Euthyroid sick syndrome: Difference between revisions

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{{Euthyroid sick syndrome}}
{{Euthyroid sick syndrome}}
{{CMG}}; {{AE}}
{{CMG}}; {{AE}}{{Akshun}}


{{SK}} sick euthyroid syndrome; non-thyroidal illness syndrome; low T3 low T4 syndrome
{{SK}} sick euthyroid syndrome; non-thyroidal illness syndrome (NTIS); low T3 low T4 syndrome; thyroid allostasis in critical illness, tumours, uraemia and starvation (TACITUS)


{{Infobox_Disease |
'''For patient information, click [[Xyz (patient information)|here]]'''
Name = {{PAGENAME}} |
Image = |
Caption = |
DiseasesDB = |
ICD10 = {{ICD10|E|07|8|e|00}} |
ICD9 = {{ICD9|790.94}} |
ICDO = |
OMIM = |
MedlinePlus = |
MeshID = D005067 |
}}


==Overview==
==[[Euthyroid sick syndrome 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==
==[[Euthyroid sick syndrome historical perspective|Historical Perspective]]==


==Classification==
==[[Euthyroid sick syndrome classification|Classification]]==


==Pathophysiology==
==[[Euthyroid sick syndrome pathophysiology|Pathophysiology]]==
[[T3]] ([[triiodothyronine]]) is the biologically active form of [[thyroid hormone]]. Normally most of the [[T3]] ([[triiodothyronine]]) is produced by peripheral deiodination of circulating [[T4]] ([[thyroxine]]) by the enzyme 5’-monodeiodinase (type I). In [[euthyroid]] sick syndrome there occurs [[inhibition]] of the [[enzyme]] 5΄-deiodinase (type I) which leads to decrease conversion of [[T4]] to [[T3]] and increased [[reverse T3]] from decreased metabolism. [[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 (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 [[T3]] by the [[enzyme]] 5’-monodeiodinase. This is an [[adaptive]] process by which the [[Human body|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]]([[TSH]]), [[thyroxine]] ([[T4]]), and [[free T4]] ([[FT4]]) are affected in variable proportions. The drop in levels of [[T3]] and [[T4]] are more with more severe illnesses. [[Mortality rate]] is high when there is a marked decrease in serum [[T3]] and [[T4]].<ref name="GRASBERGERGOLCHER2002">{{cite journal|last1=GRASBERGER|first1=Helmut|last2=GOLCHER|first2=Henriette M.B.|last3=FINGERHUT|first3=Anja|last4=JANSSEN|first4=Onno E.|title=Loop variants of the serpin thyroxine-binding globulin: implications for hormone release upon limited proteolysis|journal=Biochemical Journal|volume=365|issue=1|year=2002|pages=311–316|issn=0264-6021|doi=10.1042/bj20020014}}</ref><ref name="pmid10554534">{{cite journal |vauthors=Schilling JU, Zimmermann T, Albrecht S, Zwipp H, Saeger HD |title=[Low T3 syndrome in multiple trauma patients--a phenomenon or important pathogenetic factor?] |language=German |journal=Med. Klin. (Munich) |volume=94 Suppl 3 |issue= |pages=66–9 |year=1999 |pmid=10554534 |doi= |url=}}</ref>


==Causes==
==[[Euthyroid sick syndrome causes|Causes]]==
Drugs leading to decreased 5'monodeiodinase are propranolol (high doses), amiodarone, and glucocorticoid therapy.


==Differentiating {{PAGENAME}} from Other Diseases==
==[[Differentiating Euthyroid sick syndrome from other diseases|Differentiating Euthyroid sick syndrome  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__
==[[Euthyroid sick syndrome epidemiology and demographics|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==
==[[Euthyroid sick syndrome risk factors|Risk Factors]]==


==Screening==
==[[Euthyroid sick syndrome screening|Screening]]==


==Natural History, Complications, and Prognosis==
==[[Euthyroid sick syndrome natural history, complications and prognosis|Natural History, Complications and Prognosis]]==
===Natural History===
 
===Complications===
 
===Prognosis===


==Diagnosis==
==Diagnosis==
===Diagnostic Criteria===
[[Euthyroid sick syndrome history and symptoms|History and Symptoms]] | [[Euthyroid sick syndrome physical examination|Physical Examination]] | [[Euthyroid sick syndrome laboratory findings|Laboratory Findings]] | [[Euthyroid sick syndrome X-ray|X-Ray Findings]] | [[Euthyroid sick syndrome CT scan|CT-Scan Findings]] | [[Euthyroid sick syndrome MRI|MRI Findings]] | [[Euthyroid sick syndrome other diagnostic studies|Other Diagnostic Studies]] | [[Euthyroid sick syndrome other imaging findings|Other Imaging Findings]]
 
==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===
[[Euthyroid sick syndrome medical therapy|Medical Therapy]] | [[Euthyroid sick syndrome surgery|Surgery]] | [[Euthyroid sick syndrome primary prevention|Primary Prevention]] | [[Euthyroid sick syndrome secondary prevention|Secondary Prevention]] | [[Euthyroid sick syndrome cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Euthyroid sick syndrome future or investigational therapies|Future or Investigational Therapies]]
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===
==Case Studies==
[[Euthyroid sick syndrome case study one|Case #1]]


==External links==
==External links==

Latest revision as of 20:59, 4 September 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Akshun Kalia M.B.B.S.[2]

Synonyms and keywords: sick euthyroid syndrome; non-thyroidal illness syndrome (NTIS); low T3 low T4 syndrome; thyroid allostasis in critical illness, tumours, uraemia and starvation (TACITUS)

For patient information, click here

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Euthyroid sick syndrome from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | X-Ray Findings | CT-Scan Findings | MRI Findings | Other Diagnostic Studies | Other Imaging Findings

Treatment

Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

Case Studies

Case #1

External links

  • McIver B, Gorman C (1997). "Euthyroid sick syndrome: an overview". Thyroid. 7 (1): 125–32. PMID 9086580.

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