61 yo M w/heart disease presenting in decompensated HF. 1/24/13 Jess Hwang
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1 61 yo M w/heart disease presenting in decompensated HF 1/24/13 Jess Hwang
2 HPI 3 weeks worsening orthopnea, PND, DOE Referred to UCMC for transplant evaluation Found to have 100% afib burden 1 month prior to admission 3 weeks ago complained to tremors to his cardiologist, amiodarone was stopped Does not recall having thyroid function tested in the past
3 HPI cont. URI symptoms 2 weeks ago No chest pain, no palpitations Mild diarrhea No weight loss No visual complaints No family history of thyroid disease
4 Heart failure history Diagnosed in 2008 after massive MI Was medically managed for 4 years 3-4 weeks ago noticed decreased exercise tolerance, DOE, PND Had been on amiodarone since 2008
5 PMH HTN CAD (s/p MI in 2008 and 5V CABG) CHF (class IV) Afib Dyslipidemia SHx Quit tobacco in 1999 (50 pack year history) No EtOH or illicits Fam Hx Mother: DM2, CHF, breast cancer PGF: lung cancer Meds ASA Lipitor Coreg Digoxin Cymbalta Lasix Aldactone Valsartan Coumadin
6 Physical exam Vitals 36.5, 97, 73/43, 97% RA, BMI 24 Gen: no apparent distress. Thin. HEENT: no scleral icterus, no proptosis. Neck: no thyromegaly/nodules/thyroid pain. CV: irregularly irregular, tachy. Pulm: basilar crackles GI: soft, nontender, normal bowel sounds Ext: mild tremor, normal reflexes Neuro: alert and oriented
7 / Labs BNP 4774 (RR < 125) EKG: afib w/rvr (HR 110)
8 Labs cont. TSH 0.01 (RR ) FT (RR ), TT (RR ) TT3 121 (RR ) rt (RR ) AntiTPO/Tg/TSI Ab neg Urine iodine: 388,874 (RR ) IL-6 < 6.2 (RR <17.4)
9 10/19 10/22 11/1 TSH ( ) FT4 ( ) TT3 (80-195) FT3 ( ) rt3 ( )
10 Thyrotoxicosis differential Thyroiditis Medications Viral Autoimmune- Graves Multinodular goiter Autonomous hyperfunctioning nodule
11 Thyroid US R lobe: 5.7 x 2.2 x 2 cm - mildly heterogeneous echotexture L lobe: 4.6 x 1.6 x 2 cm - mildly heterogeneous echotexture Isthmus: 0.4 cm Subcentimeter hypoechoic nodules measuring 0.3 and 0.4 gm in R/L lobes No lymphadenopathy IMPRESSION: mildly heterogeneous echotexture consistent with thyroiditis
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14 Hospital course Started on PTU 200 mg TID Started Prednisone 40 mg daily which he was on for a week with plan for taper Continued on Coreg BID Underwent CV and remained in NSR HF team said he does not require a heart transplant or LVAD at this time
15 Post-discharge course Followed in endocrinology clinic 1 week post-discharge and at that time (likely AIT type II vs mixed) Switched to MMI 20 mg daily Re-started Prednisone 20 mg daily Was to repeat TFTs in 2 weeks but is now following up closer to home
16 Clinical objectives/questions Review properties/effects of amiodarone Review features/treatment strategies of the AIT I vs II vs mixed Is IL-6 useful in differentiating between types
17 Amiodarone Properties Similar in structure to T4 Benzofuran ring 37% iodine by weight Elimination half-life ~50d 2-24% thyroid dysfunction
18 Mechanisms of interaction Inhibits type I 5 -deiodinase activity Decreased peripheral conversion of T4 T3 Decreased conversion of rt3 T2 Inhibit type II 5 -deiodinase activity Decreased conversion of T4 T3 in pituitary Inhibits thyroid hormone entry into peripheral tissue
19 Effect of Amiodarone on TFTs Loh KC. Postgrad Med J 2000;76:
20 Pathogenesis AIT Type I vs II Narayana S. Thera Adv in Endo and Metab :
21 Cardenas GA et al. CCJM 2003;70(7):
22 JCEM Approach to AIT.
23 Significance of IL-6 levels? JCEM 1994 Cross-sectional study: 27 AIT (15 AIT+/12 AIT-) 14 euthyroid on amiodarone 10 AIH 56 with hyperthyroidism (Graves/adenoma) 50 controls Implications for treatment
24
25 Take home points Type I AIT- iodine-induced excessive thyroid hormone synthesis, underlying abnormal thyroid. Treatment: thionamides Type II AIT- destructive thyroiditis, normal thyroid. Treatment: glucocorticoids IL-6 can be a useful marker
26 References Cardenas GA et al. Amiodarone-induced Thyrotoxicosis: Diagnostic and Therapeutic Strategies. CCJM 2003;70(7): Loh KC. Amiodarone-induced Thryoid Disorders: A Clinical Review. Postgrad Med J 2000;76: Martino E et al. Effects of Amiodarone on the Thyroid. Endo Rev 2001;22(2): Narayana S. Management of Amiodarone-Related Thyroid Problems. Thera Adv in Endo and Metab : Bartalena L et al. Serum IL-6 in Amiodarone-induced Thyrotoxicosis. JCEM 1994;78(2): Bogazzi F et al. Approach to the Patient with Amiodarone-Induced Thyrotoxicosis. JCEM 2010;95(6):
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