Is It Hashimoto’s Disease? Or Is It Something Else?

Episode Intro:

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Dr. Michael Ruscio, DC:

Hey everyone. I just wanted to pop this quick intro in here. We’ll go to the podcast in a moment that has its own intro. However, I felt I may have buried a little bit of the lead, so I wanted to just frame the issue that we’re going cover today – an incorrect diagnosis of Hashimoto’s and how to make sure that that does not happen to you. Essentially, here’s the summary on this. There are a few different ways to assess if Hashimoto’s is present or not. The reliable research-validated markers that are accurate and don’t suffer from things like false positives are TPO or thyroid peroxidase antibodies and thyroid ultrasound. There is also a marker called thyroglobulin (or Tg) and this is not accurate because it suffers from false positives and/or will be elevated in some healthy subjects. I want to frame that for you because of the case report we’ll go into in a moment here. A gentleman came in being told that he had Hashimoto’s based exclusively upon a positive Tg (or thyroglobulin) antibody while his TPO was negative, his ultrasound was normal, and his thyroid hormone levels were normal.

DrMR:

I’ll juxtapose what walked in the door from this other doctor against going through the exercise of looking at him as an individual. You could clearly see that problems in the gut causing food reactivity, combined with electrolyte insufficiency and/or dietary mismatch of too low-carb and/or too low calorie were fairly clearly causing his symptoms. The main thing I want to flag here is TPO and ultrasound are accurate for diagnosing Hashimoto’s; thyroglobulin is not. This Hashimoto’s provider made the diagnosis exclusively based upon the thyroglobulin antibodies, which should not be done. That’s the high level. I just want to drop that here and then we’ll go into a more expansive elaboration here in a moment.

DrMR:

Hey everyone. Welcome back to another episode of Dr. Ruscio, DC Radio. This is Dr. Ruscio, DC. I just wanted to go over a case from the office that recently came in. This was a choice example of what to look out for to ensure you are not roped into an incorrect hypothyroid, or more specifically in this case, Hashimoto’s diagnosis. We’re going to go through a checklist of some of the common markers that are tested and how (in this case) if you were missing just a couple pieces of this informational picture, you could be misled into thinking you had Hashimoto’s and it was driving your symptoms. If you really listen to this person’s symptoms and read them, you see that (if anything) this person probably ran a fairly high risk of being harmed if he took thyroid medication; how simple some of the underlying causes of his symptoms are to identify when we get the noise of inappropriate lab testing out of the way.

DrMR:

As Joe Mather has said so many times on the podcast — by really listening to the patient, it’s pretty clear to see that this case is not being driven by Hashimoto’s. It’s being driven prominently via the gut, potentially a too low-carb diet, and also an electrolyte insufficiency. Let’s go through this case. I’m going to bounce around here to try to fill you in on all of this and tie as much of this together as possible.

Patient Symptoms & Incorrect Hashimoto’s Diagnosis

DrMR:

A gentleman recently came into the clinic. He was a 45 year old male with the following symptoms: bloating & stomach pain, shaky hands, lightheadedness, brain fog, irregular heartbeat, headaches, fatigue, and difficulty gaining weight. He came to see us because he was working with another doctor. I think it may have been a local functional healthcare provider. He said, “You know, doc, something just seemed a little off to me with this other provider. Not sure exactly what it is, but I wanted to check in with you and get a second opinion.” I’m quite glad he did because he was incorrectly diagnosed with Hashimoto’s. So, what were the labs that this provider ran? The labs the other provider ran were a full thyroid hormone assay — including TSH, T4, T3, reverse T3, thyroperoxidase antibodies (TPO), and thyroglobulin antibodies. TSH came back at 2.4, which is normal. Some in the field will say you want to be below 2.5. There’s pretty much zero evidence supporting that, but that’s what some people will say.

