Low TSH, high T4, high ESR, throat pain, two thyroid nodules

[SamK1]

I have two thyroid nodules shown on ultrasound, one on the left and one on the right.  They measure 1.0 x 0.9 x 0.8 and 1.0 x 0.9 x 0.7 cm.  My TSH is 0.01, T4 3.2 (my PCP did not order T3) and ESR was 64.  I have had jaw pain, headache, and throat pain ranging from sore throat to a sharp pain at the base of my throat, often when I swallow.  From what I have read, it sounds like I have subacute thyroiditis except that I am now sweating often, have heat intolerance, and awaken at 3:00 am feeling like my heart is pounding (I just started metoprolol for this).

I am trying to get into see an endocrinologist.  My PCP ordered a thyroid uptake scan so I would have those results when I go to see endocrine but I would prefer to avoid that if possible.  I have a couple of concerns.  I am currently breastfeeding and I don't wish to stop at this time but I don't know how long after the scan before it would be safe to do so again (I can't get a straight answer).  I am not sure if a FNA biopsy would give enough info (I definitely want to rule out cancer and know next best treatment steps).  I also had a family physician friend tell me that I should only have an FNA done on the referral of endocrine to someone REALLLY good because she's seen those yield inconclusive info if there is poor technique.

My major question is...is it best to have the uptake scan first (possible before FNA)?  If so, how long do I need to avoid breastfeeding after?  It sounds like it might depend on the dose and isotope used.  What are the possibilities and recommended time frames?  Should I have the milk tested with a gamma counter?

Thank you for any info that you can provide!

[Mark Lupo, M.D.]

Yes - looks like subacute thyroiditis and the uptake will likely be very low.  Ask the nuclear medicine tech about breast feeding but usually it's a limited time (to avoid it).
The "nodules" may be areas of inflamation in this setting and often we recheck US in 3 months unless highly suspicious.  These "nodules" are quite small, so the key will be ultrasound appearance.

[SamK1]

Thank you so much for the info, Dr. Lupo.   I really appreciate it.  One more thing I didn't mention is that the radiology report described the  nodules as "ill-defined" and "solid" with prominent heterogeneous appearance of both right and left thyroid lobes.  The isthmus is also heterogeneous and there was noted to be increased flow in the thyroid gland.  Hopefully, this is also consistent with an inflammatory picture rather than something more serious.

Thank you again.  I would definitely come to see you if I lived in Florida!