Study of Proportion and Pattern of Sick Euthyroid Syndrome in Patients with Sepsis in Intensive Care Unit of a Tertiary Care Hospital in South Kerala

BACKGROUND Patients with critical illness can have changes in thyroid hormone metabolism along with changes within the hypothalamus-pituitary-thyroid axis, even though there is no previous history of thyroid disease. Such changes have been named as “Sick Euthyroid Syndrome” or “Non-Thyroidal Illness Syndrome (NTIS)”. Such alterations in thyroid function can be seen in patients with sepsis and they are known to affect the prognosis of the disease. The most common abnormality in sick euthyroid syndrome is low serum T3. This study aims to find the proportion and pattern of sick euthyroid syndrome in patients with sepsis. METHODS This was a hospital based cross sectional study done in the Department of Internal Medicine in a tertiary care centre in south Kerala. 100 patients with diagnosis of sepsis were selected based on American College of Chest Physician / Society of Critical Care Medicine 2001 Consensus Conference definitions, and included in the study. Serum levels of total T3, total T4 and TSH were measured and the proportion of patients with various abnormalities in thyroid hormone levels and the pattern of abnormalities were analysed. RESULTS The mean age of study group was 67.9 years (with standard deviation of 7.184). Female to male ratio was 1.08:1. Proportion of sick euthyroid syndrome in patients with sepsis was 71 %. Low T3 was seen in 69 % patients, low T4 in 11 % and low TSH in 11 %. TSH was above reference range in 3 % patients. The most common pattern of sick euthyroid syndrome was low T3 with normal T4 and TSH in 54 % patients. Low T3 with low T4 and normal TSH was seen in 6 % patients; low T3, T4, TSH in 5 % patients; low T3, elevated TSH, normal T4 in 3 % patients; low TSH with normal T3 and T4 in 2 % patients and low T3, low TSH and normal T4 in 1 % patients. CONCLUSIONS Proportion of sick euthyroid syndrome in sepsis was 71 % and the most common pattern was low T3 with normal T4 and TSH seen in 54 % patients. KEYWORDS Sick Euthyroid Syndrome, T3, T4, TSH

Sick euthyroid syndrome and its association with cardiogenic shock in acute coronary syndromes

Introduction Sick euthyroid syndrome (SES) constitutes an acute response to stress, and patients who develop it usually show more severe illness than those who do not. It could be related to disease severity in acute coronary syndrome (ACS), as assessed with Killip-Kimball class (KK), since cardiomyocytes are specifically sensitive to T3 levels. Objective To determine the prevalence of SES and low T3 in patients with ACS, and to assess its association with disease severity. Methods Prospective, observational and single center study in consecutive patients admitted to the CCU with a diagnosis of ACS. Clinical variables were collected from medical records; blood samples were obtained at admission to measure TSH, T3 and free T4 levels. SES was defined as low T3 with normal TSH and free T4. Maximum KK was determined by treating physicians. Categorical variables were compared with the chi-squared test, and categorical variables with Kruskal-Wallis and Wilcoxon tests. Statistical significance was set at p<0.05. Results There were 149 patients with complete data available for analysis. Their age was 67.8±12.4 years, and 64% were male. A total of 16.3% had SES. There were 7.5% patients with SES and KK-A, 34.8% KK-B, 14.3% KK-C and 70% KK-D (p<0.001). Thus, SES was more frequent in patients with some grade of heart failure, particularly cardiogenic shock. Figure 1 shows the difference in T3 values according to Killip-Kimball class. Conclusion Cardiomyocytes lack deiodinase and only possess T3 receptors, which makes them dependent on circulating T3 levels. T3 directly stimulates calcium channel and contractile protein synthesis in cardiomyocytes, and its deficit could affect cardiac contractility. Future studies should determine if thyroid hormone administration in cardiogenic shock can improve contractility and contribute to hemodynamic stability. T3 values according to Killip-Kimball Funding Acknowledgement Type of funding source: None

Thyroid profile in pulmonary tuberculosis patients: a prospective study in a tertiary medical college of southern Odisha

<p class="abstract"><strong>Background:</strong> Globally, an estimated 10.0 million (range, 9.0 to 11.1 million) people infected with tuberculosis (TB). Developing country like India accounts for one fourth of the global tuberculosis burden. TB is associated with diffuse functional impairment of most endocrine organs.</p><p class="abstract"><strong>Methods:</strong> We conducted a study to evaluate the thyroid profile status in new sputum positive pulmonary tuberculosis patients, aged 12 years and above; attended and admitted to chest and TB, Medicine Department of SLN MCH, Koraput, Odisha from January 2019 to December 2019. Patients with H/o old pulmonary tuberculosis, patient with known neurological, hypothalamic-pituitary or thyroid disorders, kidney disease, malignancies and patients receiving medications known to interfere with thyroid hormone metabolism were excluded from the study. Statistical analysis was done by using SPSS version 21.0 software. Results were expressed in average±SD, frequencies and percentages. Continuous data were compared using Student’s t-test. A p value &lt;0.05 was considered as statistically significant and p value &lt;0.001 was considered as statistically extremely significant.</p><p class="abstract"><strong>Results:</strong> Mean age of the study group was 37.31±15.63 years. 54 patients (40.30%) were in 20 to 40 years of age group. We found, 48 (35.82%) pulmonary tuberculosis patients had sick euthyroid syndrome out of 134 pulmonary tuberculosis patients.</p><p class="abstract"><strong>Conclusions: </strong>Sick euthyroid syndrome occurs commonly in pulmonary tuberculosis patients with increasing incidence with advanced age, and also seen in patients with advanced pulmonary tuberculosis patients; therefore, requires monitoring of thyroid function test for its timely initiation of therapy.</p><p class="abstract"> </p>

