UNIVERSITY OF KHARTOUM

Faculty of Medicine

Postgraduate Medical Studies Board

Thyroid Function in the Sick Thyroid Syndrome

in Khartoum and El Shaab Teaching Hospitals,
Khartoum- Sudan

By
Dr. Mawahib Omer Bashir
M.B.B.S (University of Khartoum)

A thesis submitted in partial fulfillment for the requirements of the

Degree of Clinical MD in Pathology, June 2005

Supervisor
Dr. Mustafa Dafa Alla Mustafa
Associate Professor of Pathology
Department of Pathology
Faculty of Medicine
University of Khartoum
 ‫‪Ο‬‬
‫ﻗﺎﻝ ﺍﷲ ﺗﻌﺎﻟﻰ ‪:‬‬

‫ﺇﻧﺎ ﻋﺮﺿﻨﺎ ﺍﻷﻣﺎﻧﺔ ﻋﻠﻰ ﺍﻟﺴﻤﻮﺍﺕ ﻭﺍﻷﺭﺽ )‬

‫ﻭﺍﻟﺠﺒﺎﻝ ﻓﺄﺑﻴﻦ ﺃﻥ ﻳﺤﻤﻠﻨﻬﺎ ﻭﺃﺷﻔﻘﻦ ﻣﻨﻬﺎ ﻭﺣﻤﻠﻬﺎ‬
‫(ﺍﻹﻧﺴﺎﻥ ﺇﻧﻪ ﻛﺎﻥ ﻇﻠﻮﻣﺎﹰ ﺟﻬﻮﻻﹰ‬
‫ﺻﺪﻕ ﺍﷲ ﺍﻟﻌﻈﻴﻢ‬
‫ﺳﻮﺭﺓ ﺍﻷﺣﺰﺍﺏ‬
‫ﺍﻵﻳﺔ )‪(72‬‬

‫‪CONTENTS‬‬
 Page
Dedication I
Acknowledgment II
Abbreviations III
English abstract V
Arabic abstract VII
List of figures IX
List of tables X
CHAPTER ONE
INTRODUCTION AND LITERATURE REVIEW 1
1.1. Anatomic and functional embryology 1
1.2. Histology 2
1.3. Formation and secretion of thyroid hormones 3
1.4. Storage and release of hormones 4
1.5. Metabolism of thyroid hormones 6
1.6. Regulation of thyroid hormones 8
1.7. Mechanism of action 10
1.8. Effect of thyroid hormones 10
1.9. Clinical considerations 11
1.10. Tests of thyroid function 15
1.11. Exogenous and endogenous factors that influence
thyroid hormone economy 15
1.12. Effects of illness (Euthyroid sick syndrome) 19
JUSTIFICATION 42
OBJECTIVES 43

CHAPTER TWO
2. METHODOLOGY 44
2.1. Study design, area and duration 44
2.2. Study population 44
2.3 Inclusion criteria 44
2.4 Exclusion criteria 44
2.5 Tools 45
CHAPTER THREE
3. RESULTS 52
3.1. Characteristics of the studied patients 52
3.2. Serum levels of thyroid hormones among ALL studied
patients: 53
3.3 Alteration of thyroid hormone economy in relation to clinical
condition of the patients 55
3.4 Distribution of studied patients according to the duration
of illness 56
3.5. Alteration of thyroid hormone economy in relation to
clinical diagnosis 56
3.6. Thyroid hormones profile in patients receiving drugs
known to affect thyroid hormones levels 58
3.7. Control group 59
CHAPTER FOUR
4. DISCUSSION 86
CONCLUSION 97
RECOMMENDATIONS 98
REFERENCES 99
APPENDIX
To the soul of my mother.
 I express may gratitude and thanks to my supervisor

Dr. Mustafa Dafa Alla Mustafa for supervision, constant support,

criticism, guidance and encouragement and also special thanks

are extended to the members of the Pathology Department,

University of Khartoum.

Heart-felt thanks go to patients and their relatives who made

this thesis possible.

I am also thankful to the staff of the Laboratory and Research

Unit at Khartoum Teaching Hospital, especially Dr. Abdalla Abdel

Karim, Director of the Laboratories, Khartoum Teaching Hospital,

who allowed me to work in his laboratory.

May I seize this opportunity to thank Dr. Mashair Abdel Gadir,

Paediatrician, who encouraged me continuously during this work.

Gratitude and appreciation are extended to Miss. Widad

A/Magsood for typing this manuscript and Miss. Fatima Elmoaiz

who helped me in performing the statistical analysis.

My gratitude, of course, is extended to my husband and kids

for their patience, support and encouragement.

Finally, many thanks go to my father, brothers, sisters,

friends and all who helped in the development and improvement of

this study.
List of Abbreviations

ACTCH Adrenocorticotropic hormone

AMP Adenosine mono phosphate

CCU Cardiac Care Unit

D1 Type 1 deiodinase

D2 Type 2 deiodinase

DIT Di-iodo tyrosine

FSH Follicle stimulating hormone

FT3 Free tri-iodothyronine

FT4 Free thyroxine

FT4I Free thyroxine index

FT31 Free triiodothyronine index

HCG Human chorionic gonadotropin

HF Heart failure

ICU Intensive Care Unit

IHD Ischemic heart disease

LDL Low density lipoprotein

LH Luteinizing hormone

MIT Mono idotyrosine

MRNA Messenger ribonucleic acid

NTIs Non thyroidal illness syndrome

RAIU Radio iodine uptake

RIA Radio immunoassay

RT3 Reverse tri-iodothyronine

T4 Thyroxine

T3 Tri-iodothyronine

TT4 Total Thyroxine

TT3 Total triiodothyronine

TBG Thyroxine binding globulin

TBPA Thyroxine binding prealbumine

THBR Thyroid hormone binding ratio

TTR Trans-thyretin

TR Thyroid receptor

TRH Thyrotropin releasing hormone

TSH Thyroid stimulating hormone

ABSTRACT
 This is prospective, case control, hospital based study was

conducted at Khartoum Teaching Hospital and El Shaab Teaching

Hospital in the period October 2004 to January 2005.

In this study, serum thyroid hormone levels (TSH, TT4,

TT3,FFT4 and FT3) were measured using a sensitive

chemiluminescence immunoassay automated system and kits

(immulite®) in 60 hospitalized patients suffering from acute

orchronic systemic non-thyroidal illness and 21 apparently healthy

individuals as controls. Selection criteria were satisfied by

hospitalized patients who had no past history or family history of

thyroid disease nor evidence of clinical and/or laboratory

abnormalities suggestive of primary thyroid or pituitary dysfunction.

The objective of this study was to determine the pattern of

alteration in thyroid hormone economy in various non-thyroidal

illnesses in Khartoum Sudan and also to correlate these alterations

with the severity of illness and therapeutic drugs used.

The results were compared with both reference ranges

provided by the Immulite ® manufacturer with its kits and results

obtained on control subjects. The study concluded that there was a

statistically significant reduction in total triiodothyronine levels and

free triiodthyronine levels in 38 (63.33%) and 32 (52.33%)

respectively and elevated thyroxine levels in 12 (20%) of patients.

In spite of these alterations TSH levels were normal in 55

(91.67%) of studied patients.

The study also categorized patients into groups: Those

who had low T3 only; those had elevated T4 only; a group who had

low T3 and T4 and a group who had low T3,T4 and TSH. It was

also found that the degree of alteration of thyroid hormone levels

appears to be correlated with the severity of the disease and the

administration of some drug which affect thyroid hormone

economy.

Finally this study recommends that large prospective,

carefully controlled studies should be done to monitor thyroid

function test findings during and after recovery from NTI.

The study also recommends that thyroid function tests

should not be requested during illness unless there is strong

evidence of coexistence of thyroid disease, and should be

repeated when non-thyroidal illness is resolved and that the

request form should contain all relevant clinical information, and

that close contact between clinicians and pathologists be

maintained to facilitate good interpretation of test results and also

that every lab should establish its own reference range.

 ‫ﻤﻠﺨﺹ ﺍﻷﻁﺭﻭﺤﺔ‬

‫ﻫﺫﻩ ﺩﺭﺍﺴﺔ ﻤﻘﺎﺭﻨﺔ ﺘﺤﻠﻴﻠﻴﺔ ﺃﺠﺭﻴﺕ ﻓﻲ ﻤﺴﺘﺸﻔﻰ ﺍﻟﺨﺭﻁﻭﻡ ﺍﻟﺘﻌﻠﻴﻤﻲ ﻭﻤﺴﺘـﺸﻔﻰ ﺍﻟـﺸﻌﺏ‬

‫ﺍﻟﺘﻌﻠﻴﻤﻲ ﻓﻲ ﺍﻟﻔﺘﺭﺓ ﻤﺎ ﺒﻴﻥ ﺃﻜﺘﻭﺒﺭ ‪2004‬ﻡ ﺇﻟﻰ ﻴﻨﺎﻴﺭ ‪2005‬ﻡ‪.‬‬

‫ﻓﻲ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺴﺔ ﺘﻡ ﺍﺨﺘﻴﺎﺭ ‪ 60‬ﺤﺎﻟﺔ ﻤﻥ ﺍﻟﻤﺭﻀﻰ ﻓﻲ ﺍﻟﻤﺴﺘـﺸﻔﻰ ﺍﻟـﺫﻴﻥ ﻴﻌـﺎﻨﻭﻥ ﻤـﻥ‬

‫ﺃﻤﺭﺍﺽ ﺤﺎﺩﺓ ﺃﻭ ﻤﺯﻤﻨﺔ‪ .‬ﻭﺃﻴﻀﹰﺎ ﺘﻡ ﺍﺨﺘﻴﺎﺭ ‪ 21‬ﺤﺎﻟﺔ ﻤﻥ ﺃﻓﺭﺍﺩ )ﻻ ﻴﻌﺎﻨﻭﻥ ﻤﻥ ﺃﻱ ﻤﺭﺽ( ﻟﻘﻴﺎﺱ‬

‫‪ .‬ﻭﻗﻭﺭﻨﺕ ﺍﻟﻨﺘﺎﺌﺞ ﻤـﻊ ﺍﻟﻤﻌـﺩل )‪(TSH, TT4, TT3, FT3, FT4‬ﻫﺭﻤﻭﻨﺎﺕ ﺍﻟﻐﺩﺓ ﺍﻟﺩﺭﻗﻴﺔ‬

‫ﻭﺃﻴﻀﹰﺎ ﻤﻊ)‪(Immulite‬ﺍﻟﻁﺒﻴﻌﻲ ﻟﻤﺴﺘﻭﻯ ﺍﻟﻬﺭﻤﻭﻨﺎﺕ ﺒﻭﺍﺴﻁﺔ ﺍﻟﺠﻬﺎﺯ‬ ‫)‪. (Controls‬‬

‫ﺘﻡ ﻭﻀﻊ ﺃﺴﺱ ﻟﻼﺨﺘﻴﺎﺭ ﺁﺨﺫﻴﻥ ﻓﻲ ﺍﻻﻋﺘﺒﺎﺭ ﺃﻥ ﻴﻜﻭﻥ ﺍﻟﻤﺭﻴﺽ ﻟﻴﺱ ﻟﻪ ﺃﻱ ﻋﻼﻤﺎﺕ ﺘﺩل‬

‫ﻋﻠﻰ ﺃﺼﺎﺒﺘﻪ ﺒﻤﺭﺽ ﺃﻭﻟﻲ ﻓﻲ ﺍﻟﻐﺩﺓ ﺍﻟﺩﺭﻗﻴﺔ ﺃﻭ ﺍﻟﻨﺨﺎﻤﻴﺔ ﺘﺸﺨﻴﺼﻴﹰﺎ ﺃﻭ ﻤﻌﻤﻠﻴﹰﺎ‪.‬‬

‫ﻫﺩﻓﺕ ﺍﻟﺩﺭﺍﺴﺔ ﻟﻤﻌﺭﻓﺔ ﺍﻟﺘﻐﻴﺭﺍﺕ ﺍﻟﺘﻲ ﺘﺤﺩﺙ ﻓﻲ ﻤﺴﺘﻭﻯ ﻫﺭﻤﻭﻨﺎﺕ ﺍﻟﻐﺩﺓ ﺍﻟﺩﺭﻗﻴﺔ ﻨﺘﻴﺠـﺔ‬

‫ﻟﻸﻤﺭﺍﺽ ﺍﻟﻌﻀﻭﻴﺔ ﺍﻷﺨﺭﻯ ﻓﻲ ﺍﻟﺴﻭﺩﺍﻥ – ﺍﻟﺨﺭﻁﻭﻡ ﻭﺭﺒﻁ ﻫﺫﻩ ﺍﻟﺘﻐﻴﺭﺍﺕ ﻤﻊ ﺤـﺩﺓ ﺍﻟﻤـﺭﺽ‬

‫ﻭﺍﺴﺘﻌﻤﺎل ﺍﻟﻌﻘﺎﻗﻴﺭ ﺍﻟﻁﺒﻴﺔ‪.‬‬

‫( ﻭ ‪TT3‬ﺨﻠﺼﺕ ﻫﺫﻩ ﺍﻟﺩﺭﺍﺴﺔ ﺃﻨﻪ ﻴﻭﺠﺩ ﺘﻐﻴﺭ ﺇﺤﺼﺎﺌﻲ ﻤﻠﻤـﻭﺱ ﺒﺎﻟﻨـﺴﺒﺔ ﻟﻨﻘـﺼﺎﻥ )‬

‫ﻓﻲ ﺍﻟﺩﻡ ﻋﻨﺩ ‪ 38‬ﺤﺎﻟﺔ )‪ 32 (%63.33‬ﺤﺎﻟﺔ )‪ (%53.33‬ﻋﻠﻰ ﺍﻟﺘﻭﺍﻟﻲ‪ ،‬ﻭﺃﻴﻀﹰﺎ ﻫﻨﺎﻟﻙ )‪(FT3‬‬

