June 2003, Volume 53, Issue 6

Review Articles

Euthyroid Sick Syndrome

A. Sattar  ( Departments of Chemical Pathology and Endocrinology and Haematology*, Armed Forces Institute of Pathology, Rawalpindi. )
N. Asif  ( Departments of Chemical Pathology and Endocrinology and Haematology*, Armed Forces Institute of Pathology, Rawalpindi. )
M. M. Dawood  ( Departments of Chemical Pathology and Endocrinology and Haematology*, Armed Forces Institute of Pathology, Rawalpindi. )
T. Rafi  ( Departments of Chemical Pathology and Endocrinology and Haematology*, Armed Forces Institute of Pathology, Rawalpindi. )
Z. Rehman  ( Departments of Chemical Pathology and Endocrinology and Haematology*, Armed Forces Institute of Pathology, Rawalpindi. )
M. Aamir  ( Departments of Chemical Pathology and Endocrinology and Haematology*, Armed Forces Institute of Pathology, Rawalpindi. )


Abnormalities in the circulating thyroid hormone concentration, without associated pituitary or thyroid disease, are seen in a variety of nonthyroidal illnesses (NIH). These abnormalities may be low plasma triiodothyronine (T3), low thyroxine (T4) or a combination of both, with an inappropriately normal plasma thyrotropin (TSH). These could be because of various factors acting on monodeiodinase, a key enzyme for the conversion of T4 to T3, or on transport system for thyroid hormones. Role of cytokines and other inflammatory mediators through their actions on hypothalamus, pituitary or thyroid gland has been extensively investigated, but their real action in vivo remains unclear. Knowledge of these hormone abnormalities is necessary to avoid errors in the diagnosis of thyroid disease. Whether the hormone responses in euthyroid sick syndrome represent part of an adaptive response, which lowers tissue energy requirement in systemic illness, or is a maladaptive response inducing damage to tissues in hypothyroidism, remains unclear. The thyroid function disturbances correlate with the disease severity, and low levels of thyroid hormones predict a poor prognosis in severe illness. The use of thyroid hormone therapy is still controversial in such illnesses, as few controlled trials have shown conflicting results for treatment with T3.
Abnormalities in the circulating levels of thyroid hormones, without evidence of coexisting thyroid or pituitary gland disease, are commonly seen in a wide variety of systemic nonthyroidal illnesses. Interpreting the test results and knowing what to do with the results when there is no evidence of thyroid dysfunction can be a challenge.1 The term "euthyroid sick syndrome" is used to describe these abnormalities in thyroid function tests. It is the most common biochemical abnormality of endocrine function among medical inpatients; the incidence may be as high as 70%.2 The observed thyroid hormone abnormalities do not indicate thyroid disease, but seem to represent a response to the underlying illness, as these invariably disappear with recovery from underlying illness. The term "nonthyroidal illness syndrome" (NTIS) seems more appropriate alternative designation, as it does not presume the metabolic status of the patient.3
Appropriate and timely recognition of abnormalities of thyroid function in various nonthyroidal systemic illnesses has paramount importance because of three main reasons: (a) Abnormal results of thyroid function tests can sometimes mimic or at other times mask the biochemical changes observed in patients with intrinsic thyroid disease.4 (b) The hormonal response in euthyroid sick syndrome represents the part of an adaptive response to illness, so the treatment of these systemic illnesses with thyroxine is not of much help.5 (c) The severity and nature of changes in thyroid function tests have implications on the prognosis in such cases.6

Patterns of Euthyroid Sick Syndrome

Various patterns of thyroid hormone and TSH concentrations have been reported in euthyroid sick syndrome, reflecting the type and severity of illness.3 Chopra et al.7 have divided these patterns into following four major types:

