The double line sign as a clinical sign of hashimoto's thyroiditis.¶
by u/Drwillpowers · 41 points · 63 comments · source
So along with many of the other things I'm working on, I'm trying to collect a case series right now on what I call "The Double Line Sign". I'd like to make a little mini case report on this, as I haven't seen much else on this as a clinical sign.
I noticed over the years that patients I diagnose with hashimoto's thyroiditis (which I do very very often in my population) often have two creases in their neck despite not being overweight or old enough for these sort of folds to have a reason to form.
I postulate that the reason for this is that intermittent swelling of the thyroid gland results in an anatomic "bulge" at this location, which later goes on to create a skin fold when tilting the head forward that otherwise would not normally happen for the patient. As a result, physically fit and young patients with no good reason for having a skin crease in their neck will have two, positioned approximately above and below the thyroid.
This has been remarked on in literature for surgeons as anatomical landmarks for the purposes of identifying where to make an incision for thyroid related surgeries, but I haven't been able to find anyone using it as a marker for autoimmune thyroiditis in young people.
Whenever I happen to spot one of these on someone, I order the Anti-TPO and Anti-thyroglobulin antibodies on them and about 90% of the time, I get a positive result back. In those who I don't get a positive result, they often have strong family histories of Hashimoto's and I wonder if they will later seroconvert if I keep checking. Maybe someday when I'm dead people will call it the "Powers Double Line Sign" which has a nice ring to it.
If anyone here has hashimoto's and notices this on themselves, or, if you don't and you notice a lack of this, or vice versa, feel free to comment.
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My neck, 37 Male, no crease, no thyroid disease.
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Comments¶
u/RestlessGGod · 3 points
I have a Hashimoto's diagnosis and a double (albeit faint) line too (25, 5'3, 115 lbs). My mom (56, 5'5, ~170 lbs), also diagnosed, doesn't seem to have it though (maaybe just one line, if you squint really hard).
u/Acrobatic-Chain-7003 · 2 points
yea taking mtf hormones gives u these lines
u/[deleted] · 1 points
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u/Drwillpowers · 1 points
You could. But when you get tested, TSH is not enough.
You need to get the thyroid peroxidase and thyroglobulin antibodies. And often, those are not positive but the lines are there first. Eventually they tend to become positive. Considering that your mom has it, there's reasonably good odds that you will eventually develop it.
u/[deleted] · 1 points
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u/Drwillpowers · 1 points
It is something easily treated, easily missed, and when people find out that they have it, it's a good thing, because they can suddenly feel much better.
u/National-Yak-5093 · 1 points
I have the double lines. my BMI is around 20 and I'm 38 with excellent (Indian , protected with sunscreen) skin. I have slight hyperthyroidism which I mitigate with methamazole (which I'm not sure is the right solution here--open to suggestions). most recent labs here: https://imgur.com/a/Pl3TPWY the methamazole is keeping everything barely in range I think
u/Drwillpowers · 1 points
Yeah, it doesn't matter if it's hypo or hyper, if the thyroid swells, you get the lines.
u/Drwillpowers · 1 points
You could. But when you get tested, TSH is not enough.
You need to get the thyroid peroxidase and thyroglobulin antibodies. And often, those are not positive but the lines are there first. Eventually they tend to become positive. Considering that your mom has it, there's reasonably good odds that you will eventually develop it.
u/[deleted] · 1 points
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u/Drwillpowers · 1 points
I think about 15% of all cases are? So yes.
u/Still_Armadillo_321 · 1 points
https://preview.redd.it/6n24adig0loe1.jpeg?width=2316&format=pjpg&auto=webp&s=e40205a07199c42961541a28769c18605f67aa15
Holy shit, I’ve always wondered why I had these deep lines. Significant family history of thyroid issues on both sides of family. I’m only 32 but I have frequent instances of exhaustion and then anxious energy. What labs do I need?
u/Still_Armadillo_321 · 1 points
32, F, 135lbs, 5ft 3in. Use lotion like it’s my mf job and still have the creases.
u/Drwillpowers · 1 points
TSH t4 t3 (free on both) thyroglobulin antibody and thyroid peroxidase antibodies.
