Efficiency of Wayne's and Zulewski's Clinical Score for Diagnosing Hyperthyroidism and Hypothyroidism in younger adults:

A Prospective Study in Palakkad

Sreeja P. A¹*, Irene. V. R¹, Dawn. V. J², Ameena Kadar K. A³, Neema K. M⁴

¹Professor, Faculty of Pharmacy, Department of Pharmacy Practice,

Dr. M.G.R. Educational and Research Institute, Velappanchavadi, Chennai – 600077.

¹Assistant Professor, Department of Pharmacy Practice,

Sanjo College of Pharmaceutical Studies, Vellapara, Kuzhalmannam, Palakkad, Kerala – 678702.

²Associate Professor, Department of Pharmacy Practice,

Sanjo College of Pharmaceutical Studies, Vellapara, Kuzhalmannam, Palakkad, Kerala – 678702.

³Assistant Professor, Department of Pharmacy Practice, Grace College of Pharmacy, Kerala – 678004.

⁴M.Pharm Post Graduate, Department of Pharmacy Practice,

Grace College of Pharmacy, Athalur, Kodunthirapully, Palakkad, Kerala - 678004.

*Corresponding Author E-mail: sreejavinod318@gmail

ABSTRACT:

Introduction: Of all endocrine conditions, thyroid-related disorders are the most prominent. In contrast to hyperthyroidism, hypothyroidism is more prevalent in India. In thyroidology, clinical assessments have long been employed to aid in the identification of thyroid dysfunction. Aim and Objective: To figure out how well Wayne's and Zulewski's score works in patients with hyperthyroidism and hypothyroidism. Materials and Methods: A six-month prospective observational study with patients aged 10 to 30 was conducted out. Eight instances had hyperthyroidism and ninety-three cases had hypothyroidism out of the 101 cases that were evaluated. Patient demographic information, clinical history, and physical examination data were gathered. Using Zulewski's score and logistic regression analysis, the odds ratio and its significance for the prevalence of various signs and symptoms have been determined. Result and Discussion: Out of 103 patients studied, 93 patients were having hypothyroidism and 8 patients with hyperthyroidism. The prevalence of Hypothyroidism, Subclinical hypothyroidism, Euthyroidism, Toxic hyperthyroidism, Equivocal and Euthyroidism were 10.7%, 40.9%, 49.5%, 37.5%, 50% and 12.5% by using clinical scoring index. Conclusion: Clinical scoring index, Wayne's index and Zulewski's index are not in common use and as score can vary with the observer, but in careful monitoring and observation of the patients we can identify the thyroid disease and commonly seen certain sign and symptoms are not included in clinical scoring index. So, the diagnosis and interpretation of types of thyroid disorder were very difficult by using only the clinical scoring index.

KEYWORDS: Hypothyroidism, Hyperthyroidism, Wayne’s index and Zulewski's index, Thyroid disorders.

INTRODUCTION:

