Thyrotoxicosis factitia (TF) is also known as thyroxine addict or metabolic malingerer [1] [2] syndrome. It occurs in patients who are prescribed a very high dose of thyroid hormones as medication (iatrogenic); or those who consume thyroid hormone medication surreptitiously for weight loss or to increase their energy levels or to decrease sleep but deny taking the medication (intentional); or in children (accidental) or adults who consume meat containing thyroid tissue (accidental).

Clinical presentation of TF is identical to thyrotoxicosis except that patients with TF do not have a goiter (thyromegaly) and unlike patients with Grave's disease, they have neither exophthalmos nor myxedema (thickened skin over their shins). Features of thyrotoxicosis like anxiety, hyperactivity, increased perspiration, dyspnea, intolerance to heat, unexplained weight loss, diarrhea, fine tremors, hyperreflexia, tremulousness, palpitations and atrial fibrillation are seen in TF too. Complications like cardiac arrhythmias, hypermetabolism, hyperpyrexia, thyroid storm and myocardial infarction have been reported in TF [3] [4].

• Weight Loss

  It occurs in patients who are prescribed a very high dose of thyroid hormones as medication (iatrogenic); or those who consume thyroid hormone medication surreptitiously for weight loss or to increase their energy levels or to decrease sleep but deny [symptoma.com]

  Classic symptoms of hyperthyroidism tachycardia usually sinus a fib common too sweating/feeling warm poor sleep weight loss possible fine tremor eye signs (Graves only) Causes of these symptoms usually Graves disease in the west toxic multinodular goitre [emergencymedicineireland.com]

  Accidental overdose has been reported in people taking weight-loss supplements that contain T3 and T4. Exogenous hyperthyroidism can lead to bone loss and cardiac dysfunction, including arrhythmia, heart failure, and myocardial infarction. [visualdx.com]

  Features of MyAccess include: Remote Access Favorites Save figures into PowerPoint Download tables as PDFsGo to My Dashboard Close Sweating, weight loss or gain, anxiety, palpitations, loose stools, heat intolerance, fatigue, menstrual irregularity Tachycardia [accessmedicine.mhmedical.com]

  In our case thyroxine was abused for weight loss and energy boost up causing junctional arrhythmias leading to cardiac arrest. [tandfonline.com]

• Fever

  Fever should not be treated with cooling mattresses, and Tylenol is ineffective. Fever may be controlled with Demerol (25-50 mg intravenously Q 6 hours) and chlorpromazine (25-50 mg intravenously Q 6 hours). [thebigl.co]

  In subacute (De Quervain's) thyroiditis symptoms patients may have fever in the initial phase and the thyroid is tender. [jiscmail.ac.uk]

  Agranulocytosis occurs in 1 in 300 patients treated with thionamides and presents as a sore throat, mouth ulcers and high fever. [statpearls.com]

  It usually causes fever and pain in the neck, jaw or ear. [nhs.uk]

  Rarely, methimazole or propylthiouracil may cause fever, sore throat, or other signs of infection. If you develop these symptoms, contact your doctor immediately. [medicinenet.com]

• Heat Intolerance

  Signs and symptoms vary between people and may include irritability, muscle weakness, sleeping problems, a fast heartbeat, heat intolerance, diarrhea, enlargement of the thyroid, and weight loss. [dbpedia.org]

  Features of MyAccess include: Remote Access Favorites Save figures into PowerPoint Download tables as PDFsGo to My Dashboard Close Sweating, weight loss or gain, anxiety, palpitations, loose stools, heat intolerance, fatigue, menstrual irregularity Tachycardia [accessmedicine.mhmedical.com]

  They may include Being nervous or irritable Mood swings Fatigue or muscle weakness Heat intolerance Trouble sleeping Hand tremors Rapid and irregular heartbeat Frequent bowel movements or diarrhea Weight loss Goiter, which is an enlarged thyroid that [icdlist.com]

