International Journal of Current Research and Review
ISSN: 2231-2196 (Print)ISSN: 0975-5241 (Online)
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IJCRR - 13(4), February, 2021

Pages: 25-28

Date of Publication: 16-Feb-2021


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Neuropathy in Newly Diagnosed Hyperthyroid Patients: A Case-Control Study

Author: Ahmad Faraz, Sangeeta Singhal, M. Mobarak Hossain, S. S. Siddiqui

Category: Healthcare

Abstract:Introduction: Hyperthyroidism is a common endocrinologic disorder affecting many organ systems. Several neurological diseases like acute and chronic myopathy, periodic paralysis, ophthalmoplegia, and rarely myasthenia gravis are known associations of thyrotoxicosis. However, neuropathy in hyperthyroidism is not frequently reported. Objective: To evaluate the occurrence of neuropathy in hyperthyroid patients. Methods: 60 patients of hyperthyroidism were included in the study, detailed history and clinical examination was performed. 60 normal subjects were included as a control. Nerve Conduction Studies were performed in neurophysiology lab of Physiology dept of JNMC Aligarh. Result: While comparing motor conduction parameters of hyperthyroid patients with the control group, NCV and Latencies do not show a significant difference, while the Amplitude of the Median Nerve in both the limbs shows a significant decrease. On comparing Sensory conduction parameters of hyperthyroid patients with the control group, the amplitude of the Median Nerve, Sural Nerve shows a significant decrease, while latencies of Median Nerve and Sural Nerve is increased in hyperthyroid patients. Conclusion: Our study indicates predominant sensorimotor axonal neuropathy in newly diagnosed hyperthyroid patients. We suggest neurological investigation should be included at the time of diagnosis in these patients.

Keywords: Hyperthyroidism, Neurophysiology, Nerve Conduction Velocity, Neuropathy, Sensorimotor Neuropathy, Sensory Nerve Conduction Velocity, Motor Nerve Conduction Velocity

Full Text:

Introduction

The thyroid hormone is required by cells and tissues for basic metabolism for their normal functioning. The thyroid hormone has profound impacts on prenatal and even during postnatal life on the developing brain.1,2 The thyroid hormone also plays an important part in the growth of the brain and spinal cord and myelination of neurons in adults. Prevalence of Hyperthyroidism is increased in urban population and the highest prevalence is found in the age group of 30 – 49 years.3 Hyperthyroidism is characterized by heat intolerance, sweating, increased pulse pressure, a fine tremor of the outstretched fingers, tachycardia, atrial fibrillation in the elderly, hyperreflexia, hyperactivity, irritability, muscle weakness, proximal myopathy.4 Musculoskeletal and neurological involvement often manifests as fatigue, muscle weakness, and paralysis. Thyrotoxicosis is associated with various neurological diseases like acute and chronic myopathy, periodic paralysis, ophthalmoplegia, and rarely myasthenia gravis. Neuromuscular association and primary muscle disorder are associated with hyperthyroidism.5 However, neuropathy in hyperthyroidism is not frequently reported. Our study aims to find out the effect of hyperthyroidism in neuropathy.

Materials and Methods

Ethical clearance was taken from the ethical committee of J.N. Medical College. Patients attending the Rajiv Gandhi Centre for diabetes and Endocrinology were evaluated for inclusion and exclusion criteria. Patients who gave valid written and informed consent were included in the study.

Study population

Sixty patients of newly diagnosed hyperthyroidism defined by decreased Thyroid Stimulating Hormone (TSH) and raised FT4 were taken from Rajiv Gandhi Centre of Diabetes and Endocrinology. Patients with overt hyperthyroidism were included in the study. Patients having Diabetes Mellitus, Hypertension, and Renal failure, alcoholic hepatitis, vitamin B12 deficiency, patients taking steroids, neuropathies associated with malnutrition, toxic agents e.g. metal or drugs, and neuropathy from other conditions were excluded from the study. Sixty normal subjects who gave informed consent and are willing to participate in the study were included in our study.

