Endocrine Abstracts

Graves’ disease relapse is a common occurrence during the postpartum period which is due to resurgence of immune system after pregnancy. In most cases, overt clinical symptoms are seen and the timing of its occurrence varies from 4 to 8 months. This is a case of a 33 year old lady referred after an MTOP with bilateral pappiloedema and subsequently diagnosed with Graves relapse. She had a background of Graves’ disease 7 years ago initially treated medically and had two previous relapses. Pregnancy was unplanned and eventually had Medical termination of pregnancy (MTOP) at 20 weeks of gestation for Down’s syndrome on fetal scans. The Thyroid function test was monitored during the antenatal clinic and normal a month before the MTOP. She developed headache about 12 hours after the use of mifepristone which progressively worsened with associated progressive visual impairments. Of note is the rapid weight gain previously before and during the pregnancy, has gained about 20 kg in the previous 2 years. Fundoscopy revealed bilateral papilloedema and MRI showed raised intracranial pressure with no structural brain disease. She had an LP with opening pressure of 35 cm and closing pressure of 12 cm H20. Blood subsequently showed TSH<0.01 and FT4 44 two months after which necessitated Endocrinology referral. No other discriminative features of hyperthyroidism apart from tachycardia and she was more concerned with the progressive visual loss and headache that is not controlled by simple analgesics impacting her quality of life. Literature was reviewed which confirmed previous case reports, she was advised that hyperthyroidism may be the cause of the IIH. While treatment of hyperthyroidism might work if it is responsible for the IIH, it might make it more difficult to lose weight which is the treatment for the weight gain as another possible risk factor. We therefore offered the treatment for hyperthyroidism and encouraged the Neurologists to start the treatment of IIH. She however chose not to take any of these medications but started lifestyle modification for weight loss which improved her IIH symptoms significantly and after 12 weeks, she started a low dose of PTU. This case illustrates the dilemma faced when thyrotoxicosis presents with non classical signs and symptoms and in this case, hyperthyroidism co-existed with other risks factors for IIH and it was difficult to know the risk factor responsible initially. However, the dominant risks was not the thyrotoxicosis but excessive weight gain.