‫( ‪ 12‬ﻓﻰ ﺤﺎﻟﺔ )‪ .(%20‬ﻭﺒﺎﻟﺭﻏﻡ ﻤﻥ ﻜل ﻫـﺫﻩ ﺍﻟﺘﻐﻴـﺭﺍﺕ ﻤـﺴﺘﻭﻯ ‪TT4‬ﺯﻴﺎﺩﺓ ﻓﻲ ﻤﺴﺘﻭﻯ )‬

‫ﺍﻟﻬﺭﻤﻭﻥ ﺍﻟﻤﻨﺸﻁ ﻟﻠﻐﺩﺓ ﺍﻟﺩﺭﻗﻴﺔ ﻁﺒﻴﻌﻲ ﻋﻨﺩ ‪ 55‬ﺤﺎﻟﺔ )‪ (%91.67‬ﻤﻥ ﺍﻟﻤﺭﻀﻰ‪ .‬ﻭﻗـﺩ ﺼـﻨﻑ‬

‫ﺍﻟﻤﺭﻀﻰ ﻋﻠﻰ ﺤﺴﺏ ﺍﻟﺘﻐﻴﺭﺍﺕ ﻓﻲ ﻤﺴﺘﻭﻯ ﺍﻟﻬﺭﻤﻭﻨﺎﺕ‪ ،‬ﺇﻟﻰ ﻤﺠﻤﻭﻋﺔ ﻟﺩﻴﻬﺎ ﻨﻘﺼﺎﻥ ﻓﻘـﻁ ﻓـﻲ‬

‫)‪(T3, T4, TSH‬ﻤﺠﻤﻭﻋﺔ ﻟﺩﻴﻬﺎ ﻨﻘﺼﺎﻥ ﻓـﻲ (‪ ،(T3, T4‬ﻤﺠﻤﻭﻋﺔ ﻟﺩﻴﻬﺎ ﻨﻘﺼﺎﻥ ﻓﻲ )‪)T3‬‬

‫‪(T4).‬ﻭﻤﺠﻤﻭﻋﺔ ﺃﺨﺭﻯ ﻟﺩﻴﻬﺎ ﺯﻴﺎﺩﺓ ﻓﻲ‬

 ‫ﺃﻴﻀﹰﺎ ﺨﻠﺼﺕ ﺃﻥ ﻫﻨﺎﻟﻙ ﻋﻼﻗﺔ ﺒﻴﻥ ﺤﺩﺓ ﺍﻟﻤﺭﺽ ﻭﺍﺴﺘﻌﻤﺎل ﺍﻟﻌﻘﺎﻗﻴﺭ ﺍﻟﺘﻲ ﻟﻬﺎ ﺁﺜﺭ ﻋﻠـﻰ‬

‫ﻨﺸﺎﻁ ﺍﻟﻐﺩﺓ ﺍﻟﺩﺭﻗﻴﺔ ﻭﻤﺩﻯ ﺍﻟﺘﻐﻴﺭﺍﺕ ﺍﻟﺘﻲ ﺘﺤﺩﺙ ﻓﻲ ﻤﺴﺘﻭﻯ ﻫﺫﻩ ﺍﻟﻬﺭﻤﻭﻨﺎﺕ‪.‬‬

‫ﻓﻲ ﻨﻬﺎﻴﺔ ﺍﻟﻤﻁﺎﻑ ﺃﻭﺼﺕ ﺍﻟﺩﺭﺍﺴﺔ ﺒﺈﺠﺭﺍﺀ ﺩﺭﺍﺴﺔ ﺃﺨﺭﻯ ﺒﺼﻭﺭﺓ ﺃﻜﺒﺭ ﻤﻥ ﻫـﺫﻩ ﻭﺘﺤـﺕ‬

‫ﻅﺭﻭﻑ ﺘﺤﻜﻤﻴﺔ ﻟﻤﺭﺍﻗﺒﺔ ﻭﻅﻴﻔﺔ ﺍﻟﻐﺩﺓ ﺍﻟﺩﺭﻗﻴﺔ ﺃﺜﻨﺎﺀ ﺍﻟﻤﺭﺽ ﻭﺒﻌﺩ ﺍﻟﺸﻔﺎﺀ‪ .‬ﻭﺃﻴﻀﹰﺎ ﺃﻭﺼﺕ ﺒﻌـﺩﻡ‬

‫ﻋﻤل ﺃﻱ ﻓﺤﺹ ﻟﻬﺭﻤﻭﻨﺎﺕ ﺍﻟﻐﺩﺓ ﺃﺜﻨﺎﺀ ﺍﻟﻤﺭﺽ ﺇﻻ ﺇﺫﺍ ﻜﺎﻥ ﻫﻨﺎﻟﻙ ﺩﻟﻴل ﻗﻭﻱ ﻋﻠﻰ ﻭﺠﻭﺩ ﺇﺼـﺎﺒﺔ‬

‫ﻓﻲ ﺍﻟﻐﺩﺓ ﺍﻟﺩﺭﻗﻴﺔ ﻭﺇﺫﺍ ﺘﻡ ﻫﺫﺍ ﺍﻟﻔﺤﺹ‪ .‬ﻴﺠﺏ ﺃﻥ ﻴﻌﺎﺩ ﺒﻌﺩ ﺸﻔﺎﺀ ﺍﻟﻤﺭﻴﺽ‪ ،‬ﻜﻤﺎ ﺃﻭﺼﺕ ﺒﺄﻥ ﺘﻜﻭﻥ‬

‫ﻫﻨﺎﻟﻙ ﻋﻼﻗﺔ ﻤﺎ ﺒﻴﻥ ﺍﻟﻁﺒﻴﺏ ﺍﻟﻤﻌﺎﻟﺞ ﻭﺃﺨﺼﺎﺌﻲ ﻋﻠﻡ ﺍﻷﻤﺭﺍﺽ ﻭﺃﻥ ﻴﻤﻸ ﺃﻭﺭﻨﻴﻙ ﻁﻠﺏ ﺍﻟﻔﺤـﺹ‬

‫ﺒﻜل ﺍﻟﻤﻌﻠﻭﻤﺎﺕ ﺍﻟﻤﻬﻤﺔ ﻟﻜﻲ ﺘﺴﺎﻋﺩ ﻓﻲ ﻓﻬﻡ ﻨﺘﺎﺌﺞ ﺍﻟﻔﺤﻭﺼﺎﺕ‪ .‬ﻭﺃﻴﻀﹰﺎ ﺃﻭﺼﺕ ﺒﺄﻥ ﻴﻜـﻭﻥ ﻟﻜـل‬

‫ﻤﻌﻤل ﺍﻟﻤﻌﺩل ﺍﻟﻁﺒﻴﻌﻲ ﻟﻨﺘﺎﺌﺞ ﺍﻟﻔﺤﻭﺼﺎﺕ ﺍﻟﺨﺎﺼﺔ ﺒﻪ‪.‬‬

 LIST OF FIGURES
Page

Figure 1: Distribution of studied patients according to age 61

Figure 2: Distribution of studied patients according to sex 62

Figure 3: Distribution of studied patients according to residence 63

Figure 4: TSH levels in studied patients 64

Figure 5: TT4 levels in studied patients 65

Figure 6: TT3 levels in studied patients 66

Figure 7: FT3 levels in studied patients 67

Figure 8: FT4 levels in studied patients 68

Figure 9: Distribution of the studied patients according to the

duration of illness 69

Figure 10: Distribution of the studied patients according to the

receiving drugs 70
 LIST OF TABLES
Page
Table 1: Relation between TT3 and TT4 levels in studied
patients 71
Table 2: Relation between TT3 and TSH levels in studied
patients 71
Table 3: Distribution of studied population according to thyroid
hormone levels 72
Table 4: Alteration of TSH levels in studied population
according to condition of the patients 72
Table 5: Alteration of TT4 levels in studied patients according
to condition of the patients 73
Table 6: Alteration of TT3 levels in studied patients according
to condition of the patient 73
Table 7: Alteration of FT3 levels in studied patients according
to condition of the patients 74
Table 8: Alteration of FT4 levels in studied patients according
to condition of the patients 74
Table 9: Alteration of TSH levels in studied patients according
to the clinical diagnosis 75
Table 10: Alteration of TT3 levels in studied patients according
to the clinical diagnosis 76
Table 11: Alteration of TT4 levels in studied patients according
to the clinical diagnosis 77
Table 12: Alteration of FT3 levels in studied patients according
to the clinical diagnosis 78
Table 13: Alteration of FT4 levels in studied patients according
to the clinical diagnosis 79
Table 14: Effect of drugs on TSH levels in the studied patients 80
Table 15: Effect of drugs on T4 levels in the studied patients 80
Table 16: Effect of drugs on T3 levels in the studied patients 81
Table 17: Effect of drugs on FT4 levels in the studied patients 81
Table 18: Effect of drugs on FT3 levels in the studied patients 82
Table 19: Thyroid hormones level sin the studied controls 82
Table 20: Statistical test comparing TSH levels in the studied
controls and patients 83
Table 21: Statistical test comparing TT4 levels in the studied
controls and patients 83
Table 22: Statistical test comparing TT3 levels in the studied
controls and patients 84
Table 23: Statistical test comparing FT3 levels in the studied
controls and patients 84
Table 24: Statistical test comparing FT3 levels in the studied
controls and patients 85
 INTRODUCTION AND LITERATURE REVIEW

1.1. Anatomic and functional embryology:

The human thyroid gland is first recognizable about one

month after conception when the embryo is approximately 3.5 to 4

mm in length.

The embryogenesis and certain aspects of the thyroid

function are closely interlinked with the gastrointestinal tract (1).

Thyroid tissue is present in all vertebrates. In mammals the

thyroid originates from an evagination of the floor of the pharynx,

and a thyroglossal duct marking the path of the thyroid from the

tongue to the neck sometimes persists in the adult.(2)

The thyroid gland, located immediately below the larynx on

each side of and anterior to the trachea, is one of the largest of the

endocrine glands, normally weighing 15 to 20 grams in adults.(3)

The normal thyroid is made up of two lobes joined by a thin band of

tissue, the isthmus. Two connective-tissue capsules enclose the

gland. The outer is not well defined and attaches the thyroid to the

trachea. On the posterior surface of the thyroid, the two pairs of

parathyroids are situated between the two capsules.(4) Two pairs of

vessels constitute the major arterial blood supply, namely the

superior thyroid artery, arising from the external carotid artery, and
the inferior thyroid artery, arising from subclavian artery. Estimates

of thyroid blood flow range from 4 to 6 ml/min/gm.(1)

The thyroid is innervated by both adrenergic and

cholinergic nervous systems via fibers arising from the cervical

ganglia and vagus nerve, respectively.(1)

1.2. Histology:

The functional unit of the gland is the thyroid follicle or

acinus. This consists of cuboidal epithelial cells arranged as

roughly spheroidal sacs, the lumen of which contains colloid. (4)

The height of follicular cells varies among follicles

depending on their state of activity. In highly active follicles, the

epithelium is mainly cuboidal, whereas in less active follicles the

epithelum appears flattened.(5) Each follicle is surrounded by a

basement membrane and the parafollicular, calcitonin-secreting, c-

cells lie between this membrane and the follicular cells.(4) The c-

cells produce the polypeptide calcitonin, which is involved in

calcium regulation. From 20 to 40 follicles are demarcated by

connective tissue septa to form a lobule supplied by a single artery.

