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Year : 2013  |  Volume : 10  |  Issue : 4  |  Page : 26-33

ITSCON Abstracts

Date of Web Publication2-Feb-2013

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. ITSCON Abstracts. Thyroid Res Pract 2013;10, Suppl S1:26-33

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. ITSCON Abstracts. Thyroid Res Pract [serial online] 2013 [cited 2022 Dec 5];10, Suppl S1:26-33. Available from: https://www.thetrp.net/text.asp?2013/10/4/26/106821

  Section 1: Epidemiology Top

Prevalence of thyroid disorders in a population of type 2 diabetic patients

Tittu Oommen 1 , Nisha. B 2 , R. V. Jayakumar, Vasantha Nair, Harish. K, Usha Menon, Praveen V.P, Arun. S. Menon

1Presenting author- DM resident, Amrita Institute of Medial Science, Kochi, 2Chief author- Assoc. Prof. in Endocrinology, Amrita Institute of Medial Science, Kochi

Objective: Thyroid disease is a pathological state that can adversely affect diabetes control and has the potential to negatively affect patient outcomes. The objective of the study was to determine the prevalence of thyroid disorders in a population of type 2 diabetic patients as compared to controls. Design and Methods: 145 patients with type 2 diabetes, who presented to the outpatient department of endocrinology, were included in the study. Results: The preliminary results were as follows. The study population consisted of 76% males and 24 % females. 24% had thyroid disorders, equally distributed among males and females. 23% had features of MNG. Anti TPO antibody positivity was seen in 12% of subjects. Detailed results will be presented during the conference.

Prevalence of thyroid dysfunction in pregnancy

Seena John 1 , K. Umadevi 2 , Pramila Kalra 3, Mala Dharmalingam 4

1 Junior resident 3 rd year, Department of Obstetrics and Gynaecology, M S Ramaiah Medical college and teaching hospital, Bangalore (PRESENTING AUTHOR), 2 Visiting Professor, Department of Obstetrics and Gynaecology, M. S. Ramaiah Medical College and teaching hospital, Bangalore, 3 Associate Professor, Department of Endocrinology, M. S. Ramaiah Medical College and teaching hospital, Bangalore, 4 Professor and HOD, Department of Endocrinology-M. S. Ramaiah Medical College and teaching hospital, Bangalore, India

Introduction: Thyroid dysfunction is common in pregnancy and can lead to various complications in pregnancy if left untreated. Aims and objectives: The aim of this study was to determine the prevalence of thyroid dysfunction and thyroid antibody positivity in pregnant women and to determine the maternal and perinatal outcome in these pregnant women. Materials and Methods: 550 women irrespective of their period of gestation on their first antenatal visit were studied and followed up till the time of delivery. The study was conducted at M. S. Ramaiah Medical College and teaching hospitals, Bangalore. Results: In the present study out of 550 subjects 39.1% were diagnosed to have hypothyroidism when trimester specific reference ranges were used for diagnosis. Only three subjects had hyperthyroidism. Prevalence of thyroid autoimmunity among the hypothyroid women was found to be 4.2% (p = 0.760). Ninety out of 215 women (41.9%) who developed hypothyroidism were primigravida. In the present study, out of 215 hypothyroid pregnant women most common maternal complication was preeclampsia (20.9%) (p= 0.000), followed by IUGR (10.7%) (p = 0.029), preterm labour (4.7%), and abruptio placentae (2.3%). In the hyperthyroid group one woman (33.3%) had preeclampsia. Rate of caesarean section in hypothyroid group was 46.5% (p = 0.025). In relation to fetal outcome from the present study, low birth weight (13.5%) was found to be the major cause of fetal morbidity. This was followed by neonatal hyperbilirubinemia. Conclusions: Maternal hypothyroidism was most commonly associated with preeclampsia followed by IUGR. There was a high rate of Cesarean section in this group.

Demographic data of thyroiditis from Bangalore

K. M. Prasanna Kumar 1 , Pramila Kalra 2 , K. G. Kallur 3, Vidya Vadyanathan 3 , Murali Nadig 4

1 Hon Professor, of Department of Endocrinology, M. S. Ramaiah Medical College and teaching hospital, Bangalore, 2 Associate Professor, Department of Endocrinology, M. S. Ramaiah Medical College and teaching hospital, Bangalore (PRESENTING AUTHOR),
3 Nuclear medicine specialist -HCG, Bangalore
4 Nuclear medicine specialist-Elbit diagnostics, Bangalore
5 Nuclear medicine specialist-Clumax diagnostics, Bangalore

Background: Thyroiditis involves thyroid gland inflammation due to a wide variety of causes. The common varieties are subacute, silent and postpartum thyroiditis. Aims and Objectives: To retrospectively collect demographic data of thyroiditis from Bangalore over the past 5 years. Materials and Methods: Data was collected from three major nuclear medicine centres in Bangalore of the patients who came for Technetium 99m pertechnetate scan of the thyroid. The diagnosis was based on the Tc 99 scan evidence of thyroiditis in these patients. Results: The total number of cases recorded were 2462 .The females were more commonly affected compared to males with sex distribution of 1659 females vs. 803 males (2:1). The mean age of females was 32.3 ±11.34 years while the mean age of males was 40.0±12.4 years. The highest numbers of cases were recorded in the month of June and July. Conclusions: The females developed thyroiditis more frequently and at an earlier age as compared to males . This data could give us an insight into the demographic pattern of thyroiditis in our country and may help in planning future preventive strategies.

The spectrum of thyroid swellings as evaluated in a tertiary hospital

Mathew KC, Pavanan K, Agnasamma J, Savithry MC.

