elevated thyroid peroxidase antibody after thyroidectomy

elevated thyroid peroxidase antibody after thyroidectomy

Treatments can help. Objective . [5] They included 737 men and 771 women in their study. Sign up for free, and stay up to date on research advancements, health tips and current health topics, like COVID-19, plus expertise on managing health. However, a diagnostic dilemma occurs when the patient presents with thyroid-stimulating hormone (TSH) suppression. In these patients structural recurrence is rare, more frequently diagnosed in the first 5 years from initial treatment and almost invariably localized in neck lymph . Search dates: June 6, 2011, through February 29, 2012, and March 30, 2014. Thyroid ultrasonography in subacute thyroiditis shows a nonuniform echotexture, hypoechoic areas, and decreased vascularity throughout the gland. Keywords: T3 tests are often useful to diagnosis hyperthyroidism or to determine the severity of the hyperthyroidism. A high TSH level indicates that the thyroid gland is not making enough thyroid hormone (primary hypothyroidism). 174 views Reviewed >2 years ago. Objective: The study aimed to assess antithyroid antibodies in patients with benign thyroid masses and the effect of total thyroidectomy on the antibodies titers. 4 Iatrogenic forms of hypothyroidism occur after thyroid surgery, radioiodine therapy, and neck . First myopathy seen in . Introduction: Papillary thyroid cancer (PTC) is the most common endocrine malignancy. Background: To investigate whether high thyroid peroxidase antibody (TPOAb) and thyroglobulin antibody (TgAb) levels are associated with increased risk of lymph node metastasis (LNM) of thyroid cancer. Most of these patients will have recovery of euthyroidism, but some may benefit from treatment aimed at relieving symptoms of hyperthyroidism or hypothyroidism, provided they are monitored for anticipated changes in thyroid function. Many thanks for replying so quickly Stella5349 and Barb135. Unable to load your collection due to an error, Unable to load your delegates due to an error. Thank you for this information. 2018 Jan;163(1):118-123. doi: 10.1016/j.surg.2017.05.028. Changes in TSH can serve as an early warning system often occurring before the actual level of thyroid hormones in the body becomes too high or too low. Second, the laboratory test result should be interpreted within the context of the medical status of the patient. Only show this user . A TPO test detects antibodies against TPO in the blood. Measurement of free T3 is possible, but is often not reliable and therefore not typically helpful. Thyroid peroxidase antibodies will usually go away if a radical thyroidectomy is done for thyCa but may not if a lot of thyroid tissue remains after thyroidectomy for goitre/nodule removal or hyperthyroidism. RADIOACTIVE IODINE UPTAKE Your result is 300+ which means positive. Do you have high TPO or high TPOab? I don't believe it was a TPOab. Therefore, this activity can be measured by having an individual swallow a small amount of iodine, which is radioactive. Anterior neck pain in the area of the thyroid bed is the cardinal feature of subacute thyroiditis and is most often what prompts patients to seek medical attention. If it's your antibody levels that are at 300, this would indicate that you have the autoimmune thyroid disease called Hashimoto's Thyroiditis. If thyroglobulin levels are low even in the presence of stimulation by a raised TSH, this is very reassuring and indicates absence of recurrence in papillary and follicular thyroid cancers (differentiated thyroid cancers). Chronic autoimmune thyroiditis (Hashimoto thyroiditis) is the most common form. Our purpose was to describe the TgAb resolution time course and the significance of persistent antibody elevation after thyroidectomy. Chronic autoimmune thyroiditis (Hashimoto thyroiditis, chronic lymphocytic thyroiditis), Hypothyroidism; rarely thyrotoxicosis secondary to alternating stimulating and inhibiting thyroid autoantibodies, Infectious thyroiditis (suppurative thyroiditis), Thyroid pain, high fever, leukocytosis, and cervical lymphadenopathy; focal inflammation may result in compressive symptoms such as dysphonia or dysphagia; patients may assume a posture to limit neck extension; palpation may reveal focal or diffuse swelling of the thyroid gland and the overlying skin will be warm and erythematous; presence of fluctuance suggests abscess formation, Multiple infectious organisms, most commonly bacterial, Thyroid fine-needle aspiration with Gram stain and culture; blood cultures; neck magnetic resonance imaging or computed tomography with contrast