Thyroid Disorders Community
MULTINODAL THYROID AND HYPERTHYROIDISM
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This patient support community is for discussions relating to thyroid issues, goiter, Graves disease, Hashimoto's Thyroiditis, Human Growth Hormone (HGH), hyperthyroid, hypothyroid, metabolism, parathyroid, pituitary gland, thyroiditis, and thyroid Stimulating Hormone (TSH).

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MULTINODAL THYROID AND HYPERTHYROIDISM

hi ALL, AM BRAND NEW TO THIS FORUM AND TO THIS PROBLEM - 3 DAY NOVICE LOL.  I posted a question re this somewhere but I think was the wrong forum!!!  I had a cervical spine CT the other day for an unrelated problem (although it now seems that there maybe a relationship after all - chronic pain and inflammation in arm and shoulder).  The CT incidently showed two "well demarcated hypo dense areas 15mm and 5mm in left thyroid lobe"  My doctor did an ultrasound on radiologsts advice and findings were multiple nodules in both lobes with a goitre????  my doc said its called multinodal thryoid disease but at this stage not sure why etc......  an autoimmune problem was a word thrown about, as was Graves. so was cancer!  she did a blood which showed low TSH, .  And so has just done a T-4 test (foreign langauge to me) but no result yet for that one.  She said that as I have a family history of cancer, I need to have another scan, iodine uptake to see if hot or cold nodules.  
Now here is what I have understood but dont know if I really "get the idea right".  If they are hot, they are producing too much T-4 and as there is too much T-4, then a message is sent to pituitory to say not to send so much TSH to thyroid - hence that may explain why my TSH is low.  If these are hot and making too much T-4, then the treatment is either surgery to remove thyroid of radioactive iodine to destroy it? How am I going so far?????  there are a LOT of nodules,
If they are cold, it suggests potential malignancy and the treatment seems the same anyway, kill the poor old thyroid???  
If T-4 does come back high (and so is why TSH so low) then chances are the little fellas are going to be hot, right??? as cold ones dont make T-4 ...... thats where I am not sure if I do "get it" lol

Either way, from what I have read, there are issues for me with treatment options. The pills you can take each day to cool down the hot guys and supress the hormones, are contraindicated, apparently (correct me please!) if on blood thinners (I on warfarin).  However, and I havent read this but have been told in the past, that iodine and other radioactive contrasts (have never been allowed to have contrast) are  bad for people with CKD (chronic kidney disease which I have), so that leaves one option, surgical removal.  However (LOL LOL LOL) I am on warfarin which greatly thins the blood - the reason I was given the other day for the ortho surgeon being unable to operate on my poor shoulder!  Does that leave me screwed?????
Finally I promise, wow I have a lot of questions, but forgive me being a very very newbie here.  I have struggled with the following for ages now and was starting to feel like a total lost cause or nut case. Severe depression which just doesnt respond that well to anything, severe insomnia due to absolutely insane night itching - scratch to you bleed stuff, and a large assortment of joint, muscle and tendon inflammatory type disorders. Please tell me I am not just falling apart at the ripe old age of 51,and that there is some relationship between these and thyroid!!!!!   I have done a lot of "homework" in three days and have seen mention of some of those in relation to hyperthyroidism,  clear me up with these answers you will be my friends for life!!!!  Dr did say need urgent referral to endocrine specialist but urgent could mean  anything!!! A normal wait in Oz is about 4 months, she promised me would be nowhere near that, but the wait is awful either way!!!  
She also said "dont mean to scare you but......."  she succeeded !
20 Comments Post a Comment
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Avatar_f_tn
I'm not sure I can answer all your questions, but I can start.  If I forget to answer anything, feel free to give me a nudge down the road!

Thyroid 101:  The pituitary (master endocrine gland) checks blood levels of the two thyroid hormones, T3 and T4.  If levels are low, it puts out TSH to stimulate the thyroid to produce thyroid hormones.  If too high, it doesn't put out TSH.  T4 is produced by the thyroid and so is a little T3.  However, most T3 comes from the conversion of T4 to T3.  This is not technically a thyroid function, but a metabolic function.  It happens mostly in the liver and kidneys, but at lesser sites ubiquitous throughout the body.  T4 is the "storage" form of the thyroid hormones.  It floats around in your blood until your cells require it.  However, before they can use it, it must be converted to T3, the "active" form of the thyroid hormones.

Graves' disease is autoimmune hyperthyroidism.  With Graves', antibodies act like TSH and attach to the TSH receptors in the thyroid.  Thus, the thyroid is now under the control of the antibodies and no longer the pituitary.  

