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Fulltext Thyroid associated ophthalmopathy - a review

Mallika PS, Tan AK, Aziz S, Syed Alwi SAR, Chong MS, Vanitha R, et al.

Malays Fam Physician, 2009;4(1):8-14.
PMID: 25606151 MyJurnal

Thyroid associated ophthalmopathy is an autoimmune disorder affecting the orbital and periorbital tissues. Hyperthyroidism is commonly associated with thyroid associated ophthalmopathy, however in 5% to 10% of cases it is euthyroid. Genetic, environmental and endogenous factors play a role in the initiation of the thyroid ophthalmopathy. Smoking has been identified as the strongest risk factor for the development of the disorder. The pathogenesis involves activation of both humoral and cell mediated immunity with subsequent production of gycoaminoglycans, hyaluronic acid resulting in oedema formation, increase extraocular mass and adipogenesis in the orbit. The natural history of the disease progresses from active to inactive fibrotic stage over a period of years. Diagnosis is mainly clinical and almost all patients with ophthalmopathy exhibit some form of thyroid abnormality on further testing. Treatment is based on the clinical severity of the disease. Non-severe cases are managed by supportive measures to reduce the symptomatology and severe cases are treated by either medical or surgical decompression. Rehabilitative surgery is done for quiescent disease to reduce diplopia and improve cosmesis.

Matched MeSH terms: Hyperthyroidism
Fulltext The prevalence of skin manifestations in thyrotoxicosis--a retrospective study

Ramanathan M, Abidin MN, Muthukumarappan M

Med J Malaysia, 1989 Dec;44(4):324-8.
PMID: 2520042

The presenting features of 236 thyrotoxic patients seen in the thyroid clinic were reviewed. 18.65% of these patterns had one or more dermatological complaints at presentation. There was no specific difference in this group of patients when compared with the general hyperthyroid population with regard to age, race, sex, duration of hyperthyroidism or biochemical indices of thyrotoxicosis. The two major complaints were itching and alopecia. The prevalence of pruritus at 6.4% in our series was identical to that of other workers, but we had a much lower occurrence of alopecia at 2.6%. The diagnosis of thyrotoxicosis was delayed in two patients in whom the only major complaint was pruritus. These symptoms cleared quickly when these patients became euthyroid. However there were other patients who noted hair loss with anti-thyroid medications. The incidence of vitiligo, eczema, onycholysis in our series was much lower those quoted in the Western literature The occurrence of pretibial myoxoedema in our series is similar to that of other workers from this region. The other miscellaneous manifestations include urticaria, xanthelasma and systemic lupus erythematosis. In conclusion we feel the cutaneous manifestations of hyperthyroidism are common in our patients.

Matched MeSH terms: Hyperthyroidism*
The effects of propranolol on skeletal muscle contraction, lipid peroxidation products and antioxidant activity in experimental hyperthyroidism

Zaiton Z, Merican Z, Khalid BA, Mohamed JB, Baharom S

Gen. Pharmacol., 1993 Jan;24(1):195-9.
PMID: 8482496

1. The mean levels of lipid peroxidation products, namely conjugated diene and malonaldehyde, were increased in the soleus muscles of hyperthyroid cats, while the mean glutathione peroxidase activity was decreased. No corresponding similar changes were noted in the fast extensor digitorum longus muscles and serum. 2. Propranolol administration prevented the increase in conjugated diene level in the soleus muscles of hyperthyroid cat but not the malonaldehyde level. It also prevented the reduction in glutathione peroxidase activity in the slow oxidative soleus muscles of hyperthyroid cats. 3. Maximal twitch tension, subtetanic tension and maximum tetanic tension of soleus and EDL muscles were reduced in hyperthyroid cats. Propranolol administration for 5 weeks to hyperthyroid cats did not prevent the reduction in tension of contractions of these muscles. 4. It is suggested that lipid peroxidation might not be responsible for the myopathy in hyperthyroidism and propranolol administration does not improve skeletal muscle function in hyperthyroid animals.