The function of a lobule may vary from that of its neighbors.(1)

Microvilli project into the colloid from the apexes of the thyroid

cells, and canaliculi extend into them. There is a prominent

endoplasmic reticulum, a feature common to most glandular cells

and secretory droplets of thyroglobulin are seen.(1, 4)

1.3. Formation and secretion of thyroid hormones:

The principal hormones secreted by thyroid are thyroxine (T4)

and tri-iodothyronine (T3). (2, 3) T3 is also formed in peripheral tissues by
deiodination of T4; both hormones are iodine-containing amino acids. A
small amount of reverse tri-iodo-thyronine (3, 3', 5'-tri-
iodothyronine, RT3) is also found in thyroid venous blood. T3 is more
active than T4, whereas RT3 is inactive,(2) about 93 percent of
metabolically active hormone secreted by the thyroid gland is thyroxine,
and 7% tri-iodothytonine. Tri-iodothyronine (T3) is about four times as
potent as thyroxine, but it is present in the blood in much smaller
quantities and persists for much shorter time than does thyroxine.(3)
Iodine is the most important element in the biosynthesis of
thyroid hormones. Approximately 150 mg of iodine is absorbed in the
intestine each day. The thyroid gland has a very high attraction for iodine
and traps about 70 mg/day at the base of the cell by active transport. The
iodide is then transported to the follicular lumen. The iodide molecule is
oxidized by peroxidase, presumably at the interface of the cell and the
lumen, to a more reactive form, I0 or I+. This form combines with the
glycoprotein thyroglobulin.(6) This glycoprotein is made up of two
subunits and has a molecular weight of 660,000. It contains 10%
carbohydrate by weight, and also contains 123 tyrosine residues, but only
four to eight of these are normally incorporated into thyroid hormones.(2)
Thyroglobulin acts as a preformed matrix containing tyrosyl
groups to which the reactive iodine attaches to form the hydroxyl residues
of monoiodotyrosine (MIT) and diidotyrosine (DIT).
The next step is the enzymatic coupling of the iodinated tyrosine
molecules, catalyzed by peroxidase to form T4 or T3. The coupling of two
DIT molecules forms T4. The coupling of one DIT molecule and one MIT
molecule result in the formation of T3 (3, 5, 3' - T3) or reverse T3 (rT3)
of (3, 3', 5' - T3).(6)
1.4. Storage and release of hormones:

After synthesis of the thyroid hormones has run its course,

each thyroglobulin molecule contains up to 30 thyroxine molecules

and a few triiodothyronine molecules, in this form, the thyroid

hormones are stored in the follicles in an amount sufficient to

supply the body with its normal requirements of thyroid hormones

for 2 - 3 months. Release of thyroid hormones involves pinocytosis

of the colloid by follicular cells, fusion with lysosomes to form

phagocytic vacuoles and proteolysis.(7) Thyroid hormones are

hence released into blood stream. Proteolysis also results in the

liberation of mono and di-iodothyronines (MIT and DIT), these are

usually degraded within thyroid follicular cells and their iodine is

retained and re-utilized. A small amount of thyroglobulin also

reaches the blood stream.(7)

Thyroid hormones in the blood are transported almost

completely bound to specific binding proteins. The bound forms of

the hormones are inactive.(7,8) The bound form of T4 accounts for

99.97% of all T4, and the bound form of T3 accounts for 99.8% of

the circulating level of the hormone, only 0.03% of T4 and 0.2%

ofT3 circulate in a free non-protein bound, form.(8) T4 and T3 are

bound in a firm but reversible bond to several proteins, all of which

are synthesized in the liver.(9,10) There are three thyroid hormone

binding proteins, thyroxine binding globulin (TBG), transthyretin in

(TTR) thyroxine-binding prealbumin (TBPA), and thyroxine-binding

albumin (TBA).(7,8) T4 binds predominately to (TBG), (70% - 75%),

to a lesser extent to TTR (15% - 20% and to a slight extent to

albumin (10%). T3 is bound by TBG and TBA but very little by

TTR. Normally, only one third of the available protein binding sites

are occupied by the thyroid hormones. (7)

The amounts of thyroid-binding proteins vary in some

(8)
physiologic and pathologic state, e.g. TBG is increased during

pregnancy, genetically or by estrogen. It may decrease due to

genetic absence, protein losing states causing disease, severe

illness, acromegaly and androgens.(6)

The binding globulins serve to increase the duration of the

hormones in plasma by protecting them from degradation and renal

excretion. They also buffer the organism from abrupt changes in

hormone level.(8) The binding may also reduce the amount of

thyroid hormones lost through the kidneys and it has been

suggested that the binding protein may have a specific role in

facilitating hormone uptake by cells.(7)

1.5. Metabolism of thyroid hormones:

The most important pathway for metabolism of T4 is the

monodeiodination of its outer ring to form the active thyroid

hormone T3. (11, 12) Inner-ring deiodination of T4 and T3 and further

deiodination reactions deactivate the hormones. (13, 14)

One-third of the circulating T4 is normally converted to T3

in adult humans, and 45% is converted to RT3, only about 13% of

circulating T3 is secreted by the thyroid and 87% is formed by

deiodination of T4. Similarly, only 5% of circulating RT3 is secreted

by the thyroid and 95% is formed by deiodination of T4. Two

different enzymes are involved, 5- deiodinase catalyzing the

formation of T3 and 5- deiodinase catalyzing the formation of

RT3.(2) Three deiodinases have been identified in mammalian

tissues.(15,16)

Deiodinases 1 and 2 (D1 and D2) catalyze outer-ring

monodeiodination, thereby producing T3. D1 also catalyzes

removal of an inner-ring iodine from T3 and T4 prefers and the

sulfated derivatives as substrates.(1) The type 3 deiodinase (D3) is

an obligate inner ring monodeiodinase with a preference for T3 as

substrate.(1) The deiodinase in liver and kidney microsomes is a

type I iodothyronine deiodinase (5-D1).

Type II deiodinase (5- D II) is found in the brain, the

pituitary and brown fat. Type III deiodinase (5-DI) is found in the

placenta and brain. 5' - DI is unique in that it contains the rare

amino acid slenocystine in which the sulfur in cysteine is replaced

by selenium i.e. it is a selonoprotein.(2) In the liver, T4 and T3 are

conjugated to form sulfate and glucuronides. These conjugates

enter the bile and pass into the intestine. The thyroid conjugates

are hydrolyzed, and some are reabsorbed, but some are excreted
in the stool. In addition, some T4 and T3 pass directly from the

circulation to intestinal lumen.(2)

1.6. Regulation of thyroid hormones:

The hypothalamic-pituitary-thyroid axis (HPTA) is the

neuroendocrine system that regulates the production and secretion

of thyroid hormones.(6) In addition, there is an inverse relationship

between the glandular organic iodine level and the rate of hormone

formation. Such autoregulatory mechanisms serve to stabilize the

rate of hormone synthesis despite fluctuations in the availability of

substrate such as iodine.(1)

Regulation of the thyroid begins with the hypothalamus.

Thyrotropin-releasing hormone (TRH) is a tripeptide released by

the hypothalamus. It travels along the hypothalamic stalk to the

beta cells of the anterior pituitary, where it stimulates synthesis and

release of thyrotropin or thyroid stimulating hormone (TSH).(6) TRH

binds to a receptor in thyrotrope membrane(17,18) for induction of the

thyrotrope response.(1) The neuron bodies producing TRH are

innervated by catecholamine, neuropeptide and somatostatin-

containing axons, all of which potentially influence the rate of

synthesis of the prepro-TRH molecule.(1) T3 suppresses the level of

prepro-TRH mRNA by T3 in the hypothalamus,(19,20) but normal

feedback regulation of prepro-TRH mRNA synthesis by thyroid

hormone required a combination of T3 and T4 in the circulation, the

latter giving rise of T3 via direct local synthesis in the central

nervous system at the pituitary level.(20) The secretion of TSH

seems to be regulated by an interplay of negative feedback from

circulating free T3 and T4, TRH, and inhibitory hypothalamus

neurotransmitters, such as somatostatin and dopamine.(21,22)

TSH is a glycoprotein secreted by the thyrotropes in the

anteromedial portion of adenohypophysis. TSH is composed of an

alpha-subunit of about 14 kd that is common to luteinizing hormone

(LH), follicle stimulating hormone (FSH), and human chorionic

gonadotrophin (HcG) and a specific beta-subunit that in the case of

TSH, is a 112 amino acid protein.(23,24) TSH acts like other

polypeptide hormones in that when it binds with receptor sites, it

activates adenyl cyclase, which then catalyses a reaction to

produce cyclic adnosine monophosphate (AMP).(25,26) The biologic

half-life of human TSH is about 60 minutes. TSH is degraded

mostly in the kidney and to a lesser extent in the liver.(1,2)

TSH is the main stimulus for the uptake of iodide by the

thyroid gland and also stimulates the activation of the protease

enzymes, which in turn catalyze the hydrolysis of thyroglobulin, the

storage forms of T4 and T3. TSH also acts to increase the size

and number of follicular cells. (7)

TRH acts in the thyrotrope to stimulate the release and

later synthesis of TSH, while thyroid hormones (T3, T4) inhibit

these functions.(1)

The influence of iodine availability, in contrast to the

feedback control effected via TSH which maintains the plasma or

tissue concentration of the thyroid hormones, acts as an intrinsic

autoregulatory mechanism to maintain the constancy of thyroid

hormone stores and also plays a role in the capacity of the thyroid

to overcome factors that impair hormone synthesis.(1)

1.7. Mechanism of action:

Thyroid hormones enter cells, and T3 binds to thyroid

receptors (TR) in the nuclei. T4 can also bind but not as avidly. The

hormone-receptor complex then binds to DNA via zinc fingers and

affects the expression of a variety of different genes that code for

enzymes, which regulate cell function. Thus, the nuclear receptors

for thyroid hormone are members of the superfamily of hormone-

sensitive nuclear transcription factors.(2)

1.8. Effect of thyroid hormones:

Thyroid hormone actions include calorigenesis and oxygen

consumption by means of regulation of carbohydrate, lipid and

protein metabolism. They also control nervous system activity and

brain development, cardiovascular stimulation, bone and tissue

growth and development, gastrointestinal regulation and sexual

maturation.(2,3,6) So the thyroid gland is essential for normal growth

and development and has many effects on metabolic processes.(7)

1.9. Clinical considerations:

These embrace metabolic manifestations of thyroid

disease related either to excessive or inadequate production of

thyroid hormones. The clinical syndrome that results from

hyperthyroidism is thyrotoxicosis. The term myxodema is often

used to describe the entire clinical syndrome of hypothyroidism, but

it strictly refers to the dryness of the skin.(7)

1.9.1. Thyrotoxicosis:

The term thyrotoxicosis refers to the biochemical and

physiological manifestations of excessive quantities of the thyroid

hormone.(1) The term hyperthyroidism is reserved for disorders that

result from over production of hormone by the thyroid itself, Grave's

disease being the most common. The manifestations depend on

the severity of the disease, the age of the patients, the presence or

absence of extrathyroidal manifestations and the specific disorder

producing thyrotoxicosis.(1)
 The symptoms found in thyrotoxicosis are related to the

catabolic-hypermetabolic effects of thyroid hormones or the

increased metabolic activity in various tissues and increased

sensitivity to catecholamines.(27)

The symptoms may include nervousness, irritability,

insomnia, fine tremor, excessive sweating, heat intolerance,

flushed face, pruritus, tachycardia, frequent bowel movements,

hyperkinesis, weight loss that occurs even though the patient eats

well, gynecomastia, oligomenorrhoea; amenorrhea; decreased

libido, loss of muscles mass, loss of fat stores producing an

increase in plasma fatty acids, a decrease in serum cholesterol and

LDL lipoprotein(9) and apolipoprotein B,(28) a tendency toward

ketosis, a negative nitrogen balance, exercise intolerance, easy

fatigability, dyspnoea on exertion and a warm and moist skin with

patchy depigmentation.(7) There may also be a recession of the

nails from the nail beds, clubbing of the fingers and toes and

swelling of the subcutaneous tissues.(29,30) The hematological

manifestations include a decrease of the white blood cells count

because of a decrease of neutrophils. Lymphocytosis also occurs.

The patient may be physiologically ‘anaemic’ despite an increased

red blood cell mass due to excess demand for oxygen.(26)

Approximately 20% of the patients have hypercalcemia an

 subsequent polyuria. Long term risks include abnormal bone

metabolism leading to osteoporosis, and the development of

cardiac atrial fibrillation, and exopthalmus.(3,6)

Causes of thyrotoxicosis can be divided into two

subcategories based on results of the radioactive iodine uptake

(RAIU) test. Uptake is increased (or normal) in Grave's disease,

toxic multinodular goiter, TSH secreting tumors, trophoblastic

tumours and toxic adenoma. RAIU is suppressed in subacute

thyroditis, silent thyroditis, chronic thyroiditis, struma ovarii,

metastatic thyroid carcinoma or as a result of excessive circulating

iodine (e.g. from x-ray dyes, medications or absorption through the

skin. (31, 32)

1.9.2. Hypothyroidism:

Hypothyroidism occurs when there are insufficient levels of

thyroid hormones to provide metabolic needs at the cellular level.(6)

The incidence of hypothyroidism in the United State is about

0.5%,(33,34) and it affects females about four times as often as

males. Congenital hypothyroidism exists at a rate of around 1 in

4000 births.(35,36)

Many structural or functional abnormalities can impair

production of thyroid hormones and cause the clinical state termed

hypothyroidism. The causes can be divided into three main

categories: (1) Permanent loss or atrophy of thyroid tissue

(primary hypothyroidism) (2) hypothyroidism with compensatory

thyroid enlargement due to transient or progressive impairment of

hormone biosynthesis (goitrous hypothyroidism), and (3)

insufficient stimulation of normal gland as a result of hypothalamic

or pituitary disease or defects in the TSH molecule itself (control or

central hypothyroidism). Primary and goitrous hypothyroidism

account for approximately 95% of cases; only 5% or less being due

to TSH deficiency. (1)

Hypothyroidism can be manifested in all organ systems,

and these manifestation are largely independent of the underlying

disorder, but are functions of the degree of hormone deficiency.(1)

Symptoms of hypothyroidism include enlargement of the thyroid

gland or goiter, impairment of cognition(including memory, speech

and attention span), fatigue, slowing of mental and physical

performance, changes in personality, intolerance to cold, exertional

dyspnoea; hoarseness, constipation, decreased sweating, easy

bruising, muscle cramps, paresthesias, and dry skin.

