Ask an Expert

Any physician may submit a question regarding a thyroid patient to ldegroot@earthlink.net 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.

Please note that Thyroidologists who hold opinions that differ from the advice we have offered are welcome to send in responses, and we will publish these comments. Commentators should kindly include name, office address, and Email address.

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 lazarus@cardiff.ac.uk

To read questions from patients click here.

 

15 YR OLD MALE WITH  WITH PAPILLARY CANCER AND LYMPN NODE METASTASES–  28 September 2016
QUESTION–Can you please help us with this case of a 15 y/o Male. He also has RHD.
In 2015 he was managed as toxic MNgoiter. Nov 2015: fnab thyroiditis
August 2016: underwent  total thyroidectomy +Neck dissection. Histopath: pap ca 2 cm greatest diameter R & isthmus.  Extrathyroidal & capsular invasion present, lymphovascular invasion present . LN Level 2,3,4  6/9  + for tumor involvement. LN Level 2b,left 1/1 positive . LN level 6 right , I/1 positive
Pediatric stage: T3N1b
Whole body scan ( sept 1, 2016 residual tracer avid remnants in the anterior neck. No evidence of distant tracer avid mets. TG ab 7.49 1u/ml.  TG > 500 ng/ ml.
We’re scheduling him for Rai. Sir Is there an existing RAI-131 dosing guide in pediatric patients .
Thanks very much for your inputs. Dr Lynn Bilar
RESPONSE— I agree with the decision to treat with radioiodine. Regarding the dose in pediatric patients, we usually advocate the use of 1 mCi per kg body weight, but a 15 y/o boy is almost like an adult and thus, in the presence of diffuse lymph node metastases, a fixed dose of 100 mCi (possibly after preparation with recombinant human TSH) should be preferred. Furio Pacini MD
 

TREATMENT OF ASYMPTOMATIC NODULAR GOITER-22 JUNE 2016

QUESTION–I am an endocrinologist from Mexico. This is the neck CT (see below) of a 65 year old woman who consulted because a muscular complaint in the upper back. She had a modest goiter and no other symptoms. Her TSH was 3.6. T3 and T4 normal. No antibodies. No respiratory complaints. The patient refused surgery. My question is: what treatment option does the expert suggest in this patient? Jose Diaz Suare, MD

RESPONSE–Thank you for asking us to suggest the best treatment for your patient, a 65 year old female with a moderate goiter and normal thyroid functions. As the patient did not agree to be submitted to a surgical procedure, the best treatment could be the use of recombinant human thyrotropin (available in the US) followed by radioiodine treatment. Two recently  published studies are indicated below:
Fast S, et al.   Long-term efficacy of modified-release recombinant human thyrotropin augmented radioiodine therapy for benign multinodular goiter: results from a multicenter, international, randomized, placebo-controlled, dose-selection study. Thyroid. 2014 , 24(4):727-35. doi: 10.1089/thy. 2013.0370. Epub 2014.
Graf H.  Recombinant human TSH and radioactive iodine therapy in the management of benign multinodular goiter. Eur J Endocrinol. 2015, 172(2):R47-52. doi: 10.1530/EJE-14-0608. Epub 2014. Review.
Sincerely,  Geraldo Medeiros-Neto, MD

tdm-expert-6-2-16-cat-neck2

HYPOTHYROID SYMPTOMS (?) AND THEIR TREATMENT- 3 September 2014

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

 

 

 

Component FREE T3 T4 THYROXINE, FREE TSH
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

 

 

