Endocrine Abstracts

Graves’ disease is a very common cause of thyrotoxicosis and it runs a relapsing remitting course due to varying immunogenicity of the pathogenic autoantibodies. Medical treatment is the preferred means of treatment by patients especially in the uncomplicated and non relapsing cases. Few studies have established the additional benefit of thionamides on immunogenic characteristics in Graves’s disease. This is a case of a 30 year old lady diagnosed with Graves’ disease 10 years ago during the puerperium and treated medically in India for 6 months. She had a relapse 4 years after initial treatment when she was referred to our thyroid clinic with weight loss, tremor and palpitations. On examination, she had diffuse goitre with no orbitopathy and high TRAb of 97.8 with FT4 of 67.1. She initially opted for medical therapy after discussing risks of further relapses and in the course of treatment, noticed fluctuating course while on carbimazole in terms of the TFT and TRAb levels. We reiterated the need for compliance and need for definitive treatment due to inability to achieve remission while on medical therapy. She eventually opted for thyroidectomy (as she had small children at home). Due to the very poor control, the surgery was delayed and eventually when she was scheduled 3 years ago, she cancelled it with no documented reasons and continued on medical treatment. Her FT4 in the last six years has ranged between 35.4 and >100 (normal range 12-22) with suppressed TSH<0.01 (normal 1-5) and TRAb 12.4 and >100. She has had several episodes of severe thyrotoxicosis with unrecordable high FT4 above 100 and high immunologic activity TRAb above 100 while on standard dose of carbimazole. However, during hospital admissions, she had reasonable response to high dose Carbimazole and prednisolone which confirmed poor drug compliance. The cause of her non compliance may be related to fatigue (long term medical treatment for which she was not insightful), no underlined psychopathology. Despite reiterating the needs for compliance and clarifying complications of poorly controlled thyrotoxicosis, she is still having unsteady TFT and persistently unrecordable high TRAb. This case illustrate the vicious cycle of poor drug compliance leading to upsurge of immunogenicity which continued to trigger recurrent refractory Graves’ disease leading to multiple hospital admissions- which suggests the possible benefits of carbimazole on immunogenicity.