Graves’ disease

Patient Presentation:
J.R., a 32 y/o female presents with complaints of anxiety accompanied by a “racing heart.” She reports a recent job loss and attributes presenting symptoms with this event. A thorough history revealed concerns of weight loss, and missed period. Physical examination reveals: HR 105 with regular rhythm, B.P. 132/90, presence of fine bilateral hand tremor, presence of perspiration, skin is warm to touch, and minimal non-tender enlargement of thyroid gland is detectable upon palpation.

Differential List:
Anxiety, Hyperthyroid, must rule out Pregnancy

Diagnosis:

TSH assay 0.03 mU/L – Normal Values (0.5-5.0 mU/L)
Serum Total T4 12.5 mcg/dl – Normal Values (4.6-11.2mcg/dl), T3 205 ng/dl – Normal Values (75-195ng/dl)
24-hour radioiodine uptake and scan reveals a moderate to high degree of radioiodine uptake. Normal to high levels is consistent with hyperthyroidism due to Graves’ disease.
- In patients with contraindications for radioiodine uptake (i.e. Nursing Mothers) laboratory tests for presence of thyroid stimulating immunoglobulin and ultrasound assessment of thyroid blood flow may also be useful.
hCG level undetectable – (detectable levels of hCG are a positive for pregnancy)

The high T3/T4 and low TSH indicate Graves' disease.

Treatment:

Beta Blocker (atenolol) 25-50 mg PO Daily to improve symptoms of tachycardia, tremor, anxiety, and heat intolerance.
Thionamide therapy is initiated and a euthyroid state may be achieved in 3-8 wks. Methimazole is the preferred drug because it works quickly, has minimal side effects and requires a 1x daily dose. 10mg PO is a good place to start due to JR’s mild presentation. Methimazole is considered teratogenic in the first trimester; Propylthiouracil is a safe alternative.
Patient was referred to an endocrinologist for follow-up and further management.

More on Graves’ Disease:
Graves’ is the most common form of hyperthyroidism and occurs more frequently in women than men (5:1). It is an autoimmune disorder that is associated with genetic factors and interaction with environmental triggers such as stressful life events, childbirth, and infection. This disorder is caused by TSH receptor antibodies, which stimulate the thyroid. Thyroid stimulation results in an increased gland size, with an increased production and release of hormones. Patients often present with ophthalmopathy, which includes exophthalmos.

Case created by Jaime Records, 2011.