Hashimoto's vs Grave's ...

[karletta]

After receiving my last test results on antibodies, one of you kindly suggested the possibility of having "Hashimoto's thyroiditis"... I found this article as well:
http://thyroid.about.com/cs/hypothyroidism/a/hypoandhyper.htm

And I'm wondering if that's my case.

I have been hyperthyroid since April 2010 and diagnosed in May with Grave's disease.

I suppose that the doctor concluded this because of the following initial values:

TSHRAb - 9.5  (range <.04 IU/l)
TPOAb   - 280 ( <60 U/mL)  
FT4        - 38   (9 - 19 pmol/l)
FT3        - 16    (2.6 - 6 pmol/L)
TSH       - 0.002 (.5 - 3.6 mU/l)

However, they never checked the TPOAb again..., I got some checkes somewhere else, getting these increased everytime, being the last reading over 1300 (range <60 U/mL) <- January2012

I had an additional TSHRAb check in sept which was 7.7 (<.04 IU/l)

My last thyroid levels from dec are:

FT4 - 26
FT3 - 9.6
TSH - 0.008

I got PTU medicine but i cannot say I have been taking it frequently cause it makes me feel bad. So my values have come down on its own more or less....

But given the last TPOAb values now I'm wondering if I have  been misdiagnosed and instead of Grave's i suffer of Hashimoto, but got checked in a hyperthyroid phase...

How should i interpret the relation of TSHRab and TPOab? I got advise in early question to check the TSI antibodies but, isn't so that these are part of TSHRAb or even the same but tested differently?

How should my doctor rule out one or the other? what is the ratio between these two antibodies to declare whether you have hashimoto's or graves? Is it even treated differently?

I have many other questions but i will post them separately - thanks in advance you all

[goolarra]

It is true that Graves' is virtually synonymous with hyper...virtually.  However, there are several other conditions that can cause temporary hyper states - postpartum thyroiditis, DeQuervain's thyroiditis and, as you know, Hashi's can have a hyper phase.  However, the hyper phase of all of these is typically shorter than yours has been.  

"Thyroid-Stimulating Immunoglobulins (TSI) / TSH Stimulating Antibodies (TSAb)
TSH receptor antibodies (TRAb) are seen in most patients with a history of, or who currently have, Graves' disease. Testing is usually done for a specific type of stimulating TRAb that goes by several different names, including:
• Thyroid-Stimulating Immunoglobulins (TSI)
• TSH stimulating antibodies (TSAb)
Thyroid-stimulating immunoglobulins (TSI) can be detected in the majority - some estimates say as many as 75 to 90 percent - of Graves' disease patients. The higher the levels, the more active the Graves' disease is thought to be. (The absence of these antibodies does not, however, rule out Graves' disease.) Less commonly, some people with Hashimoto's disease also have these antibodies, and this can cause periodic short term episodes of hyperthyroidism.
When monitoring TSI, elevated levels may help predict relapse of Graves' disease, and lowered TSI levels may indicate that Graves' disease treatment is working."

My personal opinion:  I don't think there's much doubt you have Graves', but monitoring your TSI levels could be valuable information in treatment.

So, correct me if I'm wrong:  You do have hyper symptoms, but they are sporadic, occuring mostly when you are under stress.  These symptoms are, by and large, something you can live with.

Have you ever tried a lower dose of PTU?  Instead of 50 mg every once in a while, I wonder how you'd feel on a smaller, but consistent, dose.  Sporadic use of meds for thyroid disease often just compounds the problem.

"But in any case i don't think these medicines (ptu inclusive) "cures" you, it only controls the symptoms by lowering your thyroid levels, but they don't do anything agains the antibodies... so if i don't get those antibodies down, i will always get the symptoms back (which is interesting thing nowadays, i'll explain further)"

Very true, there is no cure for any autoimmune thyroid disease.  It's all treatable, but as you say, all we can do is either replace hormones if hypo or take anti-thyroid meds if hyper.  Antibodies can go into remission, but they never go away.  They're always waiting in the wings.

[Red_Star]

No problem. :)  Your lower back pain and stiff neck may be due to magnesium deficiency.  Both are noted symptoms of deficiency. Another thread you may be interested in:

http://www.medhelp.org/posts/Thyroid-Disorders/Diagnosed-with-Hashimotos-AND-Graves-disease/show/944756

[karletta]

( cont....)


-- " WHY aren't you having raging hyper symptoms with those labs???  "

That's an excellent question!! And the funny thing is that in this case the bloody endos don't hear my no-symptoms... and don't acknowledge some facts.

So let me explain, in the beginning i did have all kind of hyperT symptoms, and i think that's why they concluded i had grave's:
- I  lost weight (not that much but that was the only good thing) hahaha...
-  the mood swings and agression was the worst part....
- bloodshot red eyes...
- eating a lot and not getting fat (that was cool also i have to say hhaha) ...
- very weak!! couldnt open a bottle of water! ...
- heart beat racing.. bla bla bla bla... you might know them all and i got them all...

