Transient Recurrence of Hyperthyroidism After Delivery in Graves' Disease

Amino, Nobuyuki; Miyai, Kiyoshi; Yamamoto, Taro; Kuro, Ritsuko; Tanaka, Fumiko; Takahashi, Osamu; Kumahara, Yuichi

doi:10.1210/jcem-44-1-130

Cited by 76 publications

(13 citation statements)

References 12 publications

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“…Postpartum thyroid syndromes distinct from postpartum thyroiditis have also been identified and include postpartum disturbances in thyroid function in patients with previous or current thyroid disease (2,3,13) and postpartum secondary hypothyroidism (14,15). Combinations of these postpartum thyroid syndromes, as well as combinations of preexisting Graves' disease and Hashimoto's disease with postpartum thyroiditis, have also been described (16 -19).…”

Section: Introductionmentioning

confidence: 99%

Postpartum Thyroiditis and Autoimmune Thyroiditis in Women of Childbearing Age: Recent Insights and Consequences for Antenatal and Postnatal Care

2001

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Postpartum thyroiditis is a syndrome of transient or permanent thyroid dysfunction occurring in the first year after delivery and based on an autoimmune inflammation of the thyroid. The prevalence ranges from 5-7%. We discuss the role of antibodies (especially thyroid peroxidase antibodies), complement, activated T cells, and apoptosis in the outbreak of postpartum thyroiditis. Postpartum thyroiditis is conceptualized as an acute phase of autoimmune thyroid destruction in the context of an existing and ongoing process of thyroid autosensitization. From pregnancy an enhanced state of immune tolerance ensues. A rebound reaction to this pregnancy-associated immune suppression after delivery explains the aggravation of autoimmune syndromes in the puerperal period, e.g., the occurrence of clinically overt postpartum thyroiditis. Low thyroid reserve due to autoimmune thyroiditis is increasingly recognized as a serious health problem. 1) Thyroid autoimmunity increases the probability of spontaneous fetal loss. 2) Thyroid failure due to autoimmune thyroiditis-often mild and subclinical-can lead to permanent and significant impairment in neuropsychological performance of the offspring. 3) Evidence is emerging that as women age subclinical hypothyroidism-as a sequel of postpartum thyroiditis-predisposes them to cardiovascular disease. Hence, postpartum thyroiditis is no longer considered a mild and transient disorder. Screening is considered.

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Section: Introductionmentioning

confidence: 99%

Postpartum Thyroiditis and Autoimmune Thyroiditis in Women of Childbearing Age: Recent Insights and Consequences for Antenatal and Postnatal Care

2001

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“…(J Clin Endocrinol Metab 53: 113, 1981) D ESTRUCTION-induced thyrotoxicosis is often observed in patients with subacute thyroiditis (1, 2), silent or painless thyroiditis (2-6), hyperthyroiditis (7), chronic lymphocytic thyroiditis (8), and postpartum painless thyroiditis (9,10). Moreover, similar thyrotoxicosis induced by destruction is observed postpartum in patients with previously diagnosed Graves' disease (11,12). It is very important to differentiate these types of thyrotoxicosis from stimulation-induced hyperthyroidism in Graves' disease, since the usual therapeutic measures for Graves' disease are contraindicated in these types (5,7,8,10).…”

mentioning

confidence: 99%

Serum Ratio of Triiodothyronine to Thyroxine, and Thyroxine-Binding Globulin and Calcitonin Concentrations in Graves' Disease and Destruction- Induced Thyrotoxicosis*

Amino

Yabu

Miki

et al. 1981

The Journal of Clinical Endocrinology & Metabolism

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120

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The serum ratios of T3 to T4, and T4-binding globulin (TBG) and calcitonin concentrations were studied in cases of thyrotoxic Graves' disease and destruction-induced thyrotoxicosis. In 272 patients with Graves' disease, 209 of 240 (87%) untreated patients without complications had high T3 to T4 ratios (nanograms per micrograms) of more than 20. Six of 32 (19%) patients with Graves' disease who had complications (15 with pregnancy, 14 with increased TBG, and 3 with conditions associated with a low T3 syndrome) had high T3 to T4 ratios. Eleven of 74 (15%) patients with destruction-induced thyrotoxicosis (24 with subacute thyroiditis, 39 with postpartum transient thyrotoxicosis, and 11 with spontaneous transient thyrotoxicosis) had high T3 to T4 ratios. Patients who had serum T4 levels of more than 30 micrograms/dl and/or T3 levels of more than 800 ng/dl had Graves' disease. There was no significant correlation between the T3 to T4 ratio and activities of thyroid-stimulating immunoglobulins in thyrotoxic patients with Graves' disease who had no complications. The average serum levels of TBG in destruction-induced thyrotoxicosis and thyrotoxic Graves' disease were 20.7 +/- 4.3 micrograms/ml (mean +/- SD; n = 22), and 19.9 +/- 4.0 (n = 41), respectively, which were significantly lower than that in healthy subjects (22.7 +/- 4.4 micrograms/ml; n = 165), but there was no difference between the values in the two groups of thyrotoxicosis patients. The average serum level of calcitonin in destruction-induced thyrotoxicosis patients was 96.7 +/- 66.7 pg/ml (n = 21), which was significantly (P less than 0.05) higher than the values in patients with thyrotoxic Graves' disease (62.0 +/- 44.7 pg/ml; n = 26) and in healthy subjects (63.9 +/- 31.2 pg/ml; n = 29), but the difference in values in the two groups of thyrotoxicosis was not clinically useful because of considerable overlap of individual values. The T3 to T4 ratio is a simple and helpful index for the differentiation of the two types of thyrotoxicosis. A T3 to T4 ratio less than 20 in thyrotoxic patients before therapy is a laboratory signal of destruction-induced thyrotoxicosis or Graves' disease with complications, but final differentiation should be confirmed by measuring radioactive iodine uptake.

