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]

  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

  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]

  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]

• Rigor

  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]

• 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]

  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]

  appetite, heat intolerance with increased sweating, palpitations, tremor, anxiety, proximal muscle weakness, alopecia and increased fatigability. [statpearls.com]

  appetite increased frequency of bowel movements proximal muscle weakness irregular menses Signs of Graves' Disease tremors tachycardia flow murmurs warm and moist skin hyperreflexia with rapid relaxation phases goiter with a bruit proptosis diplopia [clinicaladvisor.com]

• Regurgitation

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

  There was mild mitral and tricuspid regurgitation. 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]

• Food Intolerance

  For the past five years he had vague right upper quadrant distress unrelated to food; he had done nothing to secure relief. He always had a fried and fatty food intolerance which produced “gas and sour stomach.” [kundoc.com]

• 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]

  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 three patients, asymptomatic bouts of supraventricular tachycardia, paroxysmal atrial fibrillation, or ventricular tachycardia disappeared during diltiazem therapy. [jamanetwork.com]

  Thyroid hormone abuse should be considered in all patients with unexplained sinus tachycardia, especially in those who take thyroid hormone to promote weight loss. [academic.oup.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]

• 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

  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]

  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]

• 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]

  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]

  They may have goiter, tachycardia or atrial fibrillation, dyspnea, abdominal tenderness, hyperreflexia, proximal muscle weakness, tremor, and gynecomastia. [statpearls.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]

  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]

  African American patients often note darkening of their skin. • Tachycardia or atrial fibrillation is present with cutaneous vasodilation leading to a widening of the pulse pressure and a rapid falloff in the transmitted pulse wave (collapsing pulse). • A fine [slideshare.net]

• 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]

• 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]

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]

• 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

  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]

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]

Treatment is with medicines, radioiodine therapy, or thyroid surgery. No single treatment works for everyone. NIH: National Institute of Diabetes and Digestive and Kidney Diseases [Learn More] [icdlist.com]

It is important to determine the cause of the thyrotoxicosis, as this determines treatment. [doi.org]

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

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) Return to top Factitious hyperthyroidism will clear up on its own when you stop taking or lower the dose of thyroid hormone. [oer2go.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]

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]

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, 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]

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]

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]

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]

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]

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]

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]

Nature. 1997; 390: 88–91 Crossref | PubMed | Scopus (979) | Google ScholarSee all References This strategy counteracts the proapoptotic effect of excessive β1-adrenergic Gs protein pathway activation and seems to act as a physiological balance to prevent [kidney-international.org]

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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