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It would be interesting to know if the patient has other features of thyroid disease,e.g. goitre or other features of Graves disease. The results appear to be in line with hyperthyroidism, rather than simply analytical problems/drug interaction. The negative anti-TPO and negative I-131 scan ( assuming this refer to thyroid uptake) are typical of thyroiditis. However, a small number of patients with hyperthyroism (clinical and biochemical) do have a 'normal' uptake.Are there also abnormalities indicating non specific changes on acute/subacute illness?
Hyperthyridism, of course, may not respond to Carbimazole (CBZ). I am not sure of the dose given and the duration (?4 weeks). A higher dose of CBZ or change to propythiuracil is another option. In resistent cases steroids have been tried and reported to induce a remission (report last 1998/199) in PGMJ, though I have no personal experience of this. If the clinician is happy with diagnosis of hyperthyroidism he/she could consider RA-iodine therapy with anti-thyroid pre and post RAI. If all fails, and surgery deemed to be the only option then treatment with iodine prior to thyroidectomy could be considered.
hope this is useful.
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Ahmed Waise FRCP FRCPath
Cosultant Chemcial Pathologist
Friarage hospital,
Northallerton, North Yorks
DL6 1JG
Tel 01609 763030
Fax 01609 764632
EMail: [log in to unmask]
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From: Roy Fisher[SMTP:[log in to unmask]]
Reply To: Roy Fisher
Sent: 26 June 1999 09:43
To: acbmailbase
Subject: Enigmatic Thyroid Case
We would appreciate any thoughts on this case of a 54 year old man who was first admitted at the end of April with clinical details of sob and tremor.He was found to have a chest infection. The TFTs results were consistent with severe hyperthyroidism:
FT4 > 155 pmol/L (ref: 9.8 - 23.1)
FT3 > 30.8 " ( " 3.5 - 6.5 ) All on ACS Centaur.
TSH < 0.01 IU/L (" 0.3 - 5.5)
However,we have never seen levels this abnormal before. On referral to the endocrinologist he was not considered to be that clinically thyrotoxic but more likely to be a thyroiditis. He was nevertheless treated with carbimazole but showed no real clinical or biochemical improvement over the next 4 weeks. Other tests casting doubt on the diagnosis were negative TPO antibodies and a marginally elevated SHBG( 62nmol/L, Ref : 15-45). A check for heterophilic antibody interference was negative. We referred a sample to Dr Raggatt who confirmed the very high FT4 level by the 2-step Delfia assay, even at 1/16 dilution and also the undetectable TSH level. Antibodies to FT4 can be excluded as a cause.
PMH. mild renal impairment for 3 years, has a heart valve defect, a pacemaker and has been polycythaemic.
Current medication: captopril, bumetanide, warfarin. He was on amiodarone for 4-5 months about 2 years ago with normal TFT results.
The carbimazole therapy was stopped and he was sent home 2 weeks ago, but was readmitted last Thursday. He is now rather poorly, has lost weight, has muscle wasting and is cachetic. His CRP was 150 mg/L, albumin 31g/L. The I-131 scan was negative!
Does he have severe atypical hyperthyroidism that requires surgical treatment? What other thyroid tests could be done ? total T4/T3 or FT4 by ED
Is there underlying malignancy or severe infection
An urgent fine needle thyroid biopsy is planned and an abdominal CT, and a check for
endocarditis.
Any comments or suggestions would be most appreciated.
Roy Fisher
Consultant Biochemist
Royal Cornwall Hospital
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Tel 01872 252546