Diagnostic Utility of Genetic Testing in Hyperthyroxinemia With Non-Suppressed TSH

Hyperthyroxinemia with non-suppressed thyroid-stimulating hormone (TSH) is a complex clinical entity that presents significant diagnostic challenges. Inherited causes include resistance to thyroid hormone beta (RTHβ), characterised by highly variable clinical presentation, and familial dysalbuminemic hyperthyroxinemia (FDH), a form of assay interference caused by pathogenic variants in the ALB gene leading to pseudo elevation of free thyroxine (FT4). This study aimed to characterise the clinical, laboratory, and molecular features of a paediatric cohort presenting with hyperthyroxinemia and non-suppressed TSH, and to identify clinical parameters that may aid in differential diagnosis.

In this retrospective observational study, 25 children from 19 unrelated families with elevated FT4 and non-suppressed TSH were evaluated. Clinical history, anthropometric data, physical examination findings, vital signs, laboratory results, radiological imaging, and sequencing data of the THRB and/or ALB genes were reviewed.

THRB gene sequencing was performed in 21 children from 18 families, identifying pathogenic or likely pathogenic variants in six patients from six unrelated families, including a novel variant c.997 G > C, p.(Glu333Gln), consistent with a diagnosis of RTHβ in 33.3% of those tested. Among these patients, tachycardia was observed in three cases (50%). ALB gene sequencing was completed in 16 children from 13 families, revealing the hotspot variant c.725 G > A, p.(Arg242His) in 12 patients from six unrelated families, corresponding to FDH in 46.2% of those tested. None of the FDH-confirmed patients exhibited tachycardia or other signs of thyroid dysfunction. FT4 and TSH levels were similar between RTHβ and FDH groups; however, FT3 levels tended to be lower in FDH, although FT3/FT4 ratio did not differ significantly.

Our findings highlight the critical role of molecular testing in accurately diagnosing the underlying cause of elevated FT4 with non-suppressed TSH and in preventing unnecessary interventions. Hotspot analysis of the ALB gene is recommended as a first-line test, particularly in asymptomatic individuals.