Matched MeSH terms: Hyperthyroidism/chemically induced; Hyperthyroidism/metabolism*
Takotsubo cardiomyopathy in association with hyperthyroidism

Zuhdi AS, Yaakob ZH, Sadiq MA, Ismail MD, Undok AW, Ahmad WA

Medicina (Kaunas), 2011;47(4):219-21.
PMID: 21829054

Takotsubo cardiomyopathy is a rare, acute, nonischemic cardiomyopathy causing transient left ventricular dysfunction, which can mimic myocardial infarction on its presentation. While many cardiac manifestations have been associated with hyperthyroidism, we report a rare case where it has precipitated takotsubo cardiomyopathy.

Matched MeSH terms: Hyperthyroidism/complications; Hyperthyroidism/diagnosis*
Fulltext Subclinical hypothyroidism among patients with depressive disorders

Siti Yazmin Zahari Sham, Nor Aini Umar, Zarida Hambali, Rosdinom Razali, Mohd Rizal Abdul Manaf

Malaysian Journal of Medicine and Health Sciences, 2014;10(2):71-78.
MyJurnal

Subclinical hypothyroidism (SHT) is a biochemical diagnosis, defined as an elevated Thyroid Stimulating Hormone (TSH) with normal free thyroxine (FT4). It affects 4-10% of the adult population and is more prevalent in elderly women. Its commonest cause is autoimmune thyroiditis, detected by anti- thyroid peroxidase antibody (TPO-Ab). About 2-5% of SHT patients progress to overt hypothyroidism annually. The SHT prevalence among depressed patients ranges between 3% and 17%. This study aimed to determine the prevalence of SHT and TPO-Ab positivity among patients diagnosed with depressive disorders. It was a cross-sectional study carried out in the Universiti Kebangsaan Malaysia Medical Centre over a 12 months period. Serum TSH, FT4 and TPO-Ab were measured. Results showed that 82% of depressed patients were euthyroid, 4% had SHT, 11% had subclinical hyperthyroidism and 2% had discordant thyroid function. TPO-Ab positivity among the subjects was 7%, one of whom had SHT. In conclusion, the prevalence of SHT and TPO-Ab positivity in the study population, at 4% and 7%, respectively, were comparable to previous findings.

Matched MeSH terms: Hyperthyroidism
Slow carbamazepine clearance in a nonadherent Malay woman with epilepsy and thyrotoxicosis

Yeap LL, Lim KS, Ng CC, Hui-Ping Khor A, Lo YL

Ther Drug Monit, 2014 Feb;36(1):3-9.
PMID: 24342894 DOI: 10.1097/FTD.0000000000000024

The authors describe a case of a 37-year-old Malay lady with an unusually slow carbamazepine clearance, which may be related to genetic polymorphisms of drug metabolizing enzymes and transporters. When given a small daily dose of 200 mg immediate-release carbamazepine, this patient experienced drowsiness. Subsequently, she reduced her carbamazepine dose to 200 mg twice a week (on Mondays and Fridays), resulting in poor seizure control. At the same time, the patient was diagnosed with hyperthyroidism and was given carbimazole and propranolol. Hyperthyroidism and the concurrent use of these antihyperthyroid agents may have further slowed down the metabolism of carbamazepine. Therapeutic drug monitoring of carbamazepine was carried out, and a slow carbamazepine clearance of 1.45 L·h⁻¹ per 70 kg was observed. Genotyping of selected genetic variants in CYP3A4, CYP3A5, EPHX1, ABCB1, and ABCC2 revealed that she has CYP3A5*3/*3 and ABCB1 3435-CC genotypes. Both genotypes have been shown to be associated with higher adjusted mean serum carbamazepine concentration in Chinese and Korean patients with epilepsy. Physicians should be vigilant about the risk of adverse effects among patients with a slow carbamazepine clearance, especially in Malays. Simulations of carbamazepine dosing regimen based on the pharmacokinetic parameters of this patient were performed to allow individualization of drug therapy.

