bluuebunny/crossref_metadata_2025_split huggingface dataset:
Iatrogenic Hyperthyroidism With Recurrent Functioning Thyroid Tissue 40 Years After Thyroidectomy for Graves’ Disease
Authors: Penquite Sara Ashlyn , Galvez Juan Pablo 
Published: May 2021

Abstract
Background: Graves’ disease is an immune-mediated cause of thyrotoxicosis treated with anti-thyroid drugs (ADTs), radioactive iodine (RAI) or thyroidectomy. Thyroidectomy has been documented to have the lowest rate of recurrence amongst treatment options1. Data regarding long-term recurrence rates is limited beyond 54 months.
Clinical Case: An asymptomatic 59 year old female was found to have recurrent thyrotoxicosis on routine laboratory testing. The patient underwent thyroidectomy at age 19 years for Graves’ disease. Prior records unavailable to clarify initial surgical intervention. The patient had post-surgical hypothyroidism which was managed with levothyroxine 100mcg once daily for over 20 years. A biochemically euthyroid state was clearly documented on prior laboratory testing. Initial laboratory testing with TSH &lt;0.01mIU/L (0.45-4.50), FT3 2.8ng/dL (0.8-1.7). Levothyroxine was discontinued with persistent thyrotoxicosis after 8 weeks: TSH &lt;0.01, FT3 5.7, FT4 1.74. Radioactive Iodine Uptake and scan was obtained after administration of 6uCi of iodine-131 which demonstrated 50.8% uptake of radioactive iodine at 24 hours (Normal 10-30%). The left thyroid gland was noted to be in normal position and enlarged with diffuse increase intensity of radiotracer uptake. The right thyroid gland was surgically absent. The patient subsequently underwent completion thyroidectomy with endocrine surgery with resolution of hyperthyroid state. Surgical pathology was benign and consistent with Graves’ disease and multinodular goiter. The patient did become hypothyroid post-operatively and required levothyroxine replacement. She is clinically and biochemically euthyroid on levothyroxine 100mcg once daily 14 months post-operatively.
Conclusion: This is a case of recurrent hyperthyroidism approximately 40 years after definitive treatment with thyroidectomy. Although it is unclear whether patient underwent total thyroidectomy or subtotal thyroidectomy for initial intervention, the recurrence of thyrotoxicosis after such a long period of time has not previously been reported in the literature to the knowledge of this writer. This has important implications regarding the underlying pathophysiology of Graves’ disease and the ability of remnant thyroid tissue to regenerate over time. This also has important implications for long-term monitoring in patients with history of thyroidectomy for Graves’ disease.
Reference: 1. Sundaresh, V., Brito, J. P., Wang, Z., Prokop, L. J., Stan, M. N., Murad, M. H., & Bahn, R. S. (2013). Comparative effectiveness of therapies for Graves’ hyperthyroidism: a systematic review and network meta-analysis. The Journal of clinical endocrinology and metabolism, 98(9), 3671–3677.
Low-Dose Prednisone Therapy is Efficacious in Treating Painful Subacute Thyroiditis
Authors: Shakir Mohamed K M , Leimbach Robert D , Sherin Rinsha P V , Orestes Michael I , Mai Vinh Q , Hoang Thanh Duc 
Published: May 2021

Abstract
Subacute thyroiditis (SAT) usually presents with neck pain, radiating to ears and is often associated with hyperthyroidism. Currently the available treatment involves administration of NSAID or in more symptomatic patients prednisone 40mg daily tapered over 6 weeks or longer. We report successful treatment of 3 patients (Pts) with SAT with low-dose prednisone therapy (20mg/day) (LDP20) initially and tapered over 4 weeks. Patient 1: A 32-year-old female presented with severe neck pain radiating to both ears and low- grade fever of 2-weeks duration. Two weeks prior, patient had cold-like symptoms lasting for 3 days. Physical examination: HR 110bpm, tremors of fingers noted, tenderness of the anterior neck present, thyroid 30-gms in size. Labs: ESR 92 mm/hr, CRP 3.2 mg/dL, TSH &lt;0.005 uIU/mL, free T4 2.71 ng/dL, total T3 168 ng/mL. Thyroid scan and uptake showed a 24-hrs uptake &lt;1%, thyroid gland not visualized, consistent with SAT. Patient was