Clinical Evaluation

Patients included in the study were screened for neuromuscular symptoms such as weakness, tiredness, myalgia, stiffness, cramps, numbness, tingling, pain, and paraesthesia. Neurological examination for motor and the sensory system was done, it includes Pin-prick, light touch, and vibration sensation evaluation of cranial nerves, motor power, and reflexes.

Nerve Conduction Studies

MNCV

NCS was carried out according to standardized protocols for the bilateral median, ulnar, and common peroneal nerve. The negative end of the stimulator was positioned near to the active electrode. The surface recording electrodes were used and placed in belly tendon montage; the active electrode is placed adjacent to the motor point and reference near to tendon. A ground electrode has been positioned between the stimulating and the recording electrodes. Stimulation intensity was slowly raised and the value at which the amplitude did not increase was calculated as the supramaximal strength. This stimulation intensity was used to record a Compound Muscle Action Potential (CMAP). At two points along its path, motor or mixed nerve was stimulated. Distance has been calculated in mm between two points of stimulation, Motor Nerve Conduction Velocity (MNCV) was calculated by dividing distance and latency difference between the proximal and the distal latencies (ms). The nerve conduction velocity is expressed as m/s and amplitude in mv.6

SNCV

In our study sensory nerves were tested by antidromic recording. In an antidromic conduction study, the proximal point of a nerve is stimulated and distally, Sensory Nerve Action Potential (SNAP) is recorded. In Sensory Conduction study averaging of signal enhancement is required. The averaged signal enhancement is directly proportional to the square root of the no. of trials. The latency of potential is calculated from the stimulus artefact to the initial positive peak. SNCV unlike MNCV is measured by stimulating at a single stimulation site since sensory nerve conduction does not include neuromuscular transmission time and muscle propagation time. Thus, the SNCV was calculated by dividing the distance (mm) between the stimulating and recording sites by the latency (ms). The nerve conduction velocity is expressed as m/s.5

Statistical analyses 

Analyses were done using SPSS 21.0. Data were expressed as mean ± SD, the normalcy of data was assessed by the Kolmogorov Smirnoff test. Unpaired t-tests were used for comparison between quantitative variables. Chi-square tests were used to compare differences in the categorical variables. The con?dence interval (CI) was set at 95%.

Results

We evaluated 85 patients of hyperthyroidism and they were assessed for inclusion and exclusion criteria. 60 subjects were included in the study who gave valid consent and were newly diagnosed hyperthyroid patients and met with inclusion criteria. and 60 normal subjects. The mean age of hyperthyroid patients was 33.2±3.58 and that of control is 32.1±3.81 and is statistically non-significant. 18 patients (30 %) presented with a tingling sensation in lower limbs, 20 (33.3%) patients complain of numbness, 6 patients presented with pain. TSH level of Hyperthyroid patients is less than 0.02 mU/l and FT4 is 50.6 ± 3.4.

On comparing motor conduction parameters in hyperthyroid patients with a control group, NCV and Latencies do not show a significant difference, while Amplitude of Median Nerve in both the limbs (Rt median: 9.41 ± 3.2, Lt Median: 10.12 ± 4.5) shows a significant decrease (Table 1).

While comparing Sensory conduction parameters in hyperthyroid patients with a control group, the amplitude of Median Nerve (Rt Median Nerve: 26.71 ± 5.9, Lt Median Nerve: 28.32± 6.2), Sural Nerve (Rt Sural Nerve: 22.80 ± 2.6, Lt Sural Nerve: 21.73 ± 3.6) shows a significant decrease, while latencies of Median Nerve (Rt Median Nerve: 3.69 ± .69, Lt Median Nerve: 3.43 ± .80) and Sural Nerve (Rt Sural Nerve: 3.31 ± .62, Lt Sural Nerve:3.29 ± .59) is increased in hyperthyroid patients when compared with control (Table 2).

Discussion

In the present study, our results showed that the amplitude of the median and sural nerve in hyperthyroid patients is significantly decreased as compared to the control group. The latency of the sural nerve is increased, while the Nerve Conduction Velocity of these nerves showed no significant results. Duyff et al7 in their study concluded that 20 % of Hyperthyroid patients present with sensorimotor axonal polyneuropathy, they also pointed a very good response to neuropathy by anti-thyroid treatment. MNCV of the median nerve, ulnar nerve, and common peroneal nerve in the hyperthyroid subject is not decreased.13 Yüksel et al8 shows increased latency of sural nerve in hyperthyroid patients.