Matched MeSH terms: Hyperthyroidism/drug therapy; Hyperthyroidism/physiopathology
Severe hypothyroidism presenting with supraventricular tachycardia

Mak WW, Raja Nurazni RA, Mohamed Badrulnizam LB

Med J Malaysia, 2018 10;73(5):349-350.
PMID: 30350825 MyJurnal

Thyroid disease is common and can have various systemic manifestations including cardiac diseases. Hypothyroidism is commonly associated with sinus bradycardia, low QRS complexes, prolonged QT interval and conduction blocks but rarely may cause arrhythmias. We present a patient who presented with presyncope and supraventricular tachycardia with severe hypothyroidism. Patient responded well to thyroxine replacement with biochemical improvement, the disappearance of arrhythmia after restoration of euthyroidism suggests that hypothyroidism might be the cause of supraventricular tachycardia. The aim of this report is to underline the possible aetiological link between supraventricular tachycardia and hypothyroidism, although supraventricular arrhythmias are ordinary features of hyperthyroidism.

Matched MeSH terms: Hyperthyroidism
Serum creatine kinase: an adjunct biochemical index of subclinical thyrotoxicosis?

Wan Nazaimoon WM, Siaw FS, Sheriff IH, Faridah I, Khalid BA

Ann. Clin. Biochem., 2001 Jan;38(Pt 1):57-8.
PMID: 11270843
Matched MeSH terms: Hyperthyroidism/diagnosis; Hyperthyroidism/enzymology*
Fulltext Serum alpha-i acid glycoprotein in thyroid dysfunctions

Ho CL, Cheah JS

Med J Malaysia, 1982 Mar;37(1):70-1.
PMID: 7121352

The serum alpha-1 acid glycoprotein of 9 euthyroid subjects, 14 hypothyroid patients and 21 hyperthyroid patients was determined by radial immunodiffussion in agar plates. The serum alpha1 acid glycoprotein level in both the hypothyroid and hyperthyroid patients were significantly lowered when compared to the euthyroid subjects. There was no significant correlation between the alpha-1 acid glycoprotein level mid the Liothyronine resin uptake (T3 resin. uptake) and the serum total Thyroxine Iodide (T4I) level.

Matched MeSH terms: Hyperthyroidism/blood
Fulltext Results of long-term follow-up after compensated fixed-dose therapy for thyrotoxicosis

Zaini A, Khir A, Doi SA, Chan SP, Paramsothy M, Khoo BH

J Int Med Res, 1992 Jun;20(3):279-88.
PMID: 1397673

To evaluate the effects of simple compensated fixed-dose iodine-131 therapy for thyrotoxicosis, the long-term results for 74 patients treated with a fixed dose of iodine-131 ranging from 5 to 12 mCi (185 to 444 MBq) were evaluated in the first 2 years of a trial. The dose selected was loosely based on the gross size of the thyroid gland. Routine antithyroid drug therapy was given for a minimum of 3 months after iodine-131 therapy. The mean (+/- SD) duration of follow-up was 74.5 +/- 42 months. The results indicated that roughly 25% of patients treated in this way will become hypothyroid after 5 years and that 85% are cured (need no further therapy during the follow-up period) using a single dose of iodine-131. Of those cured using a single iodine-131 dose, 81% were no longer receiving drugs after 6 months and 85% after 1 year. Such a regimen seems currently to be among the best available where prolonged periods of medication-free euthyroidism after therapy are sought.

