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Any physician may submit a question regarding a thyroid patient to and one of our panel of expert thyroidologists will attempt to provide an answer as soon as possible by return Email. Physicians should provide adequate clinical information about the problem, and provide their name, office address, and telephone number. We will send an answer by Email to the address provided, and will publish the question and the response on this page. The name of the questioning physician WILL be published unless specific instruction not to do so is provided in the original Email. This service is available only to physicians.

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We attempt to answer important questions from readers, if time permits, and publish those of value to other readers in this column. Please send questions to Dr John Lazarus

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QUESTION-I will appreciate for help in another patient who is a neurosurgeon, had RAI for graves disease in 2009. He has been on levothyroxine since then but for last 6-8 months, he has been having episodes of dizziness and vertigo. He tend to have these symptoms when his TFT levels are in euthyroid range but feels extremely WELL when his TSH is high. His TFT are shown below. I checked his TSH with HAMA and it did not change. As you can see, in May 2014, when his TFT were normal, we had to admit him to hospital for his symptoms. His alpha subunit to TSH ratio is less than 1 when his TSH is 5.5 FT4 is 1.1 ad FT3 is 2.0 and alpha subunit is 0.5. MRI of pituitary has been done and is normal.

Is it pituitary resistance to TH that he AQUIRED in 2013?

Iftikhar A. Malik, M.D. , TCP Endocrinology




Latest Ref Rng 2.8-5.3 pg/mL 0.7-1.9 ng/dL 0.50-5.00 uIU/mL
3/7/2011 3.4 1.3 3.12
9/2/2011 3.2 1.5 3.99
1/6/2012 3.6 1.3 4.22
2/18/2013 3.2 1.3 4.42
7/17/2013 3.7 1.6 2.15
10/8/2013     4.17
12/23/2013     7.81 (H)
2/7/2014     10.60 (H)
3/25/2014     8.05 (H)
4/25/2014 3.3 0.8 9.11 (H)
5/18/2014 3.1 1.8 1.18
5/27/2014 3.0 1.1 12.30 (H)
6/6/2014 3.0 0.9 14.20 (H)
6/28/2014 2.8 0.8 17.60 (H)
7/31/2014 3.0 1.0 19.20 (H)
8/26/2014 3.1 1.3 12.57 (H)


RESPONSE-Whether  the episodes of dizziness and vertigo related directly to the thyroid hormone levels in the past is unclear.  but they could at this time. Most likely your patient needs a slight increase in T4 dose. Most patients on thyroxine need to have a T4 at the top end of the normal range in order to be properly replaced, with normal T3, TSH of 1-2, and feeling best (as on 5/18). The TSH recorded on 5/18 is strange, but possibly his dose of thyroxine was somehow  higher just before that test, since his fT4 was at the unusual level of 1.8 at that time.   L De Groot,  MD




QUESTION-Currently, in India we are consuming iodized salts everyday still there is very high prevalence of thyroid cases. My question is that in clinical practice do doctors need to completely avoid any nutritional supplement containing iodine (100-150mcg), considering that we all are consuming iodine salts and additional iodine containing preparation though in nutritional amount will be harmful to patient. Kindly throw some light on this issue. Makwana Altaf A;  M.Pharmacy (Pharmacology)
RESPONSE-As you have correctly pointed out the Universal Salt Iodisation Program (USI) in India has had its “ups and downs” and there have been many reports in the literature of it not being as effective as one had hoped for.

Indeed, in a very recent publication in Clinical Endocrinology by Marwaha et al ( Vol 76,905-910) it is clear that iodine deficiency remains prominent in India. In the study population of schoolchildren in Delhi 16.4% had goitre  and 7.3% were hypothyroid.

If you cannot access the article please let me know and I will send it to you.

Dr Pandav from AAIMS informs me that current iodised salt coverage in India is only 71%, therefore one would expect to see persistence of endemic goitre and other manifestations of IDD.

The current WHO/ICCIDD/UNICEF recommendation is that where USI coverage is not effective then pregnant women should be taking an iodine supplement of 150 ug per day. There is no recommendation for men or children to take a supplement. It is recommended that iodine intake should not exceed 500 ug per day. The normal iodine  RDI for adults and children is 150 ug and for pregnant and breastfeeding women it should be 250 ug per day.
Sincerely, Prof C J Eastman AM