A comparison of the SNCV does not show a significant decrease in the conduction velocity of the median, ulnar, and common peroneal nerve in hyperthyroid subjects as compared to the SNCV of these nerves in the control subjects. But sensory latency of the Sural nerve is increased bilaterally in hyperthyroid subjects as compared to control subjects. In hyperthyroid cases latency of sural nerve is increased when compared with normal subjects. Feibel and Campa concluded that their patient of hyperthyroidism presented with a latent sensorimotor polyneuropathy.9 Ludin et al. (1969) show neuropathic involvement in hyperthyroidism, they hypothesized that their patients had a subclinical polyneuropathy.10 Roquer et al., (1993) in their prospective study, found Carpal Tunnel Syndrome (CTS)in 5% of hyperthyroid patients in the initial survey. They concluded that CTS should be considered another peripheral neurological manifestation associated with hyperthyroidism.11 Sözay et al., (1994) show a decrease in the amplitude of sensory nerves. The SNCV of the sural nerve is decreased by 35.5%. They concluded that electrophysiological studies can be an important diagnostic tool for asymptomatic hyperthyroid patients.12 Sweed et al., (2007) conducted their study on hyperthyroidism in geriatric patients, they revealed evidence of motor neuropathy in the upper limb of axonal type. The prevalence of affection in the hyperthyroid group was found in 25% of cases. Also, entrapment neuropathy of the median nerve has been observed in 25% of hyperthyroid patients.13 A case report on the hyperthyroid patient reveals acute polyneuropathy in hyperthyroidism.14 Ajeena, (2013) concluded that in hyperthyroid patients, nerve conduction parameters were not significant when compared with that of the control group. But they also said that there were 10 (32.2%) hyperthyroid patients, where the sural nerve was the most commonly involved, and 10 (32.2%) of them had CTS.15 Although the reason for neuropathy in hyperthyroid patients is still known, it has been hypothesized to be either a direct effect of increased thyroid hormones, immune-mediated or due to a hypermetabolic state reducing these essential nutrients of nerves.16 Further studies are required to ascertain the exact cause. Various studies suggest myopathy as a predominant manifestation of hyperthyroidism, but we cannot deny the fact that neuropathy is also associated with hyperthyroidism. The amplitude of the Median nerve and the Sural nerve is decreased which suggests that there is sensorimotor axonal neuropathy. Further several studies pointed in this direction. The exact pathogenesis is still not known.

Conclusion

Neuropathy in hyperthyroidism is an underdiagnosed condition, most studies correlate myopathy with hyperthyroidism. But our study indicates predominant sensorimotor axonal neuropathy in newly diagnosed hyperthyroid patients. We suggest neurological investigation should be included at the time of diagnosis in these patients. Further studies should be done to find out the pathogenesis of neuropathy in hyperthyroidism.

Acknowledgment: We would like to acknowledge the support provided by Aley Mustafa. We would like to thank the Department of Physiology and Rajiv Gandhi Centre for Diabetes and Endocrinology for the smooth running of the study.

Conflict of interest: None of the authors declared any conflict of interest

Funding: The Study was self-financed.

References:

  1. Bernal J. Iodine and brain development. Biofactors 1999;10:271–276.

  2. Oppenheimer JH, Schwartz HL. Molecular basis of thyroid hormone-dependent brain development. Endocr Rev 1997; 18: 462–475.

  3. Deokar PG, Nagdeote AN, Lanje MJ, Basutkar DG. Prevalence of Thyroid Disorders in A Tertiary Care Center. Int J Cur Res Rev 2016; 8(9):26- 30.

  4. Tonner DR, Schlechte JA. Neurological complications of the thyroid and parathyroid disease. Med Clin North Am 1993;77:251-263.

  5. Fisher M, Matell JE, Ullrich I, Gutrecht JA. Pyramidal tract de?cits and poly-neuropathy in hyperthyroidism. Am J Med 1985;78:1041–1044.

