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Arch Metab. Endocrinol 2016;60/3 inpatients atrisk. measures suggest prophylactic andto cal significanceofICM-induced thyrotoxicosis andpossible treatment. prophylaxis the necessary athigherriskandsummarizing the populationsthatare dysfunction, indicating types of ICM-induced thyroid and study(4)discussedindetailtheprevalence a recent Finally, treatment. andprompt tion ofadversereactions theuseofICMallowforearlyrecogni factors before ofrisk ofthepresence (3), suggestingthatscreening adverseoutcomeofICM dysfunction asanimportant thyroid recognized article Anotherreview exposure. ofsupraphysiologiciodine commonsource increasingly (2),identifiedICMasan andhyperthyroidism roidism marizing the mechanisms of -induced hypothy review,recent ofiodine-deficiency(1).A in areas sum autonomy,roid elderlyandliving especiallyiftheyare R INTRODUCTION weeks after ICMadministration. patients withsuppressed TSH and/orpalpablegoiter, started thedaybeforeandcontinuedfortwo in high-risk populations, such as administration of perchlorate anda thionamide class to elderly cians shouldbeaware ofthispossiblethyroid-specific effect. Prophylactic drugscouldbeconsidered thefactthatalargenumberofICMexaminations areperformedineverydaypractice,physiGiven importance, bytheattending asitmayhave animpacttotherecommendationsgiven physician. with antithyroid . This is the shortest time reported in theliteratureand it is of clinical sented withsymptomsandlaboratoryfindingstypicalofthyrotoxicosis. She was treatedsuccessfully nal expansion.Less than24hafter theiodine-basedcontrastmedia(ICM)administration,shepre computed tomography (CT)scan(totaliodineloadof35g)inordertoevaluate theextentofretroster A 66year-old womanwithahistoryofeuthyroid multinodulargoiterunderwentaheadand neck SUMMARY Ioannis Iakovou and review oftheliterature hyperthyroidism: casereport Radio--induced Dimitrios G.Dimitrios Goulis with Graves’diseaseormultinodulargoiterandthy crisisinpatients iodide,whichmaycausethyrotoxic free The aim of this case report wastoillustratethe clini The aimofthiscasereport media (ICM)solutionscontainsmallamountsof adiographic, water-soluble, iodine-basedcontrast 1 ,Zapandiotis Apostolos 2 Arch EndocrinolMetab. 2016;60(3):287-9 2 , VassileiosMpalaris - - - - - increased pressure), sweatandtremor, bloodpressure), suggestiveincreased symptoms(tachycardia, complained ofcardiovascular took place.Lessthan24h aftertheCT, thepatient theCTscan oneweekbefore performed tigraphy were total iodineloadof35g.Blood testsand intravenouslygivinga contrast agentwasadministered 1).Avolumeof100mL350mgI/mL limits (Figure ate theextentofgoiter’sexpansionanditsanatomical the and neckcomputedtomography(CT)scanfollowed Pre-operatively, notmeasured]. TSHR) were ahead (anti- antibodies against TSH receptor U/mL, whereas (anti-Tg) 120 mL, antibodies against thyroglobulin (anti-TPO)75U/ peroxidase bodies againstthyroid (fT dothyronine (fT thyroxine (TSH),free hormone stimulating thyroid to theuppermediastinum.Serum multinodulargoiter, ofeuthyroid submerging history We the case of a66year-old present woman with a CASE REPORT with marginally positive thyroid autoantibodies[anti with marginally positivethyroid mU/mL, 11.6pg/mLand2.9pg/mL,respectively, 99m 1 , Tc toevalu scintigraphy(uptake2.4%),inorder

3 ) concentrations were normal at1.8 normal ) concentrationswere - - - Accepted onNov/5/2015 Received onMay/14/2015 [email protected] [email protected] 56403 – Thessaloniki, Greece Department, Papageorgiou Hospital, Academic NuclearMedicine Ioannis Iakovou Correspondence to: 2 1 DOI: 10.1590/2359-3997000000143 of Thessaloniki, Greece of Thessaloniki, Medical School, Aristotle University of ObstetricsandGynecology, Endocrinology, FirstDepartment University of Thessaloniki, Greece Medicine, MedicalSchool, Aristotle UnitofReproductive Third DepartmentofNuclear case report 4 ) and free triio ) andfree 99m Tc-scin 287 - - - -