Questions from Doctors

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  5. Diffuse Lung Micro-mets with Residual Neck Nodes in Place
  6. Amiodarone Induced Thyrotoxicosis
  7. Prolonged TSH Suppression After Antithyroid Therapy of Graves
  8. Hypothyroidism and Ascites
  9. Oral T4 Causing a Rash?
  10. Lower Limit of TSH for Replacement T4 Treatment in Pregancy
  11. 131-I Treatment and Risk to Later Pregnancy
  12. Invasive Papillary Thyroid Cancer in a 71 Yr Old
  13. Graves’ Disease in Pregancy and Atd Allergy, Possible Treatment?
  14. Hyperthyroidism and Increasing LFT Abnormalities, What Therapy?
  15. Graves, Exophthalmos, Mediastinal Mass, Heart Disease?
  16. Need for Iodine Supplementation During Pregnancy
  17. Possible T4 Malabsorption and Abdominal Disease
  18. Possible Euthyroid Graves’ Disease
  19. Follicular Neoplasm in a 19yr Old Female
  20. Therapy of Probable (?) Sporadic MTC
  21. Iodine Deficiency and Hypothyroidism in Early Pregnancy
  22. Ovarian Mass and Hyperthyroidism
  23. Fna “Positive” Contralateral Node Following Hemithyroidectomy
  24. rhTSH vs Hormone Withdrawal in RAI Therapy
  25. Pet-scan Positive Mediastinal ? Met After RAI and Prior Nediastinal Operation
  26. Pregnant (Post RAI on T4) Woman with Elevated TSAb
  27. Repeated Miscarriages in a Young Woman with Hashimoto’s Thyroiditis and Antibodies
  28. Residual Papillary Cancer: RAI vs Surgery??
  29. Hurthle Cells in an FNA of a Hashimoto’s Gland
  30. Prior Radiation to Bone and Use of Teriparatide
  31. Treatment of 2.3cm Unifocal Follicular Variant of Papillary Cancer
  32. Possible Thyroid Hormone Resistance
  33. Intermittent Hyperthyroidism and Hypothyroidism
  34. Interferon Therapy and Hyperthyroidism
  35. RAI Ablation in Stage 1 Papillary Thyroid Cancer?
  36. Thyroid Cancer with High TG Response to TSH but Negative Scan
  37. Hot Nodule and Sub-clinical Hyperthyroidism
  38. Gestational Hypertyroidism?
  39. A Case of Galactorrhea
  40. RAI Treatment with Extensive Lung Metastases
  41. Therapy of Advance Follicular Thyroid Cancer
  42. Neonatal Goiter with Normal TFTs
  43. Multiple Drugs for Schizophrenia, and Low T4 and T3 Levels
  44. Tracheal Invasion in Papillary Thyroid Carcinoma
  45. Possible Effects of Amiodarone
  46. Treatment for Progressive Hurthle Cell Thyroid Carcinoma
  47. Primary Hypothyroidism and Worsening Exophthalmos
  48. Thyroid CA, Invasion, Positive Nodes, and TG Antibodies
  49. Radiation and Possible Thyroid Malignancy
  50. Thyroid Hormone Resistance Vs. TSH-oma
  51. Thyrotoxicosis with Low RAIU
  52. Hypergonadotropic Hypogonadism and Congenital Rubella
  53. Use PTU After MMI Induced LFT Abnormalities?
  54. Low T4 and T3 but Normal TSH
  55. Follow-up of an Incidentally Found Papillary CA
  56. Struma Ovarii with Malignancy
  57. Mild Hyperthyroidism, Questionable Cause
  58. Thyroiditis, Hypothyroidism, Pregnancy
  59. Papillary CA, AITD, Neg Ab, Pos TG
  60. Twin Pregnancy, Low TSH, Normal T4 and T3
  61. Hyperthyroidism, Low Uptake, Negative Ab
  62. Microcarcinoma in Teenager with Dyshormonogenesis
  63. Hot Nodule with Indeterminate Histology
  64. Management of a Mediastinal Mass
  65. Normal T4 Ranges in Pregnancy
  66. RAI Treatment While Pregnant
  67. Thyroiditis, or GRTH?
  68. Thyroxin Dose After Thyroidectomy for Papillary Cancer
  69. Iodine Supplements in Hashimoto’s Thyroiditis
  70. Subclinical Hyperthyroidism and Conception
  71. Thyroid Tissue in a Lateral Mass, with Thyroiditis; is It Cancer?
  72. Hyperthyroidism in the Truly Elderly
  73. Thyroxin Absorption Test
  74. Invasive Papillary Cancer and Enlarged Node
  75. Graves Disease and Incidental Thyroid Cancer
  76. Hyperthyroidism and Amenorrhea
  77. Borderline Elevated T3/Subclinical Hyperthyroidism?
  78. Thyroid Hormone Resistance?
  79. Aggressive MTC with Post-op Elevated CT and CEA
