A 36 years old female presented with a 3 months history of easy fatigability, cold intolerance, polymenorrhagia, constipation and weight gain in the beginning of year 2005. On examination she had bradycardia and dry skin. The thyroid gland was palpable, non-tender mostly diffuse but some nodular feeling at upper pole of left lobe. Clinical suspicion of primary hypothyroidism was made and it was confirmed by TSH value of greater than 50 uIU/ml with FT4 of less than 0.30 ng/dl and positive thyroid antibodies. Thyroxine was started at a dose of 100 mcg/day. Gradually the requirement of thyroxine decreased and by the end of 2005 onwards she maintained her TSH within normal range on 50 mcg/day of thyroxine. In the beginning of 2008 the dose was further reduced to 25 mcg/day but again towards the end of 2009 thyroxine dose was increased to 50 mcg/day because of slightly increased TSH of 8.86 uIU/ml. Slightly more than a year later in the beginning of 2011, she presented with weight loss of 3 kg with a feeling of anxiety and associated tremors of hands. TSH at this time was less than 0.005 uIU/ml with a FT4 of 2.4 ng/dl, confirming the state of thyrotoxicosis. Thyroxine was stopped and patient was observed intermittently over a period of 6 months. She remained clinically and biochemically hyperthyroid with a repeat TSH of <0.005 uIU/ml and an FT4 of 2.66 ng/dl. Thyroid scintigraphy with technetium 99 was done and it showed an increased homogenous tracer uptake. Finally she was started on Neomercazole in mid of 2011and remains on it till to date.
46 years old female, mother of 3 children diagnosed as having primary hypothyroidism on the basis of clinical symptoms of easy fatigability, weight gain and increase sleep and a serum TSH level of >75 uIU/ml, FT4: 0.25 ng/dl and strongly positive thyroid antibodies in December 2002. Thyroxine 50 mcg/day was started which she continued. After 2 years she presented to us with complain of weight loss. Her serum TSH level was 0.035 uIU/ml and a T4: 7.84 ng/dl so thyroxine was stopped. She came for follow up after 5 months with serum TSH: 0.010 uIU/ml off thyroxine. After another 6 months her serum TSH remained suppressed with a value of 0.018 uIU/ml and an FT4 of 1.18 ng/dl and she remained off thyroxine. After further 2 years her TSH was 0.837 uIU/ml, FT4 0.922 ng/dl and FT3 3.06. And after 1 year she presented with a TSH level of <0.005 uIU/ml, raised FT4 and positive thyroid microsomal antibodies (1: 1600). Techniteum 99 thyroid scan showed diffusely increased homogenous tracer uptake. Neomercazole was started at the dose of 5 mg/day which was gradually increased to 10 mg/day. She followed up after 4 months with TSH: 0.01 uIU/ml, T4: 5.84 ng/dl, T3: 1.99 ng/dl. Neomercazole was continued. Then she came for follow up after 1 year, at this time she was clinically euthyroid but biochemically hypothyroid with serum TSH: 14.89 uIU/ml, FT4:0.65 ng/dl. Neomercazole was stopped and advised to repeat TFT’s after 8 weeks. She came after 4 months with TSH: 3.98 uIU/ml, so no treatment was advised. After a period of 1 year she again came with complains of weight loss and palpitations. At this time her TSH: < 0.005 uIU/ml, FT4: 2.25 ng/dl. Neomercazole was restarted and Radioactive iodine 131 ablation planned.