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March 16, 2010

Other Illnesses, Thyroid

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Question from El Paso, Texas, USA:

Now 11, my son was diagnosed with type 1 on September 15, 2009. His blood sugar was 585 mg/dl [32.5 mmol/L] and his A1c was 12.3. His regimen is six or seven units of Lantus at 8:30 p.m. and four units of NovoLog for 60 grams of carbohydrates at each meal. If his blood sugar is lower than 100 mg/dl [5.6 mmol/L] at bedtime, he gets a 15 to 30 grams of carbohydrates snack. By mid-January 2010, his A1c was 5.6.

At the time of his diagnosis, his TSH was elevated but the endocrinologist wanted to wait and see if it dropped before treating. His TSH did not drop and, by end of October 2009, my son started taking 25 mcg of Levoxyl. Early February laboratory work showed that his TSH was down but his T4 was extremely elevated. The doctor withdrew the Levoxyl in mid-February. Two weeks later, laboratory work showed that my son’s T4 was 8.1 and his TSH was too low at 0.01. He will be retested on March 17. The doctor says his diabetes is well controlled and cannot explain the chronic fatigue, headaches (dull ache exacerbated by reading/writing) and dark under eye circles that have kept my son out of school. The doctor referred us to an allergist and psychologist. Of 26 allergens, he was allergic to all except four. Vitamin D 25-OHD3 is 28, 25-OHD2 is <4. Is there something else we should look for...anemia? chronic fatigue? pituitary? My son loves school and misses his friends and wants to return to his competitive fencing. He does not mind counting carbohydrates or injecting insulin but he is growing weary of feeling well only sporadically.

Answer:

From: DTeam Staff

It looks like extensive testing has taken place but I do not think that the thyroid problems explain the symptoms. Such thyroid problems are rather common and need to be watched. Do you know if thyroid antibodies were checked and if he has Hashimoto’s thyroiditis? If positive, this would make me believe future thyroid treatment may be indicated. We usually watch thyroid functions at diagnosis and then annually since we find abnormalities about 20 to 40% of the time. In your child’s case, the symptoms are not explained by the mild TSH elevation and obviously adding a small dose of thyroid hormone did not solve the problem.

I would also assume that celiac disease was checked for and negative. Sometimes, there are variants where the main transglutaminase antibody is negative but the somewhat noisier anti-gliadin antibodies are positive. Going gluten-free solves this problem and perhaps this could explain the ongoing fatigue.

The low vitamin D2 levels are common and unrelated to the symptoms or the diabetes. The total vitamin D levels are moderately low so I would give him some high dose daily vitamin D supplements to boost these levels above 50 and see if they then can be sustained. Sometimes there are subtle fatigue symptoms which are “fixed” with more vitamin D but usually there are no symptoms. I would guess that his symptoms are not related but fixing the low vitamin D level will remove future cardiac, blood pressure, cancer and bone risks.

Lastly, adrenal insufficiency called Addison’s disease, sometimes will show up associated with autoimmune disease like diabetes, Hashimoto;’s thyroiditis, celiac disease. This would require a morning cortisol and CTH test and an adrenal antibody test – all straight-forward tests.

You should go back and talk with your diabetes team to see what they think may explain these symptoms, make sure all these things have been checked out and then proceed from there since it does not look like it is diabetes related.

SB