Diagnosed with Graves Disease...But Could It Be Hashitoxicosis?

[decotah]

Diagnosed With Graves... But Could It Be Hashitoxicosis?

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Hello everyone,
I have just been diagnosed with Graves Disease and the doctor feels I should start Tapazole on the lowest dose and see her in a few weeks. I have a sinking feel she's wrong, though...and wonder if it could actually be Hashitoxicosis. I don't have any symptoms at all (apart from weight loss, but that has been gradual and I have been doing Weight Watchers religiously). I will give you all the lab results I have, and then I'd be curious what your opinions are. I also had an ultrasound that showed no nodules and according to the first endo I saw (I ditched him because he was a jerk) said the shape and look of it was that of Hashimoto's. I should also mention that my father has hypothyroidism and my mother had lupus. Please let me know what you think. Thanks!

Thyroid Peroxidase (TPO) Ab 299 IU/mL
Serum thyroglobulin 26.1 ng/ML
Thyroglobulin, Antibody <1.0
Thyroid Stim Immunoglobulin 102 % (0-139 ref range)
T3 Uptake 29
Free Thyroxine Index 2.0 1
TSH 0.045 uIU/mL
T4,Free(Direct) 1.18 ng/dL
Triiodothyronine (T3) 107 ng/dL (107-180 ref range)
Iodine Uptake: 6 hr. 38%, 24 hr. 56.3%  

[decotah]

Okay...a lot has changed in the past week, so I wanted to share the latest. First of all, I found out that I don't have mitral valve prolapse. It turns out that a lot of people had been diagnosed with it that didn't have it and they have learned this since guidelines have changed. I was one of those people and found out when I had my echocardiogram. This is obviously great news, and also very relevant to my endo's treatment plan since he had based his decision to start me on methimazole asap on me having mvp. I had initially asked him to wait a few weeks to see if my tsh changed because I am wondering if this is Hashitoxicosis rather than Graves. Since mvp is no longer an issue, I called to find out if he would reconsider me waiting to start the meds. He had just gotten my most recent test results back when I called, and said the mvp variable doesn't even matter anymore, because my tsh is now normal. My total t3 and free t4 are still normal (they have been all along). He said because of this, he doesn't think putting me on meds makes sense (and I obviously agree). Sounds like good news overall, but he said I did test positive for TRAB. It's not a crazy high level of antibodies, but positive, nonetheless. He is still convinced it's Graves, but just mild Graves and we will keep rechecking my tsh, t3, and t4 every six weeks for a while. I am very happy about his decision not to prescribe medication, but I am still curious if this could be Hashitoxicosis rather than Graves because my tsh has risen *a lot* in a very short amount of time and because my t3 and t4 keep falling with every retest and are much closer to the low end than high at this point. I understand that I had a high iodine update, but I know it can be moderately high (which mine was) with Hashitoxicosis. Same goes for my TSI antibodies (not positive, but present) and TRAB (positive, but not high). I know they're indicative of Graves, but I read they can be present in Hashitoxicosis as well. All these things, combined with me being told that my ultrasound "looks like Hashimoto's disease" and the fact that my TPO antibodies are elevated...make me really wonder. I will repost the original levels along with the newest results to see what you think. Thanks!

Previous Levels

TSH 0.012 9/17/14
TSH 0.016, T4 Free, Direct 1.28 9/23/14

Thyroid Peroxidase (TPO) Ab 299 IU/mL Mid-Oct.
Serum thyroglobulin 26.1 ng/ML Mid-Oct.
Thyroglobulin, Antibody <1.0  Mid-Oct.
Thyroid Stim Immunoglobulin 102 % (0-139 ref range)  Mid-Oct.
T3 Uptake 29 10/3/14
Free Thyroxine Index 2.0 1 10/3/14
TSH 0.045 uIU/mL 10/3/14
T4,Free(Direct) 1.18 ng/dL
Triiodothyronine (T3) 107 ng/dL (107-180 ref range) 10/3/14
Iodine Uptake: 6 hr. 38%, 24 hr. 56.3%  Mid-Oct.

Here are the most recent results from 10/25/14:
TSH .444 (This is NOT a typo and I didn't forget a zero...haha)
T4, Free (Direct) 1.04 (ref range .82-1.77)
T3 84 (ref range 71-180)

TSH Receptor Antibody 2.1 (ref range 1.5 positive)

[Barb135]

The doctor wouldn't incur cost by ordering FT3 - he'd simply pass it on to you.  And T3 isn't really affected that much by other factors - it's TSH that fluctuates greatly... Of the total T3 in your blood approximately 90-95% is bound by protein, which is why we test the Free (unbound) portion, which is what's available to be used by the individual cells.

"true" hyperthyroidism is based on FT3 and FT4 levels.  Subclinical, by definition means that something is not severe enough to present definite or readily observable symptoms.

