Euthyroid sick syndrome: Difference between revisions
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==Overview== | ==Overview== | ||
Euthyroid sick syndrome is a [[thyroid hormone]] disorder where the levels of T3 ([[triiodothyronine]]) and/or T4 ([[thyroxine]]) are at unusual levels, in the setting of a nonthyroidal [[illness]]. Thyroid hormones play a major role in the metabolism, growth and maturation of the human body. [[Euthyroid]] sick [[syndrome]] is seen in conditions of [[starvation]] and [[critical illness]] such as [[sepsis]], [[surgery]], [[Physical trauma|severe trauma]], [[burns]], [[metabolic disorders]], [[bone marrow transplantation]], and [[malignancy]]. During these [[Stress (medicine)|stress]] conditions, there occurs [[hypermetabolism]], increased energy expenditure, [[hyperglycemia]], and muscle loss. It is speculated, that the body in order to contain this [[hypermetabolism]] induces some degree of [[hypothyroidism]] by inhibiting deiodination of [[T4]] to [[Triiodothyronine|T3]] by the enzyme 5’-monodeiodinase. This is an adaptive process by which the body prevents further [[muscle]] and [[calorie]] loss. [[Euthyroid]] sick syndrome presents with low serum [[T3]]. Depending upon the severity and duration of the [[Stress (medicine)|stress]] inducing condition, the thyroid-stimulating hormone([[Thyroid-stimulating hormone|TSH]]), [[thyroxine]] (T4), and [[free T4]] (FT4) are affected in variable proportions.<ref name="pmid9712558">{{cite journal |vauthors=Plank LD, Connolly AB, Hill GL |title=Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis |journal=Ann. Surg. |volume=228 |issue=2 |pages=146–58 |year=1998 |pmid=9712558 |pmc=1191454 |doi= |url=}}</ref><ref name="pmid21724536">{{cite journal |vauthors=Economidou F, Douka E, Tzanela M, Nanas S, Kotanidou A |title=Thyroid function during critical illness |journal=Hormones (Athens) |volume=10 |issue=2 |pages=117–24 |year=2011 |pmid=21724536 |doi= |url=}}</ref><ref name="pmid30020">{{cite journal |vauthors=Harris AR, Fang SL, Vagenakis AG, Braverman LE |title=Effect of starvation, nutriment replacement, and hypothyroidism on in vitro hepatic T4 to T3 conversion in the rat |journal=Metab. Clin. Exp. |volume=27 |issue=11 |pages=1680–90 |year=1978 |pmid=30020 |doi= |url=}}</ref> | |||
==Historical Perspective== | ==Historical Perspective== | ||
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==Pathophysiology== | ==Pathophysiology== | ||
==Causes== | |||
Drugs leading to decreased 5'monodeiodinase are propranolol (high doses), amiodarone, and glucocorticoid therapy. | |||
==Differentiating {{PAGENAME}} from Other Diseases== | ==Differentiating {{PAGENAME}} from Other Diseases== | ||
[[Fasting]], [[starvation]], [[sepsis]], [[Physical trauma|trauma]], [[cardiopulmonary bypass]], [[malignancy]], [[heart failure]], [[hypothermia]], [[myocardial infarction]], [[chronic renal failure]], [[cirrhosis]], and [[diabetic ketoacidosis]]. | |||
__NOTOC__ | |||
==Epidemiology and Demographics== | ==Epidemiology and Demographics== | ||
Euthyroid sick syndrome is seen in 40-100% patients of nonthyroidal illness. | |||
===Age=== | |||
Euthyroid sick syndrome is more commonly seen in elderly population. People over 65 have more chronic illnesses and have a greater probability of developing euthyroid sick syndrome. | |||
===Race=== | |||
Euthyroid sick syndrome has no racial predilection. | |||
===Sex=== | |||