ADEQUATE IODINE SUPPLEMENTATION IN INDIA??   22 July 2012

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

  1. POSSIBLE RTH-BETA?    12/12/15
  2. RECURRENT GRAVES’ THYROTOXICOSIS, AND POSSIBLE PREGNANCY
  3. CLINICAL HYPERTHYROIDISM, LOW TSH, HIGH fT4, POSITIVE PERTECHNETATE SCAN, NEG Ab
  4. INCIDENTAL THYROID MEDULLARY CARCINOMA: 27 March 2012
  5. REQUIRED TREATMENT OF HYPERTHYROIDISM BEFORE SURGERY
  6. Possible Thyroid Hormone Resistance
  7. Diffuse Lung Micro-mets with Residual Neck Nodes in Place
  8. Amiodarone Induced Thyrotoxicosis
  9. Prolonged TSH Suppression After Antithyroid Therapy of Graves
  10. Hypothyroidism and Ascites
  11. Oral T4 Causing a Rash?
  12. Lower Limit of TSH for Replacement T4 Treatment in Pregancy
  13. 131-I Treatment and Risk to Later Pregnancy
  14. Invasive Papillary Thyroid Cancer in a 71 Yr Old
  15. Graves’ Disease in Pregancy and Atd Allergy, Possible Treatment?
  16. Hyperthyroidism and Increasing LFT Abnormalities, What Therapy?
  17. Graves, Exophthalmos, Mediastinal Mass, Heart Disease?
  18. Need for Iodine Supplementation During Pregnancy
  19. Possible T4 Malabsorption and Abdominal Disease
  20. Possible Euthyroid Graves’ Disease
  21. Follicular Neoplasm in a 19yr Old Female
  22. Therapy of Probable (?) Sporadic MTC
  23. Iodine Deficiency and Hypothyroidism in Early Pregnancy
  24. Ovarian Mass and Hyperthyroidism
  25. Fna “Positive” Contralateral Node Following Hemithyroidectomy
  26. rhTSH vs Hormone Withdrawal in RAI Therapy
  27. Pet-scan Positive Mediastinal ? Met After RAI and Prior Nediastinal Operation
  28. Pregnant (Post RAI on T4) Woman with Elevated TSAb
  29. Repeated Miscarriages in a Young Woman with Hashimoto’s Thyroiditis and Antibodies
  30. Residual Papillary Cancer: RAI vs Surgery??
  31. Hurthle Cells in an FNA of a Hashimoto’s Gland
  32. Prior Radiation to Bone and Use of Teriparatide
  33. Treatment of 2.3cm Unifocal Follicular Variant of Papillary Cancer
  34. Possible Thyroid Hormone Resistance
  35. Intermittent Hyperthyroidism and Hypothyroidism
  36. Interferon Therapy and Hyperthyroidism
  37. RAI Ablation in Stage 1 Papillary Thyroid Cancer?
  38. Thyroid Cancer with High TG Response to TSH but Negative Scan
  39. Hot Nodule and Sub-clinical Hyperthyroidism
  40. Gestational Hypertyroidism?
  41. A Case of Galactorrhea
  42. RAI Treatment with Extensive Lung Metastases
  43. Therapy of Advance Follicular Thyroid Cancer
  44. Neonatal Goiter with Normal TFTs
  45. Multiple Drugs for Schizophrenia, and Low T4 and T3 Levels
  46. Tracheal Invasion in Papillary Thyroid Carcinoma
  47. Possible Effects of Amiodarone
  48. Treatment for Progressive Hurthle Cell Thyroid Carcinoma
  49. Primary Hypothyroidism and Worsening Exophthalmos
  50. Thyroid CA, Invasion, Positive Nodes, and TG Antibodies
  51. Radiation and Possible Thyroid Malignancy
  52. Thyroid Hormone Resistance Vs. TSH-oma
  53. Thyrotoxicosis with Low RAIU
  54. Hypergonadotropic Hypogonadism and Congenital Rubella
  55. Use PTU After MMI Induced LFT Abnormalities?
  56. Low T4 and T3 but Normal TSH
  57. Follow-up of an Incidentally Found Papillary CA
  58. Struma Ovarii with Malignancy
  59. Mild Hyperthyroidism, Questionable Cause
  60. Thyroiditis, Hypothyroidism, Pregnancy
  61. Papillary CA, AITD, Neg Ab, Pos TG
  62. Twin Pregnancy, Low TSH, Normal T4 and T3
  63. Hyperthyroidism, Low Uptake, Negative Ab
  64. Microcarcinoma in Teenager with Dyshormonogenesis
  65. Hot Nodule with Indeterminate Histology
  66. Management of a Mediastinal Mass
  67. Normal T4 Ranges in Pregnancy
  68. RAI Treatment While Pregnant
  69. Thyroiditis, or GRTH?
  70. Thyroxin Dose After Thyroidectomy for Papillary Cancer
  71. Iodine Supplements in Hashimoto’s Thyroiditis
  72. Subclinical Hyperthyroidism and Conception
  73. Thyroid Tissue in a Lateral Mass, with Thyroiditis; is It Cancer?
  74. Hyperthyroidism in the Truly Elderly
  75. Thyroxin Absorption Test
  76. Invasive Papillary Cancer and Enlarged Node
  77. Graves Disease and Incidental Thyroid Cancer
