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    9 Years Follow-up of a Patient with Pituitary Form of Resistance to Thyroid Hormones (PRTH): Comparison of Two Treatment Periods of D-Thyroxine and Triiodothyroacetic Acid (TRIAC)
    (Walter De Gruyter Gmbh, 2009) Güran, Tülay; Turan, Serap; Bircan, Rifat; Bereket, Abdullah
    Patients with pituitary resistance to thyroid hormones (PRTH) exhibit features of hyperthyroidism due to normal sensitivity to thyroid hormones in some of the peripheral tissues. There is a lack of information in the literature on the long-term follow-up and treatment of patients with PRTH. Here, we present long-term (9 years) clinical and biochemical follow-up of a patient with PRTH under the treatment of D-T4 initially (for 1.5 years) followed by TRIAC for 5.5 years. An 11.5 year-old girl was evaluated for goiter, palpitations, heat intolerance, sleep disorders, nervousness and frequent stools for 3 years. Her thyroid function tests were consistent with PRTH. Molecular analysis revealed a heterozygous missense mutation of the TR beta gene at codon 243 in exon 7 (R243Q) and a silent mutation at codon 245 in the index patient and the mother who was later also diagnosed to have PRTH. The patient was started on D-T4 treatment since she exhibited clinical symptoms of hyperthyroidism. After 1.5 years, D-T4 treatment was switched to TRIAC which lasted 5.5 years. During the long course of both treatments, thyroid hormones, TSH, heart rate, thyroid size, and markers of peripheral thyroid status (SHBG and alkaline phosphatase) were monitored. It was concluded that compared to D-T4, TRIAC treatment is more effective in suppressing TSH and lowering thyroid hormone levels in PRTH. However, both treatments were unable to reduce thyroid size. The effects of treatment on symptomatology were also modest. Spontaneous improvement in symptoms was observed with age.
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    Alopecia: Association with Resistance to Thyroid Hormones
    (Freund Publishing House Ltd, 2009) Güran, Tülay; Bircan, Rifat; Turan, Serap; Bereket, Abdullah
    Resistance to thyroid hormone (RTH) syndrome is caused by thyroid hormone beta receptor (TR beta) mutations. Goiter, learning disabilities, psychological abnormalities, sinus tachycardia, hearing deficits, short stature, and growth delay are among the most common symptoms in patients with RTH. Alopecia areata (AA) is an autoimmune disease of the hair follicle, frequently associated with other autoimmune disorders. In some cases local alopecia of different genetic backgrounds could be misdiagnosed as AA. We describe here clinical, biochemical and genetic features of a family having RTH syndrome, caused by a novel TR beta mutation, coexistent with alopecia. Mutational analyses of the TR beta gene and the hairless gene (HR) in genomic DNA were performed. The index patient is a 9-(4)/(12) year-old boy with RTH due to a novel heterozygous missense mutation of the TR beta gene (I353V), and diffuse, patchy alopecia without autoimmune thyroid disease. This mutation was also detected in his father and elder brother, who also have local alopecia. One of his paternal aunts and paternal grandmother have local alopecia and they have previously been operated for goiter. Although they refused any genetic analysis, the pre-operative medical report of the paternal aunt was compatible with RTH. A second paternal aunt has alopecia totalis universalis but has no RTH mutation in genomic DNA. Genomic DNA sequence of the HR gene of the family (index patient, two brothers, father, mother and second paternal aunt) was normal as well. Conclusion: We speculate that RTH due to a novel I353V TR beta 1 mutation could be causally related to different phenotypic expressions of alopecia in this family, either by a direct effect of unresponsiveness to T3 of the hair follicle or by the modulated action of the HR gene.