Factitiously Elevated Total Triiodothyronine in a Euthyroid Patient with Multiple Myeloma

Sporadic reports of factitious elevations of thyroid hormones related to laboratory interference from autoantibodies and multiple myeloma paraproteins have appeared in the literature. Such clinically confusing laboratory results can lead to erroneous diagnoses and inappropriate treatments. We report an additional case of a patient with multiple myeloma and an IgG paraproteinemia who had such a spurious elevation of total T3 complicating her levothyroxine management of hypothyroidism. In addition, we alert clinicians that differences in performance characteristics between various manufacturers’ test platforms may also cause spurious reports.

Isolated Lacrimal Gland Enlargement in Thyroid-Related Orbitopathy

Thyroid-related orbitopathy (TRO) is considered to be an inflammatory autoimmune disorder that commonly presents with extraocular muscle and retrobulbar fat enlargement. Lacrimal gland enlargement in TRO has been reported in the past in association with other radiological findings. Our case represents an isolated lacrimal gland enlargement as a presenting radiological finding in an euthyroid patient showing elevation of thyroid-stimulating immunoglobulin. After ruling out possible pathologies such as a monoclonal process, lacrimal epithelial tumor, or a nonspecific orbital inflammation, the patient underwent orbital decompression, serial botulinum toxin injections, and upper eyelid-retraction surgical correction. After two years of follow-up, the patient developed new-onset diplopia; consequent imaging showed extraocular muscle enlargement which was not present on previous imaging.

Pretibial myxedema in a euthyroid patient: a case report

Background Pretibial myxedema also known as localized myxedema, thyroid dermopathy, or infiltrative dermopathy and rarely as localized mucinosis is an infrequent manifestation of Graves’ disease. It can appear before, during, or after the thyrotoxic state. Euthyroid pretibial myxedema is a rare presentation with few case reports in the literature. This case highlights the importance of considering pretibial myxedema when characteristic skin lesions are observed in a euthyroid patient. Case presentation A 72-year old male Ethiopian patient with a very rare presentation of biopsy-proven pretibial myxedema in a euthyroid state without history of thyroid disease and absence of thyroid autoimmune markers. Resolution of skin lesion was achieved after topical corticosteroid application. Conclusion Absence of history of thyroid disorder and normal thyroid function tests should not exclude the diagnosis of pretibial myxedema.

A case report of thyroid-associated Orbitopathy with elevated TPO antibodies

Background Thyroid associated orbitopathy (TAO) is defined as an immune mediated inflammatory process affecting the extraocular muscles, connective and adipose tissue of uncertain etiopathogenesis. TAO are classically described in Grave’s disease (GD) however it may occur in euthyroid and hypothyroid patients. Those patients usually test positive for Thyroid Stimulating Hormone receptor antibodies (TRAb). For instance, only few cases of severe Hashimoto’s thyroiditis (HT) associated orbitopathy with negative TRAb are reported to date. Case presentation Herewith we report a rare case of a middle-aged female who presented with bilateral progressive upper and lower palpebral edema and a unilateral marked proptosis associated with asthenia, headache and decrease in visual acuity. Biological investigation was notable for high levels of anti-thyroid peroxidase antibodies (Anti-TPO) in an otherwise euthyroid patient with negative TRAb. Orbital Magnetic resonance imaging revealed edema of the extraocular muscles and inflammation of periorbital soft tissue. The patient received a treatment with intravenous methylprednisolone followed by oral treatment with prednisone. This regimen was both effective and safe with minimal metabolic side effects in our patient. Conclusion Minor ocular manifestations of HT are common; however, severe sight threatening ophtalmopathy in the absence of TRAb is rare. Multiple differential diagnosis should be considered and investigated before diagnosing this rare entity. Management of similar cases is currently based on reports and no clear guidelines have been elaborated, corticosteroids is the mainstream of treatment with a potential benefit of selenium supplementation in mild to moderate cases.

SAT-490 A Case of Unilateral Exophthalmos Due to Thyroid Orbitopathy and Its Association with Chronic Kidney Disease

