Tireotropin i hormoni štitnjače u eutireoidnom Hashimotovu tireoiditisu

Little is known about thyrotropin (TSH) and thyroid hormones in euthyroid Hashimoto’s thyroiditis (HT), thus the aim was to investigate TSH and thyroid hormone economy in euthyroid HT and its relation to thyroid function. Ninety-five patients with euthyroid HT with normal TSH and thyroid hormones on the last follow up between 2009 and 2011 were investigated. Previous observation period ranged from 1.5 to 4.8 (mean 2.8) years, and they had never been treated with levothyroxine. The results of TSH and thyroid hormones were compared with 210 healthy subjects and expressed as median (25%-75%). According to TSH value, the subjects were divided into quartiles: TSH 0.4-0.99 (1q), 1.0-1.99 (2q), 2.0-2.99 (3q) and 3.0-4.0 mIU /L (4q). Euthyroid HT patients had higher TSH (2.53 [1.79-3.14] vs.1.95 [1.24-2.72], p<0.001). T4 and T3 were not different. The distribution of TSH in HT patients was significantly shifted to the right; 71% of patients were in the 3q and 4q groups. When HT patients with higher TSH (3q and 4q) were compared with those with lower TSH (1q and 2q), significant differences emerged in TSH (3.01 [2.48-3.48] vs.1.45 [1.07-1.71] mIU /L), T4 (99.0 [88.2-112.0] vs.112.0 [105.0-122.0] nmol/L) and T3 (1.78 [1.48-2.05] vs. 2.10 [1.85-2.21] nmol/L; p<0.01). TPO values were similar in both groups. A gradually increasing proportion of euthyroid HT patients with at least one supranormal TSH during the observation period were found: 0% in 1q, 10% in 2q, 15% in 3q and 44% in 4q TSH group. Euthyroid HT patients maintain euthyroidism only under strenuous TSH stimulation. The patients with high normal TSH are identified as those with a major risk of hypothyroidism in the near future.Malo je poznato o vrijednostima tireoptropina (TSH) i hormona štitnjače u eutireoidnom Hashimotovu tireoiditisu (HT) te je cilj bio istražiti razinu TSH i hormona štitnjače u HT i njihov odnos prema funkciji štitnjače. Ispitano je 95 bolesnika s eutireoidnim HT s normalnim TSH i hormonima štitnjače na posljednjoj kontroli između 2009. i 2011. godine. Prethodno razdoblje promatranja variralo je od 1,5 do 4,8 (u prosjeku 2,8) godina, bolesnici nisu nikada liječeni levotiroksinom. Rezultati TSH i hormona štitnjače uspoređeni su s onima u 210 zdravih osoba i prikazani kao medijan (25%-75%). Prema vrijednosti TSH ispitanici su podijeljeni u kvartile: TSH 0,4-0,99 (1q), 1,0-1,99 (2q), 2,0-2,99 (3q) i 3,0-4,0 mIU /L (4q). Eutireoidni bolesnici s HT imali su viši TSH (2,53 [1,79-3,14] prema 1,95 [1,24-2,72], p<0,001). T4 i T3 se nisu razlikovali. Raspodjela TSH u HT izrazito je pomaknuta udesno. Ukupno je 71% bolesnika bilo u skupini 3q i 4q. Kada se usporede HT bolesnici s višim (3q i 4q) i nižim TSH (1q i 2q) nalaze se značajne razlike u TSH (3,01 [2,48-3,48] prema 1,45 [1,07-1,71] mIU /L), T4 (99,0 [88,2-112,0] prema 112,0 [105,0-122,0] nmol/L) i T3 (1,78 [1,48- 2,05] prema 2,10 [1,85-2,21] nmol/L; p<0,01). Vrijednosti TPO bile su slične u obje skupine HT bolesnika. Opažen je postupni porast postotka eutireoidnih HT bolesnika s najmanje jednom povišenom vrijednošću TSH tijekom razdoblja promatranja: 0% u skupini 1q, 10% u 2q, 15% in 3q i 44% u skupini 4q. Eutireoidni bolesnici s HT održavaju eutireozu jedino uz povećanu stimulaciju pomoću TSH. Bolesnici s visoko normalnim TSH imaju najveći rizik nastupa hipotireoze u bliskoj budućnosti

Incidentno povišena vrijednost tireotropina u inače dobro liječenih hipotireoidnih bolesnika ne zahtijeva povišenje doze levotiroksina

