SocialMedicine Posted July 17, 2013 Share Posted July 17, 2013 Just evaluated a woman with hyperthyroid. TSH undetectable essentially T4 a 16 with T3 much higher. Thyroid Antibodies +. Also seems like she has a hemolytic anemia (hgb 9.7, LDH 450) but a normal reticulocyte count. I uncovered an elevated protein count on chemistry and electrophoresis. Would the antibodies against thyroid be enough to cause an overall gamma globulin elevation? I always preach not obtaining medical advice online but I was unable to aquire this information in a few text readings and for the time I have lost access to medline. She arrived with a Sx of anxiety and irregular menses ... very stable appearance and the symptoms were ongoing for 6 years. Within 1 week of my visit she was in the ER with a thyroid storm diagnosis. So maybe the other symptoms are unrelated and a coincidence [TABLE=width: 100%] [TR] [TD=width: 30%]PROTEIN, TOTAL, SERUM[/TD] [TD=width: 30%]8.7[/TD] [TD=width: 5%] H[/TD] [TD]6.1-8.1 g/dL[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc]F[/TD] [TD=width: 30%] PROT. ELECTROPHORESIS,SER[/TD] [TD=width: 30%][/TD] [TD=width: 5%] [/TD] [TD] [/TD] [TD]TBR[/TD] [/TR] [TR] [TD=width: 2%] [/TD] [TD=colspan: 7] - Faint band visible with overall polyclonal pattern in the[/TD] [/TR] [TR] [TD=width: 2%] [/TD] [TD=colspan: 7] - gamma region. This may represent an inflammatory or acute[/TD] [/TR] [TR] [TD=width: 2%] [/TD] [TD=colspan: 7] - phase response, but a developing plasma cell disorder cannot[/TD] [/TR] [TR] [TD=width: 2%] [/TD] [TD=colspan: 7] - be excluded. Serum and urine immunofixation may be useful, if[/TD] [/TR] [TR] [TD=width: 2%] [/TD] [TD=colspan: 7] - clinically indicated.[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc]F[/TD] [TD=width: 30%] ALBUMIN[/TD] [TD=width: 30%]3.38[/TD] [TD=width: 5%] L[/TD] [TD]3.50 - 4.70 g/dL[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc]F[/TD] [TD=width: 30%] ALPHA-1-GLOBULIN[/TD] [TD=width: 30%]0.35[/TD] [TD=width: 5%] H[/TD] [TD]0.10 - 0.30 g/dL[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc]F[/TD] [TD=width: 30%] ALPHA-2-GLOBULIN[/TD] [TD=width: 30%]0.77[/TD] [TD=width: 5%] [/TD] [TD]0.50 - 1.00 g/dL[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc]F[/TD] [TD=width: 30%] BETA GLOBULIN[/TD] [TD=width: 30%]0.90[/TD] [TD=width: 5%] [/TD] [TD]0.80 - 1.40 g/dL[/TD] [TD]TBR[/TD] [/TR] [TR] [TD=bgcolor: #4c8cbc]F[/TD] [TD=width: 30%] GAMMA GLOBULIN[/TD] [TD=width: 30%]3.31[/TD] [TD=width: 5%] H[/TD] [TD]0.60 - 1.60 g/dL[/TD] [TD]TBR[/TD] [/TR] [/TABLE] Link to comment Share on other sites More sharing options...
rcdavis Posted July 18, 2013 Share Posted July 18, 2013 Which antibodies ( anti-tg, anti-tpo, anti microsomal, anti-thyroid receptor) were positive ? It may be that she has an autosomal thyroiditis.. Did you do immunophoresis to differentiate the immunoglobulins.. If you have these results, I may be able to help you differentiate the form of thyroiditis...TGE concern, of course is her gamma globulinemia... Does she have any lymphadenopathy! Any myalgias?any hilar lymphadenopathy? Any suggestion of other endocrinopathies suggestive of one of the MEA syndromes.. Any plasma cells on the differential? Link to comment Share on other sites More sharing options...
SocialMedicine Posted July 18, 2013 Author Share Posted July 18, 2013 anti tg and tpo present. otherwise normal antibodies. I suspect graves given higher T3 and antibody presence. I met up with her for the second time yesterday and evaluated the GG further ... I did not do a immunophoresis ... however did run autoimmune profile and based on all of her test results she almost certainly has SLE as well. I do not think she had a thyroid storm after all which is what the endocrine MD felt ... rather I think she is having a flare of SLE and will have a conversation with rheumatology asap. Link to comment Share on other sites More sharing options...
rcdavis Posted July 18, 2013 Share Posted July 18, 2013 Nice, sle certainly would explain autoimmune hyperthyroid.. As would early hashimotos. An SPEP would help settle gammaglobinopathy .. Infectious autoimmune, inflammatory, allergic. Btw, I miss the days when we would discuss CASES, and not degrees. I quit being a moderator when a couple other mods jumped in my Cheerios for commenting on a fellow PAs questions about signs and symptoms. This is a professional forum, and, as long as the case is blinded so as to avoid HIPPA, and advise is considered just that advise, I see no problem with it, Certainly is more interesting than a lot of the other stuff..and, in seeing what you are treating, and how you are thinking, you help the rest of us by broadening our ddx and approach to treatments. At least you help me. Link to comment Share on other sites More sharing options...
Guest Paula Posted July 18, 2013 Share Posted July 18, 2013 Interesting case. These cases help me too. It sends me to the "books" to study up on differential diagnoses. Link to comment Share on other sites More sharing options...
Corpsman2PA Posted July 20, 2013 Share Posted July 20, 2013 Btw, I miss the days when we would discuss CASES, and not degrees. I quit being a moderator when a couple other mods jumped in my Cheerios for commenting on a fellow PAs questions about signs and symptoms. This is a professional forum, and, as long as the case is blinded so as to avoid HIPPA, and advise is considered just that advise, I see no problem with it, Certainly is more interesting than a lot of the other stuff..and, in seeing what you are treating, and how you are thinking, you help the rest of us by broadening our ddx and approach to treatments. At least you help me. And as a student reading your thought process and approach, it's a great help. And I don't care what degree you have ;) Link to comment Share on other sites More sharing options...
MedicinePower Posted July 21, 2013 Share Posted July 21, 2013 so as to avoid HIPPA, No such thing. It's HIPAA. Link to comment Share on other sites More sharing options...
Recommended Posts
Archived
This topic is now archived and is closed to further replies.