  78. Hyperthyroidism and Amenorrhea
  79. Borderline Elevated T3/Subclinical Hyperthyroidism?
  80. Thyroid Hormone Resistance?
  81. Aggressive MTC with Post-op Elevated CT and CEA
  82. Infant with Genetic Problem and Hypothyroidism
  83. A Child with Non-Autoimmune Hyperthyroidism
  84. Hurthle Cell Tumor, Mico-CA, Post-Lobectomy
  85. Cholestasis from MMI
  86. Neonate with Possible Hypothyroidism
  87. Adiation and Breast Feeding
  88. Rai Treatment After Lugol’s Iodine
  89. Thyroid Patient with Asthma, Allergy to Carbimazole, Allery to Ptu?
  90. Preparation for Treatment of a Toxic Adenoma
  91. Possible Resistance to Thyroid Hormone
  92. Minimally Invasive Follicular Carcinoma
  93. Positive I-131 Scan Post Therapeutic I-131
  94. Nodules After RAI Therapy of TMNG
  95. Diagnosis and Treatment of NTIS
  96. Carbimazole Treatment and Hair Loss
  97. Abnormal Thyroid Tests in Pregnancy
  98. Hashimoto’s, Urticaria, and Stomach Pains
  99. Hurthle Cell Carcinoma, Residual Disease Post-op
  100. Chroic Urticaria, Thyroxine Treatment, Thyroid Cancer
  101. Thyroid Hormone Resistance Vs. TSH-oma?
  102. Elevated Hormone Levels, Congenital Hypothyroidism, Psychiatric Problem
  103. Surgery with Adrenal Mass; “Incidental” Medullary Carcinoma
  104. Normal Thyroid Tests Except for Elevated RT3
  105. Congenital Thyroid Deficiency, No Raiu, and Thyroid Cancer
  106. Liver Failure and Severe Thyrotoxicosis
  107. Hypothyroisim, Renal Insufficiency, and RAI Therapy
  108. Thyrotoxicosis and Pregnancy
  109. Thyrotoxic Hypokalemic Paralysis and 131-I Therapy
  110. Thyroid Cyst, and Mild Hyperthyroidism, in Pregnancy
  111. “Subclinical Hypothyroidism” with Normal freeT4 and TSH
  112. Onset Long After
  113. Thyrotoxicosis, Ventricular Fibrillation, Hypokalemia
  114. “Incidental” Medullary Carcinoma
  115. Growing Hot Nodule
  116. Malabsorption of Thyroxine?
  117. Neonate with Large Goiter
  118. Central Hypothyroidism?
  119. Thyroid Hormone and TSH Levels During Pregnancy
  120. Positive Antibodies, and Growing Nodules
  121. Thyroxine Dosage and Surgery, or After 131-I Treatment
  122. 131-I Treatment in Renal Failure
  123. Thyroiditis: Relation to Sertraline, and Lack of Melanin
  124. Atypical Graves’ Disease
  125. Therapy of a Patient with a Solitary Vertebral Metastasis
  126. Amiodarone and Recurrent Graves’ disease
  127. Nodules, Positive Antibodies, and Treatment?
  128. Sublinical Hyperthyroidism and Substernal Goiter
  129. Thyroid Carcinoma Diagnosed by Bronchoscopy
  130. T4 Suppression Therapy Post Radiation Exposure
  131. Follow-up in Differentiated Thyroid Cancers Under 1cm
  132. Hurthle Cell Nodule and Hyperthyroidism in Hashimoto’s Gland
  133. Hives, Angioedema, and Hashimoto’s Thyroiditis
  134. Hyperthyroidism in Pregnancy
  135. Add Recombinant TSH to Endogenous TSH for Ablation?
  136. Hyperthyroidism in Pregnancy; Cause and Treatment?
  137. Amiodarone Induced Thyrotoxicosis
  138. What Condition Does This Person Suffer From?
  139. What to Do with an Incidental 1mm Papillary Cancer?
  140. Therapy of Thyroid Cancer with Known Positive Neck Nodes, Elevated TG, and Negative Scan?
  141. Is This Graves’ Disease?
  142. Hashimoto’s, Transient Hypothyroidism, and an Elevated RAIU
  143. When is a Pentagastrin Test Advised in Following MTC?
  144. How Long to Wait After Operation Before RAI Ablation?
  145. Do We Really Need to Do Both fT4 and TSH in Evaluating Patients?
  146. How to Manage Fetal Hypothyroidism and Goiter
  147. How to Manage Existing Hypothyroidism Perioperatively in a Patient NPO?
  148. How to Treat Sub-clinical Hypothyroidism?
  149. Patient Seeks Counseling About the Possibility of Future Thyroid Exacerbations
  150. “Hashimoto’s Encephalitis”?
  151. Primary Vs Secondary Hypothyroidism, and Financial Problems
  152. Infant with Chylothorax and Apparent Hypothyroidism
  153. Managing Hashimoto’s in Pregnancy
  154. Does This Person Have Thyroid Hormone Resistance?
  155. Thyroid Hormone Treatment and Uric Acid Level
  156. Thyroxine Requirement During Pregnancy