Department Medicine, Pathology, Amala Institute of Medical Sciences, Thrissur, India

Aims & Object of Study: This is a retrospective analysis of pattern of Thyroid swellings reported to Amala Institute of Medical Sciences Teaching Hospital during the period Dec.2005 to Dec. 2010. Methodology: History, Clinical examination, Routine investigations, Thyroid function tests-T3, T4, TSH, in relevant cases TPO antibodies, Thyroglobulin antibodies were estimated. FNA/FNAC thyroid routinely done in all cases. Results: 200 cases of thyroid swellings presented during above period were analyzed in detail. They included Colloid goiter 97, Lymphocytic Thyroiditis 56, Hashimotos disease 39, Graves' disease 5 [Table 1[Additional file 1]],[Table 2[Additional file 2]],[Table 3[Additional file 3]] and [Table 4[Additional file 4]]., Carcinoma Thyroid 3. Conclusions: Routine examination of neck, relevant Lab investigations followed by Fine Needle Aspiration (FNA/FNAC) of Thyroid swelling can be very valuable in detecting Thyroid disorders.48.5% constituted by colloid goiter, 47.5% Autoimmune Thyroid Disorders (together Hashimotos thyroiditis 19.5% and Lymphocytic thyroiditis 28%) which can be alarming. Hyperthyroidism 2.5%, Ca. thyroid 1.5%. Message: Stressing the need for routine palpation of neck, relevant TFT followed by FNA/FNAC thyroid.

  Section 2: Hypothyroidism Top

Cardiac autonomic function in patients with subclinical hypothyroidism

Pramila Kalra 1 , K. M. Prasanna Kumar 2 , Vikram K. Yeragani 3

2 Hon Professor, Department of Endocrinology, M S Ramaiah Medical college and teaching hospital, Bangalore, 1 Associate professor of Endocrinology, M S Ramaiah Medical college and teaching hospital, Bangalore, (PRESENTING AUTHOR)
3 Professor of Psychiatry Wayne UniversitySchool of Medicine, Baltimore, USA

Background: Patients with subclinical hypothyroidism may have higher incidence of coronary heart disease. Aim and Objectives: To evaluate beat-to-beat R-R interval variability and vascular stiffness in patients with subclinical hypothyroidism compared to normal controls. Subjects and Methods: We compared linear measures of R-R interval variability using the surface ECG during supine posture. Spectral analysis was done to obtain VLF (very low frequency)(0.003-0.04 Hz), LF(low frequency (0.04-0.15Hz) and HF high frequency(0.15-0.4Hz). The high frequency represents vagal regulation (parasympathetic) and low frequency represents both parasympathetic and sympathetic regulation. Results: A total of 64 cases with subclinical hypothyroidism and 40 controls were taken. There was no difference in BMI and age in the two groups.The high frequency component of R-R LF to HF ratio(measure of heart rate variability) was higher in cases (1.32±1.01) compared to controls (0.995±0.708) (p=0.04)and another measure of heart rate variability that is natural log of RRHF was higher in controls compared to cases (5.95±1.05 in controls compared to 5.38±1.14 in cases) (p=0.02).The difference in the left and the right brachial PWV (pulse wave velocity) was higher in cases compared to controls (30.17 ± 40.53 in cases vs. 11.42 ± 56.7 in controls) (p=0.06). Conclusions: There is decreased vagal function in subclinical hypothyroidism patients. The sympathovagal balance is altered in subclinical hypothyroidism to a predominant sympathetic activity. The PWV (pulse wave velocity) a measure of atherosclerosis is higher in subclinical hypothyroidism. Left differences between PWV and also ABI are exaggerated, which has been previously shown in cardiac and anxiety patients. We hypothesize this could be due to vagal dysfunction.

Hoffman's syndrome: Case report

Prashant Kaduskar 1 , Pramila Kalra 2, Mala Dharmalingam 3 , A. Nalini 4

1 Senior Resident (Abstract presenter), Department of Endocrinology, M.S. Ramaiah Medical College, Bangalore, 2 Associate professor, Department of Endocrinology, M.S. Ramaiah Medical College, Bangalore, 3 Professor and HOD, Department of Endocrinology, M.S. Ramaiah Medical College, Bangalore, 4 Professor, Department of Neurology, National Institute of Mental Health and Neurosciences, Bangalore

Background: Hoffman's syndrome is characterized by the presence of pseudo hypertrophy of calf muscles, stiffness and proximal muscle weakness in presence of primary hypothyroidism. It is rare entity and may be an uncommon presentation of untreated primary hypothyroidism. Clinical Cases : Mr. R. and Mr. L., 35 and 24 yrs gentlemen, presented with complaints of tiredness, lethargy, cold intolerance, calf muscle weakness and hypertrophy of two years duration. Their developmental history, milestones, family history were normal. Mr. R had increased sleep and constipation. On examination both Mr. R and Mr. L had typical symptoms and signs suggestive of primary hypothyroidism; in addition Mr. L had bilateral conductive hearing loss. Neurological examination revealed calf muscle hypertrophy and delayed ankle reflexes along with knee and ankle extensor muscles weakness (power 4/5) in both patients. Thyroid gland size was enlarged in both patients. Rest of the examination was unremarkable. TSH was > 100 uIU/ml in both. CPK levels were 6995 IU/L in Mr. R and 2422 IU/L in Mr. L. EMG was normal in both. NCV was normal in Mr. L whereas Mr. R had mild sensory axonal neuropathy. Both the patients were started on thyroid replacement therapy in a dose of 1.6ug/kg/day and were followed up after 3 months. Both showed significant clinical improvement in muscle weakness and reduction in calf muscle size. Conclusion: Hypothyroidism causes enlargement of muscle size but decreased power due to accumulation of glycosaminogycans which is reversible after adequate thyroxine replacement.

Key words : Pseudohypertrophy, Proximal, Glycosaminoglycans KAS Praveen, Sarfaraz Aslam, TK Dutta. Hoffman's Syndrome: A rare neurological presentation of hypothyroidism. Indian journal of Nutrition, Pharmacology, Neurological Diseases. 2011; Vol.1(2) :201-203

Endoscopic thyroidevaluation

Nataraj G.