DrMR:

As a quick aside, where that comes from is that’s the goal for TSH when someone is on thyroid medication. However, it doesn’t work in the reverse order. By this, I mean that if someone is coming in with no prior diagnosis and you’re looking to interpret their TSH to either inform a diagnosis of hypothyroid or not, then the cutoff of 2.5 does not hold. The lab range is 4.5 and TSH can even go as high as seven, maybe 10, before it really signifies a problem. There are differing views on that, but if you look at the overwhelming trendline in the evidence, it suggests we want to be looking at a TSH above seven when we start to really look at it as indicative of a problem and/or diagnostic.

DrMR:

So, his TSH was at 2.4. The free T4 (the other thing we want to look at in conjunction with the TSH) was at 1.13. The range here is essentially 0.8 to 1.8, so smack dab(ish) in the middle. Now, here’s where the story gets interesting. Remember, he was told he has Hashimoto’s. His TPO was normal, but his thyroglobulin was 621. Now, it’s 621 on a scale from zero to 0.9. The ranges from lab to lab vary more for thyroglobulin than they do TPO. So, he comes in and says that the Hashimoto’s doctor (there’s the irony right there <laugh>) diagnosed him with Hashimoto’s. They were probably doing so and wanting to help the person, but you have to fact-check some of these things. As a provider/clinician, you have to look to build a case. So, I’m saying — TPO is the accurate antibody… thyroglobulin is known to be elevated in some perfectly healthy individuals… and there are also other things that can elevate the thyroglobulin. Let’s cover a quick supporting point for the statement that thyroglobulin is not diagnostic of Hashimoto’s.

DrMR:

I’m quoting a paper here. The name of this paper that appears in ScienceDirect is “Thyroglobulin, Thyroperoxidase, and Thyroid Receptor Antibodies” by Burke: “A positive thyroglobulin antibody is not diagnostic of Hashimoto’s thyroiditis because thyroglobulin antibodies are found in numerous other conditions. They are present in approximately 50% of Graves’ disease, 20% of non-toxic goiter and cancer cases, and also in normal individuals – especially females.” And to quote another section from this paper regarding thyroglobulin antibodies: “They are also present in 10% to 27% of healthy adults.” This is the important background content. Now, I know this, of course, because I’ve checked this. Also, in defense of this provider, when I was doing certain postdoc training (or more specifically, certain supplement company funded weekend seminars), it put Hashimoto’s on my radar in a more robust fashion. I’m thankful for that, but these details were not disclosed.

DrMR:

This is one of the challenges with industry-funded seminars. Sadly, there does not seem to be a lot of incentive for a nuanced discussion. I think this is something providers need to be better about. Providers seem to flock to the seminars that give them the most absolutist and extreme narratives because they’re just people, right? People click on the most extreme headlines and they watch the most extreme news. It seems that the nuance is lost in a lot of cases. This is where (if I’m going to speculate here) this overreach on behalf of the provider was coming from. As another aside, we’re going to be doing an up-to-date appraisal on what research is showing for how impactful or non-impactful thyroglobulin antibodies are.

DrMR:

I reviewed this one or two years ago in detail. It’s been a little while since I’ve done a deep dive. As you can imagine, in keeping with our philosophy of being evidence-guided (by guiding, we mean it’s going to modulate your path going forward in time), we’re going to reappraise this. In my quick cross reference, these are things that came up as I’m going through this case and double checking myself. I don’t ever want to rest on any position for too long and I’m always double checking these things.

Ultrasounds & Benign Nodules

DrMR:

Zooming us back out… this individual is told the source of his symptoms is the Hashimoto’s. Now, we’ve qualified that the thyroglobulin is not an accurate measure. What else could we use? Well, we could use an ultrasound. You may remember a few discussions we’ve had in the past that the ultrasound is also a way to diagnose Hashimoto’s. It’s a bit more of an invasive measure and expensive to do, so it’s not done as often as TPO antibodies, but it’s also a measure.

DrMR:

So, this gentleman also had a thyroid ultrasound. His Hashimoto’s doctor should have said, “Well, thyroglobulin is not a reliable marker for Hashimoto’s. TPO is and that’s negative. The best test we have is the TPO and your TPO is negative. Therefore, the evidence pretty squarely shows that you do not have Hashimoto’s. However, do you have an ultrasound?” “Oh yes. Funny you should ask.” I’m not sure who requested this ultrasound (maybe it was his PCP or his endocrinologist), but he had an ultrasound. That would give you another data point to cross reference to be as confident as possible. In short, the ultrasound finds no evidence of Hashimoto’s. It does find one nodule that does not meet the criteria for any type of follow-up study/follow-up biopsy – meaning it appears to be a benign nodule.

