Manejo del paciente con Hipertiroidismo en consulta externa de la Unidad Técnica de Endocrinología del Hospital Carlos Andrade Marín / Management of the patient with hyperthyroidism in the outpatient clinic of the Technical Unit of Endocrinology of the Endocrinology Technical Unit of the Carlos Andrade Marín Hospital

El hipertiroidismo es un trastorno caracterizado por el exceso de hormonas tiroideas. El déficit de yodo es un factor clave en dicha patología y en lugares con suficiencia del mismo se asocian a au-toinmunidad tiroidea. La prevalencia de hipertiroidismo mani-fiesto varía del 0,2% al 1,3% en áreas con suficiencia de yodo, sin embargo, esto puede variar en cada país por diferencias en umbrales de diagnóstico, sensibilidad de ensayo y población se-leccionada. Un reporte de The Third National Health and Nutri-tion Examination Survey (NHANES III) mostró que el hiperti-roidismo manifiesto se presenta en 0,7% de la población general e hipertiroidismo subclínico en el 1,7%1,2.En incidencia, la patología se asocia con la suplementación de yodo, con la mayor frecuencia en áreas de deficiencias, por au-mento de nódulos tiroideos en la población anciana, teniendo a regiones de áreas montañosas como América del Sur, África Central y suroeste de Asia dentro de este grupo. Un meta aná-lisis de estudios europeos mostró una incidencia general de 50 casos por 100000 personas/años1. En Ecuador, según los datos del Instituto Nacional de Estadísticas y Censos (INEC) del 2017, se reportaron 157 casos de hipertiroidismo, de los cuales la En-fermedad de Graves (EG) fue la causa más común, seguida por el bocio multinodular tóxico (BMNT) y finalmente el adenoma tóxico (AT) con una incidencia de 61 %, 24 % y 14 % respecti-vamente3.Los pacientes con esta patología tienen aumento de riesgo com-plicaciones cardiovasculares y mortalidad por todas las causas, siendo falla cardíaca uno de sus principales desenlaces, así el diagnóstico precoz evita estos eventos, principalmente en pobla-ción de edad avanzada.El presente protocolo se ha realizado para un correcto trata-miento de esta patología en el Hospital de Especialidades Carlos Andrade Marín (HECAM).

Hyperthyroidism is a disorder characterized by an excess of thyroid hormones. Iodine deficiency is a key factor in this pa-thology and in places with iodine deficiency it is associated with thyroid autoimmunity. The prevalence of overt hyperthyroidism varies from 0,2% to 1,3% in iodine-sufficient areas; however, this may vary from country to country due to differences in diag-nostic thresholds, assay sensitivity, and selected population. A report from The Third National Health and Nutrition Examina-tion Survey (NHANES III) showed that overt hyperthyroidism occurs in 0,7% of the general population and subclinical hyper-thyroidism in 1,7%1,2.In incidence, the pathology is associated with iodine supplemen-tation, with the highest frequency in areas of deficiencies, due to increased thyroid nodules in the elderly population, having regions of mountainous areas such as South America, Central Africa and Southwest Asia within this group. A meta-analysis of European studies showed an overall incidence of 50 cases per 100000 person/years1. In Ecuador, according to data from the National Institute of Statistics and Census (INEC) in 2017, 157 cases of hyperthyroidism were reported, of which, Graves' di-sease (GD) was the most common cause, followed by toxic mul-tinodular goiter (BMNT) and finally toxic adenoma (TA) with an incidence of 61 %, 24 % and 14 % respectively3.Patients with this pathology have an increased risk of cardiovas-cular complications and all-cause mortality, with heart failure being one of the main outcomes, so early diagnosis avoids these events, mainly in the elderly population.The present protocol has been carried out for the correct treat-ment of this pathology at the Carlos Andrade Marín Specialties Hospital (HECAM).

La Insuficiencia Cardíaca Aguda como Manifestación de la Tirotoxicosis. A Propósito de un Caso / Acute heart failure as a manifestation of thyrotoxicosis. A case report

Introducción: La tirotoxicosis se considera una emergencia endocrinológica. Suele ser la complicación más grave y menos frecuente de una patología relativamente frecuente como es el hipertiroidismo. Tiene afectación a nivel sistémico, con especial hincapié en el sistema cardiovascular, por lo que una de las manifestaciones prevalentes y a considerar en este trabajo, es la insuficiencia cardiaca aguda. Caso clínico: Paciente femenina de 40 años con antecedente de tabaquismo e hipertiroidismo, con abandono de medicación (Metimazol) y de controles en contexto de pandemia. Consultó en reiteradas ocasiones por evento sincopal asociado a palpitaciones, agregando en esta consulta episodio tos con expectoración hemoptoica y náuseas. Laboratorio con TSH<0.01mU/L y T4 7.77pmol/L. Troponinas 19.3ng/L. Evolucionó con hipotensión sin respuesta a cristaloides y mayor disnea. Se decidió intubación orotraqueal. Se realizó ecocardiograma que informaba función sistólica con deterioro severo. Realizó tratamiento con Metimazol y solución de Lugol con mejoría de los parámetros de laboratorio. A los diez días evolucionó con abdomen agudo perforado con posterior shock séptico refractario y falleció. Discusión y conclusiones: Luego de examinar la bibliografía disponible, y contrastarla de forma retrospectiva con la evolución de la paciente, se puede observar la relación entre el hipertiroidismo y los cambios hemodinámicos. En el caso presentado, la paciente tuvo como antecedente el diagnóstico de hipertiroidismo y se consideró que el factor desencadenante fue la suspensión del metimazol; a su vez, la insuficiencia cardíaca aguda que presentó durante los primeros días de internación fue consecuencia del efecto cardiovascular directo de las hormonas tiroideas.

