Endocrine Abstracts

A 19-year-old male referred from the Ophthalmology clinic on account of staring gaze of 1 year, and an anterior neck swelling which was noticed 3 months before presentation. Anterior neck progressively increased in size. It was not painful. No history of dysphagia, voice changes or yellowness of the eyes. There was positive history of heat intolerance, weight loss despite increased appetite, irritability, restlessness, palpitations and hyperdefeacation. No history of exposure to goitrogens or chronic drug use. Patient consumes iodized salt. No skin discolouration. No known family history of anterior neck swelling or similar swelling in the neighborhood. On examination, patient was restless, palms were warm and moist, with fine tremors of outstretched hands. He had bilateral lid retraction, lid lag and exophthalmos. There was anterior neck swelling which moved with swallowing but not with tongue protrusion. Swelling was firm, non-tender, nodular, not attached to underlying structures or overlying skin. No retrosternal extension or scalp swelling. No cervical lymph node enlargement. Pulse rate was 104bpm and regular. Results of investigations revealed, free T3- 30.3 (3.1–6.8) pmol/L, free T4 – 88.2 (12.0–22.0) pmol/L, sTSH – 0.01 (0.27–4.2) uIU/ml. An assessment of toxic multinodular goiter was made, to rule out Graves’ disease. He was subsequently placed on tab carbimazole and propranolol and to review with results of investigations. On follow up, results of investigations revealed PCV 36%, total white cell count of 4300/cmm3, neutrophils 42%, lymphocytes 58% and ESR of >150 mm/hr. Thyroid ultrasound scan showed diffusely enlarged thyroid gland with multiple nodules. Thyroid antibodies were markedly elevated; anti TPO Ab- 855.20 (0-35) IU/ml, anti Tg Ab- 420.0 (up to 40) IU/ml, TSHR Ab- 27.13 (< 1.75) IU/L. A final assessment of Marine-Lenhart syndrome was made. Patient is being planned for surgical intervention once thyroid function normalizes.