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TSI of 83
I had posted previous about my 11 year old daughter and strange lab results. As I learn more about Thyroid Tests the more frustrated I'm getting with her Dr's. In my last post it was suggested that I have her TSI and TPO also tested. The nurse called me back yesterday and informed me that they DID run these tests back in June 2011:
TSI: 83 (<123)
TPO: .4 (0 - 9.0)
From my research I'm gathering that ANY TSI present suggests Hyper. Right now, they want to test her for Thyroid Hormone Resistance Due to the elevated FT4 and non-surpressed TSH - If this comes back negative they will just call her thyroid function "normal", and suggesting that we stop testing her thyroid. But now that I learn that she DOES have TSI present - I'm not sure that the test for THR is needed.
So do I proceed with the test for THR, or is this the time to find a new Dr. for her and start over? Is it possible that the TSI present is blocking something that is preventing the TSH from being surpressed?
The following labs were run in different locations. 2011 - at university location, these labs differ quite a bit from the labs ran at our local clinic. The labs run in our local clinic have always been simular to the latest one from Nov 2012:
Labs from ped endo aug 2011:
TSH: 3.53 ( .4 - 5.0 ),
FT4: 0.51 (1.1 -2.0) - Measured via Equilibrium Dialysis
Total T3: 166 (83 - 213),
Total T4: 15 (5.0 - 11.0),
thyroglobulin antibody was negative
thyroglobulin normal 22.8
Test results from our local Clinic Nov 2012:
Elevated FT4 1.89 (.58 - 1.64 ng/dl)
Normal FT3 4.02 (2.50 - 3.90 pg/mL)
Normal TSH 2.03; (.34 - 5.60 mIu/mL)
Thyroid binding globulin was normal at 21 (13-30)
Sorry for the lab re-post just wanted all the information together.
TSI: 83 (<123)
TPO: .4 (0 - 9.0)
From my research I'm gathering that ANY TSI present suggests Hyper. Right now, they want to test her for Thyroid Hormone Resistance Due to the elevated FT4 and non-surpressed TSH - If this comes back negative they will just call her thyroid function "normal", and suggesting that we stop testing her thyroid. But now that I learn that she DOES have TSI present - I'm not sure that the test for THR is needed.
So do I proceed with the test for THR, or is this the time to find a new Dr. for her and start over? Is it possible that the TSI present is blocking something that is preventing the TSH from being surpressed?
The following labs were run in different locations. 2011 - at university location, these labs differ quite a bit from the labs ran at our local clinic. The labs run in our local clinic have always been simular to the latest one from Nov 2012:
Labs from ped endo aug 2011:
TSH: 3.53 ( .4 - 5.0 ),
FT4: 0.51 (1.1 -2.0) - Measured via Equilibrium Dialysis
Total T3: 166 (83 - 213),
Total T4: 15 (5.0 - 11.0),
thyroglobulin antibody was negative
thyroglobulin normal 22.8
Test results from our local Clinic Nov 2012:
Elevated FT4 1.89 (.58 - 1.64 ng/dl)
Normal FT3 4.02 (2.50 - 3.90 pg/mL)
Normal TSH 2.03; (.34 - 5.60 mIu/mL)
Thyroid binding globulin was normal at 21 (13-30)
Sorry for the lab re-post just wanted all the information together.
I found this kind of interesting:
"FT4 is usually measured by automated analog immunoassays. In most instances, this will result in accurate results. However, abnormal types or quantities of binding proteins found in some patients and most often related to other illnesses or drug treatments, may interfere in the accurate measurement of FT4 by analog immunoassays. These problems can be overcome by measuring FT4 by equilibrium dialysis, free from interfering proteins."
If you want to read more:
http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/8859
I also find it interesting that her TT4 was so high above range and her FT4 was below. That would beg the question of why her TBG (thyroid binding globulin) or other protein was high. Was she on meds or undergoing any medical treatment when either test was done?
