Thyroid Function Tests
Introduction
Thyroid hormone secretion is stimulated by TSH from the pituitary,
which is in turn under regulation of hypothalamic TRH.
disorders affecting the over/under-secretion of T4 and T3 are common,
thus their measurement together with TSH, is frequently performed.
Biosynthesis
Thyroid hormone synthesis involves several steps:
The iodide from the bloodstream is actively taken up (trapped),
Oxidation of iodide to iodine by thyro-peroxidase
Incorporation of iodine into tyrosine residues of a large protein,
thyroglobulin.
Coupling of two iodinated tyrosine molecules yielding T4, which, still
part of the thyroglobulin molecule ( the product is stored as colloid in
the thyroid follicle).
Proteolysis of thyroglobulin by follicular cells yields the free hormone,
which is released into the bloodstream.
T3 is the active form of the hormone, and is formed in target tissues by de-
iodination of T4.
De-iodination of the inner ring of T4 yields reverse T3 (rT3), an inactive
form.
Preferential conversion to rT3 occurs in starvation and severe illness,
presumably in an attempt to limit whole body energy expenditure
(characteristic feature in sick euthyroid).
T4 and T3 are needed for normal physical growth and mental
development, and to stimulate general metabolic activity.
Thyroid hormone enters the cell and bind to their receptors in the nucleus,
which increases expression of specific genes; eg. they increase the
sensitivity of the cardiovascular and nervous systems to catecholamines.
Both T3 and T4 are extensively protein bound in the bloodstream,
principally to thyroxine-binding globulin (TBG).
T4, for example, is 99.98% protein bound, which means that only one
molecule in 5000 is free, and hence biologically active. Because it is the
free, biologically active, form of the hormone that is regulated by TSH,
Factors that increase (oestrogens) or decrease (protein malnutrition,
nephrotic syndrome) TBG will lead to an increased or decreased total T4,
respectively, while the patient remains euthyroid with a normal level of
freeT4.
Disorders of thyroid hormone
Deficient thyroid hormone secretion- hypothyroidism
Excessive thyroid hormone secretion - hyperthyroidism
Thyroid gland mass – goitre which can be diffuse with one or more
nodules
Hypothyroidism
Hypothyroidism is more prevalent with age, affecting about 6 per cent of
people over 60 years, and is more common in women.
Characteristic symptoms are due to generalized slowing down of
metabolism
It is associated with impaired plasma (LDL) cholesterol
Raised creatine kinase activity
Myopathy.
Hyponatremia and myxoedema
Hypothyroidism
Primary or secondary
hypothyroidism
Hyperthyroidism
Hyperthyroidism causes sustained high plasma concentrations of T4 and
T3.
There is often generalized increase in the metabolic rate.
Hyperthyroidism
Biochemical findings
TFTs
o TSH: suppressed
o Ft4: High but normal in subclinical hyperthyroidism
o fT3: High but normal in subclinical hyperthyroidism
Others
o Hypocholesterolaemia can occur, due to increased LDL clearance.
o Hypokalaemia may also occur, associated with
o Hyperthyrotoxic periodic paralysis.
o Plasma SHBG is increased.
o Plasma creatine kinase may be increased with
o Thyrotoxic myopathy
TFTs
Measurement of TSH
Serum Free T4 and T3
Serum total T4 and T3
T3 resin uptake tests :
Including free thyroxin index (FTI) = Total T4 x percentage resin uptake
TFTs
Measurement of total thyroid hormone alone can yield misleading
information.
Early methods sought to ‘correct’ total T4 for changes in TBG by
measuring unoccupied binding sites on TBG (radioactive T3 resin uptake
assay
However, sensitive methods are now available that are designed to
measure free hormone levels directly (freeT4 and freeT3). TSH assay
also helps by providing a useful independent marker of free thyroid
hormone status at the tissue level.
Direct methods available include ELISA, CLIA,
Investigation of thyroid disorders
Biochemical
TSH Non Biochemical
fT4 Neck xray
fT3
Auto-antibodies: Anti-thyroperoxidase
FNAC
(Anti-TPO), Trab
Neck ultrasound
Anti TG
Other anterior pituitary hormones Radionuclide scanning
Lipid profile
Serum electrolytes
Plasma glucose
Thyroid hormones
Technically easier to measure total
Total nanomole range (10-9)
Free picomole range (10-12)
Diagnostic accuracy affected by
Binding proteins
Concentrations increase with estrogen therapy, pregnancy
Genetic abnormalities in binding proteins (affinity)
Abnormal binding proteins like autoantibodies
Assess binding protein status by TBG immunoassay or by “uptake test”
Thyroid hormones
Free hormones
Measurement is done by
1. Physical separation of free hormone from bound hormone
dialysis, ultrafiltration, gel filtration
done in reference labs
2. Estimates of the free hormone in the presence of bound
hormone
unbound thyroid hormone in competition with
labelled T4/T3 for binding to a solid phase antibody
Thyroid hormones
Serum TSH measurement is the most diagnostically sensitive
test for detecting mild (subclinical), as well as overt, primary
hypo- or hyperthyroidism in ambulatory patients.
A serum TSH measurement is the therapeutic endpoint for
titrating the L-T4 replacement dose for primary hypothyroidism
and for monitoring L-T4 suppression therapy for differentiated
thyroid carcinoma.
Serum TSH measurements are more reliable than FT4 in
hospitalized patients with non-thyroidal illness
Thyroid hormones
When the serum FT4 is low and yet the serum TSH is only
minimally elevated (,10 mIU/L), a diagnosis of central
hypothyroidism should be considered.
