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Sunday, 1 December 2013

Thyroid disease: Euthyroid sick syndrome as a result of Sepsis - The Risk Factors

Euthyroid sick syndrome
Euthyroid sick syndrome is defined as a condition of  low T3 low T4 syndrome. According ot the study by the Mayo Clinic, in  other word this is the abnormalities of thyroid hormone concentrations seen commonly in a wide variety of nonthyroidal illnesses, resulting in low triiodothyronine, total thyroxine, and thyroid stimulating hormone concentrations(a). Decreased triiodothyronine (T3) levels are most common. Patients with more severe or prolonged illness also have decreased thyroxine (T4) levels. Serum reverse T3 (rT3) is increased. Patients are clinically euthyroid and do not have elevated thyroid-stimulating hormone (TSH) levels(b). Causes of euthyroid sick syndrome include a number of acute and chronic conditions, including pneumonia, fasting, starvation, sepsis, trauma, cardiopulmonary bypass, malignancy, stress, heart failure, hypothermia, myocardial infarction, chronic renal failure, cirrhosis, and diabetic ketoacidosis and inflammatory bowel disease(c). Others, in the study of classified SES into 3 subgroups according to the different alterations seen in the values of T3, T4, FT3, FT4, TSH, rT3 and TBG suggested that in SES type I the diseases seen, in order of frequency, were: obstructive chronic bronchopneumopathy with acute respiratory failure, diabetic ketoacidosis, neoplasms, ischemic heart disease, cardiac failure, chronic renal failure, liver diseases, acute cerebral vasculopathies, sepsis and collagenopathies. The disease seen in the 2 cases of SES type II was obstructive chronic bronchopneumopathy with acute respiratory failure. In SES type III the diseases seen were, in order of frequency: diabetic ketoacidosis, lung diseases, ischemic heart disease, cardiac failure, peripheral arteriopathies, acute cerebral vasculopathies, neoplasms, liver diseases, acute renal failure(d).

Euthyroid sick syndrome as a result of Sepsis  
 Sepsis is defined as a condition caused by chemicals released into the bloodstream to fight the infection trigger inflammation throughout the body as a result of severe infection(a)(b). according to the study by the University of Utah, sepsis is the commonest cause of admission to medical ICUs across the world. Mortality from sepsis continues to be high. Besides shock and multi-organ dysfunction occurring following the intense inflammatory reaction to sepsis, complications arising from sepsis-related immunoparalysis contribute to the morbidity and mortality from sepsis(c).
The Risk factors of Sepsis 
1.  Term infants, while very low birth weight (VLBW) and preterm infants
According to the study by the  Taipei City Hospital, total of 109 episodes of sepsis were identified in 100 neonates. The incidence of sepsis was 4.06% among all NICU admissions. Most neonates with early-onset sepsis were term infants, while very low birth weight (VLBW) and preterm infants accounted for the majority of cases of late-onset sepsis(14).

2. Obesity, operative vaginal delivery and age <25 years
In the study to describe the risk of maternal sepsis associated with obesity and other understudied risk factors such as operative vaginal delivery, found that ontrolling for mode of delivery and demographic and clinical factors, obese women had twice the odds of uncomplicated sepsis (OR 2.12; 95% CI 1.14-3.89) compared with women of normal weight. Age <25 years (OR 5.15; 95% CI 2.43-10.90) and operative vaginal delivery (OR 2.20; 95% CI 1.02-4.87) were also significant predictors of sepsis. Known risk factors for maternal sepsis were also significant in this study (OR for uncomplicated and severe sepsis respectively): multiparity (OR 6.29, 12.04), anaemia (OR 3.43, 18.49), labour induction (OR 3.92 severe only), caesarean section (OR 3.23, 13.35), and preterm birth (OR 2.46 uncomplicated only)(15).

3. Elder
If you are elder, you are at increased risk of sepsis

4. Patient in intensive care and with weakened immune system
Intra-abdominal infections are a common problem for the general surgeon and major sources of morbidity and mortality in the intensive care unit(16). Other indicated that severe sepsis has emerged as a major cause of admission and mortality for hospitalized HIV/AIDS patients, significantly affecting short- and longer-term survival of critically ill HIV/AIDS patients(17).

5. Invasive devices
There is a study of indwelling intravenous polyethylene catheters as factors influencing the risk of microbial colonization and sepsis(18).

6. Obesity and alcpholism
A multivariate analysis revealed that obesity (adjusted odds ratio [aOR] 21.4; 95% confidence interval [CI] 1.8-257.5) and alcoholism (aOR 6.5; 95% CI 1.3-32.8) were important predictive factors for spinal sepsis(18a).

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Sources
(a) http://en.wikipedia.org/wiki/Sepsis
(b) http://www.mayoclinic.com/health/sepsis/DS01004 
(c) http://www.ncbi.nlm.nih.gov/pubmed/24082613 

(d) http://www.ncbi.nlm.nih.gov/pubmed/8028742
(14) http://www.ncbi.nlm.nih.gov/pubmed/19579754 
(15) http://www.ncbi.nlm.nih.gov/pubmed/22251396 
(16) http://www.ncbi.nlm.nih.gov/pubmed/23153889 
(17) http://www.ncbi.nlm.nih.gov/pubmed/20698966
(18) http://www.ncbi.nlm.nih.gov/pubmed/4931311
(18a) http://www.ncbi.nlm.nih.gov/pubmed/19632847