ABSTRACT Hypothyroidism is a common condition which is readily diagnosed and managed. It can present with various symptoms including fatigue and weight gain but can rarely present with massive pericardial effusion that may be potentially fatal. A 35-year-old young married female, with prior no comorbid, presented to internal medicine outpatient department (OPD) with gradual onset of shortness of breath for 2 months. Prior to her visit to our OPD, she had been admitted in a tertiary care setup for similar symptoms where on workup she was found to have massive pericardial effusion with cardiac tamponade. On detailed investigation, she had raised thyroid-stimulating hormone. She was started on tablet levothyroxine which improved her symptoms. Despite living in a tuberculosis endemic area, pericardial effusion remains a well-recognized but often underdiagnosed manifestation of hypothyroidism. Very rarely can it present initially as a massive effusion and tamponade requiring urgent intervention.
ABSTRACT Thyroid eye disease (TED) represents a significant clinical burden in patients with Graves’ disease, with limited treatment options beyond glucocorticoids and conventional immunosuppression. Teprotumumab, a human monoclonal antibody targeting the insulin-like growth factor-1 receptor, has emerged as the first disease-modifying therapy specifically approved for active, moderate-to-severe TED. This narrative mini-review synthesizes current evidence on existing pharmacological management of TED, critically examines the gaps in conventional therapy and evaluates the mechanism of action, clinical efficacy, and safety profile of teprotumumab. Special emphasis is placed on cost considerations, accessibility challenges, and the positioning of this therapy within the Indian healthcare context, where resource constraints and out-of-pocket expenditure realities necessitate careful appraisal of high-cost biologics. While teprotumumab demonstrates remarkable efficacy in reducing proptosis and improving the quality of life, its prohibitive cost, limited availability in India, and safety concerns regarding hyperglycemia and hearing dysfunction require balanced consideration. This review provides Indian endocrinologists with an evidence-based framework for understanding teprotumumab’s role and limitations in contemporary TED management.
ABSTRACT Hirata syndrome or autoimmune hypoglycemia is a rare cause of hypoglycemia. Patients usually present multiple episodes of postprandial hypoglycemia, usually associated with neuroglycopenic symptoms. This condition has been previously described with multiple drugs such as methimazole or carbimazole in patients of Graves’ disease. We report the case of a 41-year-old woman who was diagnosed with Graves’ disease and was on remission for 3 years on methimazole therapy and was incidentally detected to have persistently low postprandial blood glucose levels on routine evaluation. She denied any symptoms that are typical of hypoglycemia. The anti-insulin antibody came out to be positive. In the absence of fasting hypoglycemia and weight gain; no prior history of diabetes, exogenous insulin, or oral antidiabetic drug use; and a long history of methimazole intake, she was diagnosed to be a case of Hirata syndrome. The culprit drug, methimazole, was stopped, and she underwent radioactive iodine ablation. The incidental detection of Hirata syndrome in a patient on methimazole therapy without symptoms of hypoglycemia raises the possibility that the incidence of Hirata syndrome reported is just the tip of the iceberg, with many asymptomatic cases remaining unidentified, particularly for patients on thionamide therapy.
ABSTRACT Retrosternal goiter (RSG) is defined as any goiter, with 50% of its mass situated below the thoracic inlet. It can be primary or secondary. Secondary RSGs are seen more commonly and are due to mediastinal extension of the neck mass. Primary RSG arise in the mediastinum without any neck component. Patients with RSG can present with neck swelling, dyspnea, dysphagia, hoarseness, or chest discomfort. The diagnosis is usually made on clinical examination and confirmed by radiological investigation. Surgical management is the primary modality of treatment for RSG. Here, we report the case of a 40-year-old female diagnosed with colloid goiter with huge retrosternal extension who was managed surgically by combined neck and sternotomy approach.