Associate Professor, PES medical college, Kuppam, AP

Summary: A 43 years male presented for recurrent abdominal pain since 2 -3 yrs. It was central, discomfort like and was recurring inspite of treatment with PPI. He had undergone upper GI Endoscopy 4 times, which showed patchy gastritis. His reassessment of history revealed fullness to bloating sensation of abdomen, also had constipation, used to pass stool once in 2-3 days. Also he had moderate myalgia, good sleep and recent weight gain of 5-6 kgs over 6 months. His clinical exam-Normal vitals, BMI=34, Abdomen- nontender,no organomegaly. Other systemic examination were normal. Investigations -CBC, RFT, Blood sugars and ultrasound abdomen were normal. Thyroid profile : TSH=79Miu/ml, T 3 - 60-ng/dl, T 4 -2.1μg/dl. He was started on Thyroxin replacement(100 μg). He showed good improvement of G I complaints, after 6-8 weeks of replacement therapy. Discussion: Here we had middle aged male individual, presented forvague abdominal complaints with some systemic manifestation. Though he was very frequently evaluated for common GI disorders and was treated for the same illness. He had recurrence of symptoms and was frequently visiting outpatient. Hypothyroidism manifests with multisystem involvement. GI features vary from abdominal pain, fullness, discomfort, commonly constipation, fissure in ano, Anemia and normal appetite. Conclusions: Hypothyroidism is one of common endocrinal illness next to diabetes.Its worthwhile to evaluate for thyroid disorders, in presence of vague prolonged illheath with multisystem features.

Reversible acute renal failure associated with primary autoimmune hypothyroidism

Rajneesh Mittal, Suryanarayana KM, Mala Dharmalingam

Institution, MS Ramaiah Medical College, Bangalore

Introduction: Hypothyroidism is associated with significant effects on the kidney. It is usually overlooked as a cause of renal impairment, thus leading to unnecessary investigations without considering hypothyroidism as one of its cause. Hereby we report a case of acute renal failure associated with hypothyroidism. Objective: To report a case of reversible renal failure in hypothyroidism. Case report : A 48 year old male, k/c/o Hodgkin's Lymphoma, who received chemotherapy in 2011, presented with history of pain in legs and malaise since one month. On examination patient had firm goitre, b/l cervival lymphadenopathy and proximal muscle weakness in lower limbs. On initial evaluation had serum TSH 87.11 μIU/ml (0.4-4.2), Free T4 0.07 ng/dl ( 0.80-2.70), undetectable Free T3 (1.4-4.4 pg/ml), Anti TPO >1000.0 U/ml (< 35.0), serum creatinine 1.9 mg/dl (0.66-1.25), Serum LDH 929 U/L (313-618), Serum creatine kinase(CPK) 668 U/L (38.0-308.0) AST 76 U/L(17-59), ALT 45 U/L (21-72), Urine examination was normal and on microscopy had no evidence of hematuria. Evaluation of cervical lymphnodes revealed tuberculosis. Treatment was instituted 100 mcg of levothyroxine along with anti tubercular drugs (ATT). After five weeks of treatment, patient's symptoms including proximal muscle weakness improved and his free T4 was 1.28ng/dl, free T3-1.73 pg/ml, Serum creatinine 1.3 mg/dl, CPK-111 U/L. Treatment with levothyroxine and ATT has been continued. Conclusion: Hypothyroidism needs to be excluded in all cases of undefined renal failure patients by estimating serum TSH and T4 levels, as treatment with levothyroxine leads to significant improvement in muscular, thyroid and renal function.

Cognitive function in subclinical hypothyroidism in the elderly

Sarita Bajaj, Ritesh Kumar, Vatsala Misra 1 , Anurag Varma, Anubha Srivasatava

Department of Medicine, MLN Medical College Allahabad, U.P., India Department of Pathology, MLN Medical College Allahabad, U.P., India 1

Aims: To study the association of cognitive function with subclinical hypothyroidism in elderly. Material and Methods: Cross-sectional case-control study of 55 patients (≥65 years) who met the criteria for subclinical hypothyroidism were recruited. Similarly 55 age, sex and education matched healthy controls were taken. Serum TSH, free T3 and free T4 were measured. Cognitive functions were assessed by using Folstein Mini Mental Examination and clock drawing test. Results: Out of the 55 diagnosed subclinical hypothyroidism cases, cognitive impairment (by MMSE) was found in 17(30.9%) while it was present in only 8( 14.54%) out of 55 controls but there was no association between cases and controls by using clock drawing test. Mean TSH of subclinical hypothyroidism with cognitive impairment was 7.52±1.22 mIU/liter and without cognitive impairment was 6.26±1.18 mIU/liter (p value=0.0007, significant). Conclusions: Prevalence of cognitive impairment was significantly higher in subclinical hypothyroidism as compared to controls. Presence of cognitive impairment correlated with the level of TSH; as TSH increased cognitive function declined.

Key Words: subclinical hypothyroidism, elderly, cognitive impairment.

Impact of hypothyroidism and thyrotoxicosis on glycated haemoglobin in non-diabetic subjects

Rana Bhattacharjee, Ajitesh Roy, Soumik Goswami, Sujoy Ghosh, Pradip Muhopadhyay, Satinath Mukhopadhyay, Subhankar Chowdhury

Department of Endocrinology and Metabolism, IPGM & ER, Kolkata

Introduction: It is known that several factors other than glycemic status can influence A1c level. Altered RBC turnover is one of them. Thyrotoxicosis is known to cause increased RBC turnover. Hypothyroidism has opposite effect.We therefore hypothesize that A1c level do not accurately reflect glycemia in hypothyroidism and thyrotoxicosis. To best of our knowledge, this is the first study measuring alteration of A1c in both hypothyroid and thyrotoxic subjects. Aims and Objectives: To determine the effects of thyroid hormone on A1c levels in non-diabetic patients with overt thyrotoxicosis and hypothyroidism and If present, whether it can be reversed by achieving euthyroid state. Methods: It is a cross sectional, followed by longitudinal observational study. Non diabetic patients attending endocrine OPD of SSKM and IPGMER, Kolkata with overt hypothyroidism (n=47), and thyrotoxicosis (n=34) were recruited as cases. Age and gender matched controls (n=46) were taken. A1c was measured at the baseline and compared between hypothyroid, thyrotoxic and control population. 27 hypothyroid and 20 thyrotoxic patients were followed up every 6 wks. A1c was rechecked after stabilization of thyroid status for at least 3 months. Post treatment A1c was compared with baseline. Results: Baseline A1c was significantly higher in hypothyroid group - Mean ( +/- SD) 5.6 (0.58) [cases] vs 5.1 (0.24) [controls]; p=.0001 In contrast, thyrotoxic patients did not have significantly different A1c values. Mean ( +/- SD) 5.2 (0.38) [cases] vs 5.1 (0.24) [controls]; p=.139 A1c reduction was significant in hypothyroid group following treatment. Mean difference = 0.19; 95% CI= 0.1-0.28; p = .0001 A1c didn't change significantly following treatment in thyrotoxic group. Mean difference = (-).02; 95% CI = (-)0.76 - 0.04; p= .46 All the groups had similar fasting and post 75gm OGTT values (baseline and post treatment). Conclusions: 1. Baseline A1c levels found to be significantly higher in hypothyroid patients than control subjects despite similar glucose levels. 2. A1c reduced significantly with treatment in hypothyroid patients.

