NYU Medical Grand Rounds
Clinical Vignette
Arnab Ghosh, MD
PGY-2
10/23/12
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
The patient is a 67 year old male who presented to
his primary care physician with palpitations.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• When reviewed in clinic by his primary
physician, he appeared clinically euthyroid
although he did have evidence of an
enlarged thyroid gland on examination by
his primary care physician.
• He was referred to an endocrinologist.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
• Past Medical History: Nil
• Past Surgical History: Nil
• Social History: Works as a dentist, occasional
social drinker, non smoker, nil illicit drug use
• Family History: Nil family history of thyroid
disease
• Medications: Nil
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
• General: He appeared well
• Thyroid Examination: a palpable thyroid
approximately one and a half times the
normal size
• Nil evidence of tenderness, dominant
nodules nor lymphadenopathy
• Nil peripheral stigmata of thyroid disease
Remainder of Physical Exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• CBC: within normal limits
• Basic Metabolic panel: within normal limits
• Hepatic panel: within normal limits
• Thyroid Stimulating Hormone (TSH)
•2.7 miU/L (N:0.4-4.0 mIU/L)
• T4 5.9 mcg/dL (N: 4.8-11.0 mcg/dL)
• T3 0.78 ng/mL (N:0.8-1.7 ng/mL)
• Anti-thyroglobulin antibody: 2.4 U/mL (>1.0 U/mL
– positive)
• Anti-thyroperoxidase antibody:14.0 U/mL (>1
U/mL – positive)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
• ECG: normal sinus rhythm with occasional
premature ventricular contractions
• Thyroid Ultrasound:
1.7x1.1cm nodule in the R lobe (hypoechoic)
9x11mm nodule in R lobe (hypoechoic)
Nil microcalcifications, nil increased vascularity
• Fine Needle Aspiration performed of larger
nodule:
Colloid in a population of lymphocytes
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
Euthyroid lymphocytic thyroiditis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Outpatient Course
• The patient was referred back to his primary
care physician, who intermittently checked
TSH levels, which remained normal
• 8 years later, the patient was referred back to
his endocrinologist with a TSH measured at
4.16 mIU/L (N:0.4-4.0mIU/L)
• Patient was clinically euthyroid during this
time
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Outpatient Course
• On repeat labs by the endocrinologist, the TSH was
measured 11.4 mIU/L
• Other laboratory values of note:
– T4 6.3 mcg/dL (N: 4.8 - 11.0 mcg/dL)
– T3 Uptake 31.7% (N: 23.5 - 40.6%)
– Free thyroid index 4.0 (N: 1.5 - 3.8)
– Anti-thyroperoxidase antibody: 239 IU/mL (normal <
27 iU/mL)
– Anti-Thyroglobulin antibody: < 20 IU/mL (normal)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Outpatient Course
• Repeat Thyroid Ultrasound performed:
Coarsely and diffusely multinodular
Mild hyperaemia of the entire thyroid
R lobe: 2 solid hypoechoic nodules, 15x10mm and
9x9mm
L inferior lobe: 8x6mm nodule
Nil calcifications
• Fine Needle Aspiration of 3 nodules:
R and L nodules: colloid with lymphocyte background
L inferior lower lobe: colloid accumulation
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Outpatient Course
The patient was started on
Levothyroxine 25 μmcg daily by
mouth
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Outpatient Course
Repeat lab values 3 months later in clinic
– TSH 2.74 miU/L (N:0.4-4.0 mIU/L)
– T4 5.7 mcg/dL (N: 4.8 - 11.0 mcg/dL)
– T3 Uptake 33.9% (N: 23.5 - 40.6%)
– Free thyroid index 1.9 (N: 1.5 - 3.8)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Hashimoto’s thyroiditis (with failing
thyroid)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS