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Elevation of Serum Urea Nitrogen in Hypothyroidism

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EXPERIENCE AND REASON-BRIEFLY RECORDED 829

component. This suggests host factors might be

more important determinants of an associated

arthritis developing than the particular virus

involved. However, the congenital heart lesion

in our patient would not appear to be related

to the development of viral arthritis and no

as-sociated disorder was apparent in Dr. Ward’s

case. These findings may also be interpreted to

indicate arthritis represents a rare complication of varicella infection.

SUMMARY

The second case of chicken pox with

associ-ated arthritis is described. Clinical features, as

well as the results of serological investigation

and synovial fluid analysis, are reported. The

differential diagnosis and rarity of this

compli-cation is discussed.

LAWRENCE M. MULHERN, M.D.

Division of Rheumatology GILBERT A. FRIDAY, M.D. Department of Pediatrics

J

OlIN A. PERRI, M.D.

Department of Orthopedic Surgery Mercy Hospital

1400 Locust

Pittsburgh, Pennsylvania 15219

REFERENCES

1. Bullowa, J. C. M., and \Vishik, S. M. :

Compli-cations of varicella. Amer. J. Dis. Child., 49: 923, 1935.

2. \Vard, j. R., and Bishop, B. : Varicella arthritis. J.A.M.A., 212:1954, 1970.

Elevation

of

Serum

Urea

Nitrogen

in Hypothyroidism

The occurrence of an elevated serum urea

nitrogen (SUN) in a hypothyroid patient

prompted us to review the records of patients

with hypothyroidism in whom a SUN or

non-protein nitrogen (NPN) was obtained prior to

treatment. The initiating case and the results of

the record review are the subject of this report.

CASE HISTORY

P. L. weighed 3,908 gm ( 8.6 pounds

)

at birth

and was the product of a 21-year-old, gravida one, Caucasian female, following a 10-month gestation period. He was initially seen at the Johns Hopkins Hospital at 5.5 months of age and was referred for evaluation of anemia. A history of constipation and infrequent crying was obtained.

The family history was unremarkable.

Physical examination revealed a length of 64.8

cm (25.5 inches), a weight of 7,454 gm

(

16.4

pounds), a head circumference of 43.9 cm (17.3

inches

)

, and an immature upper lower ratio of

1.71 (normal 1.62). The anterior fontanelle was

open, the blood pressure was 85/60 mm of Hg, the

pulse was 120 beats per minute, and the

respira-tions, 30 per minute. He had a broad thick tongue protruding from his open mouth, dry skin, and a small umbilical hernia. The Moro, suck, and grasp

reflexes and muscle tone were normal; and the

re-mainder of the examination was within normal lim-its.

Laboratory evaluation revealed a hemaglobin of 8.6 gm/100 ml, hematocrit of 27%, a T4 of 0.8 g

/100 ml, a bone age of 37 weeks’ gestation,

ab-sence of thyroid antibodies, and no visualization of the thyroid gland on scan. In addition lie was found to have an elevated SUN

(

31 and 29 mg/

100 ml), but the serum creatinine (0.8 mg/l00

ml

)

, urinalysis, creatinine clearance, IVP, voiding

cmncystourethrogram, and two urine cultures were normal.

After 4.5 months of thyroid therapy his length increased 14 cm (5.5” ), his weight, 3,818 gm

(

8.4 pounds

)

and his SUN decreased to 20 mg/100 ml.

RESULTS OF RECORD REVIEW

The records of 19 additional patients, seen

in the Pediatric Endocrine Clinic at the Johns

Hopkins Hospital, with hypothyroidism and

SUN or NPN determined prior to therapy were

reviewed (Table I).

Thyroid dysgenesis was the etiology of

hypo-thyroidism in 13 (seven females and six

males) . Four of these 13 had SUN or NPN

val-ues that were above the range of normal and

three of these four were less than 2 years of

age. Cholesterol values were elevated in six of

the patients, and five of the six were older than

2 years of age. Only two patients had both an

elevated SUN or NPN and cholesterol value.