Hypothyroidism has been shown to be associated with increased

cholesterol, LDL lipoprotein (a), apolipoprotein (b), and an

increased risk of coronary heart disease. As the disease

progresses into severe hypothyroidism, these features worsen and

the condition is referred to as myxodema, which describes non

pitting swelling of the skin.(6)

1.10. Tests of thyroid function:

Laboratory evaluation can be divided into five major

categories: (1) direct tests of thyroid function that provide

information about the handling of iodine. (2) Tests that assess the

state of the hypothalamic pituitary thyroid axis. (3) Tests that

assess the concentration and binding of the thyroid hormones in

the blood, (4) tests that assess the impact of thyroid hormones on

tissues and (5) Miscellaneous tests. (1)

1.11. Exogenous and endogenous factors that

influence thyroid hormone economy:

1.11.1. Pregnancy and maternal-fetal interaction:

Pregnancy affects virtually all aspects of thyroid hormone

economy.(37,38,39) The total serum T4 and T3 concentration rise to

levels twice those of non-pregnant women, owing to the increase in

TBG concentration in the first trimester.(40,41)

Free-T4 and T3 levels also increase slightly during the first

trimester, but return to normal by about 20 weeks of gestation and

remain so until delivery.(37,39,42) This pattern coincides with that of

hCG levels in the first trimester.(43,44) A slight decrease in serum

TSH during the first trimester indicates that the free T4 and T3
changes are not dependant on the hypothalamic pituitary

axis,(45,46,47,48). Owing to the increase in the glomerular filtration rate

(GFR) iodide clearance increases during gestation, leading to

increased dietary requirements. If these requirements are not met

T4 falls, TSH increases and goiter ensues. There is no clinically

significant change in the size of the thyroid during pregnancy in

normal women receiving adequate quantities of iodide.

1.11.2. Age:

Thyroid hormone production rates are higher per unit of

body weight in neonatal infants and children than in adults. When

expressed on a body/weight basis the daily levothyroxine

requirement is about 10mg/kg in the newborn, decreasing to about

1.6 mg/kg in adult. Requirements remain stable, except for an

increase during pregnancy, until the seventh to eight decades

when the T4 production rates decrease to 20%.(49,50)

1.11.3. Glucocorticoids:

Both corticotrophin (adrenocorticotropic hormone "ACTH"),

through its action on the adrenal cortex, and glucocorticoids

influence thyroid function. Pharmacologic doses of these agents

decrease the thyroid RAIU, iodide clearance, and turnover rate.

The fact that these alterations can be reversed by the

administration of exogenous TSH suggests, that glucocorticoids

suppress pituitary TSH secretion.(1)

1.11.4. Gender and gonadal steroids:

Thyroid diseases are more common in women than in

men, and goiter commonly develops during puberty, during

pregnancy and after the menopause.(51,52) Responses of TSH to

TRH are greater in women than in men especially in women older

than age 40 years. Estrogen appears to enhance the response to

TRH, possibly by increasing the number of TRH receptors in the

thyrotropic cells, but responses to TRH do not vary materially

during the menstrual cycle.(53,54)

1.11.5. Growth hormone:

Growth hormone does cause an increase in serum free T3

and a decrease in free T4 in both T4 treated and normal

individuals, suggesting increased conversion of T4 to T3.(55)

1.11.6. Environmental factors:

Repeated exposure to extreme cold for several months

causes a decrease in the total serum T4 concentration, but no

change in free T4. Total but not free T3 also decreases, suggesting

that this could be explained by a decrease in TBG. Only small

seasonal variations in serum T4 and T3 concentration occur in

normal subject.(56)
1.11.7. Nutrition:

Both short term and long term alteration in nutritional state

affect various aspects of thyroid hormone economy especially

peripheral hormone metabolism. When euthyroid lean or obese

subjects are starved the serum total and free T3 can decrease to

subnormal levels. (57, 58) By contrast, total T4 concentration remains

essentially unchanged or increases slightly because of a modest

decrease in iodothyronine binding. As serum T3 concentration

decreases, the concentration of rT3 increases reciprocally usually

to values about twice normal (due to decreased clearance).

Despite the decrease in free T3 concentration with starvation, the

basal serum TSH concentration and the response to TRH are

essentially unaffected.(59,60,61) It seems most likely that TRH

secretion is reduced by starvation and that this is the best

explanation for these phenomena. Chronic malnutrition, as in

protein calorie malnutrition and anorexia nervosa is also associated

with a decrease in serum T3 concentration, serum T4 level also

tends to be slightly decreased, but serum TSH concentrations and

their response to exogenous TRH are usually normal. In contrast,

over-feeding, particularly with carbohydrate, increases the T3

production rate, increases the serum T3 level, lowers the serum

rT3 concentration and increases basal thermogenesis.(62)

1.12. Effects of illness (Euthyroid sick syndrome):

Euthyroid sick syndrome can be described as abnormal

findings on thyroid function tests in the setting of non thyroidal

illness (NTI) without preexisting hypothalamic pituitary and thyroid

dysfunction and after recovery from an NTI, these thyroid function

test result abnormalities should be completely reversible. (63)

Abnormal thyroid hormone levels have been described in

the presence of heart failure, chronic renal failure, liver disease,

stress, starvation, surgery, trauma, infections and autoimmune

diseases as well as with use of a number of drugs,(64) in

gastrointestinal disease, pulmonary diseases, malignancy and

bone marrow transplantation. Multiple alterations in serum thyroid

function test findings in patients with a wide variety of NTI without

evidence of preexisting thyroid or hypothalamic pituitary disease

have been described. The most prominent alterations are low

serum (T3) and elevated (rT3), leading to the general term low T3

syndrome. Thyroid stimulating hormone (TSH), thyroxine (T4), free

T4, and free T4 index (FTI), are also affected to variable degrees

based on the severity and duration of the NTI, as the severity of

NTI increases, both serum T3 and T4 levels drop and gradually

normalized as the patient recovers.

 Figure shows changes in thyroid tests during the course of

non-thyroidal illness

Laurence M. Demers, Ph.D. F.A.C.B and Carole A. Spencer Ph.D., F.A.C.B

NACB: Laboratory Support for the Diagnosis and Monitoring of thyroid Disease

1.12.1. Types of abnormalities:

1- Low T3: this is most commonly encountered abnormality in

non-thyroidal illness. T3 levels fall rapidly within 30 minutes to

24 hours of onset of illness, while rT3 level increases.(64,65)

Thyrotropin (TSH) and total and free T4 level are usually

normal. Low T3 syndrome is thought to be due to a decrease in

T4 conversion to T3 by the hepatic deiodinase system, thus

inhibiting the generation of T3 and preventing the metabolism of

(66)
rT3. The finding of increased rT3 levels differentiates this

syndrome from true hypothyroidism, in which rT3, T3 and T4

levels would most likely all be low, an exception is in patients

with advanced AIDS, in whom baseline rT3 level are already

low.(64)

2- Low T3 and low T4: in patients who are moderately ill, low T3

levels are accompanied by low T4 levels. This has been

described in up to 20% of patients treated in intensive care

units.(63)Free thyroid hormone level are usually normal but may

be decreased in patients treated with dopamine hydrochloride or

corticosteroids. TSH levels may also be normal to low. The

mechanisms involved may be a deficiency in TBG, which leads

to low total thyroid hormone levels. Another possibility is the

presence of a thyroid hormone binding inhibitors, which lower

total thyroid hormone levels. A marked decrease in serum T4 is

 associated with a high probability of death, when serum T4

levels drop below 4 mg/dl the probability of death is about 50%;

with serum T4 levels below 2 mg/dl, the probability of death

reaches 80%.(67,68)

3- Low TSH, low T3, and low T4: this abnormality occurs in

patients with the most severe non-thyroidal illness. Although

most of these patients have TSH levels at the lower end of

normal, TSH may be undetectable in some. The findings of low

TSH and low total T4 and T3 levels suggests altered pituitary

or hypothalamic responsiveness to circulating thyroid hormone

levels. During the recovery period TSH levels return to normal

or may even rise transiently before returning to normal.(69,70,71)

4- Elevated T4: in this condition the total T4 level is elevated,

TSH level is normal or elevated and T3 is normal or high. It

may be seen in primary biliary cirrhosis and acute and chronic

active hepatitis in which TBG synthesis and release are

increased.(72) Elevated levels of total and free T4 have been

reported in patients with acute psychiatric illness.(73) Drugs

such as amiodorone hydrochloride (cardarone), propranolol

hydrochloride (inderal), and iodinated contrast agents also

elevate T4 levels by inhibiting peripheral conversion of T4 to

T3.
 5- Free T3 and free T4: most studies have found free T3

hormone to be depressed and free T4 within the reference

range low or high.(63)

1.12.2. Pathophysiology:

Proposed mechanisms explaining abnormalities in thyroid

hormone levels:

1. Accuracy of test assays in nonthyroidal illness:

Abnormalities of thyroid function test results might

represent test artifacts or true abnormalities. According to one

proposition, the assays would indicate reference range thyroid

hormone levels in the blood if appropriate tests were applied.(63)

2. Inhibition of thyroid hormone binding to thyroid-binding

proteins and tissues:

Some authors propose that serum thyroid hormone

abnormalities are due to inhibition of thyroid hormone binding to

proteins, thus preventing tests from appropriately reflecting free

hormone levels. This binding inhibitor can be present both in the

serum and in body tissues and might inhibit uptake of thyroid

hormones by cells or prevent binding to nuclear T3 receptors, thus

inhibiting the action of the hormone. This inhibitor is associated

with the non-esterified fatty acid fraction in the serum.

 Contrary to this proposition, substantial evidence indicates

that, in an in vivo state, the levels of binding inhibitors do not reach

levels sufficient to influence the circulating levels of free T4, even in

patients who are severely ill. Also, some studies have failed to

demonstrate an existing binding inhibitor.(65)

3- Cytokines:

Cytokines are thought to play a role in NTI-particularly

interleukin (IL)-1, IL-6, tumor necrosis factor (TNF)-alpha, and

interferon-beta. Cytokines are though to affect the hypothalamus,

the pituitary, or other tissues, inhibiting production of TSH, thyroid-

releasing hormone (TRH), thyroglobulin, T3, and thyroid-binding

globulins. Cytokines are also thought to decrease the activity of

type I deiodinase and to decrease the binding capacity of T3

nuclear receptors. (74, 75, 76, 77)

4- Deiodination:

Peripheral deiodination of T4 to T3 is impaired, largely

secondary to decreased activity of type I deiodinase enzyme,

which deiodinates T4 to T3. Diminished enzyme activity accounts

for decreased deiodination of T4 to T3. (78)

An alternative explanation is that reduced tissue uptake of

T4 secondary to deficiency of cytosolic cofactors (e.g. nicotinamide

adenine dinucleotide phosphate, glutathione) results in decreased

substrate for type I deiodinase enzyme. Type I deiodinase is a

selonoprotein; because selenium deficiency is common in critically

ill patients, some propose that selenium deficiency may contribute

to type I deiodinase malfunction.(79) Cytokines (e.g. IL-1 beta, TNF-

alpha, interferon-gamma) decrease type I deiodinase messenger

RNA in vitro. Type I deiodinase does not exist in the pituitary where

T3 levels are within the reference range, because of enhanced

local deiodination. This indicates that an enhancement of

intrapituitary T4 to T3 conversion exists due to pituitary-specific

and brain-specific type II deiodinase.

5- Inhibition of thyroid-releasing hormone and thyroid -

stimulating hormone secretion:

Cytokines, cortisol, and leptin, as well as changes in brain

thyroid hormone metabolism, affect inhibition and secretion of TRH

and TSH. Considerable evidence suggests that an alteration in

hypothalamic and pituitary function cause low production of thyroid

hormone. In rats, starvation reduces hypothalamic messenger

ribonucleic acid (mRNA for TRH, reduces portal serum TRH, and

lowers pituitary TSH content.(80) A recent study also documents

low TRH mRNA in hypothalamic para-ventricular nuclei in NTI

patients.(81)

6- Inhibition of plasma membrane transport of iodothyronines:

 Serum factors, such as bilirubin, nonestrified fatty acids

(NEFA), furanoic acid, hippuric acid, and indoxyl sulphate, which

are present in various NTIs, have been shown to inhibit transport of

thyroid hormones.

7- Thyroxine-binding globulin decreases and desialation:

T4 binding globulin (TBG) is a member of the serine

protease inhibitors. Diminished T4 in NTI has been proposed to be

due to low TBG caused by protease cleavage at inflammatory sites

in acute inflammatory conditions. One other hypothesis for the

cause of disproportionately low serum T4 concentrations in

patients with NTI is the presence of abnormal serum binding due to

Deleted:
(63)
desialation of TBG.

8- Other factors altering serum T4 supply:

Administration of glucagon caused a significant fall in

serum T3, suggesting that the stress-induced hyperglucagonemia

may be a contributor to the NTIS syndrome by altering intracellular

metabolism of T4.(82)

Dopamine given in support of renal function and cardiac

function must play a role in many patients who develop low

hormone levels, while in an intensive care unit setting. Dopamine

inhibits TSH secretion directly, depresses further the already

abnormal thyroid hormone levels, withdrawal of dopamine infusion

is followed by prompt dramatic elevation of TSH, a rise in T4 and

T3 and increase in the T3/rTs ratio.(65)

9- Drugs that influence thyroid function:

Deleted: T

Drugs that decrease TSH secretion: e.g. dopamine, Deleted:

Deleted: Shthyroid hormone

glucocorticoids and octreotide.

Drugs that decrease thyroid hormone secretion: lithium, iodide,

Deleted: aminodarone

and aminoglutethimide.

Drugs that increase thyroid hormone secretion: iodide and

amiodarone.

Drugs that decrease thyroxine absorption: colestipol,

cholestyramine, aluminum hydroxide, ferrous sulphate and

sucralfate.

Drugs that alter thyroxine and triiodothyronine transport in

serum: estrogens, tamoxifen, heroin, methadone, mitotine and

fluorouracil.

Drugs that alter thyroxine and triiodothyronine transport in serum

(decreased serum thyroxine-binding globulin concentration):

androgens, anabolic steroids, slow-release nicotinic acid and

glucocorticoids.