Introduction: Thyrotoxicosis is considered an endocrinological emergency; It is usually the most serious and least frequent complication of a relatively frequent pathology such as hyperthyroidism. It has systemic involvement, with special emphasis on the cardiovascular system, which is why one of the most prevalent manifestations to be considered in this work is acute heart failure. Clinical case: A 40-year-old female patient with a history of smoking and hyperthyroidism, with abandonment of medication (Methimazole) and controls in the context of a pandemic. She consulted repeatedly due to a syncopal event associated with palpitations, adding to this consultation an episode of coughing with bloody sputum and nausea. Laboratory with TSH <0.01mU/L and T4 7.77pmol/L. Troponins 19.3ng/L. He evolved with hypotension without response to crystalloids and increased dyspnea. Orotracheal intubation was decided. An echocardiogram was performed, which reported severely impaired systolic function. She underwent treatment with Methimazole and Lugol's solution with improvement in laboratory parameters. Ten days later, he developed an acute perforated abdomen with subsequent refractory septic shock and died. Discusion. Conclusion: After examining the available bibliography, and contrasting it retrospectively with the evolution of the patient, the relationship between hyperthyroidism and hemodynamic changes can be observed. In the case presented, the patient had a history of a diagnosis of hyperthyroidism, and it was considered that the triggering factor was the suspension of methimazole; In turn, the acute heart failure that she presented during the first days of hospitalization was a consequence of the direct cardiovascular effect of thyroid hormones.

Uso adecuado de las pruebas de laboratorio para la evaluación de la función tiroidea en pediatría / Appropriate use of laboratory tests for evaluation of thyroid function in pediatrics

Las pruebas de función tiroidea (PFT) son esenciales para el diagnóstico preciso y el seguimiento eficaz de la disfunción tiroidea. Existe un incremento progresivo y estable de los pedidos de PFT, incluso se han incorporado las mismas a los exámenes de salud anuales en niños sanos. Representan más del 60% de las pruebas realizadas en el laboratorio de endocrinología, tanto en adultos como en los laboratorios especializados en pediatría. Para hacer un uso eficiente de las PFT, antes de solicitarlas debemos preguntarnos… ¿Para quién? ¿Cuándo solicitarlas? ¿Qué pruebas solicitar? ¿Cómo solicitarlas? y ¿Cómo interpretar correctamente los resultados? Un resultado anormal en las PFT no siempre implica patología tiroidea asociada. Las PFT tienen importante variabilidad intra e interindividual lo que hace más compleja su correcta interpretación. La pesquisa de enfermedad tiroidea neonatal es un importante aporte a la prevención de la deficiencia mental en la infancia, su aplicación obligatoria posibilita un diagnóstico temprano, para asegurar su éxito debe considerarse en el marco de un programa integral de detección con estrategias de confirmación, tratamiento temprano y seguimiento a corto, mediano y largo plazo. No debe hacerse un uso indiscriminado de la prueba de estímulo con TRH en el diagnóstico de la patología tiroidea. En pediatría la estrategia de tamiz de enfermedad tiroidea es conveniente realizarla mediante la medición de por lo menos TSH y T4 libre e incluir la determinación de ATPO en grupos de riesgo, a diferencia de la determinación aislada de TSH como es recomendado en adultos. (AU)

Thyroid function tests (TFTs) are essential for accurate diagnosis and effective monitoring of thyroid dysfunction. There is a progressive and steady increase in requests for TFTs, and they have even been incorporated into annual health examinations in healthy children. They represent more than 60% of the tests performed in the endocrinology laboratory, both in adults and in specialized pediatric laboratories. To efficiently use TFTs, before requesting them we should ask ourselves... For whom? When to request them? Which tests to request? How to request them? and How to correctly interpret the results? An abnormal TFT result does not always imply thyroid disease. TFTs have significant intra- and inter-individual variability, which makes their correct interpretation more complex. Screening for newborn thyroid disease is an important contribution to the prevention of intellectual disability in childhood and its mandatory use enables early diagnosis; however, to ensure the test to be successful, it should be considered within the framework of a comprehensive screening program with strategies for confirmation, early treatment, and short-, medium-, and long-term follow-up. The TRH stimulation test in the diagnosis of thyroid disease should not be used indiscriminately. In children, the screening strategy for thyroid disease should be performed by measuring at least TSH and free T4 and include the measurement of TPO-ab in risk groups, as opposed to the isolated measurement of TSH as recommended in adults. (AU)

Dolor y edema de miembros inferiores por dermopatía tiroidea: presentación inusual de la enfermedad de Graves en una paciente adolescente / Lower limb pain and edema due to thyroid dermopathy: an unusual presentation of Graves disease in an adolescent patient

La enfermedad de Graves es un proceso inmunomediado en el que autoanticuerpos se dirigen contra el receptor de tirotrofina. Por su acción estimulante sobre la glándula tiroides, se genera crecimiento glandular difuso y aumento de la hormonogénesis. Se caracteriza por el comienzo subagudo de síntomas constitucionales, neuromusculares, cardiovasculares, gastrointestinales y oculares, seguidos en algunos casos de la aparición de manifestaciones cutáneas como la dermopatía tiroidea o mixedema. En pediatría la enfermedad de Graves es infrecuente (aunque es la causa más frecuente de hipertiroidismo), pero la cronología de aparición de los síntomas está bien descrita; es rara la aparición de dermopatía en ausencia de otros síntomas de hipertiroidismo y sin afectación ocular. Se presenta el caso de una paciente de 15 años con dermopatía tiroidea por enfermedad de Graves sin oftalmopatía ni otros síntomas de hipertiroidismo clínico asociados.