DrMR:

I forget the stat off-hand, but nodules occur in as many as 50% to 60% of people. They have nodules with no dysfunction at all. It’s somewhat of a normal finding for someone to have a nodule, perhaps. The other quote informed us that you’ll see thyroglobulin elevated in this benign/normal/ non-harmful nodule. In this case, the way you read all of this is that you do not have Hashimoto’s. The thyroglobulin antibody is an imprecise marker, which can be high in normal individuals and can also be elevated for other reasons (including nodules.) Now, it’s good that he had the ultrasound. He can plug into the conventional system in case something did flag on the ultrasound and he can have a follow-up biopsy. However, he’d gone through that conventional checkpoint channel (as he should have and as we always support people do in the clinic) and everything there had come back normal.

DrMR:

In recap, this person comes in and you can clearly see the evidence is sufficient to rule out the diagnosis of Hashimoto’s. However, he said that part of the reason he wanted to get a second opinion was that his Hashimoto’s doctor had eight supplements at the ready. You can hopefully start to see some of my frustration. As we’re going through the intake and I’m looking at all this, I’m saying, “This is just another case of someone being mismanaged regarding their thyroid.” I don’t make these criticisms because I’m trying to be a contrarian, but it’s alarming how often we are seeing this.

Dr. Ruscio’s, DC Resources:

Hi everyone. If you are in need of help, we have a number of resources for you. Healthy Gut, Healthy You – my book and your complete self-help guide to healing your gut. If you’re not a do-it-yourselfer, there is the clinic – The Ruscio Institute for Functional Health – and our growing clinical and supporting research team will be happy to help you. We do offer monthly support calls for our patients where I answer questions and help them along their path. Health coaching support calls every other week. We also offer health coaching independent of the clinic, for those perhaps reading the book and/or looking for guidance with diet, supplementation, et cetera. There’s also the store that has our elemental diet line, our probiotics, and other gut health and health supportive supplements. And for clinicians, there is our FFHR – The Future of Functional Health Review database – which contains case studies from our clinic, research reviews, and practice guidelines. Visit drruscio.com/resources to learn more.

Electrolyte Insufficiency & Malabsorption Issues

DrMR:

Let’s come back to his case. The bloating and stomach pain are obviously GI related. Regarding his shaky hands and lightheadedness, we need to probe a bit more deeply into the notes from his chart. After the intake, we have patients review their paperwork with one of our health coaching staff before their visit with the doctor. Therefore, when the notes get to me – or to Joe, Robert, Gavin, or Hannah – there’s already a lot of pre-filtering and double checking done. And one of his additional notes (from either Morgan or Eliza, in this case) is lightheadedness when standing up too quickly. What I love about our team (and I just want to commend everyone at the clinic) is this was bolded because our team knows this is a keystone symptom to flag. This is a hallmark symptom of electrolyte insufficiency. And guess what else electrolyte insufficiency can cause? It can cause (potentially) shaky hands, irregular heartbeat, headaches, and fatigue. So, as you start looking at all this, you see how incorrect, but potentially appealing Hashimoto’s is (not to mention the fact that Hashimoto’s doesn’t really cause much in the way of symptoms directly — that’s a whole other conversation). This person does not have Hashimoto’s and you see the difficulty gaining weight along with symptoms of electrolyte insufficiency, and I’m already thinking this person is probably either undereating, too low-carb, and/or malabsorbing. Regarding difficulty gaining weight — this means you’re either undereating or eating too low-carb. Part of that might be because he has bloating and stomach pain, so he’s trying to avoid triggers. He probably needs some guidance as to where to go. This is causing shaky hands, brain fog, lightheadedness, irregular heartbeat, headaches, and fatigue.