Drugs that alter thyroxine and triiodothyronine transport in serum

(displacement from protein-binding sites): furosemide,

fenclofenac, mefenamic acid and salicylates).

 Drugs that alter thyroxine and triiodothyronine metabolism

(increased hepatic metabolism): phenobarbital, rifampin,

phenytoin and carbamazepine.

Drugs that decreased thyroxine and triiodothyronine metabolism

by decreased thyroxine 5-deiodinase activity e.g. amiodarone,

proylthiouracil and beta adrenergic antagonist.

Certain thyroid function test result abnormalities also have

been characterized in the conditions and NTIs discussed as

follows:

1- Thermal injury: patients with significant burns exhibit typical

euthyroid sick profile values, i.e. low T3 and FT3 with increase

rT3; total T4 and free T4 levels may be slightly decreased

acutely, but normalize after a few days. Basal TSH secretion is

unchanged. (63)

2- Surgery: total T3 falls dramatically on the day of surgery and

remains significantly decreased postoperatively. The degree of

the fall is related to the severity of surgical trauma, an absolute

percent increase of free T3, also occurs on the day of the

surgery. The free T3 concentration rapidly falls to low levels

post operatively, paralleling the decline of total T3. T4 usually is

not altered on the day of surgery. One study demonstrated that

total T4 decreased during surgery with epidural anesthesia, but

increased with general anesthesia. The percent of free T4

increases during surgery and decrease postoperatively. TSH

has been found to be unchanged during surgery except with

hypothalamic surgery in witch TSH increased. (63)

3- Myocardial infarction: in 1-3 days post infarction, total T3 is

low, rT3 is elevated, and basal TSH might be elevated.

(83)
4- Renal disease: Kaptein, et al studied patients with acute

renal failure and found decreased serum T4 and T3 levels and

normal or elevated levels of free T3 and TSH in patients with

acute renal failure, but not in those with critical illness. In this

group of patients rT3 levels tended to be normal. Ramirez et

(84)
al studied patients receiving chronic haemodialysis and

found a striking prevalence of goiter (58%) and low serum T4,

T3, and TSH levels. In the nephrotic syndrome, clinical

presentation and thyroid function test findings mimic

hypothyroidism. Total T4 and free T4 levels can be normal or

reduced. Total T3 is reduced significantly, free T3 is reduced

and rT3 is unchanged in contrast to primary hypothyroidism.

Basal TSH either is unchanged or increased slightly, while TSH

response to TRH is decreased and delayed.(63)

6- Liver disease: patients with alcoholic liver disease, as reported

(85)
by Walfish et al tend to have low serum T3 levels, slightly
 reduced T4 levels, and elevated free T4 indexes because of

low-binding proteins. In chronic biliary cirrhosis and chronic

active hepatitis, as studied by Liewendahl (86) elevated TBG may

be found associated with normal free T3 and free T4 levels.

(87)
Chopra et al studied patients with hepatic cirrhosis and

found T4 to be significantly elevated T3 to be markedly

reduced, free T3 to be low and TSH to be slightly above normal.

7- Infection: in humans, serum T4 and T3 levels fall shortly after

the onset of clinical infection. This reflects decreased TSH

stimulation of the thyroid, decreased thyroidal secretion,

accelerated T4 disappearance and inhibited hormone binding to

transport proteins. With recovery, TSH release resumes and T4

and T3 levels progressively rise.(63)

8- Human immunodeficiency virus infection: patients with

asymptomatic HIV infection or AIDS and without opportunistic

Deleted: concentration within the
reference range. Their FTI value and
infections or hepatic dysfunction have serum T4 and T3 |free T4

concentration also are within the reference range or are slightly

low. Some patients may have| slightly elevated TBG

concentrations, which tend to be inversely related to the

percentage of CD4 cells. Some patient may have small

increases in serum TSH concentration. Patients with AIDS

complicated with Pneumocystis carinii infection or other serious

 infections have thyroid function alterations typical of other

severe NTI.(63)

9- Malignancy: the severity the type and the stage of malignancy

affect thyroid function tests in various ways. Effects on thyroid

function test results also are associated with nutritional status,

Deleted: 63. REF???
(63)
medication and treatment type.

1.12.3. Clinical significance:

In patients with the sick euthyroid syndrome, the degree of

reduction in thyroid hormone levels appears to be correlated with

the severity of non-thyroidal illness and may predict prognosis in

some cases.(64) In studies of the low T3 syndrome.(88) The extent

and rapidity of the decrease in T3 levels correlated with the

mortality rates in patients with tuberculosis. In another study of

patients in an intensive care unit, the mortality rate was 84% in

those with T4 values less than 3 µg/dl compared with 15% in

patients with values above 5 µg/dl.(64)

The frequency of thyroid function abnormalities is related to

the magnitude of the illness. The most common abnormalities are a

T3 reduction, occurring in about 40 -100% of cases of NTI, which

parallels the increase of rT3. As the disease severity increases, T4

levels also decrease. Most of patients who are critically ill have

reduced T4 levels. In patients who are hospitalized with or without

NTIs about 10% have abnormally low TSH values. The high

incidence occurs among the most severely ill group. International

Deleted: 63. REF???
(63)
frequency is the same as in the United States.

Mortality and morbidity depend on the underlying NTI, the

severity and possibly the duration of the illness. The magnitude of

the thyroid function test result abnormalities seem to depend on the

severity rather than the type of illness.(63)T4 is believed to fall in

proportion to severity of illness.(63)

People of all races and both sex are affected equally in

NTI. NTI can affect people at any age. The usual aging process

appears to influence the responsiveness of various tissues to

thyroid hormones, because systemic chronic illnesses are common

in individuals of an advanced age, altered metabolism might be

responsible for abnormal findings on thyroid function testing in

elderly patients experiencing chronic illness.

The examination of each patient with NTI reflects the

characteristics of her or his nonthyroidal illness. Thyroid gland

examination is unremarkable.(63)

1.12.4. Lab studies in non-thyroidal illness:

The recommended tests include the following: Total T4,

total T3, TSH, Free T3, Free T4, and rT3.

Total of thyroxine (TT4):

 T4 has routinely been measured by radioimmunoassay

(RIA). In the total thyroxine (TT4) RIA methodology, thyroid

hormone is first released from the endogenous proteins by the

addition of a reagent.

The sample is then incubated with thyroid antibody and

labeled (I125) T4 in a barbital buffer. After incubation the antigen-

antibody bound portion and the remaining free portion are

separated, and the labeled bound portion is quantified. Calibrator

are run, and the unknowns and controls are extrapolated from

standard curve.

Non isotopic immuno-techniques are widely available. The

principles of these assays are similar to RIA except that the labeled

analyte may be an enzyme as in the enzyme linked

immunosorbant assay (ELISA), a flurophore, or

chemiluminescence. Other immunotechniques may use a double

antibody or a solid-phase system. The enzyme multiplied

immunoassay technique is an enzymatic method that does not

require separation of the free and bound portions.

Serum TT4 level depends on two other major variables

besides rate of thyroid synthesis and release, the first of which is

the serum concentration of T4 binding proteins. The other, the

peripheral conversion of T4 to T3 and rT3.(6)

Free thyroxine index (FT4 I):

Calculated free thyroxine index (FT4I) is an indirect

measurement of free hormone concentrations and is based on the

equilibrium relationship of bound T4 and FT4. The FT4 is

calculated by the following formula:

FT4I = TT4 × THBR

Which THBR is thyroid hormone binding ratio.

FT4I is an adequate indication of thyroid status and has the

advantage of being simple rapid and in expensive, but the direct

free thyroxine assay is better than FT4I in case of extreme protein

abnormalities such as congenital TBG excess or deficiency or

NTI.(6)

Measured free thyroxine (FT4):

Equilibrium dialysis ultra filtration is considered the direct

reference method for FT4 determination. It is the most reliable FT4

test in cases in which severe NTI is concurrent with suspected

thyroid disease. Although reliable, the method is technically

demanding, relatively expensive, and time consuming. It usually

used as a confirmatory test.

Use of FT4 analogs:

 These methods are either one or two step. In the two-step

technique, FT4 is immunoextracted from serum on to a limited

antibody. Next, a washing step eliminated proteins and any others

interfering substances. A second labeled hormone is then added,

which binds to the unoccupied antibody sites. There is a direct

relationship between the patients FT4 and the amount of bound

labeled antibody measured. The one step immunometric technique

is similar to the tow-step technique except the labeled analog is

chemically modified to prevent it from binding to serum transport

protein. FT4 as measured by one-step analog techniques, has

been shown to be affected by protein abnormalities such as

dysalbuminemia, pregnancy, severe illness, and drugs such as

dopamine, amidarone and glucocorticoids.

Fully automated competitive immunoassay is currently available for measurement of FT4. The sample FT4 competes with a
chemiluminescent labeled FT4 analog for a limited amount of antibody. Separation occurs through paramagnetic particles in
the solid phase that are covalently bound to the antibody. The amount of FT4 in the sample is inversely proportional to the
amount of light detected.(6)

Total T3 and Free T3:

Total serum T3 is measured by immunometric techniques

similar to that of TT4. TT3 is not heavy useful as a primary

screening test for hypothyroid disorders because many non-

thyroidal factors affecting binding proteins (e.g. NTI) can influence

level of TT3. Also depend on the rate of formation from T4

peripheral deiodination, which declines during almost all significant

NTIs, stresses, administration of certain drugs and some contrast

media, also FT3 level can be performed along the same manner

as FT4 and Free T3 index is calculated similar to FT4.

Reverse T3:

Metabolically in active reverse T3 (rT3) also can be

measured by immunoassay. Almost all rT3 comes from peripheral

deiodination of T4.

RT3 is commonly elevated in patients with NTI in which the

TT3 level is often reduced.(6)

TSH:

Serum TSH assay is considered to be the first and the best

laboratory test for identification of thyroid abnormalities. The

monoclonal RIA test was not sensitive enough to distinguish

between the very low TSH values found in primary hyperthyroidism

from those found in some healthy euthyroid patients. The high

sensitivity TSH immunometric assays use two or three separate

monoclonal antibodies in the methodologies. The requirement of

binding to more then one site gives higher specificity and

sensitivity. Each new “generation” of TSH assays is characterized

by an approximate ten-fold sensitivity increase compared to the

previous one.
 Todays second generation for TSH have a sensitivity from

0.1 mu/ml to 0.01 mu/ml. Third generation TSH assays have

detection limits of 0.01 mu/ml to 0.005 mu/ml.

A key factor in improvement of sensitivity is incorporation

of chemiluminescent labels instead of radioactive isotopes in the

assays. Currently, work is under way in the development of a fourth

generation of TSH assays.(6)

There are no specific imaging studies that can be used to

diagnose NTI.(63)Thyroid sonogram, thyroid uptake and scan and

other radiological studies have no role in the diagnosis of NTI.

No typical histological findings of thyroid biopsies in NTI

exist. Also no established clinical staging of NTI exists.

The complications depend on the underlying NTI and other

organ systems involved.(63)

1.12.5. Treatment of patients with euthyroid sick syndrome:

The observed alterations in thyroid studies, which

characterized the euthyroid sick syndrome, are generally believed

to be adaptive for the individual. Direct support for the probability of

their euthyroid status is provided by evidence that these patients

do not manifest clinical or laboratory abnormalities suggestive of

hypothyroidism.(89)In the euthyroid sick syndrome, the severity of

illness has been correlated with the magnitude of changes

observed; the lowest T3 value implying the poorest prognosis for

survival. (90, 91)

The implication here is that the more sick the patient, the

more metabolically adaptive may be the low T3 level. Some studies

of the adaptive responses of the organisms to acute or chronic

illness and the function of the thyroid provide evidence that the

response of different tissues to T3 appears to be different in sick

than in euthyroid patients due to an altered nuclear T3 binding

capacity.(92,93)

There is evidence that the inflammatory cytokines, present

in many disease states, influence the responsiveness of the tissues

to thyroid hormones. This is seen at both the nuclear and

cytoplasmic level(94) and could suggest that low T3 and free T3

levels are not the only adaptations in response to illness, but that

the responsiveness of the tissues to T3 is also altered. So

intervention to correct thyroid hormone levels in patients with

serious NTI is controversial, and currently no conclusive studies

indicating long-term benefits, in terms of improving morbidity or

mortality, from the administration of thyroid hormones to critically ill

patients.(89)

Well-conducted studies performed on fasting patients have

provided evidence that the decrease in T3 level is a protective

measure that spares muscle breakdown.(95) Actions of T3 that may

improve the metabolic and haemodynamic outcome in the patients

with myocardial ischaemia, improve surfactant production in

patients with the respiratory distress syndrome, and improve

recovery in patients with renal failure are mostly unproven.(89)

A study assessing treatment of such patients with

levothyroxine sodium has shown no benefit, which may be due to

the inability of these patients to convert administered T4 to the

metabolically active T3. (96)

Controlled studies in which liothyronine sodium was

administered to patients undergoing coronary bypass procedures

showed improvement in cardiac output and lower systemic

vascular resistance in one group of 142 patients and no benefit in

another group of 211 patients.(97,98)

For all of the reasons discussed above it is believed that

there is no indication for the use of thyroid hormone

supplementation in critically ill patients whose thyroid hormone

abnormalities are consistent with the sick euthyroid syndrome. On

the other hand, a judicious trial of therapy with T4 or T3 if the TSH

level is elevated to above 5µ u/ml, especially if the free T4

concentration is also decreased should be initiated. An argument

may be made for using T3 rather than T4 because the sick patients
will only slowly convert the T4 to T3 as a result of the inhibition of

5-deiodinase. (89)

In patients who are moderately ill intervention, aside from

careful monitoring, is not recommended. Thyroid function should

be re-evaluated when the thyroid illness is resolved.(64)

Patients can be assured that this is a transient

phenomenon and that normalization of the findings on thyroid

function tests are expected with the patient's recovery from NTI. (63)
 JUSTIFICATION

As shown above, results of thyroid function

tests are often abnormal in patients who are

acutely ill. Interpreting the tests and knowing

what to do with the results when there is no

other evidence of thyroid dysfunction can be

a challenge.

