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I would like to ask your opinion regarding 10,5 years old Caucasian girl. She was referred to me after series of doctors.
Anamnesis and complaints. 6 mo ago she lost a lot of hair on the head, shortly after her parents told her about the family moving to another country. Very similar episodes had happened twice before - 6 and 4 years ago, each time related to moving to another country. The hair would grow gradually back within 4 to 6 months. Local application of steroids did not help to facilitate the re-growth of the hair.
Second major complaint is tiredness, which does not dramatically interfere with the daily life performances. Otherwise she is a happy girl, starting running into teenagers' problems (moody, sometimes quarrels with younger sister). Her school performance is good (according to her mom).
Denies constipation, rather mild diarrhea occasionally. Allergy test revealed allergy to wheat, corn, oat and sea fruits.
Family history. Two sisters from father's side were diagnosed with celiac disease and thyoid problems last year (in adulthood). Grandmother from mom's side had been taken Thyroxin 'her whole life'. Two younger sisters and parents are healthy. Objective findings. Girl's length lies within 50percentile, and her weight - within 75 percentile. Skin warm, not too dry. Bold areas on the head around 10 over 15 cm diameter, not in regular circle shape. Denies heat or cold inteolerance. No tremor, nystagm, eyes normal. Skin clear, no pigemntation or depigmentation, no signs of infection. RR 18/min, HR 60/min, BP 86/56 mm Hg. Thyroid gland I-II, firm, symmetrical. Tanner development score: B2 P3 A0.
Laboratory results. Please, find enclosed the sheet below. Tests done for celiac disease diagnosis where related to parents' concern and family history.
2005 11 04 she received Ba contrast for small bowel Xray series.
| 2005 08 22 | 2005 08 24 | 2005 08 29 | 2005 09 12 | 2005 11 17 | |
| TSH | 12.81uUI/ml
(0.25 – 5) |
11.100uIu/ml (0.400 – 4.000) | 9.84uUI/ml
(0.25 – 5) |
5.64 | |
| T3 | 229ng/dl
(70.00 – 170.00) |
230 | 176 | ||
| FT3 | 6.4 pmol/l
(2.30 – 6.29) |
7.8 | 23.60 | ||
| r-T3
(reverse T3) |
0.4 ng/ml
(0.35 – 0.95) |
||||
| T4 | 9.58 ug/ml
(4.5 – 12.50) |
8.4 ug/ml
(4.5 – 12.50) |
9.30 | 6.9 | |
| FT4 | 10.06 pmol/l
(9.0 – 20.0) |
9.38 | |||
| AST | 29 U/l
(8-39) |
25 | |||
| ALT | 18 U/l
(8 – 32) |
16 | |||
| ALP
(alkaline phosph.) |
271U/l
(36 – 126) |
272 | |||
| TBIL | 0.4 mg/dl
(0.3 – 1.2) |
0.4 | |||
| ALB | 4.6 g/dl
(3.8 – 5) |
4.5 | |||
| TP
(total protein) |
6.8 g/dl
(6.3 – 8.2) |
6.8 | |||
| GGT | 10 U/l
(8 – 78) |
12 | |||
| CBC | All normal | All normal | |||
| TMA
(thyroid microsomal AB) |
49.07
(<20%) |
||||
| TGA
(thyroid globulin AB) |
71.06
(<30%) |
||||
| TRAb
(Thyroid receptor AB) |
3.89 U/l
(0 – 5) |
||||
| Zn | 19.8mg/l
(0.47 – 1.47) |
||||
| Cu | 13.4mg/l
(0.56 – 1.56) |
2005 08 29 Thyroid US: R 39x13x12 mm L 35x10x12 mm.Both uneven, but no nodular mass observed.
2005 08 30 Pituitary MRI: Normal
Antigliadin and antiendomisial AB positive. Biopsy not performed.
Series of gastrointestinal X-rays with Ba contrast – no abnormal bowel movements.
My questions:how further could we and should we differentiate between autoimmune thyroiditis and resistance to thyroid hormones? (is T3 test necessary?) May it be a part of some polyglandular syndrome?( should she be tested for adrenal hormones?) Treatment? L-THyroxine?
With kind regards,
V.Kuehne, MD, PhD
Shanghai Worldlink Medical Center,
Response
I think the most likely diagnosis is subclinical hypothyroidism due to autoimmune thyroiditis. You ask about thyroid hormone resistance but the FT4 would be elevated in this condition (and the TSH value of 12.8 would be unusual in a newly diagnosedpatient). The normal MR pituitary virtually rules out secondary hyperthyroidism and in any case this would normally be accompanied by a high FT4.
Whyare the FT3 and T3 elevated? I would suspect assay interference. Indeed I would not have measured these in such a patient! I would check she is not taking diclofenac which causes this picture and I would get a free T3 index done as this rather old method gives reassurance usually that you are dealing with an artefact.
She also is very likely to have coeliac disease. I would undertake jejeunal biopsy to confirm the diagnosis and see what effect a gluten free diet has before doing anything else. It could be the non-specific effects of this condition are affecting the thyroid functions tests (note the rapid spontaneousfall in TSH levels), and the current TSH and FT4 values do not indicate that thyroxine is absolutely necessary, although of course there is dispute over this whole area of subclincial hypothyroidism.The alk. phos. is elevated andwhile Iguess thiscould normal in a growing girl ( but I am not a paediatrician), given her likely coeliac diseaseit may alternatively suggest osteomalacia and this should be excluded.
Her hair loss episodes might be autoimmune alopecia or previous fluctuations in thyroid function - given her coelaic disease I would also check her iron status.
Best wishes,
Tony Weetman, MD