Graves disease is an immune-mediated process characterized by the presence of autoantibodies to thyrotropin receptors. Its stimulating action on the thyroid gland causes diffuse glandular growth and increased hormone production. Graves disease is characterized by a subacute onset of non-specific, neuromuscular, cardiovascular, gastrointestinal, and eye symptoms, sometimes followed by skin manifestations, such as thyroid dermopathy or myxedema. In pediatrics, Graves disease is rare (although it is the most frequent cause of hyperthyroidism). However, the chronology of symptom onset has been well described; the development of dermopathy in the absence of other symptoms of hyperthyroidism and without eye involvement is rare. Here we describe the case of a 15-year-old female patient with thyroid dermopathy due to Graves disease without eye disease or other associated clinical symptoms of hyperthyroidism.

Screening, diagnosis and management of hypothyroidism in pregnancy: Number 10 - October 2022

Key points Pregnancy places a metabolic overload on the maternal thyroid, especially in the first trimester, mainly because of the demand imposed by the conceptus. The fetal thyroid becomes functionally mature only around pregnancy week 20. Until then, the fetus depends on the transfer of maternal thyroid hormones (THs). Thyroid hormones are essential for the adequate fetal neurofunctional and cognitive development. Hypothyroidism brings higher risks of obstetric and fetal complications, namely, first-trimester miscarriage, preeclampsia and gestational hypertension, placental abruption, prematurity, low birth weight, and higher perinatal morbidity and mortality. Primary hypothyroidism (involvement of the gland with difficulty in producing and/or releasing TH) is the most common form of disease presentation, with the main etiology of Hashimoto's thyroiditis of autoimmune origin. In about 85%-90% of cases of Hashimoto's thyroiditis, antithyroid antibodies are present; the antithyroperoxidase (ATPO) is the most frequent. Positivity for ATPO is determined when circulating values exceed the upper limit of the laboratory reference. It implies greater risks of adverse maternal-fetal outcomes. Such a correlation occurs even in ranges of maternal euthyroidism. The critical point for the diagnosis of hypothyroidism during pregnancy is an elevation of thyroid-stimulating hormone (TSH). The measurement of free thyroxine (FT4) differentiates between subclinical and overt hypothyroidism. In subclinical hypothyroidism, FT4 is within the normal range, whereas in overt hypothyroidism, FT4 values are below the lower limit of the laboratory reference. Treatment of hypothyroidism is performed with levothyroxine (LT4) replacement with the aim of achieving adequate TSH levels for pregnancy. Some women have a previous diagnosis of hypothyroidism, and may or may not be compensated at the beginning of pregnancy. Even in compensated cases, the increase in LT4 dose is necessary as soon as possible. In the postpartum period, adjustment of the LT4 dose depends on the condition of previous disease, on the positivity for ATPO, and also on the value of LT4 in use at the end of pregnancy. Recommendations In places with full technical and financial conditions, TSH testing should be performed for all pregnant women (universal screening) as early as possible, ideally at the beginning of the first trimester or even in preconception planning. In places with less access to laboratory tests, screening is reserved for cases with greater risk factors for decompensation, namely: previous thyroidectomy or radioiodine therapy, type 1 diabetes mellitus or other autoimmune diseases, presence of goiter, previous history of hypo or hyperthyroidism or previous ATPO positivity. The TSH dosage should be repeated throughout pregnancy only in these cases. The diagnosis of hypothyroidism is made from the TSH value > 4.0 mIU/L. Pregnant women with previous hypothyroidism, overt hypothyroidism diagnosed during pregnancy or those with the above-mentioned higher risk factors for decompensation should be referred for risk antenatal care, preferably in conjunction with the endocrinologist. Overt hypothyroidism in pregnancy is identified when TSH > 10 mIU/L, and treatment with LT4 is readily recommended at an initial dose of 2 mcg/kg/day. TSH values > 4.0 mUI/L and ≤ 10.0 mUI/L require FT4 measurement with two diagnostic possibilities: overt hypothyroidism when FT4 levels are below the lower limit of the laboratory reference, or subclinical hypothyroidism when FT4 levels are normal. The treatment for subclinical hypothyroidism is LT4 at an initial dose of 1 mcg/kg/day, and the dose should be doubled upon diagnosis of overt hypothyroidism. In cases of TSH > 2.5 and ≤ 4.0 mIU/L, if there are complete conditions, ATPO should be measured. If positive (above the upper limit of normal), treatment with LT4 at a dose of 50 mcg/day is indicated. If conditions are not complete, the repetition of the TSH dosage should be done only for cases at higher risk. In these cases, treatment with LT4 will be established when TSH > 4.0 mIU/L at a dose of 1 mcg/kg/day; if needed, the dose can be adjusted after FT4 evaluation. Women with previous hypothyroidism should have their LT4 dose adjusted to achieve TSH < 2.5 mIU/L at preconception. As soon as they become pregnant, they need a 30% increase in LT4 as early as possible. In practice, they should double the usual dose on two days a week. Levothyroxine should be given 30-60 minutes before breakfast or three hours or more after the last meal. Concomitant intake with ferrous sulfate, calcium carbonate, aluminum hydroxide and sucralfate should be avoided. The target of LT4 therapy during pregnancy is to achieve a TSH value < 2.5 mIU/L. Once the therapy is started, monthly control must be performed until the mentioned goal is reached. In the postpartum period, women with previous disease should resume the preconception dose. Cases diagnosed during pregnancy in use of LT4 ≤ 50 mcg/day may have the medication suspended. The others should reduce the current dose by 25% to 50% and repeat the TSH measurement in six weeks. Cases of ATPO positivity are at higher risk of developing postpartum thyroiditis and de-escalation of LT4 should be performed as explained.