[decotah]

I have no clue why he won't order the Free T3, other than the cost he would incur. I do agree that total T3 can be influenced by many factors, so Free is better. However, I think it's probably neither here nor there since he does seem to be concerned about the TSH specifically. He agrees that I'm subclinical and even mentioned that in our meeting. While what you said is completely true re: the benefits of medication in cases of subclinical, two additional factors are at play. First, I likely have Graves, as opposed to just generic subclinical hyperthyroidism and that can be a little more serious if left untreated. Also, although it's true that there have been little to no proven benefits in preventing atrial fibrillation (I have read many articles that are consistent with what you presented), they do give exception for cases of "heart disease". They also say in cases of "frankly" suppressed tsh (less than .1), there is more of a need to treat in order to avoid the patient eventually becoming overt, as opposed to subclinical...but even if you don't buy that, the mvp puts it in the exceptional category. I must say though...I'm a little confused that this doctor (along with another one I saw) consider mvp "heart disease". I was always under the impression that it's a "heart defect". It may seem that I'm splitting hairs, but in this case, it kind of does matter. It just so happens that I'm due for an echocardiogram today (total stroke of luck), so I absolutely will ask that dr's opinion of this...along with whether or not mvp is considered "heart disease". I am also anxious to get my other test results back (retest of tsh, total t3, and free t4, along with trab), as I'm curious to see if my tsh has risen at all since that initial test. Will definitely keep you posted. Thanks!

[Red_Star]

I had overt hyperthyroidism for a year which causes a whole lot of health problems. I'm happy to say no stroke although the high blood pressure for a year wasn't doing me any favours.  I too have mitral valve regurgitation but in my case due to a calcified mitral heart valve not mitral valve prolapse.

[Barb135]

"You may have a very mild form of hyperthyroidism called subclinical hyperthyroidism if your thyroid tests show that:

    Your thyroid-stimulating hormone (TSH) levels are low.
    Your thyroid hormones thyroxine (T4) and triiodothyronine (T3) are normal.

Subclinical hyperthyroidism is different from hyperthyroidism. Your TSH levels are low but your thyroid hormone levels are normal.

If you have subclinical hyperthyroidism, you may have no symptoms at all. Or you may lose weight or feel anxious.

People with subclinical hyperthyroidism may also develop some of the more serious problems related to hyperthyroidism such as heart and bone problems. But experts do not know whether the benefits of treating subclinical hyperthyroidism outweigh the risks. For this reason, if you have subclinical hyperthyroidism, your doctor may just watch you closely."

http://www.webmd.com/women/tc/subclinical-hyperthyroidism-topic-overview

MVP "can" make a hyperthyroid case a whole new ballgame, but it doesn't have to be. I'm sorry I gave the impression that it was urgent that you be treated with anti-thyroid med... not all hyperthyroidism has to be treated with anti-thyroid med and once I calculated your FT4 to be less than mid range, which doesn't even indicate that you are hyper, *I* would not want to be treated with anti-thyroid meds.

In my opinion, you endo is reacting ONLY to the TSH and is not taking the lower FT4 level into consideration at all, and let's not forget, he hasn't even bothered to order an FT3.  FT3 is the hormone that's used by the individual cells and correlates best with symptoms.  

You lost weight, because of weight watchers, not because you're hyper and you said you don't have other symptoms of being hyper, so I'm really trying to stretch my mind to figure out a good reason to go on anti-thyroid med when one has no symptoms of hyperthyroidism.

Have you discussed any of this with your cardiologist to get her/his take on how this could further affect your heart?  The endo will  have you hypo very soon, which is just as hard on your heart.  When I was very hypo, my heart rate went down into the low 30's when I slept (per holter monitor) and even when I was active/excited/upset was only in the 50's (normal is 60-100) - that's just as bad.  I would talk to my cardiologist and get his opinion before making a final decision.

Again, I'm not trying to make your decision or talk you out of anything.  I'm merely telling you what *I* would do in your situation.  

[decotah]

This is actually my third endo and the other two felt the same as he does. I decided to stick with him because he was the nicest and most patient one if three. According to all the medical literature I've read, the definition of subclinical hyperthyroidism (as opposed to overt hyperthyroidism) is that the tsh is low, but ft3 and ft4 are normal. I fit that definition. What are your thoughts on the MVP issue? He keep saying even a short period of subclinical hyperthyroidism could put me at risk of a stroke. That scares me enough to take him seriously. I did ask him about the chance of going hypo and he said that's why they're starting me on the lowest dose of Tapazole...to minimize the chance of that happening. What did you mean when you said MVP can turn a simple hyper issue into a whole other ballgame? To me, I thought it meant you agreed that it gives more of an urgency to starting the meds, but your later posts showed you don't advocate it...so I'm a little confused by the meaning of that statement. P.S.--I do very much appreciate you taking the time to give input.

[Barb135]

Here's the problem - he's saying that you are subclinically hyper, based on your TSH, when in reality you aren't hyper, because your FT4 isn't the least bit hyper.

Since he's basing your being hyper on TSH, your FT4 level will most likely be very low and you will be extremely hypo before your TSH rises enough for him to believe you're hypo.

