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Old 01-14-2013, 03:22 PM   #1
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Advice on: Normal TSH elevated T4 and elevated T3

My 11 year old daughter has had some abnormal thyroid blood test over the past 1 1/2 years. Orignal tests started in summer of 2011 when I took her to our family Dr. for excessive sweaty palms and feet along with extra hair on her arms. The results came back with an elevated total and free T4 but normal T3 and TSH. They repeated the test to rule out lab error. Results came back the same and she was referred to a pediatric endo 7 hours away.

The peds endo re-ran the blood tests (I don't have the ranges):
TSH: 3.53 (normal),
Free T4 0.51 (Low I believe this was tested via dialysis)
Total T3: 166 (normal),
Total T4: 15 (modestly elevated),
thyroglobulin antibody was negative
thyroglobulin normal 22.8

No additional follow up was recommended at that time from the pediatric endo.

In the last 6 months she has delvelop IBS, and had a new vision screening showing that she has decreased vision in her right eye to the point they are calling it a lazy eye. Because of these new symptoms I took her back into our local Dr. Who ran the thyroid panel again with the following results:
Elevated FT4 1.89 (.58 - 1.64 ng/dl)
Normal FT3 4.02 (2.50 - 3.90 pg/mL)
Normal TSH 2.03; (.34 - 5.60 mIu/mL)
Thyroid binding globulin was normal at 21 (13-30)

Because of her levels showing the FT4 still elevated, a followup appoint at the pediactric Endo (7 hours away) was made. At this appointment the Dr. told us that these thyroid levels might just be the way her body is and that we should just stop testing her thyroid. He did recommend that we should maybe test for Thyroid Hormone Resistance, "To put this to rest". If this test comes back negative he recommends no further testing.

Her list of symptoms: Sweaty hands and feet, ticker arm hair, Irritable, sensitive (cries about EVERYTHING), very low pain tolerance, Changes in vision "Lazy Eye" - This eye is also slightly larger than the other, IBS, Frequent Bowel movements (3x/day), headaches.

I had someone else recommend that we test for TPO end even the Graves only TSI antibody.

I'm wondering if there are any other tests that I should be asking to have done. Or if there are any other type of Dr.'s we should be looking at seeing. The team of pediactric endocologists are 7 hours away and did tell us they have never had a case of THR and would need to consult with a Dr. in Chicago, if that test comes back positive. I'm just VERY frusterated at this point, and any advice is welcomed.

:-)

Last edited by NDMomOf3; 01-14-2013 at 03:25 PM.

 
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Old 01-16-2013, 10:13 AM   #2
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Re: Advice on: Normal TSH elevated T4 and elevated T3

I think something's going on with her. It's not typical, though.

I second the motion to have all four antibodies checked - TPO, Tg, TSI, and TRab. She may have concurrent hypo/hyper processes going on, both Hashimoto's and Graves' diseases. It'll take a thyroid super-sleuth to discover the problem, so don't give up till you have answers!

Wishing you luck.
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Old 01-16-2013, 01:57 PM   #3
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Re: Advice on: Normal TSH elevated T4 and elevated T3

Thank you midwest!

It's been a frustrating road. Not having an pediatric Endo near by complicates it. Our Dr. thinks something is up, consults with the Ped Endo, they then send us over there (7 hours away). The 2 times we have been out there, they (peds endo) act like our local Dr. is over reacting and there is no reason for us to be over there :-(

So now I'm trying to gather as much info as I can on my own, and trying to figure out which way to turn. I think I have read that you have THR? Were your labs simiular to this? Peds Endo seemed pretty sure that this test would come back negative, since she isn't a hyperactive child.

Last edited by NDMomOf3; 01-16-2013 at 01:59 PM.

 
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Old 01-16-2013, 05:23 PM   #4
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Re: Advice on: Normal TSH elevated T4 and elevated T3

Quote:
Peds Endo seemed pretty sure that this test would come back negative, since she isn't a hyperactive child.
Which test do you mean? No thyroid symptom is always associated with any particular thyroid disease. If this guy is assuming any kind of test can be skipped based on a symptom or non-symptom, he's not the guy you want treating you.

I'm sure you're frustrated. I'd certainly be, too. Endos are the pits at treating thyroid disease in adults. I wouldn't expect a ped endo to be any better, really. And there are so few of them, the odds of getting a good one are pretty slim.

No, it's not me who has THR. (You mean Thyroid Hormone Resistance, right?) Has someone mentioned the possibility of that to you?

The odd thing about those labs is how varied they are.
The first set with high FT4 normally would suggest hyperT. But if her TSH wasn't low, that would be much less likely.
The second set has low FT4, which is hypothyroid - no contest. (Slightly elevated total T4 is moot. Total T4 is heavily influenced by estrogen, so women and girls close to puberty shouldn't even be wasting a blood sample on this worthless test.) Her high-normal TSH confirms that she was hypothyroid when that set of labs was done.

Then... To flip-flop again on the third set, with high FT4 (and FT3 too, if your numbers are typed accurately), would be hyperT on the face of it. But that "normal" TSH doesn't confirm that.

This kind of fluctuation is seen with cases of Hashitoxicosis, I think. (Am no expert on the condition, but our member lisa789 is. She has it.) That's why you need the antibody tests to check for autoimmune conditions that can cause wild swings like these.

