OSH PCP (4 weeks ago): complaints of progressive lethargy. TFT s repeated: free T4 mildly elevated, T3 elevated and TSH suppressed

Transcription

1 Anila Bindal, MD

2 OSH PCP (4 weeks ago): complaints of progressive lethargy TFT s elevated Referred to OSH Endocrinologist TFT s repeated: free T4 mildly elevated, T3 elevated and TSH suppressed

3 Thyroid US: 5 mm hypoechoic nodule in midportion of left lobe Thyroid uptake and scan: 1% iodine uptake at 6 hours markedly below normal and may reflect thyroiditis or exogenous iodine uptake (24hr uptake not done)

4 Very large liver with numerous tiny hypodensities (?tumor vs. microabscesses) Spleen with numerous round hypodense lesions (2mm-2cm) Extensive bulky retroperitoneal adenopathy and periportal adenopathy Extensive adenopathy along R common iliac artery, vein and posterior to IVC, largest para-aortic LN 2cm Moderate ascites in pelvis, and around both liver and spleen Several large masses in the R hemipelvis showing enhancement and low density, suggesting necrotic tumor or necrotic lymph node, largest 4.4x4.8 cm. Another cystic appearing mass could be lymph node or ovary Enhancing R inguinal masses Differential includes lymphoma, ovarian malignancy, lymphoproliferative disorder or an inflammatory disease

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7 F/u at Endocrinologist s office: more fatigued, tachycardic, more weight loss Sent to OSH ER for treatment of hyperthyroidism ft4 2.91; T3 3.66; TSH Pancytopenia, transaminitis Underwent R inguinal LN biopsy Transferred to UCMC

8 Constitutional: +Weight loss of 70 lbs/9 months, +Progressive lethargy x 1 month, +Night sweats CV: +Palpitations ABD: +Diarrhea, +Dry heaving, +Reduced appetite, +Early satiety x 2 months ENDO: +Heat intolerance NEURO: +Tremors MSK: +Proximal LE weakness DERM: +Hair loss, +flushing GU: LMP 6 weeks ago, much lighter than usual (otherwise regular, heavy periods), palpable LN in R groin that has been there for as long as I can remember Rest of ROS negative

9 PMH: h/o gestational HTN h/o ectopic pregnancy (tx w methotrexate) PSH: C-section x3, last 2012 Bilateral tubal ligation D&C (abortion) FH: Mother: hypothyroidism, melanotic cervical wart Sister: Leukemia Meds: MTP-XL 100mg daily NKDA SH: Lives with husband and kids Works in quality assurance for Trader Joe s Denies alcohol/illicits/tobacco

10 T: 38.1 (Tm 39) HR: 118 BP: 98/61 RR: 28 SaO2: 97% (RA) Weight: 68.8kg (151.7lbs) BMI: 25.6 GEN: NAD, resting comfortably, face appears thin HEENT: PERRLA, no proptosis/lid lag, MMM, no thyromegaly or palpable nodules, nontender thyroid CV: mildly tachycardic, regular rhythm, no murmurs PULM: clear to auscultation bilaterally ABD: soft, NT, moderately distended, +hepatomegaly, +ascites GU: palpable R inguinal LAD ~6cm EXT: no edema NEURO: alert, oriented, strength 3/5 proximal BLE; 5/5 BL upper ext, fine tremor on outstretched hands, normal patellar DTR s DERM: warm, dry, not velvety PSYCH: not agitated, cooperative, appropriate GU (by Gyn/Onc): vagina and cervix appear WNL, no blood or discharge in vagina, no vaginal lesions palpated manually, uterus anteverted and normal in size, L adnexa unremarkable, R pelvic fullness

11 ANC: N, 3L, 4M /0.6 TSH: 0.01 Free T4: 2.79 Total T4: 10.1 T3: 88 Preg neg TG Ab neg TPO Ab neg TSI neg

12 Not in severe thyrotoxicosis Treated for UTI Clearly, clinically hyperthyroid with suppressed TSH Low uptake on thyroid scan, Ab neg Differential: thyroiditis vs. ectopic thyroid tissue

13 Iodine uptake scan BEFORE or AFTER CT??

14 Mildly elevated ft4 and nml T3 elevated T3 at Endocrinologist s office Why T3 not elevated? Low albumin/binding proteins lowering total thyroid hormone relative to free levels? Free T3: 294 (nml) Some effect of T4 T3 conversion from MTP? Due to recent contrast and Wolff-Chaikoff Effect?

15 Autoregulatory phenomenon in response to excess iodine that inhibits organification in the thyroid gland by inhibiting TPO and therefore, reduces formation of the thyroid hormones It lasts ~10-30 days after excess iodine exposure It is followed by an escape phenomenon, during which normal organification resumes

16 Hyperthyroid symptoms Mildly elevated ft4, suppressed TSH Pelvic mass with bulky inguinal LAD?Ectopic thyroid tissue?struma ovarii Large iodine load (CT) and may be expected to escape the Wolff Chaikoff effect over the next week High-risk for progression into severe thyrotoxicosis

17 Also has pancytopenia of unclear origin, and transaminitis RAI? Recent iodine contrast, low uptake on scan NO Surgery? Ectopic tissue NO Antithyroid drug? Agranulocytosis and transaminitis risks/benefits

18 Methimazole 10mg bid Propanolol 10mg q6h careful with low-normal BP Trend daily CBC with diff and LFT s Trend TSH, ft4, T3, TT4?Steroids

19 Gyn-Onc: unlikely to be ovarian malignancy R pelvic fullness due to obturator adenopathy TV US: normal R ovary with complex R adnexal masses separate from ovary CA-125: 1067

20 OSH pathology: low grade mixed focal follicular lymphoma Excisional LN Biopsy T cell B-rich Lymphoma HLH? (Hemophagocytic Lymphohistiocytosis) Hyperinflammation caused by uncontrolled proliferation of activated lymphocytes and macrophages that secrete large amounts of inflammatory cytokines Pancytopenia, fevers, hepatosplenomegaly, hypertriglyceridemia, elevated ferritin, hemophagocytosis on BM Bx Thyroiditis also thought to be associated with cytokines

21 Started on CHOEP (cyclophosphamide, doxorubicin, etoposide, vincristine, prednisone) but dexamethasone substituted for prednisone to treat HLH Sudden Respiratory Distress: TTE LVEF 58% 30% MICU: Cardiogenic Shock, Tumor Lysis Syndrome, CVVHD

22 9/13 9/15 9/16 9/19 TSH 0.01 (L) 0.01 (L) 0.01 (L) 0.01 (L) Free T (H) 2.33 (H) 2.28 (H) 1.93 (H) Total T T (L) 63 (L) 48 (L) RT3 >2000 MMI 10mg bid MMI 10mg daily MMI d/c d (propanolol cont)

23 TFT s repeated: T3 low Likely due to nonthyroidal illness Vs. transient hypothyroid phase following thyroiditis due to depletion of thyroid hormone stores Propanolol discontinued

24 Also known as lymphocytic thyroiditis, spontaneously resolving hyperthyroidism Can take 2-5 months to resolve Can sometimes be mild and transient, so may be completely overlooked?autoimmune?geographic prevalence

25 Follow-Up 9/13 9/15 9/16 9/19 10/3 10/9 TSH 0.01 (L) 0.01 (L) 0.01 (L) 0.01 (L) 0.68 Free T (H) Total T (H) 2.28 (H) 1.93 (H) T (L) 63 (L) 48 (L) RT3 > (L) 1.09