Three patients had SUN or NPN values which

were at the upper limit of normal, amid one of

the three had an elevated cholesterol value. If

it is assumed that the PBI-T4 difference is 1

p.g/100 ml, then all patients with elevated SUN

or NPN values and five of the six patients with

elevated cholesterol values had corrected T4

values of 0.9 .tg/100 ml or less.

In seven (five females and two males) of the

20 patients, thyroiditis was the etiology of the

hypothyroidism. All patients were 9.5 years of

age or older. None of these patients had

ele-vated SUN or NPN values. Three of the seven

(2)

830 UREA NITROGEN IN HYPOTHYROIDISM

one of the three had an NPN value which was

at the upper limit of normal. Assuming a

PBI-T4 difference of 1 .ig/100 ml, two of the three patients with elevated cholesterol values had corrected T4 values of 0.9 p.g/100 ml or less.

Repeat SUN or NPN determinations in three

of the four patients who had elevated values

were within the range of normal when the

pa-tients were adequately treated. The fourth pa-tient whose SUN was never repeated has been

followed for 7 years post-therapy and is in

good health.

DISCUSSION

The data are suggestive that a relationship

may exist between elevated SUN values, the age of the patient, and the degree of

hypothy-roidism. Elevation of SUN values appeared to

occur prior to 2 years of age, as three of the

four patients with elevated values were less than

2 years of age. All of the patients with elevated

SUN or NPN values had corrected T4 values

of 0.9 ig/100 ml or less. Similarly cholesterol

elevation tended to occur after 2 years of age,

as eight of the nine patients with elevated

cho-lesterol values were greater than 2 years of

age. The tendency, in hypothyroidism, for

cho-lesterol elevation to occur after 2 years of age

has been noted previously.’ Interestingly,

seven of nine patients with elevated cholesterol

values also had corrected T4 values of 0.9

i.g/100 ml or less.

Crispell, et al.23 have demonstrated that a

decrease in protein synthesis occurs in

myx-edema; and Ford, et al. and Papper, et al.

indicate that renal function is subnormal in

myxedema. A decrease in amino acid

utiliza-tion, protein synthesis, combined with impaired

TABLE I

ThYRoID lhSGENEsIS PATIENTS*

Sex C’..4.

PBI T

,zg/lck;’ semi Cholesterol NPN mg/1tX ml mg/100

SUN

ml

Post Rx m

NPN

g/100 ml SUN

Time Post Rx

M 5.5nio 0.8 190 31 2O 4.5mo

1I IO.Oiiio 1.8 300 56 34 1’2.Omo

F 14.0 limo (lLI 4.8%) 140 5 - t

1I 7.5 yr 0.7 35 2 15 4.0 nio

F 6.() vk 0.4 - 20 -

-F 6.5vr 1.4 406 40 31 5.Omo

rI tL.5vr ‘2.4 20 20 14 9.Omo

F 7.0vk 1.4 180 13

lE 10(1 immo .9 155 6

1I 1.5yr 1.9 3.50 14

F l.Syr 3.1 155 9

F 6.7 yr 0.2 445 15

F 6.Svr 1.8 292 17

M 9.5vr 1.9

TIIYII0IDITIs PATIENTS

546 40

F 9.6yr 0.9 395 17

F 10.’Jyr 0.5 195 19

F 1I.Oyr (ItAl 1.5%) 195 19

1L H.7 yr L6 220 12

F 13.3yr 2.5 - 10

F 17..5yr 2.3 944 35

* Normal

t Patient has been followed for 7 years and is in good health. Cholesterol 275 tng/100 ml or less.

NPN ‘22-40 tng/100 tnt. SUN 5-’20 mg/100 nil.

PBI 4.0-8.0 jsg/100 ml.

(3)

EXPERIENCE AND REASON-BRIEFLY RECORDED 831

urea excretion could result in an elevation of

SUN. If in hypothyroidism the growth rate is

reduced to one-half, then precursor

accumula-tion would be 3.3 times greater before 2 years

of age than after 2 years of age.#{176}Thus

im-paired protein synthesis as reflected by an ele-vated SUN would likely be manifested before

2 years of age.

