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      Endemic goitre and hypothyroidism in an adult female patient dependent on total parenteral nutrition

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          Abstract

          We present the case of a thirty-year-old female patient who was referred to the endocrinology team with an enlarging goitre and biochemical hypothyroidism. She had been dependent on total parenteral nutrition for the previous six years as a result of intestinal failure thought to be caused by possible underlying mitochondrial disease. The patient also suffers from a Desmin myopathy, and at present, the exact aetiology behind her intestinal failure is not certain. The goitre was smooth and had been enlarging slowly over the previous few months. Thyroid peroxidase antibodies were found to be within normal range. Further analysis of the case showed that twelve months earlier the patients total parenteral nutrition (TPN) feed had been altered as a result of manganese toxicity. The current feeding regimen did not contain a trace element additive which had previously supplied iodine supplementation. A little detective work established that iodine content to the TPN had been reduced, the trace element additive (Additrace) was recommenced providing 1 µmol of iodine per day, equating to 130 µg of iodine. Following this change, thyroid-stimulating hormone levels returned to normal and the goitre quickly reduced in size. We present a rare case of endemic goitre and hypothyroidism in a patient receiving inadequate iodine supplementation through total parenteral nutrition.

          Learning points:
          • Endemic goitre and hypothyroidism secondary to iodine deficiency are rare in the developed world. However, the diagnosis should be considered in the setting of a diffuse goitre and negative thyroid antibodies.

          • Although rare, endemic goitre should be considered in patients who present with hypothyroidism and who are dependent on total parenteral nutrition.

          • Treatment with levothyroxine is not required in endemic goitre as thyroid function tests generally normalise with the addition of iodine to the diet/total parenteral nutrition regimen.

          • Iodine supplementation at a level recommended by the European Society for Clinical Nutrition and Metabolism (ESPEN) was observed to quickly normalise this patient’s thyroid function tests.

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          Most cited references 4

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          Requesting iodine supplementation in children on parenteral nutrition.

          Iodine supplementation of parenterally fed infants recommended by ESPGHAN is 1 microg/kg/day. To assess nutritional and thyroid status of children on parenteral nutrition (PN) through urinary iodine concentration (UIC). Children (1-17 yrs), undergoing PN and receiving an iodine supply of 1 microg/kg/day, were enrolled from 2000 to 2007. We observed 15 children (10 males, mean age 76.53+/-60.4 months) on PN from 14 to 84 weeks (mean 38.5+/-21.4). Ten were on TPN and five on PPN; nine had short bowel syndrome (SBS) and six had other intestinal diseases requiring PN. Iodine supply in TPN ranged between 1 and 1.6 microg/kg/day (mean 1.1+/-0.3 microg/kg/day), while in PPN it ranged from 2.3 to 2.8 microg/kg/day (mean 2.6+/-0.7 microg/kg/day). We found an inverse correlation between duration of PN in months and UIC (P=0.05). Four weeks after PN onset, UIC<100 microg/L was found in all SBS patients and 3/6 non-SBS patients (P<0.05). After 12 weeks, 8/15 (53%) patients had UIC<50 microg/L, but thyroxine, TSH and thyroid volume remained unchanged. A PN iodine supply of 1 microg/kg/day may be suboptimal. Higher supplies should be evaluated in controlled trials.
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            Severe Hypothyroidism From Iodine Deficiency Associated With Parenteral Nutrition

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              Iodine nutrition in adults on long-term home parenteral nutrition.

              The aim of this study was to evaluate iodine nutrition in adults on long-term home parenteral nutrition (HPN) and to compare it with iodine supplemented with PN, categorized as below or according to the European Society for Clinical Nutrition and Metabolism guidelines (ESPEN-GL) recommendation.
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                Author and article information

                Journal
                Endocrinol Diabetes Metab Case Rep
                Endocrinol Diabetes Metab Case Rep
                EDM
                Endocrinology, Diabetes & Metabolism Case Reports
                Bioscientifica Ltd (Bristol )
                2052-0573
                07 June 2017
                2017
                : 2017
                Affiliations
                [1 ]Departments of Endocrinology
                [2 ]Departments of Gastroenterology , Leeds Centre for Diabetes & Endocrinology, Leeds Teaching Hospitals NHS Trust, LeedsUK
                Author notes
                Correspondence should be addressed to R D Murray; Email: robertmurray@ 123456nhs.net
                Article
                EDM170030
                10.1530/EDM-17-0030
                5467649
                © 2017 The authors

                This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.

                Categories
                Unique/Unexpected Symptoms or Presentations of a Disease

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