treated with atenolol and LDP20 tapered over 4 weeks. Pain significantly improved after 2 days of treatment. Six weeks later TSH was 0.9 uIU/mL with a free T4 1.4 ng/dL and ESR 8 mm/hr. Patient 2: A 19-year-old female presented with left-ear pain, anterior neck pain, fever, and extreme fatigue. PE: HR 111bpm, heat shield present, tender-to-palpation thyroid, brisk DTR. Lab: CBC normal, ESR 98 mm/hr, CRP 9.9 mg/dL, TSH &lt;0.01 uIU/mL, free T4 3.8 ng/dL, total T3 210 ng/mL. Thyroid scan and uptake: uptake &lt;1%, no thyroid gland visualized and SAT was diagnosed. Patient was started on LDP20 and atenolol. Four days following prednisone therapy her symptoms completely resolved and prednisone was tapered off over 4 weeks. Thyroid functions were normal by the seventh week. Patient 3: A 38-year-old male presented with fever, fatigue, severe neck pain, palpitation and a weight loss of 8 pounds. PE: HR 120 bpm, thyroid severely tender on palpation, brisk DTR. Lab: normal CBC, ESR 128 mm/hr, CRP 11.9 mg/dL, TSH &lt;0.001 uIU/mL, free T4 4.2 ng/dL, total T3 201 ng/mL. Thyroid scan: thyroid gland not visualized and uptake was &lt; 1%. SAT was diagnosed and patient was treated with propranolol and LDP20. After 5 days the dose of prednisone was reduced to 15mg/day and the prednisone was tapered over five weeks. Patient had resolution of symptoms in 70 hours and remained asymptomatic for the next 12 months of follow-up. Thyroid function normalized by the eighth week. Conclusion: SAT is a painful disabling thyroid disorder apparently caused by a viral infection; and NSAID or high-dose steroid treatment remains the standard of care. We have treated 3 Pts with relatively lower doses of prednisone than previously recommended and attained remission successfully. Thus side effects can be avoided with lower prednisone dose.
Lyme Disease: An Autoimmunity-Based “Destructive Thyroiditis” or Just Another “Non-Thyroidal Illness”?
Authors: Dhliwayo Nyembezi , Wajahat Rana , Havrylyan Andriy , Moid Alvia , Khayr Walid , Barsano Charles P 
Published: May 2021

Abstract
There is considerable evidence that some Borrelial (Lyme spirochetal) proteins share significant antigenic properties with several thyroid-related proteins (e.g. TSH receptor, thyroglobulin, thyroid peroxidase) and can induce thyroid autoimmunity, sometimes associated with Hashimoto’s thyroiditis and perhaps also a “destructive thyroiditis” such as “silent” thyroiditis or “Hashitoxicosis.” As an acute illness, Lyme disease may also constitute a “non-thyroidal illness” capable of perturbing thyroid function tests without causing thyroid dysfunction. We report a 22-year old woman admitted with an acute paranoid schizophrenia, thyroid function tests consistent with autoimmunity, transient thyrotoxicosis (tachycardia, lid-lag, brisk DTR’s) and a greatly reduced radioiodine uptake. The thyroid was not palpably enlarged, nodular or tender. On screening assay, reactivity was demonstrated to 4 of 13 Borrelial proteins. Anti-Lyme IgM but not IgG, antibodies, were positive. This was consistent with recent Lyme disease infection. Serum TSH (NL: 0.358-3.74 mcU/ml), Free T4 (NL: 0.76-1.46 ng/dl), and Free T3 (NL: 2.18-3.98 pg/ml) were, respectively: Day1: 0.087 mcU/ml (suppressed), 1.52 ng/dl (slightly elevated), 2.07 pg/ml (slightly reduced); Day2: 0.148 (suppressed), 1.18 (normal), no FT3; Day4: 0.827 (normal), no FT4 or FT3; Day5: 1.66 (normal), 0.89 (normal), 1.77 (low). Anti-Tg and Anti-Peroxidase antibodies were both moderately elevated. Thyroid Stimulating Immunoglobulins were not elevated. The radioactive iodine uptake on Day4 was 2.8% (NL: 15-30% at 24 hr). Thyroid ultrasonogram was normal. An attractive explanation is that Lyme disease triggered a “destructive thyroiditis,” perhaps but not necessarily mediated by thyroid autoimmunity. This would account for the brief interval of thyrotoxicosis accompanied by a very low radioiodine uptake. Alternatively, Lyme disease, as an acute process, would expectedly be capable of eliciting the thyroid function abnormalities of “non-thyroidal illnesses” in general, as would acute psychosis, well-known to often resemble Graves’ disease at admission.
