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Wolf

 

I think these replies are both very reasonable. Here are my thoughts.

 

As I understand it thyroxine is absorbed in the gut by a passive process, although probably receptor-medicated. The absorption is dependent on adequate gastric acidity NEJM 2006; 354: 1787-95. The effect may be related to the thyroxine medication being salts and not the physiological form. This loss of acidity is probably the mechanism for the effect in H pylori infection Avril mentioned.

 

I wonder if the anorexia you describe itself could be the cause of these findings. Of course 'anorexia' could be a secondary symptom to the other possible GI causes, but the BMI suggests to me this is anorexia nervosa.  Low gastric acidity has been reported to occur in anorexia, presumably due to vomiting etc.  Bulimia of course if present would exacerbate this. Does she have bad teeth?  Furthermore the patient may not list antacids as 'medication'.

 

The anorexia perhaps could also explain the other nutritional deficiencies.

 

Bets regards

Steve

 

 

 

­­­­­­­­­­­­­­­­­________________________________________________________

 

 

Dr Stephen Frost

Department of Clinical Biochemistry and Immunology

Brighton and Sussex University Hospitals NHS Trust

The Princess Royal Hospital

Lewes Road

Haywards Heath

West Sussex

RH16 4EX

 

Tel 01444 441881 ext 8197

Fax 01444 414051

email [log in to unmask]

 

Views expressed  are my own and not necessarily those of the Trust.

 

-----Original Message-----
From: Mohammad Al-Jubouri [mailto:[log in to unmask]]
Sent: 10 July 2008 14:50
To: [log in to unmask]
Subject: Re: selective malabsorption of Thyroxine

 

Sorry, didn't read that Coeliac was excluded. However, still the low BMI and low B12, folate & vitamin D and the requirement for a higher thyroxine suggest a generalised malabsorption process. Avril's comment is worthy of consideration first and probably later also a trial of gluten free diet as there has been cases of antibody and biopsy negative coeliac disease.

 

regards

 

Mohammad
 

 

----- Original Message ----
From: Avril Wayte <[log in to unmask]>
To: Mohammad Al-Jubouri <[log in to unmask]>; [log in to unmask]
Sent: Thursday, 10 July, 2008 2:37:22 PM
Subject: RE: selective malabsorption of Thyroxine

Dear all

We had a similar patient last year, and think we have another at the moment, where the apparent selective malabsorption of thyroxine appeared to be due to gastric infection with Helicobacter pylori. Treatment of this condition resulted in normal absorption and normalisation of TFT after months and months of head scratching and patient observation. 

 

Regards

Avril

 

Avril Wayte

Ysbyty Gwynedd

Bangor

North Wales

 

 

From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Mohammad Al-Jubouri
Sent: 10 July 2008 14:31
To: [log in to unmask]
Subject: Re: selective malabsorption of Thyroxine

Hi Wolf,

 

Worth considering Coeliac disease in her case, I would check anti-TTG antibodies.

 

regards

 

Mohammad

 

Dr. M A Al-Jubouri, MB ChB, MSc, FRCP Edin, FRCPath
Consultant Chemical Pathologist

 

----- Original Message ----
From: "Woltersdorf, Wolf" <[log in to unmask]>
To: [log in to unmask]
Sent: Thursday, 10 July, 2008 1:36:33 PM
Subject: selective malabsorption of Thyroxine

Dear all,

 

Thyroid cases seem to be the flavour of the month so let me add another one:

 

- 31 year old caucasian female, 46kg but not thought to be anorectic, BMI ~21

- she appears to have selective malabsorption of Thyroxine

- Thyroxine doses of 400ug do not shift her high TSH but she becomes toxic with doses around 600ug

- her endocrinologist tells me that she appears to be compliant

- she is not on iron, PPIs or any other medication

- investigations for malabsorption have shown a negative duodenal biopsy and negative coeliac screen

- she has low folate, B12 and VitD levels but a normal full blood count: Hb 14.7, MCV 87.5.

- in her family history there is hypothyroidism on her maternal side but without any difficulties and she has a paternal aunt who used to be on i.m. Thyroxine 8 yrs ago. Unfortunately, her aunt is deceased now and no further details are available.

 

- the plan is to give her a trial of i.m. Thyroxine twice weekly

 

She could have a selective intestinal Thyroxine transporter problem. Does this really exist?

There could be an association with her low folate, Vit B12 and perhaps VitD.

 

I'd be grateful for your comments.

 

Wolf

 

 

Wolf Woltersdorf MD MRCP FRCPath

Consultant Chemical Pathologist

Head of U-STAR Research

University Hospitals Bristol

Bristol BS2 8HW UK

Tel: 0117-928 3245

 

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