Endocrinology grand roundsCleveland Clinic

ABHIMANYU AGGARWALInternational Visiting Physician

Maulana Azad Medical College, University of DelhiIndia

Case•63 year old female presented to the ER with pain in right side of neck for 3-4 days along with recurrent fevers and difficulty swallowing.

•It was associated with dry cough and feeling of fullness in ears. She completed a course of Augmentin for 5 days but did not get relief.

•She was found to be tachycardic and CECT Chest was performed that was negative for Pulmonary Embolism.

•TSH was found to be low and so endocrine was consulted.

ROS• WEIGHT: she lost 10 lb in 1 month• HYDRATION: no polydipsia or thirst• CARDIAC: no chest pain, dyspnea,• RESPIRATORY: positive for dry cough, no wheezing or shortness

of breath• GI: no nausea, fullness, vomiting, diarrhea, constipation• GU:no dysuria, frequency, hesitancy, hematuria, polyuria or

nocturia• SKIN: normal• NERVOUS SYSTEM: occasional paresthesias in her hands• ALL OTHER SYSTEMS: normal

PAST MEDICAL HISTORY• Ovarian Cyst • Endometriosis• Posterior Vitreous Detachment• No history of thyroid disorder

PAST SURGICAL HISTORY• Laparoscopy for endometrioma

FAMILY HISTORY: • Mother: Cataract • Father: Colon Cancer, Cataract• Sister: Hashimoto’s Hypothyroidism

SOCIAL HISTORY: • Tobacco Use: Never • Alcohol Use: Yes (rare)

Physical Examination

BP 124/68 mmHg | Pulse 87 | Temp(Src) 36.9 °C (98.4 °F) (Oral) | Resp 18 | Ht 160 cm (5' 3") | Wt 58.605 kg (129 lb 3.2 oz) | BMI 22.89 kg/m2 | Body mass index is 22.89 kg/(m^2).

Appearance well appearing, alert, in no acute distress, well-hydrated, well nourishedEYES: PERRLA, conjunctiva and sclera normal, no signs of opthalmopathyNECK Supple, no adenopathy; thyroid mildly enlarged R lobe > L, non-tender, could not appreciate discrete nodule, bruit heard on R HEART: RRR without murmur, gallop, or rubs. No ectopyLUNGS: lungs clear to auscultation, no wheezing or rhonchiABDOMEN: soft, non-tender, non-distended, non-tenderEXTREMITIES: mild tremor in fingertipsNEURO: Awake, alert and oriented x 3

Laboratory

Thyroid Ultrasound• RIGHT LOBE: Size: 5.0 x 2.0 x 2.5 cm, mildly enlarged; Echotexture: HomogeneousNodules: None.

LEFT LOBE:Size: 4.7 x 2.4 x 2.1 cm, mildly enlarged; Echotexture: HomogeneousNodules: 1.0 cm posterior lower pole complex cystic nodule, 0.7 cm mid pole mid lobe nodule, partially calcified.

ISTHMUS: AP diameter: 7 mmNodules: 0.4 cm complex cystic, predominantly solid nodule in the right side of the isthmus.

Vascularity to each thyroid lobe is symmetrically increased.

Ultrasound images

Is the increased vascularity suggestive of Graves’ disease?

• A total of 194 patients with Graves’ disease and 21 patients with painless thyroiditis were enrolled.• All patients underwent thyroid volume measurement, mean Superior Thyroid Artery PSV measurement, power Doppler sonography and proper blood testing.• Patients from both categories were further subdivided into four patterns based on vascularity – Pattern 0 through Pattern 3, with Pattern 0 being the least vascular and Pattern 3 the most vascular

Results

• In the comparison between patients with Graves’ disease and Pattern 0 and patients with Painless Thyroiditis and Pattern 0, there was not much difference, except Superior Thyroid Artery PSV. • PSV was found to be moderately useful, with a sensitivity and specificity of 75%.

