A 5-year-old male child is admitted post valvular surgery to cardiac ICU. A consultation is sent saying that there is a suspicion of secondary hypo-thyroidism. The results are as below • T3–80 ng/dL (94–269 ng/dL) • T4–3 μg/dL (7–15 μg/dL) • TSH–0.02 μ IU/mL (0.5–5.0 μ IU/L) What is the clinical diagnosis in this case? What is the next step in evaluation of this patient? What other parameters can help in the diagnosis? The child was evaluated for other evidences of hypopituitarism as below The child is in the 5th centile which is expected as the child had untreated cyanotic congenital heart disease because of which the growth is stunted so probably growth hormone deficiency does not exist. The child has no evidence of micropenis so hypopituitarism was less of a possibility as it can be a marker of hypopituitarism. The child is maintaining blood pressure and is not requiring any ionotropic support which is an indirect evidence of normal cortisol levels. Thus, the clinical diagnosis in this child is kept as sick euthyroid syndrome as the other pituitary hormones are normal and there is no clinical evidence of hypopituitarism in this child. The levels of FT4 and FT3 are also done and FT4 is found to be in the normal range for age while FT3 is low. The other anterior pituitary hormones including random serum cortisol, FSH, LH and prolactin are measured in this child and the levels are found to be normal as per the clinical state of the patient. An IGF-1 level is done to screen for growth hormone deficiency and it is found to be in the normal range for age and sex matched controls. Different critical illness states leading to NTIS • Sepsis and trauma • Starvation • Cardiac dysfunction • Renal disease • Hepatic disease • Nonseptic shock • Burns • Respiratory failure • Other disease states like systemic sclerosis
What is the prognostication of NTIS?
Medicine
The cumulative illness rating scale (CIRS) scores (severity and comorbidity index) have been found to be inversely related to FT3 and positively related to FT4 levels and the CRP (C-reactive protein) level is found to be positively associated with FT4 levels. Serum FT3 values correlates inversely with serum C-reactive protein, lactate dehydrogenase, fibrinogen and erythrocyte sedimentation rate values, and progressively decreased with increasing tertiles of age. The level of thyroid hormone correlates with mortality. Low T3 is an independent prognostic indicator in cardiac patients. Low T3 syndrome is related to NT-pro-BNP but is an independent predictor of cardiovascular mortality. Determination of rT3 may help in the prognostication of patients who may be at risk of subsequent mortality. The decrease in the level of FT4 over the course of illness has been found to a poor prognostic marker. The low thyroid hormone is thought of as a better predictor of mortality than APACHE 1 score and has been directly correlated with T4 levels in some studies. A T4 level lower than 4 μg/dL is associated with 50% probability of death while a T4 level lower than 2 μg/dL is associated with 80% probability of death. Reverse T3 to T3 ratio, elevated rT3 are independent predictor of survival. Low T3 and FT4 levels have been found to be adverse prognostic marker.
The patient in case 1 is subsequently followed up in the OPD and thyroid profile becomes normal after 6 weeks of follow-up. The hormone levels of the child in case 2 becomes normal after four weeks of follow-up without any levothyroxine supplementation and child is discharged in a stable condition from the hospital.
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