In 20 properly treated hypothyroid patients with normal thyrotropin (TSH) values during previous observation, TSH was incidentally mildly/moderately elevated (4.5-8.0 mIU/L; normal values 0.4-4.0) on the last follow up. However, they were continuously treated with the same levothyroxine (LT 4) dose (mean: 95 μg) and six months later all TSH values normalized. The authors suggest that the physicians, in response to incidentally increased TSH value in otherwise properly treated hypothyroid patients, refrain from prompt increasing the LT 4 dose unless TSH values are persistently elevated or/and progressing.Kod 20 hipotireoidnih bolesnika koji su prethodno dobro liječeni uz uredne vrijednosti tireotropina (TSH) na posljednjoj kontroli nađena je blago do umjereno povišena vrijednost TSH (4,5-8,0 mIU/L: n.v. 0,4-4,0). Ipak je nastavljeno liječenje istom dozom levotiroksina (LT 4), u prosjeku 95 μg, a nakon 6 mjeseci vrijednosti TSH su se normalizirale. Autori preporučuju da se liječnik suočen s incidentno povišenom vrijednošću TSH u inače dobro liječenih hipotireoidnih bolesnika suzdrži od povišenja doze LT 4 ako vrijednost TSH nije trajno povišena i/ili u progresiji

Snimanje mozga magnetskom rezonancom i neuropsihologijsko testiranje u jednojajčanih blizanaca nesukladnih na shizofreniju

Magnetic resonance imaging (MRI) scanning of the brain, soft neurologic signs, and personality and neuropsychologic assessment were used in a pair of monozygotic twins aged 25, discordant for schizophrenia. Brain MRI showed diffuse cortical atrophy of frontal, parietal and temporal brain lobes in both twins. Coronal plane MRI revealed decreased amygdala and hippocampus, and enlarged third and fourth lateral ventricles in the affected twin.Snimanje mozga magnetskom rezonancom (MR), nedefinirani (soft) neurološki znaci, neuropsihologijsko i psihologijsko testiranje osobnosti primijenjeni su na jednom paru jednojajčanih blizanaca starih 25 godina, od kojih jedan boluje od shizofrenije. MR mozga je u oba blizanca pokazao difuznu kortikalnu atrofiju frontalnih, parijetalnih i temporalnih režnjeva. MR u koronalnom presjeku pokazao je smanjene amigdale i hipokampus u bolesnog blizanca. U bolesnog je blizanca nađeno i proširenje trećega i lateralnih ventrikla

Zašto bolesnica s Gravesovom bolešću ostaje eutiroidna/blago hipertiroidna nakon totalne tiroidektomije - uloga antitijela na tirotropinske receptore (TRAb) i vestigalnih ostataka tiroglosalnog trakta

A young female patient suffering from Graves. disease is presented, who raised some diagnostic and therapeutic dilemmas after being diagnosed with subclinical hyperthyroidism following total thyroidectomy. This 20-year-old female patient, carrier of HLA B8 DR3 genes, was referred to our hospital for total thyroidectomy after developing severe leukopenia on both methimazole and propylthiouracil therapy. A high postoperative titer of thyrotropin receptor antibodies and positive scintigraphy finding of the pyramidal lobe and remnant thyroid tissue in the left thyroid lobe led to the administration of radioiodine. Despite further enlargement of the remnant thyroid tissue on post-radioiodine scintiscanning, the patient is currently euthyroid, with normal thyroid-stimulating hormone levels; however, her long-term prognosis remains uncertain.Opisan je slučaj bolesnice operirane zbog hipertireoze na podlozi Gravesove bolesti, u koje se na početno primijenjenu medikamentnu terapiju razvila granulocitopenija. Iako je kod bolesnice bila planirana totalna tireoidektomija, s obzirom na prijeoperacijski neprepoznat lobus piramidalis učinjena je tek djelomična resekcija štitnjače. Poslijeoperacijski se kao posljedica autoimune aktivacije ostatnog tkiva štitnjače antitijelima na tirotropinske receptore (TRAb) razvila hipertireoza, pa je daljnji tijek bolesti još uvijek nesiguran

Tumor mozga kao prototip teškog moždanog oštećenja u bolesnika sa “sindromom niskog t3”

