Question of the Week

For September 19, 2017

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ThyroglobulinThyroid-stimulating immunoglobulinThyroid-stimulating hormone–binding inhibitory immunoglobulinAntithyroid peroxidase antibodyTriiodothyronine

Key Learning Point View Case Presentation

The antibody level that is most often elevated in a patient with Hashimoto thyroiditis is the antithyroid peroxidase antibody level.

Detailed Feedback

Hashimoto thyroiditis, the most common form of thyroiditis in childhood, can manifest as an asymptomatic goiter; thyroid function can range from euthyroidism to subclinical hypothyroidism to overt hypothyroidism. Antithyroid peroxidase antibodies are present in the majority of patients with Hashimoto thyroiditis.

Thyroglobulin, a large protein, is usually measured as a tumor marker in patients with thyroid cancer who have undergone thyroidectomy and radioactive thyroid ablation. Obtaining a thyroglobulin level is not useful in patients who have not undergone thyroidectomy.

Thyroid-stimulating hormone (TSH) receptor antibodies, such as TSH-binding inhibitory immunoglobulin, are a rare cause of hypothyroidism.

Thyroid-stimulating immunoglobulins are characteristically present in patients with Graves disease, which manifests with a low TSH level and symptoms of hyperthyroidism, such as tachycardia and weight loss.

Levels of triiodothyronine (T3) are useful to measure only in the setting of hyperthyroidism, which occurs in patients who have Graves disease. Measuring T3 is unnecessary in the routine evaluation of thyroid function.

Last reviewed Oct 2023.

Citations

Alarcon G et al. Thyroid disorders. Pediatr Rev 2021 Nov; 42:604.   > View Abstract

De Luca F et al. Hashimoto's thyroiditis in childhood: presentation modes and evolution over time. Ital J Pediatr 2013 Jan 30; 39:8.   > View Abstract

32 Comments

  1. mehrdad bohloli September 19, 2017 at 7:25 am - Reply

    Hashimoto is the most common autoimmune thyroiditis and except antiTPO another marker which is antiTBG antibody shall be detected in these patients.

  2. sanjoy September 19, 2017 at 11:42 am - Reply

    Why all these costly tests? A case of puberty goiter, will improve with little dose of thyroid hormone tablets.
    In developing countries this is the simple and most effective way to diagnose and treat after estimation of T3–T4 and TSH.Rich countries can afford other costly and unnecessary tests.

    • Robert Howe MD September 19, 2017 at 11:52 am - Reply

      A TSH test costs about $3 and peroxidase antibodies are also cheaply obtained (and quickly, my local lab has same day results). Many of us would argue that establishing a correct diagnosis is fundamental to treating a patient.

    • James Simons September 19, 2017 at 11:56 am - Reply

      In this case there was just one additional test. It supports the mildly elevated TSH and makes the diagnosis. I don’t think you can argue that this was an expensive fishing trip.

    • Pranav Gupta September 20, 2017 at 10:13 am - Reply

      Cost of getting anti-TPO is similar to TSH, T4, T3, etc. Getting diagnosis prior to institution of treatment has always been helpful.

      • Amit Rastogi September 25, 2017 at 11:31 pm - Reply

        The cost in India for Anti TPO antibodies is 4 times more than what it cost for T3T4and TSH. However I agree in that the correct diagnosis be established. Other simple option would be FNAC ..

    • dr. ainulwara September 21, 2017 at 10:42 am - Reply

      Puberty goiter does not show high TSH levels. There is difference of treatment, if no symptoms but high TSH is there we must think about hashimato’s thyroiditis which need life long thyroxine to prevent overt hypothyroidism complications. Child did not cross puberty so we can not comment on menstrual cycle which can be the sole symptom sometimes. With subclinical hypothyroidism if no other symptom is there only anti TPO decides the introduction of treatment.

