I have a patient, [a] 42-year-old female, [with a] history of colorectal cancer, rectal resection, ileostomy reversal in 2017, fatigue, weight loss, and food intolerance. Cyrex 3, 4, and 10 [were] all pretty normal. Moderate microscopic yeast [was found] on Doctor’s Data, which they’re working on.

Blood work: free T3 [triiodothyronine], if that’s in the normal reference range, then it’s 9.1 and she’s not taking thyroid medication, that’s high. That is significant. It looks [like] she has a history of that if 9.1 is accurate back from July and then 5.1 in October is still high. ​Have​ the other TSH from the October labs because back in July, it’s unusual that TSH [thyroid-stimulating hormone] would be normal when T3 is that high. Usually, the most common cause of elevated T3 would be either overmedication of patients taking medication or an autoimmune hyperthyroidism presentation like Graves’ disease, or sometimes it can be the early stages of Hashimoto’s [disease]. They call that Hashimoto’s thyrotoxicosis, which is where you get this relapsing remitting immune destruction. When it’s relapsing, you get a kind of hyperthyroid presentation like the thyroid tissues being destroyed and thyroid hormones dumping into the bloodstream, and that creates a temporary hyperthyroid situation, so you can kind of see a patient vacillating back and forth between hyper and hypo in a relatively short period of time, so that’s another possibility. That’s a really unusual presentation, especially given that TSH was normal. This might be a situation where you would refer them for a thyroid ultrasound if they haven’t had that already to see if there’s, like, a diverse multinodular goiter that would be indicative of autoimmunity, since the antibodies were normal back in July. As I think you know from the course, antibody levels are not 100 percent reliable in terms of diagnosing autoimmune thyroid conditions. You might want to do a TSI [thyroid-stimulating immunoglobulin] antibody, too, because that is the one that can be elevated in Graves’ [disease]. TSI and thyroglobulin often are elevated in Graves’, but sometimes it can be just TSI alone. I hope that gives you some places to look.