Professional Documents
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Pituitary
–
T4 TS
Target Tissues
H
T3 Heart
Thyroid Gland
Liver
TR
T4 T3
Bone
T4 T3
Liver CNS
FT3
- Useful to distinguish T3 toxicosis from
subclinical thyrotoxicosis.
Reverse T3 (rT3)
- increased in NTI.
- inactive.
- helpful to exclude central hypothyroidism
Other Ancillary Tests
Serum thyroglobulin – produced and released by thyroid
gland.
- marker for recurrent thyroid cancer
- differentiate Graves disease from factitious thyrotoxicosis
Type II AIT
. Glucocorticoids – Prednisone 40-60 mg/day. Continue therapy for one to
two months before tapering
The most prominent alterations are low serum T3 and elevated reverse T3
(rT3).
Serum TSH, T4, and FT4 are also affected in variable degrees based on the
severity and duration of the NTI.
Probable mechanism:
- Decreased or inhibition of 5’-monodeiodination (endogenous cortisol
or exogenous glucocorticoid therapy, non-esterified fatty acids, cytokines
TNF, IF, IL6.)
- The peripheral production of T3 is decrease, but its clearance is
unchanged; whereas, the production of rT3 is unchanged, while its
clearance is diminished
Treatment is not needed. After recovery from an NTI, these thyroid function
test result abnormalities should be completely reversible
Case 4
A 70 yo male patient was admitted to ICU 3 days ago for pneumonia,
COPD exacerbation which required intubation. He was successfully
extubated and transferred to telemetry floor yesterday. Overnight
the telemetry shows sinus rhythm 80 to sinus tachycardia 105 with
few atrial ectopy and a normal EKG. He is on Levaquin 750mg daily,
duoneb Q4H, and hydrocortisone 60mg Q6H.
He appears frail, weak and complains only of no appetite. The BP 98/70
T.99, P.100, RR. 20, pulsox 96% on 2L. On exam, he has RLL rhonchi
but no crackles, heart rate is slightly fast but no murmur or rub. The
remaining of his exam was unremarkable.
AM lab shows WBC 13.0 Hb 12 Plt 200K, band 6%, seg. neutrophil 80%,
normal C7, TSH 0.15 (0.45-4.5), T4 normal and T3 low.
Which of the following would be appropriate to do next?
A. This patient has lab result suggestive of central hypothyroidism so
MRI of the head should be done first.
B. Order a baseline cortisol level and do a cosyntropin test to rule out
adrenal insufficiency.
C. Order a serum rT3 level and if the level is high no other test is
necessary.
D. Start patient on levothyroxine 0.025mg daily for hypothyroidism
Case 4 answer
This patient has low TSH, low T3 and normal T4. The differential
diagnoses includes central hypothyroidism, euthyroid sick syndrome
(NTI), or patient with hyperthyroidism undergoing treatment with
antithyroid medication. Base on the information given (the patient
recently went through physiological stressful event, and is on
corticosteroid and no history of hyperthyroidism) the patient most
likely has euthyroid sick syndrome. In NTI the activities of 5’-
monodeiodinase is decreased or inhibited so the peripheral
conversion of T3 diminishes and the clearance of rT3 is reduced
causing low serum T3 and high rT3. There are no abnormal finding on
neuro exam and so MRI would not be the first test. Cotrosyn test on
this patient would be inappropriate because he is on exogenous
glucocorticoid therapy (except dexamethasone) which interfere with
the test and aside from that his C7 is normal so adrenal insufficiency
is unlikely. In NTI no treatment is necessary.
Case 5
A 28 year-old woman presents with a palpable mass on the left side of her
neck. She has no neck pain and no symptoms of thyroid dysfunction.
Physical exam reveals a solitary, mobile thyroid nodule, 2 x 3 cm,
without lymphadenopathy. The patient has no family history of
thyroid disease and no history of external radiation. A blood drawn
was sent for serum TSH and FT4.