Mitral Valve Disease in Thyroid Storm
Authors: Menjura Sandra Rocio Rivera , Moyano Rivas Lia G , Gamboa Camila Parraguez , Balmaceda Cristobal , Peralta Juan P , Rocha Luis 
Published: May 2021

Abstract
Introduction: The cardiovascular effects that thyroid gland causes are widely studied. In fact, there is a known correlation between Graves’ Disease and mitral valve damage. We present the case of a patient admitted with thyroid storm and heart failure associated with severe structural damage of the mitral valve papillary muscle.
Case Report: 24 year old woman with hyperthyroidism diagnosed 12 years ago, treated irregularly with thiamazole and propranolol, leaving treatment a year ago, presents dyspnea, class III functional capacity, diarrhea and logic dysphagia of a month of evolution. Heart rate over 170 bpm, respiratory rate 48 rpm and blood pressure 143/84 mmHg. Physical exam positive for exophthalmos, grade III goiter, crackles in both lung bases, pretibial myxedema and fulfilling criteria for a thyroid storm (65 points in Burch-Wartofsky Point Scale).
First Lab Results: TSH&lt;0.005µU/mL, free T4&gt;7.7ng/dl and TRAB 37.8UI/L. Chest ray: Global cardiomegaly and pulmonary edema. EKG: Narrow complex supraventricular tachycardia. Thyroid ultrasound: Intrathoracic goiter. Transesophageal echocardiogram: Severe mitral insufficiency (Carpentier Type I and IIIB), right cavities and left ventricular enlargement, preserved right ventricular function and severe pulmonary hypertension (PSAP 71-76 mmHg).
First treated with thiamazole, hydrocortisone IV, cholestyramine and sedation, falling time after into ventilatory failure and developing delirium, requiring invasive mechanical ventilation. Tested positive for COVID- 19. Starts preparation with Lugol and undergoes Total Thyroidectomy. After surgery develops severe hypocalcemia secondary to transitory hypoparathyroidism.
During hospitalization presents multiple infections including pneumonia (Pseudomonas Aeruginosa), lung aspergillosis, bacteriuria (Enteroccocus Faecium) and candiduria (Candida Albicans and Glabrata), each one treated with multiple antibiotics and vasoactive drugs. Once stable, mitral valve replacement is realized, after which, the patient progresses favorably being discharged with programmed ambulatory controls.
Conclusion: We report a case of a patient who was presented with positive thyroid storm criteria associated with heart failure and severe mitral valve insufficiency. The case gets complicated as multiple infections take place, including COVID-19. Fortunately, because of the early and aggressive multidisciplinary management, the patient evolved favorably, overcoming the life-threatening conditions she went through.
Key Words: Thyroid storm, mitral valve insufficiency, heart failure.
Bibliography: Klein I, Danzi S. Thyroid disease and the heart. Circulation. 2007 Oct 9;116(15):1725-35. doi: 10.1161/CIRCULATIONAHA.106.678326. Erratum in: Circulation. 2008 Jan 22;117(3):e18. PMID: 17923583.
Myxedema Coma Disguised as Alcohol Withdrawal
Authors: Pahwa Dhivya , Belkin Alexander , Katriyar Neeraj 
Published: May 2021

Abstract
Introduction: Myxedema coma is a medical emergency whose symptoms may sometimes mimic other diseases such as alcohol withdrawal.
Case: A 64-year-old male with a history of alcohol abuse and bipolar disorder (on no medications) presented to the emergency department after being found on the floor surrounded by multiple open alcohol bottles. He was a poor historian but reported a previous fall. Vitals on presentation were BP 109/70, HR 110, RR 22, SpO2 of 90% on room air, and rectal temperature of 97.6 F. The remainder of the exam revealed he was alert and oriented to self and place but not time; his neck was supple and no thyroid masses were palpated; he had tremors, head swelling and abdominal tenderness. Labs demonstrated CPK 1300 U/L, Creatinine 1.0 mg/dl, glucose 120 mg/dl, and sodium 142 mmol; urine toxicology was negative and alcohol level was not elevated. He was admitted and treated for suspected alcohol withdrawal and rhabdomyolysis with intravenous fluids and benzodiazepines. However, his mental status continued to decline; he became obtunded and was hypothermic and bradycardic. Thyroid function tests (TFT) revealed TSH 98.9 uIU/mL with free T4 0.27 ng/dl. He was subsequently managed for myxedema coma and given IV levothyroxine and hydrocortisone. He improved clinically after initiation of therapy and was transitioned to oral thyroid replacement. The patient was pending discharge to sub-acute rehab however his hospital course was later complicated by aspiration pneumonia.
