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High ALKALINE PHOSPHATASE, THYROXINE, HDL levels with enlarged LYMPHNODE.

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I need help interpreting some lab results and help to determine where to go from here since my primary doctor is of no help. On April 29, 2014 I had labs done. My alkaline phosphatase levels came back as 321 with a reference range of 39-117. The doctor didn't do anything about that--wasn't concerned. I am still feeling horrible--extreme fatigue, brain fog, unable to lose weight, and then episodes of extreme dizziness, nausea, feeling faint, sweating, etc. Went to the doctor and my blood pressure was 90/60 and they ran some more labs. Now my alkaline phosphatase levels are 24 which is flagged as too low (they were too high 6 months ago at a number of 321). My other results are:
Alkaline Phosphatase 24.0 ref range 39-117 flagged as too low
T4 8.7 ref range 5.0-12.5 normal
T3 uptake % 50.3 ref range 22.5-37.0 flagged as too high
Free Thyroxine Index 4.4 ref range 1.0-3.9 flagged as too high
TSH 4.398 ref range .350-4.50 normal/borderline
HDL Cholesterol 39 ref range >39 flagged as too low
Granulocyte % 40 ref range 43-77 flagged as too low
Lymph % 50 ref range 12-46 flagged as too high

Is anything of this concerning? Does it indicate I should have some kind of treatment or further tests? Why would my alkaline phosphatase levels go from too high at 321 to too low at 24 within 6 months? What do the abnormal thyroid results indicate? I am TIRED of feeling like crap. I have 2 kids to take care of and simply cannot go on like this.

Background info: Age 29, female. 5'3" tall, 155 lbs. I also have thyroid nodules according to my last ultrasound in April. One of them was hypoechoic but again, doctor was not concerned. I have also had a hard enlarged lymph node on the left side of my neck. I oftentimes get shooting pain on that side of my neck that shoots up into the back of my ear on that same side. I have moderate neck pain everytime I drink alcohol.


Category: Family Physician-GP

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Category: Sexually Transmitted Diseases(STD)Specialist
Dr. Deepu Sebin Sebastian is online now

Expert:  Dr. Deepu Sebin Sebastian replied 4 Days.

Hello,
Thank you for your query at DoctorSpring.com
I am surprised that even though there are some thyroid nodules and you have deranged thyroid values, no further testing or intervention was mentioned.
Let me address your issues one by one :
1) Alkaline Phosphatase is produced by almost all body cells, but the bulk is by bones and liver. So any increase ( like in april ), can be due to an acute liver hepatitis, or other liver infections, or can also be due to bone resorption, but in absence of joint pain, bones do not seem like the issue in your case. However now it is 24 and there is nothing to worry about. Low alkaline phosphatase has no real significance, only when ALP is high along with ALT and AST we diagnose a patient with hepatitis and begin the treatment. It is quite possible that you probably had some liver injury at that point. If possible i would avise you to repeat LFT and upload the reports.
2) Now talking about your thyroid and the symptoms. Inability to lose weight, brain fogging, fatigue, sweating e.t.c can also happen due to deranged thyroid function. I have a strong suspicion seeing your results but to get a clearer picture i will advise you to get a thyroid profile done ( T3,T4,TSH ), becuase without seeing TSH making a diagnosis of hyper/hypothyroidism is difficult. Sometimes the symtpoms of both extremes overlap, like in your case inability to lose weight occurs in hypothyroidism, however all the other symptoms show hyperthyroidism. So i want to help you, and for that i need to see your thyroid profile reports soon. Also a nodule can be both due to hyper and hypothyroidism and presence of a nodule in the thyroid itself indicates thyroid derangement. Management should have been initiated but somehow it was ignored.
In absence of any infection, the node in the neck becomes significant. Will it be possible for you to upload your thyroid ultrasound reports? Also have you ever gotten your lymph node examined by a surgeon?
Please get back to me with your reports and additional details.
I will be awaiting your reply,
Regards.


Patient replied :

The only other thyroid tests that were done with these labs are as follows:
T4: 8.4 with a ref range of 5.0-12.5 ug/dL
T3 uptake: 50.3 with a ref range of 22.5-37 %*flagged as high
Free Thyroxine Index: 4.4 with ref range of 1.0-3.9 *flagged as high
TSH: 4.398 with a ref range of .350-4.5
No, I have not had the lymph node evaluated by a surgeon. My doctor basically laughed at me when I asked about a biopsy. It has been there for about 9 months now.
My scanner isn't working right now but this is what the thyroid ultrasound report says:
FINDINGS: The right lobe measures 3.2 x 1.2 x 1.3 cm and the left lobe 3.3 x 1.1 x 1.5 cm. Thyroid isthmus is normal in thickness at 1.4 mm. Each lobe is heterogeneous. Small bilateral nodules are seen. There are two nodules in the lower pole of the right lobe one measuring 2.7 x 2.3 x 1.7 mm and the other 3.6 x 2.6 x 2.4 mm. There is a hypoechoic nodule in the upper pole of the left lobe measuring 4.8 x 4.3 x 4.4 mm.
IMPRESSION: Normal size and shape of the thyroid gland which is somewhat heterogeneous with small bilateral thyroid nodules. No dominal nodule is identified.


Expert:  Dr. Deepu Sebin Sebastian replied 3 Days.

Hello,
Thank you for the additional details.
So nodules in the thyroid is an incidental finding in 20-40 % of the population, and in your case all of them are below 5mm, and hence no further evaluation of the nodules is necessary as of now. However a repeat ultrasound of thyroid will be helpful after 1 year. There is 1 hypoechoic nodule which is the only abnormal finding in the ultrasound. If it does not increase in size in repeat ultrasound, then FNAC won't be required.
However for your lymph node, i will advise you to schedule an appointment with a general surgeon, who can palpate and check for the consistency. If the consistency is soft-firm, then it is mostly due to some infection, however if the overall consistency is firm-hard, he may order a biposy for the lymph node. Meanwhile an appointment with the suregon will be also helpful, since he can carry out a few clinical thyroid tests ( based on palpation and some clinical signs ), which can also give a better picture of the thryoid gland function.
Though your TSH and T4 are normal, the free thyroxine index is a very sensitive indicator and it being high, points towards probable hyperthyroidism. So it can't be ruled out completely. In some cases of subclinical hyperthyroidism, T3,T4 levels may even be normal, but the patient will have some thyroid nodules along with symptoms, and we can label the patient as ' Subclinical hyperthyroid '
So i will advise you to schedule an apoointment with a general surgeon, since without physical examination it is difficult to intervene right away. He will guide you about further testing and investigations. Let me know if you can schedule an appointment any time soon.
Hope this was helpful,
Please let me know if you have further queries,
Regards.


Dr. Deepu Sebin Sebastian
Category: Sexually Transmitted Diseases(STD)Specialist
Experience: 
MD, Internal Medicine - Stanley Medical School
Medical School - MBBS - Govt. Medical College, Kottyaam

Diagnostic Prediction - Stanford School of Medicine
Received Specialty training in Critical Care, Cardiology, Neurology, Gastroenterology, Nephrology from Stanley Medical College and in Endocrinology, Rheumatology.

Hematology and Geriatrics from Madras Medical College.
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