Have you questioned your endo about any of this?

Of course, it's your decision, and you must do what you feel to be in your best interest and nothing I, or anyone else says, should affect your decision.  I'm telling you what *I* would do in your situation, but I certainly can't make a decision for you.

[decotah]

While I do agree that he is definitely placing too much emphasis on the tsh level, he is particularly influenced by my having a high uptake, in regard to his decision to treat for Graves. He actually agrees having Hashi's and Graves is a possibility, but he doesn't want to wait around for a swing because of my mitral valve prolapse. He fears even a few weeks of waiting could put me at risk for a stroke. In a case like this, I am inclined to follow his advice, but I am definitely not a fan of getting on the meds. I asked what would happen if it caused me to go hypo since my total t3 and free t4 are already normal. He said that's precisely why he's starting me on the lowest dose...to avoid that from happening and that at the first indication of me going hypo, they will stop it. He said even through I could go hypo in the future, I am (subclinically) hyper now, and because of mvp, should be given meds in the short-term,

[Barb135]

Your FT4 is at 48% of its range.  It's recommended that FT4 be about mid range, so you're good there.  That indicates that you aren't hyper, so I'd be against taking anti-thyroid med, based solely on the TSH.  I would insist on a Free T3 test - it's not that expensive and doesn't take very long. FT3 should always be done with FT4, but particularly, when hyperthyroidism is involved.

IMO - I'd lean towards you having both Graves and Hashitoxicosis.  The question is, whether you're getting ready to swing into a hyper hypo phase.  You can't tell by the TSH, as it can fluctuate by up to 75% over the course, of a day.  You have to go by the actual thyroid hormone levels and you only have the FT4, not an FT3.  

I'm sorry, I don't have a lot of faith in your endo, either, since he's placing way too much faith in TSH.

[decotah]

Right, Barb135. My endo said that he would not normally be averse to waiting a few weeks to see if my tsh rises (thus giving some evidence of Hashitoxicosis), but due to the MVP, he feels even waiting that short length of time can put me at risk for atrial fibrillation.

[Barb135]

A mitral valve prolapse can make a simple hyperthyroid issue a whole new ballgame.

[Red_Star]

I've had both types of Hashitoxicosis. The leakage hyperthyroid symptoms of active Hashimoto's are mild compared to hyperthyroid symptoms of Graves antibodies.  I also developed thyroid eye disease symptoms and pretibal myxedema due to Graves antibodies showing up as well.  My labs showed subclinical hypothyroidism when I was very hyperthyroid so the combination of antibodies did weird things lol.

My doctor wanted to prescribe anti thyroid medication but I really wanted to wait to see if I improved and two months later (after my two months of severe stress resolved) I was hypothyroid again.

[Barb135]

I never advocate starting any medication, based solely on a TSH result.

I'd lean toward you having both Hashimoto's and Graves, but with your FT4 as low as it is, I'm not convinced Graves is dominant.  I, personally, wouldn't start medication without a Free T3, along with the Free T4 test.  If need be, I'd order the panel online without a doctor's order.  But you have to do what you think is best.

[decotah]

Sorry...I made a mistake on the reference range for free t4. It's .7-1.7, but I'm still right in the middle.

[decotah]

The reference range for Free T4 is .7-2.7...so I'm smack dab in the middle. Since I posted this, I saw another endo who said because of the high uptake, he is leaning toward Graves (that isn't generally seen with Hashitoxicosis), but he isn't "closing the door" on Hashitoxicosis just yet. He wrote me a script to get my TRAB checked and he's also going to recheck my tsh, t3 (unfortunately, still just total and not free), and free t4 to see if anything has changed (from 4 weeks ago). In addition, he did an ultrasound and said it presented like Hashimoto's, just as the other doctor did. He also checked for vascularity since there is low blood flow in the case of Graves and high blood flow in Hashimoto's, but he said in this case, it wasn't extreme on either end, but certainly, there *was* blood flow. So, that just cancelled itself out...haha He said he understands why I want to wait to start Tapazole, but because I have mitral valve prolapse, even waiting a few weeks might not be a good idea due to increased risk of atrial fibrillation and stroke as a result. He said assuming my tsh hasn't changed much since the last test, he wants to just start me on 5mg of the meds and see how it goes. Do you think this plan sounds reasonable?

[Barb135]

TSI antibodies 102% (0-139  ref range).

[898_1]

the iodine uptake is high, so it most likely Grave's and Hashimoto's. Need to have test for TSI antibodies!!

[Barb135]

With your high TPOab, I'd opt for Hashitoxicosis (hyper phase of Hashi, but you could have both Hashi and Graves.

It's too bad your doctor didn't order Free T3, instead of T3 uptake and Total T3, which are both obsolete and not very useful.  Your Total T3 is at the very bottom of its range, which almost makes me think you're verging on hypo.  

What's the range for the Free T4?  Since ranges vary lab to lab, they always have to be posted with results.