J Endocrinol Metab

Journal of Endocrinology and Metabolism, ISSN 1923-2861 print, 1923-287X online, Open Access

Article copyright, the authors; Journal compilation copyright, J Endocrinol Metab and Elmer Press Inc

Journal website http://www.jofem.org

Review

Volume 9, Number 5, October 2019, pages 127-132

Differential Diagnosis of Thyrotoxicosis

Figure 1. Thyrotoxicosis with and without hyperthyroidism. fT3: free triiodothyronine; fT4: free thyroxine; TRAb: anti-TSH receptor antibody; TSH: thyroid-stimulating hormone.

Figure 2. Scintigraphic finding in a patient with Graves’ disease. Diffuse uptake of ¹²³I uptake by thyroid glands is observed in patients with Graves’ disease.

Figure 3. Typical scintigraphic pattern in patients with Graves’ disease (a), Plummer’s disease (b, c) and painless and subacute thyroiditis (d). Black area indicate uptake of ¹²³I uptake.

Figure 4. Ultrasound finding in a patient with Graves’ disease. Increased thyroid blood flow in whole thyroids is observed in a patient with Graves’ disease.

**Table 1.** Characteristics for Thyroid Storm
This table was made by modification of table in Reference 5. LDL: low-density lipoprotein; HDL: high-density lipoprotein.
Degree of hyperthyroidism
Higher free T3 (> 19 pg/mL)
Higher free T4 (> 6 µg/dL)
Hematological abnormality
Neutrophilia (> 74%)
Lymphocytopenia
Monocytopenia
Eosinopenia
Metabolic abnormality
Higher alkaline phosphatase (> 475 U/L)
Lower triglyceride
Lower LDL-cholesterol
Lower HDL-cholesterol (≤ 40 mg/dL)
Degree of immunological abnormality
Higher titer of the third-generation TSH receptor antibody (> 30 IU/L)

Table 1. Characteristics for Thyroid Storm

This table was made by modification of table in Reference 5. LDL: low-density lipoprotein; HDL: high-density lipoprotein.

Degree of hyperthyroidism

Higher free T3 (> 19 pg/mL)

Higher free T4 (> 6 µg/dL)

Hematological abnormality

Neutrophilia (> 74%)

Lymphocytopenia

Monocytopenia

Eosinopenia

Metabolic abnormality

Higher alkaline phosphatase (> 475 U/L)

Lower triglyceride

Lower LDL-cholesterol

Lower HDL-cholesterol (≤ 40 mg/dL)

Degree of immunological abnormality

Higher titer of the third-generation TSH receptor antibody (> 30 IU/L)

**Table 2.** Differences in Clinical, Endocrinological, Immunological and Biochemical Findings and Diagnostic Imaging Among Graves’ Disease, Subacute Thyroiditis and Painless Thyroiditis
	Graves’ disease		Subacute thyroiditis		Painless thyroiditis
This table was made by modification of tables in Reference 14. TSH: thyroid-stimulating hormone.
Clinical findings
Swelling	(+)	>	(+)	>	(+)
Pain	(-)		(+)		(-)
Tenderness	(-)		(+)		(-)
Scintigraphic findings
Radioactive iodine uptake	↑		↓ (acute phase)		↓
Echoic findings	Increase of blood flow	Hypoechoic lesion at a painful portion
Thyroid hormones
Free T3 (mean ± SD, pg/mL)	14.0 ± 8.0	>	8.6 ± 3.3	>	4.5 ± 1.3
Free T4 (mean ± SD, µg/dL)	3.7 ± 1.9	>	2.9 ± 0.9	>	1.7 ± 0.4
Free T3/free T4 (mean ± SD)	3.6 ± 0.7	>	3.1 ± 0.8	>	2.7 ± 0.4
TSH receptor antibody	(+)		(-)		(-)
Leukocytosis (leukocytes/µL)	5,527 ± 1,780 (-)		9,780 ± 4,013 (+)		6,386 ± 3,913 (-)
C-reactive protein
Positive rate (%)	23		90		33
Values (mean ± SD, mg/dL)	0.2 ± 0.4		4.8 ± 4.0		2.4 ± 4.8

Table 2. Differences in Clinical, Endocrinological, Immunological and Biochemical Findings and Diagnostic Imaging Among Graves’ Disease, Subacute Thyroiditis and Painless Thyroiditis

Graves’ disease

Subacute thyroiditis

Painless thyroiditis

This table was made by modification of tables in Reference 14. TSH: thyroid-stimulating hormone.

Clinical findings

Swelling

(+)

Pain

(-)

(+)

(-)

Tenderness

(-)

(+)

(-)

Scintigraphic findings

Radioactive iodine uptake

↑

↓ (acute phase)

↓

Echoic findings

Increase of blood flow

Hypoechoic lesion at a painful portion

Thyroid hormones

Free T3 (mean ± SD, pg/mL)

14.0 ± 8.0

8.6 ± 3.3

4.5 ± 1.3

Free T4 (mean ± SD, µg/dL)

3.7 ± 1.9

2.9 ± 0.9

1.7 ± 0.4

Free T3/free T4 (mean ± SD)

3.6 ± 0.7

3.1 ± 0.8

2.7 ± 0.4

TSH receptor antibody

(+)

(-)

Leukocytosis (leukocytes/µL)

5,527 ± 1,780 (-)

9,780 ± 4,013 (+)

6,386 ± 3,913 (-)

C-reactive protein

Positive rate (%)

Values (mean ± SD, mg/dL)

0.2 ± 0.4

4.8 ± 4.0

2.4 ± 4.8