media; plain radiography of the lateral neck may reveal gas in the soft tissues; thyroid autoantibodies are generally absent; serum thyroxine and triiodothyronine levels are usually normal, Acute complications may include septicemia and acute airway obstruction; later sequelae of the acute infection may include transient hypothyroidism or vocal cord paralysis, Hospitalization and treatment with intravenous antibiotics (nafcillin plus gentamicin or a third-generation cephalosporin); abscess formation may necessitate surgical drainage; euthyroidism is generally restored after treatment of infection, Hyperthyroidism alone; hyperthyroidism followed by hypothyroidism; or hypothyroidism alone within one year of parturition, Thyroid function tests; elevated TPO antibody levels; low radioactive iodine uptake in the hyperthyroid phase, Euthyroidism is generally achieved by 18 months, but up to 25% of women become permanently hypothyroid; high rate of recurrence with subsequent pregnancies, Beta blockers can be considered for significant hyperthyroid symptoms (in the hyperthyroid phase); levothyroxine for symptomatic hypothyroidism (in the hypothyroid phase) and for permanent hypothyroidism, Patients may present with thyroid pain and transient thyrotoxicosis, Clinical diagnosis made in the setting of recent previous radiation, Hyperthyroidism generally resolves within one month, Self-limited, but symptoms may be treated with beta blockers and nonsteroidal anti-inflammatory drugs, Very firm goiter or compressive symptoms (dyspnea, stridor, dysphagia), which appear disproportionate to the size of the thyroid; hypocalcemia may occur as a result of fibrotic transformation of the parathyroid glands, Autoimmunity may contribute to the pathogenesis, Most patients are euthyroid, approximately 30% are hypothyroid, Glucocorticoids and mycophenolate (Cellcept); tamoxifen may work by inhibiting fibroblast proliferation, Silent thyroiditis (silent sporadic thyroiditis, painless sporadic thyroiditis, subacute lymphocytic thyroiditis), Hyperthyroidism alone; hyperthyroidism followed by hypothyroidism; or hypothyroidism alone, Euthyroidism is generally achieved by 18 months, but up to 11% of patients become permanently hypothyroid; rarely recurs, Beta blockers can be considered for significant hyperthyroid symptoms (in the hyperthyroid phase); levothyroxine for symptomatic hypothyroidism (in the hypothyroid phase) and permanent hypothyroidism, Subacute thyroiditis (subacute granulomatous thyroiditis, giant cell thyroiditis, de Quervain thyroiditis), Thyroid pain; hyperthyroidism followed by transient hypothyroidism most commonly, Euthyroidism is generally achieved by 18 months, but up to 15% of patients become permanently hypothyroid; rarely recurs, Atrial fibrillation, ventricular arrhythmia, Persistent or recurrent cutaneous T cell lymphoma, psoriasis, graft-versus-host disease, chronic lymphocytic leukemia, Hairy cell leukemia, follicular lymphoma, malignant melanoma, AIDS-related Kaposi sarcoma, chronic hepatitis B and C, Hypothyroidism more often than hyperthyroidism, Gastrointestinal stromal tumors, renal cell carcinoma. Do not routinely order a thyroid ultrasound in patients with abnormal thyroid function tests if there is no palpable abnormality of the thyroid gland. A pair of recent studies from two different regions of India showed that euthyroid women with elevated TPO antibodies had . It is used most often in patients who have had surgery for thyroid cancer in order to monitor them after treatment. To exert its effects, T4 is converted to triiodothyronine (T3) by the removal of an iodine atom. Feelings of anxiousness, anxiety, or irritability. 1.50 - 38.5 ng/mL for women. Thyroid stimulating immunoglobulin or TSI for short (1) is the name of a blood test that is used to identify the presence of autoimmune disease in those with hyperthyroidism. Patients with overt hyperthyroidism (suppressed TSH and elevated free thyroid hormone levels) and significant symptoms can be treated with beta blockers, regardless of the etiology. 