Euthyroid sick syndrome affects men and women equally. | |||
==Risk Factors== | ==Risk Factors== | ||
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==History and symptom == | ==History and symptom == | ||
The common symptoms and signs of clinical hypothyroidism are listed in the table below. The appearance of symptoms depends on the degree of hypothyroidism severity: <ref name="pmid25305308">{{cite journal |vauthors=Carlé A, Pedersen IB, Knudsen N, Perrild H, Ovesen L, Laurberg P |title=Hypothyroid symptoms and the likelihood of overt thyroid failure: a population-based case-control study |journal=Eur. J. Endocrinol. |volume=171 |issue=5 |pages=593–602 |year=2014 |pmid=25305308 |doi=10.1530/EJE-14-0481 |url=}}</ref><ref name="pmid25086165">{{cite journal |vauthors=Diaz A, Lipman Diaz EG |title=Hypothyroidism |journal=Pediatr Rev |volume=35 |issue=8 |pages=336–47; quiz 348–9 |year=2014 |pmid=25086165 |doi=10.1542/pir.35-8-336 |url=}}</ref><ref name="pmid25122491">{{cite journal |vauthors=Samuels MH |title=Psychiatric and cognitive manifestations of hypothyroidism |journal=Curr Opin Endocrinol Diabetes Obes |volume=21 |issue=5 |pages=377–83 |year=2014 |pmid=25122491 |pmc=4264616 |doi=10.1097/MED.0000000000000089 |url=}}</ref><ref name="pmid19949140">{{cite journal |vauthors=McDermott MT |title=In the clinic. Hypothyroidism |journal=Ann. Intern. Med. |volume=151 |issue=11 |pages=ITC61 |year=2009 |pmid=19949140 |doi=10.7326/0003-4819-151-11-200912010-01006 |url=}}</ref> | |||
{| class="wikitable" | |||
! align="center" style="background: #4479BA; color: #FFFFFF; " |Symptoms | |||
! align="center" style="background: #4479BA; color: #FFFFFF; " |Constituitional | |||
! align="center" style="background: #4479BA; color: #FFFFFF; " | HEENT | |||
! align="center" style="background: #4479BA; color: #FFFFFF; " |Neuromuscular | |||
! align="center" style="background: #4479BA; color: #FFFFFF; " |Other findings | |||
|- | |||
| align="center" style="background: #DCDCDC; " |More common | |||
| | |||
* [[Fatigue]] | |||
* Cold intolerance | |||
* Decreased [[sweating]] | |||
* [[Hypothermia]] | |||
* Coarse skin | |||
* [[Weight gain]] | |||
| | |||
* [[Hoarseness]] | |||
* [[Goiter]] | |||
* Fullness in the throat and neck | |||
| | |||
* [[Depression]] | |||
* [[Emotional lability]] | |||
* [[Attention deficit]] | |||
| | |||
* [[Macroglossia]] | |||
* [[Obstructive sleep apnea]] | |||
* [[Paresthesia]] | |||
* Nerve entrapment syndromes ([[carpal tunnel syndrome]]) | |||
* [[Blurred vision]] (central hypothyroidism) | |||
|- | |||
| align="center" style="background: #DCDCDC; " |Less common | |||
| | |||
* Puffiness | |||
* [[Hair loss]] | |||
* [[Constipation]] | |||
* [[Fever]] | |||
** If accompanied by [[thyroiditis]] | |||
| | |||
* [[Sore throat]] | |||
* [[Periorbital edema]] | |||
| | |||
* Slowed speech and movements | |||
| | |||
* Pituitary hyperplasia followed by [[hyperprolactinemia]] | |||
* [[Ataxia]] | |||
* [[Myxedema coma]] (with [[Edema|non-pitting edema]]) | |||
* [[Cardiomegaly]] | |||
* [[Pericardial effusion]] | |||
* [[Ascites]] | |||
* [[Hyperlipidemia]] | |||
* [[Galactorrhea]] | |||
* [[Infertility]] | |||
|} | |||
===Physical Examination=== | |||
===Laboratory Findings=== | |||
Laboratory findings consistent with the diagnosis of euthyroid sick syndrome include | |||
{| class="wikitable" | |||
!Euthyroid sick syndrome | |||
!Laboratory test | |||
|- | |||
