What does positive anti TPO and heterogenous echotexture in ultrasound suggest?
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
Also, I am not on any medication, just multi-vitamins. Thanks
Please clarify the Vitamin D units
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.
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.
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
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