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rnin Fnvirnn Ioalth (/100 Q 7'
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LI VIIUII J dl-,l 11 XJ-t 1 'J
I
J'
171 _ 175 J-)/
JF
International Archives of
Oeupational
Environmental Health © Springer-Verlag 1992 Occupational thyroid disease Paolo Del Guerral , Nadia Caraccio l, Marina Simoncini 2 , and Fabio Monzani1 'Institute of Internal Medicine II, 2 School of Occupational Medicine, University of Pisa, Via Roma, 67, 1-56127 Pisa, Italy Received February 1 / Accepted November 4, 1991
Summary A case of thyrotoxicosis due to the occupational exposure to cosmetics in a 35-year-old beautician is reported The hormonal pattern was consistent with exogenous thyroid hormone administration, but not with iodine hyperthyroidism The patient denied she was using thyroid hormones; also, she lacked the typical features of patients with thyrotoxicosis factitia Her occupational history was carefully reviewed: A heavy exposure of the unprotected skin to cosmetic creams containing iodine, thyroid hormones, and thyroid extracts had occurred in the previous months The patient was advised to refrain from the exposure, and a persistent remission of thyrotoxicosis was observed thereafter This case suggests that percutaneous absorption of thyromimetic substances though never described before, may occur in an occupational setting We advise that such cosmetics be handled with care, not only by patients with thyroid disease but by euthyroid subjects as well; close medical surveillance over the use of such preparations seems appropriate. Key words: Thyrotoxicosis roiditis
Iodine
Cosmetics
Thy-
Introduction The occupational exposure to chemicals seldom results in endocrine disease, with reproductive disorders being the only well-known exception l3, 5 l While the interference of exogenous iodine and/or thyroid hormones with thyroid function is well characterized in non occupational situations l 1, 2, 7 l, no data are available concerning possible occupational risks We describe a case of thyrotoxicosis in a beautician due to the skin absorption of thyromimetic substances from cosmetic creams. Case history A 35-year-old patient was referred for a clinical suspicion of hyperthyroidism in October 1988; she reported anxiety, sweating, insomnia, palpitation, and tremor of the upper limbs She had been working as a beautician Offprint requests to: F Monzani, Via Roma 67, I-56127 Pisa, Kaly
for the past 12 years: Her daily job consisted of applying (by spreading or massaging) creams and ointments, usually with bare hands As an additional task, she had been operating ionophoresis equipment for aesthetic treatments for the past 6 months She appeared a healthy young lady, height 161 cm, weight 54 kg, fine tremors were seen in the upper limbs, heart rate was 95/min; she was free from eye symptoms and signs, a small thyroid was felt No skin lesions were found The erythrosedimentation rate was normal (11 mm/h). Thyroid sonography showed a small, homogeneous gland Thyroid scintiscan ( 50 ,pCi iodine-131) proved impossible to perform due to the low 3-h RAIU (radioactive iodine thyroid uptake) Urinary iodine excretion was to be regarded as elevated (see below) l7l Hormonal data are shown in Table 1 Total and free triiodothyronine were elevated, with normal total and free thyroxine and undetectable thyroid-stimulating hormone (TSH) and thyroglobulin (Tg); Tg and microsomal-specific antigen antibodies were absent and remained so with further follow-up. The lack of nodules ruled out toxic adenoma, whereas low RAIU and absence of thyroid autoantibodies, goitre, and eye involvement argued against autoimmune thyroid disorders The patient's urinary iodine excretion, although normal for countries such as the USA l1 l, was quite elevated for the population of West Tuscany, Italy, that does not receive iodine supplementation l7 l; this finding demonstrated excess iodine absorption Iodine hyperthyroidism may follow cutaneous or mucosal exposure (skin or throat disinfection, vaginal irrigation), expecially in nodular goiter or Grave's disease l1 l: Her laboratory data argued against iodine playing a major role, as it causes elevated T 3 and T4 (with T4 consistently more elevated than T 3), normal or increased serum Tg, and reduced RAIU, due to the expanded intrathyroid iodine pool l1l Our patient's hormone pattern was different; moreover, iodine hyperthyroidism did not account for undetectable Tg levels, this latter finding suggesting thyrotoxicosis instead of hyperthyroidism, in particular "thyrotoxicosis factitia" l2, 6 l due to the administration of exogenous hormones, though she lacked the compulsory personality profile of these patients, who persist in their craving and consumption of hormone preparations even after the diagnosis She was a slim, good-looking young lady and was certainly not (and had
374 Table 1 Hormonal data of study patient Standard units (SI units) TT4 1tg/dl (nmol/l)
TT3 FT 4 ng/dl (nmol/l) pg/ml (pmol/1)
FT3 TSH pg/ml (pmol/1l) i U/ml (m U/1)
Tg ng/ml (pmol/1)
RAIU %
Normal range
4 2-12 (54-154)
100-210 (1 5-3 2)
6 5-16 5 (8 3-21 2)
2 5-5 5 (3 9-8 6)
0 4-4 6 (0 4-4 6)
< 3-30 (< 4 5-45)
25-50
10/25/88 12/13/88 01/03/89 02/07/89 06/05/89
9 8 (125 4) 8 3 (106 2) 5 4 (69 1) 7 6 (97 3) 8 4 (107 5)
214 (3 3) 136 (2 1) 133 (2 1) 143 (2 2) 146 (2 3)
12 7 (16 8 8 (11 4 6 (5 7 2 (9 7 4 (9