This article cites pregnancy and oral contraceptives as culprits, but I’m sure there are others:
“Measuring FT4 directly requires complicated laboratory procedures, so FT4 is usually estimated based on the ratio of binding protein to total T4. Normal FT4 levels, when the total T4 is high or low, indicate the issue is the binding protein, not the thyroid. For example, pregnancy or the use of oral contraceptives increases levels of binding protein in the blood. In this case, the total T4 will be high due to the binding protein but the person does not have hyperthyroidism. Severe illness or the use of corticosteroids—a class of medications that treat asthma, arthritis, and skin conditions, among other health problems—can decrease binding protein levels. The total T4 measurement will be low as a consequence, but the person does not have hypothyroidism. In either case—having high binding protein or having low binding protein—the FT4 will be normal and the person has normal thyroid function—also called euthyroid.”
And this is the source:
http://www.endocrine.niddk.nih.gov/pubs/thyroidtests/thyroidtests_508.pdf
Another question: back when her FT4 was low, was she having hypo symptoms?
"FT4 is usually measured by automated analog immunoassays. In most instances, this will result in accurate results. However, abnormal types or quantities of binding proteins found in some patients and most often related to other illnesses or drug treatments, may interfere in the accurate measurement of FT4 by analog immunoassays. These problems can be overcome by measuring FT4 by equilibrium dialysis, free from interfering proteins."
If you want to read more:
http://www.mayomedicallaboratories.com/test-catalog/Clinical+and+Interpretive/8859
I also find it interesting that her TT4 was so high above range and her FT4 was below. That would beg the question of why her TBG (thyroid binding globulin) or other protein was high. Was she on meds or undergoing any medical treatment when either test was done?
This article cites pregnancy and oral contraceptives as culprits, but I’m sure there are others:
“Measuring FT4 directly requires complicated laboratory procedures, so FT4 is usually estimated based on the ratio of binding protein to total T4. Normal FT4 levels, when the total T4 is high or low, indicate the issue is the binding protein, not the thyroid. For example, pregnancy or the use of oral contraceptives increases levels of binding protein in the blood. In this case, the total T4 will be high due to the binding protein but the person does not have hyperthyroidism. Severe illness or the use of corticosteroids—a class of medications that treat asthma, arthritis, and skin conditions, among other health problems—can decrease binding protein levels. The total T4 measurement will be low as a consequence, but the person does not have hypothyroidism. In either case—having high binding protein or having low binding protein—the FT4 will be normal and the person has normal thyroid function—also called euthyroid.”
And this is the source:
http://www.endocrine.niddk.nih.gov/pubs/thyroidtests/thyroidtests_508.pdf
Another question: back when her FT4 was low, was she having hypo symptoms?
Thanks for the research!!! So nice of you!
No she wasn't on any medications when the labs were done. And no she wasn't having Hypo symptoms. Her symptoms have ALWAYS been more hyper, main symptom that started the testing was the excessive sweating (hands and feet). And the thicker hair on arms and legs.
Could the T4 be binding to the thyroglobulin? I'm not really sure what the thyroglobulin does.
Could the FT3 and TT4 being on the high side be what is causing the hyper symptoms? And does the TSI play into this at all?
Head spinning from thyroid information overload LOL :-)
No she wasn't on any medications when the labs were done. And no she wasn't having Hypo symptoms. Her symptoms have ALWAYS been more hyper, main symptom that started the testing was the excessive sweating (hands and feet). And the thicker hair on arms and legs.
Could the T4 be binding to the thyroglobulin? I'm not really sure what the thyroglobulin does.
Could the FT3 and TT4 being on the high side be what is causing the hyper symptoms? And does the TSI play into this at all?
Head spinning from thyroid information overload LOL :-)
Well, tell me when I should quit!
