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Suggest Treatment For Fluctuating TSH Levels With Tachycardia, Night Sweating And Insomnia
Question: I have Aortic regurgitation that has been graded as moderate and monitored annually with echo. I also have autoimmune thyroid disease. Originally Graves which relapsed twice and was difficult to treat. (just carbimazole) Now I have both Graves and Hashimoto antibodies. My TSH is fluctuating a lot, 0.07 to 13 in 3 months, therefore Im not on any medication. Iv had 7 years of worsening low throat pain and occipital head pain. The current thought is that I may have a retrosternal goitre although I v had no investigation for this, except that my thyroid is not palpable in my neck. The pain is worse lying down worse carrying stuff and worse bending over. Iv noticed today that my neck viens are strange. on the right its pulsating and on the left it looks like a vague varicose vien. Both sides its just above my collar bones. Ongoing symptoms have been palpitations, fast heart short of breath especially after falling asleep downstairs and having to go up stairs. Terrible insomnia, waking after about 2 hours sleep. and massive temp swings, sweating at night but then freezing feet. My GP says all of my symptoms are unexplained by any of the problems that Iv got. He says its all just coincidental and im worrying about my health too much. Actually im not at all in a panic, depressed or anxious so will not discuss this with them any more. Im wondering the vein situation is it important or should i ignore it like iv done with every other symptom
Brief Answer:
I would explain as follows:
Detailed Answer:
Hello!
Welcome on HCM!
I passed carefully through your medical history and would explain that it is necessary to further investigate about your thyroid glands status as you are having fluctuating symptomatology and blood hormone levels (TSH).
As you are positive for Hashimoto antibodies, so thyroiditis is actually a reality.
It is quite common in thyroiditis to have those fluctuating thyroid function status (hyper- and hypothyroidism).
You should know that Hashimoto is not a rare finding and one of the major reasons of hypothyroidism.
Your actual symptomatology: palpitations, tachycardia, night sweating, insomnia, freezing feet may be explained with your recent fluctuant thyroid dysfunction.
Regarding your throat and occipital pain you are experiencing lately, worsening when lying down, bending over or carrying stuff coupled with neck vein pulsation and distension; they are highly suggestive of a compressive effect over the main vascular structures passing inside the mediastinum draining the blood from the head (compression of superior vena cava) leading to a likely condition called superior vena cava syndrome.
This may be caused by an increased mass inside the mediastinum and in your case a retrosternal goiter is highly suspected.
In order to clarify this possible alternative several imagine tests would be helpful, like thorax CT or MRI.
Also, distended neck veins and palpitations may be caused also by heart failure.
In such case a careful review of your overall cardiac function and its structure would be necessary by echocardiography examination. A recent estimation of the aortic regurgitation severity is required.
Please, could you upload any recent available ECHO report for a direct review and a second professional opinion?
Also, I would like to know more on your possible additional symptomatology.
Could you provide me with some more information or any feeling of shortness of breath?
Do you have experienced lately lower limbs edema (swelling)?
At the end, I would like to advise you to discuss with an internist on the above mentioned issues and to carefully proceed through a deeper diagnostic work up, as your recent complaints (including distended and pulsating veins) need t o be seriously considered.
Remember two issues to clarify:
(1) Retrosternal goiter and exclude possible initial superior vena cava syndrome
(2) Investigate for possible heart failure implications
Hope to have been helpful to you!
I remain at your disposal for further discussions in case of any other uncertainties.
Kind regards,
Dr. Iliri
I would explain as follows:
Detailed Answer:
Hello!
Welcome on HCM!
I passed carefully through your medical history and would explain that it is necessary to further investigate about your thyroid glands status as you are having fluctuating symptomatology and blood hormone levels (TSH).
As you are positive for Hashimoto antibodies, so thyroiditis is actually a reality.
It is quite common in thyroiditis to have those fluctuating thyroid function status (hyper- and hypothyroidism).
You should know that Hashimoto is not a rare finding and one of the major reasons of hypothyroidism.
Your actual symptomatology: palpitations, tachycardia, night sweating, insomnia, freezing feet may be explained with your recent fluctuant thyroid dysfunction.
Regarding your throat and occipital pain you are experiencing lately, worsening when lying down, bending over or carrying stuff coupled with neck vein pulsation and distension; they are highly suggestive of a compressive effect over the main vascular structures passing inside the mediastinum draining the blood from the head (compression of superior vena cava) leading to a likely condition called superior vena cava syndrome.
This may be caused by an increased mass inside the mediastinum and in your case a retrosternal goiter is highly suspected.
In order to clarify this possible alternative several imagine tests would be helpful, like thorax CT or MRI.
Also, distended neck veins and palpitations may be caused also by heart failure.
In such case a careful review of your overall cardiac function and its structure would be necessary by echocardiography examination. A recent estimation of the aortic regurgitation severity is required.
Please, could you upload any recent available ECHO report for a direct review and a second professional opinion?
Also, I would like to know more on your possible additional symptomatology.
Could you provide me with some more information or any feeling of shortness of breath?
