ENDOCRINOLOGY

consultant on call

Feline Occult Hyperthyroidism

Deborah S. Greco, DVM, PhD, The Animal Medical Center, New York City

Profile EARLY OR MILD

HYPERTHYROIDISM:
Repeat the T4
Hyperthyroidism is caused by usually bilat-
Middle-aged and older hyperthyroid cats
eral (70%) adenomatous hyperplasia of the
that present with weight loss and/or goiter
thyroid gland. Hyperthyroidism occurs in
but otherwise seem normal may be difficult
middle-aged to older (> 6 yr) cats; there is
to diagnose in the early stages of
no breed or sex predilection. Hyperthyroid-
disease. Resting serum concentrations of
ism occurs more frequently in indoor cats
both T4 and T3 are above the normal range
and those consuming a canned fish-based
in most cats with hyperthyroidism; howev-
diet or diets containing liver flavor and
er, some cats with hyperthyroidism (up to
giblets. The disease is common in certain
10%) have serum concentrations of T4 that
coastal areas of the United States as well
are within the mid- to high-normal range.
as in England and Australia, but is uncom-
Because many hyperthyroid cats with nor-
mon in Japan, France, and South Africa.
Palpating to identify goiter in a cat with suspected mal serum concentrations of T4 have rela-
hyperthyroidism tively early hyperthyroidism, it is likely that
HISTORICAL AND PHYSICAL
the thyroid hormone concentrations will
EXAMINATION FINDINGS
eventually increase into the thyrotoxic
Historical findings include weight loss in con-
junction with polyphagia, restlessness and
Basic Diagnosis range if the disorder remains untreated.
Thyroid hormone concentrations in cats
increased activity, respiratory distress, weak-
Hyperthyroidism can be diagnosed in with mild hyperthyroidism may fluctuate
ness, vomiting, diarrhea, unkempt appear-
approximately 90% of cats simply by meas- into the normal range in some cats, sug-
ance or overgrooming, and such behavioral
uring total serum concentrations of T4 gesting that a diagnosis of hyperthyroidism
changes as aggression and inappropriate
(Table). However, this article focuses on cannot be excluded on the basis of the find-
elimination. The most common physical
the other 10%—those cats with occult ing of a single normal to high-normal
examination finding is goiter (Figure). Other
hyperthyroidism that have clinical signs serum T4 or T3 result alone. In cats with
physical examination findings may include
suggestive of hyperthyroidism (polyphagia, clinical signs consistent with hyper-
tachycardia, panting, hyperthermia, anxiety
polydipsia, polyuria, weight loss, goiter) but thyroidism and in cats with palpable thyroid
and overactivity, mydriasis, and long toe-
exhibit normal serum total T4 concentra- nodules, more than one serum T4 determi-
nails. On rare occasions, cardiac arrhythmia,
tions at the time of examination. These cats nation could be required to confirm a diag-
gallop rhythm, or systolic murmurs may be
may be challenging to diagnose for three nosis. Therefore, the first step should
found on auscultation. Common laboratory
reasons: 1) the hyperthyroidism may be always be to repeat the basal T4 meas-
findings can include leukocytosis with
mild or in the early stages, 2) the cat might urement; the second serum T4 determina-
eosinophilia, erythrocytosis, increased liver
have another nonthyroid illness that is sup- tion should be made at least 1 to 2 weeks
enzymes (alanine aminotransferase, aspar-
pressing total T4 into the normal range, later. An elevated serum T4 concentration is
tate aminotransferase, and alkaline phos-
and 3) T4 levels tend to fluctuate (on a daily diagnostic of hyperthyroidism. However, a
phatase), and mild azotemia. Low serum
basis or perhaps even more frequently). single serum T4 level in the normal range in
cholesterol is an uncommon finding, and uri-
nalysis is often unremarkable.
c o n t i n u e s

T3 = triiodothyronine; T4 = thyroxine; TRH = thyroid-releasing hormone; TSH = thyroid-stimulating hormone

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consultant on call CONTINUED