A prospective observational study on the interactions of drugs used in patients with hypothyroidism in pregnancy

Sri Durga Vani Madhavi. S 1 , Vineesh Sebastian 2, Krishna G. Seshadri 3 , P. Thennarasu 4 , N. Vanitha Rani 5, G. Kannan 6 , D. Chamundeeswari 7

Department of Pharmacy Practice, Faculty of Pharmacy Department of Endocrinology, Diabetes and Metabolism 3 Sri Ramachandra Medical College and Research Institute Sri Ramachandra University, Chenai, Tamilnadu, India

Objective: To assess the thyroid status, drug doses and drug interactions, in patients diagnosed with hypothyroidism before and during their pregnancy, in a tertiary care setting hospital and to improve the medication adherence by effective patient counseling. Methodology: A prospective observational study was conducted in 39 patients and the data obtained were analyzed using the SPSS 15. Paired t-test was applied to analyse the correlation between drug interactions and thyroid status of the patients. Results: A total of 22 drug-drug interactions were identified of which 14 (36%) were major interactions 8 (20%) were moderate interactions. The major interactions were found to be between levothyroxine+ferrousfumarate and levothyroxine+calciumcarbonate+ferrousfumarate; moderate was found between levothyroxine and calcium carbonate. A correlation was made between mean TSH and FT4 values of 17 patients on levothyroxine alone and 22 patients who had drug interactions with levothyroxine. The mean TSH values of patients with drug interactions were found to be higher than that of those patients on levothyroxine alone. The increase in mean TSH values was very high for those patients who had drug interactions between levothyroxine+ferrousfumarate which were statistically insignificant (P>0.05). The mean FT4 values of patients with drug interactions were found to be lower than that of those patients on levothyroxine alone. There was a decrease in mean FT4 values in patients who had drug interactions with levothyroxine than those with no interactions but none were statistically significant (P>0.05). Conclusion: Despite the increase in dose irrespective of the spacing between these drugs, the presence of calcium carbonate and ferrous fumarate influences the dosage regimen of levothyroxine and can be due to the delayed absorption of levothyroxine in the presence of these drugs, which was reflected by a reduction in the FT4 levels and an increase in TSH levels in these patients.

  Section 3: Thyrotoxicosis Top

Childhood Grave's disease: An experience from a tertiary care centre

Ghatnatti Vikrant 1 , Sarma Dipti 2 , Saikia Uma 4 ,

Senior resident 2 , Professor and Head, 3 Associate Professor, Department of Endocrinology, Gauhati Medical College, Guwahati, Assam, India

Objectives: To analyze the clinical profile of childhood Grave's disease (GD) and correlate it with treatment outcome and predictors of treatment outcome. Materials & Methods: Prospective analysis of patients with GD less than 18 years at presentation, treated with anti thyroid drugs and followed up for at least 12 months after achieving maintenance dose for one year. Results: Total of 24 patients (19 female, 5 male) with GD. Mean age at diagnosis: 14.2±3.2 yrs. Common symptoms and signs - weight loss (83.33%), excessive sweating (79.16%), palpitation (75%), poor scholastic performance (33.33%), delayed puberty (12.33%) and diffuse goitre (100%). 45% of the patients achieved remission with antithyroid drugs while 55% had relapse after stopping the drugs. Discussion: Remission rate with antithyroid drugs was 45%. Conclusion: A younger age and a lower heart rate at diagnosis are associated with higher remission rates.

A rare case of Graves' disease following Hypothyroidism

Manjunath G. Anakal 1 , Pramila Kalra 2 , Mala Dharmalingam 3

1 Senior Resident, Department of endocrinology, M.S. Ramaiah Medical College, Bangalore, 2 Associate Professor, Department of endocrinology, M.S. Ramaiah Medical College, Bangalore, 3 Professor & HOD, Department of endocrinology, M.S.Ramaiah Medical College, Bangalore

Background: Both chronic thyroiditis (Hashimoto's thyroiditis) and Graves' disease are autoimmune diseases of the thyroid gland. It is relatively common to see hypothyroidism following graves disease but it's rare to see vice versa. Graves' disease is caused by stimulation of TSH receptor antibody (TRAb), and hypothyroidism is due to a TSH-blocking antibody (TSBAb), which blocks the action of TSH hormone. Clinical Case : Here we report a 56-year-old lady who presented with primary hypothyroidism with raised TSH (TSH-65.1 μIU/mL). She was started on levothyroxine in a dose of 100 mcg per day, and for four years she maintained euthyroid state on this dose, but after four years of follow up her TSH was found to be suppressed. The levothyroxine dose was reduced and subsequently patient continued to have suppressed TSH even without any levothyroxine replacement for six months. Her TRAb (>40.0 IU/L) was significantly elevated and it was also associated with high TPOAb titers (1930 IU/L). Technetium-99m pertechnetate scan showed hyperfunctioning thyroid gland. Patient was started on small dose of methimazole 2.5 mg once a day and on follow up after six weeks she became hypothyroid with elevated TSH (TSH-29.88 μIU/mL). In view of persistently high TSH methimez was stopped but she continued to have high TSH value on follow up so she was again started on a small dose of levothyroxine 25mcg and has been called for follow up after two months. Conclusion: It is very uncommon to see primary hypothyroidism converting to Graves Disease on follow up.