Matched MeSH terms: Hyperthyroidism*
Fulltext Rapid reversal of subclinical hyperthyroidism in patients with large multinodular goitres after thyroidectomy

Lum SK

Med J Malaysia, 2013 Oct;68(5):439-40.
PMID: 24632876 MyJurnal

A patient is said to have subclinical hyperthyroidism if he has a depressed thyroid stimulating hormone (TSH) level but is clinically euthyroid and has a normal thyroxine (T4) and triiodothyronine (T3) level. The aetiology of this condition is unknown, its progression is uncertain and the value of treatment is doubtful. These 2 cases show a rapid reversal of TSH suppression within a week after thyroidectomy. This suggest an unidentified potent but innocuous suppressor of TSH is produced by some large nodular goitres. Patients with multinodular goitres with subclinical hyperthyroidism can have their anxiety allayed with assurance that their condition is benign and that their TSH suppression is due to the presence of an innocuous substance which is protective in nature. This substance, when isolated, will find a useful place in the prevention and treatment of papillary carcinoma of the thyroid because of its potent effect on the pituitary-thyroid axis without causing any peripheral effects.

Matched MeSH terms: Hyperthyroidism
Fulltext Radioiodine I-131 for the therapy of graves' disease

Mumtaz M, Lim SL, Khaw CH, Mohd Khir AS

Malays J Med Sci, 2009 Jan;16(1):25-33.
PMID: 22589645

Graves' disease is a common cause of hyperthyroidism. Treatment options for Graves' disease include antithyroid medication, surgery or radioactive iodine (I-31) or RAI. This review will focus on the approach to RAI therapy; discussing dose selection, patient preparation, and consideration before and after administering RAI, examining aspects of pre-treatment with antithyroid medication as well as discussing possible adverse events including hypothyroidism and possible worsening of thyroid-associated opthalmopathy. Follow-up is lifelong with the aim of ensuring the patient remains euthyroid or on replacement therapy if there is evidence of hypothyroidism. While there are controversies in treatment of thyrotoxicosis with RAI, with appropriate patient selection and regular follow-up, radioiodine is a safe and effective modality in achieving high cure rates.

Matched MeSH terms: Hyperthyroidism*
Fulltext Psychoses associated with thyrotoxicosis: a retrospective study of twenty cases

Tan CK

Med J Malaysia, 1985 Sep;40(3):247-51.
PMID: 3842721

A total of 23 patients with psychoses associated with thyrotoxicosis were admitted to the psychiatric unit of a University Hospital over a 13-year period, of which 20 patients were included in this retrospective study. It was found that a parallel relationship between thyrotoxicosis and psychosis appears to exist in six patients, while in the remaining 14 patients, the course of the two disease processes were largely independent of each other. Paranoid delusions and auditory hallucinations were the most prominent psychiatric symptoms. Depression was commonly seen even in patients who were not having an affective illness. In four patients, a mixed schizo-affective psychosis was seen, suggesting that the diagnostic distinction between the affective and schizophrenic reactions are often blurred in psychosis associated with thyrotoxicosis.

Matched MeSH terms: Hyperthyroidism*
Prolonged Exercise Test in Patients With History of Thyrotoxicosis

Tan HT, Tan CY, Teong CS, Ratnasingam J, Goh KJ

J Clin Neurophysiol, 2020 Aug 05.
PMID: 32773648 DOI: 10.1097/WNP.0000000000000766