• Rigor

  When MMI, thyroidectomy, and 131I cannot be used, PTU can be considered an option for a short period of time in doses of 4.7-8.6 mg/kg of body weight (116) (B) under rigorous clinical and laboratory monitoring (see below). [scielo.br]

• Diarrhea

  Features of thyrotoxicosis like anxiety, hyperactivity, increased perspiration, dyspnea, intolerance to heat, unexplained weight loss, diarrhea, fine tremors, hyperreflexia, tremulousness, palpitations and atrial fibrillation are seen in TF too. [symptoma.com]

  Signs and symptoms vary between people and may include irritability, muscle weakness, sleeping problems, a fast heartbeat, heat intolerance, diarrhea, enlargement of the thyroid, and weight loss. [dbpedia.org]

  They may include Being nervous or irritable Mood swings Fatigue or muscle weakness Heat intolerance Trouble sleeping Hand tremors Rapid and irregular heartbeat Frequent bowel movements or diarrhea Weight loss Goiter, which is an enlarged thyroid that [icdlist.com]

• Increased Appetite

  appetite Hyperactivity / irritability Heat intolerance Tremor Sweating Palpitations Diarrhoea Amenorrhoea Alopecia Signs Sinus tachycardia / atrial fibrillation Psychomotor agitation Fine tremor Warm skin Onycholysis Palmar erythema Muscle wasting / [medschool.co]

  appetite Hyperkinesia Sweating Heat intolerance Palpitations Tremor Irritability Oligomenorrhoea Infertility Psychosis, panic Lost libido Tall kids Grave's only eye signs pretibial myoedema Grave's demopathy thyroid acropachy extreme cases; soft tissue [alancam.com]

  Signs and symptoms of hyperthyroidism include: Nervousness Irritability Increased appetite Heart palpitations Heat intolerance Signs and symptoms of hypothyroidism include: Mental sluggishness Depressed mood Weight gain Decreased heart rate Increased [medicinenet.com]

  These can include diarrhoea, weight loss (although around 10% develop weight gain due to increased appetite), shaking or tremor (notably in the hands), sweating, increased heart rate that can be felt by the patient (palpitations), overactivity, agitation [yourhormones.info]

  Presentation of thyrotoxicosis Presentation of thyrotoxicosis Symptoms Weight loss despite an increased appetite. Increased or decreased appetite. Irritability. Weakness and fatigue. Diarrhoea +/- steatorrhoea. Sweating. Tremor. [gponline.com]

• Regurgitation

  Mild mitral, tricuspid regurgitation. [ncbi.nlm.nih.gov]

• Tachycardia

  Other types of arrhythmias can be sinus tachycardia, ventricular tachycardia, SVT, ventricular fibrillation and rarely cardiac arrest can also happen [13–15]. [tandfonline.com]

• Muscle Tenderness

  tenderness Present Present Skin Increased perspiration Warm and moist skin Present Present Graves dermopathy Red, swollen skin on shins and top of feet Orange peel like skin called pretibial myxedema Present in Graves disease Absent Ocular Redness and [ncbi.nlm.nih.gov]

• Increased Muscle Mass

  Creatine kinase was elevated, consistent with his increased muscle mass and recent participation in the bodybuilding competition. [edm.bioscientifica.com]

• Leg Weakness

  Our patient’s presentation was typical, with rapidly progressive symmetrical muscle weakness in both legs, without sensory symptoms or signs, or bowel or bladder dysfunction (6, 7). [edm.bioscientifica.com]

• Denial

  We are receiving denials that this provider type may not bill for t... [ Read More ] Are there new CMS CCI edits for billing out 93312, 93320 & 93325 for anesthesiologists. We are getting denials from all insurance providers when we bill for these. [coder.aapc.com]

• Tremor

  Sweating Palpitations Diarrhoea Amenorrhoea Alopecia Signs Sinus tachycardia / atrial fibrillation Psychomotor agitation Fine tremor Warm skin Onycholysis Palmar erythema Muscle wasting / weakness Hyperreflexia Alopecia Gynaecomastia Manifestations of [medschool.co]

