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A Girl with Goiter and Inappropriate Thyroid-Stimulating Hormone Secretion

¹ Department of Laboratory Medicine, Children’s Hospital Boston, and Department of Pathology, Harvard Medical School, Boston, MA;² Division of Endocrinology, Children’s Hospital Boston, and Department of Medicine, Harvard Medical School, Boston, MA.

^aAddress correspondence to this author at: Department of Laboratory Medicine, Children’s Hospital Boston, Farley 720, 300 Longwood Ave., Boston, MA 02115. E-mail mark.kellogg@childrens.harvard.edu

The first 300 words of the full text of this article appear below.

CASE

A 15-year-old white girl presented with neck tenderness. On examination, a nodule was palpated in the right thyroid lobe. The neck was supple without abnormal lymphadenopathy. Eye findings related to Graves orbitopathy were absent. Weight, height, and blood pressure were unremarkable, but the heart rate was high at 104–114 bpm. The patient had a history of attention deficit hyperactivity disorder and was taking atomoxetine and fluoxetine. There was no history of childhood neck irradiation or family history of thyroid cancer. Several maternal relatives have acquired thyroid dysfunction.

Sonography showed a 2-cm nodule in the right thyroid lobe. Fine-needle aspiration showed benign cytology, but the family requested right thyroid lobectomy for persistent neck tenderness. Preoperative laboratory data revealed a total thyroxine (T₄)¹ concentration of 170 nmol/L [reference interval (RI) 67–138 nmol/L] (13.2 µg/dL, RI 5.2–10.7), total triiodothyronine (T₃) concentration of 3.2 nmol/L (RI 1.3–2.4 nmol/L) (206 ng/dL, RI 86–153), a thyroid-stimulating hormone (TSH) concentration of 0.5 mIU/L (RI 0.3–5.0 mIU/L), and a thyroid hormone binding ratio (1/T-uptake) of 1.72 (RI 0.77–1.16) (Table 1 ). Analyses were conducted by chemiluminescent immunoassay on the Roche Elecsys 2010 platform. Free T₃ and free T₄ indices as calculated by the clinicians were 5.5 nmol/L (RI 1.3–2.4 nmol/L) and 292 nmol/L (RI 67–138 nmol/L), respectively, and, in the context of the patient’s normal TSH concentration, suggested the possibility of inappropriate TSH secretion due to resistance to thyroid hormone or a TSH-secreting pituitary adenoma. Analyses for serum free T₄ measured by direct dialysis and RIA were conducted at Mayo Medical Laboratories and revealed a normal free T₄ of 16.8 pmol/L (RI 10.3–25.8 pmol/L) (1.3 ng/dL, RI 1–2 ng/dL). Although certain of the patient’s features, including her tachycardia (1)(2), were consistent with the syndrome of inappropriate TSH secretion, this syndrome is extremely . . . [Full Text of this Article]

DISCUSSION

POINTS TO REMEMBER

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