Key words: TSH receptor antibody, autoimmune thyroid disease, Thyroiditis.

Two contrasting cases of childhood hyperthyroidism

Abhay Gundgurthi

Consultant Endocrinologist at BM Jain Hospital and Sagar Hospital, Bangalore, India

Case 1: Autonomous Functioning Thyroid Nodule Successfully Treated With Radioiodine in a Three and Half Year Old Boy Hyperthyroidism is rare in paediatric age group, the most common cause being Graves' disease. Very few cases of autonomous functioning thyroid nodule (AFTN) as a cause of paediatric hyperthyroidism have been reported. A three year old boy had become symptomatic with a swelling in neck, hypermetabolic features and accelerated growth at the age of eight months. Evaluation showed child harbouring an AFTN and was successfully treated with 131 I radioablation, which rendered him euthyroid.

Case 2: Juvenile Graves' disease with opthalmopathy, lymphadenopathy, accelerated growth and congestive cardiac failure. A 3-year-old child presented with congestive cardiac failure. On clinical evaluation was found to have hyperthyroidism with ophthalmopathy, accelerated growth, cervical lymphadenopathy, hepatosplenomegaly. He was initiated on anti-thyroid drugs and responded well to treatment. Approach to a childhood hyperthyroidism will be discussed with emphasis on controversial use of radioiodine therapy in children.

Monthly pulse methylprednisolone vs. oral prednisolone in treatment of thyroid opthalmopathy: an open labelled randomized controlled trial

Roy Ajitesh, Bhattacharjee Rana, Goswami Soumik, Thukral Anubhav, S. Chitra, Chakraborty Partho Pratim, Kousik Biswas, Ghosh Sujoy, Mukhopadhyay Satinath, Chowdhury Subhankar

Department of Endocrinology and Metabolism, SSKM Hospital and IPGMER, Kolkata, India

Introduction: Steroids form the mainstay of therapy in patients with TAO but the issue is how best to use them. Aim: To compare pulse iv methylprednisolone vs. oral prednisolone in the treatment of TAO. Material and Methods: Patients with untreated moderate-severe thyroid associated opthalmopathy (TAO) with moderate activity (CAS >2) were considered in the duration from January 2011 to December 2012. They were divided into GROUP-A(10 pt.): receiving iv. Pulse methylprednisolone (0.5gm for 3 consecutive days in a month for 4 months) and GROUP-B (10 pt): Oral prednisolone (starting with 1mg/kg/d then gradually tapered over 28 weeks). Main Outcome Measures: Assessed in terms of Major Response Criteria (MRC) and Minor Response Criteria (MiRC). Results: Intravenous glucocorticoid resulted in rapid improvement. At 1 month, 70% patients with iv therapy showed MRC& at 6months 100% showed MRC. In the patients with oral therapy at 1month only 20% showed MRC & at 6 months 50% patients showed MRC & 40% showed MiRC. At 12months 20% of those on iv showed relapse while 40% on oral had relapse. Those with diplopia 75% responded on iv, while 50% patients to oral therapy. Conclusion: In patients with active and moderate severe GO, iv glucocorticoids were more effective than oral.

Utility of color flow doppler ultrasonography in diagnosing diffuse toxic goitreth

Shruti Sharma, S. K. Singh

Department of Endocrinology & Metabolism, Institute of medical Sciences, Banaras Hindu University, Varanasi, India

Background: The nuclear scintigraphy is considered gold standard in thyrotoxicosis with thyroiditis but it has its limitations of wide availability. It is important to look for alternative that could be Color Flow Doppler Study (CFDS). Objectives: To assess the utility of CFDS in the diagnosis of diffuse toxic goitre. Methods: Thirty patients of Graves' and 20 of thyroiditis were enrolled and thyroid function test, anti TPO antibody and CFDS were done. Volume of the gland, Peak Systolic Volume and flow pattern were noted. Result: The means (± SD) of PSV and volume of gland in Graves' were 88.20±38.6cm/s and 25 ml±9.59 respectively. These values were significantly higher than thyroiditis {PSV p<0.0001 with CI95% 43.07-85.68 and volume p<0.01 with 95%CI 7.74-21.58}. The correlation of PSV in Graves' was significant only with T3 (p< 0.94) which was remarkably raised in Graves' disease as compared to thyroiditis. ROC cut off value of PSV > 45cm/s showed sensitivity of 83.3%, specificity of 89.5% % with positive predictive value of 92.6%. Conclusion: CFD, an inexpensive and non-invasive imaging procedure that was helpful in the evaluation of thyrotoxicosis to differentiate from toxic phase of thyroiditis with predictive value 92.6%. It is suggested to be an alternative to nuclear scintigraphy in these conditions.

  Section 4: Nodules and Cancer Top

A relook at the value of fnac0 as a first line screening tool for thyroid neoplasia

Varunchandra Aur 1 , Harish Kumar 2 , R. V. Jayakumar, Vasantha Nair, Usha Menon, Nisha. B, Praveen V. P, Arun. S. Menon,

Geeta Vidhyadharan, Sreekanth Moorthy.

1 DM resident, Amrita Institute of Medial Science, Kochi, 2 Chief author- HOD in Endocrinology, Amrita Institute of Medial Science, Kochi.

Corresponding author: Dr. Varunchandra Alur, DM resident, Department of Endocrinology, AIMS, Kochi- 41, India.

