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