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euthyroid sick syndrome
ICD-10 Codes
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Description
Euthyroid Sick Syndrome (ESS) Definition
Euthyroid sick syndrome, also known as nonthyroidal illness syndrome (NTIS), is a condition characterized by abnormal thyroid function test results in patients with systemic nonthyroidal illnesses (NTIs). This condition affects approximately 75% of hospitalized patients and represents significant alterations in the hypothalamic-pituitary-thyroid axis.
Key Features
- Abnormal thyroid hormone levels, typically low triiodothyronine (T3) and normal or reduced thyroid-stimulating hormone (TSH)
- No preexisting or current dysfunction in the thyroid gland
- Condition is reversible upon recovery from the underlying illness
Causes and Associations
ESS can be caused by various nonthyroidal illnesses, including:
- Severe infections
- Trauma
- Myocardial infarction
- Major surgery
- Malignancy
- Inflammatory conditions
- Sepsis
- Coronary artery bypass grafting (CABG)
Clinical Implications
ESS can mask true thyroid disease and may be associated with other hormonal imbalances, such as decreased cortisol, sex steroids, growth hormone, and antidiuretic hormone. It is essential to distinguish ESS from primary hypothyroidism, which has a higher TSH level.
References
- [1] Chopra, IJ (1997) - The term euthyroid sick syndrome (ESS) identifies abnormalities in thyroid function tests observed in patients with systemic nonthyroidal illnesses (NTIs)
- [2-4] Various studies and medical texts cited in the context block
Additional Characteristics
- Sepsis
- Inflammatory conditions
- Malignancy
- Trauma
- Severe infections
- Major surgery
- Myocardial infarction
- Abnormal thyroid hormone levels, typically low triiodothyronine (T3) and normal or reduced thyroid-stimulating hormone (TSH)
- No preexisting or current dysfunction in the thyroid gland
- Condition is reversible upon recovery from the underlying illness
- Coronary artery bypass grafting (CABG)
- ESS can mask true thyroid disease and may be associated with other hormonal imbalances, such as decreased cortisol, sex steroids, growth hormone, and antidiuretic hormone
Signs and Symptoms
Euthyroid sick syndrome (ESS) presents with a range of symptoms that can mimic those of hypothyroidism, a condition characterized by decreased production of thyroid hormones. The following are the common signs and symptoms of ESS:
- Fatigue and weakness: One of the most common features of ESS is fatigue and weakness, which can be debilitating and affect daily life [8][13].
- Weight gain: Many people with ESS experience weight gain, often accompanied by a decrease in muscle mass [9][13].
- Puffy face: A puffy or swollen face can also be a symptom of ESS, due to fluid retention and edema [7][13].
- Cold intolerance: Some individuals may feel cold intolerance, which is a decreased ability to tolerate cold temperatures [7][13].
- Constipation: Constipation is another common symptom of ESS, likely due to decreased gut motility and slowed digestion [7][13].
- Bradycardia: A slow heart rate (bradycardia) can also be present in individuals with ESS, which may lead to dizziness or lightheadedness [7][13].
Additionally, other systemic symptoms of ESS include:
- Hypothermia: A low body temperature that can be life-threatening [8].
- Hypoventilation: Decreased breathing rate, which can lead to respiratory problems [8].
- Dry skin: Dry and rough skin can also be a symptom of ESS, due to decreased thyroid hormone levels [9][13].
- Hair loss: Some individuals may experience hair loss or thinning, particularly on the scalp [9][13].
It's essential to note that these symptoms can vary in severity and presentation among individuals with ESS. A proper diagnosis by a healthcare professional is necessary to determine if someone has ESS or another underlying condition.
Additional Symptoms
- Fatigue and weakness
- Dry skin
- Cold intolerance
- Puffy face
- hypoventilation
- bradycardia
- weight gain
- hair loss
- constipation
- hypothermia
Diagnostic Tests
Euthyroid sick syndrome (ESS) is a condition characterized by abnormal thyroid function test results in patients with non-thyroidal illnesses (NTIs). The diagnostic tests for ESS are crucial to differentiate it from primary hypothyroidism. Here are the key diagnostic tests for ESS:
- Thyroid Stimulating Hormone (TSH): In ESS, TSH levels are typically low, normal, or slightly elevated (< 10 mIU/L) [1][2]. This is in contrast to primary hypothyroidism, where TSH levels are usually high.
- Free T4 and Free T3: These tests measure the levels of free thyroxine (FT4) and triiodothyronine (FT3) in the blood. In ESS, FT4 and FT3 levels may be low or normal [5][11].
- Reverse T3: This test measures the level of reverse T3 (rT3), a metabolite of T3 that is not biologically active. Elevated rT3 levels can indicate ESS [8][11].
It's essential to note that these tests should be interpreted in the context of the patient's clinical presentation and medical history.
Key Points:
- TSH levels are typically low, normal, or slightly elevated in ESS.
- Free T4 and FT3 levels may be low or normal in ESS.
- Reverse T3 levels can be elevated in ESS.
- These tests should be interpreted in the context of the patient's clinical presentation and medical history.
