Let the buyer beware

One of my patients came to me last year with a diagnosis of “recurring” thyroiditis. Review of her records revealed that she had several past episodes when her thyroid-stimulating hormone went from fully suppressed to elevated and back again. She had a radioiodine uptake in the past which was low — suggesting thyroiditis.

Last year, her TSH was optimal (the lower end of normal), she was on no thyroid hormone therapy and we elected to observe. Subsequently however, she had a TSH of <0.01 mIU/L and an elevated free thyrokine₄ of 4.19 (0.8-1.8).

Recurring thyroiditis is uncommon but I have seen a few patients who had two or three well documented episodes before ending up hypothyroid requiring thyroid HT. I have also seen other patients present with a remitting/relapsing form of Graves’ disease, alternating between hyperthyroidism and euthyroidism. Most of these eventually became hyperthyroid indefinitely.

I advised my patient to have another radioiodine uptake but she was leaving the next day to go to a tertiary medical center for other issues. She would be able to have her hyperthyroidism further evaluated there and I encouraged her to do so. Other than mild insomnia and palpitations, she did not feel poorly.

Radioiodine uptake was obtained. It was only 4% consistent with thyroiditis. However, hyperthyroidism due to exogenous thyroid hormone intake could also explain such results.

The patient was taking a nutritional supplement “to promote healthy blood sugar levels,” which she was advised to take by a local “acupuncture physiologist.” The endocrinologists where she visited had access to a lab where the contents of this supplement could be analyzed (I must admit that I am envious!). To everyone’s surprise, they found that the contents of each capsule contained 90 mcg of T₄ and 164 mcg of T₃. Our patient did not have thyroiditis; she had hyperthyroidism due to inadvertent ingestion of thyroid hormone. The capsules had been deliberately loaded with thyroid hormone.

She was advised to stop this supplement immediately and as far as I know has suffered no long-term ill effects. However, had she been older or had pre-existing cardiac disease, the outcome could have been much different. I wonder how much money we have spent on labs and imaging studies trying to figure out what was going on? I greatly worry about the potential for others to suffer harm.

Episodes such as this are unfortunately not rare. Reports of contamination of supplements with a variety of potentially harmful substances have been reported including anabolic steroids, digitalis and others. After this case, a pediatric endocrinologist told me about a case of precocious puberty she recently saw in a child taking “glandular extract.” After the cause was identified, the father asked, “Maybe I should take it?” He was serious. The family left and took the supplement with them. It had been expensive after all.

Under the Dietary Supplement Health and Education Act of 1994, the FDA has only a limited role in overseeing the manufacture of supplements. There are several companies which perform private testing. ConsumerLab.com has reported that up to 25% of supplements and 50% of multivitamins tested have had issues.

I have purposely not named the supplement my patient was taking or the manufacturer. The FDA has been notified about this incident. We shall see if anything comes of it.