|Year : 2020 | Volume
| Issue : 1 | Page : 16-19
Zulewski's clinical score and its validation in hypothyroid patients: Experience in a tertiary care center in Western India
Prachi Srivastava1, Jaideep Khare2, Sandeep Rai3, Jaishree Ghanekar3
1 Department of Dermatology, People's Medical College and Research Centre, Bhopal, Madhya Pradesh, India
2 Department of Medicine, People's Medical College and Research Centre, Bhopal, Madhya Pradesh, India
3 Department of Medicine, MGM Medical College, Navi Mumbai, Maharashtra, India
|Date of Submission||13-Feb-2019|
|Date of Decision||16-Apr-2019|
|Date of Acceptance||01-Oct-2019|
|Date of Web Publication||19-Jun-2020|
Department of Medicine, People's Medical College and Research Centre, Bhopal, Madhya Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Hypothyroidism is a common endocrine disorder with the prevalence of approximately 10.95% among the general population in India. Aim: The aim of this study was to evaluate the prevalence of various signs and symptoms of hypothyroidism and to correlate with the biochemical investigations and clinical Zulewski's score in hypothyroid patients. Materials and Methods: A total of 207 patients of hypothyroidism attending our endocrine and medicine outpatient department were included in the study. Clinical data including signs and symptoms of hypothyroidism were obtained by interviewing the patients and referring to records. Prevalence of various signs and symptoms was recorded along with anthropometric indices, and Zulewski's score was calculated. Thyroid function tests were performed along with other laboratory investigations according to the patient condition. Results: Patients aged between 18 and 72 years were included in the study with male-to-female ratio was 51:156. Patients had different signs and symptoms of clinical hypothyroidism, and 74.4% of patients had ≥5 components of Zulewski's score. Most and least common defining criteria of Zulewski's score were dry skin and hearing impairment, respectively. Conclusion: Zulewski's clinical scoring is an economic and effective tool for identifying clinical hypothyroidism and can be used as clinical basis for starting levothyroxine replacement therapy if due to unavoidable reasons, it is difficult to get thyroid function test.
Keywords: Biochemical hypothyroidism, clinical hypothyroidism, endocrine disorders, Zulewski's score
|How to cite this article:|
Srivastava P, Khare J, Rai S, Ghanekar J. Zulewski's clinical score and its validation in hypothyroid patients: Experience in a tertiary care center in Western India. CHRISMED J Health Res 2020;7:16-9
|How to cite this URL:|
Srivastava P, Khare J, Rai S, Ghanekar J. Zulewski's clinical score and its validation in hypothyroid patients: Experience in a tertiary care center in Western India. CHRISMED J Health Res [serial online] 2020 [cited 2020 Sep 28];7:16-9. Available from: http://www.cjhr.org/text.asp?2020/7/1/16/286878
| Introduction|| |
Hypothyroidism is a common endocrine disorder with the prevalence of approximately 10.95% in India. Wayne's score and Billewicz score were used in the past to diagnose hyperthyroidism and hypothyroidism, respectively, clinically.
Newer clinical scores and grades were developed with the development of diagnostic techniques, Zulewski's score is one of them.,
In our study, we try to study the Zulewski's score and prevalence of various signs and symptoms with regard to Zulewski's in our hypothyroid patients.
| Materials and Methods|| |
This was an observational cross-sectional study conducted from March 2018 to August 2018 at Endocrine and Medicine Outpatient Departments (OPDs).
All diagnosed hypothyroid patients attending endocrine or medicine OPD and willing to participate in the study were included. Patients who were critically ill, pregnant, had transient hypothyroidism (like-drug induced), or not willing to participate in the study were excluded.
A total of 400 patients were enrolled who met the inclusion criteria which included following: (1) Adult patient of diagnosed hypothyroidism and (2) willing to participate in the study.
A repeat thyroid profile was done for all patients after written and informed consent.
Only 207 patients who had deranged thyroid profile parameters and diagnosed with hypothyroidism within past 6 months were included in the study, and detailed clinical history and physical examination were done along with the review of old medical records. The Zulewski's clinical score for hypothyroidism was then calculated as described in [Table 1].
|Table 1: Zulewski's scoring on the basis of the presence of various signs and symptoms|
Click here to view
The patient was clinically considered hypothyroid if score was ≥5, euthyroid if score was <3, and intermediate if score was between 3 and 5. This score was then correlated with biochemical thyroid profile. Biochemically, the patient was considered hypothyroid if thyroid-stimulating hormone (TSH) was ≥10 mIU/L, or TSH between 4.5 and 10 mIU/L and T4 <6 μg/dl. Subclinical hypothyroidism was identified if T4 was normal, but TSH was between 4.5 and 10 mIU/L. Furthermore, the prevalence of individual signs and symptoms of Zulewski's score was noted.
The permission was taken from Institutional Ethics Committee prior to starting the project. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
| Results|| |
Male-to-female ratio was 51:156 (n = 207), with the mean age in years was 49.11 ± 11.31 and 40.87 ± 12.71, respectively. Baseline characters of our patients are described in detail in [Table 2].
