Thank you too much Cintia. I will read the article and return back for more discussion.

Dear

With Hashimoto's disease, eventually, the thyroid gland, or portions of it, are destroyed, and you are not able to produce healthy levels of thyroid hormone. For a time before your thyroid gland is completely dysfunctional, you could have a normal TSH, along with the presence of thyroid antibodies. This may be a possible explanation.

 Dear Ali,

Thank you for your answer. My patient TSH was very high and F T3 / T4 were very very low. He is related to Hashimoto, disease as he has very high antibodies. How symptoms become hyperthyroid like tachycardia, overactivity and nervousness. Euthyrodism can be accepted if F T3/ T4 are normal as thyroid destruction is incomplete and there is compensation by a moderate increase in TSH. 

@ Cintia,

I read the case history you referred me to. It is interesting that genetic mutation have led later on to production of thyroid antibodies and auto immune thyroiditis. The case report does not look similar to my patient, but I think that genetic analysis of my patient is justified and may give clues. Did you guess how hyperthyroid symptoms (not a compensated euthyroid state) can happen with a low F T3/ T4?

From a practical point of view, 2 possible other explanations:

1] Symptoms of hyperthyroidism may have come from initial phase of hyperthyroidism, but blood taken at the end of initial phase, when hypothyroidism setting in. So just need to see if symptoms persist after another few weeks?

2] Alternative co-morbidity causing the symptoms, eg: diabetes with autonomic neuropathy, tuberculosis, recreational drug use, etc?

Regards

Thanks Fazleh for your good answer. Patient is not diabetic, So only first explanation should be considered.  I think you meant antibodies initially caused hyperthyroidism and after a variable period of time thyroid cells are exhausted and classical hypothyroidism symptoms start. A good try, what do you think of the other above suggestions?

Thanks. The thyroid hormone resistance I've seen before usually has slightly elevated T4, T3 and TSH[ all slightly elevated]. But the other contributors experience may be different

So do you think this reciprocal could be due to stimulating antibodies. When thyroid cells are exhausted added to the continuous thyroid damage over variable times, thyroid will begin to fail showing classical hypothyroid symptoms. These should be seen if patient stops replacing thyroid tablets.

Is that your opinion? How much frequent do you see similar cases? What are the implications?

Thanks

Thanks

I like your theory that the antibodies may be stimulating. and explain the symptoms. Another possibility is a mix of stimulatory and inhibitory antibodies that alter their dominance over time. This is better described for Graves Thyroid disease than Hashimoto's though.

The initial hyperthyroidism with Hashimotos is usually due to destruction of the gland with release of stored hormone. Then hypothyroidism follows, because the gland is too damaged to make thyroid hormone. Then recovery of the gland or persistent hypothyroidism after that

From a practical point of view, I repeat the thyroid function tests and if it persists in the same pattern then treat the biochemical picture [thyroxine for hypothyroidism]  and follow monthly. It may all settle down and you may even be able to wean off the thyroxine

Regards

Thanks Dr. Fazleh. My observations also showed that thyroxine is ameliorating the hyperthyroid symptoms!! Could you provide the best articles or references talking about this non-classical presentation clearly. I am searching for good evidence.

Hi. I'll send you some articles. Its a very interesting topic you have. The two angles are autonomic dysfunction and blocking/stimulating antibodies.

I appreciate your help.

I will go through your references and come back for further discussions. It might take some time.

Thanks and my best wishes,

Omer

In early stages of Hashimoto’s Thyroiditis, thyroid hormone levels may be normal (euthyroid) or increased (hyperthyroidism) which is so called Hashitoxicosis.. to diagnose that kindly ask for Antithyroperoxidase (found in > 90% of cases), antithyroglobulin (found in >40% of cases)

Thanks in advance

Thank you Dr .Wesam for your answer. In my patient, Thyroid antibodies were very very high, and thyroid hormones were very very low.