1. Low T3 Syndrome

This is the most common abnormality, observed in about 70% of the hospitalized patients. Serum concentration of total triiodothyronine (T3) falls rapidly and progressively within 30 min to 24 hours of the onset of the causative illness. The degree of fall reflects the severity of disease process.8 Levels vary from undetectable to normal, and the mean value is approximately 40% of the normal level. Whenever measured, the concentration of serum free T3 (fT3) is low normal or slightly decreased.9 The daily production of T3 is decreased, while its clearance remains unchanged. The decreased conversion of thyroxine (T4) to T3 results from the inhibition of enzyme 1,5'-monodeiodinase (5'-MDI) activity, which catalyzes the deiodination of T4 to T3.10 Serum total T4 and free T4 (fT4) are normal in patients with low T3 syndrome.11
Generally serum TSH concentration and its response to thyrotropin releasing hormone (TRH) are normal. However TSH level may increase slightly, but returning to normal with recovery.12 The serum concentration of reverse T3 (rT3) is increased except in renal failure13 and traumatic brain injury.14 Daily production rate of rT3 is normal. The increase in the serum rT3 level is mainly due to its reduced metabolic clearance.15

2. Low T3 and T4 syndrome

The low T3 and T4 syndrome is observed in severely ill, moribund patients admitted to medical intensive care units. About 30-50% of patients have subnormal levels of T3 and T4. The T4 concentration falls over a period of 24-48 hours. However the fT4 values are frequently within normal limits. This disparity between low T4 values and normal fT4 levels is partly due to decreased T4 binding. Kinetic studies have shown reduced hepatic uptake and clearance of T4. The fall in circulating thyroid hormone concentration coupled with reduced clearance implies substantially low thyroidal production rates.16
Serum TSH concentration is frequently low, as measured with sensitive TSH assays and TRH responses are blunted.17 This blunted response is probably due to decrease in the enzyme activity responsible for TRH degradation, leading to impairment of TRH metabolism. TSH level rises with recovery, and may be transiently elevated until T3 and T4 levels are restored to normal.18 The rT3 synthesis diminishes due to the decreased availability of its precursor T4, but because of slow degradation rT3 concentrations are frequently increased.15
Several factors may contribute to low T3 and T4 levels. These include: (1) reduced binding proteins, e.g., thyroxine binding globulin (TBG), albumin and prealbumin especially in chronic liver disease19 and in renal dialysis20, (2) abnormal TBG due to altered sialylation21, (3) circulating competitive binding inhibitors of T4 to serum protein, including drugs22 (furosemide in high doses23), non-esterified fatty acids (NEFA) and metabolic products24 and (4) decreased serum TSH, especially in patients treated with dopamine.25

3. High T4 syndrome

This is an unusual variant of euthyroid sick syndrome, seen in approximately 1% of sick patients. High serum T4 level is seen in some systemic illnesses-notably acute intermittent porphyria26, liver diseases such as chronic active hepatitis and primary biliary cirrhosis27, acute psychiatric illness28, and patients on certain drugs such as amiodarone29, and radiocontrast agents like ipodate and iopanoic acid used for oral cholecystography.30 The serum concentration of fT4 remains normal. The high serum T4 level is usually the result of increased serum TBG. Serum T3 may be normal or increased, but fT3 concentration is typically decreased. The serum concentration of rT3 is also increased in such patients, a finding related to both a high TBG concentration and a decreased metabolism of rT3. The serum TSH is usually very low or undetectable, and TRH response is blunted to absent.16

4. Other abnormalities
Studies have shown that there is decreased nocturnal TSH surge, unrelated to ambient circulating T4 and T3 levels, but probably related to hypothalamic dysregulation.31 In addition, evidence suggests that TSH has reduced biological activity in euthyroid sick patients due to some structural abnormality.32 Euthyroid sick syndrome is also associated with low serum total protein. Low albumin33 and high sympathetic response like high cortisol and nor-epinephrine levels are also commonly seen in acutely ill patients.34
Table. Conditions associated with Euthyroid Sick Syndrome.
1.. Medical

Acute myocardial infarction.68
Acute renal failure.13
Pulmonary tuberculosis.69
Alcoholic liver disease. 70
Hepatic cirrhosis.19
Lymphomas, leukemia and during their chemotherapy. 71
Aplastic anemia.71
Obstructive chronic bronchopneumopathy with acute respiratory failure. 73
Diabetic ketoacidosis.73
Acute cerebral vasculopathies.73
Hodgkin disease.74
Chronic heart failure .75 2. Surgical

Acute and chronic spinal cord injury.76
Major trauma.77
Severe burn.1
After elective cholecystectomy. 78
During and after cardiopulmonary bypass.67 3. Infections

