May 1998 Mailbag

Letter 1

I ran across your web site, I was wodering do you answer questions, I have low
potassium and high blood pressure and weaknes in my body parts.  I urate at
times a whole lot.  I have numbness and tingling in my hands.  Could you tellme what tests to talk to my doctor about taking.Thank You for your question.

Sounds like you need an endocrinology evaluation to rule out primary aldosteronism as the cause of your low potassuim and high blood pressure.  Also, a thyroid check and additional adrenal gland work up as the examining doctor sees fit.

 

Letter 2

After having a right lobectomy of the thyroid gland,  how long is it necessary to continue with lab values regarding thyroid function?   And how often, if necessary after 1 year post op? 

Almost all patients will be able to maintain their TSH and T4 within the normal range after a lobectomy is performed.  The remain lobe will grow and increase the output of thyroxine (T4) to maintain the needs of the body.  About 7 - 8 weeks after lobectomy, checking the TSH and Free T4 will determine if the lobe can suport the body's needs.  After that, a yearly check up in individuals over age 50 would be reasonable, otherwise, in younger individuals, if symptoms of hypothyroidism occur.

 

Letter 3
I have a daughter, 12.5 yrs. old, who has some hormone problems and I was wondering about other avenues of exploration.  She was 20.5 inches and 7 lbs. 7 oz. at birth and grew at about 50% ht. and 50% weight until
third grade when her weight started to increase and her height velocity started to decrease.  In fifth grade, I thought that she was gaining weight in order to get ready for a growth spurt and she also started
breast budding.  Now, at the end of 7th grade, she still has not had a growth spurt nor progressed beyond Tanner stage II.  She has continued to gain weight and seems to have settled at around 135-140 lbs. and she
has grown maybe 1.5 centimeters since 9-1-97 and is 4 ft. 11.5 inches. She has not started her period even though she is over the 105 lb. mark.  Her response to growth hormone stimulation was blunted.  Bone age
is 12.5 yrs. MRI of the pituitary is negative.  Dexamethasone suppressed to 2.7  LH and FSH are normal.  Estradiol is low at 15.  The doctor wants to wait 2-3 months before doing any more tests but my daughter and
I are getting anxious to find the source of the problem.  Jr. high is a tough time to be so different from her friends.  Do you have any ideas? Also, I should mention that her chol. and triglycerides are high (except
HDL low) and her blood presure is normal.  I have a son, 17.5 yrs, who loses too much salt and has asthma and fainting problems.  I have a son, 15 yrs, who has a history of morning, fasting hypoglycemia that
eventually turned into insulin-dependent diabetes, diagnosed at age 12. Now, already, he has too much albumin in his urine and the doctor will be doing some more testing on him.  We live in a town that has only three, overbooked, endocrinologists and no pediatric endocrinologists. Maybe you know of some good ones in the Santa Rosa and/or San Rafael, CA area?   Thank you!

It seems as though you daughter has had an excellent work up to date.  She has a normal bone age and height and weight are still reasonable.  She has not yet menstruated, but shows signs of adrenarche (early Tanner Stage and breast buds).  She has had a negative screening test for Cushing's disease.  At this point I would agree with your doctor...waiting.  Remember, primary amenorrhea is defined as no menstruation by age 17 and your daughter is 12.5!  Regarding the necessity of growth hormone therapy, stature less than the 2nd percentile would be a consideration for treatment.  Your county medical society should be able to help with a referral.  If not, contact the American Association of Clinical Endocrinologists, based in Jacksonville, FL for a mebership listing.

 

Letter 4

I'm a medicine student from Universidad Latina de Panama, I want to review a patient with you (is my mother) because we have diferent opinion in what to do in her case, I will send you her clinical history that made my self, with all the test that she have, I'll try to scan the ultrasound, and a tyroid scintillation (radioactive iodine)but I'm not sure if I can make it.

Clinical History.
Name Eneida Riera S. Civil state: join
age:52 gender: F City: Panama

Actual disease: The patient relate that she feel a little mass in the front part of her neck since two weeks ago, when she had to apply on the neck a medicine for (I don't know what it's his name, but in spanish is cloasma) spots on the check and neck and it hurt when she touch it.

