M.W.

, a 70-kg, 23-year-old voice student, thinks that her neck has

become “fatter” during the past 3 to 4 months. She has gained 10 kg,
feels mentally sluggish, tires easily, and finds that she can no longer
hit high notes. Physical examination reveals puffy facies, yellowish
skin, delayed DTRs, and a firm, enlarged thyroid gland. Laboratory
data include the following results: FT4, 0.6 ng/dL (normal, 0.7–1.9)
TSH, 60 microunits/mL (normal, 0.4–4.0) TPA antibodies, 136
international units/L (normal, <0.8)

Assess M.W.’s thyroid status based on her clinical and laboratory

findings.

Answer :

M.W. presents with many of the clinical features of hypothyroidism

These include weight gain, mental sluggishness, easy fatigability, , puffy
facies, yellowish tint of the skin, delayed DTRs, and enlarged thyroid.
The diagnosis of hypothyroidisms confirmed by her laboratory findings of
a low FT4,an elevated TSH value, and positive Thyroid peroxidase
antibodies ( TPA) antibodies. A firm goiter, thyroid antibodies, and
clinical symptoms of hypothyroidism strongly suggest Hashimoto’s
thyroiditis. She has no history of prior antithyroid drug use, surgery, or
RAI treatment, which are common causes of iatrogenic hypothyroidism.
She is also not taking any goitrogens or drugs known to cause
hypothyroidism

Ten days after starting L-thyroxine therapy, M.W. continues to

complain of tiredness, fatigue, and difficulty singing despite excellent
adherence. Thyroid function tests show a TT4 of 4 mcg/dL, an FT4 of
0.5 ng/dL, and a TSH of 40 microunits/mL. What therapeutic options
are available? How should M.W.’s thyroid function tests be
?interpreted

Clinical improvement in the signs and symptoms of hypothyroidism and

normalization of laboratory parameters are appropriate therapeutic end
points. If the replacement dose is sufficient, some correction of her
symptoms should occur after 2 to 3 weeks, but maximal effects will not
be evident for 4 to 6 weeks. Typically, improvement of anemia and hair
and skin changes is delayed and requires several months of treatment
beforeresolution.36,70 In patients with severe myxedema, a transiently
elevated T4 level might occur at 6 weeks because the metabolic clearance
of T4 is decreased by the hypometabolic state associated with
hypothyroidism. FT4 or FT4I and TSH should be checked about 6 to 8
weeks aftertheinitiationoftherapybecauseT4 hasahalf-lifeof7days, and
three to four half-lives are needed to reach steady-state levels. Levels
obtained before this time (as in M.W.) may be misleading and should be
interpreted cautiously. No change in her l-
thyroxinedosageshouldbeattemptedatthistime.