    • Ash Sharma October 12, 2017 at 10:20 am - Reply

      The reason why you’d like to test for anti TPO antibodies is because Hashimoto’s thyroiditis is linked to thyroid lymphoma and the timelines may vary but generally a patient develops lymphoma 10 years after being diagnosed as Hashimoto’s. So you’d like to do that test not because its an excessive burden, but you can save someone’s life by being vigilant.

  3. Gordon D Deraps MD September 19, 2017 at 11:56 am - Reply

    It might be ip to know if cold has had urtkcaria or rash that has been associated with APO antibody. Would also be interested if patient has been exposed to peroxide or black molds?
    Suspect mod allergy antibodies are directed at the peroxide molecule and fluconazole acts to inhibit the mold peroxidase.
    Have had allergic reaction tomold with elevated IGE and positive ATPO thyroid tests otherwise are normal limits. A. Following these tests. Po

  4. Juan Carlos Tinoco September 19, 2017 at 12:11 pm - Reply

    This a typical case of Hashimoto Thyroiditis.
    Ver easy case!

  5. Dror September 19, 2017 at 12:22 pm - Reply

    In my opinion you should first check T4 and T3 to pestablish the diagnosis of overt hypothyroidism. Than you can continue woth anti thyroid antibodies.

    • Dr Gerret Paulsen September 20, 2017 at 6:44 am - Reply

      quite right ! TSH elevated necessitates measuring fT4, this was not given as a choice, so I also opted for fT3, but in practice one usually orders TSH , fT4 , MAK (TPO-Ab) .

    • Pranav Gupta September 20, 2017 at 10:16 am - Reply

      Even if T3, T4 are normal with elevated TSH, subclinical hypothyroidism would need to be treated. So, why invest in those investigations?

  6. Erfani.K. September 19, 2017 at 12:47 pm - Reply

    How about C.B.C. CRP.and ESR.?

  7. mohammed moinuddin September 19, 2017 at 2:09 pm - Reply

    Elevated TSH indicates primary hypothyroidism. T4 is usually done to differentiate subclinical hypothyroidism from hypothyroidism (normal in former, low in latter).T3 is a poor choice for the diagnosis of hypothyroidism because it is the last test that becomes abnormal in hypothyroidism. However, in children, in the circumstances described above, she is likely to become hypothyroid and therefore can be started on thyroid supplement making serumT4 redundant.
    Dr Derapas….can you please clarify your points
    I agree with Drs Simons and Howe.

  8. Tulin isik September 19, 2017 at 2:38 pm - Reply

    Nice and easy case thanks

  9. MOHAMMED HASHEM September 19, 2017 at 8:00 pm - Reply

    Dr Sanjay, to treat a Pt correct diagnosis is a must. Yes, it could be Puberty goitre as you said. But you need to think about d/d as in this case Hashimoto’s thyroiditis. So we should get Anti TPO Ab to confirm diagnosis. Giving Thyroid hormone replacement without confirming diagnosis is practicing like a quack which is very much prevalent in developing countries.

  10. William Mattey September 19, 2017 at 8:49 pm - Reply

    Good case… thanks …always informative.

  11. Timothy Lane, MD September 19, 2017 at 9:34 pm - Reply

    I ask what further test(s) change treatment and management. Sometimes “quacks” recognize a duck and treat it with minimal testing. This is age old question with testing driven by the Endocrine Society and desire to please others.

  12. Rasoul Ghasemian September 20, 2017 at 12:16 am - Reply

    Thankyou for your questions.
    Is it not necessary to check thyroid hormone level in this patient?For example if her thyroid hormones are very low ,Central hypothyroidism would be possible!

  13. Alhoussein Abdel Aal. MD September 20, 2017 at 2:08 am - Reply

    Very nice case
    But you should also check free T4 level because after one month of starting thyroxin, the adjustment of dose will depend on free T4 level because TSH will take 3-6 mo to come back to normal

  14. elias azar September 20, 2017 at 2:23 am - Reply

    as always a very interesting case.

