# doc stumped



## stevemanse (May 31, 2011)

Here are my results.

(H) below stands for High
(L) below stands for Low
Normal range follows each result

Uptake and scan normal. Uptake is 22.6% (range 8-35)
Free T3 5.8 H (2.0-4.5)
Free T4 1.88 H (0.82-1.76)
TSH < 0.005 L (0.45-4.4)
TPO 240 H (0-35)
Thyroid Stim Immunoglob 204 H (0-140)

Any advice is greatly appreciated.

T3, T4 and TSH are essentially the same as above for the last 4 months.

patient is NOT taking thyroid hormone or anything else.

Thanks in advance!

P.S. 44 year old male. No symptoms at all, feel great. BP and pulse are normal, BMI is normal also, sound sleeper and no anxiety. Thanks!


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## Andros (Aug 26, 2009)

stevemanse said:


> Here are my results.
> 
> (H) below stands for High
> (L) below stands for Low
> ...


Hi there and welcome to the board.

There are things going on. You are hyperthyroid.

Your doctor should not be stumped at all.

TSI
Normally, there is no TSI in the blood. If TSI is found in the blood, this indicates that the thyroid stimulating immunoglobulin is the cause of the of a person's hyperthyroidism.

http://www.medicineonline.com/topics/t/2/Thyroid-Stimulating-Immunoglobulin/TSI.html

Men more likely to have cancer than women
http://www.umm.edu/endocrin/thytum.htm

Thyroid cancer, cold nodules, men, uptake etc.
http://www.aafp.org/afp/2003/0201/p559.html

Cancer and hyper are bedmates sometimes; we see a trend.

http://www.thyroidmanager.org/Chapter18/18-cancothr.htm

Here is info on TPO.

http://onlinelibrary.wiley.com/doi/10.1111/j.1699-0463.1994.tb04888.x/abstract

TPO
http://www.nlm.nih.gov/medlineplus/ency/article/003556.htm

So, I am sorry but this must be pursued. Cancer has to be ruled in or out. Definitely!

Very glad you feel well; that right there is a good thing. What took you to the doctor in the first place to have all this checked?

The thing is; what do they mean your uptake scan was normal? What where the radiologist's comments? Do you have a printout from the scan?

A person does not have TSI (you should have none) or high TPO for no reason. Wish your doc would have done a FREE T3. That is your active hormone and would have told a lot.

Something is definitely afoot.


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## stevemanse (May 31, 2011)

RAI-U radiologist's comments are thyroid is normal in all respects. No indication of Graves disease.

Free T3 value is provided in original post.

Doc is stumped because he has no reason for high T4 and T3 and low TSH.

Thanks.


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## Andros (Aug 26, 2009)

stevemanse said:


> RAI radiologist's comments are thyroid is normal in all respects. No indication of Graves disease.
> 
> Free T3 value is provided in original post.
> 
> ...


Thank you for telling me about the Free T3 in previous post.

Well......................the info I provided on TSI (thyroid stimulating immunoglobulin) with the link is factual. Therefore the TSI is responsible for your numbers.


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## stevemanse (May 31, 2011)

Andros said:


> Thank you for telling me about the Free T3 in previous post.
> 
> Well......................the info I provided on TSI (thyroid stimulating immunoglobulin) with the link is factual. Therefore the TSI is responsible for your numbers.


The doc is trying to get a diagnosis. A high TSI isn't a diagnosis, just a high lab result.

Thanks.


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## Andros (Aug 26, 2009)

stevemanse said:


> The doc is trying to get a diagnosis. A high TSI isn't a diagnosis, just a high lab result.
> 
> Thanks.


You are welcome.


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## HeidiBR (Apr 4, 2010)

stevemanse said:


> Doc is stumped because he has no reason for high T4 and T3 and low TSH.


Isn't a low TSH and high T4 and T3 the very definition of hyperthyroidism? You are hyper, hence the values?


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## stevemanse (May 31, 2011)

HeidiBR said:


> Isn't a low TSH and high T4 and T3 the very definition of hyperthyroidism? You are hyper, hence the values?


To the best of my understanding 'hyperthyroidism' is not a diagnosis or a disease state. Graves, Hashimotos, cancer, thyroiditis, these are disease states and a doctor seeks a diagnosis of a disease that falls into these (or other) categories.

At present there is no diagnosis. Apparently the high values for T3, T4 and TSI coupled with a normal RAI-U does not provide the doctor (this doctor at least) with a compelling argument for a particular diagnosis.

That's why I posted on here, thinking perhaps someone else had seen these kinds of inconclusive (with respect to a diagnosis) results yet had received a definitive diagnosis.

Thanks.


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## HeidiBR (Apr 4, 2010)

stevemanse said:


> To the best of my understanding 'hyperthyroidism' is not a diagnosis or a disease state. Graves, Hashimotos, cancer, thyroiditis, these are disease states and a doctor seeks a diagnosis of a disease that falls into these (or other) categories.
> 
> At present there is no diagnosis. Apparently the high values for T3, T4 and TSI coupled with a normal RAI-U does not provide the doctor (this doctor at least) with a compelling argument for a particular diagnosis.
> 
> ...


Graves Disease is the most common reason for hyperthyroidism, followed by nodules on the thyroid. Has the doctor ruled those out?

Are you seeing an endocrinologist?


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## lainey (Aug 26, 2010)

Hyperthyroidism and hypothyroidism are both disease states.

The causes of these--such as Graves' disease, Hashimotos disease, thyroiditis, toxic nodules--to name a few--are determined by a particular set of identifying characteristics for each.