FELINE OCCULT HYPERTHYROIDISM

such as renal disease, diabetes mellitus,

systemic neoplasia, primary hepatic disease,
or other chronic illnesses, normal serum
thyroid hormone concentrations may be
found at the time of initial evaluation. Since
severe nonthyroid illness would be expect-
ed to decrease serum thyroid hormone con-
centrations into the low to undetectable
range in sick cats without concurrent hyper-
thyroidism, concomitant hyperthyroidism
The typical appearance of a thin, unkempt cat with long nails may not be present in the cat with early should be suspected in any middle- to old-
or mild hyperthyroidism. aged cat with severe nonthyroid illness and
normal serum T4 concentrations, especially
a cat with hyperthyroid signs does not rule tions may provide a more consistent assess- if signs of hyperthyroidism are also present.
out the disease. ment of thyroid gland status than total T4
concentrations. The finding of a high free T4 Free T4 concentrations seem to be much
Because hyperthyroidism has become more concentration (despite mid- to high-normal less affected by concurrent nonthyroid ill-
common and recognized in its early stages, levels of T4) in a cat with a consistent histo- ness and may more accurately reflect true
serum free T4 concentrations have recently ry (e.g., weight loss despite good appetite) thyroid status. Occasionally, however, cats
been shown to be more diagnostic of early and physical examination findings (e.g., with nonthyroid illness (particularly those
or “occult” hyperthyroidism. If the repeat T4 palpable thyroid nodule) supports the diag- with gastrointestinal disease that affects
test is also equivocal, then free T4 is the nosis of early occult hyperthyroidism. serum binding proteins for T4) that do not
next test indicated. However, measurement of free T4 levels have hyperthyroidism have high free T4 con-
does have the potential for false-positive centrations for reasons that are unclear.
Circulating thyroid hormones can either be results (see next section). Therefore, to avoid misdiagnosing hyperthy-
bound to carrier proteins or free (unbound) roidism, free T4 should always be evaluated
in the plasma. Most commercial T4 and T3 NONTHYROID ILLNESS WITH in conjunction with the total T4 concentra-
assays measure total concentrations, both SUSPECTED HYPERTHYROIDISM: tion. In general, the combination of a high
free and protein-bound. Because only the Free T4 free T4 value with a low total T4 concentra-
free fraction of thyroid hormone is available In hyperthyroid cats with moderate to tion (< 20 nmol/L or < 2.5 µg/dl) is indica-
for entry into the cells, free T4 determina- severe concurrent nonthyroid illness, tive of nonthyroidal illness, whereas a high

TESTS FOR HYPERTHYROIDISM IN CATS

TEST PROTOCOL REFERENCE RANGE IN CATS COMMENTS

Serum total T4 Serum sample, refrigerate or freeze, stable 1.2–4.8 µg/dl (15–62 nmol/L) Diagnoses approximately 90% of cases of
at room temperature hyperthyroidism in cats, especially with
repeat testing
T3 suppression test Collect serum sample for T3 and T4 analysis; 50% reduction in T4; T3 analysis is to ensure See text
then administer 7 doses of synthetic T3 at a compliance with administering T3 medication
dosage of 25 µg Q 8 H. Collect a sample for
T3–T4 analysis 4 hours after administration of
last T3 dose.
TRH stimulation test Administer 0.1 mg/kg TRH IV; collect samples Stimulation to at least twice baseline values See text
before and 4 hr after administration of total T4
Free T4 by dialysis Collect a single serum sample 1.21–3.4 ng/dl (15.6–44 nmol/L) —
Thyroid scintigraphy Administer mTch-99; scan thyroid gland — Limited availability