ABSTRACT Background: According to the latest National Family health survey (NHFS)-5 data, the burden of thyroid disorders being 2.7% for women and 0.5% for men in the Indian subcontinent, this makes thyroid disorder arguably the commonest endocrine disorder. Aims: This study aims to assess the acoustic and perceptual characteristics of voice with thyroid disorders using specific scientific software. Subject and Methods: The study categorizes the study population into two groups, cases and controls, by randomization. The selection criterion of patients was thyroid gland disorders with a medical diagnosis, no history of voice change, and/or absence of other possible causes of voice change. The study assesses the acoustic, perceptual and aerodynamic parameters by using videostrboscopy, PRATT SCORE (PHONOLAB ECLERIS software) and Grade, roughness, breathiness, asthenia, strain (GRBAS) (Grade, roughness, breathiness, asthenia, strain) scale analysis. Results: Changes in perceptual characteristics (GRBAS) of voice and acoustic parameters were noted. The highest deviation was seen in the acoustic parameters of shimmer and harmonic noise ratio. Patients with thyroid disorders showed a significant difference in maximum phonation time. Conclusions: The study indicated the importance of assessing and treating the symptoms of voice change in patients with thyroid disorders, since there is a significant difference in the perceptual parameters of voice among patients with thyroid disorders and normal individuals.
ABSTRACT The follicular variant of papillary thyroid carcinoma (FVPTC) is rarely associated with bone metastasis, and the connection with autonomously functioning thyroid nodules (AFTNs) is an uncommon finding. We present the case of a 53-year-old female who had painless swelling in the occipital region that gradually progressed over 3 years. The swelling measured 5 cm × 5 cm, was firm, and was nonpulsatile. Computed tomography scan of the brain revealed a lytic lesion in the posterior skull, raising suspicion of metastasis. On physical examination, she had a palpable right thyroid nodule. Thyroid function tests revealed suppressed thyroid-stimulating hormone with elevated T3 and T4 levels. The Tc-99m thyroid scan showed a hyperfunctioning thyroid nodule (AFTN) in the right thyroid lobe. Ultrasound of the neck revealed a right lobe thyroid nodule categorized as TIRADS 4. Fine-needle aspiration cytology suggested a Bethesda category IV lesion, suggestive of a follicular neoplasm. A whole-body Tc-99m-methylene diphosphonate scan revealed a rim of increased uptake with central photopenia in the occipital lesion, suggestive of metastasis. The patient was started on antithyroid drugs and underwent a total thyroidectomy after achieving euthyroidism. A histopathological examination confirmed the diagnosis of the invasive encapsulated FVPTC. Early use of functional imaging, re-evaluation of suspicious cytology, and awareness of atypical metastatic presentations were crucial for timely diagnosis and treatment.
ABSTRACT Background: Early thyroid dysfunction frequently remains undetected in young women, emphasizing the importance of identifying sensitive biochemical and genetic markers for early detection. Objective: This study investigates whether routine biochemical markers and the type II deiodinase (DIO2) Thr92Ala gene polymorphism (rs225014) correlate with early thyroid imbalances in asymptomatic young women. Materials and Methods: A cross-sectional observational study was conducted on 38 asymptomatic women aged 17–26 years. Tests included complete blood count, lipid profile, iron and vitamin levels (Vitamin B12 and Vitamin D), kidney and liver function, thyroid function tests (TFTs), and genotyping for the DIO2 SNP (rs225014). Data were analyzed using multiple linear regression and ANOVA. Results: Altered TFTs were observed in 13% of participants. Lower iron and low-density lipids levels were observed in 39% of females, while Vitamin B12 was elevated in 34%. Vitamin D deficiency was universal (100%), with low high-density lipoprotein and ferritin in 34% and 24%, respectively. Changes in cholesterol, thyroid, and blood parameters were noted. However, regression analyses found no significant correlation between thyroid markers and routine biochemical parameters, suggesting largely unaltered metabolism in these healthy women. Genotype distribution was 55% AA (wild-type), 32% AG (heterozygous), and 13% GG (mutant). Some individuals with AG and GG genotypes showed changes in thyroid-stimulating hormone, anti-thyroid peroxidase, and serum iron, indicating potential subclinical thyroid deviations. Conclusion: Routine biochemical markers alone may not predict thyroid dysregulation in healthy young females. However, DIO2 gene variations (AG and GG genotypes) may influence thyroid hormone metabolism and predispose individuals to latent endocrine changes, supporting genetic screening for earlier detection and preventive care.