Viral hepatitis type A. 79
Advanced stages of HIV. 80

4. Miscellaneous

Patients receiving antituberculosis treatment.69
Premature and sick infants. 81
Bone marrow transplantation.82
Progressive systemic sclerosis. 83
Extensive dermatitis.83
Malignant Mediterranean spotted fever.73
Acute psychiatric illness.28
Acute intermittent porphyria.26 5. Drugs

a) Inhibitors of T4 to T3 conversion

Propranolol in high doses.19
Radiographic contrast agents.30
b) Augmentation of clearance of T4 (enzyme induction)

c) Inhibitors of TSH secretion

Somatostatin.22 d) Inhibitors of thyroid hormone synthesis or release

Lithium.22 e) Inhibitors of binding of T4/T3 to serum proteins

Nonsteroidal anti-inflammatory agents.22
Salicylates. 84
Heparin. 85
Furosemide.23 f) Increasing concentration of T4 binding proteins22

Perphenazine. g) Stimulators of TSH secretion22

Dopaminergic antagonists.


The thyroid gland produces mainly two iodine-containing hormones, T4 and T3. One third of the circulating T4 is normally converted to T3 by deiodination and 45% is converted to rT3 in the peripheral tissues. Two different enzymes are involved in these conversions i.e., enzyme I, 5'-monodeiodinase (5'-MDI), catalyzing the formation of T3, and enzyme I, 5-monodeiodinase (5- MDI), catalyzing the formation of rT3. The T3 is approximately 4-5 times more potent than T4 whereas rT3 is biologically inactive. Most of the T4 and T3 circulate in reversibly bound form with various plasma proteins: thyroxine-binding globulin (TBG), transthyretin (thyroxine binding prealbumin) and albumin. Only about 0.03% of T4 and 0.3% of T3 circulate in free form.35
Figure. Biochemical changes and their mechanisms in vaious patterns of euthyroid sick syndrome.
The exact cause of changes in serum thyroid hormone and TSH concentration observed in euthyroid sick syndrome is not completely understood. Various mediators have been implicated for the observed abnormalities in thyroid hormones seen in different systemic diseases. Reduced T3 production in peripheral tissues may be related not only to a decreased 5'-MDI activity but also to decreased T4 transport into various tissues. A number of factors are responsible for these actions
(1) Transport of T4 into liver is regulated by intracellular adenosine triphosphate (ATP) and energy stores. Evidence indicates that the tissue content of ATP and high-energy phosphates is reduced in euthyroid sick syndrome. Decreased T4 tissue uptake has been documented during fasting, liver disease and critical illnesses. Substances such as 3-carboxy-3-methyl-5-propyl-2-furanpropanoic acid (CMPF), indoxyl-sulfate, free fatty acids36, hippuric acid, and bilirubin37, which are increased in various systemic illnesses are known to decrease T4 uptake into hepatocytes leading to reduced T3 generation.
(2) The enzyme 1, 5'-monodeiodinase(5'-MDI) is a low affinity and high capacity enzyme located in the major organs including liver, kidney and thyroid. It is responsible for generation of bulk of circulating T3.38 There are a number of factors, which suppress the activity of this enzyme:
(a) Compromised nutritional status: The enzyme 5'-MDI is sensitive to caloric intake especially the one derived from carbohydrates. Fasting or hyper caloric diets reduce T3 level resembling euthyroid sick syndrome.39
(b) Free radicals: Free radicals generated in the tissues also inhibit 5'-MDI activity. Moreover increased 5'-MDI activity has been observed in the presence of free radical scavengers.40
(c) Alterations in selenium status: The enzyme 5'-MDI has selenocysteine at the active site of the enzyme. Selenium acts as a cofactor and thus is critical in T3 production. Selenium deficiency is associated with a progressive reduction of 5'-MDI activity in tissues and is restored by selenium supplements.41
(3) Certain toxic metals such as cadmium42, mercury43, and lead44, and compounds such as carbon tetrachloride45 have been associated with impaired 5'-MDI activity in animal models. Similarly vitamin B12 deficiency46 and zinc deficiency47 are associated with slight reduction in this enzyme activity, thus reducing T3 level. Nicotinic acid48, lipoic acid49, organophosphate compounds50 and hyperglucagonemia51 all decrease serum thyroid hormone concentration while maintaining a euthyroid state.
Various clinical conditions and drugs associated with euthyroid sick syndrome have been summarized in Table.