Nodules can be malignant, but a single nodule is more likely to be cancer than multiple nodules...so, in this case, a LOT is good (relatively speaking)!  Many of us have nodules.  In fact, the thyroid is basically a nodule-y organ.  I once read an article by a doctor who said hhe could pick five healthy people out of a grocery line and three would have some kind of nodule.  Unfortunately, "nodule" is a very generic term, and as you're learning, can mean any number of things.

Correct, cold nodules don't produce T4, hot ones do.  

I've never heard of a diagnosis of "screwed"!  I do have to say however, that you seem to be a bit between a rock and a hard place.  Your sense of humor is intact, though!  LOL

Let me assure you that every cell in your body needs correct levels of thyroid hormones.  If hormones are off, the list and range of symptoms is lengthy.  You are not a nut case.  I think we all felt like we were falling apart until we were treated.

So, have they scheduled an uptake scan?

I'll stop here for now.  As I said, feel free to give me a nudge if there's anything I missed.
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1756321_tn?1377771734
I live in Oz too and the waiting list for my endocrinologist is around two months. You can also ask to be on the last minute cancellation list for a possible earlier appointment.  There is a Patient Travel Subsidy Scheme to help with the cost of travel and accommodation if you need to travel to see an endocrinologist.

I had acute kidney failure and have thyroid issues both hyper and hypo symptoms. I had severe itching and anaemia as two of my many symptoms of kidney failure.  Hypothyroidism is another cause of anaemia.  To add, anaemia of chronic disease is a common condition associated with a wide variety of persistent inflammatory diseases.

Diabetes is the number one cause of CKD. But to add, hypothyroidism is commonly seen with CKD and in some case studies i've read thyroid hormone replacement fully reversed CKD. Hyperthyroidism increases eGFR and renal blood flow and as a result can mask renal insufficiency or CKD.

Hypothyroidism is one cause of treatment resistant depression but more recently i read that inflammatory biomarkers are associated with treatment resistant depression. Tumor necrosis factor (TNF - one of the inflammatory cytokines) is particularly mentioned but also C-reactive protein (CRP).

There is a black box warning for all gadolinium contrast agents (Omniscan, Magnevist, OptiMARK, ProHance, Multihance) stating that patients with kidney disease or renal failure are at risk of developing Nephrogenic Systemic Fibrosis (NSF).  A eGFR of less than 30 mL/min is considered to be at a high risk of NSF and gadolinium should be avoided.  

The listed contraindications (a drug, procedure, or surgery should not be used because it may be harmful) for Radioactive Iodine Uptake (RAIU) testing are hypersensitivity reaction to iodine, pregnancy, breastfeeding, and severe Grave ophthalmopathy.

The presence of kidney disease, severe diarrhea, vomiting, and various medications (thyroid drugs, cough medicines, multivitamins, some oral contraceptives, phenothiazines, corticosteroids) may affect RAIU test results.

Warfarin has a LONG list of potential drug interactions and includes both anti-thyroid drugs and levothyroxine.

Excepts "How to stop warfarin for surgery"...

"Low thromboembolic risk:

stop warfarin 5 days pre-op;
restart warfarin post-op as soon as oral fluids are tolerated.

High thromboembolic risk:

stop warfarin 4 days pre-op and start low molecular weight heparin (LMWH) at therapeutic dose;
stop the LMWH 12-18 pre-op;
restart LMWH 6 hours post-op (assuming haemostasis achieved);
restart warfarin when oral fluids are tolerated;
stop LMWH when INR = 2.0."
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649848_tn?1357751184
There's also a possibility that you could have Hashimoto's Thyroiditis.  While Hashimoto's is most commonly associated with hypothyroidism, it can be characterized by periods of hyper, as well.

