Background: Oral tablets of levothyroxine (L-T4) are the standard of care for the treatment of Hypothyroidism and are recommended by current professional guidelines. However, patients with malabsorption syndromes, intolerance to excipients or dyes in tablets, or the intake of certain medications or foods may not be adequately controlled on these tablets. The use of liquid soft gel capsules (Tirosint) has been reported to be of value in such circumstances. Case Report: A 29 year old woman underwent total thyroidectomy followed by 124.5 mCi 131 I therapy at another facility for a right sided 3.7cm PTC with tall cell features. 12 ipsilateral central nodes were positive for cancer. Post therapy WBS was negative for evidence of distant metastases. She was placed onto branded L-T4 treatment but over the next 2 years, in spite of carefully documented adherence to her medication regimen, and with daily doses increasing from 0.1 to 0.3mg, TSH levels were unstable varying from 0.03 to 3.13μIU/ml and then 3 months later rose progressively further to 130μIU/ml. Her clinical Hypothyroidism became critical requiring emergent use of IV L-Thyroxine by her physicians who added L-T3 20μ/d to her L-T4 0.3mg but her TSH did not go below 98.54. She sought care at our institution. Issues of proper technique of medication administration were explained and emphasized with which the patient insisted she was fully compliant. Nevertheless, and in spite of a further increase in the daily L-T4 dose to 0.35mg, TSH remained excessive at 86.94. Treatment was then changed to Tirosint soft gel capsules alone starting at 0.3mg and then decreasing progressively to 0.2mg daily as her TSH reduced to 4.39 (6 months) and has remained in the range of 0.011 to 0.057 over the next 3 years. Other than Vitamin D and the temporary use of Depo-Provera, the patient denied the use of any other medications or supplements. Discussion: L-T4 tablets have long been the preferred and recommended treatment form for Hypothyroidism by professional societies. (1, 2) However, reports have appeared noting poor and inconstant response to this treatment in occasional patients such as those with malabsorption syndromes such as following bariatric surgery (3) or with gastroparesis (4), or with the concomitant intake of other medications such as proton pump inhibitors (5) or foods such as coffee (6). In such circumstances, it has been reported that use of liquid L-T4 or liquid soft gel capsules containing no excipients beyond glycerin and gelatin results in improved absorption of L-T4 with better and more stable control of thyroid biochemistry including TSH. (3, 4, 5, 6, 7) We present a case of a patient with Papillary Thyroid Cancer who, following total thyroidectomy and 131 I therapy, had variable and inadequate TSH suppression with development of clinical unresponsiveness to standard branded L-T4 treatment. Switching therapy to a soft gel product has enabled stable control of TSH

Introduction: Graves‘disease is an autoimmune disorder in which the thyroid is activated by antibodies to the thyrotropin receptor. The annual incidence in women over a 20-year period is around 0.5 per 1000, with the highest risk of onset between the ages of 40 and 60 years; it is thus the most prevalent autoimmune disorder in the United States 1 . This is 1/10 as common in men as in women. Treatment of Graves’ disease can be complicated by intrinsic aspects of the disease itself and also by effects of the therapy chosen. Case report: A 49 year old man presented to our emergency department with a three month history of palpitations, weight loss, heat intolerance, sweating, eye irritation and tremors. Physical examination revealed tachycardia (107 bpm), a fine tremor to the outstretched hands, bilateral stare, diffuse thyromegaly with bruit. Labs: TSH < 0.005 (0.35-3.4 uIU/ml), TT3 604 (70 -190 ng/dl), TT4 25.28 (4.5 - 12.1ug/dl), TSI 341 (< 140 %). Treatment was started on methimazole 10mg TID and propranolol 20mg TID. He had homogenous activity with a 24 hour uptake of 78 % on thyroid isotope scan. Diagnosis of Graves ’ disease was made and he was treated with 6.1 mCi of RAI. One month later, the patient presented with stare, conjunctival chemosis, lid lag, increased lacrimation, restricted extra ocular muscle movements worse on upward gaze, and periorbital edema. He was seen by Ophthalmology and started on prednisone 60 mg PO daily, with improvement in ocular findings. Two weeks thereafter was started, patient presented with agitation and anxiety. TSH was 0.006, TT4 9.4, TT3 88. Steroid induced psychosis was diagnosed and the prednisone dose was reduced, then gradually tapered off. The psychosis resolved. Post 131I Hypothyroidism developed and he became euthyroid with L-thyroxine replacement. Discussion: Graves’ ophthalmopathy occurs in a mild form in 25% to 50% of patients with Graves’ disease, with about 3% to 5% of patients having severe eye disease. Smoking, high levels of pre-treatment T3 (more than twice the upper limit of normal) and RAI induced release of retro orbital antigens cross reacting with thyrotropin receptor antigen are associated with an increased risk of ophthalmopathy .The risk of developing ophthalmopathy is around 20% after RAI and the risk of severe ophthalmopathy is around 7% 1 . At least 12 months follow-up after RAI is essential as ophthalmopathy usually develops or worsens within 6 months after RAI but can occur even after 2 years. Early treatment with glucocorticoids in appropriately selected patients is recommended for active, moderate to severe and sight-threatening disease. Serious neuropsychiatric effects occur in about 6% of patients who receive steroids. 3 Although the effects of glucocorticoids are unpredictable, the administered dose is the most significant risk factor for the development of neuropsychiatric symptoms. Dosage reduction typically results in clinical recovery.

Background: Phimosis defined as the inability to retract the prepuce over the glans of penis is a common condition affecting boys. Objective was to study the effectiveness of topical steroid therapy (0.05% clobetasol propionate cream) in boys with phimosis in the age group of 5 to 10 years.  Methods: This retrospective observational study was conducted at the Department of Pediatrics and Department of Surgery at Arunai Medical College and Hospital, Thiruvannamalai, Tamilnadu, India among 74 boys in the age group of 5 to 10 years with phimosis. The effect of twice daily application of 0.05% clobetasol propionate cream for six weeks on phimosis was studied.  Results: out of the 74 boys, 25 (33.78%) were in the age group of 5 to 6 years, 20 (27.02%) in the age group of 7 to 8 years and 29 (39.19%) in the age group of 9 to 10 years. As per Kikiros et al system of grading of retraction of foreskin, majority of the boys 30 (40.54%) were grade 4, followed by grade 2 (24 boys, 32.43%), grade 3 (14 boys, 18.93%) and grade 5 (6 boys, 8.1%). Out of the 74 boys with phimosis, 53 boys (71.62%) had associated complications. After 6 weeks of topical steroid therapy, 39 (52.71%) boys showed complete response, 24 (32.43%) boys showed partial response and 11 (14.86%) boys showed no response to the treatment regimen. There was no significant correlation between age of boys and grade of phimosis with treatment response. Significant correlation was noted between history of urinary tract infection and treatment response. None of the other complications showed significant correlation with treatment response. None of the boys had any side effects to topical steroid therapy.  Conclusions: Topical steroid application can be tried as an effective treatment modality in boys with phimosis in the age group of 5 to 10 years.