  6. Mishra UK, Kalita J. Clinical Neurophysiology 2nd ed.New Delhi: Elsevier; 2006.

  7. Duyff RF, Van den Bosch J, Laman DM, van Loon BJ, Linssen WH. Neuromuscular findings in thyroid dysfunction: a prospective clinical and electrodiagnostic study. J Neurol Neurosurg Psychiatry 2000 Jun;68(6):750-755.

  8. Yüksel G, Karlikaya G, Tanrida? T, Us Ö, Akyüz G.Nerve Conduction Studies, SEP and Blink Reflex Studies in Recently Diagnosed, Untreated Thyroid Disease Patients. J Neurological Sci [Turkish] 2007;24(1):10:7-15.

  9. Feibel JH,  Campa JF.Thyrotoxic neuropathy (Basedow’s paraplegia). J Neurol Neurosurg Psychiatry 1976;39(5):491–497.

  10. Ludin HP, Spiess H, Koenig MP. Neuromuscular dysfunction associated with thyrotoxicosis. Eur Neurol 1969;2:269-278.

  11. Roquer J, Cano JF. Carpal tunnel syndrome and hyperthyroidism. A prospective study. Acta Neurol Scand 1983;88:149–152.

  12. Sözay S, Gökçe-Kutsal Y, Celiker R, Erbas T, Ba?göze O. Neuroelectrophysiological evaluation of untreated hyperthyroid patients. Thyroidology 1994; 6(2): 55–59.

  13. Sweed HS, Nasser AA, Khalil S, Bayomi I.Cognitive and Neuromuscular Assessment in Geriatric Patients with Thyroid Dysfunction. Egypt J Neurol Psychiat Neurosurg 2007;44(1): 235-237.

  14. Al-Wahaibi AK, Kumar S, Al-Risi A, Wali F. Thyrotoxic Neuropathy: A rare cause of acute flaccid paraplegia. Sultan Qaboos Univ Med J 2017;17(4):e460-e463.

  15. Ajeena IM. Prevalence of Neuromuscular Abnormalities in Newly Diagnosed Patients with Thyroid Dysfunction. Am J Res Comm 2013;1(3):79–88.

  16. Al-Wahaibi AK, Kumar S, Al-Risi A, Wali F. Thyrotoxic Neuropathy: A rare cause of acute flaccid paraplegia. Sultan Qaboos Univ Med J 2017;17(4):e460-e463.

Announcements

Dr. Pramod Kumar Manjhi joined Editor-in-Chief since July 2021 onwards

COPE guidelines for Reviewers

SCOPUS indexing: 2014, 2019 to 2021


Awards, Research and Publication incentive Schemes by IJCRR

Best Article Award: 

One article from every issue is selected for the ‘Best Article Award’. Authors of selected ‘Best Article’ are rewarded with a certificate. IJCRR Editorial Board members select one ‘Best Article’ from the published issue based on originality, novelty, social usefulness of the work. The corresponding author of selected ‘Best Article Award’ is communicated and information of award is displayed on IJCRR’s website. Drop a mail to editor@ijcrr.com for more details.

Women Researcher Award:

This award is instituted to encourage women researchers to publish her work in IJCRR. Women researcher, who intends to publish her research work in IJCRR as the first author is eligible to apply for this award. Editorial Board members decide on the selection of women researchers based on the originality, novelty, and social contribution of the research work. The corresponding author of the selected manuscript is communicated and information is displayed on IJCRR’s website. Under this award selected women, the author is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.

Emerging Researcher Award:

‘Emerging Researcher Award’ is instituted to encourage student researchers to publish their work in IJCRR. Student researchers, who intend to publish their research or review work in IJCRR as the first author are eligible to apply for this award. Editorial Board members decide on the selection of student researchers for the said award based on originality, novelty, and social applicability of the research work. Under this award selected student researcher is eligible for publication incentives. Drop a mail to editor@ijcrr.com for more details.