  15. steve verbinski September 20, 2017 at 12:34 pm - Reply

    There seems to be some debate as to whether or not to check antiTPO antibodies. I was taught to check these in such a case. However i’m curious how would it change management if they were negative? What further testing would this prompt, and how would that affect choice of treatment?

  16. Bernardo Bergroth September 20, 2017 at 12:45 pm - Reply

    Confused question? want to confirm hypothyroidism o tiroiditis ?

  17. Lanfranco de Clari September 20, 2017 at 12:49 pm - Reply

    In a case like this superb one, it where much more interessant to look if the patient also has OTHER AUTOIMMUNE ABNORMALITIES besides Hashimoto’s .

  18. Bushra Mufty M.D. September 20, 2017 at 1:34 pm - Reply

    how about confirming diagnosis with fine needle aspirate ?specially when thyroid is hard to palpation?

  19. mohammed moinuddin September 20, 2017 at 5:22 pm - Reply

    In this educational wonderful forum, there appears to be no communication or answers to the questions asked.
    For example:
    Bushra Mufty MD…… ANTI TPO is a non invasive test and Thyroid FNA, although beningn is still invasive procedure.And in these circumstances it gives the same information.
    de Clari MD…..Yes, it may be worthwhile
    Verbinski, MD…..anti TPO titres, if hi may indicate the progression to overt hypothyroidism and also can differentiate puberty goitre from Hashimoto`s
    AA Aal, MD….. in graves` disease the TSH may take longer time to become normal than T4 rather than in hypothyroidism to drop to normal from elevated levels
    R Ghasemian, MD….If T4 is low it confirms primary hypothyroidism. TSH is normal or low in Secondary (Pit) hypothyroidism.
    T3 is the last test among T4 and TSH and T3 to become abnormal in hypo thyroidism

  20. Sergio Costa September 21, 2017 at 5:23 am - Reply

    Easy and very nice case. Thanks.

  21. Carol Roberts, MD, ABO&HNS, ABIHM September 21, 2017 at 11:51 am - Reply

    In my experience a patient like this should be tested for iodine levels. We still have a lot of goiter in this country, now more than ever, that is due to low iodine (dietary choices and poor soil) as well as competing halogens – fluorine, chlorine and bromine, which are abundant in the environment. Giving iodine will fix that and the child is not committed to taking thyroid meds for the rest of her life. Don’t forget the rest of the family too, they may be low in iodine! It’s not just the goiter belt anymore, now everyone is at risk!

    • Gil Holmes, MD September 28, 2017 at 1:14 pm - Reply

      It is really really hard to be iodine deficient in this country. When I had thyroid cancer and was eating a low iodine diet in prep for my scans, it was almost impossible to find non-organic food that was not supplemented.
      We spent double our normal grocery bill going to organic stores to assure minimal iodine intake. One does not just accidentally eat a low iodine diet in the US.

  22. Ronak September 21, 2017 at 12:26 pm - Reply

    Before any comment one should read basics of thyroid hormone synthesis. The approach to choose the answer TPO antibody in the absence of any clinical history and from available choice seems appropriate.

  23. Dr.Muhammad Arif Rana. September 25, 2017 at 9:30 am - Reply

    Dear respected Sir/Mam,
    Please, send your autistic children/children to schools for productive education by the supervision of own parents/own family members(brothers/sisters/grand parents etc.) and by the guidance of school teachers to become good and realist citizens of a nation. Parents ought to send their children/autistic children to doctors /GP/FP/counselors/psychologists/psychiatrists/nurse-scientists doctors for their mental-physical soon recovery (if they need treatment-counseling by the observation of parents/doctors).Parents/children/autistic children/physicians/counselors/teachers are productive human resources due to their social-educational -humanity roles towards development of a society and nation.
    With kindest regards.
    Dr.Muhammad Arif Rana.
    (General Practitioner-Family Doctor-Counselor)-SIG.
    Manikgonj-1800,Bangladesh .
    September 25,2017.Monday.
    07:29 pm.

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