The changes in patients with non-thyroidal

illness must be distinguished from those

resulting from thyroid disease, a distinction

that is essential for appropriate diagnosis

and therapy, because some clinicians might

consider treatment with thyroid hormone in

hospitalized patients with low serum levels of

T4 and T3 which is usually due to euthyroid

sick syndrome. Moreover, no similar study

was published from Sudan.

OBJECTIVES

To study the pattern of alterations in thyroid

hormone economy in various non-thyroidal

illnesses in Khartoum, Sudan and also to

correlate these alterations with the severity

of the illness.
To become familiar with abnormal thyroid

function test patterns seen in patients with

serious non-thyroidal illness in order to

understand appropriate diagnostic tests

and treatment approaches for managing

thyroid test abnormalities in seriously ill

patients.

2. METHODOLOGY
2.1. Study design, area and duration:

This is a prospective case control hospital-based study,

conducted at Khartoum Teaching Hospital and El Shaab Teaching

Hospital, Khartoum, during the period October 2004 to January

2005.

2.2. Study population:

The study included hospitalized patients with acute or

chronic systemic non-thyroidal illnesses and 21 apparently healthy

age and sex matched adults as a control group.

2.3 Inclusion criteria:

Hospitalized patients with wide variety of NTI such as liver,

cardiovascular, pulmonary and cerebral disease, renal

insufficiency, tuberculosis, sepsis, trauma and post surgery.

The patients had no evidence of thyroid disease during

their hospital stay.

2.4 Exclusion criteria:

Patients who manifested clinical or laboratory abnormalities

suggestive of primary thyroid or pituitary dysfunction.

Patients with a history of thyroid disease, thyroid surgery,

radioisotope and known medications used for treatment of thyroid

disease such as thyroxine or antithyroid drugs.

 Patients with a family history of thyroid disease.

Patients who refused to participate in the study.

2.5 Tools:

2.5.1 Consent:

Verbal consent was taken from the administration of the

hospital, treating doctors and from patients or their relative if they

were severely ill.

2.5.2 Questionnaire:

A questionnaire (appendix 1) was designed, containing

data regarding the personal data, name, age, sex tribe and

residence of the patients. It also contains clinical information such

as clinical diagnosis, duration of illness, condition of the patient and

the drugs used, past medical history and any history of thyroid

disease, surgery or medication.

Examination was done to exclude any signs of thyroid

abnormalities. The levels of thyroid hormones including total T4

and T3, free T4 and T3 and TSH were then recorded.

2.5.3. Study protocol:

Sixty patients with acute (duration of illness less than two

weeks) or chronic (duration of illness more than two weeks) illness.

Patients with severe illnesses (multi organ failure, comatose, ICU

 patients) and patients with moderate illnesses. 21 apparently

healthy adults as controls underwent estimation their serum thyroid

hormones levels. The age of study subjects ranged between 18

and 80 years and included both males and females.

2.5.4. Methods of blood collection:

Blood was collected from patients under aseptic conditions.

Five ml of venous blood were taken by a disposable syringe and

left to clot inside the syringe. Centrifugation was done after

complete clot formation had taken place. Serum was separated in

a plane container and stored at -20°C until the time of analysis.

Grossly Lipaemic or haemolysed samples were excluded.

2.5.5.1. Quantitative measurement of serum

thyroid hormones:

This was done by the Immulite® Automated Immunoassay

analyzer, which is a continuous flow, random access instrument

that performs automated chemiluminescent Immunoassays.

2.5.5.2 Immulite® Product Description and how it works:

(appendix 2)

2.5.5.3. Thyroid hormones measurement by the Immulite®

analyzer:

1- TSH:

Principle of the procedure: Immunometric assay, these

assays can be one- cycle or two-cycle. The unlabeled antigen

binds to the immobilized anti-body and is measured after the

labeled antibody is added.

Material supplied: TSH test unit, each barcode labeled unit

contains one bead coated with monoclonal murine anti-TSH and

barcoded TSH reagent: 6.5 ml alkaline phosphatase conjugated

to polyclonal goat anti-TSH in buffer. Incubation cycle 1 × 60

minutes also TSH adjusters which are two vials of lyophilized

human TSH in serum/buffer matrix (adjustment interval every

four weeks).

Quality control samples used: controls or sample pools with at

least two levels (low and high) of TSH.

Expected values euthyroid 0.4 - 4 µU/ml.

Analytical sensitivity 0.002µU/ml.

Linearity: the assay maintains good linearity even at very low

concentrations of TSH.

Specificity: the antibody is highly specific for TSH.

2- Total T4:

Principle of the procedure: competitive immunoassay, in

which the labeled antigen and the unlabeled antigen compete for

binding sites on the antibody-coated bead. Under these

 conditions, the antibody bound labeled antigen is inversely

proportional to the concentration of the unlabeled antigen.

Incubation cycles: 2 × 30 minutes.

Material supplied: Total T4 test unit. Each barcode labeled unit

contains one bead coated with monoclonal murine anti-T4

antibody. Total T4 reagent wedges also with barcoded 6.5 ml

alkaline phosphatase conjugated to T4.

Quality control used: controls or sample pools with at least two

levels low and high T4 and also by intra-assay and inter-assay

precision.

Specificity: The antibody is highly specific for T4.

Linearity the samples were assayed under various dilutions.

‘Normal’ values: 4.5 - 12.5 mg/dl.

Analytical sensitivity: 0.4 mg/dl.

3- Total T3:

The same as total T4 in the principle of the procedure,

material supplied but here specific free T3 and quality control

procedure. Expected value 81 - 179 ng/dl.

Analytical sensitivity 35 ng/dl.

 4- FreeT3:

Principle of the procedure also competitive analogue-based

immunoassay. The assay employs several features to preserve

the equilibrium between free and protein- bound T3 and to

measure accurately the unbound fraction. Incubation cycles 2 ×

30 minutes.

Material supplied: free T3 test units: each code-labeled unit

contains one bead coated with monoclonal murine anti-T3

antibody. Free T3 reagent wedges with brocades one of them

(LF3A) contain 6.5 ml ligand-labeled T3 analog in buffer with

preservative and (LF3B) and others 6.5 ml alkaline phosphatase

conjugated to anti-ligand in buffer with preservative.

Expected values: 1.5 - 4.1 pg/ml.

Analytical sensitivity: 1.0 pg /ml/

Quality control: also the same as mentioned above and the

antibody is highly specific.

Linearity: since dilution shifts the equilibrium between free and

protein-bound T3, so the assay can not be expected to

maintain linearity under dilution.

Interference and limitations:

1- A variety of drugs which can affect the binding of T3 to the

thyroid hormone carrier proteins.

2- Circulating autoantibody to T3 and hormone binding inhibitor.

3- Heparin has been reported to have both in vivo and in vitro

effects on free thyroid hormones.

4- Heterophilic antibodies in human serum can react with

immunoglobulins included with assay components. Samples

from patients routinely exposed to animals or animal serum

products can demonstrate this type of interference.

5- In rare condition associated with extreme variations in albumin-

binding capacity such as familial dysalbuminemia.

5- FreeT4:

Principle of the procedure: competitive immunoassay,

incubation cycles. 2 x 30 minutes.

Material supplied: the same of free T3 but here specific for

Free T4.

The Immulite free T4 procedure is a direct or single test assay,

in the sense that its results are not calculated as a fraction of

total T4, but interpolated from a stander curve calibrated in

terms of free T4 concentration. In this aspect it differs from

classic equilibrium dialysis methods and from so-called free T4

index determinations as well it requires neither a pre-incubation

steps nor preliminary isolation of the free fraction by dialysis or

column chromatography.
 Quality control as mentioned above.

Expected values: euthyroid: 0.8 - 1.9 ng/dl.

Analytical sensitivity: 0.15 ng/dl.

Specificity: the antibody is highly specific for T4.

Interference the same as free T3.

Statistical analysis:

The data was entered into the computer. The statistical

package (STATA) was used for analysis. The Chi-square test and

t- student test were used to compare the data.

A p value of less than 0,05 was considered statistically

significant.

3. RESULTS

Sixty patients with acute and chronic non-thyroidal illness

and 21 apparently healthy age and sex matched control subjects

were studied using a chemiluminescent enzyme immunoassay of

thyroid hormones. The results were compared with both reference

values provided by the manufacturer of the assay kits and with the

results of the control subjects.

3.1. Characteristics of the studied patients:

3.1.1. Age distribution:

 Among the studied patients the ages ranged from 18-85

years. 21(35%) were between 41-60 years. 19 (31.67%) were

aged between 21-40 years; 13 (21.67%) between 61-80 years;

5(8.33%) had ages less than or equal to 20 years and only

2(3.33%) were >80 years (Fig. 1).

3.1.2. Sex characteristics of the studied patients:

Fourty three patients (71.67%) were males and

17(28.33%) were females (Fig. 2)

3.1.3. Distribution of studied patients according to residence:

The majority, 50 (83.33%) of studied patients were from

the middle of Sudan. Five (8.33%) were from the Eastern Sudan,

two (3.33%) from the North, two (3.33%) were from the West and

one (1.67%) was from the South (Fig. 3). MAP

3.2. Serum levels of thyroid hormones among ALL studied

patients:

3.2.1. Thyroid stimulating hormone (TSH):

Fifty five (91.67%) of the studied patients had normal

serum TSH (0.4 - 4 µ/u/ml), four (6.67%) had low serum TSH
(< 0.4 µ/u/ml) and only one (1.66%) had high serum TSH

(> 4 µ/u/ml) (Fig. 4).

3.2.2. Total thyroxin (TT4):

Forty three (71.67%) of studied patients had normal TT4

(4.5 -12.5 µg/dl), 12(20%) had highTT4 and five (8.33%) had a low

level of TT4 (Fig. 5).

3.2.3. Total tri-iodothyronine (TT3):

Thirty eight (63.33%) of the studied patients had low TT3

(<81µg/dl), 22(36.67%) had normal TT3 (81-179 µg/dl), and none

had high TT3 (Fig. 6). 20 patients out of the 38 with low TT3 had a

TT3 level < 40 µg/dl.

3.2.4. Free triiodothyronine level (FT3):

Thirty-two (53.33%) of the studied patients had a low FT3

and 28 (46.67%) had normal FT3 (1.5 - 4.1 pg/ml) (Fig. 7).

3.2.5. Free thyroxine level (FT4):

Forty one (68.33%) of studied patients had normal FT4

(0.8 - 1.9 µg/dl) and 19 (31.67%) had low FT4 (Fig. 8).

3.2.6. Distribution of studied patients according to the

duration of illness:

Thirty-eight (63.33%) patients had acute illness; 22

(36.67%) had chronic illness (Fig. 9).

3.2.7. Relation between TT3 and TT4 level in studied ALL

patients:

Thirty-two (84.21%) of the studied patients with low TT3

had normal TT4; four (10.53%) had low TT4 and two (5.26%) had

high TT4.

11 (50%) of the studied patients with normal TT3 had normal TT4,

10 (45.45%) had high TT4 and one (4.55%) had low TT4 (Table

1).

3.2.8. Relation between TT3 and TSH level in studied patients:

Thirty three (86.84%) of the patients with low T3 had

normal TSH, 4 (10.53%) of patients with low TT3 had low TSH

and 1(2.63%) patient had a high TSH. All patients with normal TT3

22(100%) had a normal TSH (Table 2).

3.2.9. Distribution of thyroid hormone profiles among studied

patients:

Thirty two (53.33%) had low TT3 only with normal TT4

and TSH, 4 (6.67%) had low TT3, TT4 with normal TSH, one

patient (1.67%) had low T3, TT4 and TSH, 12(20%) had high total

T4 only 1 (18.33%) had a ‘normal’ thyroid profile (Table 3).

3.3 Alteration of thyroid hormone economy in relation to

clinical condition of the patients:

 All studied patients with low TSH (100%) were severely ill, the

one patient who had high TSH was severely ill. (Table 4).

TT4: four (80%) patients who had low TT4 were severely ill; 9

(75%) patients who had high TT4 were severely ill (Table 5).

TT3: 28 (73.68) of studied patients with low TT3 were severely

ill and 10) (26.31%) patients with low T3 were moderately ill

(Table 6).

FT3: 25 (78.13) patients with low free T3 were severely ill and 7

(21.87%) were moderately ill (Table 7).

FT4: 14 (73.68) patients with low FT4 were severely ill and 5

(26.32) were moderately ill (Table 8).

3.4 Distribution of studied patients according to the

duration of illness:

Thirty eight (63.33%) had acute illness, 22 (36.67%) had

chronic illness (Fig. 9).

3.5. Alteration of thyroid hormone economy in relation to

clinical diagnosis (Tables 9 -13):

3.5.1. Renal diseases:

Ten of studied patients had renal disease,( chronic renal

failure and nephrotic syndrome)9 patients had normal TSH, one

patient had a high TSH, 8 patients had low T3 and 2 patients had

low T4, while 7 patients had low free T3 and Free T4.

