18-03-2025
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
DESCRIPTION
28y/M
k/c/o Hypothyroidism came for routine follow up
H/o easy fatigability + associated with body pains, not affecting daily life activities
H/o significant Hair loss (according to patient) diffuse, no patchy areas on scalp
H/o weight loss 3kgs in a month
H/o darkish discolouration + around the neck
no c/o constipation, abnormal weight gain, lethargy, palpitations
k/c/o hypothyroidism since his 12 years of age on medication Thyronorm 175mg
H/o constipation +
H/o haemorrhidectomy 2 years back
No other comorbidities
Trunkal obesity +
FAMILY HISTORY:
Father, (RMP by profession), died when the patient was of 4-5 yrs of age, due to unknown diabetic complication.
Mother, (housewife by occupation), died when the patient was an infant (he doesn't know any details about it)
Elder sister, died before he was born, details unknown about her mortality
Younger sister, died when the patient was about 1-2 yr old, details unknown about her mortality
ON PRESENTATION
pt is conscious, coherent,cooperative
Afebrile
Bp:110/70mmhg
PR: 70 bpm
RR: 16cpm
Spo2 :99% at room air
cvs: s1s2 heard, (loud S2, soft S1), no murmurs
Rs: BAE present, normal vesicular breath sounds, no added sounds
P/A: soft and non-tender
Cns : No focal neurological
deficit
No delayed reflexes
grbs : 108 mg/dl
[18-03-2025 19:32] PPM 1: 👆@PPM2 check out this patient's TFT inspite of being on 175 mcg thyroxine since 12 years !!
@PPM3 please remove the images of his eyes as they may serve as identifiers. Also pm @CR the
signed informed consent form for her to create the case report.
[18-03-2025 19.33] PPM 3: Ok sir.
[18-03-2025 19:34] PPM 1: @PPM3 tell us more about how he was diagnosed with hypothyroidism 12 years back and his hypothyroidism journey since last 12 years.
How frequently did he check his TFTs?
[18-03-2025 19:40] PPM 3: He was apparently shorter than his peers in school. So his father, being an RMP, took him to a hospital in Hyderabad and got some investigations done as a general checkup. Which incidentally led to him being diagnosed as hypothyroid.
[18-03-2025 19:41] PPM 3: He doesn't have the documents for previous checkups except for the recent one being 4months ago, by an endocrinologist, sir.
[18-03-2025 19:44] PPM 1: He might remember if his TFTs were controlled since his age of 16 and at
what doses were they controlled then?
[18-03-2025 19:46] PPM 3: Before this endocrinologist checkup, he was on T. Thyronorm 100mcg sir
[18-03-2025 19:46] PPM 1: And we repeated our TFT here after how many days of 175 mcg?
[18-03-2025 19.47] PPM 3: After 10/08/2024 sir
[18-03-2025 19:47] PPM 3: 7 months sir
[19-03-2025 07:20] PPM 1: 👆@PPM2 your endocrine inputs needed here
[19-03-2025 16.33] PPM 1: https://youtube.com/shorts/TCIxvI_3ctM?feature=shared
[19-03-2025 16:41] PPM 2: We need Free T4 and Free T3. How and when is the patient taking the
LTX?
[19-03-2025 16:41] PPM 2: Tbh I would check for Addisons in him.
[19-03-2025 16:43] PPM 2: When does he take his tablets and at what time?
[19-03-2025 16:49] PPM 1: 👆@PPM3
[19-03-2025 18.15] PPM 3: Till now, he was quite irregular with his medications sir. Sometimes he'd
take around 3-4am. Sometimes it's in the morning but he'd only wait for about 15-20mins and have his
breakfast, other times he'd forget to take his dose when travelling.
[19-03-2025 18:19] PPM 3: We asked him to wait for few more days for further evaluation, but he
apparently came unprepared and was willing to follow up with us later.
He's currently on his way home and was asked to review this Friday. But he told he couldn't this week,
but will come next Friday
[19-03-2025 19:55] PPM 1: Is he in this group?
[19-03-2025 19:56] PPM 3: Yes sir
[19-03-2025 20:01] PPM 1: Let's say he's the patient's immediate advocate just so that he
can remain deidentified in all conversations
[19-03-2025 20:01] PPM 3: Okay sir
[19-03-2025 21:09] PPM 2: This very likely answers it.