The purpose of our study was to contribute to better understanding of cerebrospinal fluid (CSF) as a valuable biological material in the research of brain tumors within the “low T3 syndrome”, and to discuss the role of thyroid hormones in the central nervous system in subjects with severe cerebral lesions. We studied the levels of total triiodothyronine (tT3), total thyroxine (tT4), free triiodothyronine (fT3), free thyroxine (fT4), reverse triiodothyronine (rT3) and thyrotropin (TSH) in serum, and fT3, fT4, rT3 and TSH levels in CSF of patients with brain tumor, and compared the results with control group. Study results indicated a statistically significantly higher level of rT3 in serum and CSF of brain tumor patients vs. control group (p<0.05). The rT3/fT3 ratio was highest in CSF and serum of brain tumor patients, yielding a statistically significant difference (p<0.05). These results could suggest higher permeability of the blood brain barrier in brain tumor patients. We also assume that rT3, in the framework of “cerebral low T3 syndrome”, is also generated through local intracerebral conversion. Disruption of this process in severe cerebral lesion can lead to increased rT3 concentrations, i.e. development of the “low T3 syndrome”.Cilj studije bio je doprinijeti boljem poznavanju cerebrospinalne tekućine kao vrijednog biološkog materijala u istraživanju moždanih tumora i “sindroma niskog T3”, te razmotriti ulogu hormona štitnjače unutar središnjega živčanog sustava kod bolesnika s ozbiljnim moždanim oštećenjem. Analizirali smo razinu ukupnog trijodtironina (tT3), ukupnog tiroksina (tT4), slobodnog trijodtironina (fT3), slobodnog tiroksina (fT4), reverznog trijodtironina (rT3) i tireotropina (TSH) u serumu i razinu fT3, fT4, rT3 i TSH u cerebrospinalnoj tekućini u bolesnika s tumorom mozga te dobivene rezultate usporedili s kontrolnom skupinom ispitanika. Rezultati su ukazali na statistički značajno veću razinu rT3 u serumu i cerebrospinalnoj tekućini u bolesnika s tumorom mozga u usporedbi s kontrolnom skupinom (p<0,05). Odnos rT3/fT3 bio je također statistički značajno veći kod bolesnika s tumorom mozga (p<0,05). Naše istraživanje moglo bi ukazivati na veću propustljivost krvno-moždane barijere u bolesnika s tumorom mozga. Također pretpostavljamo da se u bolesnika s tumorom mozga rT3 pojačano stvara kroz aktivniju intracerebralnu pretvorbu. Svakako, naši rezultati trebaju biti potvrđeni i daljnjim podrobnijim istraživanjima

Tireotoksična kriza u 75-godišnje bolesnice

A 75-year-old female patient was admitted to the Intensive Care Unit with the signs of thyrotoxic crisis. Although hyperthyroidism had been previously suspected, thyrosuppressive therapy was not initiated on time. This along with other adverse factors like acute urinary infection contributed to deterioration and unfavorable development of the disease. Clinical improvement was noticed 24 hours from the introduction of combined therapy with propylthiouracil, propranolol, hydrocortisone and cardiotonics for rapid atrial fibrillation caused by atherosclerotic and thyrotoxic heart, supplemented with sedatives and necessary medical care. Shortly upon normalization of the thyroid hormone levels, RJ therapy was administered as a final solution. Pancytopenia verified before the initiation of thyrostatic therapy also contributed to this solution. The intention of this case report is to point to the yet possible occurrence of thyrotoxic crisis, which is nowadays extremely rare owing to appropriate management of hyperthyroidism. Nevertheless, may the disease failed to be recognized on time and therapy is introduced too late, along with other unfavorable factors such as acute infection, the disease can still occur sporadically. Although the mortality rate has been drastically lowered, it is still rather high, i.e. about 7%, therefore these patients should be treated at intensive care unit.Žena u dobi od 75 godina primljena je u Jedinicu za intenzivno liječenje pod slikom tireotoksične krize. Iako se je već ranije sumnjalo na hipertireozu, tireosupresivna terapija nije započeta na vrijeme, što je uz negativne pridružene čimbenike (akutna mokraćna infekcija) doprinijelo nepovoljnom razvoju bolesti. Kombinirana terapija propiltiouracilom, propranololom, hidrokortizonom te kardiotonicima zbog brze atrijske fibrilacije u sklopu aterosklerotskog i tireotoksičnog srca, uza sedative i ostale potporne mjere dovela je do kliničkog poboljšanja već nakon 24 h. Ubrzo nakon normalizacije hormona štitnjače primijenjena je RJ terapija kao definitivno rješenje, čemu je doprinijela i pancitopenija dokazana jo. prije započete terapije tireostaticima. Ovim prikazom želi se ukazati na jo. uvijek moguću pojavu tireotoksične krize koja je danas zahvaljujući primjerenom liječenju hipertireoze izrazito rijetka, no uz neprepoznavanje bolesti i zakašnjelu terapiju te nepovoljne druge čimbenike (npr. akutni infekt) jo. se uvijek može sporadično susresti. Iako je smrtnost drastično smanjena, ipak je jo. uvijek dosta visoka i iznosi oko 7%, zbog čega i takvi bolesnici zahtijevaju smještaj u jedinice za intenzivno liječenje