  Features of thyrotoxicosis like anxiety, hyperactivity, increased perspiration, dyspnea, intolerance to heat, unexplained weight loss, diarrhea, fine tremors, hyperreflexia, tremulousness, palpitations and atrial fibrillation are seen in TF too. [symptoma.com]

  Access Favorites Save figures into PowerPoint Download tables as PDFsGo to My Dashboard Close Sweating, weight loss or gain, anxiety, palpitations, loose stools, heat intolerance, fatigue, menstrual irregularity Tachycardia; warm, moist skin; stare; tremor [accessmedicine.mhmedical.com]

  Classic symptoms of hyperthyroidism tachycardia usually sinus a fib common too sweating/feeling warm poor sleep weight loss possible fine tremor eye signs (Graves only) Causes of these symptoms usually Graves disease in the west toxic multinodular goitre [emergencymedicineireland.com]

  They may include Being nervous or irritable Mood swings Fatigue or muscle weakness Heat intolerance Trouble sleeping Hand tremors Rapid and irregular heartbeat Frequent bowel movements or diarrhea Weight loss Goiter, which is an enlarged thyroid that [icdlist.com]

• Hyperreflexia

  Features of thyrotoxicosis like anxiety, hyperactivity, increased perspiration, dyspnea, intolerance to heat, unexplained weight loss, diarrhea, fine tremors, hyperreflexia, tremulousness, palpitations and atrial fibrillation are seen in TF too. [symptoma.com]

  Hyperactivity / irritability Heat intolerance Tremor Sweating Palpitations Diarrhoea Amenorrhoea Alopecia Signs Sinus tachycardia / atrial fibrillation Psychomotor agitation Fine tremor Warm skin Onycholysis Palmar erythema Muscle wasting / weakness Hyperreflexia [medschool.co]

  and testicular malignancies may cause hyperthyroidism Heat intolerance, sweating Palpitations Pruritus Frequent bowel movements Weight loss (or gain) Menstrual irregularities Nervousness, fine resting tremor Fatigue Muscle weakness, muscle cramps, hyperreflexia [accessmedicine.mhmedical.com]

  Her physician found no obvious tremors, hyperdynamic apex, or hyperreflexia on physical exam. To rule out laboratory error from the second set of tests, her physician ordered yet another round of blood work. [mdedge.com]

• Fine Tremor

  Features of thyrotoxicosis like anxiety, hyperactivity, increased perspiration, dyspnea, intolerance to heat, unexplained weight loss, diarrhea, fine tremors, hyperreflexia, tremulousness, palpitations and atrial fibrillation are seen in TF too. [symptoma.com]

  Classic symptoms of hyperthyroidism tachycardia usually sinus a fib common too sweating/feeling warm poor sleep weight loss possible fine tremor eye signs (Graves only) Causes of these symptoms usually Graves disease in the west toxic multinodular goitre [emergencymedicineireland.com]

  Sweating Palpitations Diarrhoea Amenorrhoea Alopecia Signs Sinus tachycardia / atrial fibrillation Psychomotor agitation Fine tremor Warm skin Onycholysis Palmar erythema Muscle wasting / weakness Hyperreflexia Alopecia Gynaecomastia Manifestations of [medschool.co]

  She had mild tachycardia (112 beats/minute) and fine tremor of the hands. She had no thyroid enlargement, thyroid bruits, eye signs or pretibial myxedema. [cmaj.ca]

  Tremor. Mental illness: may range from anxiety to psychosis. Heat intolerance. Loss of libido. Oligomenorrhoea or amenorrhoea. Signs Palmar erythema. Sweaty and warm palms. Fine tremor. Tachycardia - AF (common in elderly). [gponline.com]

