Graves Disease and lymph nodes

[sciano7]

Hello Dr,

Since 2001 I have been having on and off thyroid symptoms (losing hair, weight gain, transient difficulty in swallowing). The symptoms returned in 2007. I subsequently had an u/s and an RAIU. The u/s showed mildly enlarged thyroid, but it also said "right side of the neck shows a lymph node measuring 1.6 x 0.3 x 0.7 cm. The hilum of the node is not well defined. The left neck shows no lymph nodes." and "the gland appears mildly heterogeneous in echotexture. The mid left lobe laterally shows a small solid well-defined nodular area measuring 0.3 x 0.2 x 0.3 cm". Impression: Mildly enlarged and mildly heterogeneous thyroid gland with a single solid 3 mm nodule noted on the left as described. Changes could be due to inflammatory disease. This could represent an early multinodular goiter.I cannot find the copy of the RAIU, but the uptake was completely normal and the overall impression was that it was multinodular in appearance and may be an early form of thyroiditis although no nodules were actually seen-- "no well-defined hot or dominant cold nodules seen'. My TSH has been normal (1.5-2.65). My Endo put me on 25mcg to shrink the goiter and my TSH is actually higher now than it was when I was first put on it and the highest it's ever been (2.65). Since I have dry eye (dx 2003), I went on my own and got a TSI test done (TPO and TG were NEG). Sure enough, it came back positive at 153%. Endo confirmed it was Euthyroid Graves Disease. I made an appt with an opthamologist who said I have no evidence of any eye disease at this time. I should also mention I was dx with insulin resistance a month ago. My questions are :1. Isn't it unusual to have neg TPO and TG in Graves? 2. Should I be worried that the lymph node present did not have well defined hilum-- how like is this cancer? 3.Does euthyroid Graves pose a significant risk to future pregnancies? And anything else you would recommend this point going forward. Thank you!

[Mark Lupo, M.D.]

The TPO and Tg antibodies may be negative in Graves.

[Mark Lupo, M.D.]

Euthyroid Graves seems like the right diagnosis -- it is an immune system attack which explains the heterogeneity.  The lymph node may be a reactive response to this, usually reactive nodes have a preserved hilum - so if this increases, it may need biospy.  Graves does increase risks during pregnancy as TSI can cross the placenta - you would need to watch thyroid levels closely -- and reconsider taking synthroid as if the Graves become active then this would only add to the excess in thyroid hormone.