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Original Question

John O’Malley is a 30-year-old non-verbal man with autism who attends a day program where he enjoys community, activities and volunteer work. Several years ago, John developed severe maladaptive behaviors that were uncharacteristic of him. He was extremely anxious and developed aggressive behaviors. At that time, John’s primary care physician ordered several blood tests to determine what might be bothering him. The doctor explained to John’s parents that thyroid function tests are sometimes used to diagnose a thyroid condition when individuals develop behavioral issues. Since John’s mother had been diagnosed with hypothyroidism, it was logical to order thyroid tests as this condition can run in families. John’s thyroid stimulating hormone (TSH) was low, and his T4 level was in the normal range, albeit very low end of the normal range. Since John could not report symptoms and was clearly distraught, his doctor decided to measure the other hormones that are released from the anterior pituitary gland and a cortisol level (Table 1). The blood tests revealed follicle stimulating hormone (FSH), luteinizing hormone (LH), and growth hormone (GH) were all low as was his cortisol level. John’s primary care physician was concerned about a possible brain abnormality and referred him to an endocrinologist. TSH (mIU/mL) T4 (ng/dL) T3 Free (mIU/mL) LH (mIU/mL) FSH mIU/mL PRL (ng/mL) GH (ng/mL) Cortisol (mcg/dL) Normal Range 0.40-4.50 0.8-1.8 80-200 1.5-9.3 1.6-8 2.0-18 0.4-10 4-22 John’s Results 0.3 0.8 99 0.9 1.4 1.0 0.3 3.8 The endocrinologist ordered an MRI of his brain, and the results were normal. The endocrinologist thought that the hormonal decrease from the anterior pituitary gland might be due to stress. Several changes were made to John’s day program to alleviate stress and one of his medications was reduced by his psychiatrist after this doctor viewed a video of John’s agitated state. Within two months John’s pituitary hormones normalized as one of his psychiatric medications was considerably reduced and he no longer needed to see the endocrinologist. Four years later John’s caregivers noted that John was having difficulty sleeping and that several times a night he would wake up and pace in the hallway. He was overheated despite having air conditioning, and although he was usually motivated to participate in activities, he started to complain of being tired, was irritable, and had lost weight. John had always suffered from anxiety, however it seemed to be getting worse, and John appeared to be irritable while working at his job at the bakery and library café. John’s caregivers decided to schedule an appointment with the endocrinologist he had seen a few years earlier. Due to John’s history, the endocrinologist ordered bloodwork and did a clinical examination of John. The neurological exam appeared normal and showed no sign of disease. The following blood work was ordered: a complete blood count (CBC), comprehensive metabolic panel (CMP), FSH, LH, cortisol, prolactin (PRL), TSH and GH, free T4, and a thyroid antibody test. The endocrinologist also ordered an ultrasound of John’s thyroid gland. The CBC and the CMP were normal. FSH, LH, PRL, GH, thyroid antibody tests, and the cortisol level were also normal, as were the thyroid ultrasound and the thyroid antibody tests. The TSH and T4 were measured and repeated a month later at the same time of day in the early morning and those results are shown below in Table 2. Endocrine Results March 2023 Result Normal Range Free T4 (ng/dL) 0.9 0.8-1.8 TSH (ulU/mL) 0.29 0.40-4.50 Endocrine Results April 2023 (repeated) Free T4 (ng/dL) 1.0 0.8-1.8 TSH (ulU/mL) 0.17 0.40-4.50 Considering John’s history and the fact that he was verbally unable to report his symptoms, the endocrinologist thought it made sense to monitor John’s TSH, T4, and total T3 levels in six months. The doctor explained that due to John’s autism, it was possible that his brain functioned differently regarding hormonal release, and that a low TSH level could be normal for John if his T4 levels stayed within the normal range. However, the doctor also stated that the case presented some clinical uncertainties, and it would make sense to monitor John’s thyroid hormones. Initial Post To better understand John’s condition, each person in your discussion group will answer all four questions: When John first visited the endocrinologist, he had an MRI. What condition was ruled out with the results of John’s MRI? Why do you think the doctor did not order another MRI for John’s current situation? If a person had Grave’s disease, a type of hyperthyroidism, would you expect their blood levels of TSH and T4 to be decreased or elevated? What symptoms would be present? Refer to John’s latest test results and consider his levels of T4 and TSH. Based on John’s test results, do you think John has Grave’s disease? Since John’s mother has Hashimoto’s disease, a type of hypothyroidism, prior to treatment would you expect her blood levels of TSH and T4 to be decreased or elevated? Based on John’s signs and symptoms, do you think John has hypothyroidism? The endocrinologist will check John’s TSH, T4, and total T3 in six months to monitor for subclinical hyperthyroidism. What is subclinical hyperthyroidism? Why do you think the endocrinologist wants to measure total T3 levels?

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