Thyrotoxicosis

Look closely: Made up of women

The most common cause of thyrotoxicosis (toxicity due to too much thyroid hormone) is Graves' Disease, an autoimmune disorder in which antibodies stimulate the thyroid into constantly over producing. Minor cause: thyrotoxicosis factitia in which the hormone is ingested in excessive amounts either purposely (as to lose weight!) or accidentally as in a documented case of hamburger thyrotoxicosis. What would that be? Seems that somewhere in the Midwest, there was a very large family. All of them except one came down with severe symptoms consistent with thyrotoxicosis although their thyroids looked normal.  What was going on? Why was the one kid different from the rest? Turns out he hated hamburger. Every night, the whole family chowed down on hamburger purchased on the cheap from a local meat packing firm. The meat was chock full of thyroid glands ground up. Other people in town had a more varied menu.

An old chemistry joke:

What's the difference between an enzyme and a hormone?

You ask this to a scientist. They would drone on and on how enzymes are always proteins, hormones could be proteins too but often are steroids, peptides, or other molecules. Both catalyst reactions. Heat and stomach acid would destroy most enzymes but not hormones necessarily (such as thyroid hormone!), yadda, yadda...

You can't hear an enzyme.

I showed up in the ER with a whopping case of thyrotoxicosis about 14 years ago. I didn't know what it was. I assumed there was something very wrong with my heart as it was beating out of my chest. My femoral pulse looked like someone was inside of me kicking out though more regularly and quickly than any baby could..about 120 times per minute at rest. Previous resting heart rate: around 50 as I was a marathon runner and a triathlete. But now I was having a very hard time running. I had collapsed on a stairmaster a few days before banning me from the fitness center until I had a doctor's OK. (I was used to a certain routine: I figured if I could climb so many flights in a certain time one week, I should be able to do it the next week and tried to ignore my flagging body). All sorts of heart tests ensued in which it was determined that my heart was OK. I eventually was referred to an internist who diagnosed me correctly in one minute. He had noticed that I was sweating sitting with only a paper gown on me when the temperature was around 50 due to some malfunctioning air conditioner. He, Dr. Death Breath, told me that my care would be under his chief resident, Dr. Doogie Howser, so named by me as he seemed impossibly young. Dr. Death Breath, so named as he seemed to be putrefying on the inside, managed to hang in there until last year when I had read his obit. Dr. Doogie dutifully went through the common symptoms of Graves' Disease. I had them all. He finally addressed a more minor manifestation:

Do you have frequent urination?

What's that?

Often. Having to urinate often.

I know what frequent means. I just want to know how often you think is often.

Well having to get up at night for instance.

That's not normal?

NO.

You never get up at night? (violating some cardinal rule of never asking a doctor a personal question but as you probably know, I ignore that one).

No. Never.

Well I guess I surround myself with abnormal people even though I am fairly sure they don't have Graves'. Who doesn't get up at night when they are in their 40s?

Of course as young as Doogie was, he might have been still wetting the bed. He still had baby fat. He was a slow talker. One manifestation of Graves' Disease is speaking very quickly (though rarely finishing a sentence; you're bored and on to the next thought. Listen to George Bush Sr. speech: no complete sentences, also had Graves'). I wasn't sure if he was speaking extra slowly as to somehow slow me down or he thought I had comprehension issues. People naturally slow down their speech when speaking to children, the younger the slower. I am guessing he thought I was five, at least mentally.

You...will....need....to...be...on ...this...medication...for ...the...rest...of...your....life. Do...you...under...stand?

The next time I saw Doogie, a few days later after all the lab tests were in confirming Death Breath's diagnosis, he was accompanied by at least 6 similarly young people.

I hope you don't mind. This is a teaching hospital and rarely do we get to see such a florid case of Graves'.

Sure, why not. (at least there would not be any random sticking of hands up my vajayjay as by the OB interns while I was in labor with Shanna. By the time I had Josh, I became more forceful in dealing with these interns. One young man taking an intake history while I was in labor with Josh, kept asking the same question repeatedly as if I were deaf and as if I wasn't in the middle of a contraction. I sent him packing, the young snot. Don't ask questions in the middle of a contraction!)

They felt my impossibly hot skin. They noticed my very nice complexion (a plus of Graves'). They had me extend my arm and put a little piece of paper on my knuckles and timed the frequency of my tremors contrasting it with that of a Parkinson's patient. (this was somewhat humiliating..it appeared that I was nervous and I am not a nervous person. These stupid tremors made my job very difficult as fine motor skills were necessary. Also my handwriting went to hell. Also they did not go unnoticed by a certain co-worker who went to the powers that be or were to say that either I was on drugs of some sort or had poisoned myself in the lab). I gave them all a little speech educating them on the many manifestations of Graves'..

Then Doogie said Note her speech. Very typical of a Graves' patient.

 I clammed up embarassed. The show was over. It's like telling a patient that you are going to determine their respiratory rate and then expect them to  breathe normally. Not going to happen.

I took  an antithyroid drug for a year: PTU. This is the same substance formerly used in high school biology classes to determine if you were a taster, a genetic trait. No more monitoring genetic traits anymore; too sticky of an issue. Fortunately I am not a taster as it would be a very bitter substance to a taster and I had to take it 4 times a day as its half life was so short. Doogie thought I wasn't getting any better though by then I felt fine. My thyroid was still huge: he thought it needed to be destroyed and refused to give me any more PTU.

Before there were treatment options for Graves'; one third would spontaneously get better, one third would have symptoms come and go; one third would die. I could have it surgically removed (no thanks: one of the mom's nerve to her larynx was severed in this operation, she had to breathe through a trach for a month and obviously couldn't speak) or destroyed by beta rays emitted by I131. Flash forward to the last time I saw my oncologist. She seemed unusually interested where I was getting my 'natural' thyroid replacement hormone. They have some form you fill out saying what meds you are on and if you need refills. I once said, yes I need a refill for Prilesec and was denied even though the doctor could fill it in a second versus me and the half hour long automated menu. I said, the natural stuff is no longer available (due to the manufacturer refusing to do the bioavailability tests needed) and am back to the Synthetic stuff, which I do not like. But I wondered why she cared until I noticed the smily neck scar. She had opted for the surgery as the beta rays might destroy her eggs. (my unsolicited advice: better get cracking with those eggs). Of course I didn't care that they fried my eggs. I was done birthin' babies. I do wonder if they damaged other crucial body parts such as the C cells within the thyroid and the parathyroids living on top of the thyroid. I wanted to discuss with her why she opted for the natural stuff as the official party line is that it should be avoided. But it is her business and considerably off topic. She was to be assessing me for recurrences and nothing more.

A beautiful day here and the biggest football game is on-going. So far, it looks good for UM. But anything can happen.