[19-03-2025 21:10] PPM 1: What could be the reason for his childhood onset
hypothyroidism?
[19-03-2025 21:19] PPM 2: The likeliest reason would be Autoimmunity. Either Hashimoto or as part of
Autoimmune Polyglandular Syndrome.
[19-03-2025 21:20] PPM 2: Which is why I'd offer screening for cortisol deficiency. Both very closely
mimic each other.
[11-07-2025 10.20] PPM 3: 
[11-07-2025 10:47] PPM 1: What was the need for TPO in a patient taking 175 mcg of thyroxine for 12 years? How much thyroxine is he on now? Also if you scan the qr code all identifiers will be visible so deidentification also necessitates removal of qr codes
[11-07-2025 10:57] PPM 3: 1. To confirm hashimoto's or other autoimmune conditions sir. And since his anti-tpo is true high, it'll also rule out any non compliance.
2. Currently he's on 200mcg sir
3. Okay sir
[11-07-2025 12:28] PPM 1: Please explain how TPO is related to compliance!
Also why do we need to confirm Hashimotos after 12 years! How would it change our management?
[11-07-2025 18.46] PPM 3: Excellent questions—let's clarify both the *compliance connection* and *why confirming Hashimoto's matters after 12 years* in this unique case of refractory hypothyroidism (TSH persistently >400).
---
### 1. *How Anti-TPO Relates to Compliance*
Anti-TPO antibodies *do not directly measure compliance, but they help **distinguish between true treatment resistance vs. non-adherence*:
- *If Anti-TPO is POSITIVE*:
- Strongly suggests *autoimmune destruction (Hashimoto's)* is driving high levothyroxine requirements.
- Points toward *malabsorption or comorbidities* (e.g., celiac disease, autoimmune gastritis) as the cause of uncontrolled TSH—*not poor compliance*.
- → Directs workup toward *GI testing, drug interactions, or antibody interference*.
- *If Anti-TPO is NEGATIVE*:
- Makes autoimmune thyroiditis less likely (though not impossible—10-15% of Hashimoto's is seronegative).
- Increases suspicion for:
- *Non-compliance* (patient not taking levothyroxine consistently).
- *Non-autoimmune causes* (e.g., iodine deficiency, pituitary dysfunction, assay interference).
- Rare conditions like *consumptive hypothyroidism* or TSH receptor mutations.
- → Focuses efforts on *adherence counseling, verifying medication quality, or repeating TSH with a different assay*.
#### Key Takeaway:
Anti-TPO status *guides where to look next* when treatment fails.
- ✅ *Positive TPO* → Investigate malabsorption/comorbidities.
- ❌ *Negative TPO* → Prioritize adherence verification and rule out assay errors.
---
### 2. *Why Confirm Hashimoto's After 12 Years?*
Even with a long history of hypothyroidism, confirming autoimmune etiology *changes management in 4 critical ways* for this patient:
#### 🔍 *a) Explains Refractory Hypothyroidism*
- Hashimoto's can cause *ongoing gland destruction*, increasing levothyroxine needs over time.
- Associated comorbidities (celiac disease, autoimmune gastritis) directly *impair T4 absorption*—requiring specific interventions:
- Example: Celiac disease (↑ in Hashimoto's patients) → Gluten-free diet improves T4 absorption.
- Example: Autoimmune gastritis → Low stomach acid → Needs liquid levothyroxine or thyroxine injections.
#### ⚠ *b) Identifies Risk for Blocking Antibodies*
- Rarely, Hashimoto's patients develop *blocking TSH receptor antibodies (TBII)*:
- Accelerate thyroid destruction → Higher T4 doses needed.
- Can interfere with TSH assays → Falsely elevated TSH readings.
- *Action: Order **TRAb (TSH receptor antibody) testing* to check for blocking activity.
#### 🤰 *c) Pregnancy Implications (If Applicable)*
- Hashimoto's (especially with ↑ anti-TPO) *increases risks*:
- Miscarriage, preterm birth, fetal neurodevelopmental issues.
- Postpartum thyroiditis (15% of women).
- *Action*:
- Target TSH *<2.5 mIU/L* in pregnancy (aggressive dose adjustments).