ABSTRACT Background: Chronic urticaria (CU) is a common inflammatory skin disorder with an often unidentified etiology. Growing evidence suggests an autoimmune basis, particularly an association with thyroid dysfunction and thyroid autoimmunity. However, data from South Asian populations, including Bangladesh, remain limited. Objective: The objective of this study was to evaluate the association of thyroid dysfunction and thyroid autoimmunity among patients with CU and to explore associated demographic, clinical, and laboratory correlations. Methods: This cross-sectional study was conducted from January to June 2025 at a tertiary care hospital in Dhaka, Bangladesh. A total of 187 patients aged 5–60 years with CU of more than 6 weeks’ duration were enrolled. Demographic and clinical data were collected using a structured questionnaire. Laboratory investigations included thyroid function tests (thyroid-stimulating hormone [TSH], free T3, and free T4), thyroid autoantibodies (anti-thyroid peroxidase [anti-TPO], anti-thyroglobulin [anti-Tg], and TSH receptor antibody), serum immunoglobulin E (IgE), eosinophil count, and complete blood count. Statistical analysis was performed using SPSS version 23, with P < 0.05 considered statistically significant. Results: Abnormal thyroid function was observed in 51.33% of patients, with overt hypothyroidism being the most common abnormality (34.22%). Anti-TPO antibodies were positive in 67.01% and anti-Tg antibodies in 52.8% of the tested patients. Thyroid disorders and autoantibody positivity were significantly more common among females. Patients with thyroid disorders had higher eosinophil counts, and serum IgE levels were significantly elevated in anti-TPO-positive cases. Several clinical manifestations and comorbidities showed significant associations with thyroid disorders. Conclusion: CU is strongly associated with thyroid dysfunction and thyroid autoimmunity. Routine screening for thyroid abnormalities should be considered in patients with CU.
ABSTRACT Thyroid hormones are important regulators of bone remodeling and mineralization, and thyroid function status is a key factor affecting bone strength. This review aims to summarize the existing literature on the association between thyroid disorders and osteoporosis. For this review, the PubMed digital database was searched using the keywords: (“fracture” OR “bone” OR “dual energy x ray absorptiometry” OR “dexa” OR “dxa”) AND (“thyroid” OR “hypothyroidism” OR “hyperthyroidism”). Original research articles, systematic reviews, and meta-analyses were scrutinized and the results summarized. The article discusses the action of thyroid hormones on bones and the skeletal effects of variations in thyroid hormone levels within the euthyroid range. The pathophysiological mechanism and clinical consequences of thyrotoxicosis-associated bone resorption, and the effect of treatment of thyrotoxicosis on skeletal health have been reviewed. In addition, the variable data on effects of subclinical hyperthyroidism on bone density and fracture risk (at various skeletal sites) have been examined carefully and summarized. Individuals with differentiated thyroid carcinoma frequently require long-term thyroid-stimulating hormone (TSH) suppression using supraphysiologic doses of thyroxine to reduce the risk of recurrence. The review delves into the effects of TSH-suppressive therapy on bone health and fractures. Studies evaluating skeletal consequences of overt hypothyroidism and subclinical hypothyroidism have also been looked into, and conclusions drawn. The association between resistance to thyroid hormones and osteoporosis has also been touched upon. Finally, the article summarizes the medical treatment of secondary osteoporosis in thyroid disorders, including the roles of anti-thyroid therapy, anti-osteoporosis therapy, and Vitamin D therapy.
