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Test Screening Serum thyroid-stimulating hormone (TSH) (sensitive assay) Free thyroxine (FT4) Serum TSH Antithyroglobulin and antithyroperoxidase antibodies Serum TSH (sensitive assay) Triiodothyronine (T3) (radioiodine) 123 I uptake and scan Antithyroglobulin and antimicrosomal antibodies Thyroid-stimulating immunoglobulin (TSI); TSH receptor antibody (TSH-R Ab [stim]) Fine-needle aspiration (FNA) biopsy 123 I uptake and scan 99m Tc scan Ultrasonography Comment Most sensitive test for primary hypothyroidism and hyperthyroidism Excellent test High in primary and low in secondary hypothyroidism Elevated in Hashimoto s thyroiditis Suppressed except in TSH-secreting pituitary tumor or pituitary hyperplasia (rare) Elevated Increased uptake; diffuse versus hot areas on scan Elevated in Graves disease Usually (65%) positive in Graves disease Best diagnostic method for thyroid cancer Cancer is usually cold ; less reliable than FNA biopsy Vascular versus avascular Useful to assist FNA biopsy Useful in assessing the risk of malignancy (multinodular goiter or pure cysts are less likely to be malignant) Useful to monitor nodules and patients after thyroid surgery for carcinoma

hyperthyroidism (Table 26 5) in patients who are clinically euthyroid Serum T4 is frequently low in patients with severe illness, caloric deprivation, or major surgery who have accelerated peripheral metabolism of serum T4 to reverse T3 (rT3) Furthermore, in most patients who are critically ill, there is a circulating inhibitor of thyroid hormone binding to serum thyroid-binding proteins (TBPs) This causes the RT3U to be misleadingly low, causing the computed FT4I to be very low The presence of a very low serum T4 in severe nonthyroidal illness indicates a poor prognosis Direct assays of FT4 often show low levels of FT4 in severe illness Because studies of giving replacement T4 to such patients have shown no improvement in survival, they are considered euthyroid Serum TSH tends to be suppressed in severe nonthyroidal illness, making the diagnosis of concurrent primary hypothyroidism quite difficult, although the presence of a goiter suggests the diagnosis The clinician must decide whether such severely ill patients (with a low serum T4 but nonelevated TSH) might have hypothyroidism due to pituitary insufficiency Patients without symptoms of prior brain lesion or hypopituitarism are very unlikely to suddenly develop hypopituitarism during an unrelated illness Patients with diabetes insipidus, hypopituitarism, or other signs of a central nervous system lesion may have T4 given empirically True secondary hypothyroidism due to direct dopamine suppression of TSH-secreting cells may develop in patients receiving prolonged dopamine infusions Certain antiseizure medications cause low serum FT4 levels by accelerating hepatic conversion of T4 to T3; serum TSH levels are normal

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Functions | Pricing | Pricing Control | Define Condition Tables | Display Condition Tables Press F4 to see a list of condition tables, shown in Figure 8-3, in which we are able to see that none have sales organization, customer condition group, and material fields However, there is a standard condition table 004 that we may use for the second step of accessing a record based on the material only But we ll have to create a condition table for our first access, which we ll do in the next section

Ando T et al Thyrotropin receptor antibodies: new insights into their actions and clinical relevance Best Pract Res Clin Endocrinol Metab 2005 Mar;19(1):33 52 [PMID: 15826921] Bowen RA et al Effect of blood collection tubes on total triiodothyronine and other laboratory assays Clin Chem 2005 Feb;51(2): 424 33 [PMID: 15576427] Helfand M; US Preventive Services Task Force Screening for subclinical thyroid dysfunction in nonpregnant adults: a summary of the evidence for the US Preventive Services Task Force Ann Intern Med 2004 Jan 20;140(2):128 41 [PMID: 14734337]

Weakness, fatigue, cold intolerance, constipation, weight change, depression, menorrhagia, hoarseness Dry skin, bradycardia, delayed return of deep tendon reflexes Anemia, hyponatremia T4 and radioactive iodine uptake usually low TSH elevated in primary hypothyroidism

Hypothyroidism is common, affecting over 1% of the general population and about 5% of individuals over age 60 years Thyroid hormone deficiency affects almost all body functions The degree of severity ranges from mild and unrecognized hypothyroid states to striking myxedema The fluid retention seen in myxedema is caused by the interstitial accumulation of hydrophilic mucopolysaccharides, which leads to lymphe-

Table 26 4 Factors that may cause aberrations in laboratory tests that may be mistaken for primary hypothyroidism1

Low Serum T4 or T3 Laboratory error Acute psychiatric problems Cirrhosis Nephrotic syndrome Familial thyroid-binding globulin deficiency Severe illness Drugs Androgens Asparaginase Carbamazepine Chloral hydrate Corticosteroids Diclofenac (T3) Fenclofenac Flouracil Halofenate Mitotane Naproxen (T3) Nicotinic acid Oxcarbazepine Phenobarbital Penytoion (total T4 may be as low as 2 mcg/dL) Salicylates (large doses T3 and T4) Sertraline T3 therapy True primary hypothyroidism may coexist T4, levothyroxine; T3, triiodothyronine; TSH, thyroid-stimulating hormone

Table 26 5 Factors that can cause aberrations in laboratory tests that may be mistaken for spontaneous clinical primary hyperthyroidism1

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