13 y/o Goiter with Normal Labs

[Amielpz]

My daughter complains of unexplained intermittent ear and neck pain and at times feels as if she gets choked easily(rarely).  This happened about 6 months ago which resulted in a CT of neck which found an incidental 5mm thyroid nodule.  Her ped. drew Thyroid labs( TSH,T3,T4) which came back normal so she didn't feel it needed any f/u.  I made an apt with a Ped. Endo for f/u and we just had her thyroid ultrasounded. He didn't specify if he felt the nodules looked benign, but Im assuming that they must have if he didn't note it. The US Tech (30 years of experience that I work with) told me of the goiter but also stated that she had increased vascularity that he felt consistent with thyroiditis, however this was not mentioned by Radiologist.
Right lobe:  3.6*1.3*0.8
Left lobe:   4.5*1.6*0.8
Isthmus:     0.2cm
There are multiple small nodules in both thyroid lobes, the largest being in the left measuring 0.6*0.4*0.5cm
Impression:  Findings Consistent with multinodular goiter.
My question is with normal labs, is this just something that we leave alone in a 13 year old or is it more concerning with normal labs?  She doesn't have a follow up appt for another month.  Thanks

[Amielpz]

Hi. Barb, I was just looking back at our posts and wanted to update you if you are still on here.  My daughter is followed by a ped. endo who orders tsh/free t.4 every 9 months with ultrasound.  So far, the ultrasound is always unchanged..multinodular goiter.  Her most current labs were T4: 0.9 (range 0.9-1.8) and tsh: 1.7 ( 0.4-6).    She continues with abd bloating, reflux, constipation, freq h/a.'s, . complains a lot of leg numbness, and seems to be getting a lot of anxiety.  She carries weight around her belly, even though she is an athlete and very active, she has puffy hands, feet, and neck.  She is 15 y/o 5'2 about 138-140.  She is complaining of something daily and I am trying to differentiate...could this be her thyroid, or do I simply have a "complainer" on my hands.  Thanks for any insight.  

[Amielpz]

Thank you for all your help! I will ask. She goes back end of December.

[Barb135]

Constipation and puffiness are prime symptoms of hypo.. not all symptoms last for long periods of time.. I used to have "intermittent" symptoms, too, until I became really hypo and my symptoms hung around most of the time.

"She gets I'm (sic) the car in 40 degree weather and turns the air on".. would this be after participating in heavy sports?  

Here's my experience:   I was hypo for some time before being diagnosed.  I walk every morning, for about an hour.  When I leave the house it can be cold because of a higher than normal wind or just downright cold.  As I walk, my body builds up heat and if there's not a way to dissipate that heat (removing a jacket, etc), when I come into the house (or anywhere out of the wind) I feel really warm.

Is there any way you can get her doctor to give a trial dosage of thyroid  hormones, based on the low FT4?  If not, insist on an FT3 test.

FT3 is the hormone that individual cells use, and which correlates with symptoms, so insist that they test for that, next time thyroid tests are done.  She should receive FT3, FT4 and TSH, every time thyroid labs are done.

[Amielpz]

Another thing I find interesting is that  unlike hypo,  she stays hot. She gets I'm the car in 40 degree weather and turns the air on.. She is big into sports but even when she hasn't been playing sports she's hot.

[Amielpz]

Only constipation and intermittent puffiness where one week she looks heavy with swollen face and neck but the next week she looks ' normal'  ( not sure if that would be thyroid related or not),

[Barb135]

Your daughter's FT4 is quite low in the range (only 22%); does she have symptoms of hypothyroidism, other than the ear pain?  Many people are hypo, even with labs in thr normal range.  

It's possible that she really does have Hashimoto's, but the antibodies just haven't ramped up yet.  I'd have them tested again in a few months.

[Amielpz]

thyroid TPO Ab   < 10.0.  Range ( 0.0-35  IU/ml)
Thyroid globulin Ab  <20.  Range. ( 0.0-35.0)

[Barb135]

I don't think you need a biopsy; thyroid nodules are common and hers are very small, so it's unlikely that they'd even be able to get adequate tissue.  Most of us with Hashimoto's have nodules.

What were the actual results and ranges of the antibody tests?

[Amielpz]

Her antibodies were negative
Lab work was:    free thyroxine. 1.1.   ( 0.9-1.8)
                             TSh.               0.983. ( 0.400-6.000)

With labs being normal should I be requesting a biopsy? Thanks

[Barb135]

Thyroiditis is a "flare" of swollen/inflammation... yes, it could cause intermittent pain.  Thyroiditis is also indicative of Hashimoto's -- another reason for getting antibodies tested.

[Amielpz]

Thank U! No none at all thus far.. And she knew that only those two tests were done by her pediatrician... If she has thyroiditis ( as the US tech thought she did) can that cause intermittent neck pain? Thanks for your help!!

[Barb135]

Unfortunately, the thyroid blood tests don't really tell a lot.  Thyroxine is T4, which is the main hormone produced by the thyroid, but it's Total T4, which is considered obsolete and of little value.   Of that T4, a lot of it will be bound by protein and unusable.  We need to know the amount that's not bound by protein and is "Free" to be converted to T3, which is the active hormone.  Apparently, T3 wasn't tested?

Your daughter also needs to be tested for thyroid antibodies, to determine whether or not she has an autoimmune thyroid disease called Hashimoto's Thyroiditis.  

Is she scheduled to have blood work again, before she goes back to the doctor in a month?  If so, do know what tests are being run?

[Amielpz]

Thanks! The two labs they checked were:  TSH-  2.456 range is 0.400-6.00. And Thyroxine is 8.7.  Range was 4.5-10.9

[Barb135]

What were the actual results of the TSH, T3 and T4, and were those Free or Total T3/T4?  Please post the results and include reference ranges, as those vary lab to lab and have to come from your daughter's own report.

Has your daughter been tested for thyroid antibodies?  Does she have any other symptoms of either hypothyroidism or hyperthyroidism?  

Multinodular goiter is very common and is usually nothing to worry about.