Recently, particular attention has been focused on the role of cytokines in the pathogenesis of euthyroid sick syndrome. Cytokines are multifunctional molecules with different biological effects on target cells. These can have autocrine, paracrine or endocrine actions. Cytokines may have a physiological or pathophysiological role contributing to development of euthyroid sick syndrome.52
Among the different cytokines studied, tumor necrosis factor-a (TNF-a) is perhaps the most promising and best-studied candidate for a mediator of euthyroid sick syndrome. Infusion of TNF-a in man produces a decrease in serum T3, T4 and TSH levels and a rise in rT3.53 The infusion of interleukin-1. (IL-1)54, interleukin-6 (IL-6)55, and interferon-a (IFN-a)56 also produce the similar results. It has been shown that IL-1 and TNF-a both can induce the release of IL-6, suggesting that IL-6 may be the mediator of cytokine induced thyroid hormone changes. Several studies have been done to find the role of interferon-g, IL-2, IL-8, and IL-10 in patients with euthyroid sick syndrome, but no evidence for their pathogenic role have been found.57,58
Thus, it seems certain that nonthyroidal illness (NTI) is associated with an increased production and release of cytokines but the degree of cytokines involvement and their specific role in the pathogenesis remain controversial and undermined.52 One possibility is that NTI per se causes an increase in cytokine production and which is the only factor responsible for changes in euthyroid sick syndrome. A second possibility is that through incompletely understood mechanisms, the illness produces both an increase in cytokine levels and changes in thyroid function tests, the latter being totally independent of cytokine variations. The third and more likely model relates changes in thyroid parameters to both a direct effect of disease and the illness-related increase in cytokine production and release. This model best fits with available data indicating that in addition to the effects of cytokines, other substances, such as 3-carboxy-3-methyl-5-propyl-2-furanpropanoic acid (CMPF), indoxyl-sulfate, bilirubin, and FFA36,37 probably participate in the pathogenesis of euthyroid sick syndrome by reducing thyroid hormone transport into cells and thereby decreasing peripheral T3 production. Various biochemical changes associated with euthyroid sick syndrome have been summarized in Figure.

Clinical Significance

Abnormal thyroid function tests are observed as frequently in systemic euthyroid sick syndrome as in intrinsic thyroid disease. These changes may mimic or mask the biochemical abnormalities of true thyroid disease.
It has been observed that the severity and nature of changes in thyroid function tests are related to prognosis of the systemic illness. The low serum T3 or T4 levels predict increased mortality from liver cirrhosis,19 advanced congestive heart failure59, and several other systemic illnesses, thus indicating poor prognosis.
There is a suggestive evidence that tissue hypothyroidism occurs because of low supplies of T3 and T4. However many believe that patients with nonthyroidal illness syndrome (NTIS) are metabolically euthyroid, even in the presence of low serum T3 and T4. Recent studies have shown that tissues of patients dying of NTIS contain substantially lower levels of thyroid hormones (T3 and T4) than did tissues of control subjects dying suddenly.60 In contrast, studies also suggest that there is an increase in T3 receptor number and binding affinity in NTIS, an indication of a possible increase in tissue sensitivity to T3 that may contribute to maintenance of euthyroid state, despite low serum T3.61
It remains unresolved whether the hormone responses in euthyroid sick syndrome represent part of an adaptive response to systemic illness, which lowers tissue energy requirements in face of systemic illness, or a maladaptive response, that impairs tissue function and makes recovery from life threatening illness less likely.3


The vast majority of patients of euthyroid sick syndrome, who recover from their underlying illnesses, have prompt recovery of the hypothalamic-pituitary-thyroid axis and therefore do not require any treatment. In case of more severe illness, showing evidence of tissue hypothyroidism, trials of intervention are certainly justified.
Several studies have examined the effect of treatment with thyroid hormones. Treatment with T4 is not beneficial as explained by diminished conversion of T4 to metabolically more active T3. It may not be useful even in patients with low free T4 values.62 However there is difference of opinion on treatment with T3, regarding its benefits or otherwise in patient of NTIS. Limited studies have shown some beneficial effects of treatment with T3 in patients of dopamine dependent septic shock63, brain injury,14 sepsis after pulmonary infarction64, for recovery in organ recipients65 and patients with hemorrhagic shock.66 The T3 administration to patients undergoing cardio-thoracic surgery has shown benefits as measured by cardiac output and decreased systemic vascular resistance.67 Other studies have demonstrated beneficial effects of T3 treatment in low cardiac output states related to myocardial ischemia, heart transplantation and for patients with hyperlipidemia.68 Clearly, the aforementioned benefits of T3 treatment associated with sepsis, cardiopulmonary bypass, respiratory failure, or a surgical procedure suggest that there is a need for additional controlled studies to determine the scope of such treatment. Much more is required to be learnt about the dose-response ratios, and possible adverse effects of T3 treatment.62


