Normal TSH with increased uptake

[giannasi]

Hi, thanks for your time.  I went to the doctor because I thought I had enlarged lymph nodes/viral infection, but it turns out it was my thyroid, which is tender.  Nurse practitioner ran TSH only, which was 1.9, but felt nodules so she sent me for an ultrasound.  That showed three nodules in one lobe, one in the other, all seemed benign, but "upper normal" thyroid.  However an uptake scan was recommended.  That showed slightly increased uptake of 16% at 4 hours, and increased uptake of 35% at 24 hours.  I am going to an endocrinologist soon but I am wondering about your take on possible dx.  The scan said thyroiditis/Graves was indicated but I have the normal TSH.  No other thyroid bloodwork recently, I have to wait for that (have asked for it sooner). I think the uptake was diffuse, it said "no focal defect."

I am cold all the time, but sometimes more than others.  I sometimes have light periods, just recently, but not always, and go through anxious periods and I had a few weeks where I was hungry all the time, eating at 10 am. The past few days, no appetite really, and I feel heavier.  I also have RA and Raynauds. Weakness in my thighs has bothered me a lot recently, since my second son was born about 20 months ago.  At that time thyroid panel was run (TSH, T4, T3 uptake and FTI) and was all normal.  TSH tested often these past few years, always between .7 and 1.9.  . I have had episodes of shedding hair, postpartum, both at 6 months and around 10, and before methotrexate for RA (hair loss has continued, but in spells. Hair is THIN).  Pulse often seems high, restless, hard to focus.

My father has empty sella syndrome and takes 1.75 synthroid (maybe unrelated to empty sella?) plus hydrocortisone (apparently related to empty sella). He has been on synthroid since he was about 40, went from .25 up to 1.75 across time.  The adrenal issues came after that.  

I had an MRI about 1.5 years ago for another reason that showed normal pituitary at that angle.

[Mark Lupo, M.D.]

The thyroid levels appear normal.  The nuclear scan does not add anything to the evaluation and the slightly high uptake levels are not meaningful in the absence of thyroid dysfunction and may be due to relative low iodine in the diet.  The exception would be a fluctuation in thyroid function but the repeatedly normal TSH levels over time suggest against this.

From a thyroid standpoint the nodules may need FNA biopsy depending on size and characteristics on ultrasound -- the endocrinologist will review this w / you.

With your dad's history (despite your normal pituitary MRI) -- would repeat TSH along with a free T4 & T3.  With your autoimmune history, may be of interest to test thyroid antibodies -- this is sometimes associated with nodular thyroid.

[giannasi]

Doctor, I am not sure whether you ever follow up on these, but...

Endo ran the following tests with the following results:
TSH: still normal (1.4)
B12: high--890
Sjogrens antibodies--negative
4 thyroid antibody tests--all negative

He did not order T3 or T4 but did order a second uptake scan.  His thought is that I may have some type of thyroiditis and the first upper normal scan was taken at the start of its course.  He felt it may be possible that this scan is zero, in which case it would be subacute thyroiditis.  But can that happen with normal TSH?  And if this scan is also high normal, what could that mean?

When I related the history he thought it was a case of an overreacting nurse practitioner, until he felt my thyroid which is "exquisitly tender."  But that is about the only thing I have to work with.

[giannasi]

Meant to add: I am a 30 year old female.  Most obvious symptom recently has been tremendous hunger all the time (but often very cold at the same time).  Only other abnormal bloodwork is that I am anemic, probably related to RA.  I had my ACTH run once about 2-3 years ago and it was normal.