Sounds like you're in the early phases. When I'm highly suspicious on someone I'll repeat this annually. It inevitably goes positive eventually. I know only one person thus far that has this and hasn't seroconverted and she works for me and so it drives me nuts wondering why!
u/Worried-Beach9078 · 1 points
What do you recommend to do if someone tomorrow looks in the mirror and "holy shit, I have these!"? Apart from ordering test, is there any treatment that they can start to immediately stop (put in remission without early damage) this disease?
u/Drwillpowers · 2 points
There is limited evidence for LDN. Anecdotally. I just suppress people kind of the same way the endocrine society recommends treatment post thyroidectomy for cancer but not quite as hard. Just a "low" but non zero TSH. Anecdotally I've seen it work sort of like a thyroid mood stabilizer. It throws less temper tantrums when it has to do less work.
u/stranglemefather · 1 points
ive never been diagnosed with hashimotos but i was diagnosed with congenital hypothyroidism at around 2 years old and was told by my pediatric endo that my thyroid is so small that she could not confidently identify it through physical exam. i just noticed today after seeing this post that i have these 2 lines.
I've just started looking into this recently so im not sure if there is a lot of medical literature or if you could provide any insight but I've been really interested in seeing if having congenital hypothyroidism influenced me being autistic and transsexual. Im assuming the lack of thyroid hormone in my early development may have caused some sort of change in my brain structure/function and possibly caused my underwhelming response to masculinizing hormone treatment?
u/Prudent_Year_6383 · 1 points
26 F diagnosed with hashimoto's recently and I have a double line too!
u/PatientPleasant1164 · 1 points
https://preview.redd.it/1o9zhicad8pf1.jpeg?width=1536&format=pjpg&auto=webp&s=d87143be843faf48d337f1af86d4d4c757709ee4
Does this count? I’m trying to get a proper diagnosis, I have requested blood work and another ultrasound. I was previously diagnosed adrenal insufficiency but I don’t believe that’s the case. I’m super fat and can’t lose any weight I’m fatigued constantly itchy and sometimes have hives there’s a few other things. My thyroid has been enlarged for all my life and it’s gotten bigger. I can’t seem to find a doctor to take me seriously. It’s always just mind your calories cut back and exercise. I don’t eat much, never have(there’s been times I’ve completely forgot). I have moderate exercise(low energy) and I don’t snack or endulge in junk food often(I don’t care for it, it’s not a thought) and I don’t drink soda…im lost
u/PatientPleasant1164 · 1 points
https://preview.redd.it/fjglw0jfe8pf1.jpeg?width=1536&format=pjpg&auto=webp&s=57a547fda36d757ac34f920337fe0a0b6f68e336
u/populardeviation · 1 points
Old post, but, for your research -- I have these lines, and have for quite some time! I likely have Hashimoto's Thyroiditis (I'm partially through the diagnostic phase, but the tests and symptoms so far line up), and there is a history of Thyroid and Autoimmune disease in my family. Oh, and I have an extremely lean neck. Fascinating!
u/Aggravating_Head_827 · 2 points
Kind of hard to see due to age and wrinkles but I’ve had double lines my whole life…
https://preview.redd.it/7w5xmewyihpg1.jpeg?width=1213&format=pjpg&auto=webp&s=bdf5d393993d53c020590e3ef12f9b6a4775f77d
u/FondantGetOut · -12 points
This is... quite possibly the dumbest shit I've ever read.
u/Drwillpowers · 10 points
Care to elaborate?
u/[deleted] · 1 points
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u/Emikyuu · 1 points
Ok... i don't have diagnosed Hashimoto but maybe i should ask my endo... i have visit at 16/09.
36 MtF, 179cm, 75kg and link to my neck... feel free to bite :PBut seriously, do you think it can mean something?
u/Drwillpowers · 1 points
I mean that's a faint one, but it's easy to run the antibody and find out.
u/Wildbore309 · 1 points
I have 2 or 3 major creases: one much below Adam's apple and two parallel lines right on its bottom end spaced about 5-6mm apart, there's also a less apparent but still noticeable fourth crease right on the top end of the Adam's apple. Does that make me Japanese or dangerously sick? Maybe I qualify to become a martial artist 🤷🏻♀️
u/Wildbore309 · 1 points
Ps. I was born with an enlarged thymus. I have no clue what does that mean. At my 38 I only think that I have to watch out for my liver because I feel it zaps me from time to time and swells during running.
u/Wildbore309 · 1 points
Ps. I was born with an enlarged thymus. I have no clue what does that mean. At my 38 I only think that I have to watch out for my liver because I feel it zaps me from time to time and swells during running.
u/halfnhalf1211 · 1 points
You may be onto something.
I am 52, mtf, 195 lbs. and I have the same two rings around my neck at the locations you have identified. I also have a third ring at the base of neck where it meets the shoulders. I thought they were due to age.
I don't have any diagnosis for Hashimoto or other thyroid issues, my doc has been observing but hasn't done anything other than observation and ordering Thyroid Peroxidase (TPO) Ab tests.