Alterations in thyroid function tests are fairly common in patients with NTI. Multiple, complex and incompletely understood mechanisms are involved. Awareness of these alterations helps in avoiding errors in the diagnosis of thyroid disorders and inappropriate therapy. FT4 and fT3 are the investigations of choice to differentiate between euthyroid sick syndrome and intrinsic thyroid disease. Since thyroid hormone alterations are seen in about 50-70% of the hospitalized patients, therefore investigations of hypothalamic-pituitary-thyroid axis may be tested after a week or so, after recovery.


1. Pauline MC, Arcot AD. Sick euthyroid syndrome: what to do when thyroid function tests are abnormal in critically ill patients. Postgrad Med 1999;105:215-19.

2. The NHS in Scotland. Laboratory statistics 1999. Edinburg: Information and Statistics Division, 1999.

3. Chopra IJ. Nonthyroidal illness syndrome or euthyroid sick syndrome? Endocrinol Pract 1996;2:45-52.

4. Goichot B, Sapin R, Schlienger JL. Euthyroid sick syndrome: recent physiopathologic findings. Rev Med Intern 1998;19:640-8.

5. Acker CG, Singh AR, Flick RP, et al. A trial of thyroxine in acute renal failure. Kid Int 2000; 7:293-8.

6. Philips RH, Valente WA, Caplan ES, et al. Circulating thyroid hormone changes in acute trauma: prognostic implications for clinical outcome. J Trauma 1984;24:116-19.

7. Chopra IJ. Euthyroid sick syndrome: Is it a misnomer? J Clin EndocrinolMetab 1997;82:329-34.

8. Marechaud R. Low T3 syndrome. Rev Prat 1998;48:2018-22.

9. Chopra IJ, Taing P, Mikus L. Direct determination of free triodothyronine(T3) in undiluted serum by equilibrium dialysis/radioimmunoassay. Thyroid 1996;6:255-9.

10. Moreno M, Berry MJ, Horst C. Activation and inactivation of thyroid hormone by type 1 iodothyronine deiodinase. FEBS Lett 1994;344:143-6.

11. Nelson JC, Tomei RT. Direct determination of free thyroxine undiluted serum by equilibrium dialysis /radio immunoassay. Clin Chem 1988;34 :1737-44.

12. Adriaans R, Romijn JA, Brabant G, et al. Pulsatile thyrotropin secretion in non-thyroidal illness. J Clin Endocrinol Metab 1993;77:1313-17.

13. Spector DA, Davis PJ, Helderman H, et al. Thyroid function and metabolic state in renal failure. Ann Intern Med 1976;85:724-30.

14. Woolf PD, Lee LA, Hamill RW, et al. Thyroid test abnormalities in traumatic brain injury: correlation with neurologic impairment with sympathetic nervous system activation. Am J Med 1998;84:201-8.

15. Chopra IJ. An assessment of daily production and significance of thyroidal secretion of 3 ,3',5' triiodothronine (reverse T3) in man. J Clin Invest 1976 ;58:32-40.

16. Docter R, Krenning EP, de Jong M, et al. The sick euthyroid syndrome: changes in thyroid hormone serum parameters and hormone metabolism. Clin Endocrinol 1993;39:499-518.

17. Persani L. Hypothalamic thyrotropin-releasing hormone and thyrotropin
biological activity. Thyroid 1998;8:941-5.

18. Duntas LH, Nguyen T, Keck FS, et al. Changes in metabolism of TRH in euthyroid sick syndrome. Eur J Endocrinol 1999;141:337-41.

19. Bernardi M, De Palma R, Trevisan F, et al. " Low T3 syndrome" in cirrhosis: effect of beta-blockade. Am J Gastroenterol 1989;84:727-31.