E-mail: [email protected]

Background: The ability to diagnose thyroid malignancy early and accurately is still a matter of debate. In this study aim was to audit the diagnostic accuracy of Fine needle aspiration cytology (FNAC) in the diagnosis of thyroid malignancy. Material and Methods: We studied all the FNAC done at our institute for a period of 2 months, with patients who presented with thyroid enlargement and under went Ultra sound (US) guided FNAC, unguided FNAC and thyroid surgery. Each FNAC retrospectively was classified according to Betesda classification. We studied the diagnostic accuracy of FNAC thyroid. Results: Out of 200 FNAC studied, males were 34 (17%) females were 166 (83%). Clinically 71 (36%) patients had single nodule, 104 (52%) patients had multi nodular goiter (MNG) and 25 (12%) patients had diffuse thyroid enlargement. USG thyroid showed 50 (25%) had single nodule, 94(47%) had MNG, 10(5%) had diffuse. Total of 154(77%) FNAC were guided and 46 (23%) were unguided. Out of 200 cases 29 underwent Histopathology examination (HPE) and 19 were positive for malignancy. 16 patients were positive with FNAC and 3 were negative with FNAC. With these results Sensitivity of FNAC is 84%, specificity 100%, positive predictive value 100%, negative predictive value 75% and accuracy 89%. Conclusion: We confirmed FNAC of the thyroid to be an accurate test in detection of thyroid neoplasia.

Determination of thyroglobulin and thyroglobulin antibody in patients with well differentiated thyroid carcinoma and its correlation with clinicopathological features of the disease

Adlyne Reena Asirvatham, Vasantha Nair, Praveen V. P, Harish Kumar, Nisha B, Arun Menon, Usha Menon

Amrita Institute of Medical Sciences, Cochin, Kerala

Introduction: Thyroglobulin (TG) is considered as a reliable marker of recurrent disease in patients with well-differentiated thyroid carcinoma. The presence of circulating auto-antibodies to TG (TGAb) may interfere with the TG assay, causing false positive or false negative results. Hence this study was done to analyse the presence of both thyroglobulin and thyroglobulin antibody in well-differentiated thyroid carcinoma and its correlation with Clinicopathological features of the disease. Objective: To study the thyroglobulin and thyroglobulin antibody levels in patients with well-differentiated thyroid carcinoma. Study Design : This is a retrospective study in which 250 patients diagnosed with well differentiated thyroid carcinoma are studied. Case records from the database were analysed between the time period of January 2005 and December 2012. Sample parameters included serum thyroglobulin and thyroglobulin antibody levels. Results: The analysis is ongoing. The final results will be presented in the meeting. Keywords: Thyroglobulin, Thyroglobulin Antibody, Thyroid Carcinoma

Our experience with papillary microcancer of thyroid

Anulekha Mary John 1 , Paul M Jacob 2 , Sheela Nair 3, Regi Oommen 4 , Simon Rajaratnam 1

Department of Endocrinology, 1 Endocrine Surgery, 2 Pathology, 3 Nuclear Medicine 4 Christian Medical College, Vellore

Introduction: Papillary micro carcinoma of thyroid (PMC) describes a focus of papillary thyroid cancer that is less than 1 cm in size. These tumours are frequently found on histo pathological examination of thyroid specimens, operated upon for an indication other than suspected malignancy. Methods: Over a period of 7 years (2005 - 2012), 76 cases of PMC were identified among 1300 thyroidectomy specimens. Their clinico pathologic features, treatment, and long-term outcomes were analyzed. Results: There were 18 men and 58 women, the male: female ratio was 1:3. The median age at presentation was 43 years (range 18 - 72 years). The mean tumor size was 4.1 ± 2.3 mm, 17% of cases had tumors > 6mm in size. Forty three percent(33) had multifocal tumor and 15 of them had tumors restricted to one lobe. Ten patients (13.1%) had cervical lymph node metastasis, 2 (2.6%) had evidence of vascular invasion on biopsy and 1 (1.3%) had metastasis to bone. Most patients (78.9%) underwent total thyroidectomy with or without lymph node dissection (out of eleven patients who had neck dissection, 6 were central alone,one left, and the rest had both. Fifteen patients (19.7%) who initially had hemithyroidectomy subsequently underwent completion thyroidectomy. Radioactive iodine ablation (36.8%) and levothyroxine suppressive doses were used when the tumor was multifocal or > 6mm in size. The mean duration of follow up was 20.2 ±13.5 months. Only one patient had cervical lymph node recurrence 25 months following surgery. Conclusions: Papillary micro carcinoma presented with advanced disease such as lymph node metastasis in 13% and distant metastasis in 1.3% of our cases. Howeverthe prognosis remains excellent even in these cases.

Skull metastasis as the presenting feature of mixed medullary and follcular thyroid carcinoma

Indira Maisnam, Manoj Kataria, Sandeep Chaudhary, Deep Dutta, Sujoy Ghosh, Subhankar Chowdhury, Satinath Mukhopadhyay

Department of Endocrinology & Metabolism, IPGMER & SSKM Hospital, 244 AJC Bose Road, Kolkata, India

Skull metastasis secondary to thyroid carcinoma is rare, with isolated reports, predominantly from follicular thyroid carcinoma. Mixed medullary and follicular thyroid carcinoma (MMFTC) is a rare form of thyroid carcinoma with less than 40 cases reported till date. MMFTC causing skull metastasis has not been reported previously. We report a 54-year lady with goiter for 2 years, who presented with 18cm diameter swelling over anterior part of skull of 6 months duration, which was predominantly lytic, with erosion of the underlying bone on computerized tomography. FNAC from the swelling as well as the goiter was similar showing small polyhedral cells in clusters having hyperchromatic nuclei with scant cytoplasm as well as a few thyroid follicular cells. She underwent total thyroidectomy. Histopathology of 3 × 2cm nodule in total thyroidectomy specimen revealed polygonal tumor cells arranged in nests and whorls, and extracellular amyloid deposit suggestive of medullary thyroid carcinoma along with areas of thyroid follicles showing cells with hyperchromatic nuclei, scant cytoplasm and evidence of vascular invasion confirming the diagnosis of MMFTC. This perhaps the first report of MMFTC causing skull metastasis. Any patient with lytic skull metastasis with unknown primary should undergo evaluation to rule out occult thyroid malignancy.