|Mild euthyroid sick syndrome | |||
| | |||
* Low [[Triiodothyronine|T3]] | |||
* Normal [[T4]] | |||
* Normal [[fT4]] | |||
* Normal [[Thyroid-stimulating hormone|TSH]] | |||
* Elevated [[reverse T3]] | |||
|- | |||
|Moderate euthyroid sick syndrome | |||
| | |||
* Low [[T3]] | |||
* Normal [[T4]] | |||
* Normal to elevated [[fT4]] | |||
* Normal to elevated [[TSH]] | |||
* Elevated [[reverse T3]] | |||
|- | |||
|Severe euthyroid sick syndrome | |||
| | |||
* Low [[T3]] | |||
* Low [[T4]] | |||
* Low [[Thyroid-stimulating hormone|TSH]] | |||
* Normal to low [[fT4]] | |||
* Elevated [[reverse T3]] | |||
|} | |||
===Imaging Findings=== | |||
===Other Diagnostic Studies=== | |||
In euthyroid sick syndrome the thyroid gland appears normal. Therefore, there is no role of thyroid uptake scan in euthyroid sick syndrome. | |||
==Treatment== | ==Treatment== | ||
===Medical Therapy=== | ===Medical Therapy=== | ||
Ill patients may have normal to low TSH depending on the spectrum of illness. Total T4 and T3 levels may be altered by [[binding protein]] abnormalities, and medications. [[Reverse T3]] are generally increased signifying inhibition of normal Type 1 enzyme or reduced clearance of reverse T3. Measurement of free T4 and/or free T3 levels will be normal. | |||
===Surgery=== | ===Surgery=== | ||
Revision as of 14:19, 4 August 2017
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Euthyroid sick syndrome Microchapters |
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Euthyroid sick syndrome On the Web |
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Risk calculators and risk factors for Euthyroid sick syndrome |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:
Synonyms and keywords: sick euthyroid syndrome; non-thyroidal illness syndrome; low T3 low T4 syndrome
| Euthyroid sick syndrome | |
| ICD-10 | E07.8 |
|---|---|
| ICD-9 | 790.94 |
| MeSH | D005067 |
Overview
Euthyroid sick syndrome is a thyroid hormone disorder where the levels of T3 (triiodothyronine) and/or T4 (thyroxine) are at unusual levels, in the setting of a nonthyroidal illness. Thyroid hormones play a major role in the metabolism, growth and maturation of the human body. Euthyroid sick syndrome is seen in conditions of starvation and critical illness such as sepsis, surgery, severe trauma, burns, metabolic disorders, bone marrow transplantation, and malignancy. During these stress conditions, there occurs hypermetabolism, increased energy expenditure, hyperglycemia, and muscle loss. It is speculated, that the body in order to contain this hypermetabolism induces some degree of hypothyroidism by inhibiting deiodination of T4 to T3 by the enzyme 5’-monodeiodinase. This is an adaptive process by which the body prevents further muscle and calorie loss. Euthyroid sick syndrome presents with low serum T3. Depending upon the severity and duration of the stress inducing condition, the thyroid-stimulating hormone(TSH), thyroxine (T4), and free T4 (FT4) are affected in variable proportions.[1][2][3]
Historical Perspective
Classification
Pathophysiology
Causes
Drugs leading to decreased 5'monodeiodinase are propranolol (high doses), amiodarone, and glucocorticoid therapy.
Differentiating Euthyroid sick syndrome from Other Diseases
Fasting, starvation, sepsis, trauma, cardiopulmonary bypass, malignancy, heart failure, hypothermia, myocardial infarction, chronic renal failure, cirrhosis, and diabetic ketoacidosis.
