endocrine teaching endocrine teaching interesting thyroid cases wednesday, february 29, 2012 dr....

Endocrine Teaching

Interesting

Thyroid Cases

Wednesday, February 29, 2012

Dr. Merrill Edmonds

Case 142-year-old male• Decreased energy x 2 years• Fatigue, insomnia, depressed• No improvement on antidepressant• No family history of thyroid disease• Smoking 1ppd, no alcohol• Farmer• Diagnosed with hypothyroidism April 2, 2011

• TSH = 10.0• CBC, RF, CRP, ANA all normal

Case 1

Hypothyroid – started on thyroxine

Date Thyroxine Dose TSH

May 3, 2011 0.05 9.95

May 31, 2011 0.10 7.72

June 28, 2011 0.15 8.64

July 20, 2011 0.15 8.60

Sept 7, 2011 0.00 109.80

Oct 17, 2011 0.10 20.75

Nov 28, 2011 0.20 12.69

Dec 19, 2011 0.40 10.44

Jan 16, 2012 0.60 8.48

Case 1

Other meds – Pariet 20 mg daily; B12 1000mcg daily

On examinaton:Ht 182 cm, Wt 91.0 Kg; BMI 27.5

BP 130/83 HR 79/min

No orthostatic drop in BP but HR increased to 98/min

Slight tremor

Thyroid normal

?Proximal muscle weakness

Case 1

Investigations:

TSH = 8.48

free T4 = 61

free T3 = 19.6

anti-TPO = 5 (<35)

TBII < 1.0

25 OH Vitamin D = 49 (IgA = 0.8, IgM = 0.4)

Celiac = negative

Case 1

Causes?• Pituitary Tumor

• Thyroid hormone resistance

• Interference with assay

• Other?

What to do?

Case 2

HPI:• Hyperthyroid 2002 – Rx radioactive iodine • Hypothyroid 2003

• Thyroxine 0.15 mg daily

• Hyperthyroid August 2009• Sudden onset of shakiness, tachycardia, loss of weight

despite good appetite, insomnia• TSH = .05; free T4 = 26• Stopped thyroxine

Case 2

• Hyperthyroidism• October, 2009 – off thyroxine 2 months

- still symptomatic• TSH = 0.05; free T4 = 28• 131I uptake = 0% Scan = nothing

• Started on PTU but developed nausea and vomiting and hematemesis – no ulcers

• January, 2010 – TSH = .05; free T4 = 35• March, 2010 – TSH = .05; free T4 = 30

Case 2Hyperthyroid• May 14, 2010 – seen in Urgent Endocrine Clinic

• History as above• Still shaky, palpitations, weight loss of 30 lbs since Aug 2009

• No family history of thyroid disease• Mother died from cancer when patient was 12 years old

• Examination – hyperthyroid but no goitre

• TSH =<.01; free T4 = 48; free T3 = 10.3

• Thyroid antibodies negative, TBII negative

• 131I uptake = 0% Body Scan = no uptake

• Transvaginal ultrasound normal

Case 2

Hyperthyroid• May 27/10 – Rx Tapazole 30 mg daily• June 7/10 – TSH <0.1; fT4 = 62; fT3 = 14.1• Aug 27/10 – TSH <0.1; fT4 = >90; T3 = 3.6

– Thyroglobulin = 0.6 - referral to ENT – recommends thyroidectomy for microscopic production of thyroxine in her thyroid

Case 2• Sept 2010

- month’s holiday in Portugal – in hospital for 2 weeks with severe headache

• Oct 14/10 - Severe headache, slurred speech, facial droop, left

hemiparesis and numbness

- Admitted to local hospital

Seen urgently in clinic – no new findings

Recommend – keep in hospital for a week with no access to personal belongings – repeat thyroid tests in a week

She insists on leaving after a few days

Case 2

Case 2

• Feb 24, 2011 Severe headache, slurred speech, facial droop, left arm

and leg weakness

Seen by neurology – examination normal

Investigations negative

• May 19, 2011Weak, tired, barely able to work

Hypoglycemia – cap sugars in 2-3 range

Admission to hospital arranged but had to go home first

Case 2

Case 2

• Admitted to hospital• Sent for chest xray• Room searched – large bottle of levothyroxine 0.2

mg tablets• She knew nothing about the bottle and didn’t know

how it got there• Finally admitted to taking thyroxine off and on –

usually just before visits to doctor or getting blood taken

• Lots of stress at home.

Case 3

36 y/o female• Hyperthyroid 1996

• Tapazole for 18 months but no remission• treated with 131I in 1998

• Hypothyroid 1998• treated with thyroxine 0.1mg daily - TSH normal

• Spontaneous abortion 2004 at 6 mos• baby small for dates

Case 3

36 y/o female• Hyperthyroid 1996• Hypothyroid 1998 -on thyroxine 0.1mg daily - TSH normal

• Spontaneous abortion 2004 at 6 mos• Pregnant - 3 mos

• What to do?• TSH

Case 3

36 y/o female• Hyperthyroid 1996• Hypothyroid 1998 -on thyroxine 0.1mg daily - TSH normal

• Spontaneous abortion 2004 at 6 mos• Pregnant - 6 mos

• Baby small for dates• Fetal tachy

• Treatment?

Case 3

TSH receptor antibodies (TSHR-Ab)• Diagnostic value

• Graves’ - 70-100%• level grossly parallels the degree of hyperthyroidism• probably no better than degree of hyperthyroidism and

size of goitre in predicting remission• not helpful in deciding the form of treatment

• Fetal hyperthyroidism (2-10% of women with Graves’)• Should measure TBII in:

• previous Graves’ Rx with Sx or I131

• concurrent hyper and pregnancy (early 3rd trimester)• previous neonatal hyperthyroidism (early in 1st trim)

Case 4

19 y/o female• Pregnant - 6 weeks

• hyperemesis• palpitations, shakiness• TSH <0.001, free T4 = 35 (11-22)

• What to do?

Case 4

Case 5

Hyperthyroid Feb/2006• 5 months postpartem - breast feeding• weight loss (6 lbs) despite ravenous appetite• palpitations, insomnia

• Lab• TSH < 0.01 (0.3-5.5)• free T4 33 (11-22)

• What to do next?