Pendulum swings from hypo- to hyperthyroidism: thyrotoxicosis after severe hypothyroidism following neck irradiation in a patient with a history of Hodgkin’s lymphoma

Lewandowski, Krzysztof C.; Dąbrowska, Katarzyna; Makarewicz, Jacek; Lewiński, Andrzej

doi:10.1186/s13044-016-0030-1

Cited by 9 publications

(8 citation statements)

References 10 publications

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“…Khatiwada et al observed significantly lower iron levels in hypothyroid Nepalese children and a strong correlation between iron deficiency and anemia with hypothyroidism. Anemic children tended to have higher TSH and iron deficient children had significantly lower fT3 levels than iron sufficient children [ 82 ].…”

Section: Intestinal Influences On the Thyroidmentioning

confidence: 99%

Thyroid-Gut-Axis: How Does the Microbiota Influence Thyroid Function?

et al. 2020

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A healthy gut microbiota not only has beneficial effects on the activity of the immune system, but also on thyroid function. Thyroid and intestinal diseases prevalently coexist—Hashimoto’s thyroiditis (HT) and Graves’ disease (GD) are the most common autoimmune thyroid diseases (AITD) and often co-occur with Celiac Disease (CD) and Non-celiac wheat sensitivity (NCWS). This can be explained by the damaged intestinal barrier and the following increase of intestinal permeability, allowing antigens to pass more easily and activate the immune system or cross-react with extraintestinal tissues, respectively. Dysbiosis has not only been found in AITDs, but has also been reported in thyroid carcinoma, in which an increased number of carcinogenic and inflammatory bacterial strains were observed. Additionally, the composition of the gut microbiota has an influence on the availability of essential micronutrients for the thyroid gland. Iodine, iron, and copper are crucial for thyroid hormone synthesis, selenium and zinc are needed for converting T4 to T3, and vitamin D assists in regulating the immune response. Those micronutrients are often found to be deficient in AITDs, resulting in malfunctioning of the thyroid. Bariatric surgery can lead to an inadequate absorption of these nutrients and further implicates changes in thyroid stimulating hormone (TSH) and T3 levels. Supplementation of probiotics showed beneficial effects on thyroid hormones and thyroid function in general. A literature research was performed to examine the interplay between gut microbiota and thyroid disorders that should be considered when treating patients suffering from thyroid diseases. Multifactorial therapeutic and preventive management strategies could be established and more specifically adjusted to patients, depending on their gut bacteria composition. Future well-powered human studies are warranted to evaluate the impact of alterations in gut microbiota on thyroid function and diseases.

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Section: Intestinal Influences On the Thyroidmentioning

confidence: 99%

Thyroid-Gut-Axis: How Does the Microbiota Influence Thyroid Function?

et al. 2020

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“…There are reports, that after neck irradiation, Graves' disease (GD), an autoimmune disease may develop in patients previously being treated for hypothyroidism and interestingly one third of patients with Graves' hyperthyroidism had received thyroxine treatment before its onset [2]. Therefore thyroid hormone-replacement therapy in patients with hypothyroidism after irradiation of the neck does not always eliminate the risk of other thyroid abnormalities, including GD at a later date [4]. It is postulated that thyroiditis observed in Hodgkin's disease may be the result of immune regulation dysfunction.…”