Epidemiology and Demographics
Euthyroid sick syndrome is seen in 40-100% patients of nonthyroidal illness.
Age
Euthyroid sick syndrome is more commonly seen in elderly population. People over 65 have more chronic illnesses and have a greater probability of developing euthyroid sick syndrome.
Race
Euthyroid sick syndrome has no racial predilection.
Sex
Euthyroid sick syndrome affects men and women equally.
Risk Factors
Screening
Natural History, Complications, and Prognosis
Natural History
Complications
Prognosis
Diagnosis
Diagnostic Criteria
History and symptom
The common symptoms and signs of clinical hypothyroidism are listed in the table below. The appearance of symptoms depends on the degree of hypothyroidism severity: [4][5][6][7]
| Symptoms | Constituitional | HEENT | Neuromuscular | Other findings |
|---|---|---|---|---|
| More common |
|
|
| |
| Less common |
|
|
|
Physical Examination
Laboratory Findings
Laboratory findings consistent with the diagnosis of euthyroid sick syndrome include
| Euthyroid sick syndrome | Laboratory test |
|---|---|
| Mild euthyroid sick syndrome |
|
| Moderate euthyroid sick syndrome |
|
| Severe euthyroid sick syndrome |
|
Imaging Findings
Other Diagnostic Studies
In euthyroid sick syndrome the thyroid gland appears normal. Therefore, there is no role of thyroid uptake scan in euthyroid sick syndrome.
Treatment
Medical Therapy
Ill patients may have normal to low TSH depending on the spectrum of illness. Total T4 and T3 levels may be altered by binding protein abnormalities, and medications. Reverse T3 are generally increased signifying inhibition of normal Type 1 enzyme or reduced clearance of reverse T3. Measurement of free T4 and/or free T3 levels will be normal.
Surgery
Prevention
External links
- McIver B, Gorman C (1997). "Euthyroid sick syndrome: an overview". Thyroid. 7 (1): 125–32. PMID 9086580.
References
- ↑ Plank LD, Connolly AB, Hill GL (1998). "Sequential changes in the metabolic response in severely septic patients during the first 23 days after the onset of peritonitis". Ann. Surg. 228 (2): 146–58. PMC 1191454. PMID 9712558.
- ↑ Economidou F, Douka E, Tzanela M, Nanas S, Kotanidou A (2011). "Thyroid function during critical illness". Hormones (Athens). 10 (2): 117–24. PMID 21724536.
- ↑ Harris AR, Fang SL, Vagenakis AG, Braverman LE (1978). "Effect of starvation, nutriment replacement, and hypothyroidism on in vitro hepatic T4 to T3 conversion in the rat". Metab. Clin. Exp. 27 (11): 1680–90. PMID 30020.
- ↑ Carlé A, Pedersen IB, Knudsen N, Perrild H, Ovesen L, Laurberg P (2014). "Hypothyroid symptoms and the likelihood of overt thyroid failure: a population-based case-control study". Eur. J. Endocrinol. 171 (5): 593–602. doi:10.1530/EJE-14-0481. PMID 25305308.
- ↑ Diaz A, Lipman Diaz EG (2014). "Hypothyroidism". Pediatr Rev. 35 (8): 336–47, quiz 348–9. doi:10.1542/pir.35-8-336. PMID 25086165.
- ↑ Samuels MH (2014). "Psychiatric and cognitive manifestations of hypothyroidism". Curr Opin Endocrinol Diabetes Obes. 21 (5): 377–83. doi:10.1097/MED.0000000000000089. PMC 4264616. PMID 25122491.
- ↑ McDermott MT (2009). "In the clinic. Hypothyroidism". Ann. Intern. Med. 151 (11): ITC61. doi:10.7326/0003-4819-151-11-200912010-01006. PMID 19949140.