Discussion: Myxedema coma is a medical emergency as severe hypothyroidism leads to slowed functioning of multiple organs. Risk factors include female gender and age above 60 years; it is seen more commonly in colder months. Symptoms include decreased mental status, feelings of cold and tongue swelling while physical exam may reveal hypothermia, hypoventilation, bradycardia, an enlarged goiter, thinning hair and non-pitting edema. Lab studies usually reveal an elevated TSH with low T4; there may also be hyponatremia and hypoglycemia. Myxedema coma is a clinical and laboratory diagnosis; if there is clinical suspicion for myxedema coma, IV thyroid replacement should be administered promptly without waiting for lab results. Stress-dose steroids should also be administered and TFTs should be monitored every 48 hours. Clinical symptoms usually improve over one week of treatment. Mortality of myxedema coma is reported to be up to 40% in hospitalized patients. Our patient’s presentation of suspected alcohol withdrawal masked his diagnosis of myxedema coma.
Conclusion: Physicians should keep myxedema coma in the differential for patients who present with suspected alcohol withdrawal and develop worsening mental status and hypothermia.
Reference: DynaMed. (2020, October 22). Myxedema Coma. Retrieved October 23, 2020, from https://www-dynamed-com.arktos.nyit.edu/topics/dmp~AN~T1584563697784.
Myxedema Coma: Improving Outcomes With Prompt Recognition and Therapy
Authors: Parihar Aisha 
Published: May 2021

Abstract
Background: Myxedema coma, a misnomer for severe hypothyroidism, is a rare endocrine emergency with an incidence of 1.08 cases per million people per year and a high mortality rate ranging from 30-50%. A delay in diagnosis and treatment worsens the prognosis and increases morbidity and mortality. Delayed management often leads to decompensation, presenting as uncontrolled persistent hypothermia, severe electrolyte derangements, and a potential for ventilator requirement needing ICU care. We present a patient in hypothyroid crisis who was promptly managed in a non-ICU setting who demonstrated a relatively early improvement in vital signs, thyroid lab values, and return to baseline mental status.
Clinical Case: A 75 year old female with past medical history of hypothyroidism, atrial fibrillation, hypertension, coronary artery disease, depression, tardive dyskinesia, and dementia presented to the hospital in the month of December due to confusion after a mechanical fall that resulted in a head laceration requiring multiple stitches. Trauma work up included a CT scan of the head that was negative. On presentation, patient was also hypothermic, bradycardic, hypotensive, and lethargic with an altered mental status. Sepsis work up was negative. TSH was checked on day of admission and found to be significantly elevated to &gt; 100 mcIU/mL, consistent with severe hypothyroidism. Free T4 and total T3 levels were low. Patient was immediately given intravenous levothyroxine 300 mcg followed by oral levothyroxine 125 mcg daily. In addition, intravenous hydrocortisone 100 mg every 8 hours was started until adrenal insufficiency was ruled out with a normal cortisol level. Upon discussion with family, it was learned that patient had not been taking her home medications indicating non-compliance to thyroid replacement therapy as the etiology for her hypothyroid crisis. Within a day of initiating therapy, TSH levels drastically improved with a reduction by 50%. Bradycardia, hypotension, and hypothermia resolved as well. In three days, patient’s mentation improved back to baseline and TSH, free T4, and total T3 continued to normalize.
Conclusion: This case demonstrates how prompt recognition of hypothyroid crisis and immediate therapy can lead to early improvement in outcomes such as reversibility of mental status, normalization of vital signs and lab values, prevention of escalation of care to an ICU setting, and overall morbidity and mortality.
New Onset Recurrent Acute Infectious Thyroiditis in an Adult Patient
Authors: Al Hommos Nisreen Abu , James Deirdre 
Published: May 2021

Abstract
Introduction: Acute infectious thyroiditis can be seen in patients with congenital abnormalities of the piriform sinus, underlying autoimmune disease, or the immunocompromised. In most patients, an upper respiratory tract infection precedes the development of the neck abscess. Case description: The patient is a 39-year-old Caucasian woman with history of Hidradenitis suppurativa (HS) and thrombocytopenia who presented to the hospital with sore throat, dysphagia and left-sided neck swelling. She was recently started on Humira for HS. Review of systems was significant for heat intolerance, weight loss, palpitations and panic attacks. Family history was positive for Hashimoto’s thyroiditis. Initial lab evaluation was significant for elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), mildly elevated free T4 (FT4) with suppressed thyroid stimulating hormone (TSH). She was found to have a nearly 6 cm left-sided thyroid abscess, which was eventually drained. Contrasted CT imaging showed multiple left laryngeal space abscesses with extension to the left thyroid gland. TSH gradually increased over two months to nearly 4 times upper limit of normal accompanied by low normal FT4. TSI and TPO antibodies were negative. Clinical course was complicated by recurrent abscesses which required percutaneous drainage and intravenous antibiotics. Discussion: Acute infectious thyroiditis is extremely rare disorder of the thyroid gland in adults. Most patients present with recurrent abscesses early during childhood. Imaging studies such as CT scan, preferred over MRI, and barium swallow can show a fistula connecting the piriform sinus and left lobe of the thyroid gland. Treatment includes needle aspiration, followed by drainage and IV antibiotic therapy. Surgical excision of the entire sinus tract and the involved area of the thyroid gland is the best method to achieve definitive cure.
