The hypothalamus-pituitary-thyroid feedback control is a dynamic, adaptive system. In situations of illness and deprivation of energy representing type 1 allostasis, the stress response operates to alter both its set point and peripheral transfer parameters. In contrast, type 2 allostatic load, typically effective in psychosocial stress, pregnancy, metabolic syndrome and adaptation to cold, produces a nearly opposite phenotype of predictive plasticity. The non-thyroidal illness syndrome (NTIS) or thyroid allostasis in critical illness, tumours, uraemia and starvation (TACITUS), commonly observed in hospitalised patients, displays a historically well-studied pattern of allostatic thyroid response. This is characterised by decreased total and free thyroid hormone concentrations and varying levels of thyroid-stimulating hormone (TSH) ranging from decreased (in severe cases) to normal or even elevated (mainly in the recovery phase) TSH concentrations. An acute versus chronic stage (wasting syndrome) of TACITUS can be discerned. The two types differ in molecular mechanisms and prognosis. The acute adaptation of thyroid hormone metabolism to critical illness may prove beneficial to the organism, whereas the far more complex molecular alterations associated with chronic illness frequently lead to allostatic overload. The latter is associated with poor outcome, independently of the underlying disease. Adaptive responses of thyroid homeostasis extend to alterations in thyroid hormone concentrations during fetal life, periods of weight gain or loss, thermoregulation, physical exercise and psychiatric diseases. The various forms of thyroid allostasis pose serious problems in differential diagnosis of thyroid disease. This review article provides an overview of physiological mechanisms as well as major diagnostic and therapeutic implications of thyroid allostasis under a variety of developmental and straining conditions.

/pdf/thyroid-allostasis-adaptive-responses-of-thyrotropic-44amr7edjf.pdf

Thyroid Allostasis–Adaptive Responses of Thyrotropic Feedback Control to Conditions of Strain, Stress, and Developmental Programming

https://www.jstage.jst.go.jp/article/jea/27/3/27_27_117/_pdf

Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan

Development of an objective tool for the diagnosis of myxedema coma.

Myxedema coma is a rare endocrine emergency resulting from the decompensation of severe hypothyroidism, which is associated with a high mortality rate. It is characterized by the deterioration of mental status, hypothermia, hypotension, hyponatremia, and hypoventilation. Early disease diagnosis and advancements in intensive supportive care have reduced the mortality rate. Besides intensive supportive care, appropriate management of the underlying thyroid hormone deficiency is essential. However, as the disease is rare and unrecognized, evidence-based treatment of myxedema has not yet been established in many countries. An 84-year-old Japanese man with a history of Hashimoto's thyroiditis was referred to our hospital. On arrival, conscious disturbance, hypothermia, hypotension, and hypoventilation were observed. He had discontinued thyroid hormone replacement therapy for a year. He was diagnosed with myxedema coma. Immediately, he received intensive supportive care and a combination therapy of 200 μg levothyroxine and 50 μg liothyronine until the fifth hospital day. Subsequently, monotherapy with levothyroxine was continued at a dose of 150 μg daily. The thyroid hormone level reached the normal range a few days later, and cardiovascular disease did not develop during hospitalization. This case demonstrated the efficacy of the combination of levothyroxine and liothyronine in treating myxedema coma.

/pdf/successful-treatment-of-myxedema-coma-with-a-combination-of-4su3tzgjw0.pdf

Successful treatment of myxedema coma with a combination of levothyroxine and liothyronine.

Abstract Background Severe hypothyroidism (SH) is a rare but life-threatening endocrine emergency. Only a few data are available on its management and outcomes of the most severe forms requiring ICU admission. We aimed to describe the clinical manifestations, management, and in-ICU and 6-month survival rates of these patients. Methods We conducted a retrospective, multicenter study over 18 years in 32 French ICUs. The local medical records of patients from each participating ICU were screened using the International Classification of Disease 10th revision. Inclusion criteria were the presence of biological hypothyroidism associated with at least one cardinal sign among alteration of consciousness, hypothermia and circulatory failure, and at least one SH-related organ failure. Results Eighty-two patients were included in the study. Thyroiditis and thyroidectomy represented the main SH etiologies (29% and 19%, respectively), while hypothyroidism was unknown in 44 patients (54%) before ICU admission. The most frequent SH triggers were levothyroxine discontinuation (28%), sepsis (15%), and amiodarone-related hypothyroidism (11%). Clinical presentations included hypothermia (66%), hemodynamic failure (57%), and coma (52%). In-ICU and 6-month mortality rates were 26% and 39%, respectively. Multivariable analyses retained age &gt; 70 years [odds ratio OR 6.01 (1.75–24.1)] Sequential Organ-Failure Assessment score cardiovascular component ≥ 2 [OR 11.1 (2.47–84.2)] and ventilation component ≥ 2 [OR 4.52 (1.27–18.6)] as being independently associated with in-ICU mortality. Conclusions SH is a rare life-threatening emergency with various clinical presentations. Hemodynamic and respiratory failures are strongly associated with worse outcomes. The very high mortality prompts early diagnosis and rapid levothyroxine administration with close cardiac and hemodynamic monitoring. 

/pdf/critically-ill-severe-hypothyroidism-a-retrospective-1wjxm8qb.pdf

Critically ill severe hypothyroidism: a retrospective multicenter cohort study

A Diagnostic Scoring System for Myxedema Coma

Given the overwhelming evidence that both alcohol consumption and smoking accelerate the progression of hepatitis C virus (HCV)-induced liver disease, we evaluated the frequency of alcohol and smoking counseling of patients with HCV-induced liver disease by their primary care internists and gastroenterologists. One hundred and twenty-three medical records of consecutive patients with HCV-induced liver disease referred by an internist to a gastroenterologist for its management were reviewed. Patient gender, race, history of and counseling against alcohol and tobacco use by a physician and a gastroenterologist were obtained. A database was created using Microsoft Excel. There were 105 African-Americans, 12 Caucasians and six patients of other races/ethnicities. Forty-six (37%) patients were daily tobacco users and 34 (28%) patients were daily alcohol consumers. There was a statistically significant difference in the frequencies of alcohol (P = 0.0002) and smoking cessation (P = 0.0022) between gastroenterologists and internists. This study reveals that internists and gastroenterologists, alike, inadequately counsel patients with hepatitis C about tobacco and alcohol use.

Frequency of alcohol and smoking cessation counseling in hepatitis C patients among internists and gastroenterologists.

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A Diagnostic Scoring System for Myxedema Coma

Frequency of alcohol and smoking cessation counseling in hepatitis C patients among internists and gastroenterologists.