Also, i was in menopause, no periods and HORRIBLE heat waves!!!

BUT, they started being less and less somehow in August, when i had jumped out of all the stress around, changed job, got married had a wonderful honeymoon in Seychelles islands...

Another interesting thing (which frustrated me a lot) is that from Aug - Nov i gained 6-7kg!!!

And another magical thing that happened in November is that i started getting my periods back... so far i have had already 4... the heat waves dissapeared... i get moody as before with the PMS but i don't have anymore those agressive rage attacks... (per instance i was in drama before my period and now when is gone, im back to normal... that has been me always)

My heartbeat has slowdown... it is so long that i don't use any betablocker....   if i get stressed then starts pumping again and then i get pissed, has been in that order... but otherwise i have an average of 55-67 bpm... my pressure is also down, now is approx 107/60 average ....

These were my averages before falling so sick (normal for me as i am a runner/swimmer and sports person)

I was able to start jogging again and doing excercise...  of course before i had a bicycle accident last oct and fracture ONLY my thumb (by the degree of the accident i shouldn't be walking i think, so thanks God to that) ... as a matter of "protection" i would take a beta-blocker when jogging a 15km just in case... not sure if i need it though...

Another thing which went down dramatically were my liver values (ALAT) from 135 (10 - 45 U/l) in June to 38-40 since October....

The only thing that i have are dry eyes, a bit red, not like before but i still have those eye symptoms.... otherwise i couldn't say i have any!

Which is strange cause i don't think i have completely lowered my thyroid values (since december was a horrible stressful month and i did get a lot of symptoms mostly in the last week of the year <-- political family christmas you can imagine!)

Nowadays, i hardly take any PTU cause i get bad headache when i take it... I might be taking it every 2 days, 1 pill of 50mg or so...

I do have a considerable amount of low back pain and neck pain (too stiff), but i have had that since forever i remember and i tested positive in this antigen HLA-B27 (test done in Jul 2010) ... i got it because of constant pain in the sacrum-ilium joint (SI Joint) ... i have that pain and bother since forever, still nowadays, can't say i got it with the thyroid problem

Also, i contracted a virus called Chikungunya when i was living in India, i tested positive in RNA test of CHIKV (or something like that) somewhere in 2006, this is known to affect the "small joints" so, the finger joints hurted a lot at some point.... i passed this to my mother i think...

For some reason i think the two above might have something to do... but still i don't know why i don't have any hyperT symptoms anymore...

I do get them but only when im under stress, but as said, i have greatly reduced that part...

I don't know if might help to say that my strong period of stress (work related, 24-7, work conflicts and so son) started in dec 2009 .... as i was in very bad mood and situation , the occupational health doctor tested my  thyroid values already in June 2010, (naturally didn't tell me, i just recently realized.) ... FT4 was 18.3 (11 - 23 pmol/l - different lab) and TSH 1.2

But your question, i can't answer...


If you have more thoughts on my "weird" case, please let me know!!!

Thank you very very very much

Now one question:

Should i ask to get TSI tested? what if they say: "TSI is the same as TSHRab?" ... they have side once that Grave's is a synonymous of hyperthyroidism is just a "fancy name" to give to hyperT... ha!

T H A N K Y O U !!!! <3

[karletta]

Hello Goolarra,

Thank you for replying and trying to help me understand... I really really appreciate!!.

Here are some comments/answers and further questions :) , I am sorry for the length of it, in fact i have to make two parts... I try to provide as much info, if you find it useful i really appreciate any other opinion, whether from expert or not....

-- "Your FT3 and FT4 have come down between August and December, but you are still very, very hyper (according to your labs)."

Well, that's nothing, in comparison to July, were my FT4 was 54 and FT3 20 ...

Basically i got a peak in July which was coincidentally right after a horrible stressful situation at work the worst of the worst (shouts and i got an official warning and my boss wanted me to get fired) and just 2 weeks before my wedding...  no wonder why i felt so bad, but by the day of the wedding i felt good again... (i was all the time on sick leave)


-- " Do you have Hashi's as well?"

I don't know, that has been now my question due to the last TPO results and my current symptoms which i describe further next.

I am suppose to have a session with a doctor in couple of weeks. The problem is - if you have read other posts of min - that they don't really want to listen, they are pushing pushing pushing pushing to either get my thyroid removed or get into RAI. Which is definitively a no. (cause it doesnt fix the root cause) ...

Since I've been also left alone with a lot of questions (cause answering will take more than their 20-min consultation (where they have to use it to convince me on removing my thyroid), i don't want to make a stupid decision either.