The thyroid is considered the most significant endocrine organ. Thyroid hormones regulate the equilibrium of the body and metabolism in a variety of ways, and their elevated concentration may end up in a variety different issues^1,2. The thyroid gland, one of the biggest endocrine glands in the body, is crucial to the body's growth, development, and metabolism. Additionally, it aids in the regulation of numerous bodily processes by continuously delivering a constant amount of thyroid hormones into the bloodstream³. Triiodothyronine (T3), tetraiodothyronine, or thyroxine (T4) are the hormones that are synthesized by the thyroid gland. The base metabolic rate is increased by thyroid hormones. They improve the process of protein production^3,4. There are an estimated 42 million thyroid problem sufferers in India, while the prevalence of thyroid disorders globally is 0.6% in men and 25% in women⁵. A range of thyroid gland problems known as thyroid dysfunction can cause either hyper- or hypothyroidism⁶. Any condition that causes a thyroid hormone shortage is referred to as hypothyroidism. This includes diseases of the pituitary or hypothalamus, generalized tissue resistance to thyroid hormone, and conditions that directly affect the thyroid gland⁷. The condition thyrotoxicosis is rather prevalent. The most prevalent conditions affecting the thyroid gland are hyper- and hypothyroidism, as well as nodules in the thyroid, which are often benign thyroid tumors but have the potential to progress into thyroid cancer⁵. The general constellation of thyroid disorders in young people and adults in India is similar to that documented in many different regions of the universe. 2% had hyperthyroidism, 19% had euthyroid goiters, and 79% of the 800 children alluded to had hypothyroidism^7,8. Thyroid issues are influenced by age, sex, ethnicity, geography, and, most importantly, iodine intake^9,10. Despite having a low appetite, being cold intolerance, constipation, and fatigue, hypothyroid people gain weight^10,11. Previous research revealed a connection between children's obesity and thyroid function. These days, one of the endocrine illnesses that worries people is hypothyroidism in obese women^11,10. However, no hard evidence was discovered^12,8. In thyroidology, clinical ratings have been used for decades to aid in determining the presence of thyroid dysfunction. Older generations of endocrinologists are associated with the recognized Wayne's score and Billewicz score, which are useful in the clinical evaluation of hyperthyroidism and hypothyroidism^7,13. A clinical scoring instrument called Wayne's index is used for evaluating hyperthyroidism. There will be three sections to the score: Confirmed in 1969 against thyroid iodine absorption and plasma protein-bound iodine, and in 1979 against thyroid-stimulating hormone (TSH), triiodothyronine (T3), and free thyroxine (FT4), the Billewicz scoring index is a cost-effective therapeutic index¹⁴. Even though this measure is easy to use and accurate in diagnosing hypothyroidism, additional clinical scores and grades Zulewski's score being one of them have been produced with the advancement of diagnostic techniques^10,11,15. In this research, we aim to evaluate the usefulness of Wayne's index and Zulewski's score as well as the frequency of different Wayne's and Zulewski's signs and symptoms in our hypothyroid and hyperthyroid patients.

MATERIAL AND METHODS:

After acquiring ethical clearance, the prospective observational study had been carried out for six months at Quality Clinic and Lab in Palakkad and the outpatient department of Rajiv Gandhi Cooperative hospital. In our study, we included outpatients with thyroid abnormalities of any gender and age between 10 and 30 years old. Patients with cancer, women who were pregnant or nursing, while those grabbing medications that alter the thyroid profile, including iodine-containing drugs, phenytoin, dopamine, steroids, and amiodarone, were not included. The necessary data, containing clinical history, patient physical examination results, and demographic information (age, gender), was gathered using a specially created gathering form. Wayne's scoring index and Zulewski's score were utilized in this analysis, based on 12 symptoms and indications that are commonly associated with hypothyroidism. Whenever the patient's score was higher than 5, it was deemed clinically hypothyroid; when it was between 0 and 2, it was regarded subclinical hypothyroidism¹⁵.Wayne's score, which ranged from +45 to -25 and was based on nine symptoms and signs, was used for the diagnosis of hyperthyroidism. A score of more than 19 suggested toxic hyperthyroidism, a score of 11–19 indicated ambiguous hyperthyroidism, and a score of less than 11 indicated euthyroidism.

STATISTICAL ANALYSIS:

MS Excel 2007 was used to enter all of the collected cases and determine the percentages of the different parameters. The odds ratio (OR) for the recognized signs and symptoms was determined by logistic regression analysis. Continuous variables were expressed as mean ±standard deviation (mean±SD).

RESULTS AND DISCUSSION:

A total of 101 cases were collected during the study period of which 93(92%) hypothyroid and 8(8%) hyperthyroid were enrolled after satisfying the inclusion criteria. A similar study was conducted by Dorgalaleh Aet al., 2012, which demonstrated the prevalence of hypothyroidism was more important when comparing to hyperthyroidism¹². (Figure:1) shows prevalence of thyroid disorders) Among the 101 enrolled subjects, females were more predominant than males with a percentage of 91% and 9% respectively. The age groups were categorized into10-15Yrs, 16-20Yrs, 21-25Yrs and 26-30Yrs under which patients among 26-30 yrs were more predominant than the other groups with a mean± SD of 29.08±1.14yrs. The various signs and symptoms identified using Zulewski's score is described in Table 2, in which weight gain was the most common symptom followed by dry skin and periorbital puffiness. Hearing impairment was the least common symptom observed. This was in concordance with the weight growth was the most prevalent criteria in a prior study by Yadav V, Jha RK, Pawar A, et al., with a prevalence of 90.38% (141 of 156)¹⁶. Signs and symptoms of euthyroidism, hypothyroidism, and subclinical hypothyroidism were found to be significantly correlated in the logistic regression analysis¹⁵. Ankle reflex (OR 15.57), periorbital puffiness (OR 13.3), constipation (OR 14.4), dry skin (OR 6.23), paraesthesia (OR 18.61), coarse skin (OR 18.2), and weight increases (OR 3.64) were also found to be statistically significantly correlated. (Table 1). Zulewski’s clinical score was categorized into hypothyroidism Subclinical hypothyroidism and Euthyroidism with a score of >5, 3-5 and 0-2 respectively. Out of 93 enrolled subjects we found10 hypothyroid, 38 Subclinical hypothyroid and 46 euthyroid with a percentage of 10.7, 40.9, and 49.5 respectively which was similar to a study conducted by Kalra S et al.,¹³. (Table 2)

(Table:3) describes about the sign and symptoms not included in the Zulewski's score in which menstrual problems and fatigue were the most common sign and symptoms with the percentage of 47.3% and 40.9% respectively. Increased cholesterol and rapid heart rate were the least common sign and symptoms with the prevalence of 3.2% and 6.4%. Similar studies conducted by Yadav V, Jha RK, Pawar A, et al., and Ferreira-Hermosillo A, Toledo JO, Cordoba K also emphasize on the efficacy of Zulewski's score as a tool for the early estimation of lipid abnormalities^16,17.

(Table: 4) lists the different hyperthyroidism symptoms and indicators based on Wayne's score. The most prevalent symptoms in our study were fatigue and palpitations, which is consistent with the findings of a prior study conducted in 2019 by Dr. Smitha S. Rao et al., which found that fatigue (90%) and palpitations (93%) were the most common symptoms. The lack of statistical significance among the signs and symptoms found in our study may have been caused by a smaller sample size ¹⁷.

(Table 5) describes, Types of hyperthyroidism based on Wayne's index. Wayne's index was categorized into toxic hyperthyroidism, equivocal and euthyroidism with a score of >19, 11-19 and <11. Our study found that 37.5%, 50% and 12.5% were having toxic hyperthyroidism, equivocal and euthyroidism respectively. Multiple studies conducted by Naraintran S.et al., and Sandeep Kumar et al., has conducted a similar in which they also used Wayne’s index for diagnosing hyperthyroidism^18,19. Also it’s how the distribution based on sign and symptoms not included in the Wayne’s scoring index, in which goiter, broken sleep and abdominal pain were most important sign and symptoms. Infertility and hair loss were the least common sign and symptoms with the percentage of 12.5%^20,21. (Table 6)

Prevalence of thyroid disorders:

Figure: 1. Depicts the prevalence of hypothyroidism as more prevalent thyroid disorders

Various signs and symptoms of hypothyroidism identified with Zulewski’s score:

Table 1. Represents the signs and symptoms of hypothyroidism using Zulewski’s score among the enrolled subjects

Symptoms and signs	Euthyroidism (n=46)	Subclinical Hypothyroidism (n=38)	Hypothyroidism (n=10)	OR	p-value
Symptoms
Diminished sweating	1	3	1	4.09	0.21
Hoarseness of voice	0	0	2	5.0	0.30
Paraesthesia	2	13	9	18.61	0.0002
Dry skin	12	24	9	6.23	0.0001
Constipation	2	12	7	14.4	0.0006
Hearing impairment	0	1	0	2.93	0.51
Weight gain	25	30	9	3.64	0.006
SIGNS
Slow movements	0	1	3	9.40	0.13
Ankle reflex	3	15	10	15.57	<0.0001
Coarse skin	1	8	3	18.2	0.0060
Periorbital puffiness	6	23	9	13.3	<0.0001
Cold skin	2	6	0	3.14	0.17

Types of hypothyroidism based on Zulewski's score:

Table 2. Shows the various types of hypothyroidism based on Zulewski’s score in which most of the participants were having Euthyroidism

