Numerous nodules on thyroid

[brocktami]

My 14 year old daughter has had strep throat twice, the flu once and a terrible cough that hasn't gone away in the last month and half.  Two weeks her doctor noticed that her thyroid is enlarged and sent her for blood work.  Her TSH, T3 and T4 all came back within normal range.  So, her doctor ordered an ultrasound of her thyroid.  For some reason the radiologist emailed the report to me before my doctor has called me (he is out of the office this afternoon).  Here is what the radiologist's report says....

Right thyroid lobe 7 x 2.4 cm.  Left thyroid lobe 6.5 x 2.4 cm.
Bilateral solid nodules are present, the largest approximately 1.3 cm
in diameter.  

IMPRESSION:  Enlarged thyroid lobes with numerous bilateral solid
nodules, the largest 1.3 cm in diameter in the mid right lobe.

Can anyone tell me what that means?  I read that a normal thyroid lobe measures 4 to 6 cm in length and 1.3 to 1.8 cm in thickness. And, some specialists advocating biopsy of nodules greater than 1 cm in size, whereas others advocate biopsy of nodules greater than 1.5 cm  in size.  Is this report concerning?  I know everyone is trying to keep my calm and are telling me not to worry but the findings seems worrisome to me.

I'm a very concerned mother!

Thanks,
Tami

[brocktami]

Thank you for the reply goolarra.  The doctor did say that she has the antibody (I hope I'm using the correct term) for Hashimoto's thyroiditis, but that currently it is not affecting her levels.  It was not a surprise to me that she tested positive for Hashimoto's as I too have it and I've been told my children are higher risk because I have it.  

Here are her lab results:
ORDERED:   Comp Meta Panel, TSH, T3 Free, T4 Free
-------------------------------------------------
Comp Meta Panel
Glucose         89    Reference 70-109 mg/dL
Potassium 4.0   Reference 3.5-5.1 mmol/L
Sodium         143 Reference 136-145 mmol/L
Chloride       111 Reference 98-107 mmol/L
CO2             27    Reference 21-32 mmol/L
BUN             13    Reference 7-18 mg/dL
Creatinine     0.82  Reference 0.4-0.7 mg/dL
Calcium         8.9   Reference 8.5-10.1 mg/dL
Alkaline Phos   90    Reference 153-362 U/L
TBil           0.4   Reference 0.2-1.0 mg/dL
ALT             26    Reference 12-78 U/L
AST             16    Reference 3-45 U/L
Total Protein   7.3   Reference 6.4-8.2 g/dL
Albumin         4.1   Reference 3.4-5.0 g/dL
Anion Gap       5.0   Reference 5.0-15.0 mmol/L
Alb/Glob Ratio 1.3   Reference 1.3-2.5
Globulin       3.2   Reference 2.4-4.0 g/dL
TSH             1.670 Reference 0.463-3.980 uIU/mL
T3 Free         3.00  Reference 2.91-4.53 pg/mL
T4 Free         1.00  Reference 0.78-1.33 ng/dL
Her doctor also emailed me last night and this is what he said:
"
I saw the report - she has some thyroid cysts that none of which were scary or concerning. If you and I had thyroid ultrasound we too would have cysts and nodules.  Nothing on her scan made me concerned - we just know that at some point we will have to get thyroid medicines on board. I need to get a pediatric endocrinologist involved now to help us decide the time frame."

His office called this morning and sent a referral over to the pediatric endocrinologist.  There is only one in our area so telling how long it will be before we get seen.

I'm not stressing out like I was yesterday but I'm still very concern.  I'm not sure what questions to ask the endo.  Any advise would be greatly appreciated.

Thanks again for replying.

Tami

[goolarra]

The new format is a bit confusing at first.  Also, this site has never liked the less-than and greater-than symbols.  I find it best to spell out the words so you don't lose any of your text.

TPOab is positive, and yes, that's where the Hashi's diagnosis comes from.  Don't be scared of the huge number...that's very common.