• Tremulousness

  Features of thyrotoxicosis like anxiety, hyperactivity, increased perspiration, dyspnea, intolerance to heat, unexplained weight loss, diarrhea, fine tremors, hyperreflexia, tremulousness, palpitations and atrial fibrillation are seen in TF too. [symptoma.com]

  Symptoms of hyperthyroidism include heat intolerance, irritability, weight loss, frequent bowel movements, proximal muscle weakness, tremulousness, anxiety, fever, and fatigue. Menstruating females often suffer oligomenorrhea. [thebigl.co]

  Clinically, she was extremely thyrotoxic, weepy, combative, and tremulous, with a pulse of 180 beats per minute. The thyroid was not palpable. Her free T4 was >6.0 ng/dL, her total T3 was 2,519 ng/dL, and her TSH was suppressed. [jnm.snmjournals.org]

  Iodine is also used in preparation for subtotal thyroidectomy, in severe thyrocardiac disease, and in acute surgical emergencies Propranolol decreases tremulousness, palpitations, excessive sweating, eyelid retraction, and heart rate. [quizlet.com]

• Hand Tremor

  They may include Being nervous or irritable Mood swings Fatigue or muscle weakness Heat intolerance Trouble sleeping Hand tremors Rapid and irregular heartbeat Frequent bowel movements or diarrhea Weight loss Goiter, which is an enlarged thyroid that [icdlist.com]

The initial diagnosis of TF is based on clinical suspicion. A detailed history is essential to determine medicine intake, diet, the degree of symptom progression and underlying psychiatric issues. Physical examination should take into consideration the patient's heart rate, basal metabolic rate, presence or absence of goiter, exophthalmos, and myxedema. Laboratory biochemical tests are required to determine total triiodothyronine (T3), total thyroxine (T4), thyroid-stimulating hormone (TSH), TSH receptor, and thyroglobulin level. An elevated free thyroxine index (ratio of T-4 to T-3) [5], diminished thyroglobulin level [6] with an increased basal metabolic rate are diagnostic of TF. Patients with a positive TSH receptor and hyperthyroidism can be misdiagnosed as Grave's disease [7]. To distinguish TF from other causes of thyrotoxicosis, fecal thyroxine levels can be obtained with elevated levels confirming the diagnosis of TF [8].

An imaging study like color doppler ultrasonography is also useful to diagnose TF as it demonstrates the lack of thyroid blood flow [9]. If a patient has an elevated free thyroid hormone level with low TSH levels but is not able to provide a history of ingesting thyroid hormones, a radioactive iodine I-123 uptake is indicated and a low uptake is suggestive of TF [10].

A psychiatrist referral must be considered to exclude Munchausen syndrome [11] and other psychiatric disorders.

• Mediastinal Shift

  Chest X-ray showed mixed interstitial and alveolar opacities within the mid and upper lung zones, more on the left side with no cardiomegaly or mediastinal shifting. [tandfonline.com]

• Increased Basal Metabolic Rate

  Physical examination should take into consideration the patient's heart rate, basal metabolic rate, presence or absence of goiter, exophthalmos, and myxedema. [symptoma.com]

  […] hormone affects almost every tissue and organ system in the body by increasing basal metabolic rate and tissue thermogenesis. [statpearls.com]

  ACTIONS OF THYROID HORMONE • Increases oxygen consumption • Increases carbohydrate and lipid catabolism • Stimulates protein synthesis • Increases basal metabolic rate • Increases thermogenesis • Increases expression of the low-density lipoprotein (LDL [quizlet.com]

• Early Repolarization

  Thyroxine causes early repolarization changes and also increases coronary vascular spasm. A study conducted on 403 patients with various kinds of hyperthyroidism evaluated the types of arrhythmias [16]. [ncbi.nlm.nih.gov]

• Prominent U Wave

  His 12-lead ECG showed low-voltage P- and T-waves, prominent U-waves and a prolonged QT interval of 520 ms. Creatine kinase was elevated, consistent with his increased muscle mass and recent participation in the bodybuilding competition. [edm.bioscientifica.com]

