Endocrine Abstracts

Grave’s disease is an auto-immune condition associated with hyperthyroidism caused by TSH-receptor antibodies (TRAB) expressed by follicular cells of the thyroid gland. Grave’s ophthalmopathy has been reported in 25% of the patients and is rarely associated with dermopathy and thyroid acropachy. Management is by anti-thyroid drugs, radioactive iodine ablation or surgery, either alone or in combination. We present a rare case of resistant Graves who has detectable antibodies and thyroid remnant after being treated with all the above. A 55 years old lady presented with typical symptoms of hyperthyroidism associated with weight loss, sweating, palpitations and weight loss. Examination revealed an anxious lady with obvious outstretched hand tremors including extra thyroid manifestations such as thyroid acropachy, pretibial myxoedema and orbitopathy. Biochemistry confirmed the presence of TRAB 226.7 u/l, a suppressed TSH 0.14 mU/l with elevated T4 levels. She was treated with carbimazole and referred to ophthalmology for her eye disease. Due to worsening eye disease and high TRAB titres, she underwent a subtotal thyroidectomy and later, after 7 years, a total thyroidectomy. This did not have any significant impact on her TRAB levels. Thyroid uptake scan in 2012 revealing uptake in the thyroid bed. She had radioactive iodine treatment in 2013 under cover of high dose steroids with aim to reduce the TRAB and improve her acropachy and eye disease. A repeat uptake scan in 2017 has shown remnant thyroid tissue in the right thyroid bed reflecting residual active thyroid disease. This was treated again with a further dose of RAI in 2018. She is currently still under regular follow up by the local endocrinology team. This is a rare case of resistant Graves with persistent active thyroid tissue despite surgical and radioactive ablation of thyroid.