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‘Weed’ out hyperthyroidism
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A 42-year-old woman was referred by her primary care physician for an initial evaluation of hyperthyroidism.
She had been experiencing worsening fatigue for 2.5 years and was previously diagnosed with hyperthyroidism by another endocrinologist. However, a radioactive iodine uptake and scan were within normal limits and did not show a “hot nodule.” Her symptoms did not improve when she was taking methimazole for several weeks. She noted intentional weight loss of 14 lb in 3 months after changing her diet. However, she had given up exercise due to fatigue and palpitations.
On review of systems, the patient reported insomnia, anxiety, palpitations, nervousness, jitteriness, heat intolerance and increased perspiration. She denied jaundice, constipation, hoarseness, distended abdomen, cold intolerance and irregular menses.
Her medical history consisted of seasonal allergies, migraine, mitral valve prolapse, anxiety, arthralgia, chronic fatigue syndrome and insomnia. She had no known drug allergies. Her mother had a history of hypothyroidism. The patient had never smoked, did not drink alcohol or take recreational drugs and was working as a copywriter. She was very proud of her weight loss, which she had achieved “naturally and with will power.”
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Medications consisted of olopatadine 0.1% (Patanol, Alcon); zolpidem 12.5 mg nightly (Ambien CR, Sanofi-Aventis); fluticasone (Flonase, GlaxoSmithKline) 50 mcg/actuation nasal spray; atenolol 50 mg oral tablet daily; and sertraline 25 mg oral tablet daily (Zoloft, Pfizer).
Her nutritional supplements included fish oil, cod liver oil, a women’s multivitamin and “super-enzymes.” The patient had been taking nutritional supplements sporadically during the past 2 years.
On physical exam, blood pressure was 100 mm Hg/70 mm Hg; heart rate was 60 beats per minute; height 69.5”; weight 132 lb (59.875 kg); no thyroid enlargement, bruit, nodule or tenderness. There was no proptosis, tremor or anxiety, and the exam was overall unremarkable.
Pertinent labs included: thyroid-stimulating hormone, 0.06 mcIU/mL (normal range: 0.34-5.60); total triiodothyronine, 208 ng/dL (normal range: 87-178); free thyroxine, 0.9 ng/dL (normal range: 0.6-1.1); thyroglobulin antibody, 1.2 U/mL (normal range: 0-4.1); thyroid peroxidase (microsomal) antibody, 13 IU/mL (normal range: 0-5.6); and TSH-receptor antibody was negative.
What is the best next step in the management of this patient?
A. Call the previous endocrinologist and find out the dose of methimazole she had been prescribed. Then prescribe twice the dose and ensure that the patient stays on the medication for at least 6 months.
B. Refer the patient to a surgeon for thyroidectomy.
C. Ask the patient to make a photocopy of the ingredients of all her nutritional supplements and fax or email them to the office.
D. Explain to the patient that she was suffering from nonthyroidal illness/sick euthyroid syndrome and refer her back to her internist.
CASE DISCUSSION:
Answer: C
This patient has several symptoms of hyperthyroidism and the suppressed TSH to go along with it, making nonthyroidal illness an unlikely choice (D). Given the negative TSH-receptor antibody, the reportedly normal radioactive iodine uptake and the poor response to methimazole, Graves’ disease appears to be unlikely; restarting methimazole at a higher dose does not appear to be the best route to success (A). In the absence of an autonomous adenoma or Graves’ disease, surgery does not appear to be warranted (B). The best approach is to get as much information as possible about her nutritional supplements (C).
The patient called back later that week and read the contents off the bottle of her “all-natural” preparation that was intended to “support a healthy lifestyle.” One of the ingredients listed was ashwagandha, an herb that has been reported to cause hyperthyroidism. I therefore recommended stopping the nutritional supplement for several weeks and then getting repeat labs. The patient was initially agreeable to that plan, but then asked: “If I no longer take this supplement, will I gain weight?” I explained that she may indeed gain weight once we alleviated her hyperthyroidism, but that she would have fewer palpitations and less anxiety. However, the patient declared she was reluctant to stop the supplement if there was any chance of weight gain, and she never returned for follow-up.
If you ever encounter a lean, middle-aged woman with palpitations who is anxious to continue taking ashwagandha, tell her I said “hi!”
Ronald Tamler, MD, PhD, MBA, is clinical director of the Mount Sinai Diabetes Center, N.Y. He is also an Endocrine Today Editorial Board member.
Disclosure: Dr. Tamler reports no relevant financial disclosures.