Also, there's a possibility of pituitary dysfunction, since her TSH doesn't seem to reflect what the free Ts are doing, as it should be.

I wish I knew more than that. I hope it helped, at least a little.
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Old 01-16-2013, 09:46 PM   #5
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Re: Advice on: Normal TSH elevated T4 and elevated T3

Thanks again for the help. Yes I was referring to Thyroid Hormone Resitance, and this is the test he was thinking would come back negative because she wasn't a hyperactive kid. Last trip out to the ped endo (dec 2012)
He sent us home with information on running this test.

Her labs from our local Dr. have always came back simular to the last labs posted - elevated FT4, and High range FT3 with normal range TSH. The lab with the low T4 was from our 1st trip to the Ped Endo. He told us that he was going to run the test different than our local lab and because of this was expecting the results to come back normal. I think that he ran them with "direct equilibrium dialysis". I just found out that these labs came back with the Low T4 3 weeks ago. One of those if you don't hear from us the test was normal things! Learned my lesson there ALWAYS call them and get the results! Wonder if the dialysis had anything to do with those numbers being SO different.

Do you know if a Low Albumin level can have any affect on the FT4? My other daughter years ago had a blood test run for recurring croup. The Dr. was looking for an allergy trigger and found that she had a low albumin level. They re-tested it about 1x year for 3 years. With the same results. Nothing was ever discovered to be the cause. Although they didn't really even look for a cause and just kind of let it go.

:-)

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Old 03-20-2013, 03:49 PM   #6
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Re: Advice on: Normal TSH elevated T4 and elevated T3

Being that the FT4 did not come back high on equilibrium dialysis and the thyroid binding globulin is in the normal range, it is unlikely that this is resistance to thyroid hormone. Looks more like some type of assay interference (antibodies maybe) skewing the numbers. Heterophile antibodies are a possibility. If anything, with the TSH being above 3 and the FT4 by equillibrium dialysis being low, it appears that she might be hypo (gotta love puberty). She might be euthyroid too. Might look into familial dysalbuminaemic hyperthyroxinaemia too seeing as you mentioned there's an issue with your other daughter's albumin numbers.

Helen

Last edited by Administrator; 03-21-2013 at 03:10 AM.

 
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Old 03-20-2013, 07:37 PM   #7
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Re: Advice on: Normal TSH elevated T4 and elevated T3

Thanks Helen,

Funny I just finally got a copy of the actual lab results from that Aug 2011 visit. The Dr. had told us that he was going to run the FT4 via equilibrium dialysis, but according to the lab report it wasn't. So I'm not sure what was up with that Low FT4 in Aug 2011. She did have Antibodies checked in June of 2011 and did have TSI present but not positive:

TSI was 83 (<123)
TPO was .4 (<9)
TgAb was <20 (<20)

My other daughter has the low Albumin level - she has never had thyroid levels check so I don't know if there is a simular pattern.

We have another appointment tomorrow with our local Dr. I'm pretty sure they are going to recommend that we just call her thyroid function normal, and be done. I'm going to ask for my piece of mind that we at least do an ultrasound of thyroid and run the complete panel with the antibodies, one last time.

Do you know if they test for the Heterophile antibodies automatically when running these test via assay? Or should I request that they run that as well?

Again thanks for taking the time to post a reply.

:-)

 
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Old 03-20-2013, 09:19 PM   #8
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Re: Advice on: Normal TSH elevated T4 and elevated T3

Sorry I should have added that since posting this in Jan. I have gathered copies of past lab reports, so I now have a better lab history.

June 2011:
TSH: 5.59 (.34 - 5.6)
FT4: 2.17 (.58 - 1.64) H
TSI: 83 ( < 123)
TPO AB: .4 (0 - 9)
TgAb: <20 ( < 20)

July 2011:
TSH: 2.7 (.3 - 5.0)
TT4: 15.4 ( 5 - 12.5) H
FT4: 1.7 (.8 - 1.8)
T3: 172 ( 88 -190)
FT3: 4.4 (2 - 3.5) H

Aug 2011:
TSH: 3.53 (.4 - 5.0)
TT4: 15 (5 - 11) H
FT4: .51 (.70 - 1.85) L * I thought this was done by direct dialysis but turns out it was - Competitive immunoassay.
TT3: 160 (83 - 213)

Nov 2012:
TSH: 2.03 (.34 - 5.60)
FT4: 1.89 (.58 - 1.64) H
FT3: 4.02 (2.5 - 3.90) H
TBG: 21 ( 13 - 30)

Last edited by NDMomOf3; 03-20-2013 at 09:27 PM.

 
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Old 05-20-2013, 04:06 PM   #9
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Re: Advice on: Normal TSH elevated T4 and elevated T3

Wanted to post an update incase others are trying to find answers of this same thing high FT4 non suppressed TSH.

Our new Dr. had genetic test done on all of our family members. My children all have a mutated albumin gene that is causing the thyroid test abnormalities. This condition is called: Familial dysalbuminemic hyperthyroxinemia (FDH).

The symptoms are more than likely related to something other than the thyroid. Possibly celiac.

This condition could have been found A LOT sooner (2 years ago) had the FT4 been run via equilibrium dialysis, after they ruled out lab error.

THANK YOU everyone for the posts and thoughts on these unusual lab results. Just relieved to FINALLY have the answers!!

:-)

 
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