Concluded Case

Alternating Hyperthyroidism and Hypothyroidism

42 yo male with no significant comorbidities presented with diffuse neck swelling 4 months ago. his neck swelling subsided over time. 3 months ago, his T4 was 12.8, TSH- 0.16(decreased) Towards Hyperthyroism Pt was kept under observation. No t/t except for NSAIDS was initiated. Pt was recalled with repeat titres. USG neck(march 2020)- diffuse enlargement of thyroid gland. Now his T3,T4 is normal, TSH is 10.26(elevated). Do we treat for Hypothyroidism as his TSH is high or Observe (as T3,T4 is normal).

(Edited)

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Concluded answer
Infact this pt is treated overtly In first step if pt was a c/o hypothyroidism than correct doses of L-thyroxine were not monitored and adjusted Hence pt landed in hyperthyrodism and again treated for hyperthyroidism so pt is in hypothyroidism Right now just start L-thyroxine 12.5 ug 1od and keep monitoring TFT monthly or 3 monthly acc stepup doses of L-thyroxine Also adv ft3 ft4 and anti TPO
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Thank you Dr Pavan for tagging me. I have few queries regarding this case. 1) Is the patient taking any drugs for Thyroid abnormality? 2) Is Thyroid swelling associated with fever or pain at the time of presentation? 3) Did you treat with any drugs for hyperthyroidism? 4) Is it simple goitre to disappear on its own with out any treatment or he is on drugs like Amiodarone, lithium, interferons, Tyrosine kinase inhibitors, Alemtuzumab , and iodine containing drugs, steroids or alcohol abuse or radiotherapy may cause Thyroid swelling and abnormal Thyroid function. 5) Rule out autoimmune Hashimotos thyroiditis . Clinical picture showing initial hyperthyroidism followed by Hypothyroidism favours Hashimotos thyroiditis. Order for anti Tpo antibodies to rule out autoimmune Hashimotos thyroiditis. 6) Did you repeat the USG scan of thyroid after the swelling subsides.? 7) Did you order any FNAC for conclusion of diagnosis.? 8) Are there any symptoms of Hypothyroidism in this case? 9) Rule out iatrogenic Hypothyroidism followed by taking carbimazole or methimazole for hyperthyroidism? 10) Rule out any pituitary tumors by ordering MRI brain Coming to the treatment, Identify the cause and treat it. Start with low dose of thyroxine 25 mcg on empty stomach and adjust the dose after 4 weeks by repeating TFT.
Thank you for your detailed answer ! 1,2,3 No 4 he is not on any medications 5. Ok 6. I have advised 7. Not done 8. Pt is only having fatigue 9. He is not on carbimazole/methi 10. I shall keep this in consideration.
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Infact this pt is treated overtly In first step if pt was a c/o hypothyroidism than correct doses of L-thyroxine were not monitored and adjusted Hence pt landed in hyperthyrodism and again treated for hyperthyroidism so pt is in hypothyroidism Right now just start L-thyroxine 12.5 ug 1od and keep monitoring TFT monthly or 3 monthly acc stepup doses of L-thyroxine Also adv ft3 ft4 and anti TPO
Sir, this pt was kept under observation. Pt was never treated for hyperthyroidism. He was called for repeat titres
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Thanx Dr.Pavanji for inviting to comment. Well, this generally hapoens due to excess or lover dose. dose . And Anti TPO must be assased for thyroid antibody to rule our Hashimoto thyroditis. You mentioned every details but nog a single word of what medicines given & at what dose.?
Thank you Sir for your valuable comment. No specific treatment was initiated and pt was kept under observation. Only NSAIDs were given and pt was advised for repeat titres
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U can start thyronorm 12.5 mg

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