Time-dependent changes in FT4 and FT3 levels measured using mass spectrometry after an acute ingestion of excess levothyroxine in a case with hypothyroidism
Abstract Background Thyrotoxicosis is common disorder among endocrine dysfunctions. It is not rare that the free thyroid hormone level exceeds the measurement range of immunoassay. Such extreme high concentration of free thyroid hormone is generally considered to be impossible to measure correctly b...
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doaj-77c94707652a4ba49ec1c2f9d402b1092020-11-25T02:02:17ZengBMCThyroid Research1756-66142020-05-011311610.1186/s13044-020-00078-7Time-dependent changes in FT4 and FT3 levels measured using mass spectrometry after an acute ingestion of excess levothyroxine in a case with hypothyroidismYuko Ito0Satoru Suzuki1Yoshiko Matsumoto2Chiyo Ohkouchi3Satoshi Suzuki4Manabu Iwadate5Sanae Midorikawa6Susumu Yokoya7Shinichi Suzuki8Hiroki Shimura9Department of Laboratory Medicine, School of Medicine, Fukushima Medical UniversityThyroid and Endocrinology Center, Fukushima Medical University HospitalThyroid and Endocrinology Center, Fukushima Medical University HospitalThyroid and Endocrinology Center, Fukushima Medical University HospitalThyroid and Endocrinology Center, Fukushima Medical University HospitalThyroid and Endocrinology Center, Fukushima Medical University HospitalThyroid and Endocrinology Center, Fukushima Medical University HospitalThyroid and Endocrinology Center, Fukushima Medical University HospitalThyroid and Endocrinology Center, Fukushima Medical University HospitalDepartment of Laboratory Medicine, School of Medicine, Fukushima Medical UniversityAbstract Background Thyrotoxicosis is common disorder among endocrine dysfunctions. It is not rare that the free thyroid hormone level exceeds the measurement range of immunoassay. Such extreme high concentration of free thyroid hormone is generally considered to be impossible to measure correctly because of changes in the balance between free hormones and binding proteins by dilution of serum. Using liquid chromatography-tandem mass spectrometry (LC-MS/MS), however, higher concentrations are able to be determined. Case presentation We present a case of a 21-year-old female with congenital hypothyroidism who had taken a total of 5 mg levothyroxine over three consecutive days following discontinuance of the medication for a month. Immunoassay performed 3 hours after the last ingestion showed that the patient’s free thyroxine (FT4) was over 100 pmol/L and her free triiodothyronine (FT3) was 24.5 pmol/L. With a temporary cessation of levothyroxine, the patient was kept for observation without any other medication. Two days after the last ingestion, FT4 was still over 100 pmol/L and FT3 was increased to 28.8 pmol/L. After an additional 4 days, both FT4 and FT3 levels decreased. Through this period, no thyrotoxic symptom or physical sign had appeared. We also measured FT4 and FT3 levels in her cryopreserved serum by ultrafiltration LC-MS/MS. Her FT4 level measured by ultrafiltration LC-MS/MS on the visiting day and 2 days later were 160.0 and 135.5 pmol/L, respectively, indicating that the toxic dose of levothyroxine was partly changed to T3 during the 2 days. The FT3/FT4 ratios were revealed to be low, accounting for the patient’s benign clinical course despite temporal toxic exposure to levothyroxine. It is implied that prior discontinuation of supplementary levothyroxine increases potential vacant binding sites for thyroid hormone as a buffer to prevent toxic T3 effect. Conclusion It was helpful to clarify the time dependent changes in free thyroid hormone levels by ultrafiltration LC-MS/MS in discussing the clinical course in this case. Though mass spectrometry has a disadvantage in speed for routine laboratory use, its accurate measurement, particularly of levels exceeding the measurable range of the immunoassay, provides valuable information for more appropriate management of extreme thyrotoxicosis.http://link.springer.com/article/10.1186/s13044-020-00078-7Free thyroid hormoneThyrotoxicosisCongenital hypothyroidismExcess levothyroxineMass spectrometryImmunoassay |
collection |
DOAJ |
language |
English |
format |
Article |
sources |
DOAJ |
author |
Yuko Ito Satoru Suzuki Yoshiko Matsumoto Chiyo Ohkouchi Satoshi Suzuki Manabu Iwadate Sanae Midorikawa Susumu Yokoya Shinichi Suzuki Hiroki Shimura |