Effects of Hyperthyroidism on Contractility and Na+/Ca2+ Exchanger Activity in the Isolated Papillary Muscle of Rats

Abstract Background: Hyperthyroidism (Hy) is an endocrine disorder, in which the thyroid hormones markedly alter the cardiac function. Increased myocardial contractility and cardiac output, improvement in diastolic relaxation, changes in electrical activity, increments in ventricular mass, and arrhythmias have been reported. However, the influences of thyroid hormones upon molecular mechanisms of cardiac functions have not yet been fully understood. Objectives: To evaluate changes in cardiac contractile parameters and the Na+/Ca2+ exchanger (NCX) function in induced hyperthyroid rats. Methods: Hy was induced by intraperitoneal injections of T3 (15 μg/100 g) for 10 days. Contractile parameters and NCX function were evaluated in the isolated papillary muscle. Data normality was confirmed by the Shapiro-Wilk test. The comparison between groups was performed through an unpaired Student's t-test. Results are expressed as mean ± SD. The accepted significance level was p < 0.05. Results: Our data revealed, in the Hy group, an increase of 30.98% in the maximum speed of diastolic relaxation (-284.64 ± 70.70 vs. -217.31 ± 40.30 mN/mm2/sec (p = 0.027)) and a boost of 149% in the NCX function in late phase of relaxation (20.17 ± 7.90 vs. 50.22 ± 11.94 minutes (p = 0.002)), with no changes in the maximum twitch force (p = 0.605) or maximum speed of systolic contraction (p = 0.208) when compared to the control. Conclusion: The improvement in relaxation parameters is hypothetically attributed to an increase in Sarco-Endoplasmic Reticulum Ca2+ATPase isoform 2 (SERCA2) expression and an increased calcium flow through L-type channels that boosted the NCX function.

Hipotiroidismo subclínico y pérdida de embarazo: una revisión de la literatura / Subclinical Hypothyroidism and Pregnancy Loss: A Literature Review

Existe una alta prevalencia de hipotiroidismo subclínico (SCH) en el embarazo. Está vinculado a una importante morbilidad y mortalidad materna y fetal. Los efectos de SCH sobre el embarazo incluyen mayores riesgos de hipertensión gestacional y ruptura prematura de membranas (PROM). Sus fetos y bebés tenían más probabilidades de sufrir de bajo peso al nacer (LBW) y retraso del crecimiento intrauterino (IUGR). El riesgo de aborto espontáneo se informa alto en varios estudios para SCH no tratado. SCH se asocia directamente con una mayor presencia de anti -cuerpos anti TPO en suero materno. La detección temprana y el tratamiento de SCH han sido testigos de mejores resultados en términos de resultado del embarazo. Esta revisión se centra para establecer la relación de una mayor prevalencia de SCH en los países en desarrollo, así como su asociación con el aumento de los cuerpos anti TPO en suero materna y sacar una conclusión que puede ayudar a reducir las razones y proporcionar una solución. Este estudio concluyó que SCH es más frecuente en los países en desarrollo, ya sea debido a la deficiencia de yodo, una disminución de la conciencia sobre este problema o menos acceso a las instalaciones médicas. Por lo tanto, se sugiere que las hembras con antecedentes de partos prematuros, IUGR anteriores o abortos involuntarios deben someterse a una detección de hipotiroidismo subclínico y niveles de anticuerpos anti TPO durante sus visitas prenatales

There is a high prevalence of subclinical hypothyroidism (SCH) in pregnancy. It is linked to significant maternal and fetal morbidity and mortality. SCH's effects on pregnancy include increased risks of gestational hypertension and premature rupture of membranes (PROM). Their fetuses and infants had been more likely to suffer from low birth weight (LBW) and intrauterine growth retardation (IUGR). The risk of miscarriage is reported high in various studies for untreated SCH. SCH is directly associated with increased presence of anti TPO anti bodies in maternal serum. Early detection and treatment of SCH have witnessed better results in terms of pregnancy outcome. This review focuses to establish the relationship of increased prevalence of SCH in the developing countries as well as its association with increased anti TPO anti bodies in maternal serum and draw a conclusion which can help narrow down the reasons and provide solution. This study concluded that SCH is more prevalent in developing countries, either due to iodine deficiency, decreased awareness about this problem or less access to medical facilities. Therefore, it is suggested that females with history of preterm deliveries, previous IUGRs, or miscarriages should undergo screening for subclinical hypothyroidism and Anti TPO antibody levels during their antenatal visits.

