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chloride at 10 gm/day for one week resulted in a marked lowered T3 and T4 levels (TSH = 28.1 IU/L; T4 = 3.4 g
increase in urine bromide levels and a sharp drop in serum %; T3 = 114 ng %). She was placed on 50 mcg/day of
bromide. While on the chloride load, urinary frequency Synthroid. After two months on Synthroid, her fatigue
improves for the first time in five years, but fatigue wors- improved markedly. Follow-up blood tests revealed a
ened, and she experienced facial and body acne. No sig- euthyroid state with normal TSH (TSH = 1.2 IU/L; T4 =
nificant change in symptomatology was observed while 8.7 g %; T3 = 128 ng %). However, urinary frequency
on vitamin C. The responses of her symptoms to various was still present. During the next four years while on
treatments modalities by self-assessment are summa- Synthroid, exopthalmos followed a relapsing/remitting
rized in Table 1. The treatment modalities are cumula- course with symptomatic periods alternating with as-
tive and added sequentially in the patients management. ymptomatic periods. The exopthalmos would be her
Measurements of serum and urine bromide and iodide guide to how her illness was progressing.
levels reported in this manuscript were performed by
ion-selective electrode assay, following chromatography One year ago, orthoiodosupplementation was imple-
on strong anion exchanger cartridges.3,7 mented following the iodine/iodide loading test with evi-
dence of whole body sufficiency for iodine (90% of the
Case Report load recovered in the 24-hour urine collection) but with a
The patient is a 52-year-old, white, female nurse (height very low basal serum iodide level (0.016 mg/L). The
= 64 inches; weight = 140 pounds) with a past history of patient experienced an exacerbation of all of her symp-
hyperthyroidism. Her medical history was unremarkable toms including exopthalmos following the loading test.
until five years ago when she presented with tachycardia, However, she did feel an increase in energy and warmth
tremors, exopthalmos, and urinary frequency. Thyroid after the first dose of iodine. Over the next few months,
blood tests revealed slightly elevated total T3 and ele- she titrated the iodine down from 50 mg to 12.5 mg
vated T4 along with a suppressed TSH (TSH <0.02 IU/L; every other day (average daily dose 6.25 mg/day). Al-
T4 = 17.1 g %; T3 = 187 ng %). Her endocrinologist though she felt better on orthoiodosupplementation, the
recommended treatment with radioiodide. After doing relapsing/remitting course of exopthalmos was still pre-
some research on this subject, the patient chose not to sent. However, the patient felt her exopthalmos was
proceed with this treatment. She did not pursue any overall improving following orthoiodosupplementation.
course of therapy at this point as she felt her symptoms She was able to tolerate a daily average of 6.25 mg io-
were not severe enough to justify radioablation of the thy- dine during the year, while on Synthroid.
roid. She was followed with thyroid function tests. Her
clinical history is summarized in Table 2. Approximately four months ago, she was placed on vita-
min C sustained release (Optimox C-500) at 3 gm/day.
Four years ago, she developed severe fatigue. Thyroid She continued the every other day iodine 12.5 mg. Prior
function tests revealed elevated TSH and with slightly (Continued on next page)
Table 2
Chronology of Patients Medical History
30
= Mean of 6 normal female subjects
3
= Patient with iodide transport defect
Prior to intervention
2.5
% iodide load excreted = 90%
Baseline serum iodide = 0.016 mg/L
2
1.5
0.5
v
0
Pre 0.5 1 2 3 4 5 6 7 8 9 10 11 12 24 hrs
Time Post ingestion of Iodoral 50 mg load
The patient excreted 90% of the iodine load, but her basal serum inorganic iodide level was very low 0.016 m/L. This
pattern suggests a defect in the iodine retention mechanism.
This resulted in a bromide detoxification reaction. The observation that in some cases a repeat loading test
patient became very fatigued. In addition, she devel- three months after orthoiodosupplementation resulted
oped facial and body acne, most likely due to mild in a decreased percentage load excreted instead of the
bromism. However, one positive response to the chlo- expected increase. This explains why in some cases
ride load was that urinary frequency decreased signifi- patients feel better on orthoiodosupplementation al-
cantly during that week. This was the first time that though the repeat loading test three months following
frequency of urination became normal since the onset orthoiodosupplementation reveals a greater retention of
of Graves disease five years ago. iodine and a drop in percentage load excreted. The
milder forms of iodine retention defect will probably be
Discussion overlooked until a more refined procedure is worked
To our knowledge, this is the first case report of a pa- out to assess accurately the efficiency of the iodine
tient with evidence of a very defective retention mecha- transport mechanism. To be discussed later, the sali-
nism for iodine who was studied with serial serum io- vary/serum iodide ratio may be the test that will detect
dide levels prior to and following intervention. A com- various levels of iodine transport defect, the greater the
bination of orthoiodosupplementation in amounts of ratio, the more efficient the transport system.
iodine the patients could tolerate and administration of
the antioxydant vitamin C via the oral route improved We have previously observed that some patients who
the performance of the iodine retention mechanism. experienced side effects while on orthoiodosupplemen-
Repair of a defective iodine cellular transport mecha- tation excreted large amounts of bromide in the urine.
nism following orthoiodosupplementation combined Orthoiodosupplementation induced and increased mo-
with a complete nutritional program may explain our (Continued on next page)
Figure 2
Serum Profile of Inorganic Iodide Levels Following the Iodine/Iodide Load (50 mg)
in 6 Normal Subjects and in 1 Patient with Iodide Transport Defect
Following 3 Months of Intervention with Sustained-Release Vitamin C at 3 mg/day
Serum inorganic iodide levels (mg/L)
3
= M ea n of 6 n orm al fem ale su b jects
2.5
= P a tien t w ith iod id e tr an sp o rt d efect
P ost 3 m on th s V itam in C 3 g/da y
2
% iod id e lo ad ex creted = 49 .2 %
B a selin e seru m iod id e = 0.4 2 m g/L
1.5
0.5
v
0
P r e 0.5 1 2 3 4 5 6 7 8 9 10 11 12 24 h r s
T im e P ost in ge stion of Iod or al 50 m g lo ad
She excreted 49.2% of the iodine load and the baseline serum level was 0.42 mg/L, evidence of improved function of the io-
dine cellular transport mechanism.
Figure 3
Serum Profile of Bromide Levels Post Iodine Loading
250
Serum inorganic bromide levels (mg/L)
150
100
50
0
0 1 2 4 6 8.5 11 h rs
T im e post in gestion of Iodoral 50 m g load
The heavy horizontal line represents the upper limit of serum bromide levels reported in normal subjects.