5 8 (9 1) 4 4 (6 9) 2 7 (4 2) 3 2 (5 0) 2 9 (4 5)
< 0 1 (< O 1)
;l,
rnin Fnvirnn Ioalth (/100 Q 7'
v~J;u,
LI VIIUII J dl-,l 11 XJ-t 1 'J
I
J'
171 _ 175 J-)/
JF
International Archives of
Oeupational
Environmental Health © Springer-Verlag 1992 Occupational thyroid disease Paolo Del Guerral , Nadia Caraccio l, Marina Simoncini 2 , and Fabio Monzani1 'Institute of Internal Medicine II, 2 School of Occupational Medicine, University of Pisa, Via Roma, 67, 1-56127 Pisa, Italy Received February 1 / Accepted November 4, 1991
Summary A case of thyrotoxicosis due to the occupational exposure to cosmetics in a 35-year-old beautician is reported The hormonal pattern was consistent with exogenous thyroid hormone administration, but not with iodine hyperthyroidism The patient denied she was using thyroid hormones; also, she lacked the typical features of patients with thyrotoxicosis factitia Her occupational history was carefully reviewed: A heavy exposure of the unprotected skin to cosmetic creams containing iodine, thyroid hormones, and thyroid extracts had occurred in the previous months The patient was advised to refrain from the exposure, and a persistent remission of thyrotoxicosis was observed thereafter This case suggests that percutaneous absorption of thyromimetic substances though never described before, may occur in an occupational setting We advise that such cosmetics be handled with care, not only by patients with thyroid disease but by euthyroid subjects as well; close medical surveillance over the use of such preparations seems appropriate. Key words: Thyrotoxicosis roiditis
Iodine
Cosmetics
Thy-
Introduction The occupational exposure to chemicals seldom results in endocrine disease, with reproductive disorders being the only well-known exception l3, 5 l While the interference of exogenous iodine and/or thyroid hormones with thyroid function is well characterized in non occupational situations l 1, 2, 7 l, no data are available concerning possible occupational risks We describe a case of thyrotoxicosis in a beautician due to the skin absorption of thyromimetic substances from cosmetic creams. Case history A 35-year-old patient was referred for a clinical suspicion of hyperthyroidism in October 1988; she reported anxiety, sweating, insomnia, palpitation, and tremor of the upper limbs She had been working as a beautician Offprint requests to: F Monzani, Via Roma 67, I-56127 Pisa, Kaly
for the past 12 years: Her daily job consisted of applying (by spreading or massaging) creams and ointments, usually with bare hands As an additional task, she had been operating ionophoresis equipment for aesthetic treatments for the past 6 months She appeared a healthy young lady, height 161 cm, weight 54 kg, fine tremors were seen in the upper limbs, heart rate was 95/min; she was free from eye symptoms and signs, a small thyroid was felt No skin lesions were found The erythrosedimentation rate was normal (11 mm/h). Thyroid sonography showed a small, homogeneous gland Thyroid scintiscan ( 50 ,pCi iodine-131) proved impossible to perform due to the low 3-h RAIU (radioactive iodine thyroid uptake) Urinary iodine excretion was to be regarded as elevated (see below) l7l Hormonal data are shown in Table 1 Total and free triiodothyronine were elevated, with normal total and free thyroxine and undetectable thyroid-stimulating hormone (TSH) and thyroglobulin (Tg); Tg and microsomal-specific antigen antibodies were absent and remained so with further follow-up. The lack of nodules ruled out toxic adenoma, whereas low RAIU and absence of thyroid autoantibodies, goitre, and eye involvement argued against autoimmune thyroid disorders The patient's urinary iodine excretion, although normal for countries such as the USA l1 l, was quite elevated for the population of West Tuscany, Italy, that does not receive iodine supplementation l7 l; this finding demonstrated excess iodine absorption Iodine hyperthyroidism may follow cutaneous or mucosal exposure (skin or throat disinfection, vaginal irrigation), expecially in nodular goiter or Grave's disease l1 l: Her laboratory data argued against iodine playing a major role, as it causes elevated T 3 and T4 (with T4 consistently more elevated than T 3), normal or increased serum Tg, and reduced RAIU, due to the expanded intrathyroid iodine pool l1l Our patient's hormone pattern was different; moreover, iodine hyperthyroidism did not account for undetectable Tg levels, this latter finding suggesting thyrotoxicosis instead of hyperthyroidism, in particular "thyrotoxicosis factitia" l2, 6 l due to the administration of exogenous hormones, though she lacked the compulsory personality profile of these patients, who persist in their craving and consumption of hormone preparations even after the diagnosis She was a slim, good-looking young lady and was certainly not (and had
374 Table 1 Hormonal data of study patient Standard units (SI units) TT4 1tg/dl (nmol/l)
TT3 FT 4 ng/dl (nmol/l) pg/ml (pmol/1)
FT3 TSH pg/ml (pmol/1l) i U/ml (m U/1)
Tg ng/ml (pmol/1)
RAIU %
Normal range
4 2-12 (54-154)
100-210 (1 5-3 2)
6 5-16 5 (8 3-21 2)
2 5-5 5 (3 9-8 6)
0 4-4 6 (0 4-4 6)
< 3-30 (< 4 5-45)
25-50
10/25/88 12/13/88 01/03/89 02/07/89 06/05/89
9 8 (125 4) 8 3 (106 2) 5 4 (69 1) 7 6 (97 3) 8 4 (107 5)
214 (3 3) 136 (2 1) 133 (2 1) 143 (2 2) 146 (2 3)
12 7 (16 8 8 (11 4 6 (5 7 2 (9 7 4 (9
5 8 (9 1) 4 4 (6 9) 2 7 (4 2) 3 2 (5 0) 2 9 (4 5)
< 0 1 (< O 1)
