Top

Undiagnosed juvenile hypothyroidism and resultant irreversible brain damage: Cannot we do anything? p. 41
Partha Pratim Chakraborty, Sugata Narayan Biswas
DOI:10.4103/0973-0354.200565  
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