Serum TSH measurements are an important pre-natal and first
trimester screening test to detect mild (subclinical)
hypothyroidism in the mother.
A low TSH in the setting of a multinodular goiter suggests the
presence of mild (subclinical) hyperthyroidism.
A serum TSH measurement is required for confirming that an
elevated thyroid hormone level is due to hyperthyroidism and not
a thyroid hormone binding protein abnormality.
Thyroid hormones
Conditions in which TSH alone might be misleading
Recent treatment of thyrotoxicosis
Pituitary disease
Non-thyroidal illness
Thyroid Auto-antibodies
Three principal auto-antigens are involved in Autoimmune thyroid
disease
1. Thyroid Peroxidase
2. Thyroglobulin
3. TSH receptor
Thyroid Auto-antibodies
Antibodies to Thyroid Peroxidase
Preferred method is Immunoassay
Diagnosis of Autoimmune Thyroid Disease
Risk factor for Autoimmune Thyroid Disease
Risk factor for hypothyroidism during Interferon alpha,
Interleukin-2 or Lithium therapy
Risk factor for thyroid dysfunction during amiodarone
therapy
Risk factor for hypothyroidism in Down’s Syndrome patients
Risk factor for thyroid dysfunction during pregnancy and for
post-partum thyroiditis
Risk factor for miscarriage and in-vitro fertilization failure
Thyroid Auto-antibodies
Serum Thyroglobulin Antibody testing is
1. primarily used as an adjunct test when serum Tg measurements
are requested.
2. In patients with Differentiated thyroid cancer (DTC)
low antibody concentrations can interfere with the Tg
measurements
serial TgAb measurements themselves may serve as a
surrgogate tumor marker test for TgAb-positive patients in
whom Tg testing may be unreliable
Thyroid Auto-antibodies
Thyroid receptor antibody (TRAb)
Comprised of
Thyroid stimulating immunoglobulin
TSH receptor blocking antibodies
Thyroid growth stimulating immunoglobulins
Meaured by bioassays or by “receptor” assays
Clinical Utility
Distinguish Grave’s disease from Factitious Ingestion
Predict course of Grave’s disease
Predict fetal of neonatal thyroid dysfunction in mother with Grave’s
Thyroglobulin
Serum levels indicate
1. Mass of thyroid tissue present
2. Any inflammation or injury to the thyroid gland
3. Amount to stimulation of TSH receptor by TRAb
Clinical Use
4. Tumour marker for DTC
Measure pre-op to validate that
1. That the tumour can secrete TG
2. It’s use as a tumour marker
Can be assessed baseline and after stimulation by TSH
Calcitonin
Produced by the C-cells
Tumour marker for Medullary Thyroid Carcinoma (MEN IIA, IIB,
FMTC)
Rise in the level of Calcitonin in early MTC at the microcarcinoma
stage
Positive correlation between CT and Tumor Mass
Basal and Dynamic testing (following Pentagastrin and Calcium)
RET Protooncogene
mutations underlie MTC, almost all with the mutation develop MTC
Urinary Iodine measurements
Iodine essential for normal thyroid gland function
Iodine deficiency responsible for endemic goitre and cretinism
Majority of ingested iodine is excreted in the urine
Only reflects recent dietary patern
Major use is for epidemiologic purposes
Use 24 hour urine sample
Other tests
Fine Needle aspiration and cytology
Indicated for all patients with palpable or solitary nodules
Thyroid Ultrasound
Can detect non-palpable nodules
TFTs - Interpretation
Panel Common Others
↓TSH, ↑Ft3 or ↑FT4↑↓ Primary Hyperthyroidism Transient thyroiditis
Grave’s disease Postpartum
Multinodular Goitre Lymphocytic
Toxic Nodule De Quervain’s
Thyroid ingestion
Struma Ovarii
↓TSH Normal FT3, FT4 Subclinical hyperthyroidism Steroid therapy
Thyroxine ingestion Non thyroidal illness
↓/Normal TSH, ↓FT3, FT4 Non thyroidal illness Pituitary disease
Recent treatment for Congenital TSH or TRH
hyperthyroidism deficiency
↑ TSH, ↓FT4, ↓FT3 Primary Hypothyroidism Amiodarone
Post thyroidectomy Iodine deficiency
Chronic Autoimmune
thyroiditis
Post radioiodine
↑TSH, normal FT4, FT3 Subclinical autoimmune Heterophile antibodies
thyroidism Recovery phase of NTI
Normal or ↑ FT4, FT3 Amiodarone
TSH Secreting tumour
TFTs - Interpretation
Subclinical hypothyroidism
Subclinical (compensated hypothyroidism) is the state in which plasma
TSH concentration is raised but the total or fT4 concentration still falls
within the reference range.
Subclinical hyperthyroidism
Subclinical hyperthyroidism may occur with a low or suppressed TSH
concentration but normal (usually high-normal) plasma fT4 and fT3
concentrations.
The condition may progress to full-blown hyperthyroidism with
suppressed plasma TSH and raised plasma fT4 and fT3 concentrations.
Non-Thyroidal Illnesses/Sick Euthyroid Syndrome
Any acute severe illness causing abnormalities in circulating TSH
or hormone levels in the absence of underlying thyroid disease.
Importance is because of misleading information from thyroid
testing during periods of acute illness.
Unless a thyroid disorder is strongly suspected, routine testing of
thyroid function should be avoided in acutely ill patients