DrMR:

I hope it’s easy to see here that when we have the right systems of data organization and management as someone goes through the intake process, and I’m reviewing the chart before our first visit where we do the history, I am already seeing this pattern. Hashimoto’s was an incorrect diagnosis. You clearly have gut symptoms and you’re also expressing some hallmark symptoms of electrolyte insufficiency and/or undereating and too low-carb. What we want to do here is fix your gut so that you have no bloating and stomach pain in reaction to foods, correct the undereating or too low-carb dieting, and support that with some electrolytes. This will go very, very far in resolving his symptoms.

Treatment History & Reinforcing the Hypothesis

DrMR:

If we look at his treatment history, we see that a low FODMAP diet has been helpful in the past. We see that he does not respond to fasting and he had negative reactions to ketogenic dieting. This is another flag that someone has either burnt out too low-carb or too low calorie. As I’m looking all of this over, I’m seeing additional reinforcement of my hypothesis. I then look at his treatment history further. What has helped? Probiotics have helped. Rifaximin has helped. Electrolytes have helped. He tried them when doing low-carb. Digestive repairing nutrients have been helpful. He had a reaction to hydrochloric acid. He commented to me later when we got into our visit that the gut supports were really the only supports that he felt were helpful, further reinforcing my hypothesis.

DrMR:

My hypothesis here is that this person, firstly, is not Hashimoto’s. We want to get that first checkpoint of getting the incorrect prior diagnoses out of the way and corrected, and then GI reactivity, so to speak. There’s probably some dysbiosis, SIBO, etc. causing him to either undereat or eat too low-carb. I take all of that away just from looking at his symptoms and literally one of the bolded remarks from the notes the health coach did before I saw him. And then they can toggle over to his diet history and see instant reinforcement that he had a negative reaction to keto. Further, I can see that the line of therapy that has been helpful for him is twofold — One – Gut supports and Two – Electrolytes. So boom, boom, boom… see the hypothesis, see the likely underlying causative factors, and then quickly cross reference his treatment history + his dietary history to get reinforcement. By the time I go to the visit with this gentleman, I already have things 80% to 90% mapped out.

DrMR:

In any case, I just wanted to share this because it was a good example. And I’m going to try to start doing this more often. Please let me know by the way, if this is helpful or not. I wanted to just share, firstly, that synopsis on the diagnostic criteria for Hashimoto’s so you don’t get pulled into thinking you have Hashimoto’s solely based upon thyroglobulin (Tg) antibodies. This is also a chance to showcase how crucially important it is that we move over to this model of treating patients and not treating labs because in this case (and hopefully I’ve convinced you of the accuracy of my hypothesis), everything came him from his symptoms and his history.

DrMR:

We see his symptoms. His symptoms indicate a problem in the GI, electrolyte insufficiency, and/or undereating or too low-carb. We quickly see the dizziness when standing. That’s a hallmark reinforcing that he’s either electrolyte insufficient or too low calorie and/or too low-carb. And then we look at his diet + treatment history. He reacts to negatively to ketogenic. He was helped from electrolytes and GI supports were the only line of support that seemed to help him. This is the way we’re looking at things in the clinic and why we recommend treating people and not labs. We have this four component analysis we go through: the person’s history, their symptoms, their response to treatment (and we covered all that), and their labs. In this case, the labs didn’t help us figure out what was causing this gentleman’s problems, but we did have to look at them to help get him off of the hypothesis of Hashimoto’s and onto a problem that GI combined with too low calorie/too low-carb and/or electrolyte insufficiency.

DrMR:

Again, just hoping this all makes sense in relation to the model the field has to move towards, which is really listening to the patient. We can get so much from this information. I’m glad this gentleman came in and I’m excited to get him started. Again, I just wanted to share that. If you have had some similar analyses and/or symptoms, hopefully this provides you a few ideas of where to go with your healthcare provider. Or if you’re doing the self-treatment route and/or if you’re in need of a second opinion, please feel free to reach out to the clinic. Any of us at the clinic would be happy to review your case and help you along the road. All right, guys – I hope that helps. I will talk to you next time. Bye-bye.

Outro:

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