Hipertiroidismo en niños y adolescentes: experiencia en un hospital universitario en Colombia / Hyperthyroidism in children and adolescents: Experience in a university hospital in Colombia

Introducción. El hipertiroidismo es una condición heterogénea caracterizada por la producción excesiva de hormonas tiroideas. Su aparición en la edad pediátrica representa un reto diagnóstico y terapéutico. Objetivo. Describir las características clínicas y paraclínicas, así como la evolución y las diferencias entre las principales causas etiológicas de los pacientes con hipertiroidismo atendidos por el Servicio de Endocrinología Pediátrica del Hospital Universitario San Vicente Fundación en Medellín, Colombia, entre el 1° de julio de 2015 y el 30 de junio de 2020. Materiales y métodos. Se hizo un estudio observacional transversal con recolección retrospectiva de la información. Resultados. Se incluyeron 54 pacientes con una edad media de 11,9 años, 72,2 % de ellos mujeres. El 11,1 % tenía antecedentes familiares de enfermedad de Graves y 29,6 % de otras enfermedades tiroideas. El bocio fue la manifestación clínica más frecuente (83,3 %). El 92,6 % había recibido terapia con metimazol, el 79,6 % requirió betabloqueador y el 11,2 % necesitó una terapia farmacológica adicional. Se presentaron reacciones adversas a la medicación en el 16,7 %. En el 20,4 % de los pacientes hubo resolución del hipertiroidismo (espontánea: 9,3 %; posterior a la ablación con yodo radiactivo: 9,3 %, y después de la cirugía: 1,9 %). Conclusión. El hipertiroidismo es una enfermedad con manifestaciones clínicas diversas. La causa más frecuente es la enfermedad de Graves, seguida por la hashitoxicosis. En este estudio, la hashitoxicosis fue más frecuente que en estudios previos. La duración y los efectos secundarios del tratamiento farmacológico fueron similares a los reportados previamente, pero es de resaltar la mayor frecuencia de agranulocitosis en nuestra población.

Introduction: Hyperthyroidism is a heterogeneous condition characterized by the excessive production of thyroid hormones. It represents a diagnostic and therapeutic challenge. Objective: To describe the clinical and paraclinical characteristics and the evolution and differences between the main etiologies in patients with hyperthyroidism treated by the Pediatric Endocrinology Service at the Hospital Universitario San Vicente Fundación in Medellín, Colombia, between July 1st., 2015, and June 30th., 2020. Materials and methods: We conducted a cross-sectional observational study with retrospective data collection. Results: We included 54 patients with a mean age of 11.9 years, 72.2% of whom were female; 85.2% had no history of comorbidities related to autoimmunity; 11.1% had a family history of Graves' disease, and 29.6% of other thyroid diseases. Goiter was the most frequent clinical manifestation (83.3%) and 92.6% of the patients received treatment with methimazole, 79.6% required beta-blockers, and 11.2% additional drug therapy. Adverse drug reactions occurred in 16.7% of the patients and in 20.4% there was a resolution of hyperthyroidism (spontaneous: 9.3%; after radio-iodine ablation: 9.3%, and after surgery: 1.9%). Conclusion: Hyperthyroidism is a disease with diverse clinical manifestations. Its most frequent cause is Graves' disease followed by hashitoxicosis, which in this study had a higher frequency than that reported in the literature. The duration and side effects of pharmacological treatment were similar to those previously reported, but the higher frequency of agranulocytosis is noteworthy.

Doença de Graves e sua recidiva: relato de caso / Grave's disease and its relapse: case repor

A doença de Graves (DG) é uma patologia autoimune que acomete a glândula tireoide e é a causa mais comum de hipertireoidismo. O principal grupo acometido por DG são as mulheres. Sendo assim, relatamos caso de paciente com 52 anos, do sexo feminino, com diagnóstico de Doença de Graves, que caracteriza quadro de hipertireoidismo. A paciente iniciou tratamento com tapazol (tiamazol) durante um ano e realizou pausa, recomendada pelo médico. No entanto, a paciente não retratou melhora e iniciou sintomatologia semelhante a dengue, como mal estar geral e fadiga muscular. Assim, realizou procura médica, e, inicialmente, foi diagnosticada com quadro de dengue, mas não houve melhora dos sintomas e procurou, portanto, endocrinologista. Realizou novos exames e foi confirmado quadro recidivo de Doença de Graves. Dessa maneira, iniciou novo tratamento. O estudo tem como objetivo relatar e discutir quadro de Doença de Graves associada a hipertireoidismo

Grave's disease (DG) is an autoimmune pathology that affects the thyroid gland and it's the most commom cause of hipertireoidism. The main group affected by DG are woman. That way we related a case of patient with 52 years, female with the diagnose of Grave's disease, that shows a patient conditioning of hipertireoidism. The patient began the treatment with tapazol during a year and made a pause recommended by the doctor. Therefore the patient didn't indicate progress and started a symptomatology similar to dengue fever, as general malaise and muscle fatigue. There by the patient searched for a doctor and initially was diagnosed with a patient conditioning of dengue fever, but she didn't manifested a improving of symptoms, and then searched for an endocrinologist. Realized then new exams and a recurrence case of grave´s disease was confirmed. This way the patient started a new treatment. Thus, the present study aims to report and discuss Graves' disease associated with hyperthyroidism.