Yes, the T4 does bind to the TBG (thyroxine binding globulin, not thyroglobulin (TG), that's something else entirely). That's how T4 is stored and gets around your bloodstream; it kind of hitches a ride on the TBG (protein). FT4 is the tiny bit (compared to total) of T4 that's not attached to protein and can be used by the body, since it's free (unbound). So, when there's too much TBG, your total T4 can be high, but your FT4 still low because too much of the TT4 is bound to TBG.
Hyper symptoms are caused by high FT3 and/or FT4 levels. That's the ONLY thing that causes hyper symptoms. FT3 is the test that correlates best with symptoms. T3 is the "active" form of the thyroid hormones. It's the only form your cells can use. So, if for some reason your FT3 is high and your FT4 low, you can still feel very hyper. (Unfortunately, we don't have FT3 in that first set of tests, so don't know what it was doing. T3, like T4, can be bound or free, so we can't assume anything from the TT3.)
Crash course in Thyroid 101, just in case: The pituitary is the master endocrine gland and controls all the others, including thyroid. When the pit senses low levels of FT3 and/or FT4, it puts out more TSH to stimulate the thyroid to produce hormone. The thyroid responds by putting out more T4 and T3, and the whole cycle starts over again.
TSI are thyroid stimulating immunoglobulins. They are antibodies created by the immune system, and they attach to TSH receptors in the thyroid and act like TSH. However, once this happens (Graves' disease), the thyroid is no longer under the control of the pit, but under the control of the antibodies. The antibodies are pretty indiscriminate and don't give a hoot if FT3 and FT4 levels are too high; they just keep telling the thyroid to produce more and more, and you have hyper symptoms. But, it's not the antibodies themselves that produce those symptoms, it's the high FT3 and FT4 levels that they cause that produce the symptoms.
When TSI is high, TSH is usually very low (unless something else is going on at the same time) because so much FT3 and FT4 is in the bloodstream that it's suppressed. TSI is doing its job, though a little too aggressively.
Sleep on it...
Yes, the T4 does bind to the TBG (thyroxine binding globulin, not thyroglobulin (TG), that's something else entirely). That's how T4 is stored and gets around your bloodstream; it kind of hitches a ride on the TBG (protein). FT4 is the tiny bit (compared to total) of T4 that's not attached to protein and can be used by the body, since it's free (unbound). So, when there's too much TBG, your total T4 can be high, but your FT4 still low because too much of the TT4 is bound to TBG.
Hyper symptoms are caused by high FT3 and/or FT4 levels. That's the ONLY thing that causes hyper symptoms. FT3 is the test that correlates best with symptoms. T3 is the "active" form of the thyroid hormones. It's the only form your cells can use. So, if for some reason your FT3 is high and your FT4 low, you can still feel very hyper. (Unfortunately, we don't have FT3 in that first set of tests, so don't know what it was doing. T3, like T4, can be bound or free, so we can't assume anything from the TT3.)
Crash course in Thyroid 101, just in case: The pituitary is the master endocrine gland and controls all the others, including thyroid. When the pit senses low levels of FT3 and/or FT4, it puts out more TSH to stimulate the thyroid to produce hormone. The thyroid responds by putting out more T4 and T3, and the whole cycle starts over again.
TSI are thyroid stimulating immunoglobulins. They are antibodies created by the immune system, and they attach to TSH receptors in the thyroid and act like TSH. However, once this happens (Graves' disease), the thyroid is no longer under the control of the pit, but under the control of the antibodies. The antibodies are pretty indiscriminate and don't give a hoot if FT3 and FT4 levels are too high; they just keep telling the thyroid to produce more and more, and you have hyper symptoms. But, it's not the antibodies themselves that produce those symptoms, it's the high FT3 and FT4 levels that they cause that produce the symptoms.
When TSI is high, TSH is usually very low (unless something else is going on at the same time) because so much FT3 and FT4 is in the bloodstream that it's suppressed. TSI is doing its job, though a little too aggressively.
