nyu medical grand rounds clinical vignette arnab ghosh, md pgy-2 10/23/12 u nited s tates d...

NYU Medical Grand Rounds Clinical Vignette

Arnab Ghosh, MDPGY-2

10/23/12

UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

The patient is a 67 year old male who presented to his primary care physician with palpitations.

Chief Complaint


• When reviewed in clinic by his primary physician, he appeared clinically euthyroid although he did have evidence of an enlarged thyroid gland on examination by his primary care physician.• He was referred to an endocrinologist.

History of Present Illness


Additional History

• Past Medical History: Nil

• Past Surgical History: Nil

• Social History: Works as a dentist, occasional social drinker, non smoker, nil illicit drug use

• Family History: Nil family history of thyroid disease

• Medications: Nil


Physical Examination

• General: He appeared well• Thyroid Examination: a palpable thyroid approximately one and a half times the normal size

• Nil evidence of tenderness, dominant nodules nor lymphadenopathy• Nil peripheral stigmata of thyroid disease

Remainder of Physical Exam was normal


Laboratory Findings• CBC: within normal limits• Basic Metabolic panel: within normal limits• Hepatic panel: within normal limits• Thyroid Stimulating Hormone (TSH)

•2.7 miU/L (N:0.4-4.0 mIU/L)• T4 5.9 mcg/dL (N: 4.8-11.0 mcg/dL)• T3 0.78 ng/mL (N:0.8-1.7 ng/mL) • Anti-thyroglobulin antibody: 2.4 U/mL (>1.0 U/mL – positive)• Anti-thyroperoxidase antibody:14.0 U/mL (>1 U/mL – positive)


Other Studies

• ECG: normal sinus rhythm with occasional premature ventricular contractions• Thyroid Ultrasound:

1.7x1.1cm nodule in the R lobe (hypoechoic)9x11mm nodule in R lobe (hypoechoic)Nil microcalcifications, nil increased vascularity

• Fine Needle Aspiration performed of larger nodule:

Colloid in a population of lymphocytesUNITED STATES DEPARTMENT OF VETERANS AFFAIRS

Euthyroid lymphocytic thyroiditis

Working Diagnosis


• The patient was referred back to his primary care physician, who intermittently checked TSH levels, which remained normal

• 8 years later, the patient was referred back to his endocrinologist with a TSH measured at 4.16 mIU/L (N:0.4-4.0mIU/L)

• Patient was clinically euthyroid during this

time

Outpatient Course


• On repeat labs by the endocrinologist, the TSH was measured 11.4 mIU/L

• Other laboratory values of note:– T4 6.3 mcg/dL (N: 4.8 - 11.0 mcg/dL)

– T3 Uptake 31.7% (N: 23.5 - 40.6%)

– Free thyroid index 4.0 (N: 1.5 - 3.8)

– Anti-thyroperoxidase antibody: 239 IU/mL (normal < 27 iU/mL)

– Anti-Thyroglobulin antibody: < 20 IU/mL (normal)

Outpatient Course


• Repeat Thyroid Ultrasound performed:Coarsely and diffusely multinodularMild hyperaemia of the entire thyroidR lobe: 2 solid hypoechoic nodules, 15x10mm and

9x9mmL inferior lobe: 8x6mm noduleNil calcifications• Fine Needle Aspiration of 3 nodules:R and L nodules: colloid with lymphocyte backgroundL inferior lower lobe: colloid accumulation

Outpatient Course


The patient was started on Levothyroxine 25 μmcg daily by

mouth

Outpatient Course


Repeat lab values 3 months later in clinic

– TSH 2.74 miU/L (N:0.4-4.0 mIU/L)

– T4 5.7 mcg/dL (N: 4.8 - 11.0 mcg/dL)

– T3 Uptake 33.9% (N: 23.5 - 40.6%)

– Free thyroid index 1.9 (N: 1.5 - 3.8)

Outpatient Course


Hashimoto’s thyroiditis (with failing thyroid)

Final Diagnosis


nyu medical grand rounds clinical vignette arnab ghosh, md pgy-2 10/23/12 u nited s tates d...

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