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What does positive anti TPO and heterogenous echotexture in ultrasound suggest?

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Posted on Mon, 21 Jul 2014
Question: TPO ab test=839, thyroglobulin ab test negative, globulin=3.6, cortisol free urine=51, normal tsh, pth=103, abnormal thyroid/parathyroid ultrasound: rt thyroid 5.1x2.x2. w/heterogeneous parenchymal echotexture, no nodules.Left thyroid 4.9x1.7x1.6 heterogeneous parenchymal echotexture, no nodules. thyroid isthmus=3mm,no nodules, questionable ill defined hypoechoic lesion posterior to rt thyroid lobe 3.6x1.1x1.cm difficult to exclude parathyroid lesion. impression:questionable artifact w/in normal tissue vs ill defined parathyroid nodule posterior to thyroid gland. Does this sound bad? MEN1 disease in family.
doctor
Answered by Dr. Binu Parameswaran Pillai (58 minutes later)
Brief Answer:
HEllo

Detailed Answer:
Hello,
Good day.
Noted your history and the MEN1 in family.
The positive anti TPO and heterogenous echotexture in ultrasound is consistent with hashimoto's thyroiditis. Are you taking Levothyroxine?

In this scenario, there can be appperance of nodules ( pseudonodule) in the ultrasound which have to be assessed later. So the "questionable" nodule in posterior aspect of left thyroid lobe is a red herring. Cant give lot of importance to it now, nut need a repeat ultrasound after 3-6 months especially in view of elevated PTH and family history.

Noted that Urine free cortisol is normal. PTH is elevated, but can happen not only in MEN1 but in a number of other situation including Vitamin D deficiency. In view of rise in PTH, you need to get following tests done
1) Serum corrected calcium ( calcium, albumin)
2) Serum Phosphorus( fasting)
3) Urine calcium/creatinine ratio
4) Serum alkaline phosphatase
5) Vitamin D level.

These tests will tell us the reason for PTH elevation. If the phosphorus is low and urine calcium/creatinine ratio is high, then you will also need Xrays of your hands and fingers to look for evidence of hyperparathyroidism. In this scenario, you may also require a DXA scan of Hips/Spine and Forearm bone to assess bone density. You may also require a SESTAMIBI scan. But these tests can wait and we can decide based on above tests. Please relax, your PTH is elevated, but not terribly high. We cant ignore it, but it is not dangerously high.

As part of MEN1 work up, you will also need to do a PROLACTIN level.

Could you explain bit about your family history of MEN1. How is that person related to you. Did he/she had parathyroid adenoma/pituitary tumour ?? Was genetic testing done in that person ?

Would appreciate a reply

Regards
Binu
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Binu Parameswaran Pillai (38 minutes later)
Thank you for your quick reply. My twin sister has it, she had tumors in her lungs, abdomen and had a problem with her thyroid (probably parathyroid). She said she had NET and it was hereditary, so when I look that up, it refers to MEN1. She has had chemo and surgery. My serum calcium is 9.1, albumin is 4.2, phosphorus is 2.5, urine calcium was 290 last month and is 383 this month, prolactin is 9, vitamin D, 25-oh hydroxy is 38, alkaline phosphate is 75, a/g ratio is 1.2, creatinine quant is 2, creatinine clearance is 111 and the creatinine is 1.25, I have osteopenia. I am concerned that a tumor may be in my thymus-relating to the MEN 1, since I do not have flushing, diarrhea, weight loss, etc. so I don't think I have any tumors in the midgut area, but of course, I don't know. Thanks again for your quick reply, XXXXXXX
Also, I am not on any medication, just multi-vitamins. Thanks
doctor
Answered by Dr. Binu Parameswaran Pillai (39 minutes later)
Brief Answer:
Please clarify the Vitamin D units

Detailed Answer:
Thank you for the reply.
I believe your sister had carcinoid tumours. She would had flushing etc at that time.
Not all neuro endocrine tumours refers to MEN ( multiple endocrine neoplasia). Did she have a parathyroid adenoma or prolactin elevation along with the lung/abdomen tumour ??

Your prolactin seems to be normal. Calcium and Phosphorus levels are normal ( I hope it was a fasting sample). Alkaline phosphatase is normal too.
Your urine calcium is elevated ( hypercalciuria). Did you have kidney stones anytime ??.

VITAMIN D of 38, was it ng/ml or pg/L. If it is ng/ml it is normal. If it is pg/L it is low. PLEASE CLARIFY THIS PART

Now the dilemma is, if the elevated PTH is causing the high urine calcium or the high urine calcium is causing the PTH elevation !!!