Therapy with L-thyroxine and Omnadren after Cardiac Surgery. A Case Report

Background: Cardiopulmonary bypass in cardiac surgery produces systemic inflammatory response and catabolic state. Severe stress frequently causes abnormalities in thyroid hormones in the absence of primary thyroid disease, defined as sick euthyroid syndrome (SES). Materials and methods: Supplementation therapy with thyroid and anabolic hormones in combination with an adequate nutritional support has been used to improve outcome in critically ill patient after cardiac surgery. Results: Administration of thyroid and anabolic hormones significantly improved patient&rsquo;s condition. Conclusions: Supplementation therapy with thyroid and anabolic hormones in combination with an adequate nutritional support could be used to improve hemodynamics, achieve transition to anabolic metabolism and enhance recovery, which could eventually help for a reduction in post-operative morbidity and mortality.

PREVALENCE OF SICK EUTHYROID SYNDROME IN NON-THYROIDAL ILLNESS

INTRODUCTION: Sick euthyroid syndrome is also known as low triiodothyronine (T3) syndrome or non-thyroidal illness syndrome which is characterized by alterations in the levels of thyroid hormones in the absence of any disorder related to thyroid gland or hypothalamic-hypophysial axis. Abnormal findings on thyroid functions tests which occur in the setting of a non thyroidal illness (NTI) without preexisting hypothalamic-pituitary and thyroid gland dysfunction. In the 1970s initially described low T3 (triiodothyronine) syndrome, known as the euthyroid sick syndrome or the nonthyroidal illness syndrome (NTIS). This can be representing especially in in critically ill patients, particularly those admitted to intensive care units. Although by definition these abnormalities are not related to intrinsic diseases of hypothalamus-pituitary-thyroid axis though rather represent imbalances in thyroid hormone production, metabolism, and action. As there is progress in illness gradual development of a more complex syndrome associated with low levels of T3 and thyroxine (T4). AIM: The main objective of this study is to study clinical profile sick euthyroid syndrome in Non-thyroidal Illness. MATERIAL AND METHODS: Total 60 patients were included in this study with the diagnosis of euthyroid syndrome with suggestive of Non-thyroidal Illness. From all the patients detail history were recorded as data as well as all the necessary lab investigations were recorded as hemogram, renal function test, liver function test, ECG, Chest roentgenogram, and thyroid function status and serum cholrine esterase. RESULT: Total 60 patients were including in this study within the period of study with different age group. Patients with age group 20-30 years age group shows majority followed by age group 30-40 years age group as 33.3% and 30% respectively. Among the 60 patients only 15 patients were observed as sick Euthyroid. Out of 15 patients with sick Euthyroid 60% showed Low T3 alone and 40% shows changes in T3, T4 & TSH Levels. CONCLUSION: Non-thyroidal illness syndrome is common among male in comparisons to female with the middle ages. Since the mechanism of sick euthyroid syndrome is similar to sick euthyroid syndrome in other critical care illnesses. Therefore more and more studies should be done for the better evaluation of the prognostic value of NTIS in critically ill. Thyroid functions should be assessed routinely in patients for prevent of Non-thyroidal illness syndrome. KEYWORDS: sick euthyroid syndrome, Non-thyroidal Illness, Thyroid

Thyroid Hormone Replacement Therapy in Critically Ill Patients: Lack of Promising Evidence for Physiologically Sound Approaches

