Letter to the Editor
Hyperthyroidism due to gestational trophoblastic tumor
Hipertiroidismo secundario a tumor trofoblástico gestacional
Víctor José Simón Frapolli
, Ángel López Montalbán, María Molina Vega
Corresponding author
Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen de la Victoria, Campus Teatinos, Málaga, Spain
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In addition to the more common aetiologies, such as Graves' disease, toxic multinodular goitre, toxic adenoma, and subacute thyroiditis, there are less common causes, such as hyperthyroidism due to excessive production of human chorionic gonadotropin (hCG) that occurs in gestational trophoblastic disease (GTD).<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 50-year-old woman, with an obstetric record of two full-term pregnancies and no miscarriages, with a personal history of hypertension, type 2 diabetes and morbid obesity, referred from primary care due to an incidental finding of primary hyperthyroidism during an outpatient study of dyspepsia and abdominal pain. Without substance abuse or surgical interventions. Usual treatment: valsartan 160<span class="elsevierStyleHsp" style=""></span>mg/hydrochlorothiazide 25<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h, sitagliptin 100<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h, metformin 1000<span class="elsevierStyleHsp" style=""></span>mg/empagliflozin 10<span class="elsevierStyleHsp" style=""></span>mg/12<span class="elsevierStyleHsp" style=""></span>h, doxazosin 8<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>hy carvedilol 25<span class="elsevierStyleHsp" style=""></span>mg/24<span class="elsevierStyleHsp" style=""></span>h. She reported unquantified weight loss in recent months and nervousness. No distal tremor, palpitations, or anterior cervical symptoms. Date of last menstrual period 4<span class="elsevierStyleHsp" style=""></span>months before. Physical examination: height 156<span class="elsevierStyleHsp" style=""></span>cm, weight 115<span class="elsevierStyleHsp" style=""></span>kg, BMI 47.2<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Supplementary tests: GPT 15 (7−40<span class="elsevierStyleHsp" style=""></span>U/l), GGT 76 (5−55<span class="elsevierStyleHsp" style=""></span>U/l), TSH 0.03 (0.4−5<span class="elsevierStyleHsp" style=""></span>μUI/ml), FT4 22.85 (11−22<span class="elsevierStyleHsp" style=""></span>pmol/l), FT3 7.82 (3.10–6.80<span class="elsevierStyleHsp" style=""></span>pmol/l), TSI 0.92 (<2<span class="elsevierStyleHsp" style=""></span>IU/ml), TPO 41.7 (<60<span class="elsevierStyleHsp" style=""></span>IU/ml). Thyroid ultrasound: slightly enlarged thyroid at the expense of the isthmus, with homogeneous echostructure and globally increased vascularity. No pathological nodules or lymphadenopathies are visible.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Given the diagnosis of frank hyperthyroidism, thiamazole 5<span class="elsevierStyleHsp" style=""></span>mg 1 tablet/12<span class="elsevierStyleHsp" style=""></span>h was prescribed and a thyroid scintigraphy was requested, which showed increased and diffuse uptake in both thyroid lobes compatible with the clinical suspicion of diffuse goitre.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Two months later, she went to the emergency department for metrorrhagia, fever, and abdominal pain. Abdominopelvic ultrasound: large 14<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>12<span class="elsevierStyleHsp" style=""></span>cm hypervascularised endometrial mass invading the myometrium, with no other findings of interest. Endometrial biopsy: chorionic decidual tissue finding, hCG 154,059 (<2.0<span class="elsevierStyleHsp" style=""></span>IU/l). Abdominopelvic CT: greatly enlarged anteverted uterus reaching the periumbilical region with heterogeneous content inside related to endometrial thickening with a neoplastic appearance. Bilateral parauterine vascular dilatations. Nodes in bilateral external iliac chain of up to 7<span class="elsevierStyleHsp" style=""></span>mm. No free fluid in the abdominal cavity.</p><p id="par0030" class="elsevierStylePara elsevierViewall">Given the suspicion of GTD, a total hysterectomy plus double adnexectomy was performed. Pathological examination of the surgical specimen: invasive complete mole-type gestational trophoblastic tumor.</p><p id="par0035" class="elsevierStylePara elsevierViewall">One-month follow-up with clinical improvement and return to normal thyroid function: TSH 6.52, FT4 and FT3 normal, TSI negative, hCG decreasing but still positive, reducing thiamazole 5<span class="elsevierStyleHsp" style=""></span>mg to 1<span class="elsevierStyleHsp" style=""></span>tablet/day. On the next visit, TSH 4.51 and the rest was normal, thiamazole was discontinued. Two months later, TSH 1.88. Last three hCG measurements with undetectable levels.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Hyperthyroidism due to excessive hCG production in GTD is a rare aetiology resulting from the structural similarity between hCG and TSH, acquiring the ability to stimulate the same receptors, particularly when high concentrations of TSH are present. GTD comprises a set of interrelated entities whose common features include hyperplasia of the trophoblastic epithelium (cytotrophoblast, syncytiotrophoblast) and a sharp increase in hCG (usually ><span class="elsevierStyleHsp" style=""></span>200<span class="elsevierStyleHsp" style=""></span>IU/ml). The most common symptom is metrorrhagia, followed by menstrual cycle abnormalities, vomiting, anaemia, early pre-eclampsia, hyperthyroidism and uterine overgrowth in advanced cases. In the absence of metastatic disease, the curative treatment for GTD is tumor removal, which will also result in progressive return to normal thyroid function. Hysterectomy is often considered in women who have completed their reproductive desire, to reduce the risk of disease persistence.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2–4</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Antithyroid drugs are the treatment of choice to restore thyroid function prior to the surgical approach. In addition, beta-blockers (propranolol is the preferred choice)<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> can be administered in patients with severe hyperthyroidism and no systolic dysfunction.</p><p id="par0050" class="elsevierStylePara elsevierViewall">This clinical case serves as a context to insist on the importance of a broad differential diagnosis of hyperthyroidism. Although hyperthyroidism associated with hCG production is generally uncommon, it is very important to be aware of it, especially if there is a history of previous pregnancy. A subgroup corresponds to transient hyperthyroidism with spontaneous regression; however, those associated with GTD must be diagnosed and treated appropriately, as the patient’s prognosis depends on it.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hyperthyroidism and thyrotoxicosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "D. Devereaux" 1 => "S.Z. 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