  80. Infant with Genetic Problem and Hypothyroidism
  81. A Child with Non-Autoimmune Hyperthyroidism
  82. Hurthle Cell Tumor, Mico-CA, Post-Lobectomy
  83. Cholestasis from MMI
  84. Neonate with Possible Hypothyroidism
  85. Adiation and Breast Feeding
  86. Rai Treatment After Lugol’s Iodine
  87. Thyroid Patient with Asthma, Allergy to Carbimazole, Allery to Ptu?
  88. Preparation for Treatment of a Toxic Adenoma
  89. Possible Resistance to Thyroid Hormone
  90. Minimally Invasive Follicular Carcinoma
  91. Positive I-131 Scan Post Therapeutic I-131
  92. Nodules After RAI Therapy of TMNG
  93. Diagnosis and Treatment of NTIS
  94. Carbimazole Treatment and Hair Loss
  95. Abnormal Thyroid Tests in Pregnancy
  96. Hashimoto’s, Urticaria, and Stomach Pains
  97. Hurthle Cell Carcinoma, Residual Disease Post-op
  98. Chroic Urticaria, Thyroxine Treatment, Thyroid Cancer
  99. Thyroid Hormone Resistance Vs. TSH-oma?
  100. Elevated Hormone Levels, Congenital Hypothyroidism, Psychiatric Problem
  101. Surgery with Adrenal Mass; “Incidental” Medullary Carcinoma
  102. Normal Thyroid Tests Except for Elevated RT3
  103. Congenital Thyroid Deficiency, No Raiu, and Thyroid Cancer
  104. Liver Failure and Severe Thyrotoxicosis
  105. Hypothyroisim, Renal Insufficiency, and RAI Therapy
  106. Thyrotoxicosis and Pregnancy
  107. Thyrotoxic Hypokalemic Paralysis and 131-I Therapy
  108. Thyroid Cyst, and Mild Hyperthyroidism, in Pregnancy
  109. “Subclinical Hypothyroidism” with Normal freeT4 and TSH
  110. Onset Long After
  111. Thyrotoxicosis, Ventricular Fibrillation, Hypokalemia
  112. “Incidental” Medullary Carcinoma
  113. Growing Hot Nodule
  114. Malabsorption of Thyroxine?
  115. Neonate with Large Goiter
  116. Central Hypothyroidism?
  117. Thyroid Hormone and TSH Levels During Pregnancy
  118. Positive Antibodies, and Growing Nodules
  119. Thyroxine Dosage and Surgery, or After 131-I Treatment
  120. 131-I Treatment in Renal Failure
  121. Thyroiditis: Relation to Sertraline, and Lack of Melanin
  122. Atypical Graves’ Disease
  123. Therapy of a Patient with a Solitary Vertebral Metastasis
  124. Amiodarone and Recurrent Graves’ disease
  125. Nodules, Positive Antibodies, and Treatment?
  126. Sublinical Hyperthyroidism and Substernal Goiter
  127. Thyroid Carcinoma Diagnosed by Bronchoscopy
  128. T4 Suppression Therapy Post Radiation Exposure
  129. Follow-up in Differentiated Thyroid Cancers Under 1cm
  130. Hurthle Cell Nodule and Hyperthyroidism in Hashimoto’s Gland
  131. Hives, Angioedema, and Hashimoto’s Thyroiditis
  132. Hyperthyroidism in Pregnancy
  133. Add Recombinant TSH to Endogenous TSH for Ablation?
  134. Hyperthyroidism in Pregnancy; Cause and Treatment?
  135. Amiodarone Induced Thyrotoxicosis
  136. What Condition Does This Person Suffer From?
  137. What to Do with an Incidental 1mm Papillary Cancer?
  138. Therapy of Thyroid Cancer with Known Positive Neck Nodes, Elevated TG, and Negative Scan?
  139. Is This Graves’ Disease?
  140. Hashimoto’s, Transient Hypothyroidism, and an Elevated RAIU
  141. When is a Pentagastrin Test Advised in Following MTC?
  142. How Long to Wait After Operation Before RAI Ablation?
  143. Do We Really Need to Do Both fT4 and TSH in Evaluating Patients?
  144. How to Manage Fetal Hypothyroidism and Goiter
  145. How to Manage Existing Hypothyroidism Perioperatively in a Patient NPO?
  146. How to Treat Sub-clinical Hypothyroidism?
  147. Patient Seeks Counseling About the Possibility of Future Thyroid Exacerbations
  148. “Hashimoto’s Encephalitis”?
  149. Primary Vs Secondary Hypothyroidism, and Financial Problems
  150. Infant with Chylothorax and Apparent Hypothyroidism
  151. Managing Hashimoto’s in Pregnancy
  152. Does This Person Have Thyroid Hormone Resistance?
  153. Thyroid Hormone Treatment and Uric Acid Level
  154. Thyroxine Requirement During Pregnancy