Endocrine Abstracts

Rationale: Grave’s disease (GD) is the most common subtype of autoimmune hyperthyroidism, which can manifest with a variety of extrathyroidal clinical syndromes such as ophthalmopathy, pretibial myxedema (dermopathy), acropathy, cardiomyopathy, and encephalopathy. In very rare instances, GD can also be diagnosed following severe gastrointestinal symptoms such as dysphagia, heartburn, nausea and vomiting. We hereby describe a rare case of GD with digestive symptoms which were later diagnosed as achalasia.

Case presentation: A 26 years old Portuguese woman presented thyrotoxicosis at 2 months of pregnancy. Anti-thyroid stimulating hormone receptor antibody (TSI) was present, and she was diagnosed as GD. Anti-thyroid medication was chosen as the initial treatment for Grave’s disease. However, this treatment failed to normalize free triiodothyronine (FT3), free thyroxine (FT4) and thyroid stimulation hormone (TSH). Throughout pregnancy and three months after delivery, patient had sensation of ‘burning’ in the anterior cervical region, which extended to the epigastric region. She reported feeling the worst in the morning after waking up noticing an improvement following the ingestion of refrigerated liquids. Daily post prandial vomiting (10 times) became more frequent, with important weight loss (from 76 to 56 kg in the three months after delivery), progressive dysphagia, and global lethargy. No exophtalmus or skin changes were present. Thyroid gland was painless and normal in size. Laboratory assessment showed low serum TSH (< 0,01 mUI/l) and increased both serum FT3 (27,3 pmol/l) and FT4 (63 pmol/l). TSI was still present (4,2 IU/l). A computed tomography scan of the chest and an upper digestive endoscopy were carried out, considering predominant dysphagy-related symptoms, suggestive of esophageal achalasia involving the lower esophageal sphincter. In relation to the significant weight loss, an endoscopic esophageal dilatation was performed in order to improve nutritional status and allow antithyroid drugs treatment to pass through stomach. After dilatation and treatment with anti-thyroid medication, symptoms resolved. Patient recovered her body weight remarkably (56 to a current 64 in one month). FT4, FT3 and TSH normalized after one month of therapy.

Conclusion: We present here a rare case of GD associated with achalasia diagnosed one year after the initial treatment for GD. In case of gastrointestinal symptoms such as dysphagia and vomiting in GD, physicians need to be aware of the possible diagnostic of achalasia as delay in the diagnosis could possibly result in potential harm and/or unnecessary interventions.