( Hypercalciuria is a stimuli for PTH elevation and on the contrary, primary hyperparathyroidism itself can cause high urine calcium... But in your case, the blood calcium and phosphorus levels are normal, hence primary hyperparathyroidism is unlikely, but it is possible). In primary hyperparathyroidism, I expect the calcium to be high and phosphorus to be low. But there is an entity called as



I REALISE THAT IT MAY CONFUSE YOURSELF AS WELL AS THE PHYSCIAN. I would suggest to recheck PTH and fasting serum calcium/albumin/phosphorus and urine calcium/creatinine ratio after a month and if PTH is still high, you will need a SESTAMIBI scan. The Thyroid ultrasound need to be repeated in 3 months to look the " questionable" nodule in left lobe.

Regards
Binu

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Binu Parameswaran Pillai (27 minutes later)
Thanks for your reply, the Vitamin D is 38 ng/ml, I have had no kidney stones, but my GFR is 59.38, but the doctor said that since my creatinine is ok, my kidneys are ok. My sister, unfortunately, has disassociated herself from the family and I am not sure about the specifics, except that she is still alive and she was diagnosed 9 years ago with "carcinoid carcinoma", nodules in her lungs, kidney stone and a PET scan showed a tumor in her abdomen. I am waiting for results of a Chromogranin A test. I just had a chest x-ray which the doctor said was normal. I am still concerned about having lung/thymus tumors since I have a consistent cough, neck pain, swelled lymph nodes at my collarbone. I really appreciate the time you are spending on my questions. Thanks again.
doctor
Answered by Dr. Binu Parameswaran Pillai (35 minutes later)
Brief Answer:
Hi

Detailed Answer:
Thank you.
Vitamin D is normal. So yet another cause of elevated PTH is ruled out ( low Vitamin D is another cause of rise in PTH).

With all secondary causes of PTH elevation ruled out, the 2 possibilities are

1) Primary Hyperparathyroidism ( there is an entity called normocalcemic primary hyperparathyroidism).

2) Rise in PTH due to hypercalciuria.

Chromogranin A is a marker of few neuro endocrine tumours. It will not rule out a parathyroid adenoma.

Please do not worry. Chest Xray being normal is reassuring. If you are still concerned about an occult carcinoid tumour, then we can do a urinary 5-hydroxyindoleacetic acid (5-HIAA) level.

Your neck area lymphnode enlargement has to be looked at separately. I am sure that your GP can fix it. However, Ultrasound didn't mention that.

Regards
Binu

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Follow up: Dr. Binu Parameswaran Pillai (52 minutes later)
Thank you!
doctor
Answered by Dr. Binu Parameswaran Pillai (28 minutes later)
Brief Answer:
Hi

Detailed Answer:
You are welcome. I hope i answered your query. You are welcome to ask more questions. But if you have no further questions now, you may please close the query.


Wish you all the best

Kind regards
Binu
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Dr. Binu Parameswaran Pillai

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What does positive anti TPO and heterogenous echotexture in ultrasound suggest?

Brief Answer: HEllo Detailed Answer: Hello, Good day. Noted your history and the MEN1 in family. The positive anti TPO and heterogenous echotexture in ultrasound is consistent with hashimoto's thyroiditis. Are you taking Levothyroxine? In this scenario, there can be appperance of nodules ( pseudonodule) in the ultrasound which have to be assessed later. So the "questionable" nodule in posterior aspect of left thyroid lobe is a red herring. Cant give lot of importance to it now, nut need a repeat ultrasound after 3-6 months especially in view of elevated PTH and family history. Noted that Urine free cortisol is normal. PTH is elevated, but can happen not only in MEN1 but in a number of other situation including Vitamin D deficiency. In view of rise in PTH, you need to get following tests done 1) Serum corrected calcium ( calcium, albumin) 2) Serum Phosphorus( fasting) 3) Urine calcium/creatinine ratio 4) Serum alkaline phosphatase 5) Vitamin D level. These tests will tell us the reason for PTH elevation. If the phosphorus is low and urine calcium/creatinine ratio is high, then you will also need Xrays of your hands and fingers to look for evidence of hyperparathyroidism. In this scenario, you may also require a DXA scan of Hips/Spine and Forearm bone to assess bone density. You may also require a SESTAMIBI scan. But these tests can wait and we can decide based on above tests. Please relax, your PTH is elevated, but not terribly high. We cant ignore it, but it is not dangerously high. As part of MEN1 work up, you will also need to do a PROLACTIN level. Could you explain bit about your family history of MEN1. How is that person related to you. Did he/she had parathyroid adenoma/pituitary tumour ?? Was genetic testing done in that person ? Would appreciate a reply Regards Binu