Thyroid antibody tests, Thyroid Peroxidase Antibodies (TPOab) and Thyroglobulin Antibodies (TGab) will diagnose Hashimoto's; Thyroid Stimulating Immunoglobulin is the definitive test for Graves Disease.
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4822967_tn?1367660296
thanks so much for all that!  "screwed" is aussie jargon lol for in trouble or "hot water" so, yes betwen a rock and a hard place - good guess .Had the CT Thursday but my doctor only got the ultrasound and low tsh results late Friday, so I have to call Monday morning to book the iodine test.  She did call the lab on Friday though to ask them to do T-4 tests on the sample they already had. So will keep you posted, thanks again!
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4822967_tn?1367660296
wow that was comprehensive, we seem to have much the same of everything!  so the CKD I have produces many of the same symptoms if thyroid malfunction - in either direction. Funny I had heard before that this insane eg itching of a night was not unusual in CKD, but when I asked the neph she looked at me like I had just spoken another langage ???  It seems, if I get what you say, that there may even be a link between my CKD and thyroid malffunction?  God I hope its not two months. When the dr was going through all my results with me Friday, my assertive friend who came with me asked would I need a endo, and the dr said "yes, and I dont mean in a few weeks, I mean much sooner"  h,,,, having said that I live in a rural area (although large) and the doc has just relocated from Sydney. I live in Bathurst
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4822967_tn?1367660296
oh forgot re cessation of warfarin.  My dr is extremely reluctant as I am on lifleong.  It was ceased for 5 days about 6 weeks back so I could have a minor surgery , whilst ceased I was on clexane needles as a hopeful substitute. However, within a week of this, and before the warfarin got back up to therapeutic levels, I ended up in RPA in sydney for two weeks with a av fistula completed blocked with blood clots!  An av fistula is a surgically created vein access for dialysis. ie they attach a vein to a bg juicy artery via  agraft . The pressure of the artery makes the vein fat and juicy, which is needed for that reason.  The vascular guy at rpa who operated to clear tthe clots out of the AV fistula said that the warfarin cannot and never shoudl be stopped and that any bleeding risk was less of a threat than the potential threats of more blood clots, saying bleeding will just to be dealt with!  Hence a surgeon would treat me like the plague!   He said that clexane was not protective enough if you had CKD with a variable level of function???  I was put on heparin infusion instead for a week to get warfarin levels back up.  So thats the big issue, no iodine due to CKD and no surgery due to clotting issues AND the meds for thyroid (hyper) all seem to be contraindicated in CKd - as I said "screwed" lol
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4822967_tn?1367660296
sorry, yet another reply , you gave so much infor I pick up more each time I read, hence my many replies!   I just noted this part of your answer "Hyperthyroidism increases eGFR and renal blood flow and as a result can mask renal insufficiency or CKD" and a big "light" came on.  I was diagnosed with CKD a couple of years ago now. My eGFR fell FAST from 90 down to 42 in just over 12 months. And yet, I then had one out of the blue 7 weeks ago that said 88 !!!! I was stunned as was my gp.  I ended up not bothering to go to my next neph appointment as I felt there had been some magical cure. And yet, the one done last week was on the way back down, showing another sharp fall, but not as low as it has been????  I couldnt believe that an EGFR could fluctuate so wildy.  We are sure that the very low ones  were pretty spot on as it was supported by renal ultrasound that showed (bilateral cortical thinning and scarring mid pole, slightly worse on right" said consistent with CKD.  So now, according to what I have just learned, the thyroid could be confusing the higher EGFR results - well that burst my bubble lol. though I was convinced those higher promsing egfr somehow had to be flawed!   I dont like the idea of the iodine uptake study, given CKD, but I guess you have to weigh up the risks either side? of not having it done at all.  I know when I had a CT once that the radiologist, knowing my history, refused contrast, so this could be interesting.
ps I dont have diabetes so that wasnt a contributor to CKD, I had my bladder out ten years ago, a cancer complication, and so my kidneys are under constant urine infection attack - see told you I was "screwed" but yes, I have a crazy sense of humor and it really helps!  I am starting to think that a lot of my "issues" could have one underlying factor?  eg a domino effect perhaps?  ie who could be that unlucky in one lifetime for not at least  some of it to be related? fingers crossed get this thyroid sorted and some of the other issues may improve!
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4822967_tn?1367660296
its all so confusing, I tried to explain it to my daughter the other day and she was more lost than I was!  I am having, if the radioligist doesnt turn me away, an iodine uptake study done next week sometime, and a T-4 has been done but dont know the results. TSH was low, CT showed 2 nodules 15mm and 5mm left side but then the ultrasound showed many on both,with one that appeared "dominant". Havent hear of the other tests (bloods) you mentionned, well not yet!. Wow the other day I didnt even know what the heck the thyroid was lol, what a fast education this has been, and all due to a cervical scan done for a shoulder and arm injury !!!  thank god I buggered my shoulder hey?  I always told my children, things often happen for a reason!
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Avatar_f_tn
I did check the drug interactions between methimazole (Tapizole), carbimazole and PTU (the three major ATMs...anti-thyroid meds) and warfarin.  While interactions are listed, it appears ATMs enhance the blood thinning effect of warfarin.  The warning was that warfarin might have to be lowered once on ATMs.  Not the best situation, but given the alternatives...

Are your going to do the RAIU despite the iodine?
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1756321_tn?1377771734
Yes, i did write quite a lot. Lucky i can type fast. hehe.  

Thyroid hormone, either too much or not enough, can affect kidney function. My kidney isn't up to scratch and looks to be a combination severe insulin resistance and hypothyroidism. Taking 100mg of elemental magnesium a day for three months was too much for my kidney. Lucky i didn't realise i was only taking one third of the RDA but i still corrected my severe magnesium deficiency (retained magnesium during this time).

