Updated: 6/19/2019

Euthyroid Sick Syndrome (ESS)

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Snapshot
  • A 65-year-old man with hypertension, hyperlipidemia, and diabetes presented to the emergency room for fevers, fatigue, and a productive cough over the past few days. His temperature is 102.1°F (38.9°C) and mean arterial pressure is 63 mmHg. Further evaluation demonstrates a leukocytosis, elevated procalcitonin, and a radiographic focal consolidation in his left lower lobe. He denies any temperature intolerance, weight changes, any nail and skin abnormalities, diarrhea, or constipation. He was admitted to the intensive care unit for treatment of sepsis secondary to pneumonia. On admission, labs for thyroid function were ordered and found to be abnormal.
Introduction
  • Clinical definition­­
    • abnormal thyroid function tests in a normally functioning thyroid that occurs in the setting of a nonthyroidal illness
  • Epidemiology
    • demographics
      • frequently in hospitalized patients
    • risk factors
      • acute illness
        • sepsis
        • diabetic ketoacidosis
      • chronic illness
        • cancer
        • cardiac illness
        • anorexia nervosa and fasting
        • human immunodeficiency virus
        • inflammatory bowel disease and other autoimmune diseases
        • liver disease
        • renal disease
  • Pathogenesis
    • hypothesized that reduced thyroid hormones may limit catabolism during illness
      • cytokines downregulate thyroid hormone synthesis
      • altered deiodinase enzyme activity
        • ↓ conversion of thyroxine (T4) to (triiodothyronine) T3
        • ↑ conversion of T4 to reverse T3
        • ↓ thyroid binding globulin
Presentation
  • Symptoms and physical exam are variable and specific to underlying nonthyroidal illness
Studies
  • Diagnostic testing
    • diagnostic approach
      • evaluate lab findings in the context of acute or chronic illness
    • studies
      • thyroid function tests including TSH, total T4, free T4, total T3, free T3, and reverse T3
    • biopsy
      • not indicated but would demonstrate a normal thyroid gland
  • Diagnostic criteria
    • typical findings
      • ↓ T3
      • normal or ↑ T4 and reverse T3
      • normal or ↓ TSH
    • severe findings
      • ↓ T3, T4, and TSH
Differential
  • Thyroid disease
    • distinguishing factors
      • physical exam and symptoms consistent with hyperthyroidism or hypothyroidism
      • co-existing euthyroid sick syndrome can mask true thyroid disease
  • Central hypopituitarism
    • distinguishing factor
      • loss of other hormones in addition to ↓ T4 include ↓ cortisol, sex steroids, growth hormone, and antidiuretic hormone
  • Medication-related
    • distinguishing factors
      • perform medication review
      • common medications include lithium, amiodarone, glucocorticoids, estrogens, androgens, and biotin supplementation
Treatment
  • Management approach
    • treat and manage underlying illness 
    • thyroid hormone replacement is not indicated and can lead to overtreatment though controversial
    • monitor thyroid function studies after the resolution of the acute illness episode
Complications
  • None
 

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(M3.EC.15.77) A 73-year-old woman with a history of COPD and hypertension presents to the emergency room with altered mental status. Her husband reports that the patient was suffering from worsening fatigue and a productive cough over the last several days. Her temperature is 102°F (38.9°C), blood pressure is 155/95 mmHg, pulse is 99/min, respirations are 33/min, and oxygen saturation is 92% on room air. A chest radiograph is performed as seen in Figure A. The patient is given ceftriaxone, azithromycin, BiPAP, albuterol, ipratropium, and prednisone, and is admitted to the ICU. On day 1 in the ICU, laboratory studies are ordered as seen below.

Serum
TSH: 4.0 microU/mL
T3: 12 ng/dL
T4: 4.5 ug/dL

Which of the following is the most appropriate next step in management for this patient's abnormal thyroid function tests?
Tested Concept

QID: 103018
FIGURES:
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Continue current treatment regimen

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Fine needle aspiration

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T3

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4

Thyroxine

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Ultrasound of the thyroid

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M 11 E

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