8. T4 and T3 circulate almost entirely bound to specific transport proteins. Thyroid. FT4 and FT3 levels did not differ in patients with a mild lymphocytic infiltration compared to those with a severe lymphocytic infiltration (21.1 vs 32 ng/L, P = 0.5 for FT4 and 8.1 vs 13.2, P = 0.18 for FT3). Do not order a total or free triiodothyronine level when assessing levothyroxine dose in hypothyroid patients. This content is owned by the AAFP. Women tend to have slightly higher thyroglobulin levels than men [ 8 ]. Treatment with thyroid hormone in patients with elevated TPO antibody levels and subclinical hypothyroidism (TSH level greater than the upper limit of the reference range, but less than 10 mIU per L) is reasonable, especially if symptoms of hypothyroidism are present. Follow up visits were done every 3 months for 18 months and the thyroid hormone therapy was adjusted as needed. Epub 2019 Mar 12. Thyroid cancer can also produce elevated thyroglobulin antibodies. The follow-up of patients with differentiated thyroid cancer and undetectable thyroglobulin (Tg) and Tg antibodies during ablation. Patients who are hyperthyroid will have an elevated T3 level. To provide you with the most relevant and helpful information, and understand which Treatment with beta blockers (propranolol, 10 to 20 mg four times per day) may be initiated in symptomatic women and is acceptable in those who are breastfeeding.18 Therapy is usually required for only one to three months, and patients can be tapered off medication fairly quickly. Therefore, this activity can be measured by having an individual swallow a small amount of iodine, which is radioactive. sharing sensitive information, make sure youre on a federal "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Tg is included in this brochure of thyroid function tests to communicate that, although measured frequently in certain scenarios and individuals, Tg is not a primary measure of thyroid hormone function. It occurs when your body makes antibodies that attack the cells in your thyroid. . Xu J, Bergren R, Schneider D, Chen H, Sippel RS. Hashimoto thyroiditis is part of the spectrum of autoimmune thyroid diseases (AITDs) and is characterized by the destruction of thyroid cells by various cell- and antibody-mediated immune processes. Regression analysis of patients with antibody resolution yielded an average decline of -11% IU/mL per month 2.2%. TPO converts iodide ions absorbed from food into an active form of iodine to be used by the body. However, monitoring anti-TPO antibodies come with their own limitations. Elevated TSH antibodies. Learn how we can help. While TPO-antibodies are more indicative of Hashimotos thyroiditis, elevated anti-TG antibodies are often reported on lab results, creating concern for patients. Surgery. Very high TPO more common with autoimmune thyroiditis (Hashimoto's) To confirm suspicion of hyper Graves. Silent thyroiditis is similar to postpartum thyroiditis, but its presentation is not limited to the postpartum state. It is still unclear which dietary strategy would be the most beneficial. information highlighted below and resubmit the form. More than 98% of patients achieve an excellent response with no evidence of clinical, biochemical, or structural disease after initial treatment. Patients typically present with a nontender goiter, hypothyroidism, and an elevated TPO antibody level. Elevated levels may also indicate a high risk of thyroid cancer recurrence after treatment [ 4. Thyroid antibodies explained . My recent antibody levels came back 421 last week (May 30, 2013). In its mildest form, hyperthyroidism may not cause noticeable symptoms; however, in some patients, excess thyroid hormone and the resulting effects on the body can have significant consequences. Blood tests to measure these hormones are readily available and widely used, but not all are useful in all situations. After screening about 150 subjects were assigned to two groups. Conclusions: Results: Patients were in the age group of 18 to 79 years. Surgical complications included local postsurgical infections in 3 patients, prolonged low calcium levels in 3, and early postoperative hoarse voice quality which improved spontaneously or with therapy in 4. Hello everyone, I wanted to ask you about your experience with elevated thyroglobulin levels years after thyroidectomy. 6 months later the LN was still elevated but the Tg was detectable at 0.7. Finally risk of surgical complications has to be taken into consideration. These antibodies can be a sign of: Hashimoto disease, also known as Hashimoto thyroiditis. The amount of TSH that the pituitary sends into the bloodstream depends on the amount of T4 that the pituitary sees. A prospective study of hospitalised COVID-19 patients conducted in Hong Kong showed that the majority of those with abnormal thyroid function (13.1% of the group) had low TSH concentrations, but only one of 191 participants (0.5%) had a high TSH concentration and a high thyroid peroxidase antibody titre. Additionally, TgAb+ positive patients were also stratified into those with persistent TgAb elevation and those without. my Tg was undetectable before RAI and after. Thyroid function tests. Of 247 patients (77% women, 23% men; mean 45.7 1.0 y) with TgAb measured preoperatively, 34 (14%) were TgAb+ (20 IU/mL; mean 298.1 99.2 IU/mL). include protected health information. Unauthorized use of these marks is strictly prohibited. Because T4 contains iodine, the thyroid gland must pull a large amount of iodine from the bloodstream in order to make an appropriate amount of T4. PMID: 30856652. KL2 TR000428/TR/NCATS NIH HHS/United States, R01 CA176911/CA/NCI NIH HHS/United States, T35 DK062709/DK/NIDDK NIH HHS/United States, UL1 TR000427/TR/NCATS NIH HHS/United States. Your thyroid is a small, butterfly-shaped gland in the front of your neck. I had RAI Nov 1, 2012. [ 1] BACKGROUND THE FULL ARTICLE TITLE: This site needs JavaScript to work properly. We disclaim all responsibility for the professional qualifications and licensing of, and services provided by, any physician or other health providers posting on or otherwise referred to on this Site and/or any Third Party Site. Indeterminate thyroid nodules (ITN) are commonly encountered among the general population, with a malignancy rate of 10 to 40%. This raises the possibility that some symptoms may be related to the autoimmune condition itself. Third, the degree of hyperthyroidism and the severity of symptoms should be considered. During that time, the only intervention was the use of nigella extract. Tg is included in this brochure of thyroid function tests to communicate that, although measured frequently in certain scenarios and individuals, Tg is not a primary measure of thyroid hormone function. A low TSH with an elevated FT4 or FTI is found in individuals who have hyperthyroidism. PMC T4 TESTS sured by elevated thyroid peroxidase antibody (TPO Ab).6,7 To date, there is no algorithm for treatment in these refractory cases. It is characterized by varying degrees of lymphocytic infiltration and fibrotic transformation of the thyroid gland. Currently, total thyroidectomy (TT) is widely used to treat benign thyroid diseases and thyroid carcinoma. During the thyrotoxic phase of subacute thyroiditis, this test shows a low uptake of iodine (less than 1% to 2%). A very high RAIU is seen in individuals whose thyroid gland is overactive (hyperthyroidism), while a low RAIU is seen when the thyroid gland is underactive (hypothyroidism). Hypothyroidism, or an underactive thyroid, is a common problem. Thyroid hormone supplementation is generally not necessary for the transient hypothyroid phase of subacute thyroiditis unless patients are symptomatic or have clear signs of hypothyroidism. This generally occurs within six months after achievement of euthyroidism. Indeed, some patients with high TPOAb levels and normal thyroid hormone levels (without medication) will present with symptoms similar to those of patients with hypothyroidism. These non-self proteins are called antigens. I had TT in January 2009, and in November 2016 my Tg level was suddenly detectable after being undetectable for years. A Free T4 measures what is not bound and able to enter and affect the body tissues. Didn't find the answer you were looking for? What in the world could be going on? An overactive thyroid causes problems with organs like the heart, as well as bones and muscles. The person is pregnant be aware that after the first trimester, thyroid autoantibodies may be negative due to immune suppression in pregnancy. By the end of the eight weeks, those given nigella saw their thyroid function improve and their thyroid antibodies lower by an average of 50% 29. Accessed Aug. 5, 2020. It is not intended to be and should not be interpreted as medical advice or a diagnosis of any health or fitness problem, condition or disease; or a recommendation for a specific test, doctor, care provider, procedure, treatment plan, product, or course of action. Clinical implications of anti-thyroglobulin antibody measurement before surgery in thyroid cancer. It is used most often in patients who have had surgery for thyroid cancer in order to monitor them after treatment. