Endocrine Abstracts

Graves disease is an autoimmune disorder of the thyroid gland. It is a very rare condition that a Graves patient presents with spontaneous hypothyroidism. Hypothyroidism during the course of Graves’ disease occurs commonly due to radio-iodine (RAI) therapy or thyroidectomy. It may also develop after anti-thyroid drug (ATD) treatment. We present a case of 44 years old Emarati male heavy smoker diagnosed with graves’ disease after thyrotoxic manifestations, associated with graves opthalmopathy. He received a course of ATD for one year then reverted to euthyroid state. Patient was off treatment for 18months when he started to have thyrotoxic manifestations again with high TPO and thyroglobulin antibodies. Patient was restarted on carbimazole (required high dose). RAI uptake scan showed diffuse uptake. Two years later while he was still on carbimazole he developed graves dermopathy and improved on topical steroid. Later steroid pulse therapy was started for the worsening Graves opthalmopathy. Planned for surgery after opthalmopathy improvement, but patient refused surgery and opted to stay on ATD. Carbimazole tapered according to thyroid function test (TFT) until he was off ATD for 2 months. Then he had developed hypothyroid manifestation. TFT revealed hypothyrodism, started on thyroxine adjusted according to TFT reaching 200mcg currently. This case highlights the importance of spontaneous development of hypothyroidism in hyperthyroid graves. Hyper- and hypothyroidism occur depending on the predominant antibody during that period. Switching between stimulating and blocking antibodies. Thioamides have been associated with decreased levels of stimulating-TRAb, allowing blocking-TRAb to dominate. Nonetheless, the switch from one end of the spectrum to the other remains difficult to predict. Also its worth to mention that, our patient had the extreme of hyperthyroidism to hypothyroidism with out sever symptoms of both.