Perfil clínico e terapêutico dos pacientes com hipertireoidismo do ambulatório de endocrinologia de um hospital universitário do sul do Brasil / Perfil clínico e terapêutico dos pacientes com hipertireoidismo do ambulatório de endocrinologia de um hospital universitário do sul do BrasilClinical and therapeutic profile of patients with hyperthyroidism in an outpatient endocrine clinic at a university hospital in southern Brazil

.Introdução: O hipertireoidismo decorre da elevação sérica dos hormônios tireoidianos, secundária à hiperfunção da glândula tireoide, sendo as principais causas a Doença de Graves (DG) e os Bócios Nodulares Tóxicos (BNT). Objetivos: Avaliar o perfil clínico e modalidades terapêuticas aplicadas em pacientes com diagnóstico de hipertireoidismo acompanhados em um Hospital Universitário no Sul do Brasil. Métodos: Estudo observacional, transversal e descritivo, com inclusão de pacientes com diagnóstico de hipertireoidismo por DG e BNT; foram coletados dados epidemiológicos, clínicos, laboratoriais e de tratamento. Resultados: A maioria dos pacientes foi referenciada pela atenção primária e encontrava-se em uso prévio de droga antitireoidiana (DAT). A variável idade obteve diferença estatisticamente significativa entre as etiologias de DG e BNT; em ambas houve predomínio de incidência no sexo feminino. A DG apresentou maior frequência de sinais e sintomas de tireotoxicose, ao passo que o BNT mostrou mais sinais e sintomas de compressão. Houve remissão da doença em 23,2% dos pacientes com DG tratados com DAT; em 23,2% dos pacientes optou-se pela manutenção de metimazol em baixa dose por mais de 36 meses e em 16,1% foi realizado tratamento definitivo. No BNT foram preferidas terapias definitivas, principalmente a tireoidectomia, em 27,5% dos pacientes. Doses baixas de metimazol por mais de 36 meses foram utilizados também no BNT, em 22,5% dos pacientes. Conclusão: O hipertireoidismo é uma doença heterogênea, desde a clínica inicial até a terapêutica, entre suas etiologias mais prevalentes. Observou-se uma tendência de priorizar as terapias medicamentosas em longo prazo com baixas doses, tanto na DG quanto no BNT. (AU)

Perfil clínico e terapêutico dos pacientes com hipertireoidismo do ambulatório de endocrinologia de um hospital universitário do sul do BrasilClinical and therapeutic profile of patients with hyperthyroidism in an outpatient endocrine clinic at a university hospital in southern Brazil ARTIGO ORIGINALRafael Antonio Parabocz1, Renata Soares Carvalho1, Gianna Carla Alberti Schrut1, Ana Claudia Garabeli Cavalli Kluthcovsky1, Matheo Augusto Morandi Stumpf1Introduction: Hyperthyroidism results from the serum elevation of thyroid hormones, secondary to hyperfunction of the thyroid gland. The main causes are Graves' disease (DG) and Toxic Nodular Goiters (BNT). Objectives: Evaluate the clinical profile and therapeutic modalities applied in patients diagnosed with hyperthyroidism followed up at a University Hospital in Southern Brazil. Methods: Observational, cross-sectional and descriptive study, including patients diagnosed with hyperthyroidism by DG and BNT; epidemiological, clinical, laboratory and treatment data were collected. Results: Most patients were referred by primary care and had been using antithyroid drugs (DAT). The age variable obtained showed a statistically significant difference between the etiologies of DG and BNT; in both, there was a predominance of incidence in females. DG showed a higher frequency of signs and symptoms of thyrotoxicosis, while BNT showed more signs and symptoms of compression. There was remission of the disease in 23.2% of patients with DG treated with DAT; in 23.2% of the patients, low-dose methimazole was maintained for more than 36 months and in 16.1%, definitive treatment was performed. In BNT, definitive therapies were preferred, mainly thyroidectomy, in 27.5% of patients. Low doses of methimazole for more than 36 months were also used in BNT in 22.5% of patients. Conclusion: Hyperthyroidism is a heterogeneous disease, from initial clinic to therapy, among its most prevalent etiologies. There was a tendency to prioritize long-term drug therapies with low doses, both in DG and BNT. (AU)

Hipoplasia de medula óssea: manifestação atípica do hipertireoidismo / Bone marrow hypoplasia: atypical manifestation of hyperthyroidism / Hipoplasia de la médula ósea: manifestación atípica del hipertiroidismo

Alterações hematológicas, como anemia ou pancitopenia, podem ser manifestações atípicas do hipertireoidismo. Embora a maioria dos casos de pancitopenia na doença de Graves seja decorrente do uso de drogas antitireoidianas ­ tionamidas ­, ela também pode estar associada ao quadro de hipertireoidismo não tratado e, assim, se manifestar como uma complicação grave. Este estudo tem como objetivo relatar o caso de uma paciente portadora de hipertireoidismo que evoluiu durante o internamento por pancitopenia secundária à doença primária. As informações foram obtidas por meio da revisão do prontuário, entrevista com a paciente e revisão da literatura. Trata-se de uma paciente do sexo feminino, de 39 anos, internada em um hospital de Salvador por apresentar um quadro de edema em membros inferiores que evoluiu progressivamente para anasarca por 45 dias. Associados ao quadro, a paciente apresentava perda ponderal, dispneia paroxística noturna, taquicardia, sudorese e calafrios, além dos exames laboratoriais terem apresentado pancitopenia. O caso relatado demonstra uma manifestação atípica e rara do hipertireoidismo, que melhorou após o início do tratamento e do estado de eutireoidismo.

