Endocrine Abstracts

Background: Thioamide-resistant severe Graves’ thyrotoxicosis (SGT) is rare and often poor patient adherence to therapy is suspected. Management is truly challenging.

Case report: 36-year-old female with SGT was referred for further management. The diagnosis was made 5 years ago following delivery of her first son. During her second pregnancy 2 years ago, she required emergency caesarean with the indication of foetal tachycardia. She received high dose of carbimazole and/or propylthiouracil. Previous attempts of surgery failed. She did not achieve euthyroid with lugol iodine. She attended A&E 10 times in 12 months with SGT. Clinically, she had signs of SGT, large goitre, thyroid bruit and significant thyroid eye signs.

Investigation: Her Free T3 was always above the assay measurable upper limit. Thyroid stimulating antibody (TSI) was marginally raised. MRI obit confirmed changes with chronic thyroid eye disease.

Management: Carbimazole 20mg TDS and propranolol 80mg TDS were started. Weekly follow up was arranged. Patient accidentally continued to take PTU 100mg BD for 2 weeks. Adherence to therapy was evidenced by empty blister packs and side effects with generalised urticaria. TFT did not change. 3 weeks later, Lithium 250mg TDS was started. Urgent hospital admission was arranged to control SGT and planned semi-emergency thyroidectomy. Colestyramine 3g TDS, prednisolone 30mg OD were prescribed. Lugols solution was given 10 days prior to surgery (during the junior doctors strikes). Her TFT stabilised and she had successful thyroidectomy on day 14.

Discussion: We presented truly thioamide-resistance case that needs significant co-ordinating effort of prescribing, monitoring, admitting to hospital and MDT approach against an NHS front door pressure. The case also highlights the lack of correlation between TSI and severity of Graves