Could this be Graves disease?

[IrisT]

Dear Doctor Mark:

Based on the info below, my main questions are:
1. In your opinion, could this be Graves disease? What points toward/against a Graves diagnosis?
2. Do most Endos consider the TSI test definitive for Graves even if levels are less than 125%? What is your opinion on that?
3. I've read some medical literature that dopaminergic agents can affect thyroid hormone tests. Is it possible that the medications I've taken longterm (Wellbutrin and Adderall, both of which affect dopamine) might be skewing my lab numbers?

***PATIENT INFO***
Female, 41
History of depression (10+ years); Dx w/Adult ADD (~5 years); carpal tunnel (surgery, both hands); periodontal disease/infection.
Daily Rx meds: Wellbutrin-XL 30 mg; Adderall-XR 20 mg.
Family history heavy in thyroid disease and autoimmune disease, including hypothyroid, Graves, Lupus, CFS, MS, Rhuematoid Arthritis.

Patient symptoms: goiter (painless), fatigue, low energy, low libido, dry skin, mild hair changes, pretibial rash (past 2 years), recent menstrual changes (lighter flow), irritability, insomnia (trouble falling asleep), recent itchy hives-type rash on torso (past 6 weeks).

GOITER INFO
Complex cold nodule on left lobe, 1.9 x 2.8 cm.
FNA: "benign colloid adenomatoid nodule"
RAI-U (range 15-30%): 6-hr 8.9% (below normal); 24-hr 19.6% (within limits but low-normal)

All thyroid hormone tests are Euthyroid. Please see below for Lab Test results; note Iron deficiency.

Sorry post is so long. Thank you for your opinion!




  

[IrisT]

Continued from above...

MOST RECENT LABS--MARCH 2007:
TSH 0.95  (.4-5.5)
fT4 1.3  (.8-1.8)
fT3 275 (230-420)
T-3Uptake  31%  (22-35%)

TPO-Ab <10  (<35)
Tg-Ab  <20  (<20)
TSI-Ab  107% (<125%)

Additional tests for Calcium, Vit B-12, and Magnesium were normal/unremarkable; Iron Total was low-normal; Ferritin was LOW:
Iron Total 47 (35-175)
Ferritin   8 LOW  (10-232)


PREVIOUS LABS--FEB 2007:
TSH 0.84  (.3-5.6)
FT4  0.9   (.6-1.1)
T3, Total 107 (60-181)
T4, Total 9.5  (4.5-12.5)
Reverse T3 0.31  (0.11-0.32)

Other:
Estradiol 155 (</= 480)
Testosterone 29 (20-76)
Progesterone 8.5 (3-28)
Cortisol 8.4 (3-17)
DHEA  145 (130-980)
Iodine 62 (40-92)


PREVIOUS LABS--FEB 2005
TSH 0.64   (.49-4.67)
FT4  1.2   (.7-1.9)

Estradiol 82
LH 3.93

[IrisT]

Darn it, I thought this was the Doctors forum :-(

Oh well. Anyone else care to comment?

[GravesLady]

You are not on thyroid medication with the March 07' Labs?

My comments will be referring to these Labs due to being the most recent.

No Graves'.  It looks like early Hashi Thyroiditis. If this is the case you probably will go full blown Hashi in the near future.  Have levels checked on a regular bases.

TSI lower than 125 % is normal.  In Graves' TSI would be quite high, with low undetectable TSH, FT-4 high and FT-3 even higher. Later after treatment the FTs will switch positions.

Antibodies must coincide with thyroid blood levels because just the presence of these antibodies is not enough for a diagnosis since certain percent of women in the population have these antibodies in the absence of thyroid disease .  As well as, other autoimmune disorders such as Sj

[IrisT]

Thank you for replying. No, I'm never been on thyroid medication of any kind.

My enlarged nodule was noticed in Feb 2007 by my family doctor. Since then I've had ultrasound, RAI uptake scans, and saw an ENT for FNA. Also saw an osteopathic doc who ran lots of lab tests my family doc wasn't willing to run. Tomorrow I see an Endo who I hope can make sense of it all.

If it is Hashi's, wouldn't that have shown up on the FNA pathology report? I thought that was the most definitive way to determine Hashi's?

Also, if it is Hashi's, why do I have the TSI antibodies? I've been told on other thyroid forums that the TSI test is absolutely definitive for Graves even if under 125%. I've read the same in medical literature--explaining that normal people do not have any TSI antiboides, and that the lab reference number of 125% is the level at which most people experience hyperT symptoms.

I just found out last week I have Iron deficiency (one step away from anemia), which may account for some symptoms I attributed to HypoT.

The Graves idea didn't make sense to me at first, but now it's starting to. For one thing, I notice menstrual changes in the past few months--cycle is still regular but flow is considerably lighter. Also experiencing irritability, higher than normal body temps during the day, increasing skin sensitivity/itchy rashes (plus had the pretibial rash for past two years), insomnia, and noticing some eye issues (sensitivity to light, dry, irritated, bloodshot).

Thanks again. I appreciate your opinion.

Iris

[GravesLady]

Mark Lupo, M.D.. Dr. Lupo
http://www.medhelp.org/forums/thyroid/wwwboard.html