Conclusion: Lower left-sided thyroid abscess extending from the pyriform fossa to the thyroid bed should raise the suspicion for underlying third or fourth branchial fistula. Most cases present during childhood, but one third of cases occur in adults. Surgical excision after confirming the presence of a fistulous tract with imaging is the treatment of choice.
Oscillating Hypo-Hyperthyroidism; a Rare Type of Autoimmune Thyroiditis in Adolescence
Authors: Akinseye Leah I 
Published: May 2021

Abstract
Background: Spontaneous conversion of hypothyroidism to hyperthyroidism and vice versa is a unique autoimmune entity characterized by the oscillating activity of thyrotropin blocking inhibiting immunoglobulin (TBII) and thyroid-stimulating immunoglobulin (TSI). The simultaneous presence of both antibodies is a rare phenomenon in children. Clinical Case: At 11 years of age a female with Trisomy 21 and mild developmental delay had elevated TSH 5.4uIU/mL (0.4-4.5), normal thyroxine (T4), negative thyroglobulin peroxide antibody (anti-TPO), and thyroglobulin antibody (Anti-Tg). Levothyroxine (LT4) 1.2mcg/kg/day was started. At 12 years of age, she relocated, and the same treatment was continued. About 7 months later, she was referred for weight loss of 8lbs, tachycardia, high BP, suppressed TSH &lt;0.015uIU/mL, high total T4 15.9ng/dL (4.5-12.0), and anti-TPO 38 IU/mL (&lt;9). She was diagnosed with hyperthyroidism and LT4 was discontinued. Repeat lab showed persistently undetectable TSH, high T4, TBII 70 (normal &lt;16%), and TSI 698 (&lt;140 %). Methimazole (MMI) 0.38mg/kg/day and Atenolol 25mg daily was started for Grave’s disease.
At 15 years of age, she presented with symptoms of hypothyroidism; 10lb weight gain in 2months, high TSH &gt;150mIU/L, low FreeT4 0.12ng/dl (0.8-2), anti-TPO 95 IU/mL, and TSI 2.1 IU/L (0.0 - 0.55). MMI was discontinued and she was started on LT4 0.9mcg/kg/day. Repeat TFT’s 5weeks later showed a normal TSH and Free T4. Thyroid ultrasound showed a diffusely enlarged gland; right lobe - 3.9 x 2.0 x 2.0 cm (volume of: 7.6 mL) and left lobe 4.5 x 1.6 x 2.4 cm (volume: 8.6 mL) with increased vascularity on color Doppler consistent with diffuse thyroiditis. A year later, she developed hyperthyroid symptoms for the second time with 6lb weight loss, tachycardia, suppressed TSH &lt;0.015uIU/mL, elevated free T4 &gt;6.9ng/dl, TBII 8.6 U/L (&lt;1.0), and TSI 12 IU/L. However, this time her TSI level was significantly higher than when she was hypothyroid. She was treated with MMI 0.15mg/kg/day which was increased to 0.3mg/kg/day, and 3months later she reverted to hypothyroidism; TSH 17.5uIU/mL, Low free T4 0.54ng/dl, normal total T3, with 15lb weight gain. Her MMI dose was lowered to 0.15mg/kg/day, however more definitive treatment options including thyroidectomy and radioactive iodine ablation was discussed with the family. Conclusion: The spectrum of autoimmune thyroid disorders span between extremes of Hashimoto’s thyroiditis and Graves’ disease, but rarely in adolescents, these conditions can co-exist, and management can be challenging and tedious to the patient, family, and physician. Since autoantibody status/titer may not always predict the clinical course, it is important for clinicians to keep a high index of suspicion of this process when the clinical course is atypical. Definitive therapy with thyroidectomy or radioactive iodine ablation may be a suitable option in these cases.