• Myocardial Fibrosis

  The echocardiogram results were normal except for mild septal hypokinesis, and a gadolinium-enhanced cardiac MRI scan showed reduced long axis motion consistent with early interstitial myocardial fibrosis from steroid use. [edm.bioscientifica.com]

• Prominent A-Wave

  His 12-lead ECG showed low-voltage P- and T-waves, prominent U-waves and a prolonged QT interval of 520 ms. Creatine kinase was elevated, consistent with his increased muscle mass and recent participation in the bodybuilding competition. [edm.bioscientifica.com]

This chapter will focus on the prevalence, consequences and the treatment of the thyrotoxicosis factitia, as a complication of inappropriate L- thyroxine treatment for obesity, following the ingestion of beef contaminated with thyroid gland and after [iris.unina.it]

Table 3 Reported cases of HBS post thyrotoxicosis treatment of which the onset prolongs beyond 96 hours, including ours Age (y)/ethnicity/sex Thyrotoxicosis etiology Duration of thyrotoxicosis (mo) Definite thyrotoxicosis treatment Onset of HBS since [aot.amegroups.com]

Radio Active Iodine treatment – RAI Rx. 4. Thyroidectomy – Subtotal or Total 5. NSAIDs and Corticosteroids – for SAT 12. www.drsarma.in Symptom Relief 1. [slideshare.net]

There is controversy about the treatment of mild (subclinical) hypothyroidism. Generally, benefits of treatment are clearest in younger populations. [accesspharmacy.mhmedical.com]

Treatment of iodine-induced thyrotoxicosis is complex because an iodine-enriched thyroid makes treatment with 131I unfeasible for several weeks and reduces the efficacy of ATD treatment. [scielo.br]

Historical Perspective Classification Pathophysiology Causes Differentiating Thyrotoxicosis factitia from Other Diseases Epidemiology and Demographics Risk Factors Screening Natural History, Complications, and Prognosis Natural History Complications Prognosis [wikidoc.org]

After defining the dysfunction or disease, the text presents the epidemiology, etiopathogenesis, clinical features, first and second level tests for diagnosis, first and second line therapies, prognosis, and recommendations for follow-up. [books.google.com]

Exams and Tests Blood tests used to diagnose factitious hyperthyroidism include: Free T4 Radioactive iodine uptake Thyroglobulin Total T3 Total T4 TSH Outlook (Prognosis) Factitious hyperthyroidism will clear up on its own when you stop taking or lower [health.firstlighthealthsystem.org]

Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. [icd10coded.com]

These findings well correlate with the etiology of thyrotoxicosis factitia and may represent an additional, useful tool to confirm the diagnosis. [ncbi.nlm.nih.gov]

Summarize the various treatment options available for hyperthyroidism, depending on specific etiology. [statpearls.com]

Etiology, Pathogenesis, and Pathology 20. [slideshare.net]

After defining the dysfunction or disease, the text presents the epidemiology, etiopathogenesis, clinical features, first and second level tests for diagnosis, first and second line therapies, prognosis, and recommendations for follow-up. [books.google.com]

Historical Perspective Classification Pathophysiology Causes Differentiating Thyrotoxicosis factitia from Other Diseases Epidemiology and Demographics Risk Factors Screening Natural History, Complications, and Prognosis Natural History Complications Prognosis [wikidoc.org]

Epidemiology 1% of the population peak incidence 30-50y F>M Most common cause of endogenous hyperthyroidism Aetiology Unknown Genetic predisposition: HLA-DR3, -B8, DR2 CTLA-4 polymorphisms Potentially environmental factors: viral or bacterial infection [alancam.com]

من الصفحات Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text, 10th Edition has been extensively revised and streamlined to deliver the most comprehensive coverage of the thyroid including anatomy, development, biochemistry, physiology, pathophysiology [books.google.com]