Retrospective analysis of anaplastic carcinoma

Roma Pradhan, Amit Agarwal Punita Lal, Manoj Jain

Background: Anaplastic thyroid carcinoma is one of the most aggressive human malignancies, with patient survival usually measured in months. Fifty cases of anaplastic carcinoma of the thyroid treated at SGPGI Lucknow were reviewed. Materials and Methods: The medical records of 50 patients diagnosed with ATC at SGPGI between 2000 and 2012 were reviewed and available information was extracted and analyzed. Results: There were 54% women and 46% men, and their median age at diagnosis was 50 years. 36% patients were below the age of 50 years. 32% of patients had previously existing goitre out of which 4% patients had transformation from well differentiated thyroid cancers. 46% patients had size greater than 10 cm at initial presentation. The most common initial presentation was rapidly enlarging mass present in 56% of patients. 48% patients had dysphagia during presentation. Change in voice was present in 44% of cases. All cases were retrospectively staged according to the Union for International Cancer Control classification system, and the results were stage IVA in 4 % cases, stage IVB in 60% cases, and stage IVC in 36% cases at initial presentation. 58% did not consent for any form of therapy. 10% patients received radiotherapy, 18% received radiotherapy and chemotherapy,4% received only chemotherapy and only 10% underwent surgery. Only 3 patients received multimodal therapy (surgery, radiotherapy, and chemotherapy). Conclusion: ATC in India presents at an early age (<50yrs) with a rapidly enlarging mass with majority of the patients not opting for any form of treatment and thus carries a dismal prognosis.

Efficacy and safety of percutaneous ethanol ablation of predominantly cystic vs. complex cystic benign thyroid nodules: Experience from a tertiary care institute in Eastern India

Nupur Basu, Deep Dutta*, Indira Maisnam*, Swadhapriya Basu, Sujoy Ghosh, Subhankar Chowdhury*, Satinath Mukhopadhyay*

Department of Radiology, IPGMER & SSKM Hospital, 244 AJC Bose Road, Calcutta, *Department of Endocrinology & Metabolism, IPGMER & SSKM Hospital, 244 AJC Bose Road, Calcutta, India

Aims & Objectives: Percutaneous aspiration and ethanol injection (PEI) is effective in managingcystic thyroid nodules (6-28% thyroid nodules) with success rate of 38-85%.This study aimed to evaluate efficacy and safety of PEI in predominantly cystic (<20% solid component; Group-1) vs. complex cystic thyroid nodules (20-50% solid component; Group-2), in achieving complete response (CR; >50% cyst volume reduction). Methods: Cystic nodules were aspirated ultrasonography guided using a 22G (25mm) needle with a 20 ml syringe in supine position, neck extended. Sterile 100% ethanol (Bengal Chemicals, India), 50-100% volume aspirated was injected into each nodule. Patients were reviewed monthly for 3 months and thereafter 3 monthly for minimum 6 months. Non-responders at 1 month with <20% reduction in cyst volume underwent a second PEI. Results: 35 patients (Group-1: 23 and Group-2: 12) out of initially considered 90 patients were studied.Mean follow up was 7.49±1.6 months.The CR rate of PEI was 65.71% (Group-1: 86.36% and Group-2: 30.76%; P<0.001) at 6 months. The odds ratio for CR in patients with complex cysts was 0.18 (0.08-0.40). Only 8/23 responders (34.7%) achieved CR at 1 month. 42.85% (15/35) achieved emission between 1 and 6 months follow up. Baseline cyst volume,volume and nature of aspirate, or volume of ethanol injected did not predict outcome. Conclusions: PEI is safe and should be the treatment of choice in patients with predominantly cystic thyroid nodules. PEI for complex thyroid cysts are associated with a lower CR, increased recurrence and need for repeated PEI.

  Section 5: Miscellaeneous Top

A case of Sheehan's syndrome with unusual presentation

Manjunath G. Anakal 1 , K. M. Suryanaryana 2

1 Senior Resident, Department of Endocrinology, M. S. Ramaiah Medical College, Bangalore, 2 Senior Professor, Department of endocrinology, M. S. Ramaiah Medical College, Bangalore

Background: Sheehan's syndrome occurs as a result of ischemic pituitary necrosis due to severe postpartum hemorrhage, causing hypopituitarism manifesting as lactational failure and followed by GH, Gonadotropins, thyrotropin deficiency and adrenal failure. Clinical Case: We report a 48-year-old woman who presented in Sept 2012 with amenorrhea of 17 years, severe fatigue, lethargy, swelling of face and all over body, and change in voice. She had profuse post-portem hemorrhage after twin delivery 17 years back, lactated for 6 months, and placed on thyroxine100 μg replacement as a case hypothyroidism when reported to a doctor for tiredness, weakness and amenorrhea. As she did not regain menses she stopped thyroxine after 4 years. On examination, BP- 120/70 mm Hg, no postural hypotension, pulse- 64; weight-54 kg. She had hoarse voice, facial puffiness, dry skin and delayed ankle jerk. Laboratory evaluation revealed TSH-2.3μIU/mL, T4 0.1, PRL-1.4 ng/mL (3.8-23.0), LH 1.06 mIU/mL, FSH 3.64 mIU/mL, AM Cortisol 1.32 μg/dL, ACTH- 5 ng/L, stimulated cortisol with 250 μg synacthen - 4.83μg/dL, sodium 132 mmol/L potassium 4.6 mmol/L, ECG-low voltage complexes, MRI-empty sella, BMD-osteoporosis. Diagnosed as Sheehan's Syndrome with features of panhypopituitarism and was instituted replacement hydrocortisone, thyroxine and bisphosphonates for osteoporosis. After 2 months of follow up she has shown significant improvement. Conclusion: The interesting points in this patient of Sheehan's Syndrome is that she did not have any lactational failure and she presented with classical clinical features of primary hypothyroidism after a long gap of 17 years.

