Endocrine Abstracts

A 23-year-old female presented with a three-month history of palpitations, tremors and recent anxiety. This was associated with hot flushes in the morning, heat intolerance and increase in appetite. Otherwise, bowel habits were normal and the patient suffered from long-standing menorrhagia with regular menstrual cycles. She denied a recent viral illness, neck pain or swelling, dysphagia, shortness of breath or dysphonia. She denied thyroid eye disease symptoms. She denied a past history of radiation or family history of thyroid cancer. The patient had no other medical or surgical history and denied smoking or alcohol intake. On examination, the patient appeared clinically hyperthyroid with an evident tremor of the out-stretched hands, sinus tachycardia and a palpable goitre, however there was no associated lymphadenopathy, thyroid bruits or thyroid eye signs. Complete blood count and Liver Function Tests were normal at baseline. Ultrasound of the Neck and Thyroid showed a swollen and hyperaemic thyroid gland. The parenchyma was diffusely inhomogeneous in echotexture and mostly hypo-echoic with overall increase in Doppler signal in-keeping with Graves’ Disease. Seven years ago, the patient presented to her paediatric endocrinologist with fever, pharyngitis and thyrotoxic thyroid function tests. She was diagnosed with acute Epstein-Barr virus confirmed on PCR and treated conservatively. Anti-TSH Receptor Antibody and anti-TPO Antibody were negative and US Neck/Thyroid was in-keeping with a subacute thyroiditis. However, on-being reviewed more than one month after the viral infection, the patient remained clinically hyperthyroid, retained thyrotoxic thyroid function tests and was presumed to have Graves’ Disease. She was therefore started on Carbimazole 5 mg 8-hourly and titrated down over the span of a year. The patient was started on Propranolol 10 mg 8-hourly and Carbimazole 20 mg 12-hourly, and advised to start contraception. Risks of becoming pregnant while on Carbimazole and in the current thyrotoxic phase explained. Side effects of Carbimazole, including agranulocytosis and hepatitis, were also explained. She was counselled on radioactive iodine therapy (RAIDT) vs total thyroidectomy as a form of definitive treatment as this was a relapse of Graves’. Risks and benefits of both were explained and patient chose to undergo RAIDT once euthyroid on Carbimazole. Thyroid function tests were repeated every 6 weeks and Carbimazole down-titrated accordingly.