Confused by results

[Jules77733]

Hi Dr. Lupo,

I posted a question last week asking what was going on with me as I went from having a TSH of 4.05 (which was around ~2.00 a year before this) to 5.45 in less than a week, in early May 2008 (range: 0.4 - 4.0). When my TSH was 5.45, my free T4 was measured as 1.3 (right in the middle of the normal range). Your thoughts were that I potentially had hypothyroidism (Hashimoto's being most likely), but that I should look at adrenal insufficiency, as well.

I had bloodwork done late last week at a different lab, and from what I managed to gather from the nurse I just spoke with over the phone, my bloodwork results are:

TSH: 1.58 (range is 0.4 - 4.0 also, I believe)
T4: 7.5 (range: 7.5 - 12.5; I guess they didn't check free T4...?)
Everything else: normal (no Lyme disease, CBC was apparently in normal ranges, blood sugar was normal, etc.)

The only test I wasn't able to have done was the AM Cortisol, but I should be getting this done later this week. My ultrasound apparently had "something" in it, but nothing worrisome enough that warranted the doctor actually calling me about my results; so I have to wait to find out at my appt. next week. I'm still experiencing all of the same symptoms: joint pain/swelling, extreme fatigue, really tight neck up to my ear with lump on right side, tremoring, etc. except now I'm getting lightheaded more frequently and seem to be experiencing some abdominal discomfort and pain.

What are your thoughts on what might be happening, and how do you recommend I proceed? My doctor doesn't seem to think there's a problem, but I'm not so convinced since I'm feeling this way even while taking 400mg Provigil and 15mg Meloxicam (NSAID), plus allergy medication. My uncle and his mother (my grandmother) both had colorectal or bowel cancer and I've heard this can cause thyroid problems.....but I there isn't a known history of thyroid problems in my family.

Thank you so much for your help!

-Julia

[Mark Lupo, M.D.]

Hard to say this is thyroid at this point - -would consider antibody testing to see if there is a risk of developing a long-term thyroid problem, but there may have been some transient issues (some type of thyroiditis, but not a classic sub-acute).  keep working with your doctor to get to the bottom of it.

[898]

Julia: So far it is just speculation but :"subacute painless thyroiditis and subacute painful thyroiditis can both cause transient hypothyroidism. The hypothyroidism is transient because the thyroid is not destroyed."
Source: Merk Manuals; www.merck.com/mmhe/sec13/ch163/ch163c.html

[Jules77733]

That's definitely something to think about, 898. The only reason I'd say I likely don't have that is the lack of pain in my thryoid. Occasionally, I'll get soreness on the right, where it seems to be more swollen, or an aching, but in general, I don't have much pain. According to a few definitions I looked up of subacute thyroiditis, it's usually very painful, and due to a virus. When I first began experiencing these symptoms, I had bloodwork done and my CBC was normal (including leukocytes).I also tested negative for mono and strep throat. And if there are "leakage" of thyroid hormones into my system from having subacute thyroiditis of some sort, why is my T4 closer to the lower end of the normal range? I guess I'll have to wait until next week to find out if my thyroid antibodies were tested...I don't think T3 was, because when I asked if T3 and T4 were measured, the nurse said T4 was (and then gave me the number).

I'm not sure what's going on. Some other symptoms I forgot to mention in my original post were that my eyes are still puffy, I'm still always cold, and I'm losing weight, as opposed to gaining it, though I sometimes feel my appetite has been increasing as of late. Is it possible to go from hypo to hyper if I'm not on any kind of synthetic hormone or treatment for this? I am taking an NSAID, but I started taking this after the bloodwork was done, so this couldn't have interfered with the TSH or T4 level...............

[Jules77733]

Oh, quick point: I've never had a fever any of the times I've been to the doctor's office over the past two months, though my blood pressure seems to have dropped a lot for me (used to be around 120/98; now I seem to be more around 98/65), my heart rate has increased (used to be ~65bpm, now it's ~86bpm), and my temperature last time I was in the doctor's office was 98.9, which is prettyyy high for me since I usually measure it as being under 98...but this probably isn't very significant.

[898]

I found the article about silent thyroiditis; but I believe it is too genreal:
"Definition    
Silent thyroiditis is inflammation of the thyroid gland that involves alternating hyperthyroidism and hypothyroidism followed by recovery.
Causes    
The cause of this type of thyroiditis is unknown. The disease affects women more often than men and usually develops in people between age 13 and 80.
Symptoms    
The initial symptoms are those of hyperthyroidism (overactivity of the thyroid gland), and may last for 3 months or less. Later symptoms may be more characteristic of an underactive thyroid (including fatigue, cold intolerance) until the thyroid recovers.
Symptoms are usually mild and may include:
• Fatigue
• Frequent bowel movements
• Heat intolerance
• Increased appetite
• Increased sweating
• Irritability
• Muscle cramps
• Menstrual irregularities
• Nervousness, restlessness
• Palpitations
• Weakness
• Weight loss
Exams and Tests  
A physical examination reveals an enlarged thyroid gland. The heart rate may be rapid and the hands may shake.
Tests may show that radioactive iodine uptake is decreased and blood levels of the thyroid hormones T3 and T4 are increased [???]
A thyroid biopsy shows lymphocytes (a type of white blood cells) in the gland.
Treatment    
Treatment is based on symptoms. Beta-blockers relieve rapid heart rate and excessive sweating.
Outlook (Prognosis)    
Generally, silent thyroiditis will go away on its own within 1 year, with the acute phase ending in 3 months. Some people may develop hypothyroidism over time, so regular follow ups with a doctor are recommended.
Possible Complications    
Hypothyroidism may develop".

References    
AACE Thyroid Task Force. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Evaluation and Treatment of Hyperthyroidism and Hypothyroidism. Endocr Pract. 2002;8(6) 459.
Update Date: 10/24/2007

[Jules77733]

Hi again, Dr. Lupo,

Update: apparently there was something that showed up in my thyroid ultrasound. There were "no discrete nodules", but there was an "irregular pattern in thyroid" that my doctor described as "slightly heterogeneous thyroid parenchyma". The nurse I spoke with clarified this as likely meaning "heterogeneous patches of inflammation within the thyroid" comprised of a "very slight mixture of cells". With my bloodwork being 'normal' and my apparent drop in TSH what might this mean? The doctor wants me to have an RAIU procedure done, but I'm not quite sure what she would be looking for in this case, and if this is the best way to proceed.

Thank you very much--I'm unable to get an appointment with an endocrinologist until mid-August, so I really value your input.

-Julia