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 free T4 value with a high-normal T4 concen- concentrations after exogenous T3 adminis-
tration (>25 nmol/L or >3.0 µg/dl) is sug-
gestive of hyperthyroidism.
tration. In contrast, when the test is done in
cats with hyperthyroidism—even those with
at a glance
only slightly high or high-normal resting
serum T4 levels—minimal if any suppression WHAT TO DO
Advanced Diagnosis of serum T4 concentrations is seen. Cats Diagnosis may be achieved after
with hyperthyroidism have postliothyronine any given step, precluding the need
for succeeding steps.
TESTING FOR OCCULT serum T4 values greater than 20 nmol/L
(approximately 1.5 µg/dl), whereas normal 1. Submit serum sample for total T4
HYPERTHYROIDISM
analysis
Thyroid Hormone (Triiodothyronine) cats and cats with nonthyroid disease have
2. Repeat T4 measurement 1-2
Suppression Test T4 values less than 20 nmol/L.
weeks later
If a thyroid nodule cannot be palpated or if 3. Submit sample for free T4 analysis
another illness is known to be present, the Serum T3 concentrations can be used to (False-positive results sometimes
diagnosis of hyperthyroidism should be monitor owner compliance with giving the occur for unknown reasons;
confirmed with T3 suppression or thyroid drug. If inadequate T4 suppression is found evaluate in conjunction with total
scintigraphy, which remain the gold stan- but serum T3 values do not increase after T4 test results, Steps 1 & 2)
dards for diagnosis of occult hyperthy- treatment with liothyronine, problems with 4. Conduct T3 suppression test
roidism in cats. Inhibition of pituitary TSH owner compliance should be suspected (Owner compliance is a limiting
and test results should be considered factor.)
secretion by high circulating concentrations
questionable. 5. Perform either:
of thyroid hormone is a characteristic fea-
• TRH stimulation test
ture of normal pituitary-thyroid regulation. (Induces transient illness;
Administration of T3 decreases TSH secre- Thyrotropin-Releasing Hormone evaluate patient before use.)
tion in normal cats; this can be detected by Stimulation Test OR
a decrease in serum T4 concentrations. In In clinically normal cats, administration of • Thyroid scintigraphy
contrast, when thyroid function is TRH causes increased TSH secretion and
autonomous, as in cats with hyperthy- serum T4 concentrations, whereas in cats
roidism, administration of thyroid hormone with hyperthyroidism, the TSH and serum T4 nonthyroid disease. The relative increase
has little or no effect on thyroid function response to TRH is blunted or absent. The (percentage increase) in serum T4 concentra-
because TSH secretion has already been TRH stimulation test is performed by collect- tion after administration of TRH is the most
chronically suppressed. ing blood for serum T4 and T3 determina- sensitive criterion for predicting whether
tions before and 4 hours after intravenous cats are hyperthyroid. An increase in serum
To perform the T3 suppression test in cats, administration of 0.1 mg/kg TRH (Relefact T4 less than 50% is consistent with mild
draw a blood sample for determination of TRH—Hoechst-Roussel Pharmaceuticals, hyperthyroidism. Cats with hyperthyroidism
basal serum concentrations of total T4 and Somerville, NJ; Thypinone, Abbott have lost the normal pituitary-thyroid axis
T3 (Table). Centrifuge the blood sample, Diagnostics—Abbott Park, IL) (Table). Many suppression associated with negative feed-
remove the serum, and keep it refrigerated cats become transiently ill after TRH injec- back; therefore, there will not be an
or frozen. Instruct the owner to administer tion, manifesting vomiting, salivation, urina- increase in serum total T4 values after TRH
oral T3 (liothyronine [Cytomel—Jones tion, and defecation after administration of stimulation. ■
Medical Industries, St. Louis, MO]) on the TRH. Thus, the test is an in-hospital proce-
following morning at a dosage of 25 µg 3 dure and is less desirable than the T3-sup- See Aids & Resources, back page,
times daily for 2 days. On the morning of pression test or thyroid scintigraphy. Cats for references, further reading,
the third day, the owner gives a seventh 25- with mild hyperthyroidism show little if any and contacts.
µg dose of liothyronine and brings the cat to increase in serum T4 values after administra-
the veterinary clinic within 2 to 4 hours for tion of TRH, whereas a consistent increase
serum T4 and T3 determinations. When the of serum T4 concentrations (approximately
T3 suppression test is performed in normal 2-fold) occurs after TRH administration in
cats, there is a marked decrease in serum T4 both clinically normal cats and those with

T3 = triiodothyronine; T4 = thyroxine; TRH = thyroid-releasing hormone; TSH = thyroid-stimulating hormone

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