20. Kayima JK, Otieno LS, Gitau W, et al. Thyroid hormone profiles in patients with chronic renal failure on conservative management and regular haemodialysis. East Afr Med J 1992;69:333-6.

21. Mendel CM, Lauaghton CW, McMahon FA, et al. Inability to detect an inhibitor of thyroxine-serum protein binding in sera from patients withnonthyroidal illness. Metabolism 1991;40:491-502.

22. Green WL. Effects of drugs on thyroid hormone metabolism. In: Wu SY,ed. Current issues in endocrinology and metabolism: thyroid hormone metabolism. Regulation and clinical implications. Boston: Blackwell, 1991, pp. 239-45.

23. Stockigt JR, Lim CF, Barlo JW, et al. High concentrations of furosemide inhibit serum binding of thyroxine. J Clin Endocrinol Metab 1984;59:62-6.

24. Nicolson RE, Reilly CP, Pannall PR, et al. Do non-esterified fatty acids displace thyroxine from its plasma binding sites in severe non-thyroidal illnesses? Clin Chem 1989;35:931-4.

25. Van den Berghe G, de Zegher F, Lauwers P. Dopamine and the sick euthyroid syndrome in critical illness. Clin Endocrinol 1994;41:731-7.

26 . Hollander TS, Scott RI, Tshudy DP, et al. Increase iodine and thyroxine binding in acute porphyria. N Engl J Med 1967;177:995-1000.

27. Caregaro L, Alberino F, Amodio P, et al. Nutritional and prognostic significance of serum hypothyroxinemia in hospitalized patients with liver cirrhosis. J Hepatol 1998;28:115-21.

28. Sokolov ST, KutcherSP, Joffe RT. Basal thyroid indices in adolescent depression and bipolar disorder. J Am Acad Child Adolesc Psychiatry 1994;33:469-75.

29. Nademane K, Piwonka RW, Singh BN, et al. Amiodarone and thyroid function. Prog Cardiovasc Dis 1989;31:427-37.

30. Felicetta JV, Green WL, Nelp WB. Inhibition of hepatic binding of thyroxine by cholecystographic agents. J Clin Invest 1980; 65:1032-40.

31. Romijn JA, Wiersinga WM. Decreased nocturnal surge of thyrotropin in non-thyroidal illness. J Clin Endocrinol Metab 1990;70:35-42.

32. Magner J, Roy P, Fainter L, et al. Transiently decreased sialylation of thyrotropin (TSH) in a patient with euthyroid sick syndrome. Thyroid 1997;7:55-61.

33. Langster W. Diagnosis of thyroid hormone transport protein anomalies:an overview. Acta Med Austriaca 1996;23:31-40.

34. Girvent M, Maestro S, Hernandz R, et al.. Euthyroid sick syndrome: associated endocrine abnormalities and outcome in elderly patients undergoing emergency operation. Surgery 1998;123:560-7.

35. Visser TJ. Pathways of thyroid hormone metabolism. Acta Med Austriaca 1996;23:10-16.

36. Everts ME, Lim CE, Moerings EPCM, et al. Effects of a furan fatty acid and indoxyl sulfate on thyroid hormone uptake in cultured anterior pituitary cells. Am J Physiol 1995;268:E974-9.

37. Lim CF, Docter R, Visser TJ, et al. Inhibition of thyroxine transport into cultured rat hepatocytes by serum of non-uremic critically ill patients: effects of bilirubin and nonesterified fatty acids. J Clin Endocrinol Metab 1993;76:1165-72.

38. Berry MJ, Larsen PR. Molecular structure and biochemical characterization of type 1 iodothyronine deiodinase. In: Molecular Biology and Alternate Pathways. Boca Raton (FL): CRC Press 1994, pp.1-22.

39. Lim CF, Dsocter R, Krenning EP, et al. Transport of thyroxine into cultured rat hepatocytes: effects of mild nonthyroidal illness and caloric restriction in obese subjects. Clin Endocronol 1994;40:79-85.

40. Barregard-Slebodzinska E, Pietras B. The protective role of some antioxidants and scavengers on the free radicals-induced inhibition of the liver iodothyronine 5'-monodeiodinase activity and thiols content. J Physiol Pharmacol 1997;48:451-9.