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“…One PPT patient had altered Ig levels which followed the course described by Amino et al (9) and prompted us to measure Igs in patients with other variants of thyroiditis. Nine additional patients (six with SAT and three with PTT) had serial Ig measurements.…”

Section: Discussionmentioning

confidence: 91%

“…Painless thyroiditis with thyrotoxicosis (PTT) and postpartum thyroiditis with thyrotoxicosis (PPT), also painless, follow a similar clinical course. However, thyroid aspiration biopsies showing chronic lymphocytic infiltrates (3,4), HLA typing showing an increased frequency of DR antigens (5-7) and positive tests for thyroid antibodies (3,(8)(9)(10) all suggest an underlying autoimmune basis for these latter two disorders. In all three illnesses, inflammatory thyroid destruction often results in discharge of thyroid hormone into the circulation and development of transient thyrotoxicosis.…”

mentioning

confidence: 99%

Thyroid Iodine Content and Serum Thyroglobulin: Cues to the Natural History of Destruction-Induced Thyroiditis*

Smallridge

Keyser

Herle

et al. 1986

The Journal of Clinical Endocrinology & Metabolism

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Twenty-eight patients with destructive thyroiditis were followed to study the natural history of healing of thyroid gland injury. All had sequential measurements of thyroidal iodine [127I] content by fluorescent scanning (normal mean, 10.1 mg), 17 had serial serum thyroglobulin (Tg) measurements (normal, less than 21 ng/ml), and 13 had perchlorate discharge studies during the recovery phase. Seventeen patients had painful subacute thyroiditis (SAT), 9 had painless thyroiditis with thyrotoxicosis (PTT), and 2 had postpartum thyroiditis with thyrotoxicosis (PPT). Thyroidal iodine content decreased from a mean of 9.8 to a nadir of 3.8 mg in patients with SAT and from 8.5 to a nadir of 3.5 mg in patients with PTT. Mean serum Tg concentrations were highest (approximately 165 ng/ml) in both groups 1-3 months after the onset of symptoms. Abnormalities in both 127I content and Tg levels persisted for 2 or more yr in some individuals. No patient had detectable Tg antibodies by hemagglutination, but low titers were detected intermittently by sensitive RIA in 5 PTT patients. Microsomal antibodies were positive in only 1 of 16 SAT patients, but in 4 of 7 PTT patients and in both PPT patients. Three patients had positive perchlorate discharge tests (2 of 8 with SAT, 0 of 4 with PTT, and 1 of 1 with PPT). Permanent hypothyroidism occurred in 3 patients (2 with PTT; 1 with SAT and positive antibodies), but did not correlate with perchlorate results. HLA typing and serum immunoglobulin measurements were not useful for predicting the clinical course. These data indicate that several years may be necessary for complete resolution of destructive thyroiditis; many patients have evidence of thyroid injury persisting long after serum thyroid hormone and TSH levels become normal.

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Transient Recurrence of Hyperthyroidism After Delivery in Graves' Disease

Cited by 76 publications

References 12 publications

Postpartum Thyroiditis and Autoimmune Thyroiditis in Women of Childbearing Age: Recent Insights and Consequences for Antenatal and Postnatal Care

Postpartum Thyroiditis and Autoimmune Thyroiditis in Women of Childbearing Age: Recent Insights and Consequences for Antenatal and Postnatal Care

Serum Ratio of Triiodothyronine to Thyroxine, and Thyroxine-Binding Globulin and Calcitonin Concentrations in Graves' Disease and Destruction- Induced Thyrotoxicosis*

Thyroid Iodine Content and Serum Thyroglobulin: Cues to the Natural History of Destruction-Induced Thyroiditis*

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