# High thyroid antibodies, high TSI, low TSH, etc.



## marilano

Starting a couple of months ago, I was having symptoms of hyperthyroidism (after years of feeling like I had hypothyroidism, which was untreated). My TSH was .06 about 6 weeks ago, and the most recent result is .29 (Kaiser gives the reference range as between .1 and 5, which differs from most of what I've seen). I've had elevated TPO Ab for a while, and the latest is 494 (normal under 30). And I had asked my dr. to have the lab check for TSI (since it seemed like I was hyperthyroid), and the result is 140 (which seems to be elevated; Kaiser's website didn't list a reference range). Before these recent tests, my TSH had been between about 2 and 3 for the last few years. Hashimoto's thyroiditis runs in my family (as do other thyroid problems). I'm in my late 50's and female. I'm not on any thyroid medication, and I'm wondering if I have Hashimoto's with fluctuating hyperthyroidism, or something like Hashitoxicosis. I haven't had a nuclear scan yet but my dr. may or may not order one. If the dr. treated me for hyperthyroidism but I'm really hypothyroid with periods of being hyper, that would probably create new problems. Any ideas or suggestions for how to proceed at this point? I think Kaiser's policy will be "wait and see" unless I ask for further followup.


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## Andros

marilano said:


> Starting a couple of months ago, I was having symptoms of hyperthyroidism (after years of feeling like I had hypothyroidism, which was untreated). My TSH was .06 about 6 weeks ago, and the most recent result is .29 (Kaiser gives the reference range as between .1 and 5, which differs from most of what I've seen). I've had elevated TPO Ab for a while, and the latest is 494 (normal under 30). And I had asked my dr. to have the lab check for TSI (since it seemed like I was hyperthyroid), and the result is 140 (which seems to be elevated; Kaiser's website didn't list a reference range). Before these recent tests, my TSH had been between about 2 and 3 for the last few years. Hashimoto's thyroiditis runs in my family (as do other thyroid problems). I'm in my late 50's and female. I'm not on any thyroid medication, and I'm wondering if I have Hashimoto's with fluctuating hyperthyroidism, or something like Hashitoxicosis. I haven't had a nuclear scan yet but my dr. may or may not order one. If the dr. treated me for hyperthyroidism but I'm really hypothyroid with periods of being hyper, that would probably create new problems. Any ideas or suggestions for how to proceed at this point? I think Kaiser's policy will be "wait and see" unless I ask for further followup.


Welcome to the Board, Marilano! I believe that a nuclear scan is important as cancer must be ruled out. Cancer often presents as hyper.

The patient should have no TSI (thyroid stimulating immunoglobulin); if the patient does, that is the antibody responsible for hyperthyroid.

Here is a credible reference for that....

While the normal range is <130% activity, individuals who are normal do not produce TSI and have levels <2% activity.

http://graves.medshelf.org/Lab_Tests

You may have Hashitoxicosis, it would not be a surprise. Our Moderator has that and I am sure she will be along soon.


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## Lovlkn

Hi Marialano,

I was dx'd with hashitoxicoses when my thyroid was removed 5 years after a graves DX. My TPO's went from 476 at my Graves DX to over 2000 when I finally decided to have surgery. The hashitoxicosis was thought to be the cause of why I never could stabilize on anti thyroid medications as I mainly presented hyper symptoms.

I am including a definition of what exactly Hashitoxicosis is although I have heard other explanations I think this is fairly easy to grasp. As I understand the medical community they will only treat the symptoms you present with but eventually your thyroid will burn itself out and you will become hypo.

http://graves.medshelf.org/Hashitoxicosis

Hashitoxicosis is an autoimmune thyroid disorder, in which individuals with autoimmune hypothyrodism, usually Hashimoto's thyroiditis (HT), experience intermittent or sporadic periods where they also have symptoms of hyperthyrodism. In some ways, these patients can be described as having both HT and Graves' disease since the antibodies associated with both diseases are present. 
The disease process in Hashitoxicosis focuses around the thyroid cell destruction seen in autoimmune hypothyroidism. Here, thyroid peroxidase and thyroglobulin antibodies cause thyroid cell inflammation and destruction. As thyroid cells die, their stored supplies of thyroid hormone are suddenly released into the blood circulation. These sudden bursts of thyroid hormone are responsible for the symptoms of hyperthyroidism. Often patients think that they need to have their medications adjusted and they suspect that their thyroid medication is too high. On other days, when they're dragging, depressed and experiencing weight gain, they suspect that their thyroid hormone replacement dose is too low. 
Blocking TSH receptor antibodies in Hashitoxicosis can prevent the thyroid cell from absorbing thyroid hormone, worsening hypothyroidism. And stimulating TSH receptor antibodies can cause periods where excess thyroid hormone is produced. Depending on which antibodies predominate on a given day, symptoms can vary. 
Furthermore, these sudden bursts of thyroid hormone affect laboratory results. If a patient experiences many recurring bursts of thyroid hormone, their blood thyroid hormone levels will be elevated. If this happens over a period of weeks, their TSH levels will drop. Depending on when they have their laboratory tests run, it can appear as if they're now hyperthyroid. If their medication is cut, they may soon be complaining of symptoms of hypothyroidism. 
Patients with GD who have achieved remission after being on antithyroid drugs may also experience Hashitoxicosis. So can ablated patients who still have some remaining functional thyroid tissue. These patients worry that active Graves' disease has returned and ask to be put back on ATD's. Others who have had RAI end up having a second or third dose of RAI. A wait and see approach can prevent this from happening. 
For patients who have symptoms of both hypothyroidism and hyperthyroidism but have never been diagnosed, diagnosis can be elusive. Often the periods of hypothyroidism and hyperthyroidism will balance each other out, causing normal thyroid hormone levels. Without a careful evaluation of symptoms, it will appear as if these patients are euthyroid. One clue is in the patient who shows signs of Graves' ophthalmopathy or thyroid eye disease. 
*If they have the proper antibody tests run, and are diagnosed with Hashitoxicosis, then they can be properly monitored and learn how to adjust their own thyroid meds depending on symptoms. *A definitive diagnosis can be made by biopsy, that is, fine needle aspiration. A lymphocytic (white blood cell) infiltration of the thyroid will be seen, and there will be certain cellular changes, particularly the presence of Hurthle cells. A probably diagnosis can also be made by thyroid antibody tests. In Hashitoxicosis, thyroid peroxidase, thyroglobulin, thyroid binding inhibiting immunoglobulins (TBII) and thyroid stimulating immunoglobulins (TSI or stimulating TSH receptor antibodies) will all be present. 
Anyone who is genetically predisposed to autoimmune thyroid disease can develop Hashitoxicosis. It's not uncommon in one's lifetime to have HT, GD, primary myxedema and Hashitoxicosis at different times. According to some researchers, Hashitoxicosis is most likely to be encountered in the early stages of autoimmune hypothyroidism. Patients with GD who have achieved remission may actually be experiencing the early stages of spontaneous hypothyroidism when symptoms of Hashitoxicosis emerge.