In last 3 years they have been: 48 IU/mL (in 2022), 57 IU/mL (in 2021), and 59 IU/mL (in 2020).
Although, it is going down but am getting concerned as I am noticing something strange....I have periodic mild sore throat, and it comes and goes.
The weird part I also noticed that the sore throat at times come in right after my HRT Ev injections and after few hours it goes away. Not sure if hrt is is a contributor to this.
I would be interested to know your take on this.
u/Drwillpowers · 1 points
Yeah I mean that sounds pretty much textbook. And if you have a positive tpo, that's basically showing that you have the autoimmune disease. It's just not done enough damage to your thyroid yet for you to be hypothyroid.
u/unexpected_daughter · 1 points
I never even noticed I have those two lines until I checked just now… I’ll ask Sommer to add these to my upcoming labs.
u/Rimewind · 1 points
Hmm. My thyroid function is fine as of a few years back (25) but I definitely got those lines on me. I could try to see if the test is covered by my shit insurance.
u/rayofsunshaine · 1 points
oh snap i‘ve had these neck lines for as long as i can remember and i’ve always been on the smaller side. i took a thyroid med for a little while when i started seeing you but i don’t remember what for
u/DeannaWilliams222 · 1 points
So how many trans women do you see that have this "double line sign" but no indication of thyroid issue, even with the tests you do for it?
Is it possible this is simply a result of estradiol based HRT?
I noticed both myself and my partner have these lines (at least it appears that way to me), and that's a striking coincidence. Someone else commented something along the lines "that's what happens when you dose estradiol"... I haven't read much on this, so I'm curious about your perspective on this.
u/Drwillpowers · 1 points
The majority of the time when I see the lines, they have the positive antibody test.
The lines I'm talking about are quite pronounced. They are very obvious. This is not just a faint crease in the neck. I'm also talking about people in their twenties.
u/Acrobatic-Chain-7003 · -1 points
yes that person was me.I said mtf hormones mess with your thyroid
u/DeannaWilliams222 · 2 points
I just looked at your post and comment history.... Enough said.
u/[deleted] · -2 points
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u/Drwillpowers · 6 points
So none of the people in the photographs are transgender and this has literally nothing to do with hormone therapy.
This is just an entirely separate thing that I noticed by being a doctor.
But cool thanks for your opinion.
u/DeannaWilliams222 · 2 points
>I did my studying on the subject.half the effects that are said to happen while on hormones do not.
>?.A biological males body does not know what a womans body is or how it functions therefore this fat distribution going to woman areas are false.
https://pubmed.ncbi.nlm.nih.gov/9950792/
You are quite simply wrong.
u/Acrobatic-Chain-7003 · -1 points
It says gaining fat in them areas.But you have to take into consideration that the reversal of hormones slows motab therefore causing weight gain.older people tend to gain weight in thighs and buttocks region
u/DeannaWilliams222 · 2 points
>older people tend to gain weight in thighs and buttocks region
no. older people tend to gain weight in the midsection.
u/Acrobatic-Chain-7003 · -1 points
thats when the subject is skinny/fat. when someone is obese throughout life.as they age they gain more fat on their buttock as well as thighs.Most obese people have higher estrogen levels than testosterone
u/Acrobatic-Chain-7003 · -5 points
which is why many obese people are not as hairy
u/Strange_Relation_178 · 1 points
This is completely wrong. Men gain weight in their midsection until clinically obese and then gain in the back, upper arms and thighs. You don't need anything but eyes to see this.
u/Acrobatic-Chain-7003 · -1 points
As you age, your muscle mass decreases and your fat mass increases.
Fat is less metabolically active than muscle—you don't need as many
calories to maintain fat as you do to maintain muscle. Hormonal changes
can also lead to weight gain
u/DeannaWilliams222 · 1 points
>I have yet to see an actual before and after picture that shows the actual effects of hormones
first, my opinion is that you must be blind and ignorant.
Second... You simply don't understand biology. I'm not going to even try to take the time to explain it to you because you seem to have a closed mind.