3.5.2. Tuberculosis:

six patients diagnosed with tuberculosis (pulmonary,

abdominal, Pott's disease ), all patients had normal TSH and TT4,

low TT3 and 5 had low FT3 and only one had low FT4.

3.5.3. Diabetes septic foot (DSF):

Three patients had DSF, all patients had normal TSH, TT4

and low TT3, two had low FT3 and one had low FT4.

3.5.4. Postoperative:

Six patients undergo major surgery, two of them had low

TSH, 5 had low T3 and FT3 and only one had low T4 and 2 had

low FT4.

3.5.5. Anaemic heart failure:

Two patients were suffering from anaemia; both of them

had a normal thyroid profile.

3.5.6. Trauma:

Two patients had trauma (head and chest injury), both had

normal TSH, one had low T3, FT3 and FT4 and another had high

T4 with normal TT3, FT3 and FT4.

3.5.7. Infection:
 Three patients diagnosed had infections, all of them had

normal TSH, two had low TT3 and FT3, and one had low TT4 and

FT4.

3.5.8. Central nervous system (CNS) disease:

Two patients had CNS disease; only one patient had a

high TT4.

3.5.9. Diabetes:

One of studied patient diagnosed with DKA, had low TT3

and FT3.

3.5.10. Cardiovascular disease:

Seven patients suffering from heart failure, all of them had

normal TSH, two of them had low TT3, FT3 and three had a high

TT4 and one had low TT4.

Eight patients with ischemic heart disease (myocardial

infarction and unstable angina admitted to CCU) all of them had

normal TSH, FT3, FT4, only one had low T3 and 5 had high T4.

3.5.11. Liver diseases:

Four patients of studied patients diagnosed as portal

hypertension, all of them had normal TSH, T4 and low T3. Three

of them had low FT3 and FT4.

 Five of the studied patients were diagnosed as hepatic

failure. Two of them had low TSH, all of them had low T3, four had

low FT3, three had low free T4 and only one had low T4.

3.6. Thyroid hormones profile in patients receiving drugs

known to affect thyroid hormones levels:

Thirty eight (63.33%) of study population did not receive

drugs that are known to affect thyroid hormone levels, 22(36.67)

were receiving drugs that are known to affect thyroid hormone

levels (Fig. 10).

TSH: all patients receiving medications known to affect thyroid

hormone levels had TSH levels, which were statistically not

different from those not receiving those medications (P = 0.206)

(Table 14).

TT4: 9 patients were receiving medications known to affect

thyroid hormones level had high TT4, which were statistically

significant when compared to those not receiving those

medications (P = 0.007) (Table 15).

TT3: 6 patients were receiving medications known to affect

thyroid hormone levels had low TT3, which was statistically

significant when compared to those not receiving those

medications (P = 0.000) (Table 16).

 FT4: 6 patients were receiving medications known to affect

thyroid hormones levels and all had low FT4, which was

statistically insignificant when compared to those not receiving

those medications (P = 0.578) (Table 17).

FT3: 5 patients receiving medications known to affect thyroid

hormones levels had low FT3, which was statistically significant

when compared to those not receiving those medications (P

= 0.000) (Table 18).

3.7. Control group:

3.7.1. Thyroid hormone levels in the control group:

Among studied controls TSH levels ranged between

0.46 - 2.3 µu/ml, total T4 level ranged between 5.02 - 11.5 µg/dl,

total T3 level ranged between 80.1 - 140 ng/dl, free T3 ranged

between 2.08 - 3.25pg/ml and free T4 ranged between 0.78 -1.2

ng/dl (Table 19).

3.7.2. Alteration in thyroid hormone levels in studied patients

using the control group as a reference:

Table 20 shows alterations of TSH levels in the studied

patients compared to the studied controls. The difference in

results was statistically insignificant (P<t = 0.34. P>t = 0.627)

 Table 21 shows alterations of TT4 levels in the studied

patients compared to the studied controls. The difference in

results was statistically insignificant (P< t = 0.1477, P >t = 0.852).

Table 22 shows alteration of TT3 levels in the studied

patients compared to the studied controls. The difference in

results was statistically significant (P< t = 1.000; P >t = 0.000).

Table 23 shows alteration of FT3 levels in the studied

patients compared to the studied controls. The difference in

results was statistically significant (P< t = 0.999;P >t = 0.00000).

Table 24 shows alteration of FT4 levels in the studied

patients compared to the studied controls. The difference in

results was statistically insignificant (P< t = 0.8550; P >t = 0.145).

Figures
 Table 1: Relation between TT3 and TT4 levels

in studied patients

TT4 Low Normal High Total

TT3
 Low 4 (10.53%) 32 (84.21%) 2 (5.26%) 38 (100%)

Normal 1 (4.55%) 11 (50.00%) 10 (45.45%) 22 (100%)

Total 5 (8.33%) 43 (71.67%) 12 (20.0%) 60 (100%)

Table 2: Relation between TT3 and TSH levels

in studied patients

TSH Low Normal High Total

TT3

Low 4 (10.53%) 33 (86.84%) 1 (2.63%) 38 (100%)

Normal 0 (0.0%) 22 (100%) 0 (0.0%) 22 (100%)

Total 4 (6.67%) 55 (91.67%) 1 (1.66%) 60 (100%)

Table 3: Distribution of studied population according to

thyroid hormone levels

Thyroid hormones level Frequency Percentage

Low T3 only 32 53.33%

Elevated T4 12 20.0%

Normal thyroid function 11 18.33%

Low T3 and T4 04 6.67%

Low T3, T4 and TSH 01 1.67%

Total 60 100%

Table 4: Alteration of TSH levels in studied population

according to condition of the patients

TSH Condition Total

Moderately ill Severely ill

Low 0 (0.0%) 4 (100%) 4 (100%)

Normal 20 (36.36%) 35( 63.64) 55 (100%)

High 0 (0.0%) 1 (100%) 1 (100%)

Table 5: Alteration of TT4 levels in studied patients

according to condition of the patients

TSH Condition Total

 Moderately ill Severely ill

Low 1 (20.0%) 4 (80%) 5 (100%)

Normal 16 (37.21%) 27( 62.79%) 43 (100%)

High 03 (25.0%) 09 (75%) 12 (100%)

Table 6: Alteration of TT3 levels in studied patients

according to condition of the patient

TSH Condition Total

Moderately ill Severely ill

Low 10 (26.32%) 28 (73.68%) 38 (100%)

Normal 10 (45.46%) 12 ( 54.54%) 22 (100%)

Table 7: Alteration of FT3 levels in studied patients

according to condition of the patients

TSH Condition Total

 Moderately ill Severely ill

Low 07 (21.87%) 25 (78.13%) 32 (100%)

Normal 13 (46.43%) 15 ( 53.57%) 28 (100%)

Table 8: Alteration of FT4 levels in studied patients

according to condition of the patients

TSH Condition Total

Moderately ill Severely ill

Low 05 (26.32%) 14 (73.68%) 19 (100%)

Normal 15 (36.59%) 26 ( 63.41%) 41 (100%)

Table 9: Alteration of TSH levels in studied patients

according to the clinical diagnosis

Clinical diagnosis Low Normal High Total

Renal disease 0 9 1 10

Tuberculosis 0 6 0 6

Diabetic septic foot 0 3 0 3

Postoperative 2 4 0 6

Anaemic heart failure 0 2 0 2

Trauma 0 2 0 2

Infections 0 3 0 3

CNS disease 0 2 0 2

Diabetes 0 1 0 1

Pulmonary 0 1 0 1

Cardiovascular diseases (Heart 0 7 0 7

failure)

Cardiovascular disease 0 8 0 8

(Ischemic heart disease)

Liver disease (PHT) 0 4 0 4

Liver disease (LF) 2 3 0 5

Total 4 55 1 60

P. = 0.561.

Table 10: Alteration of TT3 levels in studied patients

according to the clinical diagnosis

Clinical diagnosis Low Normal Total

Renal disease 8 2 10

Tuberculosis 6 0 6

Diabetic septic foot 3 0 3

Postoperative 5 1 6

Anaemia 0 2 2

Trauma 1 1 2

Infections 2 1 3

CNS disease 0 2 2

Diabetes 1 0 1

Pulmonary 0 1 1

Cardiovascular diseases 2 5 7

(Heart failure)

Cardiovascular disease 1 7 8

(Ischemic heart disease)

Liver disease (PHT) 4 0 4

Liver disease (LF) 5 0 5

Total 38 22 60

P = 0.000

Table 11: Alteration of TT4 levels in studied patients

according to the clinical diagnosis

Clinical diagnosis Low Normal High Total

Renal disease 2 8 0 10

Tuberculosis 0 6 0 6

Diabetic septic foot 0 3 0 3

Postoperative 1 4 1 6

Anaemic heart failure 0 2 0 2

Trauma 0 1 1 2

Infections 0 2 1 3

CNS disease 0 1 1 2

Diabetes 0 1 0 1

Pulmonary 0 1 0 1

Cardiovascular diseases 1 3 3 7

(Heart failure)

Cardiovascular disease 0 3 5 8

(Ischemic heart disease)

Liver disease (PHT) 0 4 0 4

Liver disease (LF) 1 4 0 5

Total 5 43 12 60

P. = 0.362

Table 12: Alteration of FT3 levels in studied patients

according to the clinical diagnosis

Clinical diagnosis Low Normal Total

Renal disease 7 3 10

Tuberculosis 5 1 6

Diabetic septic foot 2 1 3

Postoperative 5 1 6

Anaemic heart failure 0 2 2

Trauma 1 1 2

Infections 2 1 3

CNS disease 0 2 2

Diabetes 1 0 1

Pulmonary 0 1 1

Cardiovascular diseases 2 5 7

(Heart failure)

Cardiovascular disease 0 8 8

(Ischemic heart disease)

Liver disease (PHT) 3 1 4

Liver disease (LF) 4 1 5

Total 32 28 60

P = 0.020

Table 13: Alteration of FT4 levels in studied patients

according to the clinical diagnosis

Clinical diagnosis Low Normal Total

Renal disease 7 3 10

Tuberculosis 1 5 6

Diabetic septic foot 1 2 3

Postoperative 2 4 6

Anaemic heart failure 0 2 2

Trauma 1 1 2

Infections 1 2 3

CNS disease 0 2 2

Diabetes 0 1 1

Pulmonary 0 1 1

Cardiovascular diseases 0 7 7

(Heart failure)

Cardiovascular disease 0 8 8

(Ischemic heart disease)

Liver disease (PHT) 3 1 4

Liver disease (LF) 3 2 5

Total 19 41 60

P = 0.044

Table 14: Effect of drugs on TSH levels in the studied patients

TSH level Low Normal High Total

Drugs
Not receiving drugs 4 33 1 38

Receiving drugs 0 22 0 22

Total 4 55 1 60

P = 0.206

Table 15: Effect of drugs on T4 levels in the studied patients

T4 level Low Normal High Total

Drugs

Not receiving drugs 3 32 3 38

Receiving drugs 2 11 9 22

Total 5 43 12 60

P = 0.007

Table 16: Effect of drugs on T3 levels in the studied patients

T3 level Low Normal Total

Drugs
Not receiving drugs 32 6 38

Receiving drugs 6 16 22

Total 38 22 60

P = 0.000

Table 17: Effect of drugs on FT4 levels in the studied patients

FT4 level Low Normal Total

Drugs

Not receiving drugs 13 25 38

Receiving drugs 6 16 22

Total 19 41 60

P = 0.578

Table 18: Effect of drugs on FT3 levels in the studied patients

 FT3 level Low Normal Total

Drugs

Not receiving drugs 27 11 38

Receiving drugs 5 17 22

Total 32 28 60

P = 0.000

Table 19: Thyroid hormones level sin the studied controls

Variables Observation Minimum Maximum

TSH 21 0.46 µu/ml 2.3 µu/ml

TT4 21 5.02 µg/dl 11.5 µg/dl

TT3 21 80.1ng/dl 140 ng/dl

FT3 11 2.08 pg/ml 3.25 pg/ml

FT4 11 0.78 ng/dl 1.2 ng/dl

P = 0.206

Table 20: Statistical test comparing TSH levels in the studied

controls and patients

Group Observation Mean Standard deviation

Control 21 1.3052 0.4605

Patients 60 1.3967 0.9929

P < t = 0.3429 P>t = 0.6571

Table 21: Statistical test comparing TT4 levels in the studied

controls and patients

Group Observation Mean Standard deviation

Control 21 7.9314 1.9209

Patients 60 8.8265 3.7138

P < t = 0.1477 P>t = 0.8523

Table 22: Statistical test comparing TT3 levels in the studied

controls and patients

Group Observation Mean Standard deviation

Control 21 107.1667 18.10274

Patients 60 55.2533 44.83916

P < t = 1.0000 P>t = 0.0000

Table 23: Statistical test comparing FT3 levels in the studied

controls and patients

Group Observation Mean Standard deviation

Control 11 2.5290 0.3636

Patients 60 1.21066 1.102485

P < t = 0.9999 P>t = 0.0001

Table 24: Statistical test comparing FT3 levels in the studied

controls and patients

Group Observation Mean Standard deviation

Control 11 0.99318 0.132141

Patients 60 0.87538 0.360162

P < t =0.9999 P>t = 0.0002

4. DISCUSSION

For more than three decades it has been known that serum

thyroid hormone levels drop during starvation and illnesses.(65) To

characterized these changes and to correlate them with severity of

the disease, types of illnesses and medications used during the

illnesses, this study was done.

The majority of patients were above 40 years of age. Males

predominated over females in this study because some of the

female patients refused donation of a blood sample for research

purposes.