Hematological changes such as anemia or pancytopenia can occur as atypical manifestations of hyperthyroidism. Although most cases of pancytopenia in Graves' disease are due to the use of antithyroid drugs (thionamides), it can also be associated with untreated hyperthyroidism, thus manifesting as a serious complication. This study aims to report the case of a 39-year-old hyperthyroid female patient who developed pancytopenia during hospitalization. Data were collected by means of the medical record, an interview conducted with the patient, and literature review. The patient was admitted to a hospital in Salvador presenting lower extremity edema that progressively evolved to anasarca within 45 days prior to the interview. She also presented weight loss, paroxysmal nocturnal dyspnea, tachycardia, sweating, chills, and laboratory test results for pancytopenia. The case reported here demonstrates an atypical and rare manifestation of hyperthyroidism that improved after the beginning of the treatment, reaching the euthyroid state.

Los cambios hematológicos como anemia o pancitopenia pueden ocurrir como manifestaciones atípicas de hipertiroidismo. Aunque la mayoría de los casos de pancitopenia en la enfermedad de Graves se deben al uso de fármacos antitiroideos (tionamidas), también se puede asociar a um hipertiroidismo no tratado y, por tanto, puede manifestarse como una complicación grave. Este estudio tiene como objetivo reportar el caso de una paciente con hipertiroidismo que desarrolló durante la hospitalización pancitopenia secundaria a la enfermedad primaria. La información se obtuvo revisando la historia clínica, entrevistando a la paciente y revisando la literatura. Se trata de una paciente de 39 años ingresada en un hospital de Salvador por presentar edema en miembros inferiores, evolucionando progresivamente a anasarca durante 45 días. Asociado a la afección, presentaba pérdida de peso, disnea paroxística nocturna, taquicardia, sudoración, escalofríos y análisis de laboratorio que mostraban pancitopenia. El caso aquí reportado demuestra una manifestación atípica y rara de hipertiroidismo, que evolucionó luego del inicio del tratamiento y del estado de eutiroidismo.

Assessment of thyroid disorders in patients with rosacea: a large case-control study

Abstract Background: The frequency of autoimmune diseases and thyroid cancer has been increasingly reported in association with rosacea. However, studies investigating thyroid diseases in rosacea are scarce with conflicting results. Objective: To investigate the relationship between thyroid disorders and rosacea. Methods: A large case-control study on ageand gender-matched 2091 rosacea patients and 9572 controls was conducted. Rosacea patients using the rosacea-specific ICD codes were compiled from the hospital records. Additionally, all participants were evaluated in terms of the presence of hypothyroidism and hyperthyroidism. Conditional logistic regression analysis was used to compute case-control odds ratios (OR) with 95% confidence intervals. Results: The analysis comprehended 2091 rosacea patients (1546 female, 545 male; mean 48.73 ± 14.53 years) and 9572 controls (7009 female, 2563 male; mean 48.73 ± 15.1 years). Whereas the rate of hypothyroidism was significantly higher in rosacea patients (OR = 1.3, 95% CI 1.13-1.49, p < 0.001), there was no significant difference in the rate of hyperthyroidism between the groups (OR = 1.12, 95% CI 0.81-1.53, p = 0.497). Stratification for gender revealed a significant association between hypothyroidism and rosacea in females (OR = 1.27, 95% CI 1.1-1.47, p = 0.002) and males (OR = 1.58, 95% CI 1.04-2.4, p = 0.032). The frequency of hypothyroidism in rosacea patients increased towards the age range of 40-49 and then decreased, parallel with the hypothyroidism frequency of the study population. Study limitations: Different subtypes and severities of rosacea were not distinguished. Conclusions: Hypothyroidism may be a comorbidity of rosacea and investigation for hypothyroidism may be appropriate when evaluating rosacea patients.

Características clínicas asociadas al hallazgo de cáncer de tiroides originado a partir de nódulos calientes en pacientes con hipertiroidismo: reporte de un caso y revisión sistemática de la literatura / Clinical characteristics associated with the finding of thyroid cancer originating from hot nodules in patients with hyperthyroidism: a case report and systematic review of the literature

La coexistencia entre cáncer de tiroides e hipertiroidismo es infrecuente, y la mayoría de las lesiones nodulares a partir de las cuales se documenta un tumor maligno en este grupo de pacientes corresponden a nódulos fríos. Justificado en el creciente número de reportes en la literatura acerca de tumores malignos diagnosticados a partir de nódulos calientes, se realizó una revisión sistemática que tuvo como objetivo determinar los posibles factores asociados con el diagnóstico de cáncer de tiroides a partir de nódulos calientes en pacientes con hipertiroidismo. Los resultados sugieren que el diagnóstico clínico de bocio nodular tóxico, lesiones nodulares de diámetro mayor de 10 mm y tipo histológico compatible con carcinoma folicular, son factores que aumentan por sí solos el riesgo de realizar el diagnóstico de cáncer a partir de un nódulo caliente