ABSTRACT Background: Weight gain after the correction of thyrotoxicosis is well recognized. However, in a substantial subset of patients, it exceeds premorbid levels and may predispose to obesity and cardiometabolic risk. Indian data on the magnitude, temporal pattern, and predictors of posttreatment weight gain in Graves’ disease are lacking. Aim: To evaluate weight trajectories during the 1 st year of antithyroid drug therapy in patients with GD and to identify the clinical predictors of excessive weight gain. Materials and Methods: In this prospective observational study from a tertiary endocrine center, 70 patients with newly diagnosed GD were followed for 12 months. Weight, body mass index (BMI), and thyroid function tests were assessed at baseline and at 3-month intervals. Multivariable linear regression was performed to identify the predictors of weight gain at 12 months. Results: Seventy patients (mean age 40.36 ± 10.49 years) completed the follow-up. Mean baseline weight was 52.59 ± 11.59 kg compared with a premorbid weight of 58.27 ± 11.36 kg. Weight and BMI increased progressively over the follow-up (P < 0.0001). At 12 months, 77.14% of patients had gained weight relative to premorbid values (mean +2.82 kg), and obesity prevalence rose from 22.86% at baseline to 52.86%. Weight gain at 9 months was the only independent predictor of total gain at 12 months (β = 1.393; P < 0.001). Conclusion: ATD-treated GD patients experience significant and sustained weight gain, surpassing premorbid levels by 9 months. The early weight trajectory especially by month nine is strongly associated with excess weight gain. Incorporating weight management and lifestyle counseling early in treatment may mitigate long-term adiposity.
ABSTRACT Pendimethalin is a dinitroaniline compound that is primarily used as a soil-applied herbicide. It is usually considered nontoxic on inhalation and has mild toxicity on ingestion or through skin exposure. Hypercalcemic crisis associated with it is extremely rare. The mechanism of which is not very clear, it is believed to be due to elevated thyroid levels which lead to increase born turnover and thus finally causing significantly elevated calcium levels. We report the case of a 25-year-old male with significantly elevated serum calcium and suppressed parathyroid hormone levels, who was diagnosed with a hyperthyroidism-induced hypercalcemic crisis. After detailed workup for the cause of hyperthyroidism, it was considered to be linked to pendimethalin. The patient was treated with methimazole and propranolol for hyperthyroidism and received intravenous fluids, salmon calcitonin, and furosemide to manage hypercalcemia. The symptoms and calcium levels normalized promptly following treatment. Although rare, clinicians should consider hyperthyroidism as a potential cause of hypercalcemic crisis and ensure prompt management, including ruling out other underlying causes and addressing both the calcium imbalance and the thyroid disorder.
ABSTRACT Graves’ disease (GD) classically presents with the triad of hyperthyroidism, diffuse goiter, and orbitopathy. However, several atypical variants pose diagnostic and therapeutic challenges. These include seronegative GD, unilateral GD, GD associated with autoimmune polyglandular syndrome, antithyroid drug-resistant GD, drug-induced GD, and Marine–Lenhart syndrome. The present review summarizes the clinical features, diagnostic considerations, pathophysiology, and management of these atypical presentations, emphasizing the need for a nuanced approach to ensure accurate diagnosis and appropriate treatment.
ABSTRACT The recurrent laryngeal nerve (RLN) is a critical structure during thyroidectomy. A rare anomaly, the non-RLN (NRLN), poses a significant surgical risk due to its unpredictable course. Injury to this variant may result in permanent vocal cord dysfunction. Intraoperative nerve monitoring (IONM) facilitates real-time identification and functional confirmation of such variants, enhancing surgical safety. We report the case of a 47-year-old woman who underwent total thyroidectomy for a symptomatic multinodular goiter. During dissection on the right side, the RLN was not identified in its usual tracheoesophageal groove. Using IONM, a transverse branch arising from the vagus nerve directly into the larynx was identified, consistent with a NRLN. The nerve was preserved with the aid of IONM, and the patient recovered uneventfully with normal postoperative vocal cord function. IONM is invaluable in detecting rare anatomical variants such as the NRLN. Awareness of this anomaly and careful dissection guided by IONM are key to preventing nerve injury and postoperative complications.
