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.
A 43 year old obese female, married, mother of 4 children was diagnosed as having hypothyroidism in the beginning of year 2011 when she felt lethargic and her TSH level was raised to 72 uIU/ml. She was started on thyroxine 150 mcg/day which was later on decreased to 100 mcg when her TSH level was suppressed to 0.5 uIU/ml after 1 month. After further 4 weeks her serum TSH came out to be further suppressed at <0.005 uIU/ml so thyroxine was stopped. The patient came for follow up after 8 weeks with serum TSH of 0.2 uIU/ml and T4 of 16.20 ng/dl (4.5-11.3). She then lost to follow up and returned in September 2011 with Thyroid function test showing serum TSH of <0.005 uIU/ml and FT4: 2.36 ng/dl. Thyroid antibodies were strongly positive. At this time she also had complained of palpitations, increased appetite, increased bowel movements, decreased sleep and tremors of hands. On examination she had no goiter and eye signs but had fine tremors of hands. She was advised to start carbimazole.