1. Endocrine Teaching Endocrine Teaching Interesting Thyroid Cases Wednesday, February 29, 2012 Dr. Merrill Edmonds

2. Case 1 42-year-old male Decreased energy x 2 years Decreased energy x 2 years Fatigue, insomnia, depressed Fatigue, insomnia, depressed No improvement on antidepressant No improvement on antidepressant No family history of thyroid disease No family history of thyroid disease Smoking 1ppd, no alcohol Smoking 1ppd, no alcohol Farmer Farmer Diagnosed with hypothyroidism April 2, 2011 Diagnosed with hypothyroidism April 2, 2011 TSH = 10.0 TSH = 10.0 CBC, RF, CRP, ANA all normal CBC, RF, CRP, ANA all normal

3. Case 1 Hypothyroid – started on thyroxine DateThyroxine DoseTSH May 3, 20110.05 9.95 May 31, 20110.10 7.72 June 28, 20110.15 8.64 July 20, 20110.15 8.60 Sept 7, 20110.00109.80 Oct 17, 20110.10 20.75 Nov 28, 20110.20 12.69 Dec 19, 20110.40 10.44 Jan 16, 20120.60 8.48

4. 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

5. 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

6. Case 1 Causes? Pituitary Tumor Pituitary Tumor Thyroid hormone resistance Thyroid hormone resistance Interference with assay Interference with assay Other? Other? What to do?

7. Case 2 HPI: Hyperthyroid 2002 – Rx radioactive iodine Hyperthyroid 2002 – Rx radioactive iodine Hypothyroid 2003 Hypothyroid 2003 Thyroxine 0.15 mg daily Thyroxine 0.15 mg daily Hyperthyroid August 2009 Hyperthyroid August 2009 Sudden onset of shakiness, tachycardia, loss of weight despite good appetite, insomnia Sudden onset of shakiness, tachycardia, loss of weight despite good appetite, insomnia TSH =.05; free T4 = 26 TSH =.05; free T4 = 26 Stopped thyroxine Stopped thyroxine

8. Case 2 Hyperthyroidism Hyperthyroidism October, 2009 – off thyroxine 2 months - still symptomatic October, 2009 – off thyroxine 2 months - still symptomatic TSH = 0.05; free T4 = 28 TSH = 0.05; free T4 = 28 131 I uptake = 0% Scan = nothing 131 I uptake = 0% Scan = nothing Started on PTU but developed nausea and vomiting and hematemesis – no ulcers Started on PTU but developed nausea and vomiting and hematemesis – no ulcers January, 2010 – TSH =.05; free T4 = 35 January, 2010 – TSH =.05; free T4 = 35 March, 2010 – TSH =.05; free T4 = 30 March, 2010 – TSH =.05; free T4 = 30

9. Case 2 Hyperthyroid May 14, 2010 – seen in Urgent Endocrine Clinic May 14, 2010 – seen in Urgent Endocrine Clinic History as above History as above Still shaky, palpitations, weight loss of 30 lbs since Aug 2009 Still shaky, palpitations, weight loss of 30 lbs since Aug 2009 No family history of thyroid disease No family history of thyroid disease Mother died from cancer when patient was 12 years old Mother died from cancer when patient was 12 years old Examination – hyperthyroid but no goitre Examination – hyperthyroid but no goitre TSH =<.01; free T4 = 48; free T3 = 10.3 TSH =<.01; free T4 = 48; free T3 = 10.3 Thyroid antibodies negative, TBII negative Thyroid antibodies negative, TBII negative 131 I uptake = 0% Body Scan = no uptake 131 I uptake = 0% Body Scan = no uptake Transvaginal ultrasound normal Transvaginal ultrasound normal

10. Case 2 Hyperthyroid May 27/10 – Rx Tapazole 30 mg daily May 27/10 – Rx Tapazole 30 mg daily June 7/10 – TSH <0.1; fT4 = 62; fT3 = 14.1 June 7/10 – TSH <0.1; fT4 = 62; fT3 = 14.1 Aug 27/10 – TSH 90; T3 = 3.6 – Thyroglobulin = 0.6 - referral to ENT – recommends thyroidectomy for microscopic production of thyroxine in her thyroid Aug 27/10 – TSH 90; T3 = 3.6 – Thyroglobulin = 0.6 - referral to ENT – recommends thyroidectomy for microscopic production of thyroxine in her thyroid