spellingShingle |
Yuko Ito Satoru Suzuki Yoshiko Matsumoto Chiyo Ohkouchi Satoshi Suzuki Manabu Iwadate Sanae Midorikawa Susumu Yokoya Shinichi Suzuki Hiroki Shimura Time-dependent changes in FT4 and FT3 levels measured using mass spectrometry after an acute ingestion of excess levothyroxine in a case with hypothyroidism Thyroid Research Free thyroid hormone Thyrotoxicosis Congenital hypothyroidism Excess levothyroxine Mass spectrometry Immunoassay |
author_facet |
Yuko Ito Satoru Suzuki Yoshiko Matsumoto Chiyo Ohkouchi Satoshi Suzuki Manabu Iwadate Sanae Midorikawa Susumu Yokoya Shinichi Suzuki Hiroki Shimura |
author_sort |
Yuko Ito |
title |
Time-dependent changes in FT4 and FT3 levels measured using mass spectrometry after an acute ingestion of excess levothyroxine in a case with hypothyroidism |
title_short |
Time-dependent changes in FT4 and FT3 levels measured using mass spectrometry after an acute ingestion of excess levothyroxine in a case with hypothyroidism |
title_full |
Time-dependent changes in FT4 and FT3 levels measured using mass spectrometry after an acute ingestion of excess levothyroxine in a case with hypothyroidism |
title_fullStr |
Time-dependent changes in FT4 and FT3 levels measured using mass spectrometry after an acute ingestion of excess levothyroxine in a case with hypothyroidism |
title_full_unstemmed |
Time-dependent changes in FT4 and FT3 levels measured using mass spectrometry after an acute ingestion of excess levothyroxine in a case with hypothyroidism |
title_sort |
time-dependent changes in ft4 and ft3 levels measured using mass spectrometry after an acute ingestion of excess levothyroxine in a case with hypothyroidism |
publisher |
BMC |
series |
Thyroid Research |
issn |
1756-6614 |
publishDate |
2020-05-01 |
description |
Abstract Background Thyrotoxicosis is common disorder among endocrine dysfunctions. It is not rare that the free thyroid hormone level exceeds the measurement range of immunoassay. Such extreme high concentration of free thyroid hormone is generally considered to be impossible to measure correctly because of changes in the balance between free hormones and binding proteins by dilution of serum. Using liquid chromatography-tandem mass spectrometry (LC-MS/MS), however, higher concentrations are able to be determined. Case presentation We present a case of a 21-year-old female with congenital hypothyroidism who had taken a total of 5 mg levothyroxine over three consecutive days following discontinuance of the medication for a month. Immunoassay performed 3 hours after the last ingestion showed that the patient’s free thyroxine (FT4) was over 100 pmol/L and her free triiodothyronine (FT3) was 24.5 pmol/L. With a temporary cessation of levothyroxine, the patient was kept for observation without any other medication. Two days after the last ingestion, FT4 was still over 100 pmol/L and FT3 was increased to 28.8 pmol/L. After an additional 4 days, both FT4 and FT3 levels decreased. Through this period, no thyrotoxic symptom or physical sign had appeared. We also measured FT4 and FT3 levels in her cryopreserved serum by ultrafiltration LC-MS/MS. Her FT4 level measured by ultrafiltration LC-MS/MS on the visiting day and 2 days later were 160.0 and 135.5 pmol/L, respectively, indicating that the toxic dose of levothyroxine was partly changed to T3 during the 2 days. The FT3/FT4 ratios were revealed to be low, accounting for the patient’s benign clinical course despite temporal toxic exposure to levothyroxine. It is implied that prior discontinuation of supplementary levothyroxine increases potential vacant binding sites for thyroid hormone as a buffer to prevent toxic T3 effect. Conclusion It was helpful to clarify the time dependent changes in free thyroid hormone levels by ultrafiltration LC-MS/MS in discussing the clinical course in this case. Though mass spectrometry has a disadvantage in speed for routine laboratory use, its accurate measurement, particularly of levels exceeding the measurable range of the immunoassay, provides valuable information for more appropriate management of extreme thyrotoxicosis. |
topic |
Free thyroid hormone Thyrotoxicosis Congenital hypothyroidism Excess levothyroxine Mass spectrometry Immunoassay |
url |
http://link.springer.com/article/10.1186/s13044-020-00078-7 |
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