Family antecedents:
Father: dead :complication post operation for a prostate cancer
Mother: dead :gallbladder cancer
Husnband: ----
Parents: brother:3 sister:1 alive
grandmother: dead :trouth cancer
uncle: dead : colon cancer
Family disease:
Falciform anemia: no Tuberculosis: no
Diabetes: no Syphilis: no
Arthritis: no Alcoholism: yes
Cancer: yes Dementia: no
Heart disease: no Epilepsy no
Hypertension: no Hepatitis: no
Hemophilia: no Goiter: no

note: Sister was oper
Personal Antecedents:
Smoke: no
Liquor: no
Drugs: oral anticonceptive and Fosamac
Scholastic dreegre: University
Food: full
Water: drinkable

Pathologic personal antecedents:
Anemia: no Syphilis: no Nephrophaties: no
Hepatitis: no Asthma: no Heart disease: no
Epilepsy: no TBC: no Lungs disease: no
Malaria: no Allergy: no Hypertension: no
Parotitis: yes Diabetes: no Cancer: no
liver disease: no

No others disease.
Interrogatory by system and devices:

Digestive: pyrosis after meals, she deny hematemesis, melena, diarrhea and constipation.

Cardiovascular: She deny thoracic pain, dyspnea, hypertension and edema.

Respiratory: She deny hemoptysis, asthma and cough.

Urinary: She deny frecuently urina, pyuria, hematuria and dysuria

Genital: Pregnancy:4 Birth:3 Cesarea:0 abort:1

Nervous System: normal

Endocrinology System: she deny polyuria, polyphagia,goiter.

Physical exploration:
General Inspection: awareness, good nutritional condition
Head: normal
eyes: normoreactives, symmetrical pupillas, normal fundus of the eye, without icteritious.
Mouth: normal teeth, hydrated mucosa, rest normal.
Nose: without epistasis, without secretions.
ears: clear, otoscopy normal.
neck: present a nodule in the rigth lobule of the tyroid, without adenophaty, without yugular dilatation.
Thorax: normal, symetrical.
breast: normal, without masses, symetrical.
heart: normal, withoutheart bruit.
lungs: normal, without murmurs, without bruit.
abdomen:normal
liver: normal
spleen: normal
extremedity: normal
skin and mucose: normal
Nervous system: normal
Results:

tyroid scintillation:
Description: Growth of the tyroid gland predominantly of the rigth lobule. There is two focal defects in the rigth lobule.
- There is a focal defect of approximately 1 cm of diameter in the medial side of the upper 1/3 of the rigth lobule
- There is a focal defect that occupy approximately the 70% of the inferior 2/3 of the rigth lobule.
The visual index of the tyroid function (relation given by the tyroid activity/ the activity in the salivary gland and the bottom) is normal.

Diagnosis impression:
Nodular Goiter. The focal defects describes in the rigth lobule correspond to a solid cold nodule. Is suggested to consider a biopsy by fine neddle.

Biopsy:
from: rigth lobule.

Hemorragic slide, with a few leucocytes and to little folicular cells without pathology.
Cytologic diagnosis: Negative by malignant cell.

Laboratory:
T4: 9.49 ug/dl (4.5 - 12.5)
TSH: 0.38 uUI/ml (0.3 - 5.0)

One Doctor want to make a surgery of the rigth half of the tyroid gland, he said that it's better to remove it now because althougth it is not malignant, in the future it may become malignant and it's better to do it now, than later. Another said that is better gave she some medicine first to see if the nodule disintegrate, and he prescribe to her: Synthroid (100mg) #100 1 capsule once per day oral.
We haven't decide yet what to do. Would you please discuss the case bettwen you and give me your advice, we don't know wath to do. We will appreciate it.
I'm sorry for all the mistake that I made in here, but I hope you'll understand, I did my best to traslate the case. Any thing that you don't understand or that is not clear, just ask me and I'll find the way to send you the rigth words.Thanks.

It sounds as though your mother has a goiter with a palpable thyroid nodule which was photopenic on the scan.  the isotope used Tc99 or I123 is not known.  The aspiration of the thyroid indicated that there was inadequate amounts of follicular material to make a conclusive diagnosis.  My advice would be to obtain a second aspiration the nodule, preferrable using ultrasound guidance.  Failing to gain a secure diagnosis at that point, perhaps a biopsy or lobectomy would then be indicated to make certain thyroid cancer is not being missed.  also, a serum thyroglobulin level should be obtained as a potential marker for thyroid cancer.

 

Letter 5
 
Is there any place I could find referrals/information about endocrinologists in my area?

The American Association of Clinical Endocrinologists and The Endocrine Society (both links on our pages) maintain a listing of members for referral.

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