Q: Thryoid

[Guest guest]

Hello great minds-I have a very strange case of thyroid labs that don't make any sense.  My patient has lupus and we are currently working with treating multiple infections and she's been doing better.  She has a history of being hypothyroid (since 19 yo) and been on thyroid hormone.    In 4/2011, she had a TSH of 0.08 and then 0.97 with a free T4 of 0.87 in 12/11 (another doctor was managing her thyroid at that time).  She had at various times stopped or reduced her thyroid and then restarted.  In December she had just restarted 125 mcg QD and said she was feeling strange in general.  She decided to stop it completely and I retested her in 4/12.  Her TSH was 249.7 (yes, 249) with a total T4 of 1.2 (alert level).  We restarted her thyroid immediately and she took 1 pill BID for 3-4 days, then dropped to 1.5 pills QD for 3-4 days and then stayed at 1 pill QD since (she made the drops herself).  I just retested her and as of yesterday, her TSH is now 0.219 and her total T4 is 10.5.  Over the last 2 months she's felt better overall, but with some specific symptoms being better and worse.  She was tired and a little dizzy in April, but nothing really remarkable, and that hasn't changed dramatically with the addition of the thyroid.

Her TPO antibodies were tested 2008 and were negative.  I am wondering what to do with this kind of dramatic change in only 2 months at a not excessive thyroid dose, ie., her total T4 is still within lab normal range.  I've decreased her dose for now but am curious about her type of response given her history and dosing- from a physiologic perspective, it doesn't make sense to me that at that thyroid dose, her TSH would change 1000x in two months with the type of T4 rise she shows.

Thanks- Hindman, ND, LAcPortland, OR