High TSH, normal levels

[Dolphin40]

Hello

So we are still having problems with my daughter. High TSH with normal levels. GOSH looked into thyroid resistance and said there are no genetic issues. Please can someone advise on her latest results?

4th Jan ‘22 


TSH - 46.90 (0.27-4.2)


FT4 - 14.8 (12-22) 


FT3 - 5.2 (4.1-7.9) 


RT3 - 15 (10-24) 


(25 mcg daily Tirosint)

Finger prick test 2 days ago

Tsh - 46

Ft4 - 16.3 (12-22)

Ft3 6.2 (3.1-6.8 )

Thanks

[Lalatoot]

My only thought was if the thyroid hormones etc were ok could the fault not be elsewhere in the thyroid pituitary loop. Say with the pituitary sending out too much hormone.

[jimh111 in reply to Lalatoot]

That's a possibility but in that case fT3 and fT4 would be high. It's a typical cause of hyperthyroidism.

[Dolphin40 in reply to Lalatoot]

How would we find this out? Her pituitary tests have been done but none of them show an issue 🤷🏻‍♀️

[Lalatoot in reply to Dolphin40]

Sorry can't be of more help apart from guessing.

[jimh111]

RTH usually presents with elevated thyroid CV hormones and a non-suppressed TSH. Her normal hormone levels might rule this out. In about 15% of RTH patients no genetic mutation can be found. I would get hold of a copy of her genetic report just in case it hasn't been tested and the hospital is fibbing.

The high TSH is strange, her TSH could have. very low bioactivity but I haven't heard of this happening. Has a doctor ever done a basic examination, checked her pulse for speed and strength, check her temperature, looked at ankle reflexes? These basic checks will confirm if she is hypo or hyper.

[Dolphin40 in reply to jimh111]

Yes all been done 😞

[June25]

I ran a SPINA test on your daughter's results.

TSH: 46.00* mIU/l

FT4: 16.30 pmol/l

FT3: 6.20 pmol/l

SPINA Results:

GT: <Not computable>

GD: 35.17 nmol/s

sGD: 1.03

TSHI: 6.0*

sTSHI: 4.91*

TTSI: 3408*

Reference ranges that SPINA used

GT: 1.41 - 8.67 pmol/s

GD: 20 - 40 nmol/s

sGD: -2.00 - +2.00

TSHI: 1.3 - 4.1

sTSHI: -2.00 - +2.00

TTSI: 100 - 150

What stands out is that TTSI is way higher than range. In the following link, you will find out the various possible causes of this at chapter 5 on TTSI.

thyroidpatients.ca/2019/06/...

Could I please backtrack a little. I used the most recent results from the finger prick tests. Was your daughter on T4 monotherapy at the time of the test? The SPINA test is not valid for T3/T4 combo therapy.

[Dolphin40 in reply to June25]

How did you do that pls?How do you treat then?

[Dolphin40 in reply to June25]

TSH has to be consistently high with t4/t3 not responding but her results over the past 2 years show she can/ is responding though,

Was anything else indicated when you did it pls? Her practitioner feels t3 is needed

[Dolphin40 in reply to June25]

No just t4

[June25 in reply to Dolphin40]

Thanks for that info. Your daughter's lab results show that she is a very good converter of T4 to T3 and her FT3 and FT4 are at good levels. So how does she feel at these levels?

From the SPINA article I have summarized how to interpret high TTSI:

TTSI data can help diagnose Resistance to Thyroid Hormone (RTH) and other disorders that mimic it, as follows:

1. Recovery from nonthyroidal illness.

2. TSH-receptor blocking antibodies in thyroid-disabled patients on therapy.

"In patients with autoimmune thyroid disease, either Graves’ or Hashimoto’s, or atrophic thyroiditis, pituitary-TSH “ultrashort feedback loop” (sometimes called the Brokken-Prummel-Wiersinga feedback loop) is subject to interference by two types of TSH-receptor antibodies, blocking and stimulating. This makes TSH-FT4 relationships abnormal in cases where thyroid function is impaired and patients are dosing T4. When the TSH-receptor blocking antibodies (TBAb) are active, the pituitary cannot sense its own TSH in circulation, so TSH secretion rate increases abnormally in relation to normal FT4 levels during thyroid hormone therapy. "

The following link expands on this topic: How TSH ultrashort feedback works, and antibody interference,

thyroidpatients.ca/2019/07/...

3. Pituitary TSH hypersecretion may be caused by a pituitary adenoma (TSH-oma).

4. A rare genetic condition called a “partial SBP2 deficiency”

As your daughter has hashis, option 2. may be of special interest.

[Dolphin40 in reply to June25]

The receptor antibodies were tested?

[June25 in reply to Dolphin40]

I'm not sure I understand you. Are you asking if the SPINA test tests receptor blocking antibodies? No, it only has the information from the blood test, ie. TSH, FT3 ans FT4 and from that it suggests possible reasons for the high TSH.

[Dolphin40 in reply to June25]

Sorry no i meant she has been tested for tshreceptor antibodies and there is no problem there 🤷🏻‍♀️

[June25]

How does your daughter feel at at this level of FT3 and FT4?

Was she tested for TSH-receptor blocking antibodies (TBAb) in particular, at the same time as this blood test?

[Dolphin40]

Better than she did on higher levels with a good tsh 🤷🏻‍♀️

Though tummy problems/pains/nausea are still one of the main issues we can’t fix 😞

No previous tests when her levels were not making sense x

[June25]

As your daughter's TSH seems to fluctuate a lot I would suggest that this is more likely to be because of hashis than because of resistance to thyroid hormone. Also, if the problem were RTH then she wouldn't feel better now than she did on higher levels. The important readings are FT3 and FT4. I think her TSH should be regarded as unreliable.

If it is not RTH then I don't see a need for T3. Your daughter is an excellent converter and her FT3 is high in range already.

Sorry I can't help with her other symptoms. Best wishes to you and your daughter.

[Dolphin40 in reply to June25]

Thanks so much for your help x