Category: Thyroid

Monitor: 24

24 - PUZZLING THYROID FUNCTIONS TESTS: EUTHYROID HYPERTRIIODOTHYRONINEMIA [AND HYPERTHYROXINEMIA] DUE TO MULTIPLE MYELOMA

Thursday, Apr 25
11:30 AM – 12:00 PM

Objective : To report an interesting case of “Euthyroid” hypertriiodothyroninemia [and hyperthyroxinemia] due monoclonal immunoglobulins of multiple myeloma, causing assay interference and spurious results.


Methods :

58 year wheel chair bound man was referred by Orthopaedic Surgeon to rule out endocrine cause for multiple vertebral fractures and severe back pain. MRI Spine: Compression osteoporotic # D6, D7, D12, L1, L3 Vertebrae. Had been treated with Bisphosphonates X 10 months, Teriparatide X 2.5 months. Medical history: Right Proximal lower limb DVT, recurrent pulmonary embolism, permanent IVC Filter implantation; hypertension; type 2 diabetes; IHD SVD LAD, S/P CABG.


Results :

Clinical/laboratory evaluation Secondary osteoporosis: Multiple Myeloma [Diagnosis missed 4 years]. Hypogonadotropic hypogonadism. Clinically Euthyroid: Height: 165cm; Weight: 74.5kg; Pulse: 109/min; BP: 172/111mmHg; BMI: 28; Thyroid: Grade 1.


Puzzling baseline thyroid profile: Baseline thyroid profile Total T3 levels >4 times upper limit of normal ULN, Total T4 1.2 times ULN, TSH high normal, Free T4/T3 mid normal.


Chemotherapy: 12 cycles Bortezomib 2mg; Thalidomide: 100mg daily; Radiotherapy D12, L1 vertebrae.


Follow up thyroid profile: Most interestingly, thyroid profile completely normalised post successful chemotherapy [and amelioration of myeloma immunoglobulins], showing Total T3, T4 and TSH levels in the normal range.


Year                                                     2016                                                    2017


                                                             Before                                                 After


                                                             Chemotherapy                                   Chemotherapy                      


Total T4 (4.5-12 µg/dl)               14.5                                                     7.4


Total T3 (60-200 ng/dl)           > 800                                                     99


TSH (0.30-5.5 µIU/ml)               4.67                                                     0.88


Free T4 (0.70-1.80 ng/dl)           1.1             


Free T3 (1.7-4.2 pg/dl)               2.9            


Protein Total (5.7-8.2 gm/dl)      12.7                                                       5.5


S Globulin (2.50-3.40 gm/dl)    9.3                                                        2.1


M Band gm%                             9.9                                                       0.19


IgG Total (7000-1600 mg/dl)     10200                                                   455


TPOAb: 147 IU/ml (< 34)


Discussion : Monoclonal Gammopathy:  Presence of monoclonal immunoglobulins in serum or urine, occurring in multiple myeloma, can cause assay interference and spurious results. It is important to recognize that multiple myeloma is one of the causes of falsely elevated thyroid hormone levels. In the background of persistent “Euthyroidism”, TSH levels dropped from 4.67 to 0.88 post chemotherapy, suggesting that these immunoglobulins were perhaps “slightly” interfering with T3/T4 negative feedback at the thyrotroph level?


Conclusion :

Monoclonal Immunoglobulins from Multiple Myeloma binding to Thyroid Hormone: 3 Cases reported till date


First case: High Affinity to T4


Second
Case: High Affinity to T3


Third
Case: Very High Affinity to T3 + Slightly High Affinity to T4 [Our case].

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Reshma B. Vijay

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes and Metabolism
Clinical Interests: Pediatric Endocrinology; Diabetes mellitus; Insulin Pumps, Continuous Glucose Monitoring and Artificial Pancreas; Growth and Puberty; Thyroid; Pituitary Adrenal disorders

Kavitha Muniraj

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty; Director Medical ; Director Research; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction; Diabetes Pharmacotherapy; Clinical Pharmacology; Pharmacovigilance; Clinical research Safety and Audits

Vasanthi Nath

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes, Internal Medicine, Geriatrics
Clinical Interests: Neuroendocrinology and Neurometabolism, Metabolic Myopathies; Thyroid tumors, Geriatric Endocrinology, Inpatient Diabetes Care and Endocrine Emergencies; Type 1 diabetes across ages

Chandraprabha S

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology Diabetes Metabolism
Clinical Interests: Pregnancy Diabetes, Pregnancy Thyroid Dysfunction, Women Health, Geriatric Endocrinology, Diabetes mellitus and Mental Health, Spiritual Medicine

Babitha D. T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty
Specialties: Endocrinology, Diabetes
Clinical Interests: Endocrine disorders of pregnancy, Pregnancy Diabetes, Cardiovascular Health, Thyroid, Inpatient diabetes care and endocrine metabolic emergencies

Muralidhara Krishna

Consultant Faculty Endocrinology Diabetes Biochemistry
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty: Endocrinology Diabetes Metabolism; Associate Professor: Clinical Biochemistry and Laboratory Medicine
Specialties: Endocrinology Diabetes Metabolism; Clinical Biochemistry
Clinical Interests: Diabetes mellitus; Thyroid Disorders; Obesity; Dyslipidemia.

Jayalakshmi T

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, Karnataka, India

Designation: Consultant and Faculty

Specialties: Endocrinology, Diabetes, Internal Medicine,
Clinical Interests: Diabetes mellitus, Cardiovascular Health, Thyroid, In Patient Diabetes Care, Endocrinology Metabolic emergencies and critical care

Nidhi Garg

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
bangalore, Karnataka, India

Designation: Senior Consultant and Faculty
Specialties: Diabetes and Metabolism
Clinical Interests: Comprehensive diabetes care, In-patient diabetes and metabolic care, Perioperative diabetes management, Diabetes and endocrine emergencies – Metabolic Intensive Care, Obesity management, Lipids and preventive cardiology, Gestational diabetes, Thyroid disorders, Type 1 diabetes across ages

Apoorva Govind

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center
Bangalore, India

Designation: (a) Fellow: Endocrinology Diabetes Medicine, Samatvam Endocrinology Diabetes Centre and Jnana Sanjeevini Medical Centre and Diabetes Hospital ; (b) Co Investigator – Clinical Research, Samatvam Science and Research Center

Specialties: Endocrinology, Diabetes, Internal Medicine

MD Chitra

Consultant Faculty Endocrinology Diabetes
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Consultant and Faculty; Trustee
Specialties: Endocrinology Diabetes; Clinical Research
Clinical Interests: Diabetes, Obesity, Dyslipidemia, Osteoporosis, Pituitary Adrenal disorders; Bone health; Cardiovascular Health; Thyroid dysfunction;

Vasudha Srikanth


India

Sathvik Reddy Chinna Bainagari

Resident Doctor
Samatvam jnana sanjeevini Diabetes hospital and medical center
Chittoor, Andhra Pradesh, India

Siddartha Dinesha

Resident, Medicine Diabetes Endocrinology
Samatvam Jnana Sanjeevini Diabetes Hospital and Medical Center

Designation: Resident: Medicine; Endocrinology Diabetes, Samatvam Endocrinology Diabetes Centre and Jnana Sanjeevini Medical Centre and Diabetes Hospital
Specialties: Endocrinology, Diabetes, Internal Medicine

Nalini Rayas

Monica Narayanaswamy

Resident doctor
Samatvam jnana sanjeevini diabetes hospital and medical centre
Chintamani, India

Keerthana Haridas

Sri Srikanta