11. Case 2 Sept 2010 Sept 2010 - month’s holiday in Portugal – in hospital for 2 weeks with severe headache Oct 14/10 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

12. Case 2

13. Feb 24, 2011 Feb 24, 2011 Severe headache, slurred speech, facial droop, left arm and leg weakness Seen by neurology – examination normal Investigations negative May 19, 2011 May 19, 2011 Weak, tired, barely able to work Hypoglycemia – cap sugars in 2-3 range Admission to hospital arranged but had to go home first

14. Case 2

15. Admitted to hospital Admitted to hospital Sent for chest xray Sent for chest xray Room searched – large bottle of levothyroxine 0.2 mg tablets Room searched – large bottle of levothyroxine 0.2 mg tablets She knew nothing about the bottle and didn’t know how it got there 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 Finally admitted to taking thyroxine off and on – usually just before visits to doctor or getting blood taken Lots of stress at home. Lots of stress at home.

16. Case 3 36 y/o female Hyperthyroid 1996 Hyperthyroid 1996 Tapazole for 18 months but no remission Tapazole for 18 months but no remission treated with 131 I in 1998 treated with 131 I in 1998 Hypothyroid 1998 Hypothyroid 1998 treated with thyroxine 0.1mg daily - TSH normal treated with thyroxine 0.1mg daily - TSH normal Spontaneous abortion 2004 at 6 mos Spontaneous abortion 2004 at 6 mos baby small for dates baby small for dates

17. Case 3 36 y/o female Hyperthyroid 1996 Hyperthyroid 1996 Hypothyroid 1998 - on thyroxine 0.1mg daily - TSH normal Hypothyroid 1998 - on thyroxine 0.1mg daily - TSH normal Spontaneous abortion 2004 at 6 mos Spontaneous abortion 2004 at 6 mos Pregnant - 3 mos Pregnant - 3 mos What to do? What to do? TSH TSH

18. Case 3 36 y/o female Hyperthyroid 1996 Hyperthyroid 1996 Hypothyroid 1998 - on thyroxine 0.1mg daily - TSH normal Hypothyroid 1998 - on thyroxine 0.1mg daily - TSH normal Spontaneous abortion 2004 at 6 mos Spontaneous abortion 2004 at 6 mos Pregnant - 6 mos Pregnant - 6 mos Baby small for dates Baby small for dates Fetal tachy Fetal tachy Treatment? Treatment?

19. Case 3 TSH receptor antibodies (TSHR-Ab) Diagnostic value Diagnostic value Graves’ - 70-100% Graves’ - 70-100% level grossly parallels the degree of hyperthyroidism level grossly parallels the degree of hyperthyroidism probably no better than degree of hyperthyroidism and size of goitre in predicting remission probably no better than degree of hyperthyroidism and size of goitre in predicting remission not helpful in deciding the form of treatment not helpful in deciding the form of treatment Fetal hyperthyroidism (2-10% of women with Graves’) Fetal hyperthyroidism (2-10% of women with Graves’) Should measure TBII in: Should measure TBII in: previous Graves’ Rx with Sx or I 131 previous Graves’ Rx with Sx or I 131 concurrent hyper and pregnancy (early 3rd trimester) concurrent hyper and pregnancy (early 3rd trimester) previous neonatal hyperthyroidism (early in 1st trim) previous neonatal hyperthyroidism (early in 1st trim)

20. Case 4 19 y/o female Pregnant - 6 weeks Pregnant - 6 weeks hyperemesis hyperemesis palpitations, shakiness palpitations, shakiness TSH <0.001, free T4 = 35 (11-22) TSH <0.001, free T4 = 35 (11-22) What to do? What to do?

21. Case 4

22. Case 5 Hyperthyroid Feb/2006 5 months postpartem - breast feeding 5 months postpartem - breast feeding weight loss (6 lbs) despite ravenous appetite weight loss (6 lbs) despite ravenous appetite palpitations, insomnia palpitations, insomnia Lab Lab TSH < 0.01 (0.3-5.5) TSH < 0.01 (0.3-5.5) free T4 33 (11-22) free T4 33 (11-22) What to do next? What to do next?