13 y/O female with JRA and Family history of thyroid disease and thyroid cancer. Normal thyroid labs from birth to 2011.
In June 2012 her Dr noted swollen cervical glands and possible enlarged thyroid on exam. Sent for ultrasound of thyroid and thyroid function studies.
U/S showed mildly heterogeneous appearance of right lobe, And a singular cyst or nodule 5mm in the left lobe.
TSH 4.83 (.4-4.5)
FT4 1.75 (.6-1.5)
Thyroid antibodies labs were negative
thyroglobulin ab <20 (0-40)
thyroid Perox ab 7 (0-26).
(she has been taking methotrexate for 18 months for JRA/spondlyoarthropathy)
She had her yearly physical/well check 1 week ago. she had a very low heart rate in the doctors office (47 bpm) it was 3:30pm. Dr sent her for ECG and that was done Aug. 13th at noon, it showed "Marked sinus bradycardia and sinus arrhythmia"
Thyroid labs were repeated (same lab, same normal values as above):
So both have risen in 6 weeks.
She is having symptoms associated to hypothyroid over the last 6-8 months; increased h/a, fatigue, muscle aches and cramps, temperature issues ( she is either too cold or too hot and can't seem to get comfortable) Restless leg, chest pains, and a nagging cough (not productive, more like a dry cough) for three months. Her pedi actually put her on an inhaler last month because of the shortness of breath.
She is active, plays sports, runs and tries very hard not to let any of this get in her way. However lately when running after about a half mile she gets "starving for air" she explained that "its like she is really thirsty and needs to gulp water but instead of water she is thirsty for air".
DOES THIS LOOK LIKE HYPOTHYROID?
CAN THE BRADYCARDIA BE ASSOCIATED WITH THE THYROID ISSUES?
WHAT TYPE OF FOLLOW UP IS NEEDED HERE? she has appointment with pedi endocrine clinic in mid November (3 months away)
Please help, I'm feeling like 3 months is too long to let this go?
With a history of JRA and being on methotrexate, this is likely a Hashimoto's with negative antibodies because of the immunosuppressive therapy, this high-normal TSH may be indicative of subclinical hypothyroidism. It would be reasonable to try a low dose of levothyroxine to see if it helps the symptoms and the low heart rate. I would not think that most 13-year-olds with a TSH of 5 would have bradycardia due to the hypothyroidism however. Her free T4 is also normal. When you see the pediatric endocrinologist, please make sure they understand that the ultrasound changes of mild heterogeneity are typical of Hashimoto's and the negative antibodies may likely be due to the methotrexate. I think this is likely early Hashimoto's with subclinical hypothyroidism.
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