Sleep on it...
THANK YOU AGAIN!! You have been extremely helpful!!
I slept on it and have a plan :-)
I'm NOT going to proceed at this time with the THR test. She hates needles and blood draws, and I just don't want to put her through that considering I don't think that's what is going on. If later we come back down that road then we run the test, but first:
I'm going to switch Dr. I think this is were the problem is. Having our pediatrician run test and then consult with the peds endo 7 hours away is causing problems. Example they ran the TSI antibody test and the peds endo Dr. didn't look at the actual test results and just got the "negative" answer from our local Dr..... She needs the SAME Dr. running the tests to be the one reading the results, and the Dr needs to know what they are looking for and what they mean. Our pediatrician doesn't know enough about Thyroid to know that those TSI antibodies were pretty high.
Then we need to get a fresh set of blood work with ALL the antibodies, and binding protiens included and Ts. The FT4 and hopfully FT3 - HAVE HAVE HAVE to be run via direct dialysis.
That 2011 lab she was technically Subclinical-Hypo and her FT4 was not even borderline low it was LOW. So I need to find out if this is the "actual" picture, slightly elevated TSH, elevated FT3 and low FT4 - If that FT3 is truly elevated this could be what is causing the hyper symptoms.
Anything else you think I should include in my plan.
:-)
I slept on it and have a plan :-)
I'm NOT going to proceed at this time with the THR test. She hates needles and blood draws, and I just don't want to put her through that considering I don't think that's what is going on. If later we come back down that road then we run the test, but first:
I'm going to switch Dr. I think this is were the problem is. Having our pediatrician run test and then consult with the peds endo 7 hours away is causing problems. Example they ran the TSI antibody test and the peds endo Dr. didn't look at the actual test results and just got the "negative" answer from our local Dr..... She needs the SAME Dr. running the tests to be the one reading the results, and the Dr needs to know what they are looking for and what they mean. Our pediatrician doesn't know enough about Thyroid to know that those TSI antibodies were pretty high.
Then we need to get a fresh set of blood work with ALL the antibodies, and binding protiens included and Ts. The FT4 and hopfully FT3 - HAVE HAVE HAVE to be run via direct dialysis.
That 2011 lab she was technically Subclinical-Hypo and her FT4 was not even borderline low it was LOW. So I need to find out if this is the "actual" picture, slightly elevated TSH, elevated FT3 and low FT4 - If that FT3 is truly elevated this could be what is causing the hyper symptoms.
Anything else you think I should include in my plan.
:-)
Isn't it great when you wake up in the morning and everything has jelled in your brain?!
I agree with you about the new doctor. You should have an endo, who is not only the one reading the tests, but who you can sit down with and discuss your concerns. Also, if once you see a new endo, he wants even more bloodwork, you can do it all at once and minimize those dreaded needles. I also tend to think that an endo closer to you, even if not a pedi endo, would be more in tune to this than your pedi is.
Has she had a thyroid ultrasound? Her endo might want to order one of those. It's completely painless. They just squirt some goo (gel as a lubricant) on your neck and run a want over your thyroid to get a good picture of it, check for nodules, etc.
That's all I can think of at the moment, but I'll keep thinking and get back to you if i come up with anything else. Good luck.
I agree with you about the new doctor. You should have an endo, who is not only the one reading the tests, but who you can sit down with and discuss your concerns. Also, if once you see a new endo, he wants even more bloodwork, you can do it all at once and minimize those dreaded needles. I also tend to think that an endo closer to you, even if not a pedi endo, would be more in tune to this than your pedi is.
Has she had a thyroid ultrasound? Her endo might want to order one of those. It's completely painless. They just squirt some goo (gel as a lubricant) on your neck and run a want over your thyroid to get a good picture of it, check for nodules, etc.
That's all I can think of at the moment, but I'll keep thinking and get back to you if i come up with anything else. Good luck.
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