Hypothyroidism is felt to result in

choies-terol elevation by greater impairment of

cho-lesteroi excretion than synthesis.6’

Sui MARY

Four of 20 patients with hypothyroidism had

elevated SUN or NPN values and three of

these four were less than 2 years of age. Nine

of the patients had elevated cholesterol values amid eight of these nine were older than 2 years

of age. Only two of the patients had both

val-ues elevated. SUN or NPN values at the upper

limit of normal were found in four additional

patients and were associated with an elevated

cholesterol value in two. All of the patients

with elevated SUN or NPN values and seven

of the nine patients with elevated cholesterol values had corrected T4 values of 0.9 g/100 nil or less.

ROBERT PENNY, M.D.

ROBERT M. BLIZZARD, M.D.

Department of Pediatrics

Johns Hopkins University

School of Medicine

725 .\‘. Wolfe

Baltimore, Maryland 21205

This work was supported by U.S. Public Health Service Grant NICHD 0-1852.

Dr. Penny is supported by Traineeship Grant TI

AM5219 from the U.S. Public Health Service.

REFERENCES

1. Wilkins, L. : The Diagnosis and Treatment of

Endocrine Disorders in Childhood and

Ado-lescence, ed. 3. Springfield, Illinois: Charles C Thomas, page 111, 1965.

2. Crispell, K. R., Parson, W., and Hollifield, G. : A study of the rate of protein synthesis before and during the administration of

L-Triiodothy-ronnie to patients with myxedema and

0 The average growth rate during the first 2

years of life is 19.1 cm per ‘ear and a decrease to

one-half would yield a rate 9.5 cm per year. After

2 spears of age the growth rate averages 5.7 cm per ear and a decrease to one-half would yield a rate of 2.9 cm per year. Therefore, 9.5 cm/2.9 cm = 3.3.

healthy volunteers using N-15 Gtvcine. J.

Clin. Invest. 35: 164, 1956.

3. Crispell, K. R., Williams, G., Hollifield, G., amid Parson, W. : Alterations of protein metabolism

in myxedema. J. Chron. Dis., 14:507, 1961.

4. Ford, R. V., Owens, J. C., Curd, G. W., Jr.,

Moyer, J. H., and Spurr, C. L.: Kidney func-tion in various thyroid states. J. Ctin. Endocr., 21:548, 1961.

5. Papper, S., and Lancestremere, R. G. : Certain

aspects of renal function in myxedema. J.

Chron. Dis., 14:495, 1961.

6. Rosenman, R. II., Byers, S. C., and Friedman,

M. : The mechanism responsible for the

al-tered blood cholesterol content in deranged

thyroid states. J. Clin. Endocr., 12: 1287, 1952.

7. Williams, R. H. : Textbook of Endocrinology,

ed. 3. Philadelphia: W. B. Saunders Co., p.

257, 1962.

Low

Voltage

Skin

Burns

The hazards accompanying the increasing

use of line-operated electrical devices for

di-agnosis and therapy as well as the more

common hospital appliances such as

elec-trically operated beds, television sets, radio

sets, and so forth have been recently

reemphasized.’ Most physicians are aware of

the dangers of alternating current (60 Hz AC)

or of high voltage direct current (DC) ,

espe-cially in relation to cardiac function. However,

few physicians seem to be aware of the hazards

of low voltage direct current. A standard text2

on laboratory safety fails to mention the

sub-ject. Low voltage direct current is used with

many different types of miniature electronic

devices and iontophoresis. Equipment failure

or misuse can result in accidental injury. \Ve

have recently had such an experience.

When Gibson and Cooke published their

plans for inducing sweat by the iontophoresis

of pilocarpine, we built our own equipment

and have used it successfully in several

thou-sand determinations during the past 1 1 years.

We recently had two accidents in which patients

were burned during iontophoresis. The bums

happened on the same day and involved two

separate patients, one an inpatient, the other

an outpatient. Both burns occurred under the

pilocarpine electrode, varied from 3 to 5 mm in

diameter, blistered, and healed slowly. One

(4)

1971;48;829

Pediatrics

Robert Penny and Robert M. Blizzard

Elevation of Serum Urea Nitrogen in Hypothyroidism

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1971;48;829

Pediatrics

Robert Penny and Robert M. Blizzard

Elevation of Serum Urea Nitrogen in Hypothyroidism

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the World Wide Web at:

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American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

References

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