Thyroid-associated orbitopathy in Hashimoto's thyroiditis

Narendra BS 1 , Pramila Kalra 2 , Mala Dharmalingam 3

1 Senior Resident, Department of Endocrinology, M. S. Ramaiah Medical College, Bangalore 2 Department of Endocrinology, M. S. Ramaiah Medical College, Bangalore 3 Professor & HOD, Department of Endocrinology, M. S. Ramaiah Medical College, Bangalore, India

Introduction: Thyroid-associated orbitopathy (TAO) is characterized by immune-mediated inflammation of the extraocular muscles surrounding orbital connective tissue and adipose tissue. The natural history of the disease progresses from active to inactive fibrotic stage over a period of years. The pathogenesis involves activation of both humoral and cell mediated immunity with subsequent production of glycosaminoglycans, hyaluronic acid resulting in oedema formation, increase extraocular mass and adipogenesis in the orbit. Several studies have noted a strong correlation between the levels of antibodies to thyrotropin receptor antibody (TRAb) and TAO in Graves' disease, but severe orbitopathy is rare in Hashimoto's thyroiditis. Case report: We report one case of severe TAO in a 35 years old female who presented to Endocrinology out patient department with Hashimoto's thyroiditis and primary hypothyroidism. Her clinical activity score (CAS) for the orbitopathy was 3, proptosis as measured by Hertel exopthalamometer in right eye was 21 mm and in the left eye was 19 mm. The computed tomography (CT) showed bilateral mild proptosis with mildly bulky medial rectus of right orbit suggestive of thyroid opthalmopathy. Since the eye muscle damage could not be due to TSH receptor antibodies, other pathogenic mechanisms may be responsible for the orbitopathy in patients with Hashimoto's thyroiditis. Treatment depends on severity of opthalmopathy; non-severe cases are managed medically and severe cases may require surgical decompression. Key words: Hashimoto's thyroiditis, Thyroid-associated orbitopathy, Thyrotropin receptor antibody.

Rare case of dual ectopic thyroid

Manjunath G. Anakal 1 , PramilaKalra 2 , Rajiv S R 3, Mala Dharmalingam 4

1 Senior Resident, Department of Endocrinology, M. S. Ramaiah Medical College, Bangalore, 2 Department of Endocrinology, M.S. Ramaiah Medical College, Bangalore, 3 Department of ENT, M.S. Ramaiah Medical College, Bangalore, 4 Professor & HOD, Department of endocrinology, M.S. Ramaiah Medical College, Bangalore, India

Background: Ectopic thyroid is a rare occurrence due to developmental defects in early stages of thyroid gland embryogenesis, during its course from the floor of the primitive foregut to its final pre-tracheal position. It is commonly found along the course of the thyroglossal duct or laterally in the neck, as well as in distant places such as the mediastinum and the subdiaphragmatic organs. Majority of cases are asymptomatic; symptoms depend on tumor size and its relationship with surrounding structures. Dual ectopic thyroid is a rare entity and only few cases have been reported in the world literature. Clinical Case: We report a case of dual ectopic thyroid in the lingual and submandibular region in an eight-year-old girl who presented with a midline swelling in the submandibular region. Thyroid function tests revealed primary hypothyroidism. Ultrasonography of the neck did not visualize thyroid in its usual location and a swelling in the submandibular region measuring 21 mm, with hypoechogenicity was noted. A thyroid scan with Technetium-99 m pertechnetate showed two foci of ectopic thyroid tissue at sublingual and submandibular region revealing dual ectopia of the thyroid gland. No uptake was seen in the normal bed. Histopathology of the swelling was consistent with thyroid tissue. Sublingual thyroid was clinically not visible. Patient has been put on levothyroxine supplementation in a dose of 100mcg and has been called for follow up. Conclusion: This is a rare case report of dual ectopic thyroid presenting with primary hypothyroidism.

Keywords: Dual ectopic thyroid, submandibular thyroid, sublingual thyroid, Hypothyroidism.

Hashimoto's thyroiditis with infiltrative ophthalmopathy

Soumik Goswami 1 , Rana Bhattacharjee 1 , Ajitesh Roy, 1 Deep Dutta 1 , Kaushik Biswas 1 , Sujoy Ghosh 2 , Satinath Mukhopadhyay 3 , Subhankar Chowdhury 4

1 Post-doctoral trainee, Department of Endocrinology & Metabolism, IPGME & R and SSKM Hospital, Kolkata. 2 Assistant Professor, Department of Endocrinology & Metabolism, IPGME & R and SSKM Hospital, Kolkata. 3 Professor, Department of Endocrinology & Metabolism, IPGME & R and SSKM Hospital, Kolkata. 4 Professor and Head, Department of Endocrinology & Metabolism, IPGME & R and SSKM Hospital, Kolkata, India

Introduction: Graves' disease and Hashimoto's thyroiditis are at opposite ends of the spectrum of autoimmune thyroid disease and infiltrative ophthalmopathy may rarely occur in the latter. Objective: To report a patient having Hashimoto's thyroiditis with infiltrative ophthalmopathy, of which there are only a few reported cases. Presentation and Management: A 45 year old lady presented with intermittent diplopia, occasional redness & epiphora, pain at rest and on movement of eyes without any change in acuity or field of vision for 3 months. 10 years earlier, she was investigated for symptoms of lethargy, loss of appetite, weight gain, constipation & cold intolerance and found to have a T4 of 4.1 μg/dl & TSH of 48 mIU/L for which she was put on 100 μg/day of LT4. The symptoms gradually subsided and subsequent TSH measurements till date have been in the lower half of the reference range. On her current presentation, examination revealed proptosis (RE 22 mm and LE 26 mm), lagophthalmos, CAS of 5/7 B/L but no diplopia and normal fundoscopy. She had a firm, diffuse Grade Ia goitre without any bruit and no evidence of pretibial myxoedema or acropachy. Serum anti TPO Ab was strongly positive at 84.19 IU/ml (Normal < 5.61 IU/ml), VEP was normal and CT scan revealed the presence of B/L exophthalmos, thickened extraocular muscles with sparing of tendons & increased retro-orbital tissue suggestive of thyroid ophthalmopathy. She was administered 3 cycles of pulse methylprednisolone (1.5 g at monthly intervals) and is presently doing well with a CAS of 0/7 and has no ocular symptoms except some degree of persistent proptosis. Conclusions: Infiltrative ophthalmopathy, which is characteristic of Graves' disease, may rarely occur in Hashimoto's thyroiditis giving credence to the supposition that they represent extremes of the spectrum of autoimmune thyroid disease although more evidence is required to firmly substantiate the same.


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