CME INDIA Case Presentation by Dr. Rajiv Kovil, M.B.B.S (Bom), D. Diabetology (Bom), Consultant Diabetologist – Dr. Kovil’s Diabetes Care Centre Mumbai, Maharashtra, India and Dr. N. K. Singh, MD, FICP, FACP,Director, Diabetes and Heart Research Centre, Dhanbad, Jharkhand, India; Editor – www.cmeindia.in.

CME INDIA Case Study

History

• 46 yr. diabetic(T2), BMI 21.
• On gliclazide, Metformin, Empagliflozin and sitagliptin.
• Maintaining hb1ac 7%. ESR-28.RFT, LFT, CBC-Normal.
• Also, on statin for dyslipidaemia.
• His look is normal, no exophthalmos, dynamic executive.
• Only complain is recent loss of weight of 5 kg, but gets palpitation often for which alprazolam was prescribed.
• Resting pulse rate is 112 to 120, varies.
• ECG-Sinus tachycardia.
• Echo. Normal.
• No clear corelation with hypoglycaemia noticed (CGM during palpitation was normal).
• No history of documented covid.
• No recent pyrexia, sweating or neck pain.

What should be done now?

• Thyroid function test was then advised.

T3, T4, TSH report is of 14th June

CME INDIA Discussion

Dr. Pankaj Singhal, Kota:

• Hyperglycaemia may be contributing to Hyperthyroidism.

Dr. N. K. Singh:

• Would you like to do more tests or start Neomercazole (NMZ)?

Dr. Pankaj Singhal, Kota:

• I think TSH receptor antibodies.
• Neomercazole has to be started. It is Graves’ disease.

Dr. Jayshree Gopal, Endocrinologist, Chennai:

• Any goitre or nodules on exam?
• Differential is Graves or toxic MNG versus thyroiditis.
• As it has been 6 weeks since initial tests recheck TSH, Free T4, Free T3.
• If thyroiditis – will be better. If persistently high – TSH receptor antibody/thyroid uptake scan to confirm diagnosis and start antithyroid meds.

Dr. N. K. Singh:

• No goitre on examination

Dr. Raju Sharma Internist, Jamshedpur:

• I would repeat the test. Plus, do an uptake scan to rule out Thyroiditis.
• Start with propranolol initially till reports.

Dr. N. K. Singh:

• Repeat test was similar.
• Propranolol started.

These tests were done subsequently

1. ATAB (17/06/2022)

2. USG Scan of Neck (17/06/2022)

3. 99mTc Thyroid Scan (17/06/2022)

Further course

• In view of above findings, no NMZ was started.
• Patient was symptomatic, having weakness/ febrile feeling/ Often palpitation/Malaise.

Thyroid Report dated 16/07/2022

Thyroid Report dated 27/07/2022

Dr. Raju Sharma Internist, Jamshedpur:

• Getting towards normal.

Dr. Awadhesh Kumar Singh, DM, Endo, Kolkata:

• Strongly advised NOT to start NMZ from the very beginning and reassured the patient that things will be easier in next 4 weeks. Only Propranolol 40mg BD was used. No steroid was given.

CME INDIA Learning Points

Why COVID history was taken?

COVID-19 mostly affects the respiratory system, but many patients also develop changes in thyroid function tests known as non-thyroidal illness syndrome (NTIS).

Enquire about BIOTIN intake before doing thyroid function test

Biotin is a dietary supplement that is taken by some for purposes like improving hair and nail quality. However, biotin can interfere with the measurement of hormone levels in the laboratory, making them inaccurate.

Knowing about Thyroiditis

Thyroiditis can occur due to:

• Painful thyroiditis – Think about infectious, subacute thyroiditis, traumatic or radiation-induced thyroiditis.
• Painless thyroiditis – Think about autoimmune, postpartum, and Drug-induced thyroiditis.

Pearls in History taking

• If symptoms of upper respiratory tract infection, it could indicate subacute thyroiditis, and other infective symptoms like fever and neck pain could indicate acute infectious thyroiditis.
• Medication history is important. It can tell about underlying Drug-induced thyroiditis.
• Take Personal history and family history, it can point towards autoimmune disease. It can help discover any increased risk of autoimmune thyroid disease.
• Ask about symptoms related to local compressive symptoms in the neck.
• Ask about difficulty in swallowing or choking sensation or hoarseness of the voice.
• It could indicate underlying large goitre or large thyroid nodule or Riedel thyroiditis.

Simplified Approach

1. Check Thyroid-stimulating hormone (TSH) – It should be checked to see if the patient has hyperthyroidism or hypothyroidism.
2. Check Thyroid microsomal antibodies and thyroid receptor antibodies. It can be checked for confirmation of autoimmune thyroid disease.
3. ESR and CRP are significantly elevated if infectious thyroiditis (bacterial).
4. Thyroid ultrasound is the most important and most commonly used imaging modality.
5. A thyroid uptake and scan needs be done to differentiate production thyroiditis or destruction thyroiditis in patients who present with thyrotoxicosis. It is characterized by low TSH with or without elevated T4 and T3. Low uptake on thyroid scan would indicate destruction thyroiditis (Hashimoto thyroiditis, infectious thyroiditis). Increased or normal uptake indicates production thyroiditis (Graves’ disease). A thyroid scan is very useful pointer to further differentiate production thyroiditis into Graves’ disease. Graves disease will show increased uptake throughout the thyroid gland. Toxic adenoma will show increased uptake in the nodule (hot nodule) with suppression of rest of the thyroid gland.
6. Fine-needle aspiration should be planned to evaluate suspicious thyroid nodules to rule out malignancy. Usually any thyroid nodule, which is less than 10 mm, can be monitored without fine-needle aspiration.

Quick Learning

• Subacute thyroiditis (subacute granulomatous thyroiditis) is characterized by:
• Neck pain or discomfort,
• A tender diffuse goiter,
• A predictable course of thyroid function evolution.
• Triphasic clinical course – Hyperthyroidism is typically the presentation. It is followed by euthyroidism, hypothyroidism.
• Ultimately there is restoration of normal thyroid function.
• No Anti-thyroid medication needed.

References:

1. Beltrão FEL et al 2021 Thyroid hormone levels during hospital admission inform disease severity and mortality in COVID-19 patients. Thyroid. Epub 2021 Sep 9. PMID: 34314259.
2. Ylli D et al 2021 Biotin interference in assays for thyroid hormones, thyrotropin and thyroglobulin. Thyroid 31:1160– 1170. PMID: 34042535.

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