I will drop my bookmarks for you, should you care to enlighten yourself on biology.
https://www.one-tab.com/page/IGYC_6xhTS2DIBCmkTNsmg
u/Red_Roslan · 1 points
Intetesting observation. I have noticed these on my neck for years too. After getting the results back recently, it showed my TPO's were 50x over the normal amount. Going to get an US of my thyroid done to confirm the diagnosis. With that said, in this day and age, many activities that make our neck tilt can cause the lines to form too. Especially if you look up tech neck, similar pictures are shown.
u/optimize4headpats · 1 points
I have the double lines. My mom has hashimoto's and has been taking medication for it since she was 13. I had my thyroglobulin antibodies and thyroid peroxidase ab checked in 2020 and they were negative. My free t4 was 0.79ng/dL (normal range: 0.7-1.48). My TSH was 2.24uIU/mL. I'm guessing that's somewhat hypothyroidal but maybe not hashimoto's?
u/Lilia1293 · 1 points
My (33f, 5'11", 190lbs) neck is really inflamed because of electrolysis now, but I don't see the lines and I have not been diagnosed with Hashimoto's. This is anecdotal and weak, but it aligns with the clinical sign you've postulated - that those without the double line have less thyroid inflammation.
u/Dill789456 · 1 points
I think I have this. Here is a pic of my neck.
https://i.imgur.com/OYdVcd3.jpg
Are these the tests you would order?
https://www.walkinlab.com/products/view/thyroid-peroxidase-tpo-antibodies-blood-test
https://www.walkinlab.com/products/view/thyroid-antithyroglobulin-antibody-taa-blood-test%EF%BB%BF
I’ve had doctors refuse to test my thyroid because I’m not obese.
u/Drwillpowers · 1 points
Yes, but yours looks very mild by comparison.
u/One_Ad2282 · 1 points
I am currently 12 months PP suffering from a pretty intense case of Thyroiditis. My TSH was 180 and I was experiencing some pretty frightening symptoms. I wonder if my two creases are from the swelling I’ve had this past year? It was pretty swollen around 6 months PP. I’m kind of hoping to come off Synthroid in the next couple of months. I’m starting to notice signs of hyper again. Or so I assume my lines mean permanent Hashimoto’s? Just thinkin’ out loud here! Ha ha.
u/Drwillpowers · 1 points
If your thyroid was severely inflamed, you could have had the creases formed from the swelling.
If your doctor is not checking all of the situations to make sure that you're either not hypo or hyper, you need to get that done.
For most of my autoimmune thyroid patients I give them a suppressive dose of thyroid medication that shuts off their own production. I keep their TSH near zero and it seems to help.
u/One_Ad2282 · 1 points
Thank you for the response. It was quite inflamed, confirmed by an ultrasound, but was easy to see with the naked eye.
When Synthroid finally brought my levels back to “normal” range, my specialist changed my bloodwork to every 3 months. I am just at 3 months today, bloodwork scheduled for tomorrow morning. I am hoping it reflects the way I am feeling and shows that it is time to (wean?) off Synthroid. Unfortunately, my specialist doesn’t seem to know much beyond basic thyroid dysfunction. I am left to search all of my symptoms online and just cross my fingers that they are normal and that I’ll one day feel normal again. A year ago, when it all started, my antibodies were 380. I didn’t think they were high enough to assume Hashimoto’s, but she did. Tomorrow’s labs just call for TSH and T4. I guess we will see!
u/Affectionate_Sun_204 · 1 points
I noticed the double line since my young age, and I thought that is just a part of my life, and never seek any medical help too! Glad to hear this is not just happened on me. Can Dr please give me some advice what type of specialist I should I look for? Thank you!!
u/autumn-autumn · 1 points
I've always had these lines, and yes, I got a very bad case of Hashimoto's when I turned 18, my TPO was 1,995 lol so you may be on to something there! I believe my mom has the same lines and the same condition.
u/katka_monita · 1 points
OMG thank you for this post, I'm just now learning about this. My mom and I both have these lines and she's beginning to have hyperthyroid issues. I wonder if I should assume this is likely in my future too.
u/[deleted] · 1 points
Omg I have this. Diagnosed hashi, with mildly swollen thyroid.
u/[deleted] · 1 points
So, selenium?
u/[deleted] · 1 points
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u/Drwillpowers · 2 points
So I would get the antibody test done as well as a thyroid stimulating immunoglobulin.
Hashimoto's can result in attacks where the total thyroid output goes up. Then after the attack, it crashes down, and then eventually normalizes. Running labs on it is sort of a crap shoot because you never know what phase you're going to catch somebody in. This is why the antibody tests are helpful to let you know that that's the situation you're in.
u/[deleted] · 1 points
I've got those lines, I thought they were just lines or wrinkles. They've been there as long as I can remember.
u/Meiguishui · 1 points
I have this. Do you see this more in trans women or trans men?
u/spiramirabilis8888 · 1 points
what can be done if you notice these lines on yourself but don't have yet hashimoto's? just test for the antibodies regularly and hope for the best, or...? I'm already supplementing methylated b vitamins, d, zinc, bone vit for suspected MPS syndrome reasons (still waiting on genetic results but fit the type 1 category very well)
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