ABSTRACT Hyperthyroidism is a common endocrine disorder characterized by excess circulating thyroid hormones, resulting in multisystem involvement and increased morbidity if inadequately treated. Thyroxine and triiodothyronine play a main role in regulating metabolism, growth, and organ function, and dysregulation of their secretion leads to thyrotoxicosis. Hyperthyroidism may be classified as overt or subclinical based on the biochemical findings. The global prevalence of hyperthyroidism ranges from 0.2% to 1.3%, with Indian studies reporting a prevalence of approximately 0.9%–1.5% in community-based populations. This review summarizes the etiopathogenesis, clinical presentation, diagnostic evaluation, and management of hyperthyroidism, with particular emphasis on evidence from India. Graves’ disease is the most common etiology in iodine-sufficient regions, followed by toxic multinodular goiter, toxic adenoma, and thyroiditis. Diagnostic approaches including biochemical testing, thyroid-stimulating hormone receptor antibody assays, thyroid ultrasonography with Doppler, and radionuclide imaging are discussed to facilitate accurate etiological differentiation. Management strategies encompassing symptomatic therapy, antithyroid drugs, radioactive iodine therapy, and surgery are reviewed. The principles of antithyroid drug dosing, titration, duration of therapy, monitoring, treatment-related adverse events, and predictors of remission and relapse are outlined. The review also discusses management considerations in special clinical situations, including acute thyroiditis, thyroid storm, and in women of child-bearing potential, during pregnancy, and lactation. Early recognition and individualized, etiology-based management are essential to prevent complications such as atrial fibrillation, osteoporosis, heart failure, and adverse pregnancy outcomes.
ABSTRACT Down’s syndrome has multisystemic manifestations, and thyroid dysfunction is a common endocrine problem in them. Hypothyroidism is commonly seen, but hyperthyroidism is rare, and it usually results from Graves’ disease. This is a case report of a girl showing a rare association between Down’s syndrome and Graves’ disease. A 10-year-old girl presented with Down’s syndrome who initially was euthyroid but had obesity during earlier clinic visits. Her body mass index (BMI) was 27.5 kg/m 2 and >95 th percentile using the Centers for Disease Control and Prevention BMI chart for girls with Down’s syndrome. She later developed progressive weight loss and anterior neck swelling. Her BMI dropped to 15.6 kg/m 2 . The thyroid function test was in keeping with hyperthyroidism. Her neck ultrasound scan revealed a diffuse goiter. Thyroid-stimulating immunoglobulin was elevated: 86.9 IU/L (<0.10), suggesting Graves’ disease. She was initially commenced on carbimazole with L-thyroxin replacement but later changed to carbimazole alone. She achieved an euthyroid state after about 10 months on treatment. We have reported a girl with the rare association between Down’s syndrome and Graves’ disease, and the management was quite challenging. Screening for thyroid disorders, including hyperthyroidism secondary to Graves’ disease, is of clinical relevance in children with Down’s syndrome.