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. Patients with elevated TPO antibodies but normal thyroid function tests (TSH and Free T4) do not necessarily require . Graves' disease is an autoimmune disease that affects the thyroid gland. Some studies suggest that TPOAb may cross-react with tissues other than the thyroid and may contribute to inflammation and general symptoms. You didn't mention how long ago you had the RAI, if only recently then that would explain your situation. The Endocrine Society/American Association of Clinical Endocrinologists. High concentrations of TPOAb identify those women who are at risk . When you get your thyroid peroxidase lab results you will see a range of what is considered "normal". Accessed Aug. 5, 2020. Graves' disease is an autoimmune disease of the thyroid . TSH level is at 5.140. The radioactivity allows the doctor to track where the iodine goes. This would indicate that the antibodies have not yet destroyed enough of your thyroid, to keep . The differential diagnosis between benign and malignant thyroid disorders and the potential identification of thyroid microcarcinomas with biochemical markers remain controversial. Supporting laboratory data include an elevated erythrocyte sedimentation rate, C-reactive protein level, and thyroglobulin level. Copyright 2015 Elsevier Inc. All rights reserved. Men and women who had chronic widespread musculoskeletal pain (often diagnosed as "fibromyalgia . Thyroid peroxidase (TPO) Antibodies. Once the T4 in the bloodstream goes above a certain level, the pituitarys production of TSH is shut off. Advertising and sponsorship opportunities. The atrophic form represents extensive thyroid fibrosis and is more likely to result in overt hypothyroidism. An official website of the United States government. Replacement therapy means the goal is a TSH in the normal range and is the usual therapy. The amount of T4 produced by the thyroid gland is controlled by another hormone, which is made in the pituitary gland located at the base of the brain, called thyroid stimulating hormone (abbreviated TSH). Autoimmune thyroid disease is the most common etiology of hypothyroidism in the United States. Mayo Clinic does not endorse any of the third party products and services advertised. Useful for follow-up of patients with differentiated thyroid cancers after thyroidectomy and radioactive iodine ablation. They found that the number of CD45 + cells infiltrating the thyroid and the elevated level of serum interleukin-6 is associated with the severity of thyroiditis . Back so soon? Like Hashimoto thyroiditis, post-partum thyroiditis is characterized by an elevated TPO antibody level, but the clinical presentation is more variable. Our purpose was to describe the TgAb resolution time course and the significance of persistent antibody elevation after thyroidectomy. All rights reserved. It is an autoimmune disease. Yamada O, Miyauchi A, Ito Y, Nakayama A, Yabuta T, Masuoka H, Fukushima M, Higashiyama T, Kihara M, Kobayashi K, Miya A. Endocr J. . just because the thyroid is no longer present you still have sick autoimmune antibodies that can cause issues. While detecting antibodies is helpful in the initial diagnosis of hypothyroidism due to autoimmune thyroiditis, following their levels over time is not helpful in detecting the development of hypothyroidism or response to therapy. The best way to initially test thyroid function is to measure the TSH level in a blood sample. In the first study, 100 people were recruited to receive nigella or a placebo for 8 weeks. Even though the results of this study indicate that surgical management of Hashimotos thyroiditis may be beneficial, it is not clear whether undergoing surgery for this relatively common disease is necessary to treat symptoms in all patients. This content does not have an English version. This study examines the effect of thyroidectomy (to decrease thyroid . The .gov means its official. Higher rates of chronic autoimmune thyroiditis have been observed in patients with type 1 diabetes mellitus, Turner syndrome, Addison disease, and untreated hepatitis C.1012 The annual incidence of chronic autoimmune thyroiditis is estimated to be 0.3 to 1.5 cases per 1,000 persons.13 Presenting symptoms depend on the degree of associated thyroid dysfunction, but most commonly include a feeling of fullness in the neck, generalized fatigue, weight gain, cold intolerance, and diffuse muscle pain. Can anyone help please? information submitted for this request. . Methods: Data of 2,352 patients who committed thyroidectomy from January 2018 to December 2018 at our institution were retrospectively reviewed.Of which, 806 patients diagnosed with thyroid . REVERSE T3 Increased sweating. Patients may present in the hypothyroid or hyper-thyroid phase. Treatment with high-dose acetylsalicylic acid or nonsteroidal anti-inflammatory drugs is directed toward relief of thyroid pain. Antithyroid peroxidase antibodies in patients with high normal range thyroid stimulating hormone. Thyroid antibodies are just a piece of the autoimmune thyroid picture. 