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Thyrotoxicosis Factitia

Thyroid Toxicity Exogenous

Thyrotoxicosis factitia is a rare disorder characterized by elevated levels of plasma thyroid hormones due to increased intake which can be iatrogenic, accidental, or intentional. Symptoms are similar to those in Grave's disease and diagnosis is based on history, examination findings, and by testing thyroid functions.


Presentation

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]
  • loss preparation Clinical findings: (1) There are clinical signs of thyrotoxicosis, depending on hormone exposure, except that ophthalmopathy is absent. (2) The thyroid gland is usually not enlarged.[meducator3.net]
  • 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]
  • In Europe, it affects around 1 in 2000 people annually. 1 Although thyrotoxicosis typically presents with weight loss, heat intolerance, and palpitations, there are a large variety of additional features, which manifest more variably with advancing age[doi.org]
Heat Intolerance
  • 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]
  • In Europe, it affects around 1 in 2000 people annually. 1 Although thyrotoxicosis typically presents with weight loss, heat intolerance, and palpitations, there are a large variety of additional features, which manifest more variably with advancing age[doi.org]
  • 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]
  • […] tumours Hyperfunctioning ovarian teratoma - struma ovarii Clinical Features Older present: Tachycardia AF HF Lid lag Periorbital oedema Goitre, bruit Diarrhoea Weight loss (can also have paradoxical weight gain) Increase appetite Hyperkinesia Sweating Heat[alancam.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]
  • . - Thyroid Storm - life-threatening medical emergency characterized by severe thyrotoxicosis, high fever (often greater than 39.4 C [103 F]), tachycardia, tachypnea, dehydration, delirium, coma, nausea, vomiting, and diarrhea.[flashcardmachine.com]
  • There was no history of chest pain, dyspnea, or of any manifestation of rheumdtic fever. Twenty years and again five years prior to admission he had a typical syndrome of pain relieved by food, and a duodenal ulcer was demonstrated by x-ray.[kundoc.com]
  • Anti Thyroid Drugs • Side effects of treatment include reversible granulocytopenia, skin rashes, fever, peripheral neuritis, polyarteritis, vasculitis, and, rarely, agranulocytosis and aplastic anemia. • The catecholamine response of thyrotoxicosis can[slideshare.net]
  • Patients with agranulocytosis usually present with fever and pharyngitis. After the drug is stopped, granulocyte counts usually start to rise within several days but may not normalize for 10-14 days.[emedicine.medscape.com]
Rigor
  • URAC's accreditation program is an independent audit to verify that A.D.A.M. follows rigorous standards of quality and accountability. A.D.A.M. is among the first to achieve this important distinction for online health information and services.[limamemorial.org]
  • When MMI, thyroidectomy, and 131 I 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]
  • 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]
  • 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]
  • For three months he had infrequent attacks of watery diarrhea without cramps or gross blood. He did not use tobacco or alcohol, and his consumption of tea and coffee was moderate.[kundoc.com]
Increased Appetite
  • 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]
  • 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]
  • In patients with Graves’ disease, the following symptoms and signs may be present: Symptoms weight loss heat intolerance fatigue hair loss irritability restlessness lack of concentration insomnia labile emotion palpitations exertional dyspnea increased[clinicaladvisor.com]
  • History and Physical Hyperthyroidism may manifest as weight loss despite an increased appetite, palpitation, nervousness, tremors, dyspnea, fatigability, diarrhea or increased GI motility, muscle weakness, heat intolerance, and diaphoresis.[statpearls.com]
  • Many common symptoms of hyperthyroidism are similar to those of adrenergic excess, such as nervousness, palpitations, hyperactivity, increased sweating, heat hypersensitivity, fatigue, increased appetite, weight loss, insomnia, weakness, and frequent[msdmanuals.com]
Food Intolerance
  • He always had a fried and fatty food intolerance which produced “gas and sour stomach.” For three months he had infrequent attacks of watery diarrhea without cramps or gross blood.[kundoc.com]
Tachycardia
  • An esmolol infusion was started to control his persistent tachycardia but this depressed his myocardial contractility. He required amrinone and noradrenaline infusions as further inotropic support.[paperity.org]
  • In three patients, asymptomatic bouts of supraventricular tachycardia, paroxysmal atrial fibrillation, or ventricular tachycardia disappeared during diltiazem therapy.[jamanetwork.com]
  • Cardiac symptoms may include congestive heart failure, which is often refractory to therapy, tachycardia, and a widened pulse pressure.[thebigl.co]
  • Signs may include warm, moist skin; tremor; tachycardia; widened pulse pressure; and atrial fibrillation.[msdmanuals.com]
  • Physical examination revealed tachycardia with a heart rate over 100 beats/min, moist skin, and an elevated body temperature (37.8 ). Chest and abdominal examinations revealed no abnormalities.[kjim.org]
Cyanosis
  • There was no cyanosis, clubbing, edema, or tremor. The skin was dry. Neurologir examination revealed no abnormality. Fig. 2.-Electrocardiogram, The hemoglobin was with a normal differential.[kundoc.com]
Heart Block
  • .: Complete Heart Block Resulting From Overdosage With Thyroid Extract, New England J. Med. 221:336, 1939. Skanse, B. M., and Riggs, D. S.: Thyrotoxicosis Factitia (Alimentary Thyrotoxicosis), J. Clin. Endocrinol. 8532, 1948. Daniel, W.[kundoc.com]
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]
  • 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]
  • Signs may include warm, moist skin; tremor; tachycardia; widened pulse pressure; and atrial fibrillation.[msdmanuals.com]
  • […] teratoma - struma ovarii Clinical Features Older present: Tachycardia AF HF Lid lag Periorbital oedema Goitre, bruit Diarrhoea Weight loss (can also have paradoxical weight gain) Increase appetite Hyperkinesia Sweating Heat intolerance Palpitations Tremor[alancam.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]
  • 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]
  • […] of concentration insomnia labile emotion palpitations exertional dyspnea increased appetite increased frequency of bowel movements proximal muscle weakness irregular menses Signs of Graves' Disease tremors tachycardia flow murmurs warm and moist skin hyperreflexia[clinicaladvisor.com]
  • In thyrotoxicosis, the skin is usually warm and wet, and fine, rapid tremors of outstretched hands, proximal muscle weakness, and hyperreflexia are frequent findings. Infiltrative dermopathy (pretibial myxedema) is a rare manifestation in GD.[scielo.br]
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]
  • 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]
  • . • A fine tremor, muscle wasting, and proximal muscle group weakness with hyperactive tendon reflexes often are present. • The thyroid usually is diffusely and symmetrically enlarged, as evidenced by an enlarged pyramidal lobe. • Overlying bruit or thrill[slideshare.net]
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]
  • 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]