Zulewski's score	Types of Hypothyroidism	No of patients (n=93)	Percentage (%)
>5	Hypothyroidism	10	10.7
3-5	Subclinical hypothyroidism	38	40.9
0-2	Euthyroidism	46	49.5

Distribution based on sign and symptoms not included in the Zulewski's scoring index:

Table: 3. Represents the various signs and symptoms shown by the enrolled subjects other than Zulewski’s index in which menstrual problem was the most reported signs and symptoms among the enrolled subjects

Sign and Symptoms	No of Patient (n=93)	Percentage (%)
Hair loss	36	38.7
Menstrual problems	44	47.3
Infertility	16	17.2
Fatigue	38	40.9
Broken sleep	14	15.0
Irritability, anxiety, depression and insomnia	13	13.9
Increased BP	34	36.5
Rapid heart rate	6	6.4
Increased cholesterol	3	3.2

Prevalence of various signs and symptoms of hyperthyroidism as identified with Wayne’s score:

Table 4. Distribution of signs and symptoms based on Wayne’s score among the enrolled subjects

Symptoms and signs		Euthyroidism (n=1)	Equivocal (n=4)	Toxic hyperthyroidism (n=3)	OR	P-value
SIGNS
Palpable thyroid		0	4	2	13	0.16
Bruit over thyroid		0	3	3	13	0.16
Exophthalmos		0	1	1	1.3	0.86
Lid retraction		0	0	0	-	-
Lid lag		0	1	0	0.6	0.84
Hyperkinesis		0	1	0	0.6	0.84
Hands Hot		0	0	3	2.3	0.63
Hand Moist		0	0	0	-	-
Causal pulse rate:		0	0	0		0
>80/min		0	0	2	1.36	0.86
>90/min		0	0	0	-	-
Atrial fibrillation		0	0	0	-	-
Symptoms
Dyspnea on effort		0	1	1	1.36	0.86
Tiredness		1	4	3	15	0.27
Palpitation		0	4	3	45	0.0823
Preference for heat		0	0	0	-	-
Preference for cold		1	1	3	0.42	0.63
Excessive sweating		0	0	0	-	-
Nervousness			3		2.33	0.63
Appetite	Increased	1	0	2	0.15	0.29
Appetite	Decreased	0	0	0	-	-
Weight	Increased	0	0	0	-	-
Weight	Decreased	1	0	2	2.3	0.63

Types of hyperthyroidism based on Wayne's index

Table 5. Represents the various types of hyperthyroidism based on Wayne's index in which most of the subjects have equivocal hypothyroidism

Wayne's score	Types of hyperthyroidism	No of patients (n = 8)	Percentage (%)
>19	Toxic hyperthyroidism	3	37.5
11-19	Equivocal	4	50
<11	Euthyroidism	1	12.5

Distribution based on sign and symptoms not included in the Wayne’s scoring index

Table 6. Depicts the various sign and symptoms not included in the Wayne’s scoring index which shows that Goiter was the most prevalent one among all the signs and symptoms

Sign and Symptoms	No of Patient (n=8)	Percentage (%)
Infertility	1	12.5
Menstrual problems	2	25
Hair loss	1	12.5
Broken sleep	4	50
Abdominal pain	4	50
Goiter	6	75
tachycardia	3	37.5

CONCLUSION:

Hypothyroidism and hyperthyroidism are common endocrine disorders and biochemical testing and clinical scoring index is used for diagnosis. In our study we are using Clinical scoring index, Wayne's index used for diagnosis of hyperthyroidism and Zulewski's index for hypothyroidism but are not in common use and score can vary with the observer but in careful monitoring and observation of the patients we can identify the thyroid diseases. In our study we also found menstrual problem, infertility, hair loss, increased BP, goiter, broken sleep and abdominal pain as other signs and symptoms, but these are not included in clinical scoring index. It is not reliable to diagnose hypo and hyperthyroidism on the basis of this clinical scoring index. So further validated scales are necessary to diagnose these conditions and more studies are required in this area.

CONFLICT OF INTEREST:

No conflicts of interest between the authors.

ACKNOWLEDGEMENT:

We sincerely thankful to management of Grace College of Pharmacy, Palakkad and staffs of both private hospital and clinic for their cooperation during the data collection period.

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