Sounds like you have what i had - uraemic pruritus. The term uraemia literally means urine in the blood!  Pruritus means itching.  I had extremely itchy skin on the top of both feet and lower back in particular. Another of my many symptoms of uraemia was Lindsay's nails (half white/half red nails).

"Uraemic pruritus is characterised by daily bouts of itching that tend to worsen at night and may prevent sleep. The itch may be generalised or localised to one area, most often the back, abdomen, head and /or arms."
- DermNet NZ - Uraemic Pruritus (Renal Itch).

A doctor on the Medhelp urology expert forum answered a question radioactive iodine and kidney failure...

http://www.medhelp.org/posts/Urology/Radioactive-iodine-and-kidney-Failure/show/1105672
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Avatar_f_tn
You might want to check out this link about magnesium:

http://www.afibbers.org/magnesium.htm

The labels are very tricky.  The labels of a 500 mg tablet of both Mg oxide and Mg glycinate will tell you that they deliver 100% RDA of elemental Mg.  However, if you check out the list at the beginning of the link, you will find that, in reality, from a 500 mg tablet of Mg oxide, you only absorb about 12 mg of ELEMENTAL Mg.  In fact, because of its laxative effect, Mg oxide can actually deplete you of Mg.  Mg glycinate delivers 100 mg per 500 mg tablet...better, but still nowhere near the 400 mg RDA of elemental Mg.  So, it's a really good thing you didn't know THAT...oh my!    
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1756321_tn?1377771734
Thanks for the article.  I was taking amino acid chelated magnesium 500mg (100mg of elemental). I had read in the past the amino acid chelates enhance mineral absorption which is why i choose that particular supplement. I didn't know the RDA was for elemental magnesium though.  Good thing in hindsight! :)
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Avatar_m_tn
Yes, thanks for that info.  Never had seen that before.  Got to increase my daily dosage of magnesium glycinate.
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4822967_tn?1367660296
Hi I want to the do test despite the iodine but the radiologist knows my hisotry of CKD. I had a ct a while back and an IVP for kidneys, but he refused the contrast. So its up to him. I hope so as I need to way up the pros and cons here and I think this is more important at this stage. Deal with the kidney fallout IF it happens
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4822967_tn?1367660296
thanks for that, I went on and read the post and it doesnt seem there should be a prob with the iodine and CKD.   I see the endocrine in two weeks, quicker than I thought. The doc called herself and made the apt so maybe pulled some strings lol.  I guess he will be my guide in it all. I am a bit upset of the last few kidney function tests though as my  egfr was 88 and then 72!!! (not in the 40s as has been for near 18 monts) ) and my normally very high creatinine had dropped to "normal" I thought there had been some miracle cure, my ddr just scratche dher head in disbelief, but it seems was just the hyperthyroid playing a nasty joke now!.  Thought was weird to have such significant kidney disease that was under a neph, and for it to all of a sudden seem to improve so much out of the blue!  Now I know, that its probably as stuffed as it always was lol. My renal ultrasound still showed bilateral cortical thinning and scars significant with CKD but then I get these magic  blood results after the poor ones
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4822967_tn?1367660296
If the T-4 is high, thats hyperthyroidism isnt it??? so its just a matter then of finding the cause?  Am guessing its all those nodules?
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Avatar_f_tn
Yes, too much T3 and/or T4 indicates hyper, except in some rather rare thyroid conditions.

You have a lot of things going on, so I'm not sure this applies to you, but overwhelmingly Graves' disease (autoimmune hyper) is the most prevalent cause of hyper.  The nodules are more likely the result of your thyroid overworking than they are the cause.  With Graves', antibodies called TSI (thyroid stimulating immonglobulins) are produced by your immune system.  These antibodies attach to TSH receptors in the thyroid and cause it to overproduce hormone.  The thyroid is no longer under the control of the pituitary, but is controlled by the antibodies.  A TSI test will probably be ordered...it's a simple blood test.

Hashimoto's thyroiditis is autoimmune hypO.  However, in the early stages, it can be characterized by a hyper phase or swings from hypo to hyper.  TPOab (thyroid peroxidase antibodies) and TGab (thyroglobulin antibodies) are the two markers for Hashi's.  Some of us are TPOab positive, some TGab positive and some both.  So, you have to test both.

Those are the two major causes of most thyroid disease.  So, testing for antibodies is a good first step.  If it's not one of those two, then we're off into more esoteric conditions, some of which are actually temporary.

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4822967_tn?1367660296
ok had the thyroid iodine test on Thursday, results showed that most nodules were hyper, the largest one said large dominant photopedic abnormality, so cold
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4822967_tn?1367660296
oh and its 20mm, seems big ?
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Avatar_f_tn
Have you been exposed to radiation?
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