University of Thessaloniki Hipokratio Hospital, Thessaloniki, Greece Summary Clinical nuclear medicine has been developed in parallel with thyroidology, providing sophisticated diagnostic and therapeutic methods and a deep insight into thyroid physiology and pathophysiology [nuclmed.gr]

Historical Perspective Classification Pathophysiology Causes Differentiating Thyrotoxicosis factitia from Other Diseases Epidemiology and Demographics Risk Factors Screening Natural History, Complications, and Prognosis Natural History Complications Prognosis [wikidoc.org]

912 páginas Werner & Ingbar’s The Thyroid: A Fundamental and Clinical Text, 10th Edition has been extensively revised and streamlined to deliver the most comprehensive coverage of the thyroid including anatomy, development, biochemistry, physiology, pathophysiology [books.google.es]

Iatrogenic hyperthyroidism may be intentional (e.g., patients with thyroid cancer who have clinicopathologic parameters that warrant thyroid-stimulating hormone suppression to prevent cancer recurrence) or inadvertent (e.g., an excessive dose of thyroid [aafp.org]

Categories M.D.C MDC Category Not Assigned For This ICD Code E05.4 Medicare Severity-Diagnosis Related Groups MS-DRG MS-DRG Category Not Assigned For This ICD Code E05.4 Clinical Classifications Software CCS CCS Category Not Assigned For This ICD Code E05.4 Prevention [medicbind.com]

This indicates that thyroid suppression with thyroid hormone may be ineffective in preventing this disease. Two patients were treated by subtotal thyroidectomy because of recurrent or prolonged episodes of SRH. [jamanetwork.com]

How can I prevent thyrotoxicosis? Most cases of thyrotoxicosis aren’t preventable. If you’re taking thyroid medication, you can prevent thyrotoxicosis by never taking more medication than your healthcare provider has prescribed you. [my.clevelandclinic.org]

1. Harvey RF. Thyroxine ‘‘addicts.’’ Br Med J (Clin Res Ed). 1973;2:35–36.
2. Gorman CA, Wahner HW, Tauxe WN. Metabolic malingerers: patients who deliberately induce or perpetuate a hypermetabolic or hypometabolic state. Am J Med. 1970;48:708–714.
3. Yoon SJ, Kim DM, Kim JU, et al. A case of thyroid storm due to thyrotoxicosis factitia. Yonsei Med J. 2003;44 :351–354.
4. Locker GJ, Kotzmann H, Frey B, et al. Factitious hyperthyroidism causing acute myocardial infarction. Thyroid. 1995;5:465–467.
5. Pearce EN. Diagnosis and management of thyrotoxicosis. BMJ. 2006 Jun 10; 332 (7554): 1369 -1379
6. Mariotti S, Martino E, Cupini C, et al. Low serum thyroglobulin as a clue to the diagnosis of thyrotoxicosis factitia. N Engl J Med. 1982;307:410–412.
7. Jahagirdar VR, Strouhal P, Holder G, Gama R, Singh BM. Thyrotoxicosis factitia masquerading as recurrent Graves’ disease: Endogenous antibody immunoassay interference, a pitfall for the unwary. Ann Clin Biochem. 2008; 45: 325-7
8. Bouillon R, Verresen L, Staels F, Bex M, De Vos P, De Roo M. The measurement of fecal thyroxine in the diagnosis of thyrotoxicosis factitia. Thyroid. 1993;3:101–103.
9. Bogazzi F, Bartalena L, Vitti P, Rago T, Brogioni S, Martino E. Color flow Doppler sonography in thyrotoxicosis factitia. J Endocrinol Invest. 1996;19: 603–606.
10. Braverman LE. Evaluation of thyroid status in patients with thyrotoxicosis. Clin Chem. 1996;42:174–178
11. Mittra ES, Niederkohr RD, Rodriguez C, et al. Uncommon causes of thyrotoxicosis. J Nucl Med 2008; 49:265-278