40 premenopausal euthyroid patients on treatment for Hashimoto’s thyroiditis along with 46 healthy control subjects were enrolled for investigation.

• It was inferred that during early phases of Hashimoto’s thyroiditis, doppler examination may show diffuse hypervascularisation similar to Graves’ disease; followed by decreased vascularity in the later stages due to fibrotic changes.

Isin Ceylan et al

What should have been the next step towards a definitive diagnosis?

Briefly, we have a patient with low TSH, high levels of free thyroid hormones and hypervascular thyroid with recent contrast exposure

Initial flow images demonstrate prominent uptake of tracer, suggesting hyperemia. Rate of tracer clearance may be prolonged. Scintigraphic findings are suggestive of Thyroiditis. However, it is uncertain if Hyperthyroid Graves’ disease could produce a similar picture. Correlation with Technetium-99M Scan could prove useful for further evaluation; Decreased uptake on the Pertechnetate Scan would favor Thyroiditis as opposed to Hyperthyroid Grave’s disease.

Nuclear Technetium sestamibi scan

• 23 patients on oral amiodarone for at least 3 months had thyroid scintigraphy and uptake measure using Tc-99m Pertechnetate and Tc-99m Sestamibi scan.

• In 14-18% of amiodarone treated patients, there is overt thyroid dysfunction, either amiodarone-induced thyrotoxicosis (AIT) or amiodarone-induced hypothyroidism (AIH).

• The thyroid uptake of SESTAMIBI is not mediated by the same mechanisms as iodine or pertechnetate, and apparently does not require preparation with low iodine intake.

• All patients underwent the pertechnetate and sestamibi thyroid uptakes and scintigraphy studies with a time interval of 4 to 15 days between the studies.

Oki et al Clinical Nuclear Medicine. 35(4):223-227, April 2010

Oki et al Clinical Nuclear Medicine. 35(4):223-227, April 2010

Reference range for uptake in normal subjects: Pertechnetate (0.35-1.7%); Sestamibi (0.03-0.23%)

•All hypothyroid patients - uptake of both tracers ( statistically significant)

Result and Conclusion

Result and Conclusion

Oki et al Clinical Nuclear Medicine. 35(4):223-227, April 2010

Reference range for uptake in normal subjects: Pertechnetate (0.35-1.7%); Sestamibi (0.03-0.23%)

• All euthyroid patients – pertechnetate uptake, sestamibi uptake (not statistically significant).• All hyperthyroid patients – one had Graves’ disease with markedly uptake of both tracers; the other three had pertechnetate uptake and sestamibi uptake (group was too small to be statistically significant).

Meanwhile, we treated our patient symptomatically with Naproxen and Atenolol 25mg q12 hrly.Labs for TRAbs, Microsomal Ab, Thyroglobulin Ab and Thyroglobulin levels sent.

Rheumatology was consulted for fevers and they wanted to know if thyroiditis/Graves’ can cause fevers.

Disease course

Primary team wanted to discharge the patient.Definitive diagnosis was not made and Antibodies were in process.Would you have discharged the patient on Methimazole?

Patient was discharged on syptomatic treatment and asked to follow up in clinic after 3 weeks. In the meanwhile, Antibody screen showed up.

Summary• Patient with hyperthyroidism, hypervascular thyroid, equivocal nuclear uptake and

scan in the setting of recent contrast exposure was diagnosed with early stage of Hashimoto’s thyroiditis.

• Hashimoto’s thyroiditis can be associated with fevers.

• Ultrasound features and Power Doppler USG of thyroid of patients with varied TFT are moderately reliable for a diagnoses of thyroid disorder, but should be accompanied with scheduled follow-ups and repeated TFTs and USG for a final diagnosis.

• Sestamibi scans, due to lack of adequate studies, are yet to be assigned a suitable role in the diagnosis and management of patients with hyper- or hypothyroidism.

• The only advantage is that they can be used independent of dietary intake or contrast administration to the patient.

Thank you!