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euthyroid sick syndrome; nonthyroidal illness syndrome; low T3 syndrome (ESS)

Etiology: 1) physical or environmental stress - excess cortisol production during acute illness [7] 2) systemic illness, 75% of patients with critical illness [1] 3) pharmaceutical agents; dopamine, glucocorticoids [7] Pathology: 1) diminished peripheral conversion of T4 -> T3 2) blunted TSH response to TRH 3) circulating inhibitors of thyroid hormone binding Laboratory: 1) low to low normal total serum T4 [1] - very low total serum T4 associated with poor outcomes [1] 2) lower total serum T3 [1] 3) low to low normal serum TSH [1] 4) high serum reverse T3 5) free thyroxine index (FTI) & free T4 may be low 6) serum cortisol may be elevated [7] 7) serum TSH is increased in the recovery phase [1] 8) allow 6-8 weeks after hospital discharge for followup thyroid function tests [1] Differential diagnosis: - subclinical hyperthyroidism Management: 1) no specific therapy required 2) thyroid function studies generally normalize by 8 weeks after recovery from precipitating event [1] 3) no further testing of hospitalized patients [1]

Related

subclinical hyperthyroidism

General

thyroid disease

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 16, 17, 18. American College of Physicians, Philadelphia 1998, 2012, 2015, 2018 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  2. Mooradian AD, Wong NC. Age-related changes in thyroid hormone action. Eur J Endocrinol 131:451, 1994 PMID: 7952155
  3. Adler SM, Wartofsky L. The nonthyroidal illness syndrome. Endocrinol Metab Clin North Am. 2007 Sep;36(3):657-72 PMID: 17673123
  4. Farwell AP Nonthyroidal illness syndrome. Curr Opin Endocrinol Diabetes Obes. 2013 Oct;20(5):478-84 PMID: 23974778
  5. Fliers E, Bianco AC, Langouche L, Boelen A. Thyroid function in critically ill patients. Lancet Diabetes Endocrinol. 2015 Oct;3(10):816-25. Review. PMID: 26071885 Free PMC Article
  6. Langouche L, Jacobs A, Van den Berg G Non thyroidal illness syndrome across the ages. J Endocr Soc 2019 3(12):2313-2315 PMID: 31745528 PMCID: PMC6853682 Free PMC article
  7. NEJM Knowledge+ Endocrinology