The TSI test has a huge gray area.  While the reference range is less-than or equal to 1.3, the fact of the matter is that people who don't have Graves' disease have TSI of less than 0.02.  1.3 is simply the level at which most people will start experiencing hyper symptoms.  So, while her TSI is in range, it's not "normal".  One of my first questions would be whether or not she also has Graves'.  TSI dock at TSH receptors in the thyroid and stimulate it to produce hormone outside of pituitary control.  I know it sounds impossible to have both Hashi's (hypo) and Graves' (hyper) at the same time, but one is dominant at any given time.  

Both your daughter's FT3 (especially) and FT4 are way too low at the moment.  So, she's definitely not hyper.  Her symptoms confirm that.  I'm hoping her endos will put her on meds.  She would feel a lot better.

Please update me on how the appointment went.  Thanks.  

[brocktami]

@goolarra I'm not familiar with this message board setup and am having a hard time following.  Sorry.  Here are her TPOab and Thyroid Stim Ig.

TPO Ab - >900.0 Reference <9.0 IU/mL
Thyroid Stim Ig - <1.0 Reference <=1.3 INFCE Result Units: TSI index

The pediatric endo's office called this morning and we have an appointment with both of the endos next Tuesday 11.17.15.  Are there any particular questions I should ask?

Thanks again for your help.

[goolarra]

What was her TPOab?

Her TSI was 900, with a reference range of less-than 1.0, correct?

[Red_Star]

When my vitamin D levels dropped to 30 nmol/L (12 ng/mL in the US measurements) my immune system was very poor and I was sick on and off for months until I started vitamin D supplements. I had a really bad case of acute bronchitis where I coughed up blood for three weeks to a extremely painful bout of strep throat for a month followed a couple of weeks later by another bout of strep throat which lasted about two weeks.  Other symptoms I personally had of vitamin D deficiency included bone pain in my hands, calcium deficiency with positive chvostek sign,  some muscle weakness, and having to clear my throat of excess mucus. There are a long list of possible symptoms of vitamin D deficiency though.

***

Relative vitamin D insufficiency in Hashimoto's thyroiditis. Thyroid. 2011 Aug;21(8):891-6....

"The prevalence of vitamin D insufficiency in HT cases (148 of 161, 92%) was significantly higher than that observed in healthy controls (102 of 162, 63%, p < 0.0001). Among HT cases, the prevalence rate of vitamin D insufficiency showed a trend to be higher in patients with overt hypothyroidism (47 of 50, 94%) or subclinical hypothyroidism (44 of 45, 98%) than in those with euthyroidism (57 of 66, 86%), but the differences were not significant (p = 0.083)."

[goolarra]

TSH             1.670 Reference 0.463-3.980 uIU/mL
T3 Free         3.00  Reference 2.91-4.53 pg/mL
T4 Free         1.00  Reference 0.78-1.33 ng/dL

I copied these down here just to make them easier to discuss.

Thyroid lab reference ranges are very flawed.  Consequently, any FT4 or FT3 result in the bottom 50% of the range should be suspect for hypothyroidism.  Your daughter's FT4 is 40% of range, which isn't too bad, but her FT3 is only 5% of range, which is way too low.  FT3 is the test that correlates best with symptoms, so it's not surprising she has acquired an array of hypo symptoms.  Unfortunately, her TSH is good.  I say "unfortunately" because many doctors are fixated on TSH and won't treat until it goes out of range.  I think she would be best starting meds with her symptoms.  

You are using the correct term.  There are two antibodies that, when elevated, indicate Hashi's.  One is TPOab (thyroid peroxidase antibodies), and the other is TGab (thyroglobulin antibodies).  Only one has to be elevated to indicate Hashi's.  We can have antibodies for years, or even decades, before they do enough damage to cause symptoms.  They can also go like gangbusters.  Autoimmune diseases do run in families.  Nodules are even more common with Hashi's.  I read an article a while back by a doctor who said that if he pulled five healthy people out of a grocery line, three of them would have nodules.

Be sure to bring a list of symptoms with you to the endo appointment.  You don't want to forget anything, and you can leave him with your handout.  Of course, you should bring the results of this thyroid test and the antibody results as well.  