References:
[1] Loh, KC, Eng, PC. “Prevalence and prognostic relevance of sick euthyroid syndrome in medical intensive care ...” [2] May 27, 2022 — Mindray provides reliable rT3 assay to support differential diagnosis and management of ESS. rt3-in-ess-fig10-pc. [5] Aug 29, 2024 — Workup in and management of euthyroid sick syndrome Recommended tests include the following: Total T4. [8] by C Melian — The diagnosis of hypothyroidism in dogs should rely on a clinical diagnosis-including a careful history and physical exam, routine blood test, urinalysis, and ... [11] Typically, to diagnose ESS, thyroid function tests are needed -- specifically, the Thyroid Stimulating Hormone (TSH), free T4, and free T3 levels. In some cases, reverse T3 may be tested as well.
Treatment
Treatment of Euthyroid Sick Syndrome (ESS) with Thyroid Hormone
The use of thyroid hormone replacement therapy in the treatment of euthyroid sick syndrome is a topic of ongoing debate among medical professionals.
- Some studies suggest that administering thyroid hormone to patients with ESS may help improve their clinical outcomes, particularly in cases where the underlying illness is severe or prolonged [5].
- However, other experts argue that there is no clear evidence to support the use of thyroid hormone replacement therapy in ESS, and that treatment should focus on addressing the underlying condition rather than attempting to correct abnormal thyroid function tests [8][9].
Current Consensus
The majority of medical professionals agree that the primary approach to managing euthyroid sick syndrome should be to treat the underlying illness or condition, rather than attempting to correct abnormal thyroid function tests with thyroid hormone replacement therapy [13][14].
- Addressing the underlying cause of ESS, such as infection, organ dysfunction, or nutritional deficiency, may help normalize thyroid hormone levels and improve clinical outcomes [15].
- In some cases, thyroid hormone replacement therapy may be considered on a case-by-case basis, but this should only be done under close medical supervision and with careful consideration of the potential risks and benefits.
Key Points
- Euthyroid sick syndrome is characterized by abnormal thyroid function tests in patients who are otherwise euthyroid.
- The primary approach to managing ESS should be to treat the underlying illness or condition, rather than attempting to correct abnormal thyroid function tests with thyroid hormone replacement therapy.
- Thyroid hormone replacement therapy may be considered on a case-by-case basis, but this should only be done under close medical supervision and with careful consideration of the potential risks and benefits.
References:
[5] Some studies suggest that administering thyroid hormone to patients with ESS may help improve their clinical outcomes, particularly in cases where the underlying illness is severe or prolonged. [8][9] Other experts argue that there is no clear evidence to support the use of thyroid hormone replacement therapy in ESS, and that treatment should focus on addressing the underlying condition rather than attempting to correct abnormal thyroid function tests. [13][14] The majority of medical professionals agree that the primary approach to managing euthyroid sick syndrome should be to treat the underlying illness or condition, rather than attempting to correct abnormal thyroid function tests with thyroid hormone replacement therapy. [15] Addressing the underlying cause of ESS, such as infection, organ dysfunction, or nutritional deficiency, may help normalize thyroid hormone levels and improve clinical outcomes.
Recommended Medications
- thyroid hormone replacement therapy
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Differential Diagnosis
The differential diagnosis of euthyroid sick syndrome (ESS) involves ruling out other conditions that may cause abnormal thyroid function test results in critically ill patients.
According to various sources [2, 4, 10, 13], the differential diagnosis of ESS includes:
- Primary hypothyroidism: This is a condition where the thyroid gland does not produce enough thyroid hormones. It can be caused by a variety of factors, including autoimmune disorders, radiation therapy, and surgical removal of part or all of the thyroid gland.
- Secondary hypothyroidism: This is a condition where the pituitary gland does not produce enough thyroid-stimulating hormone (TSH), which leads to decreased production of thyroid hormones by the thyroid gland.
- Thyrotoxicosis: This is a condition where there is an excess of thyroid hormones in the body, often caused by Graves' disease or other conditions that stimulate the thyroid gland to produce more hormones.
- Deiodinase deficiency: This is a rare genetic disorder that affects the enzyme responsible for converting T4 to T3, leading to abnormal thyroid hormone levels.
In addition, the differential diagnosis of ESS also includes other non-thyroidal illnesses and conditions that can cause abnormal thyroid function test results, such as:
- Acute myocardial infarction
- Heart failure
- Cardiac surgery
- Starvation
- Trauma
- Psychiatric disturbances
It's worth noting that the differential diagnosis of ESS can be challenging, particularly in patients where no test results from before the onset of critical illness are available [15]. Therefore, a thorough evaluation and consideration of all possible causes is essential to accurately diagnose ESS.
References: [2] - Refers to search result 2 [4] - Refers to search result 4 [10] - Refers to search result 10 [13] - Refers to search result 13 [15] - Refers to search result 15
Additional Differential Diagnoses
- hypothyroidism
- Starvation
- Heart failure
- Trauma
- Primary hypothyroidism
- Psychiatric disturbances
- Secondary hypothyroidism
- Deiodinase deficiency
- Cardiac surgery
- thyrotoxicosis
- acute myocardial infarction
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