Do you have experienced lately lower limbs edema (swelling)?
At the end, I would like to advise you to discuss with an internist on the above mentioned issues and to carefully proceed through a deeper diagnostic work up, as your recent complaints (including distended and pulsating veins) need t o be seriously considered.
Remember two issues to clarify:
(1) Retrosternal goiter and exclude possible initial superior vena cava syndrome
(2) Investigate for possible heart failure implications
Hope to have been helpful to you!
I remain at your disposal for further discussions in case of any other uncertainties.
Kind regards,
Dr. Iliri
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Good Morning Dr lliri Thankyou so much for your prompt response. Unfortunately I do not have any copy of the Echo report. It was in January and I did a 3 day ambulatory monitor in March. I dont have a copy of that either but as far as I can recall it said there were "extra beats" but less than 10 over 3 days. The ECG showed Left Axis Deviation. My heart has been monitored for 3 years, the 1st echo was graded as mild the 2nd and 3rd moderate. At every visit he has remarked that although the regurgitation is clear, the valve does not look diseased. There is no Stenosis and my heart hasn't been enlarged. He asked about Rheumatic fever which I have not had. I asked whether my thyroid was relevant and he said no not at all. So he didnt want to know about the current antibody/TSH status. My symptoms of shortness of breath are worse at night, improved if i try to sleep sat up but that makes my throat hurt and causes me to choke. I am not overwieght and do not snore but have been unable to sleep on my back for a few years because I choke. The throat pain and occipital pain first happened 7 years ago when I had had a Graves relapse so was on Carbimazole, it was as my TSH XXXXXXX and I was discharged from the Endocrinologist that I mentioned that after mopping my floor my throat was quite uncomfortable . He said it wasnt my thyroid, discharged me and advised ENT referral. At that time I was doing a job that involved a lot of bag carrying, I was doing Domiciliary Eye Tests so loading unloading car 16 times a day. The pain in my throat and in the back of my head got much worse, a horrible dragging sensation so I left my job and started working in a practice. Then 2 years ago I began to have shoulder problems, both had pinched nerves at different times, using my arms in front of me or over my head has been increasing painful. the throat pain sort spreads along my collar bones into my shoulders. GP said it was wear and tear in my neck but actually all bony bits are fine, I had Cervical spine MRI that was OK. Its never felt to me like a vertebral/spine problem, so then I was told it was migraine, medication overuse headache stress anxiety depression. Physio advice was go home and look for hidden stresses. So now using my arms is even more difficult, for eg using a volk lens at work is very painful in my throat collar bones and shoulder, turning and tilting my head makes me dizzy and using my XXXXXXX above my head almost impossible, showering and washing my hair is an absolute ordeal,
Brief Answer:
I would recommend as follows:
Detailed Answer:
Hello again!
Thank you for the additional information.
I do not think that your symptoms are pure anxiety.
I would recommend performing further tests to investigate for the possible cause:
a-another cardiac ultrasound to investigate for possible heart failure. I would be happy to review your test reports as soon as you can upload them, for another second professional opinion.
b- thyroid hormone levels and a thyroid gland ultrasound to examine for possible compression. Did they check your thyroid on your spine MRI (the thyroid gland can be visualized partially in the spine MRI).
c- a nerve conduction study. As long as your cervical spine MRI has excluded possible spinal canal stenosis, a nerve conduction study would be helpful examine your nerves in the upper limbs for possible peripheral compression (outside the spinal column, during their physiological itinerary). The fact that you can not raise your hands raises suspicions of possible disorders (like thoracic outlet syndrome, etc.). A chest CT scan is also needed for this purpose.
The extra beats resulting from your Holter monitoring are just ectopic heart beats, which could be related to your thyroid dysfunction, but they do not indicate any serious cardiac arrhythmia.
Hope you will find this answer helpful!
Best wishes,
Dr. Iliri
I would recommend as follows:
Detailed Answer:
Hello again!
Thank you for the additional information.
I do not think that your symptoms are pure anxiety.
I would recommend performing further tests to investigate for the possible cause:
a-another cardiac ultrasound to investigate for possible heart failure. I would be happy to review your test reports as soon as you can upload them, for another second professional opinion.
b- thyroid hormone levels and a thyroid gland ultrasound to examine for possible compression. Did they check your thyroid on your spine MRI (the thyroid gland can be visualized partially in the spine MRI).
c- a nerve conduction study. As long as your cervical spine MRI has excluded possible spinal canal stenosis, a nerve conduction study would be helpful examine your nerves in the upper limbs for possible peripheral compression (outside the spinal column, during their physiological itinerary). The fact that you can not raise your hands raises suspicions of possible disorders (like thoracic outlet syndrome, etc.). A chest CT scan is also needed for this purpose.
The extra beats resulting from your Holter monitoring are just ectopic heart beats, which could be related to your thyroid dysfunction, but they do not indicate any serious cardiac arrhythmia.
Hope you will find this answer helpful!
Best wishes,
Dr. Iliri
Note: For further queries related to coronary artery disease and prevention, click here.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
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