Koštana pregradnja i funkcija štitnjače

Many diseases are associated with more rapid bone loss and an increased risk of osteoporosis and fractures. Both hyperthyroidism and hypothyroidism as well as use of thyroid hormones or thyrosuppressant treatment influence bone turnover rates and may alter the risk of future fractures. Markers of bone remodeling are good indicators to determine bone turnover rates and potential bone loss, and correlate well with thyroid hormone levels. Untreated hyperthyroidism accelerates bone turnover resulting in net bone loss, while untreated hypothyroidism in adult humans slows down bone turnover resulting in net bone gain. In both cases, damage in bone microarchitecture occurs, leading to an increased relative risk of fractures. Effective therapies for both states are available, and in ideal case, full recovery of mineralized tissue may occur over time. Controversies are still present in patients receiving suppressive thyroxin treatment for thyroid carcinoma. It seems that suppressed thyroid-stimulating hormone with normal levels of peripheral thyroid hormones may increase the relative fracture risk in postmenopausal but not in premenopausal women. However, the exact molecular mechanisms of thyroid hormone and thyroid-stimulating hormone action on bone are not completely understood yet.Mnoge bolesti su udružene s ubrzanom koštanom razgradnjom i povećanim rizikom od nastanka osteoporoze. Poremećaji funkcije štitne žlijezde, kao i liječenje hormonima štitnjače, mogu utjecati na brzinu koštane pregradnje te utjecati na rizik od nastanka fraktura. Biljezi koštane pregradnje su dobri pokazatelji za praćenje brzine koštane pregradnje i utvrđivanje rizika od mogućeg gubitka koštane mase, i dobro koreliraju s razinom hormona štitnjače. Neliječena hipertireoza ubrzava koštanu pregradnju dovodeći do gubitka koštane mase, dok neliječena hipotireoza u ljudi usporava koštanu pregradnju te dovodi do pretjerane mineralizacije skeleta. U oba slučaja dolazi do narušavanja mikroarhitekture i povećanog rizika od nastanka fraktura. Djelotvorna je terapija dostupna za oba poremećaja rada štitne žlijezde i u idealnim će slučajevima dovesti do potpunog oporavka mineraliziranih tkiva. Nesuglasje postoji oko bolesnika koji dobivaju tireosupresivnu terapiju prilikom liječenja karcinoma štitnjače. Izgleda da suprimirane razine TSH i normalne razine perifernih hormona štitnjače mogu povećati relativni rizik za nastanak fraktura u žena nakon menopauze, ali ne i prije nje. Točni molekularni mehanizmi djelovanja hormona štitnjače i TSH na kosti još nisu do kraja rasvijetljeni

Autoimuni poliglandularni sindrom tip II. - prikaz slučaja

Presentation is made of a 41-year-old man with Addison’s disease and coexistent Hashimoto’s thyroiditis and hypothyroidism. The two diseases are presumed to be of autoimmune etiology and to manifest as part of the autoimmune polyglandular syndrome type II, as also suggested by tissue typing for HLA B8 locus. Inadequate TSH suppression with standard levothyroxine substitution therapy for a one-year period or with higher substitution doses of 200 mg during TRH stimulation, with FT4 which showed no major increase but remained within lower normal limits, indicated partial hypophyseal resistance to thyroxin and/or possible development of autoantibodies to peripheral thyroid hormones.Prikazan je 41-godišnji bolesnik s Addisonovom bolešću i pridruženim Hashimotovim tireoiditisom i hipotireozom. Za pretpostaviti je da su ove dvije bolesti autoimune etiologije i da se javljaju u okviru autoimunog poliglandularnog sindroma tipa II., na što upućuje i tipizacija tkiva u smislu HLA B8 lokusa. Nedovoljna supresija TSH standardnom nadomjestnom terapijom levotiroksinom kroz dulje vremensko razdoblje od godinu dana, kao i većim nadomjestnim dozama od 200 mg tijekom stimulacije TRH, uz FT4 koji se nije značajnije povisio, nego je ostao u nižem normalnom rasponu, ukazivala je na djelomičnu rezistenciju hipofize na tiroksin i/ili mogućnost razvoja autoantitijela na periferne hormone štitnjače