The prevalence of various identifying criteria of Zulewski's score is described in [Table 3].
|Table 3: Prevalence of various signs and symptoms of hypothyroidism as identified with Zulewski's score|
Click here to view
Coarse skin was the most common criteria of Zulewski's score among males with the prevalence of 68.63% (35 of 51), while among female weight gain was most common criteria with the prevalence of 90.38% (141 of 156). Overall, the most common criteria were dry skin with the prevalence of 82.12% (170 of 207).
Hearing impairment was the least common criteria of Zulewski's score identified in 1.96% (1 of 51) males, 1.28% (2 of 156) females, and with the overall prevalence of 1.45% (3 of 207).
Zulewski's score of ≥5 was found in 50.98% (26 of 51) males, 82.05% (128 of 156) females, and overall in 74.4% (154 of 207).
Biochemical correlation with Zulewski's score is described in [Table 4]. Among 207 patients with deranged TSH, 154 had Zulewski's score of ≥5, while 38 had score between 3 and 5 and 15 had <3.
| Discussion|| |
Hypothyroidism is a common endocrine disorder and presents with various signs and symptoms, or is diagnosed incidentally on routine investigations. Various clinical scoring systems have been identified to diagnose clinical hypothyroidism, but in this regard, clinical medicine has been overpowered by laboratory medicine. Not many studies are available to diagnose hypothyroidism clinically, and hence, the aim of our study was to identify the prevalence of various signs and symptoms of hypothyroidism according to newer clinical score, Zulewski's score, and validate its efficacy by correlating it with biochemical findings.
In our study, dry skin was the most common symptom with the prevalence of 82.12% which was in concordance with the previous study by Zulewski et al. 1997, which demonstrated the prevalence of 77%.
In our study, hearing impairment was the least common symptom with the prevalence of 1.45% which was significantly less than the previous study by Zulewski et al. which demonstrated the prevalence of 22%, although it was the least common symptom among there population. This difference may be because of different sample population and different sensitivities for hearing difficulties.
In our study, coarse skin was the most common sign with the prevalence of 81.16%, which was seen in 60% of patients by the previous study by Zulewski et al., and the most common sign was delayed ankle reflex and was seen in 77% cases. This difference may be because of racial differences.
In our study, slow movements were the least common sign with the prevalence of 25.60%, and this was in concordance with the previous study by Zulewski et al. which demonstrated the prevalence of 36%.
In our study, 154 of 207 (74.4%) with Zulewski's score of ≥5, had deranged TSH. Overt hypothyroidism was seen in 62.34% (96 of 154) patients, and biochemical subclinical hypothyroidism was seen in 37.66% (58 of 154) patients. This was in concordance with the previous study by Zulewski et al., in which 62% of biochemically overt hypothyroid were diagnosed clinically with Zulewski's score.
In our study, 38 of 207 were clinically intermediate and had Zulewski's score of 3–5, whereas 88 of 207 had biochemical subclinical hypothyroidism. Thus, 38 of 88 (43.18%) had clinical and biochemical hypothyroid concordance. This was less when compared with the previous study by Zulewski et al., in which 47% biochemically subclinical hypothyroid were diagnosed clinically. This difference may be because of different sample population and difference in sensitivities for symptoms of hypothyroidism.
In our study, 15 of 207 were clinically euthyroid and had Zulewski's score of <3, of which 7 of 119 (5.88%) and 8 of 88 (9.09%) were biochemically overt hypothyroid patients and subclinical hypothyroid, respectively, and this was in concordance with the previous study by Zulewski et al., in which 2 of 50 (4%) biochemically overt hypothyroid were clinically euthyroid.
Single-center trial with small sample size was the major limitation, also ours is a tertiary care center, thus may have possibility of sample bias which may not represent the general population.
| Conclusion|| |
Hypothyroidism is a common endocrine disorder with several comorbidities, and biochemical testing is ideal for diagnosis of hypothyroidism, but clinical scores such as Zulewski's score may be used as valid and economic aids for planning and starting the levothyroxine replacement therapy in cases where biochemical testing cannot be performed, or there is disparity between clinical and biochemical finding, and also it can be used as a mass assessment tool to prevent delay in instituting therapy to those who need it; however, further large trials are required for further validation.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
We would like to acknowledge Dr. Jalaj khare for help in statistical analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Khare J, Nalla S, Wadhwa J, Srivastava P, Reddy B, Deb P. Prevalence of metabolic syndrome in hypothyroidism: Experience in a tertiary center in South India. CHRISMED J Health Res 2017;4:19-22. [Full text]
Kalra S, Khandelwal SK, Goyal A. Clinical scoring scales in thyroidology: A compendium. Indian J Endocrinol Metab 2011;15:S89-94.
Zulewski H, Müller B, Exer P, Miserez AR, Staub JJ. Estimation of tissue hypothyroidism by a new clinical score: Evaluation of patients with various grades of hypothyroidism and controls. J Clin Endocrinol Metab 1997;82:771-6.
[Table 1], [Table 2], [Table 3], [Table 4]