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A Study by Gainneos PD et al. entitled "A Comparative Evaluation of the Levels of Salivary IgA in HIV Affected Children and the Children of the General Population within the Age Group of 9 – 12 Years – A Cross-Sectional Study" is awarded Best Article of Vol 13 issue 05 Special issue on Recent Advances in Dentistry for better Oral Health
A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" is awarded Best Article of Vol 13 issue 06
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A Study by Mohita Ray et al. entitled "Accuracy of Intra-Operative Frozen Section Consultation of Gastrointestinal Biopsy Samples in Correlation with the Final Histopathological Diagnosis" is awarded Best Article for Vol 13 issue 01
A Study by Badritdinova MN et al. entitled "Peculiarities of a Pain in Patients with Ischemic Heart Disease in the Presence of Individual Combines of the Metabolic Syndrome" is awarded Best Article for Vol 12 issue 24
A Study by Sindhu Priya E S et al. entitled "Neuroprotective activity of Pyrazolone Derivatives Against Paraquat-induced Oxidative Stress and Locomotor Impairment in Drosophila melanogaster" is awarded Best Article for Vol 12 issue 23
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A Study by Ghaffar UB et al. entitled "Correlation between Height and Foot Length in Saudi Population in Majmaah, Saudi Arabia" is awarded Best Article for Vol 12 issue 21
A Study by Siti Sarah Binti Maidin entitled "Sleep Well: Mobile Application to Address Sleeping Problems" is awarded Best Article for Vol 12 issue 20
A Study by Avijit Singh"Comparison of Post Operative Clinical Outcomes Between “Made in India” TTK Chitra Mechanical Heart Valve Versus St Jude Mechanical Heart Valve in Valve Replacement Surgery" is awarded Best Article for Vol 12 issue 19
A Study by Sonali Banerjee and Mary Mathews N. entitled "Exploring Quality of Life and Perceived Experiences Among Couples Undergoing Fertility Treatment in Western India: A Mixed Methodology" is awarded Best Article for Vol 12 issue 18
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A Study by Sudha Ramachandra & Vinay Chavan entitled "Enhanced-Hybrid-Age Layered Population Structure (E-Hybrid-ALPS): A Genetic Algorithm with Adaptive Crossover for Molecular Docking Studies of Drug Discovery Process" is awarded Best article for Vol 12 issue 15
A Study by Varsha M. Shindhe et al. entitled "A Study on Effect of Smokeless Tobacco on Pulmonary Function Tests in Class IV Workers of USM-KLE (Universiti Sains Malaysia-Karnataka Lingayat Education Society) International Medical Programme, Belagavi" is awarded Best article of Vol 12 issue 14, July 2020
A study by Amruta Choudhary et al. entitled "Family Planning Knowledge, Attitude and Practice Among Women of Reproductive Age from Rural Area of Central India" is awarded Best Article for special issue "Modern Therapeutics Applications"
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A Study by Muhammet Lutfi SELCUK and Fatma entitled "Distinction of Gray and White Matter for Some Histological Staining Methods in New Zealand Rabbit's Brain" is awarded best article for  Vol 12 issue 11
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A study by Asha Menon "Women in Child Care and Early Education: Truly Nontraditional Work" is awarded Best Article for Vol 10 issue 13
A study by Deep J. M. "Prevalence of Molar-Incisor Hypomineralization in 7-13 Years Old Children of Biratnagar, Nepal: A Cross Sectional Study" is awarded Best Article for Vol 10 issue 11 of IJCRR
A review by Chitra et al to analyse relation between Obesity and Type 2 diabetes is awarded 'Best Article' for Vol 10 issue 10 by IJCRR. 
A study by Karanpreet et al "Pregnancy Induced Hypertension: A Study on Its Multisystem Involvement" is given Best Paper Award for Vol 10 issue 09

List of Awardees

A Study by Ese Anibor et al. "Evaluation of Temporomandibular Joint Disorders Among Delta State University Students in Abraka, Nigeria" from Vol 13 issue 16 received Emerging Researcher Award


A Study by Alkhansa Mahmoud et al. entitled "mRNA Expression of Somatostatin Receptors (1-5) in MCF7 and MDA-MB231 Breast Cancer Cells" from Vol 13 issue 06 received Emerging Researcher Award


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Disclaimer: International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal.



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International Journal of Current Research and Review (IJCRR) provides platform for researchers to publish and discuss their original research and review work. IJCRR can not be held responsible for views, opinions and written statements of researchers published in this journal

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