I hope this helps.


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## marilano

Thanks very much for the replies and information, especially about Hashitoxicosis. I'd been thinking I had either that or subclinical hyperthyroidism. My main concern now is what to do. My primary care doctor at Kaiser just wants to have my blood tests repeated in 6 months and do nothing now. The endocrinologist only had tested TSH and free T4, and I'd had to ask my regular dr. to test the TPO Ab and TSI. Kaiser doctors have never tested my free T3. I don't think my dr. plans to refer me for a nuclear uptake scan, and just figures I'm slowly developing Hashimoto's. But I feel lousy and still have some symptoms of hyperthyroidism, although I also have some of hypothyroidism. I'm not on any medication for thyroid. So what should I ask for from my dr. and/or from the endocrinologist? Or is it okay to just "wait and see" for 6 months? marilano


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## Andros

marilano said:


> Thanks very much for the replies and information, especially about Hashitoxicosis. I'd been thinking I had either that or subclinical hyperthyroidism. My main concern now is what to do. My primary care doctor at Kaiser just wants to have my blood tests repeated in 6 months and do nothing now. The endocrinologist only had tested TSH and free T4, and I'd had to ask my regular dr. to test the TPO Ab and TSI. Kaiser doctors have never tested my free T3. I don't think my dr. plans to refer me for a nuclear uptake scan, and just figures I'm slowly developing Hashimoto's. But I feel lousy and still have some symptoms of hyperthyroidism, although I also have some of hypothyroidism. I'm not on any medication for thyroid. So what should I ask for from my dr. and/or from the endocrinologist? Or is it okay to just "wait and see" for 6 months? marilano


I believe you should be on some sort of medication. Lovlkn will know and I will PM her that you posted.

Meanwhile..........
http://graves.medshelf.org/Hashitoxicosis


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## Lovlkn

marilano said:


> Thanks very much for the replies and information, especially about Hashitoxicosis. I'd been thinking I had either that or subclinical hyperthyroidism. My main concern now is what to do. My primary care doctor at Kaiser just wants to have my blood tests repeated in 6 months and do nothing now. The endocrinologist only had tested TSH and free T4, and I'd had to ask my regular dr. to test the TPO Ab and TSI. Kaiser doctors have never tested my free T3. I don't think my dr. plans to refer me for a nuclear uptake scan, and just figures I'm slowly developing Hashimoto's. But I feel lousy and still have some symptoms of hyperthyroidism, although I also have some of hypothyroidism. I'm not on any medication for thyroid. So what should I ask for from my dr. and/or from the endocrinologist? Or is it okay to just "wait and see" for 6 months? marilano


You say you feel lousy so you have to decide if you want to pursue medication to treat your symptoms which will most likely swing from hyper to hypo as they have in the past. Your current doctors sound like they are not willing to do anything to help you * I've been there done that and kept changing doctors until I finally found one to treat me. My situation differs from yours in that I only ever presented with hyper symptoms * you are swinging back and forth from hyper to hypo. You have all the antibodies for both diseases and you should be able to get a referral to an endo for medication. Then the decision for you is how long do you want to wait for your thyroid to burn itself out, which it will eventually do.

From my earlier comments to you..."If they have the proper antibody tests run, and are diagnosed with Hashitoxicosis, then they can be properly monitored and learn how to adjust their own thyroid meds depending on symptoms." A doctor would most likely want you to come in and be lab tested every time you have a change of symptoms and then they would adjust your medications. This would be the first thing to try and if you are doing well on the meds they poblem solved * if you are constantly having to change up medication then you may want to consider a thyroidectomy, however if your doctors won't treat you properly now I doubt highly they will treat you properly with replacement med's.

I dealt with the hyper symptoms for 7 years undiagnosed * 5 years on anti thyroid med's and finally had enough and had my thyroid removed. If I knew then what I know now I would have had my thyroid removed after 2 years on anti thyroid meds.


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