Section: Introductionmentioning

confidence: 99%

R-CHOP-Associated Graves’ Hyperthyroidism

Mora

Hoang

et al. 2019

Case Rep Oncol

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Radiation-induced thyroid dysfunction following oncologic treatment is not uncommon, however limited literature data has been found on patients that underwent chemotherapy only. A change in thyrometabolic autoimmune status is also a rare entity. We present a case of newly diagnosed Graves’ thyrotoxicosis following a successful R-CHOP (Rituximab, Cyclophosphamide, Doxorubicine, Vincristine and Prednisone) treatment in a patient with concurrent abdominal and thyroid diffuse large B-cell lymphoma (DLBCL). Following chemotherapy, PET CT showed resolution of FDG-avid thyroid nodule as well as no evidence of the thyroid mass on repeat ultrasound. Her thyroid function also normalized. During her follow-up visit, patient reported significant unintentional weight loss and persistent fatigue over the past couple months. Repeat laboratory evaluation revealed TSH 0.005 mIU/mL, FT4 6.73 ng/dL and thyroid stimulating immunoglobulin (TSI) 535 (ref <140%). She was started on methimazole followed by radioactive iodine therapy. This unique case of Graves’ disease following R-CHOP treatment in patients with known Hashimoto’s and thyroid lymphoma is one of the first to be reported in the literature. The swing of pendulum from Hashimoto’s to Graves’ disease is very uncommon. As clinicians, we need to continue monitoring for clinical and biochemical thyroid dysfunction in this subset of population.

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“…We believe that genetically susceptible individuals may require an external trigger to switch from autoimmune hypothyroidism to Graves’ disease, such as an infection or neck irradiation ( 10 ), which would cause the balance to shift from TSH receptor-blocking antibodies to TSH receptor-stimulating antibodies. This phenomenon may not be as rare as previously thought and the physicians should be aware of this possibility if someone with a previously well-established hypothyroidism is now requiring less or no thyroid hormone replacement, and the TFTs keep demonstrating an overactive picture with no obvious reason, even many years after the diagnosis of hypothyroidism as in this case.…”

Section: Discussionmentioning

confidence: 99%

Hypothyroidism conversion to hyperthyroidism: it’s never too late

Ahmad

Hafeez

Arshad

et al. 2018

Endocrinology, Diabetes &Amp; Metabolism Case Reports

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SummaryPrimary hypothyroidism is a common endocrine condition, most commonly caused by autoimmune thyroiditis (Hashimoto’s disease) while Graves’ disease is the most common cause of hyperthyroidism. Hypothyroidism is usually a permanent condition in most patients requiring lifelong levothyroxine treatment. Transformation from Hashimoto’s disease to Graves’ disease is considered rare but recently been increasingly recognised. We describe a case of a 61-year-old lady who was diagnosed with hypothyroidism approximately three decades ago and treated with levothyroxine replacement therapy. Approximately 27 years after the initial diagnosis of hypothyroidism, she started to become biochemically and clinically hyperthyroid. This was initially managed with gradual reduction in the dose of levothyroxine, followed by complete cessation of the medication, but she remained hyperthyroid, ultimately requiring anti-thyroid treatment with Carbimazole. This case highlights that there should be a high index of suspicion for a possible conversion of hypothyroidism to hyperthyroidism, even many years after the initial diagnosis of hypothyroidism. To our knowledge, this case illustrates the longest reported time interval between the diagnosis of hypothyroidism until the conversion to hyperthyroidism.Learning points:Occurrence of Graves’ disease after primary hypothyroidism is uncommon but possible.In this case, there was a time-lapse of almost 28 years and therefore this entity may not be as rare as previously thought.Diagnosis requires careful clinical and biochemical assessment. Otherwise, the case can be easily confused for over-replacement of levothyroxine.We suggest measuring both anti-thyroid peroxidase (TPO) antibodies and TSH receptor antibodies (TRAB) in suspected cases.The underlying aetiology for the conversion is not exactly known but probably involves autoimmune switch by an external stimulus in genetically susceptible individuals.

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Pendulum swings from hypo- to hyperthyroidism: thyrotoxicosis after severe hypothyroidism following neck irradiation in a patient with a history of Hodgkin’s lymphoma

Cited by 9 publications

References 10 publications

Thyroid-Gut-Axis: How Does the Microbiota Influence Thyroid Function?

Thyroid-Gut-Axis: How Does the Microbiota Influence Thyroid Function?

R-CHOP-Associated Graves’ Hyperthyroidism

Hypothyroidism conversion to hyperthyroidism: it’s never too late

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