PURPOSE: Thyrotoxic periodic paralysis is characterized by recurrent episodes of reversible, severe proximal muscle weakness associated with hypokalemia and hyperthyroidism. Prolonged exercise test is an easy, noninvasive method of demonstrating abnormal muscle membrane excitability in periodic paralyses. Although abnormal in thyrotoxic periodic paralysis patients, the effects thyroid hormone levels in non-thyrotoxic periodic paralysis thyrotoxicosis patients have not been well studied. The study aims to evaluate thyrotoxicosis patients (regardless of thyrotoxic periodic paralysis history) with prolonged exercise test and correlate it with their thyroid status.
METHODS: This is a prospective, cross-sectional study of consecutive thyrotoxicosis patients seen at the endocrine clinic of a tertiary medical center. Thyroid status was determined biochemically before prolonged exercise test. Compound muscle action potential (CMAP) amplitudes postexercise were compared against pre-exercise amplitudes and recorded as percentage of mean baseline CMAP amplitude. Comparisons of time-dependent postexercise CMAP amplitudes and mean CMAP amplitude decrement were made between hyperthyroid and nonhyperthyroid groups.
RESULTS: Seventy-four patients were recruited, 23 (31%) men, 30 (41%) Chinese, and the mean age was 48.5 ± 16.8 years. Of 74 patients, 32 (43%) were hyperthyroid and 42 (57%) were nonhyperthyroid viz. euthyroid and hypothyroid. Time-dependent CMAP amplitudes from 10 to 45 minutes after exercise were significantly lower in hyperthyroid patients compared with nonhyperthyroid patients (P < 0.01). Mean CMAP amplitude decrement postexercise was significantly greater in hyperthyroid than nonhyperthyroid patients (23.4% ± 11.4% vs. 17.3% ± 10.5%; P = 0.02).
CONCLUSIONS: Compound muscle action potential amplitude declines on prolonged exercise test were significantly greater in hyperthyroid patients compared with nonhyperthyroid patients. Muscle membrane excitability is highly influenced by thyroid hormone level. Thyrotoxic periodic paralysis occurs from increased levels of thyroid hormone activity in susceptible patients.

Matched MeSH terms: Hyperthyroidism
Fulltext Primary thyroid lymphoma with elevated free thyroxine level

Yahaya N, Din SW, Ghazali MZ, Mustafa S

Singapore Med J, 2011 Sep;52(9):e173-6.
PMID: 21947158

Primary thyroid lymphoma (PTL) is a rare form of thyroid cancer that is known to be associated with Hashimoto thyroiditis. This association is supported by the presence of elevated titres of both antithyroglobulin and antimicrosomal antibodies in up to 95 percent of patients with PTL. Most patients with PTL present with a rapidly enlarging neck mass and compressive symptoms. The majority of thyroid cancer patients have normal levels of thyroid hormones; they are rarely hyperthyroid, with no obvious clinical features of thyrotoxicosis. We describe a patient who presented with minimal clinical features of thyrotoxicosis despite having markedly elevated serum free thyroxine and suppressed serum thyroid-stimulating hormone levels.

Matched MeSH terms: Hyperthyroidism*
Prevalence, risk factors, and clinical features of thyroid-associated ophthalmopathy in multiethnic Malaysian patients with Graves' disease

Lim SL, Lim AK, Mumtaz M, Hussein E, Wan Bebakar WM, Khir AS

Thyroid, 2008 Dec;18(12):1297-301.
PMID: 19012471 DOI: 10.1089/thy.2008.0044

The prevalence of thyroid-associated ophthalmopathy (TAO) has been reported to be lower in several Asian populations than in Caucasians. The risk factors for TAO that have been demonstrated in Caucasians have not been studied in Asian populations. The aim of this study, therefore, was to determine the prevalence, risk factors, and clinical features of TAO in a cohort of multiethnic Malaysian patients with Graves' disease (GD).

Matched MeSH terms: Hyperthyroidism*
Plasma renin and aldosterone in thyroid diseases

Asmah BJ, Wan Nazaimoon WM, Norazmi K, Tan TT, Khalid BA

Horm. Metab. Res., 1997 Nov;29(11):580-3.
PMID: 9479560 DOI: 10.1055/s-2007-979105