The TPOAb tests I did them in another country, and i haven't yet seen any endocrinologist i've been assigned since november. The private general practicioners say "we are not specialists" you have to ask were you have been followed up (so the infernal social security)

I want to be sure of what do or i have to ask/tell them and if this high number of TPOAbs mean something and that they can maybe rule out any of the diseases and if they can see me "differently" and offer different treatment or at least stop pushing me for things i don't want to do...

-- "Have you tried anything but PTU?"

Yes, in fact i started with carbimazol and methimazol but i was itching like hell, i also vomited them and dr say "ah, you might be allergic" ... and gave me ptu which is not best either.... so i couldn't really take it ever with the high dosis that dr gave me (like 3 - 5 pills a day) i was taking only 1 daily and as much as i could (or remember)

But in any case i don't think these medicines (ptu inclusive) "cures" you, it only controls the symptoms by lowering your thyroid levels, but they don't do anything agains the antibodies... so if i don't get those antibodies down, i will always get the symptoms back (which is interesting thing nowadays, i'll explain further)

Another thing that started happening in around Nov is that my white blood  cells dropped down (neutropenia?) and the doctor finally woke up, but didn't tell me what to do, just let me know that "by the way, if you get fever in these days rush to hospital"... so i immeditely stopped the PTU -without telling naturally - and i got new test dones after 2 weeks and the count went a little above the lower limit...  no hyperT strong symptoms popped whatsoever during this time

From that moment till now, i have been so sick with throat infections, flues and who-knows-what else!...

Like now, at the moment i have this fantastic SWINE FLU !! H1N1 virus which has been around and even though i haven't been in contact with anyone, i just got it...

[karletta]

Thank you red_star for the info, i will check for that article!

[goolarra]

Your FT3 and FT4 have come down between August and December, but you are still very, very hyper (according to your labs).  "But given the last TPOAb values now I'm wondering if I have  been misdiagnosed and instead of Grave's i suffer of Hashimoto, but got checked in a hyperthyroid phase... "  Were that the case, then you got checked not once, but twice, in a very hyper phase...seems like more than coincidence.

You definitely have Graves because of your elevated TSHRab.  Do you have Hashi's as well?  That's a distinct possibility, but the fact od the matter is that you are hyper (according to your labs) now.

There are other drugs available to treat hyper.  Have you tried anything but PTU?

TSI is a subset of TRab (THS receptor antibodies).  TRab can be blocking (they block the action of TSH on thyroid cells), binding (they bind to the TSH receptor and prevent TSH and other receptor antibodies from reacting with the TSH receptor) or stimulating (they stimulate thyroid cells, acting in place of TSH and order the production of excess hormones).  The last type, TSI, is considered definitive for Graves'.  

"How should my doctor rule out one or the other? what is the ratio between these two antibodies to declare whether you have hashimoto's or graves? Is it even treated differently?"  My research has indicated that TPOab is typically more elevated in Hashi's than in Graves', however I have yet to find a definition of "high" or "low" elevation, probably because it varies widely.  If you have both, you would be treated according to your labs and symptoms.

So, your FT3 and FT4 are elevated, TSH is suppressed, TRab is elevated.  The question that jumps out at me is:  WHY aren't you having raging hyper symptoms with those labs???  (I read in one of your other threads that you don't feel well when you take the PTU, but feel good when you don't, correct?)

[Red_Star]

Thyroid stimulating immunoglobulin (TSI), also known as stimulating TSH receptor antibody (TSHRAb), stimulates the thyroid gland to enlarge and release excess amounts of thyroid hormone. Greater than normal levels may indicate Graves' Disease or Hashitoxicosis. One study found TPOAb levels elevated in 90% with Hashimoto thyroiditis and 64% with Graves' disease.

An article that goes more indepth on Hashitoxicosis is by Elaine Moore: "Hashitoxicosis Update: When Hypothyroid Patients Have Flares of Hyperthyroidism".

A few excerpts:

"Hashitoxicosis is an autoimmune thyroid condition that can occur for long periods, causing transient symptoms from time to time. Alternately, it can occur as a transitional phase as patients from autoimmune hyperthyroidism to autoimmune hypothyroidism or from autoimmune hypothyroidism to autoimmune hyperthyroidism.

Autoantibodies in Hashitoxicosis:

Thyroglobulin antibodies
Blocking TSH receptor antibodies
TPO antibodies
Stimulating TSH receptor antibodies (thyroid stimulating immunoglobulins or TSI)

Patients with Hashitoxicosis also have stimulating TSH receptor antibodies although their levels may not reach the high levels (1.3 or 130 percent activity) that cause hyperthyroidism in patients with Graves’ disease.

Diagnosis:

Changes consistent with Hashitoxicosis such as Hurthle cells and enlarged thyroid cells can be seen on thyroid biopsy. The I123 uptake is generally low or normal, and tests for thyroglobulin or blocking TSH receptor antibodies and stimulating TSH receptor antibodies are positive (higher than the normal range of less than 2 percent activity). Symptoms are also an important component in diagnosis"