Summary

DOI: 10.1373/Clinchem.2007.101428

A 32-year-old female patient presented complaining of increased flushing, perspiration and heat intolerance of 3 months’ duration. Medical history included idiopathic thrombocytopenic purpura of 4 years’ duration, which had been treated by splenectomy after failed immunosuppression with prednisone and azathioprine and was currently in remission. On examination, she was found to be clinically euthyroid without a goiter. She had also developed a diffuse erythematous papular rash on the face and back, with bullous lesions on the chest.



Student Discussion

Student Discussion Document (pdf)

George van der Watt,1* David Haarburger,1 and Peter Berman1

1Division of Chemical Pathology, National Health Laboratory Service, Groote Schuur and Red Cross Children’s Hospitals, University of Cape Town, Observatory, South Africa.
*Address correspondence to this author at: Division of Chemical Pathology, National Health Laboratory Service, Groote Schuur and Red Cross Children’s Hospitals, University of Cape Town, Observatory, South Africa, 7925. Fax +27216585225; e-mail george.vanderwatt@chempath.uct.ac.za.

Case Description

A 32-year-old female patient presented complaining of increased flushing, perspiration and heat intolerance of 3 months’ duration. Medical history included idiopathic thrombocytopenic purpura of 4 years’ duration, which had been treated by splenectomy after failed immunosuppression with prednisone and azathioprine and was currently in remission. On examination, she was found to be clinically euthyroid without a goiter. She had also developed a diffuse erythematous popular rash on the face and back, with bullous lesions on the chest. Immunofluorescent antibody studies performed on a punch biopsy of skin were positive for several autoantibodies, leading to a diagnosis of subacute cutaneous lupus erythematosus. This diagnosis was further characterized by positive titers of nuclear and doublestranded DNA autoantibodies in the serum. Thyroid function testing on an Advia Centaur® Immunoassay System (Siemens Medical Solutions Diagnostics) revealed an increased concentration of serum free thyroxine (FT4)2, 90.1 pmol/L (6.97 ng/dL) (reference range 11.5–22.7 pmol/L), a nonsuppressed thyroidstimulating hormone (TSH) concentration of 1.8 mIU/L (1.8 μIU/mL) (reference range 0.35–5.5 mIU/L), and normal free triiodothyronine (FT3) concentration of 4.2 pmol/L (0.33 ng/dL) (reference range 3.5–6.5 pmol/L). Repeat investigation 1 and 2 months later revealed a progressive increase in FT4to 125.3 pmol/L (9.7 ng/dL) and ≥155 pmol/L (≥12.0 ng/dL), respectively. TSH and FT3remained within reference intervals, as did total T4by RIA, at 155 nmol/L (12 μg/dL) (reference range 58–161 nmol/L). Furthermore, she tested positive for antithyroperoxidase antibodies at 110 IU/L (reference range <37 IU/L) and antithyroglobulin antibodies at 149 IU/L (reference range <98.1). An investigation of her disconcordant thyroid function tests was initiated.

Questions to Consider

  • What are the possible reasons for discrepancies between thyroid function testing and clinical picture?
  • What are the appropriate next steps to resolve the discrepancy between clinical picture and laboratory results?
  • What would the clinical picture be if the patient had resistance to thyroid hormone? A pituitary adenoma?

Final Publication and Comments

The final published version with discussion and comments from the experts appears in the July 2008 issue of Clinical Chemistry, approximately 3-4 weeks after the Student Discussion is posted.

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DOI: 10.1373/Clinchem.2007.101428
Copyright © 2008 American Association for Clinical Chemistry