41. Van Lante F, Daher R. Plasma selenium concentrations in patients with euthyroid sick syndrome. Clin Chem 1992;38:1885-8.

42. Gupta P, Kar A. Role of ascorbic acid in cadmium-induced thyroid dysfunction and lipid peroxidation. J Appl Toxicol 1998;18:317-20.

43. Barregard L, Lindstedt G, Schutz A, et al. Endocrine function inmercury exposed chloralkal workers. Occup Environ Med 1994;51:536-40.

44. Chaurasia SS, Kar A. Protective effects of vitamin E against lead-induced deterioration of membrane associated type-1 iodothyronine5' monodeiodinase (5'MDI-1) activity in male mice. Toxicology 1997;124:203-9.

45. Dhawan D, Goel A. Hepatoprotective effects of Liv-52 and its indirect influence on the regulation of thyroid hormones in rat liver toxicity induced by carbon tetrachloride. Res Exp Med (Berl) 1994;194:203-15.

46. Greg KD. Peripheral metabolism of thyroid hormones: a review. Alter Med Rev 2000;5:306-33.

47. Nishiyama S, Futagoishi-Suginohara Y, Matsukura M, et al. Zinc supplementation alters thyroid hormone metabolism in disabled patients with zinc deficiency. J Am Coll Nutr 1994;13:62-7.

48. Shakir KM, Kroll S, Aprill BS, et al. Nicotinic acid decreases serum thyroid hormone levels while maintaining a euthyroid state. Mayo Clin Proc 1995;70:556-8.

49. Segermann J, Hoots A, Ulrich H, et al. Effect of alpha-lipoic acid on the peripheral conversion of thyroxine to triiodothyronine and on serum lipid, protein and glucose levels. Arzneimittelforschung 1991;41:1294-8.

50. Guven M, Bayram F, Unluhizarci K, et al. Endocrine changes in patients with organophosphate poisoning. Humm Exp Toxicol. 1999;18:598-601.

51. Kabadi UM, Dragstedt LR. Glucagon-induced changes in plasma thyroid hormone concentrations in healthy dogs resemble'euthyroid sick syndrome'. J Endocrinol Invest 1991;14:269-75.

52. Rasmussen AK. Cytokine actions on the thyroid gland. Dan Med Bull 2000;47:94-114.

53. Va der Poli T, Romijn JA, Wiersinga WM, et al. Tumor necrosis factor : a putative mediator of the sick euthyroid syndrome in man. JClin Endocrinol Metab 1990; 71:1567-72.

54. Hermus ARMM, Sweep CGJ, van der Meer MJM. Continuous infusion of interleukin-1b induces a non-thyroidal illness syndrome in the rat. Endocrinology 1992 ; 131:2139-46.

55. Bartalena L, Brogioni S, Grasso L, et al. Relationship of the increased serum interleukin-6 concentration to changes of thyroid function in nonthyroidal illness. J Endocrinol Invest 1994;17:269-74.

56. Corssmit EPM, Heylingenberg R, Endert E, et al. Acute effects of interferon-a administration on thyroid hormone metabolism in humans. J Clin Endocrinol Metab 1994;79:1342-46.

57. Panciera DL, Helfand SC, Soergel SA. Acute effects of continuous infusions of human recombinant interleukin-2 on serum thyroid hormone concentrations in dogs. Res Vet Sci 1995;58:96-7.

58. Boelen A, Platvoet-ter Schiphorst MC, Wiersinga WM. Relationshipbetween serum 3,5.3'-triiodothyronine and serum interleukin-8, interleukin-10 or interferon-g in patients with nonthyroidal illness. J Endocrinol Invest 1996;19:480-3.

59. Hamilton MA. Prevalence and clinical implications of abnormal thyroid hormone metabolism in advanced heart failure. Ann Thorac Surg 1993;56:S48-S52.

60. Arem R, Wiener GJ, Kaplan G, et al. Reduced thyroid hormone in fatal illness. Metabolism 1993;42:1102-8.

61. Erken Brack DE, Clemons GK. Modulation of thyroid hormone receptors by nonthyroidal stimuli. J Recept Res 1988;8:839-52.