The prevalence of iodinated contrast media (ICM)-induced thyroid dysfunction varies by regional iodine sufficiency, and there is currently no global standard for screening before or after ICM-based procedures. Transient thyroid disturbances can have serious clinical consequences following coronary angiographic (CAG) procedures. India is now predominantly iodine sufficient, but there is no regional data to guide policies to prevent ICM-induced thyroid dysfunction in the country. A longitudinal study was conducted in patients without preexisting overt thyroid disease, undergoing CAG. Thyroid function tests were performed before the procedure, and then at 6 weeks and 3 months post-CAG. Multiple-logistic-regression analyses were used to identify predictors of ICM-induced hypothyroidism (ICM-hypo) and hyperthyroidism (ICM-hyper). Among 105 patients, 22 (20.9%) developed ICM-induced thyroid dysfunction after CAG: 15 (14.3%) had hypothyroidism, and 7 (6.7%) had hyperthyroidism at 6 weeks. At 3 months, 5 (4.8%) had overt hypothyroidism, and 1 had overt hyperthyroidism. Independent predictors for ICM-Hypo included ICM-procedure within the last year (odds ratio [OR]: 14.87, 95% confidence interval [CI] 1.86–131, P = 0.01) and anti-thyroid-peroxidase antibody (TPO-Ab) positivity (OR: 16.71, 95% CI 4.06–87.8). Predictors for ICM-Hyper were anti-TPO-antibody positivity (OR: 8.71, 95% CI 1.01–108.8), contrast-induced acute kidney injury (AKI) (OR: 37.29, 95% CI 3.39–1035, P = 0.008), and lower baseline thyroid-stimulating hormone (TSH) (OR: 0.1, 95% CI 0.01–0.51). ICM caused thyroid dysfunction in one-fifth of patients undergoing CAG, though mostly transient. Even transient thyroid disorders may cause new-onset arrhythmia or heart failure in them. Routine thyroid testing before, and periodically post-CAG, is advisable, particularly for those with recent ICM exposure, contrast-induced AKI, or anti-TPO-positivity.
ABSTRACT Differentiated thyroid cancers include papillary and follicular types that arise from the follicular epithelium. Follicular thyroid carcinoma (FTC) accounts for 10%–20% of all thyroid malignancies and is most likely to produce distant metastasis by hematogenous spread. The lung and bone (spine and pelvis) are the most common sites, while skull metastasis is rare and indicates advanced disease. Few cases have reported scalp swelling as the initial presentation, which warrants a quick imaging of the thyroid and biopsy of the lesion. We report a 56-year-old female with a 15-year history of neck swelling presenting with right head vertex swelling due to metastatic parietal involvement. Although fine-needle aspiration revealed a benign (Bethesda II) cytology, histopathology confirmed the widely invasive nature of the FTC, underscoring the significance of correlating radiological and clinical features when managing similar cases.
Thyroid nodules are a prevalent clinical concern globally, with a rising incidence attributed to enhanced screening and diagnostic capabilities. In India, palpable thyroid nodules are notably common, affecting up to 12.2% of the population. The 2023 Bethesda System for Reporting Thyroid Cytopathology (TBSRTC) provides a standardized classification for fine-needle aspiration (FNA) results, categorizing nodules from nondiagnostic (Category I) to malignant (Category VI). While FNA effectively diagnoses 75%–80% of nodules, 20%–25% remain indeterminate (Bethesda III and IV). In settings like India, where advanced molecular diagnostics (e.g. Afirma Genomic sequencing classifier (GSC), Thyroseq v3) may be financially inaccessible to a significant portion of the population, intraoperative frozen section (FS) has traditionally been employed. FS offers a rapid intraoperative assessment, potentially guiding immediate surgical decisions and avoiding a second surgery if malignancy is confirmed. However, the actual clinical utility and necessity of FS, especially in indeterminate categories, are widely debated. Pathologists in India are often requested to perform FS on cytologically indeterminate nodules (Bethesda III and IV) to obtain a definitive diagnosis. The 2023 Bethesda update and recent Indian studies report malignancy rates of 15%–35% in Bethesda IV nodules, further reducing the expected yield of routine FS. This review article aims to reassess the role of FS in thyroid surgery, particularly focusing on its diagnostic performance in follicular thyroid nodules, considering its limitations, and analyzing its cost-effectiveness within the unique healthcare landscape of India.
