Endocrine Abstracts

Introduction: Graves’ disease is an autoimmune thyroid disease presenting with hyperthyroidism. In Graves’ disease, there may be diffuse enlargement in the thyroid gland, as well as nodular appearance. The risk of papillary carcinoma should always be kept in mind while the risk of malignancy is low in Graves’ disease.

Case presentation: A 50-year-old woman was admitted to our center for a second-time exacerbation of hyperthyroidism in 2015. Her history revealed a diagnosis of Graves’ disease in 2008 and her disease was in remission in the first year of treatment. She was referred to our center with the reason that the remission cannot be achieved after starting propylthiouracil treatment. In admission the ultrasound findings are,the right thyroid lobe was 19×14×45 mm, left lobe was 24×19×53 mm, and isthmus was 2.2 mm. It also showed heterogeneous parenchyma echogenicity for both thyroid lobes, due to the millimetric hypoechoic areas compatible with thyroiditis while there was no nodular appearance. Thyroid stimulated receptor antibody levels were 2.54 U/l(0–1.5). Ophthalmologic examination did not suggest thyroid ophthalmopathy. We stopped propylthiouracil treatment and started methimazole. In the follow-up of the first year euthyroid state was achieved with methimazole treatment, however hyperthyroidism emerged when methimazole dose reduced. In this period, increased levels of thyroid stimulated receptor antibody were detected (4.2 U/l). Euthyroid state could not be established despite the maximal dose of methimazole. Thyroid stimulated receptor antibody levels were 12 U/l. Surgery was planned after establishing euthyroid state with plasmapheresis therapy. Total thyroidectomy was performed and pathology revealed papillary microcarcinoma with follicular variant in a 0.5 cm lesion in the left lobe under the capsule without invasion of vascular system or the capsule. The patient is followed with thyroid suppression therapy.

Discussion: It is important to follow patients with Graves Hyperthyroidism with physical examination and ultrasound in order to assess nodules. Our patient was operated because of uncontrolled hyperthyroidism, not for malignancy. Sporadic cases of thyroid carcinoma can be seen in patients with Graves Hyperthyroidism.