new_n_lost
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A 32-year-old previously healthy woman has a 1-year history of palpitations, sweating, heat intolerance, and intermittent diarrhea. She has lost 12 lb despite a good appetite. Her niece had neonatal hypothyroidism. Physical examination reveals an anxious woman with a pulse rate of 120/min and blood pressure of 120/80 mm Hg. She exhibits a fine tremor of the hands and has moist, warm palms. Laboratory investigation shows elevated free T3 and T4 as well as increased plasma TSH levels.
Wh ich of the following is the most likely diagnosis?
A. Graves disease
B. Multinodular toxic goiter
C. Hypothyroidism of hypothalamic origin
D. Primary hypothyroidism
E. Myxedema
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| me007
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it looks like secondary hyperthyroidism
of all given - b, but i can't explain
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| Ancylostoma
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B- all the other possibilites would have a decrease in t4, except for graves that would have an depressed tsh and increased t4. That leads me too multinodular goiter, which is created due to iodine defeciency(MC) and elevated tsh. When it becomes toxic , it produces thyroid hormone. I guess if you suddenly repleneshed the iodine it may increase the T4. I just dont know why it wouldn't lower the tsh immediatly. Something to do with the binding globulin maybe.
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| Ancylostoma
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Maybe not, there is an article that says something about mutations, I didnt want to read it because it is way to long. http://edrv.endojournals.org/cgi/reprint/26/4/504... thats the link if anyone does!!
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| new_n_lost
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The Reason i posted this Question is that there is a dilemma. Its has been Specifically Mentioned in the Answer given that the Choice is A Graves diseaseand that is the CORRECT CHOICE According to the book. the explanation given is that In Most cases of Graves Hyperthyroidism, an IgG Antibody to TSH receptors known to stimulate the thyroid cells is present in the pt.'s serum. Choice B primarily occurs in Elderly pts. This is wht they have said
Any advices fellas ??
Edited by new_n_lost on 02/03/07 - 09:52 PM
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| mytime
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Here u go..It's a pitutary tumor secreting TSH..which is rare! Leading to Secondary Hyperthyroidism! So Ans. A is right. Here's something to go with it!
The blood levels of thyroid hormones can be measured directly and usually are elevated with hyperthyroidism. However, the main tool for detection of hyperthyroidism is measurement of the blood TSH level. As mentioned earlier, TSH is secreted by the pituitary gland. If an excess amount of thyroid hormone is present, TSH is "down-regulated" and the level of TSH falls in an attempt to reduce production of thyroid hormone. Thus, the measurement of TSH should result in low or undetectable levels in cases of hyperthyroidism. However, there is one exception. If the excessive amount of thyroid hormone is due to a TSH-secreting pituitary tumor, then the levels of TSH will be abnormally high. This uncommon disease is known as "secondary hyperthyroidism."
Although the blood tests mentioned previously can confirm the presence of excessive thyroid hormone, they do not point to a specific cause. If there is obvious involvement of the eyes, a diagnosis of Graves' disease is almost certain. A combination of antibody screening (for Graves' disease) and a thyroid scan using radioactively-labelled iodine (which concentrates in the thyroid gland) can help diagnose the underlying thyroid disease. These investigations are chosen on a case-by-case basis.
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| new_n_lost
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Hey Guru Ji whts the reference plz
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| Ancylostoma
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Graves is a TSI = Thyroid stimulating immunoglobulin, it stimulates the thyroid to produce t4, but elevated t4 clearly depresses tsh. Check the question again and make sure that it says elevated tsh becuase the only way it can be graves is with a decreased tsh.
I thought this was funny, but I went with the answer I was least familar with, multinodular goiter turns into toxic goiter when we replace the iodine that was originally low and lead to the original goiter. That elevated t4 would lead to depressed tsh but I thought maybe I was overlooking something.
Finally, 2ndary hyperthyroidism, would be correct, of even tertiary in the hypothalamus if that was possible, but the option is simply not there. Graves is not just a hyperthyroism, but a speciic autoimmune disease.
So I think they made an error in the question and it was supposed to be elevated t3 and t4 with a depressed TSH
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| new_n_lost
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I have i Chked n rechked the question n the answer is the same All increased n this question is also printed in USMLE ROAD MAP to Physiology 2003 ed. Pg 171
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| Ancylostoma
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I dont have the question, but you can see the lab values if you want on graves in goljan's nedocrine path notes, I just finished the thing yesterday. It clearly is a screw up.
See first line of second to last paragraph http://www.suite101.com/article.cfm/graves_diseas...
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| new_n_lost
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Alright i think its now safe to say that after an extensive research just to be sure abt the entire topic i think its A CLEAR MISPRINT in the Questiosn cos if the Answer is Graves disease then i can assure u that the TSH LEVEL SHUD BE LOW IF AND ONLY IF the cause is Primary And if we find that the TSH levels r Increased then its Definitely Sec.Hyperthyroidism n the casue is more central i.e Pitutary tumors
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| darkhorse
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TSH definitely suppressed in Graves...however even in Toxic multinodular goitre TSH is suppressed by negative feed back...now what
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| mytime
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NNL u better tell them what u have learnt. and Y Grave's is scorrect!
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| new_n_lost
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Well there is only one possibility that this particualr pt has Graves with a TSH secreting Pituitary Adenoma, this is the only reason as to y the TSH is raised. So there is a possiblility of rarest condition.
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| darkhorse
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I m sry...but i never heard about such condition ...grave's by pitutary adenoma....can u plz give some reference.
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| mytime
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Google search...honey!!!!!!!!!
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| Ancylostoma
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What is this? A case on house MD?(Favorite show)
lol I dont want to say crap, but this is purely crap. While there may be some once in a million chance of a condition like this, I will say that if you pick graves in the step 1 with a elevated tsh you will get the answer wrong Period. Please stop smoking that weed and get on the goljan wagon. Books commonly make dumb errors as you have seen in first aid, as well as in questions.
Edited by Ancylostoma on 02/05/07 - 01:56 PM
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| new_n_lost
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Dude it aint Graves by PT Adenoma its Graves + Adenoma ok
Besides the Actual Exam doesnt present with rare possibility of disease. Yes books do make insane errors.
Weed !!!!!!!! lol
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