Coexistence between thyroid cancer and hyperthyroidism is rare, and most of the nodular lesions from which a malignant tumor is documented in this group of patients correspond to cold nodules. Justified by the increasing number of reports in the literature about malignant tumors diagnosed from hot nodules, a systematic review was carried out to determine possible factors associated with the diagnosis of thyroid cancer from hot nodules in pa-tients with hyperthyroidism. The results suggest that the clinical diagnosis of toxic nodular goiter, nodular lesions of diameter > 10 mm and a histological type compatible with a follicular carcinoma, are factors that on their own increase the risk of making the diagnosis of cancer from a hot nodule

Incidence of thyroid diseases: Results from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil)

ABSTRACT Objective: To evaluate incidence of subclinical and overt hyperthyroidism and hypothyroidism. Subjects and methods: The Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) is a prospective cohort study of 15,105 civil servants, examined at baseline and over a 4-year follow-up. This analysis included 9,705 participants with normal thyroid function at baseline, follow-up information about thyroid function and with no report of using drugs that may interfere in the thyroid function. Thyroid function was defined by TSH/FT4 levels or routine use of thyroid hormones/anti-thyroid medications. Annual and cumulative (over 4-year) incidence rates were presented as percentages (95% Confidence Intervals). Results: The incidence of all overt and subclinical thyroid disease was 6.7% (1.73%/year): 0.19% for overt hyperthyroidism (0.048%/year), 0.54% for subclinical hyperthyroidism (0.14%/year), 1.98% for overt hypothyroidism (0.51%/year), and 3.99% for subclinical hypothyroidism (1.03%/year). The incidence of all thyroid diseases was higher in women, when compared to men, with a low women:men ratio (1.36). For Blacks the highest incidence was for overt hyperthyroidism, while for Whites, the highest incidence was for overt hypothyroidism. However, the highest incidence of overt hyperthyroidism was detected in Asian descendants. The presence of antithyroperoxidase antibodies at baseline was associated with higher incidence of overt thyroid diseases. Conclusion: These results showed a high incidence of hypothyroidism, which is compatible with a country with a more-than-adequate iodine intake. The low women:men ratio of the incidence of thyroid dysfunction highlights the importance of the diagnosis of thyroid diseases among men in Brazil.

Características clínicas asociadas al hallazgo de cáncer de tiroides originado a partir de nódulos calientes en pacientes con hipertiroidismo: reporte de un caso y revisión sistemática de la literatura / Clinical characteristics associated with the finding of thyroid cancer originating from hot nodules in patients with hyperthyroidism: a case report and systematic review of the literature

Abstract Coexistence between thyroid cancer and hyperthyroidism is rare, and most of the nodular lesions from which a malignant tumor is documented in this group of patients correspond to cold nodules. Justified by the increasing number of reports in the literature about malignant tumors diagnosed from hot nodules, a systematic review was carried out to determine possible factors associated with the diagnosis of thyroid cancer from hot nodules in patients with hyperthyroidism. The results suggest that the clinical diagnosis of toxic nodular goiter, nodular lesions of diameter > 10 mm and a histological type compatible with a follicular carcinoma, are factors that on their own increase the risk of making the diagnosis of cancer from a hot nodule.

Resumen La coexistencia entre cáncer de tiroides e hipertiroidismo es infrecuente, y la mayoría de las lesiones nodulares a partir de las cuales se documenta un tumor maligno en este grupo de pacientes corresponden a nódulos fríos. Justificado en el creciente número de reportes en la literatura acerca de tumores malignos diagnosticados a partir de nódulos calientes, se realizó una revisión sistemática que tuvo como objetivo determinar los posibles factores asociados con el diagnóstico de cáncer de tiroides a partir de nódulos calientes en pacientes con hipertiroidismo. Los resultados sugieren que el diagnóstico clínico de bocio nodular tóxico, lesiones nodulares de diámetro mayor de 10 mm y tipo histológico compatible con carcinoma folicular, son factores que aumentan por sí solos el riesgo de realizar el diagnóstico de cáncer a partir de un nódulo caliente.

Management of thyroid disorders during the COVID-19 outbreak: a position statement from the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism (SBEM)

ABSTRACT This position statement was prepared to guide endocrinologists on the best approach to managing thyroid disorders during the coronavirus disease (COVID-19) pandemic. The most frequent thyroid hormonal findings in patients with COVID-19, particularly in individuals with severe disease, are similar to those present in the non-thyroidal illness syndrome and require no intervention. Subacute thyroiditis has also been reported during COVID-19 infection. Diagnosis and treatment of hypothyroidism during the COVID-19 pandemic may follow usual practice; however, should avoid frequent laboratory tests in patients with previous controlled disease. Well-controlled hypo and hyperthyroidism are not associated with an increased risk of COVID-19 infection or severity. Newly diagnosed hyperthyroidism during the pandemic should be preferably treated with antithyroid drugs (ATDs), bearing in mind the possibility of rare side effects with these medications, particularly agranulocytosis, which requires immediate intervention. Definitive treatment of hyperthyroidism (radioiodine therapy or surgery) may be considered in those cases that protective protocols can be followed to avoid COVID-19 contamination or once the pandemic is over. In patients with moderate Graves' ophthalmopathy (GO) not at risk of visual loss, glucocorticoids at immunosuppressive doses should be avoided, while in those with severe GO without COVID-19 and at risk of vision loss, intravenous glucocorticoid is the therapeutic choice. Considering that most of the thyroid cancer cases are low risk and associated with an excellent prognosis, surgical procedures could and should be postponed safely during the pandemic period. Additionally, when indicated, radioiodine therapy could also be safely postponed as long as it is possible.