Workup

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.

Left Axis Deviation
  • Normal sinus rhythm, left axis deviation, no abnotmality. The white blood count was 6,850 cells per c. mm. 15.5 Gm. per cent. Erythrocyte sedimentation rate was 10 mm. per hour (Westegren).[kundoc.com]
Increased Basal Metabolic Rate
  • An elevated free thyroxine index (ratio of T-4 to T-3), diminished thyroglobulin level 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.[symptoma.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]

Treatment

  • Make the best clinical decisions with an enhanced emphasis on evidence-based practice and expert opinions on treatment strategies. Zero in on the most relevant and useful references with the aid of a more focused, concise bibliography.[books.google.com]
  • He had been refractory to thyroxine treatment and now required 0.3 mg thyroxine daily. On admission, he was hypertensive, tachycardic and found to be thyrotoxic secondary to excess thyroid hormone ingestion. Treatment with iopanoic acid was started.[paperity.org]
  • Treatment is with medicines, radioiodine therapy, or thyroid surgery. No single treatment works for everyone.[icdlist.com]

Prognosis

  • 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]
  • Prognosis Good with treatment but remission and relapse common Increased incidence of other autoimmune diseases: SLE, T1DM, Addison’s Treatment Medical B-blockers for rapid symptom control Titration of carbimazole (reduces T3 and T4 by inhibiting thyroid[alancam.com]
  • Outlook (Prognosis) Factitious hyperthyroidism will clear up on its own when you stop taking or lower the dosage of thyroid hormone.[stelizabeth.com]

Etiology

  • 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]
  • M.: Auricular Fibrillation; Its Etiology, Age Incidence and Productron by Digitalis Therapy! Am. J. M. SC. 183:35, 1932. Stroud, W. D., Laplace, L. B., and Ratsinger, J. A.: The Etiology, Prognosis, and Treatment of Auricular Fibrillation, Am. J. M.[kundoc.com]
  • Etiology In the United States and most western countries, Graves disease is the most common cause of hyperthyroidism. As Graves disease is autoimmune in etiology, this form of hyperthyroidism tends to manifest itself in younger populations.[statpearls.com]
  • The initial report of this outbreak identified no common vehicle of transmission or etiologic agent.[experts.umn.edu]

Epidemiology

  • 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]
  • 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]
Sex distribution
Age distribution

Pathophysiology

  • 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]
  • 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]
  • 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]
  • Epidemiology/Pathophysiology Graves' disease is the most common form of hyperthyroidism accounting for 60-70% of all cases. It occurs in up to 3% of the population.[ocw.tufts.edu]

Prevention

  • Natural History, Complications, and Prognosis Natural History Complications Prognosis Diagnosis Diagnostic Criteria History and Symptoms Physical Examination Laboratory Findings Imaging Findings Other Diagnostic Studies Treatment Medical Therapy Surgery Prevention[wikidoc.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]
  • Rapidly find the answers you need with separate sections on diseases and disorders, differential diagnosis, clinical algorithms, laboratory results, and clinical preventive services, plus an at-a-glance format that uses cross-references, outlines, bullets[books.google.com]
  • ., 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 hormone prescribed for hypothyroidism).[aafp.org]
  • Prevention Thyroid hormone should be taken only by prescription and under the supervision of a provider. References Davies TF, Laurberg P, Bahn RS. Hyperthyroid disorders. In: Melmed S, Polonsky KS, Larsen PR, Kronenberg HM, eds.[stelizabeth.com]

References

Article

  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

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Last updated: 2019-06-28 10:26