These can also be sub-clinical--ie lacking presenting symptoms.

Technically, at this point, your numbers indicate sub-clinical (as you say you have no symptoms) hyperthyroidism. The normal uptake scan with hyper thyroid numbers may indicate thyroiditis (see: http://www.mayoclinic.com/health/hyperthyroidism/DS00344/DSECTION=tests-and-diagnosis). I am not a doctor, but thyroiditis is a diagnosis.

However, the high TSI values point to the problem as being autoimmune in origin. In this regard, the thyroiditis may not be transient, but may result in more clinical symptoms of Grave's disease in the future.

What are your plans for follow up?


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## stevemanse (May 31, 2011)

Thanks very much for both responses.



HeidiBR said:


> Graves Disease is the most common reason for hyperthyroidism, followed by nodules on the thyroid. Has the doctor ruled those out?
> 
> Are you seeing an endocrinologist?


He initially believed it was Graves disease based on the initial labs, and said that the uptake and scan would confirm this. However, it didn't.

I am not seeing an endocrinologist, however he said that he's close to referring me to one.



lainey said:


> Hyperthyroidism and hypothyroidism are both disease states.
> 
> The causes of these--such as Graves' disease, Hashimotos disease, thyroiditis, toxic nodules--to name a few--are determined by a particular set of identifying characteristics for each.
> 
> ...


Well I'm following his recommendation. At this point he wants me to have another uptake and scan without a 24 hour wait period. He indicates that he has seen many patients where the iodine isotope was taken up quicker than the 24 hour period and that if this is what is happening would explain the normal uptake after 24 hours.

So if the immediate uptake is also normal, then he's referring me to an endocrinologist. If not, then he'll consider the condition Graves. However it appears by watching his responses and listening carefully that the normal uptake after 24 hours actually has him quite stumped.

Keep in mind that the radiologist's report indicated that the thyroid itself is normal and that there is no sign of Graves. Also the physician's (not the radiologist, the doc himself) position is that ATDs are dangerous and the optimum treatment for Graves is ablation, so that should give you an idea of where he's coming from.

Don't know if any of this makes any sense, but this is the info I have presently.

Thanks in advance for your help and any advice you can offer. Obviously if the doctor is confused I am even more so.


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## lainey (Aug 26, 2010)

Keep in mind that most docs view managing the hypothyroid patient as "easy". From the patient's perspective, that is not always the case. Medication is life long, and some people struggle to reach a "euthyroid" state.

There are positives and negatives to all forms of treatment for Graves. Conservative treatment starts with ATD's, then weaning to see if the patient stays in remission. Some people do. Ablation of any type is permanent, and not without it's risks.

If you are not clinical, ie, symptomatic, what's in it for you to take treatment at all? Your numbers could be due to transient thyroiditis. This can take 6 months to a year to resolve on its own. You are watching and waiting now. Do you have a reason not to continue to do so?

If your doc doesn't know what he's doing, I would see the endo sooner rather than later, honestly.


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## stevemanse (May 31, 2011)

lainey said:


> Keep in mind that most docs view managing the hypothyroid patient as "easy". From the patient's perspective, that is not always the case. Medication is life long, and some people struggle to reach a "euthyroid" state.
> 
> There are positives and negatives to all forms of treatment for Graves. Conservative treatment starts with ATD's, then weaning to see if the patient stays in remission. Some people do. Ablation of any type is permanent, and not without it's risks.
> 
> ...


I completely agree and have no intention of allowing them to ablate my thyroid.

However, I would like to know what's going on. He can't diagnose this as thyroiditis because of the elevated antibodies. He can't diagnose this as Graves because of the normal uptake, so he's stuck. I don't think he's incompetent and it's not clear that any other doctor is going to be able to diagnose this either. The endo is in the cards, but since all we are doing is wasting time (i.e. from my perspective getting more time to have things calm down) I am happy to see him later rather than sooner.

What's in it for me (ablation) according to the doctor is that I don't have to worry about having a coronary because of a thyroid storm. As I think you are saying, right now the possibility of that is zero anyway.

Thanks for the sound advice.

One more question. When a doc tells you how wonderful your life will be after ablation, what's the response? According to this doc, we titrate something or another and get the perfect synthroid dose, life becomes full of rose petals and kittens, and all of that jazz, none of which passes any logical smell test. What's the response when he lays all of that on you?

Thanks.


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## lainey (Aug 26, 2010)

ppfft if he were that worried about thyroid storm he wouldn't mamby pamby about making a diagnosis, he'd put you on beta blockers and ATD's stat.

Not that you shouldn't acquaint yourself with the symptoms, so that you can self-monitor, btw.

>>One more question. When a doc tells you how wonderful your life will be after ablation, what's the response? According to this doc, we titrate something or another and get the perfect synthroid dose, life becomes full of rose petals and kittens, and all of that jazz, none of which passes any logical smell test. What's the response when he lays all of that on you?<<

I would ask him point blank if he was telling me that from his own personal experience as a patient. If not, then of course there is room for individual response, no?

Most of the textbooks do say that the patient returns to "normal". Whose normal that is usually isn't a subject of discussion, but patient studies repeatedly show lingering symptoms--most of which, however, are considered innocuous. No matter, they still affect people's quality of life, but that is not often the subject of journal studies.

Thyroid disease isn't static, your body changes, your dosage changes, you have side effects. All are manageable, but lets not make it out to be as if it's NOTHING.

Was your doc absent the day they taught empathy in medical school?


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