6 7 Thyroid Peroxidase Antibodies (TPO) Optimal range: 0 -9 IU/mL Thyroid peroxidase is an enzyme used in the synthesis of thyroid hormone. Dosages of 25 to 50 mcg per day of levothyroxine can be initiated in these patients and titrated to the same TSH goals as in overt hypothyroidism. Created for people with ongoing healthcare needs but benefits everyone. Approximately 50% of women who are TPOAb positive early in pregnancy go on to develop some form of post-partum thyroid dysfunction, usually of a transient nature. Log-Rank analysis could not determine a, MeSH Feeling shaky 4. TPO signifies thyroid autoimmune in both under active and over active thyroid diseases. information is beneficial, we may combine your email and website usage information with Epub 2014 Jul 17. Matrone A, Latrofa F, Torregrossa L, Piaggi P, Gambale C, Faranda A, Ricci D, Agate L, Molinaro E, Basolo F, Vitti P, Elisei R. Thyroid. All patients were stratified to TgAb+/- groups and then further divided into those with recurrent cancer and those without. Patients with overt hypothyroidism (elevated TSH and low free T4 levels) should be treated with levothyroxine to a goal TSH level of 1 to 3 mIU per L. A starting dosage of 1.6 mcg per kg per day can be initiated, with subsequent incremental changes made every 10 to 12 weeks to achieve this goal. Recurrence; Thyroglobulin; Thyroglobulin antibody; Thyroid cancer; Total thyroidectomy. ing types of TSH receptor antibodies: a case report. When the heater is off and it becomes cold, the thermostat reads the temperature and turns on the heater. Occasionally, a low TSH may result from an abnormality in the pituitary gland, which prevents it from making enough TSH to stimulate the thyroid (secondary hypothyroidism). The thyroid has developed a very active mechanism for doing this. THYROGLOBULIN In one study of 121 children with vitiligo, 16% showed some abnormalities in the thyroid function tests, The antithyroid peroxidase antibody (Anti-tpo) was the most common disorder. Thyroid hormone therapy should resolve hypothyroid symptoms and may result in a reduction in goiter size. Dr. John Berryman and 6 doctors agree. The thyroid hormone replacement only group had no significant change in either the health survey or the fatigue scores. 20th ed. As such, antithyroid medications (thioureas) are ineffective for postpartum thyroiditis. A Total T4 measures the bound and free hormone and can change when binding proteins differ (see above). This is a primary inflammation of the thyroid that causes a mild thyrotoxic state and occurs after an upper viral respiratory infection. Accessibility MedHelp is not a medical or healthcare provider and your use of this Site does not create a doctor / patient relationship. Median time to TgAb resolution was 11.0 2.3 mo, and the majority resolved by 32.4 mo. The Best IOL for 2022 RXSight Light Adjusted Lens, Will refractive surgery such as LASIK keep me out of glasses all my life. About 10 percent of patients with chronic autoimmune hypothyroidism have atrophic thyroid glands (rather than goiter), which may represent the final stage of thyroid failure in Hashimoto's thyroiditis. T-4 hormone replacement therapy. Practice Essentials. New research has found a link between serious coronavirus infections and the thyroid. In 9 of 34 patients, antibodies had not resolved at the last follow-up and imaging could not identify recurrent disease. It is caused by antibodies that attack the thyroid and destroy it. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. 2010;42(2):111-5. 4. An abnormally high level of TSI in your body is highly predictive of a condition known as Graves' disease (2). Unlike thyroglobulin antibodies, TPO antibodies can stimulate the immune system and cause inflammation in thyroid tissue, leading to the development of thyroid disease [ 2 ]. I was referred to an endochrinologist but can't get in until the end of November. Chronic fatigue, chronic irritability, dry hair, chronic nervousness and a history of breast cancer can all be linked to elevated TPO thyroid antibodies levels. The views expressed in this article are those of the authors and do not reflect the policy or position of the U.S. Army Medical Department, Department of the Army, Department of Defense, or the U.S. government. Disease Free Survival based on TgAb status. T3 testing rarely is helpful in the hypothyroid patient, since it is the last test to become abnormal. Thyroglobulin (Tg) is a protein produced by normal thyroid cells and thyroid cancer cells. The natural history of postpartum, silent, or subacute thyroiditis may include a hyperthyroid or toxic phase of short duration, followed by transient or permanent hypothyroidism. How Long To Veg In 3 Gallon Pots, Unique Places To Stay In Pennsylvania, Freshido Nutrition Information, Articles E