The effect of thyroid hormones on the renin-angiotensin-aldosterone system has not been fully resolved. Highly specific immunoassays for measurement of renin, aldosterone, free T4 (fT4), free T3 (fT3) and ultrasensitive TSH enables a direct and more accurate measurement of these hormones. We investigated the relationship between plasma renin, aldosterone and thyroid hormones in the basal state and after intravenous frusemide. This is a cross-sectional study involving 37 patients with thyrotoxicosis, 42 rendered euthyroid with normal fT4, fT3 and TSH levels, 17 with euthyroid levels of fT4 and fT3 but suppressed TSH, and 11 with hypothyroidism. Basal plasma renin was significantly higher in thyrotoxicosis (63.4 +/- 9.8 microU/ml, mean +/- SEM) compared to euthyroid (32.7 +/- 4.4 microU/ml) and hypothyroid (26.7 +/- 9.8 microU/ml). Basal plasma renin for euthyroid with suppressed TSH (41.0 +/- 7.4 microU/ml) was significantly higher than hypothyroid (p = 0.02). Basal plasma aldosterones were not significantly different except for suppressed TSH (157.7 +/- 13 pg/ml), which was higher than normal (109.9 +/- 10.4 pg/ml; p = 0.04). Following frusemide, plasma renin and aldosterone were significantly increased in all groups. Plasma renin was highly correlated to fT3 (r = 0.405, p < 0.001), total T3 (r = 0.359, p < 0.001), fT4 (r = 0.331, p < 0.001) and TSH (r = 0.300, p < 0.001) in the basal state, but less to total T4 (r = 0.248, p < 0.01). Plasma renin correlated poorly to serum aldosterone (r = 0.212, p < 0.03). This study clearly showed that regulation of renin was mainly influenced by fT3, and that aldosterone response to frusemide was blunted in thyrotoxicosis despite normal electrolytes.

Matched MeSH terms: Hyperthyroidism*
Papillary thyroid microcarcinoma diagnosed in a patient presenting with hyperthyroidism

Surenthiran Ramanathan, Tong, Chin Voon

International e-Journal of Science, Medicine & Education, 2017;11(3):30-31.
MyJurnal

Papillary thyroid microcarcinoma is not uncommon
and constitutes almost one third of all differentiated
thyroid carcinomas. It is generally regarded as low risk
and usually an incidental finding from histopathology
examination. Some areas of management of this entity
remains uncertain and requires a multidisciplinary
approach. We present a patient who initially came to
us with symptoms of hyperthyroidism, later underwent
thyroidectomy for a suspicious lesion but was found to
have micropapillary thyroid carcinoma in another part
of her thyroid gland.

Matched MeSH terms: Hyperthyroidism
Fulltext Pancytopenia in a patient with Grave's disease

Loh HH, Tan F

Med J Malaysia, 2013 Aug;68(4):372-3.
PMID: 24145274 MyJurnal

Pancytopenia can rarely complicate Grave's disease. It can be due to uncontrolled thyrotoxicosis or as a result of rare side effect of antithyroid medication. Pernicious anemia leading to Vitamin B12 deficiency is another rare associated cause. We report a case of a patient with Grave's disease and undiagnosed pernicious anemia whom was assumed to have antithyroid drug induced pancytopenia. Failure to recognize this rare association of pernicious anemia as a cause of pancytopenia had resulted in delay in treatment and neurological complication in our patient.

Matched MeSH terms: Hyperthyroidism*
Fulltext Palm olein oil produces less lipid peroxidation products than soya bean oil

Zaiton Z, Merican Z, Khalid BA, Mohamed JB, Baharom S

Asia Pac J Clin Nutr, 1997 Jun;6(2):116-8.
PMID: 24394713

The soleus muscles of hyperthyroid rats were used to investigate the effect of palm olein oil and soya bean oil on the production of lipid peroxidation products. It was found that palm olein oil but not soya bean oil significantly decreased malonaldehyde and conjugated diene levels of the soleus muscles of hyperthyroid rats. These findings suggest that palm olein per se produces less lipid peroxidation products than soya bean oil. Such an assay method gives a composite net picture of the propensity of an oil to produce lipid peroxidation products.

Matched MeSH terms: Hyperthyroidism

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