Clinical review 86: Euthyroid sick syndrome: is it a misnomer?

Alterations in thyroid function tests are very common in patients with NTI. Multiple, complex, and incompletely understood mechanisms are involved in these abnormalities. Knowledge of these abnormalities is necessary to avoid errors in the diagnosis of thyroid disease. Measurement of serum TSH, free T4, and free T3 levels by direct equilibrium dialysis/RIA methods probably yield most useful (accurate) information in the setting of NTI. Patients with low free T4 by these methods and normal or low TSH have secondary hypothyroidism. This may be due to NTI per se, drugs administered for treatment of NTI, or associated pituitary or hypothalamic disease; the latter consideration may require evaluation of cortisol reserve, PRL, and/or gonadotropins. A serum TSH level above 20-25 microU/mL probably reflects primary hypothyroidism; accompanying findings of goiter, low free T4, and positive antithyroid antibodies help establish the diagnosis. An elevated serum concentration of rT3 argues against hypothyroidism. Studies have demonstrated no discernible benefit of treatment of NTI patients with T4. Some studies have shown a few benefits of treatment with T3 in selected cases, but much more needs to be learned. There is no evidence of harm by treatment of NTI patients with up to replacement doses of T3. As some NTI patients may indeed be hypothyroid, the term ESS should be replaced with NTIS.