The sick euthyoid syndrome, also known as nonthyroidal illness syndrome, refers to changes seen in patient thyroid function tests administered in the medical intensive care unit during episodes of critical illness(1). Low serum T3 is the most common abnormality in euthyroid sick syndrome. Both low T3 and low T4 syndrome are reported in critically ill patients and low serum T4 is related with worst outcome. These features in laboratory findings of sick euthyroid patients have been explained by circulating thyroid binding hormone inhibitor (2). Thyroid hormone signalling regulates crucial biological functions, including energy expenditure, thermogenesis, development and growth. Fliers et al. (3), in their review “Thyroid function in critically ill patients”, concluded that routine thyroid hormone replacement therapy is not recommended in non-thyroid illness syndrome in critically ill patients. As we know, decreased plasma concentrations of thyroid hormones, especially T3, in critically ill patients represent the severity of the disorder and are associated with poor outcomes. On the other hand, thyroid hormone administration has been reported to be associated with improved hemodynamics, increased cardiac output, decreased ICU length of stay, reduced need for inotropic agents and mechanical devices, decreased incidence of myocardial ischaemia and decreased incidence of atrial fibrillation and pacemaker therapy (4-6). There are some studies reported the link between low levels of thyroid hormone and sarcopenia which leads to critical ill weakness (7.8). So it may be a rational to use hormone replacement therapy in selected critically ill patients with sick euthyroid syndrome.Not to implement physiologically sound approaches just because “evidence is lacking” might be disadvantageous for these patients over time as it might probably take years until clinical evidence become available. Subsequently, based on previous trials that have introduced effectiveness or at least no effects of hormone replacement therapy for non-thyroid illness syndrome, it seems that critically ill patients without limiting conditions such as advanced age or cardiac dysfunction (e.g. CHF or ACS) might benefit from thyroid replacement therapy and depriving these patients from what they might have benefited seems unethical.As we mentioned sick euthyroid syndrome occurs with different faces in critically ill patients with some good and some bad characteristics. Tolerating the early onset hibernation response with its concomitant changes in thyroid hormone parameters seems to be beneficial and safe. But the other type of sick euthyroid syndrome which develops later during prolong ICU admission may have a different face and needs some interventions as it has impact on patients outcome.

Effect of anti-tuberculosis treatment on thyroid profile in newly detected smear positive pulmonary tuberculosis cases

Background: Tuberculosis being a systemic disease and has a capacity for wide spread dissemination. Present study aims to identify the effects of antituberculous treatment on thyroid profile in new smear positive pulmonary tuberculosis cases.Methods: This study was conducted among 60 new smear positive pulmonary tuberculosis cases attending pulmonary medicine OPD from May 2015 to April 2017. Thyroid function test in the form of free T3, free T4 and TSH was measured before initiating Anti tuberculosis treatment (ATT), at 3 months and at the end of 6 months.Results: Out of 60 patients enrolled in present study, majority were males. Diabetes mellitus was the major co morbidity. Sick euthyroid was found to have decreasing trend during the course of treatment, and hypothyroidism was found to be increasing trend end of 6 months.Conclusions: The common Thyroid Dysfunction seen during the study period was Hypothyroidism and Sick euthyroid. Anti-tuberculous medication preferably Rifampicin probably would explain the cause for these thyroid dysfunctions noticed during the study time. And those patients with significant hypothyroid need to started on thyroid supplements. Among the drugs used for treatment, rifampicin was probably the cause for thyroid dysfunction noticed during the course of treatment. Hence, authors recommend that these patients should be started on thyroid supplements after the diagnosis of significant hypothyroidism.

Asymptomatic thyroid dysfunction in human immunodeficiency virus-1-infected subjects

ABSTRACT BACKGROUND: Thyroid hormone abnormalities have been reported elsewhere in human immunodeficiency virus-1 (HIV-1)-infected individuals, but such studies in Nigerians are scarce in literature. OBJECTIVE: To evaluate thyroid function in HIV-1-infected individuals and to correlate thyroid function parameters with cluster of differentiation (CD4+) cell count. MATERIALS AND METHODS: Total thyroxine (T4), total triiodothyronine (T3), thyroid-stimulating hormone (TSH), and CD4+ were estimated in 100 HIV-1-positive individuals on highly active antiretroviral therapy (HAART), 100 HIV-1-positive HAART naïve, and 100 HIV-1-negative controls. The mean values were compared between the groups, and CD4+ cell count was correlated with measured thyroid hormones. RESULTS: Thyroid function abnormalities were seen in 52 HIV-1-positive individuals on HAART and 56 individuals without HAART treatment. The pattern of thyroid hormone abnormalities is similar in both groups. Among the individuals on HAART, 10 had subclinical hypothyroid, 42 sick euthyroid, and 48 had normal thyroid hormones levels. Similarly, among those without HAART therapy, seven had subclinical hypothyroid, 49 sick euthyroid, and 44 had normal thyroid hormones levels. The HIV-1-positive individuals had significantly lower (P < 0.001) CD4+ cell count, TSH (P < 0.05), T3 (P < 0.01), and T4 (P < 0.001) when compared with controls. On the other hand, HIV-1-positive individuals on HAART had significantly higher (P < 0.01) CD4+ cell count and lower (P< 0.05) T4 levels than the HAART naïve group. CD4+ correlated positively with T4 in HIV-1-positive individuals on HAART (r = 0.26; P = 0.016) and HAART naïve (r = 0.218; P = 0.038). There was no significant correlation between CD4+ and measured thyroid hormones in the control individuals. CONCLUSION: Asymptomatic thyroid hormone abnormalities are common in HIV-infected individuals, and these abnormalities are independent of whether the individuals were on HAART or without HAART treatment.