62. Kaplan MM. Thyroid hormone therapy. What, when and how much. Postgrad Med 1993;93:249-52.

63. Meyer T, Husch M, van den Berg E, et al. Treatment of dopamine-dependent shock with triiodothyronine: preliminary results. Deutsch Med Wochenschr 1979;104:1711-14.

64. Dulchavsky SA, Hendrick SR, Dutta S. Pulmonary biophysical effects of triiodothyronine (T3) augmentation during sepsis induced hypothyroidism. J Trauma 1993;35:104-9.

65. Novitzsky D, Cooper DKC, Human PA, et al. Triiodothyronine therapy for heart donor and recepient. J Heart Transplant 1988;7:370-6.

66. Dulchavsky SA, Maitra SR, Maurer J, et al. Beneficial effects of thyroid hormone administration in metabolic and hemodynamic function in hemorrhagic shock. FASEB J 1990;4:A952.

67. Klemperer JD, Klein I, Gomez M, et al. Thyroid hormone treatment after coronary-artery bypass surgery. N Engl J Med 1995;333:1522-7.

68. Gomberg-Maitland M. Thyroid hormone and cardiovascular disease. Am Heart J 1998;135:187-96.

69. Post FA, Soule SG, Wilcox PA, et al. The spectrum of endocrine dysfunction in active pulmonary tuberculosis. Clin Endocrinol (OXF) 1994;40:367-71.

70. Szilgyi A. Thyroid hormones and alcoholic liver disease. J Clin Gastroenterol 1987;9:189-93.

71. Nellen Hummel H, Gutierrez Esoindola G, Talavera J, et al. Effect of chemotherapy on thyroid hormone concentration in patients with malignant hemotologic diseases. Arch Med Res 1997;28:215-17.

72. Liang DS. Stroke and thyroid hormones. Chung Hua Shen ChingChingShen Ko Tsa Chih 1991;24:352-4.

73. Di Napoli M, Reda G, Zannoni G, et al. The euthyroid sick syndrome. Its incidence and clinical significance in an internal medicine department. Minerva Med 1994;85:161-5.

74. Mohn A, Di Marzio A, Cerruto M, et al. Euthyroid sick syndrome in children with Hodgkin disease. Pediatr Hematol Oncol 2001;18:211-15.

75. Shanoudy H, Soliman A, Moe S, et al. Early manifestations of "sick euthyroid" syndrome in patients with compensated chronic heart failure. J Card Fail 2001;7:146-52.

76. Bauman WA, Spungen AM. Metabolic changes in persons after spinal cord injury. Phys Med Rehabil Clin N Am 2000;11:109-40.

77. Schilling JU, Zimmermann T, Albrecht S, et al. Low T3 syndrome in multiple trauma patients - a phenomenon or important pathogenetic factor? Med Klin 1999;94:66-9.

78. Langer P, Balazova E, Vician M, et al. Acute development of low T3 syndrome and changes in pituitary-adrenocortical function after elective cholecystectomy in women: some differences between young and elderly patients. Scand J Clin Lab Invest 1992; 52:215-20.

79. Tahirovic H, Maric D. Euthyroid sick syndrome in children with acute viral hepatitis A. Acta Paediatr Hung 1991;31:233-39.

80. Bonnyns M, Bourdoux P.Thyroid and AIDS. Rev Med Brux 1995;16:361-3.

81. Fisher DA. Euthyroid low thyroxine (T4) and triiodothyronine (T3) in premature and sick neonates. Paediatr Clin North Am 1990;37:1297-1312.

82. Kami M, Tanaka Y, Chiba S, et al. Thyroid function after bone marrow transplantation: possible association between immune-mediated thyrotoxicosis and hypothyroidism. Transplantation. 2001;71:406-11.

83. Molnar I, Czirjak L. Euthyroid sick syndrome and inhibitory effect of sera on the activity of thyroid 5'-deiodinase in systemic sclerosis. Clin Exp Rheumatol 2000.18:719-24.

84. Wang R, Nelson JC, Wilcox RB. Salsalate administration - a potential pharmacological model of the sick euthyroid syndrome. J Clin Endocrinol Metab 1998;83:3095-9.

85. Jaume JC, Mendel CM, Frost PH, et al. Extremely low doses of heparin release lipase activity into the plasma and can thereby cause artifactual elevations in the serum free thyroxine concentration as measured by equilibrium dialysis. Thyroid 1996;6:79-84.

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