PDFSTRANGE THYROID TESTS
QUESTION--I have seen this patient a week ago, came with many anxiety and panic symptoms.
PCP did LAB, shows : ( not on known thyroid medication/supplements).
clinically very anxious, has fine tremor. Thyroid gland 25 g, USG shows mild heterogenity with 2 sub centimeter nodules. She is a 33 YO WF.
2/20/2015
Tsh: 0.855
Thyroid Stim Immuno: 20
Free T4: 2.86 (H)
T3,Total: 237 (H)
T4 Total: 19.8 (HH)
T3,Reverse: 54.1 (H)
THYROGLOBULIN AB: <1.0
Thyroid Peroxidase Antibodies: 9
further repeat lab shows:
2/16/2015
Tsh: 1.340
Free T4: 3.09 (H)
T3 Free: 6.8 (H)
Med list
clonazePAM (KLONOPIN) 0.5 MG tablet
clotrimazole (MYCELEX) 10 mg troche
cyanocobalamin 100 MCG tablet
fexofenadine (ALLEGRA) 60 MG tablet
fluconazole (DIFLUCAN) 150 MG tablet
metoprolol succinate ER (TOPROL-XL) 50 MG 24 hr tablet
multivitamin (THERAGRAN) tablet
nystatin (MYCOSTATIN) 100,000 unit/mL suspension
RECLIPSEN, 28, 0.15-30 mg-mcg per tablet
traZODone (DESYREL) 50 MG tablet
I am not sure, where to go from here. Need some light!! Dr Sadeka Shahani <sadeka.shahani@gmail.com
RESPONSE-The exact explanation is not clear. Is she pregnant? Check.
If she was indeed hyperthyroid, the symptoms should be quite prominent, her thyroid should be larger, and TSH suppressed. Unless the TSH is in error, which could be checked by serial dilution or mixing studies .
I suppose “transient autoimmune thyroiditis is possible, but again, TSH should Be suppressed. An RAIU would possibly help in Diagnosis, if high, or suppressed.
A TSHoma, and thyroid hormone resistance, are in theory possible, Can you get data from years ago, or on family members? Both diagnoses could be checked by a T3 suppression test, as described by Refetoff in his chapter in THYROIDMANAGER.ORG on RTH
But it seems most likely that the problem is due to some of that amazing list of meds, several of which alter TBG or alter thyroid hormone metabolism. I do not know their indication, but if possible I would gradually discontinue them one by one , until all are gone, and see what happens to her, and the tests
Keep us posted . L De Groot, MD