Endocrine Abstracts

38 year old woman presented with palpitations, chest tightness, dizziness and light headedness. There was no evidence of infection clinically or biochemically. She had a background of Alemtuzumab induced Graves’ thyrotoxicosis, relapsing remitting Multiple Sclerosis. Her regular medications included Carbimazole 20 mg three times a day, Amitriptyline 120 mg daily, Propranolol 40 mg four times a day, Tizanidine 2 mg daily (up to 18 mg), Tramadol 50 mg as required, Senna 7.5 mg daily, Chlorphenamine 4 mg daily, Fexofenadine 180 mg daily and Ibuprofen 5% gel as required. On admission, her biochemistry revealed a free T4 of 57 pmo/l and TSH of <0.01 mU/l. She also had a raised troponin of 71ng/l. ECG showed sinus tachycardia with no ST-T changes. Her Carbimazole dose was increased to 30 mg three times a day. Blood tests were done 2 days after increasing the dose of carbimazole and she remained in thyrotoxicosis with her free T4 >100 and TSH <0.01. She was therefore started on lugol’s Iodine 0.2ml three times a day, titrated up to 0.3ml three times a day. Due to her resistant thyroid storm, she was additionally treated with steroids. She had an echocardiogram which was normal. Throughout her admission, she remained in persistent sinus tachycardia at around 105 beats per minute to 130 beats per minute despite use of propranolol. The lady underwent a total thyroidectomy 20 days after she first presented. She was euthyroid (T4=22, TSH=<0.01) at the time of surgery. She recovered well post operatively and having stable calcium levels. Both the carbimazole and propranolol tablets were discontinued after surgery. She was commenced on levothyroxine 100 micrograms once daily. The histology confirmed Graves’ Disease and there was an incidental finding of a papillary thyroid cancer on histology and this was reviewed by our regional thyroid cancer MDT and they recommended conservative management in view of the incidental finding.