- Monitor TSH every 4 weeks during pregnancy.
#### 🧩 *d) Screens for Associated Autoimmune Conditions*
- Hashimoto's is linked to:
- *Type 1 diabetes* (check HbA1c).
- *Addison's disease* (AM cortisol/ACTH if fatigue/wt. loss).
- *Rheumatoid arthritis, lupus, etc.*
- *Action*: Proactively screen for symptoms/signs of these disorders.
---
### 🚨 Management Changes if Hashimoto's is Confirmed
| *Scenario* | *Actions* |
|----------------------------|-----------------------------------------------------------------------------|
| *Malabsorption* | Switch to *liquid levothyroxine* or *softgel capsules* (bypasses acid-dependent absorption). Space food/meds by 1 hour. |
| *Celiac disease* | Gluten-free diet + recheck TSH in 3 months; may need ↓ levothyroxine dose. |
| *Autoimmune gastritis* | Check B12/parietal cell antibodies; consider B12 injections. |
| *Blocking TRAb+* | Use *free T4 (not TSH)* to guide dosing; liaise with endocrinology. |
| *Pregnancy* | Immediately ↑ levothyroxine dose by 25–30%; target TSH <2.5 mIU/L. |
---
### ❗ Bottom Line
In *stable, controlled* hypothyroidism, confirming Hashimoto's after 12 years is unnecessary.
But in *refractory cases (TSH >400)*:
- Anti-TPO testing is *essential* to:
1. Rule out mimics (non-compliance, assay errors).
2. Unlock targeted workup for malabsorption/comorbidities.
3. Address pregnancy risks or blocking antibodies.
- *Changes management* from empiric dose adjustments to *precision interventions*.
Order anti-TPO now—alongside FT4, FT3, celiac serology, and TRAb—to act decisively.
[11-07-2025 19:29] PPM 1: Thanks. I'm assuming this is chatGPT. There are some areas of hallucinations such as mentioning TSH is above 400! Is it? I'm unable to see the TSH in the reports you have shared above now although I thought it was lower when you uploaded that too in the morning before you deleted them and uploaded again because of the presence of QR codes.
Also the statements made above by ChatGPT also kind of makes an insinuation that the thyroxine replacement dosage may depend on the degree of autoimmune activity? @PPM2
[11-07-2025 19:30] PPM 1: Please ask it to support it's statements above with perplexity styled searchable scientific articles
[11-07-202521.25] PPM 3: Outside TSH has been shown as >150 in documentation, and in another report it was ours it's given as 494. So I presumed the initial test could only detect till 150 or 100 hence anything greater is probably showing up as >(said limit)
[11-07-2025 21.26] PPM 3: This report he got it done outside sir recently
[11-07-2025 21:59] PPM 2: I personally think the Anti TPO antibodies have limited value in diagnosis and no value in dose titration or compliance.
[11-07-2025 22:02] PPM 2: Perhaps this will be a good reflection point for the trainees (including myself) I must admit at the beginning of one's training journey - the focus is on the nitty gritties and all sorts of stuff But as things progress - you tend to focus on patient outcomes.
Another subtle observation I made is that the best doctors are those who understand their economics well. Apart from the inherent value of the TPO in itself - was the journey to the lab for this test and the expenditure worth it? Unlikely.
[11-07-2025 22:05] PPM 2: Especially in a social Healthcare system such as in the UK
Just coming off of a CANC (combined Antenatal endocrine clinic) and one of the Obs consultant wanted the patient to come to the MDAU to get her BP checked 3 times in a 30 minute window. The patient was asking if she can do this herself at home and the consultant refused flatly, saying she wants to take "no risks"
Apart from being a bad decision clinically, this is an economically bad decision as well.
"What is medicine but politics!"
[12-07-2025 07:22] PPM 2: That consultant would be horrified to see and learn from our PaJR BP charts especially how many of our patients have actually been able to stop their anti hypertensive medications after weekly 24 hour home BP recording showed they didn't have any hypertension!
[13-07-2025 22.45] PPM 3: Is there anything we can do for this patient sir?
Other than continuing his thyroxine medication?
[14-07-2025 07.00] PPM 1: For that we need to know his clinical symptoms because till now we were mostly focused in treating his reports?
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