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Possible Euthyroid Graves’ Disease

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Question

A case of hyperthyroidism, with NORMAL thyroid profile , borderline high TSI , abnormal nuclear studies and clinical picture of hyperthyroidism.A29 y/o Hispanic female who was referred to me by a cardiologist – because of tachycardia with normal cardiac work up and normal thyroid test .She was initially diagnosed with tachycardia – during her first trimester of her pregnancy in 2006. Was placed on beta blockers PRN – later on 2007 she started to have palpitations again ( at that time she had vitamin C IV for 3 days ) since then she has on-off those episodes -Heart Rate has gone up to 120 at rest . At some point she was given thyroid medication for 3months for borderline thyroid test . Nno family history of thyroid condition . Has exophthalmos – which is getting worse in the last 4 years. On physical exam – she was found to have a thyroid bruit and palpable thyroid also has the exophthalmos, and tachycardia. Labs : showed since 2006 normal thyroid profile – has borderline high TSI , and abnormal thyroid uptake and scan. LABS-09/02/2008, THYROGLOBULIN-28.6, THYROGLOBULIN ANTIBODIES-<20. LABS-08/25/2008-TSH-2.392, THYROID STIMULATING IMMUNOGLOB-130 ( normal up to 129) , FT4-1.33 ( normal up to 1.76 ) , , TRIIDOTHYROXINE,FREE,SERUM-3.2 ( normal up to 4.2 ) , THYROID UPTAKE–09/09/2008, 6 HRS-24.2% ( n ormal up to 22 ) , 24 HRS-40.5% ( normal up to 35 ). There is homogeneous distribution of the activity throughout the thyroid gland. 2006 her TSH 1.65 , free T4 1.09 and free T3 3.2 ( normal ) Questions:

  1. My diagnosis is graves disease? Do you have any other suggestions?
  2. If you agree with the diagnosis is this a presentation that you see frequently ?
  3. What treatment should I offer the patient since she has normal thyroid test, but the clinical picture and other test are compatible with graves? She did tried tapazole low doses – to see if that would improved her symptoms but she did not tolerate it , got sick with it. She is still taking low doses B- blockers
  4. I will consider surgery as the ideal approach –due to the exophthalmos; do you have any other recommendations.

Thank you for your recommendations,

Maribel Montoya, MD, Leesburg, Florida

Response

Dr Montoya,

If the patient truly has progressive exophthalmos and an enlarged thyroid, elevated RAIU, and borderline TSAb without overt hyperthyroidism, I would guess that she has some form of Graves disease, most likely “Hashitoxicosis”. That is, a mixture of GD and Hash. Would you please check her TPO antibodies? At the moment the only indication for treatment, other than beta blocker, is for her eyes. While I do believe that removal of thyroid antigens is a primary step in controlling Graves’ ophthalmopathy, thyroidectomy would be avery aggressive step in this situation. Maybe you would like to submit a photo of her eyes (with her approval), or some measurements of exophthalmos over the years. At this time, from the information you have present so far, I would favor continued observation rather than active intervention.

L De Groot, MD