An enlarged thyroid is also a hypo symptom, and thyroid meds can reduce both the goiter and the size of the nodules.  Another reason to start meds...

I hope you don't have to wait too long for an appointment.  If they can't get you in soon, you might ask to be on a cancellation list so they call you if a slot opens up sooner.  You might mention the coughing until vomiting with difficulty breathing and that your PCP thinks it's related to thyroid enlargement...it might make them stand up and take notice.

If you have any more questions, I'll do my best...          

[brocktami]

I went back and looked at her lab report again, there was a second page that had her Thyroid Stim Ig and TPO Ab.

[brocktami]

Thyroid Stim Ig <1.0 Reference 900.0 Reference.  That is where the positive Hashi's came from I suppose.

[brocktami]

I'm sorry I forgot to answer your question about symptoms.  
• Fatigue - She sleeps all the time, a typical afternoon after school is her sleeping from the time she gets home until dinner time, waking up to eat dinner and then going to bed for the night about two hours later.  This has been a concern for me but everyone just tells me that teenagers sleep a lot.  I don't remember sleeping like that as a teen.  
• Increased sensitivity to cold - No
• Constipation - Not that she has mentioned
• Dry skin - No
• Unexplained weight gain – She is larger for her age.  5’9” and roughly 200 lbs, however, she has always been on the larger size
• Puffy face – Her face is round and always had been pudgy  
• Hoarseness – Just recently since she has been dealing with the strep, flu and coughing
• Muscle weakness – I’m not sure, she has never had great muscle tone
• Elevated blood cholesterol level – I don’t think he cholesterol levels have ever been checked
• Muscle aches, tenderness and stiffness – She has always had muscle pains.  When she was younger she was diagnosed with osgood-schlatter disease but hasn’t had any problems with that lately.  She is always complaining that her neck, shoulders and back hurt.  I chalked that pain up to her large breast size, she is currently a 38HH.
• Pain, stiffness or swelling in your joints – She does complain about pain and stiffness.  She is constantly popping whatever she can.  I have taken her to a chiropractor and she got little relief.
• Heavier than normal or irregular menstrual periods – She did have heavier than normal periods, I’m talking about bleeding through a super absorbent pad within an hour and half.  I took her to a gynecologist last January and they gave her the nexplanion implant.  The implant, combine with a month of hormone therapy and she no longer has a period.
• Thinning hair - She doesn’t have hair issues, in fact she has the most hair I've ever seen on a child.  
• Slowed heart rate – No doctor has ever mentioned her heart rate is slowed
• Depression – She is a very reserved child, who naturally is quiet but I have feared that she is depressed, although it has never be diagnosed.
• Impaired memory - She is in all honors classes and so far this year has straight A's.  She did ask me a few weeks ago if she could be tested for ADHD because she is having a hard time paying attention.  I did see concentration problems can be a symptom.

When her doctor called this morning I asked if they still think her cough is related.  We have tried over the counter and prescription cough medicines and currently she is on a steroid inhaler.  While it has gotten less frequent she is still coughing until she vomits and then air gets stuck in her throat.  She turns bright red and gets tears in her eyes.  She has to make herself burp so that she can breathe again.  As a mother it is quite scary to watch.  The nurse said that they do think the coughing and chronic sore throats are because of the thyroid being enlarged.

[goolarra]

The ultrasound confirmed what your doctor noticed, that your daughter's thyroid is enlarged.  She has what is called a multi-nodular goiter, an enlarged thyroid with nodules.  A goiter indicates the thyroid is under stress.  Nodules are very common, especially among those of us with Hashimoto's thyroiditis (autoimmune thyroid disease).  Although it seems counterintuitive, it's better to have multiple nodules than to have a single one.  Solid nodules are overgrowths of thyroid tissue, and they don't produce thyroid hormone.

Please post your daughter's TSH, FT3 and FT4 results with reference ranges.  Ranges vary lab to lab, so they have to come from her own lab report.  Results don't have to be outside normal range for us not to feel well.

Does your daughter have hypo or hyper symptoms?