Graves ophthalmopathy(GO)is the most common extra-thyroidal manifestation of Graves’ disease (GD). Most cases of GO are bilateral which may be asymmetric, whereas unilateral ophthalmopathy is less common and has been observed in 9-15% cases. Association between chronic kidney disease and unilateral Grave’s ophthalmopathy in a clinically euthyroid patient is rare. We report a case of a 24-year-old male with no previous history of any chronic medical illnesses who presented with protruded right eye for the past 6 months. He did not have any other visual symptoms or symptoms related to thyroid disease. Laboratory results revealed low TSH, normal free T3 and free T4. TSH receptor antibodies were positive. He also had elevated serum creatinine at 418 umol/L (normal levels 64 - 110 umol/L). US KUB showed bilateral small sized kidneys and increased parenchymal echogenicity suggestive of chronic kidney disease. MRI Head showed features suggestive of unilateral thyroid associated orbitopathy. Patient received 1-week course of oral prednisolone 10 mg per day after which his exophthalmos improved.Case report: A 24 year old male with no previous history of any chronic medical illnesses, presented to the clinic with protruded right eye for the past 6 months that was progressively getting worse. There was no eye pain, visual changes, ophthalmoplegia, dryness or discharge from eye. Patient did not report any other symptoms, Physical examination revealed a comfortable man with protruded right eye, lid retraction, normal eye movements and no signs of orbital cellulitis. Neck examination was significant for a mild diffuse goitre. Laboratory studies were significant for haemoglobin of 12.1 g/dl (normal 13-17 g/dl). He also had elevated serum creatinine at 418 umol/L (normal 64 - 110 umol/L). Serum electrolytes, liver function tests and lipid profile were within normal range. 24 hr urine collection showed 3.08 gm/24 hr proteinuria. Serum TSH was 0.04 mIU/L (normal 0.45 - 4.5 mIU/L), free T4 was 13.8 pmol/L (normal 9 - 20 pmol/L) and free T3 was 4.56 pmol/L (normal 2.89 - 4.88 pmol/L). Thyrotropin Receptor Ab titre was 4.69 IU/L (normal 0.00 - 1.75 IU/L). ANA, ANCA, C3, C4, Anti thyroid peroxidase and Anti GBM antibodies were negative. Screening for hepatitis B, C and HIV was negative US KUB showed bilateral small sized kidneys and increased parenchymal echogenicity suggestive of CKD. MRI Head was remarkable for proptosis of the right eye with increased retro-orbital fat, thickening and T2 hyper-intensity with sparing of the tendinous insertion involving the right inferior, medial, superior and lateral rectus muscles with crowding at the orbital apex. Features were suggestive of unilateral thyroid associated orbitopathy. Patient received 1-week course of oral prednisolone 10 mg per day after which his exophthalmos improved. An association between CKD and GO in a clinically euthyroid patient is rare.

MON-473 Evaluating Conflicting Thyroid Function Tests in New Admissions: Discordance of TSH, FreeT4 and Clinical Status: A Clinical Challenge!

Background: It is not uncommon to encounter patients whose thyroid function tests (TFTs) seem mutually inconsistent or inconsistent with a patient’s clinical status, At times, the simplest reconciliation of the findings invokes a rare disorder that we are hesitant to accept. In this case, a clinically euthyroid patient presents with elevated TSH and Free T4 (FT4) suggestive of a TSH-producing tumor or of Thyroid Hormone Resistance. Clinical Case: A 72 yr-old man with cardiomyopathy on amiodarone is admitted to the Medical Service for treatment of anasarca. He had no symptoms or signs of thyroid dysfunction and was not taking L-T4, amphetamines or propranolol. Findings on exam included normal VS, runs of atrial tachycardia, and edema from feet to scrotum. Thyroid exam was normal. Serum creatinine was 2.24 mg/dl (NL: 0.67-1.17). Bili was 2.7 mg/dl (NL: 0.67-1.17); AST and ALT were normal, Chest x-ray revealed cardiomegaly with clear lung fields. Thyroid ultrasound revealed a normal size gland containing a few sub-centimetric nodules. On Day 2 The serum FT4, by analog assay, was elevated at 1.66 ng/dl (NL: 0.76-1.46) and TSH was elevated at 9.06 mIU/L (NL: 0.35-3.74), Anti-peroxidase and anti-thyroglobulin antibodies were negative. The Medical Service’ diagnosis was “amiodarone-induced thyroiditis.” The amiodarone was discontinued and diuresis was induced with bumetanide, Endocrinology consultation was requested On Day 4 the FT4 and TSH were still elevated at 1.62 and 10.1, respectively. FT4 by dialysis was not elevated at 1.62 ng/dl (NL: 0.9-2.2). The FT3 was 2.34 pg/ml (NL: 2.18-3.98). On Day 5 Anti-thyroxine antibodies and Thyroid Stimulating Immunoglobulins (TSI) were negative. Paired TSH samples with and without neutralization of Human Anti-Mouse Antibodies (HAMA) were identical: both elevated at 8.30 mIU/L (NL: 0.4-4.50). Serum Iodine was markedly elevated at 2288 mcg/L (NL: 52-109). The FT4 levels by analog assay therefore appear to have been falsely elevated (as indicated by the dialysis assay) though not by recognized factors such as thyroxine antibodies, amphetamines or propranolol. Continued observation is necessary to further assess the transience of the post-admission TFTs. Conclusion: In patients admitted to Acute Medical or Psychiatric Services, most combinations of high or low TSH and FT4 have been reported as well other aberrations of “non-thyroidal illnesses.” In patients with conflicting TFTs at admission, especially those who are clinically euthyroid, it is generally better to allocate a few weeks for observation and monitoring than to immediately launch into searches for rare disorders. This is especially important when multiple potentially thyro-active clinical states exist, such as renal and hepatic compromise, amiodarone use, and highly elevated iodine levels.