Copyright© AE&M all rights reserved. Copyright© AE&M all rights reserved. available asfollow-upwasnotcomplete. isnot statusimprovement Hormonal and tachycardia. pressure regulation ofarterial was achieved,specifically blocking agentand thiamazole. Clinical improvement withβ treatment clinically byconservative wasimproved ThisICM-inducedthyrotoxicosis mL). fT 288 dailyintake ofiodide(150μg). recommended thousandtimesthe iodide loadof90toseveralhundred iodide.Thisisactuallyanacute may beliberatedasfree 13,500 μgofiodideand15 – 60gofboundiodinethat volume between 100 and 200 mLandcontainsabout hasa dose ofICMusedinatypical imagingprocedure (Jod–Basedowphenomenon)(4).A hyperthyroidism cal concentrationsofiodinemayleadtoiodine-induced tosupraphysiologi exposure auto-regulation, impaired (NIS)(5).Inindividualswith dium-iodide symporter ofso to the down-regulation centration, secondary to 10dayslater, oflow inorganic iodinecon asaresult as “escapephenomenon”,isassumedtooccuraweek organification, described Recommencement ofnormal excessive amounts of iodine (Wolff effect). – Chaikoff of inthepresence synthesisandsecretion, of hormone regulation gland,permitting nification inthethyroid mechanismofinhibitioniodineorga to-regulatory Normally, iodineoverloadisaccompaniedbyanau DISCUSSION Figure 1. Pre-operative (TSH0.01mU/mL,fT hyperthyroidism suggestiveof findingswere Laboratory of thyrotoxicosis. Radio-contrast inducedhyperthyroidism 3 6.9pg/mL,anti-TPO215U/mL,anti-Tg360U/ 99m Tc scintigraphy(uptake2.4%). 4 29.6 pg/mL, 29.6pg/mL, -adrenergic -adrenergic - - - - - existing thyroid disease.Theoddsratio(OR)fordevel existing thyroid among patients with pre- to 5% (4), and being greater 0.05% widelyfrom been assessedaccurately(6),varying in patients with no apparent thyroid abnormality. thyroid in patientswithnoapparent Pa withinthefirst week,even subclinical hypothyroidism cation ofhighamountsICMmightinducetransient patients.Ithasbeensuggested(9) thattheappli roid functionofsupramaximaldosesiodine ineuthy roid up to12weeksafterICMadministration. Thetimingofonsetmaybe may besubclinicalorovert. dysfunction Thyroid of thyrotoxicosis. other forms from mones. Clinicalmanifestationscannotbedifferentiated hor ofexcessquantitiesthyroid synthesis andrelease the functionissupposedtopermit autonomous thyroid of in ourcase,multinodulargoiter(7,8).Thepresence autonomy,with thyroid suchasGraves’diseaseor, as condition the pathogenesisofthisphenomenonisevery (CI)1.08-3.06](6).Riskfactorfor confidence interval hasbeenestimated to1.98[95% oping hyperthyroidism believe that universal prophylactic treatment should not shouldnot treatment believe thatuniversal prophylactic gency) that has to be continuedfor 14 days(1).We priortoexam,incaseofemer the exam(ordirectly thiamazole 30mgoncedaily, theday before starting hasbeensuggested: tration. Thefollowingregimen andcontinuedfortwoweeksafterICMadminis­ before theday started palpable goiterhasbeenrecommended, TSHand/or toelderlypatientswithsuppressed drug andathionamideclass Administration ofperchlorate theexamination. wellbefore starting be administered, could it hasbeensuggestedthatprophylactic theincidenceofiodine-inducedthyrotoxicosis, reduce administrationofICMiscontra-indicated.Toroidism, (1).Incasesofestablishedhyperthy of thyrotoxicosis thaninotherforms frequent more complications are bythehighiodideconcentrationsand ishindered drugs withthyrostatic astreatment risk patientsisimportant, ing the12weeksfollowingICMadministration. mayoccuranytimedur symptoms ofhyperthyroidism thatsignsand sician: thepatienthastobeinformed givenbytheattendingphy to therecommendations asitmayhaveanimpact and itisofclinicalimportance, intheliterature timereported edge, thisistheshortest toourknowl tion andonsetofsymptoms.According (<24h)betweenICMadministra timeinterval short wasanextremely athighrisk(9).Inourcase,there are tients withbasalTSHconcentrationsabove2μU/mL The prevalence ICM-induced thyroid disease has not diseasehasnot ICM-inducedthyroid The prevalence Little is known about the short-term effects onthy effects Little isknownabouttheshort-term Prevention of iodine-induced thyrotoxicosis inhigh- ofiodine-inducedthyrotoxicosis Prevention Arch Metab. Endocrinol 2016;60/3 ------Arch Metab. Endocrinol 2016;60/3 2. 1. REFERENCES was reported. relevant tothisarticle nopotentialconflictofinterest Disclosure: (4). effect sible thyroid-specific ofthispos Thus,physiciansshouldbeaware affected. consequence a considerable number of patients being uncommonly adverseeventsofiodideoverloadwill practice,the ineveryday performed examinations are less, thesepatientsneedtobefollowedcarefully. especiallyinelderlypatients;neverthe be administered,

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