Also patients from the central area of Sudan predominated,

although they were from different tribes. This could be explained

by migration of all these tribes to the central area in which this

study was conducted. In this study these Sociodemographic

characteristics may not be so important because people of all

(63)
races and both sexes at any age are equally affected

The non-thyroidal illnesses in this study were associated with

a prompt decline in serum T3 and serum free T3 in about (63.33%)

and (53.33%) of studied patients respectively. These results agree

with the literature in that a reduction in TT3 was (40 - 100%) of

cases.(63) Patients who had only TT3 reduction, a condition

described as low T3 syndrome, occurred in 32 patients out of 38

with low TT3, The main explanation given for this syndrome is the

reduction of T4 conversion to T3 by the hepatic deiodinase system,

which is affected by cytokines,(74,75,76) and selenium deficiency.(79)

In the T3 syndrome rT3 is usually elevated, and it is important to

differentiate the NTI syndrome from true hypothyroidism in which

rT3 is also reduced. rT3 was not included in this study because no

reagent for its assay was available in Sudan at the time of the

study and also due to financial constraints on the research budget.

The thyroxine levels in the majority of studied patients were

normal. 32 out of 43 with normal TT4 had low T3 and this supports

what has been mentioned above in that a reduction of total T3 is

due to a decrease of peripheral conversion of T4 to T3.

Five patients had low TT4, which usually occurs due to

decreased T4 binding by TBG or existence of binding inhibitors.

Another explanation is protease cleavage of TBG in inflammatory

sites.(63)

It has been reported that as the severity of illness progresses

there is a gradual development of a more complex syndrome

associated with both low T3 and low T4 levels.63) This occurred in 4

patients in this study who were severely ill and the total T3 was

markedly low below the sensitivity of the instrument. They also had

very low FT3 and FT4 and this agrees with the literature.(65)

A number of studied patients had a high level of total T4 12

(20%). 10 of them had only high TT4 .The majority of these 10

patients (8 patients) were suffering from cardiovascular problems

and were admitted to the CCU.

In the literature many factors have been reported to increase

total T4,(73) but in this study drugs seemed to play a major role

because most of the patients studied received amidarone

hydrochloride (cardarone) and propranolol hydrochloride - drugs

known to decrease thyroxine 5-deiodinase activity and so alter

thyroxine to tri-iodothyronine metabolism.(63)

Two patients had a high TT4 but low TT3. No clear

explanation was found for this finding but it has been suggested

that such patients may have underlying subtle evidence of

autonomous thyroid function that causes persistence of T4

secretion despite impairment of T4 metabolic clearance by illness

in those patients and hence the TT3 level is reduced.(1)

Free T4 is believed to represent the hormone available to tissues

and measurement of total serum T4 has only limited value. Nearly

all of the circulating T4 is bound to TBG, TBP and albumin

(ALB)(7,8)

41 of the studied patients (68.33%) had normal FT4 and we

found that all patients with high TT4 had a normal FT4 and these

findings support the explanation of high TT4 being due to the

effect of medication and not true hyperthyroidism. 19 patients

(31.67%) had low FT4 and these patients were critically ill and

suffering from renal and liver problems . this agrees with the

literature that FT4 could be low, high or within the reference

range.(63) In this study no patient had a high level of FT4 because

the results of FT4 assays in NTI are definitely method dependant

and may be influenced by a variety of variables, including inhibitors

present in serum,(65) which may have been eliminated by the highly

specific assay method used in this study. Also this study disagreed

with a study reported in 1982 by Melmed, et al.(65) In that study

patients reported with non-thyroidal illness who had normal serum

TT4 typically did not have reduced FT4 by most assay methods

whereas in this study some patients had low FT4 in spite of normal

TT4 and they were critically ill with very low levels of TT3 and FT3.

The major problem in understanding the NTIs is in analyzing data

on the level of FT4 because of the different assay methods used by

different laboratories .(65)

An important finding in this study is the normal TSH

concentration in 55(91.67%) of patients which is highly suggestive

of NTIS because TSH was not elevated in the presence of low T3

or T4 indicating that the patients are not hypothyroid. TSH was also

not reduced in the presence of high TT4 indicating that the patients

are not hyperthyroid and that these alterations are most probably
due to the effect of the illness which decreased the sensitivity of

TSH secretion to serum T3 and T4 concentration.(65)

Four patients who had a low level of TSH were severely ill

and admitted to the ICU or comatose and they also had very low

TT3 and FT3. This lowering of TSH is thought to be due to the

(80)
effect of cytokines or drugs such as dopamine.(63) The most

important differential diagnosis here is secondary hypothyroidism in

which also low TT3, TT4 and TSH test results occur and it is

excluded by additional tests such as cortisol, gonadotropins and

prolactin assays. One patient had elevated TSH. Elevation of TSH

test results occurs commonly in patients recovering from

illnesses.(63,65)

In the euthyroid sick syndrome, the severity of illness has

been correlated with the magnitude of changes observed,(89) and it

was clear in this study that alteration in thyroid function tests

occurs more frequently in patients who are severely ill. In these

patients illness may be complicated by number of medications.(1) In

such patients serum TT3 and FT3 were undetectable; serum T4

concentrations were reduced markedly or elevated. FT4 levels

were abnormal and TSH was also low in these critically ill patients.

The relation between reduction and severity of the disease was

statistically significant in the case of FT3, because the more sick

the patient, the more metabolically adaptive he/she may be the

lower the TT3 level.(89) In this study some patients with

cardiovascular disease who were severely ill had high TT4 with

normal TT3. 75% of patients who had elevated TT4 level were

severely ill. 91% of the patients had normal TSH, but all patients

who had low TSH levels were severely ill.

Regarding the clinical diagnosis of studied patients, there are

three major groups, renal, liver and cardiovascular disease.

Patients suffering from renal problems, mainly chronic renal failure

- most of them on regular dialysis, one of them diagnosed as

nephrotic syndrome and his thyroid function test findings mimicked

hypothyroidism, but basal TSH was unchanged and this agreed

with the study by Ramirez, et al.(84) Also in patients with chronic

renal failure, there was significant reduction in the level of TT3, FT3

and FT4, but TSH was normal in all patients except one who had

elevated TSH . This patient could be in the recovery phase which

also agrees with the study by Ramirez, et al.(84).

In patients suffering from cardiovascular disease - congestive

heart failure or ischemic heart disease, the reduction of TT3 and

FT3 was not like that in other severely ill patients and did not agree

with the literature, because these patients, specially those who

were admitted to the CCU (8 patients), had elevated TT4 which is

probably explained by the use of medications which also affect the

metabolism of TT3, so TT3 was not markedly low or was even

normal. The reduction of TT3 could be overcome by the effect of

medication,(63)especially in patients with myocardial infarction. The

finding of normal TSH in all patients suggests that TSH may be

important to differentiate between the euthyroid sick syndrome and

hyper or hypothyroidism as the cause of cardiovascular disease

especially congestive cardiac failure.

All patients suffering from liver problems had low TT3 and 7

out of 9 had low free T3 and this could be explained by the

impairment of peripheral conversion of T4 to T3, which depends

mainly on the liver. Only one patient had a low TT4. TSH level was

reduced in 2 patients who had hepatic failure. This study partially

agrees with the study done by Chopra, et al,(87) This partial

disagreement may have occurred because nearly half of these

patients in this study were suffering from portal hypertension due to

schistosomiasis. Such patients were not included in the study by

Chopra, et al. (87) Reduction of the hormones in patients with portal

hypertension could be due to the effect of cytokines, nutritional

status of the patient or any reason not published yet.

All patients suffering from tuberculosis had a marked

reduction in TT3 level and low FT3, but normal TSH and TT4, so
the changes here are those of the T3 syndrome the causes of

which have been mentioned previously.

The test results of thyroid function of patients studied

(63)
postoperatively agrees with the literature in that they had a

reduction of TT3 and FT3. One patient had reduction in TT4 and 2

had a reduction of FT4 and TSH levels. These patients had major

surgery and were admitted to the ICU and received many

medications.

Regarding diabetes mellitus, 3 patients had diabetic septic

foot and one had diabetic ketoacidosis. All of them showed

reduction in TT3 and FT3 paralleling the decline in TT3. These

patients had normal TSH and TT4 levels and this could be due to

effect of the infection (63) or diabetes itself in which many metabolic

disturbances occur.

Patients who presented with anaemic heart failure showed

normal thyroid function. The cause of anaemia was not known yet

and they were receiving blood transfusion which may have

corrected the abnormality if it was present or that anaemia had no

effect on thyroid function. This finding needs more study in a larger

number of patients.

Patients suffering from infection showed some alteration in

thyroid functions which agrees with the literature.(63)

 All patients mentioned above in this study showed a

reduction of TT3, FT3 and FT4 (P = <0.05) and this agrees with

other studies.(63,65)

It is clear that there was a statistically significant relation

between drugs used and the alteration of thyroid function

especially in TT4. This supports the explanation that elevated TT4

is due to the use of medications and is also supported by alteration

in FT4 which was found to be statistically not significant.

TT3 and FT3 also showed significant reduction of their levels

due to the effect of medication affecting thyroid function by many

mechanisms. The most important is prevention of conversion of

total T4 to T3 peripherally leading to reduction in total T3 because

80% of T3 is synthesized peripherally from T4 by the deiodinase

system, causing a reduction in TT3 accompanied by a reduction in

FT3.

Regarding the control group in this study we found that the

maximum value of the hormone levels in this group was less than

the upper limit of the reference range reported in the immulite®

operator's manual. This could be due to the small sample

size in this study compared with the numbers studied by the

manufacturer to establish the reference range (usually 100 or more

healthy individuals for different tests).

 Another explanation could be that the range found in the

control group is nearer to our actual reference range, so these

limits should be considered as guidelines only. Each laboratory

should establish its own reference range.

Comparing the test results of studied patients with studied

controls, it was found that the reduction of TT3 and FT3 was

statistically significant.

In this study most of the results agreed with studies

conducted worldwide. However, there were some differences due

to certain limitations. First, hormone assays are expensive in the

Sudan, so only a small number of patients were investigated. This

is not enough to characterize the pattern of the changes in each

disease. Also rT3, an important test,(63) was not included in this

study. Second, some patients in this study had no definitive

diagnosis and their investigation was not complete. Third, some

Sudanese patients (especially females) and their relatives refuse to

donate blood samples. This resulted in a random selection of

patients. Fourth, no established reference values for thyroid

hormone levels in the Sudan exist. Fifth, no similar study was

reported from the Sudan to consider it as a guideline. Finally,

follow-up of referred patients is difficult in the Sudan.

 There is currently a vast literature available on thyroid

function test changes that occur during non-thyroidal illness. This

wide topic needs more study to understand. Anyway, these results

may add something to our knowledge about non-thyroidal illness in

the Sudan.

CONCLUSION

This study concluded that reduction of T3 and free T3 were the

most commonly encountered abnormalities in non- thyroidal

illness (low T3 syndrome).

 Several abnormal thyroid function patterns have been found in

patients with serious non-thyroidal illness in this study, which

could be categorized as follows:

1- Low T3 only. 2- Low T3 and T4.

3- Low T3, T4 and TSH. 4- Elevated T4.

It has also been concluded that the degree of alteration in thyroid

hormone levels appears to be correlated with the severity of non-

thyroidal illness.

Abnormal thyroid hormone levels were more obvious in patients

suffering from chronic renal failure, cardiovascular problems, liver

disease, tuberculosis and post-major surgery.

Drugs that affect thyroid hormone levels had a significant effect in

the test result abnormalities especially the level of T4. There was a

difference between the maximum value of hormone levels in the

study control group and that provided by the manual of the

manufacturer of immulite ®.

RECOMMENDATIONS
 Large, prospective, carefully controlled studies are needed for

monitor thyroid function test findings during and after recovery

from NTI.

Thyroid function tests should not be requested during illness

unless there is strong clinical evidence of coexistence of thyroid

disease, and should be repeated when non thyroidal illness

resolves.

Informative, well-designed request forms are mandatory and

also close rapport between the clinician and laboratory is

important to facilitate good interpretation of test results.

Every laboratory should establish its own reference range and

consider ranges provided by instrument or kit manufacturers as

guidelines only.

Patients can be assured that this is a transient phenomenon

and that normalization of thyroid function tests is expected with

the patient’s recovery from non-thyroidal illness.

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 Appendix (1)
University of Khartoum
Faculty of Medicine
Department of Pathology

Questionnaire

Euthyroid sick syndrome

• Serial No.: ............................................ Date.:

..........................................
• Condition ............................................
1- Name: ......................................................
2- Age (years): …………..………………
3- Sex: 1- Male 2 - Female
4- Tribe:...............................……………………........................
5- Residence:…………………………….……………………
6- Clinical diagnosis:…………………………………….……
7- Duration of illness (in months):……………………………
8- History of thyroid illness or:……………………………
1- Surgery 2- Drug 3 -Radioiodine therapy
9- Family history of thyroid disease: Yes No
10- Drug used:…………………………………………………………………
11- Result of thyroid function test
TSH TT4 TT3 FT4 FT3
Patient value
Normal value
Comment:
 Appendix (2)
Equipment Data form

• Name of equipment: Imullite 1000.

• Model: Version 5.6.
• Serial No.: J. 3839 R.
• Voltage: 220 - 240.
• Weight: 80 kg.
• Manufacture address:
- Name: DPC (Dignostic Products Corporation).
- Address: Los Angeles- CA. 90045 USA,
5700 West 96th street.
Tel: (800) 372- 1782.
Fax: (800) 234 - 4372.