Endocrine Abstracts

GD is a common thyroid disorder which in majority of cases respond to medical treatment with thionamides.A proportion of these patients will need definitive treatment with either radioiodine ablation or total thyroidectomy. We present a case of a 21 yr old woman with a year history of overt thyrotoxic symptoms. She lost 2 stones of weight, had palpitations, heat intolerance and noticed shaky hands. On examination:She had large symmetrical goitre with bruit, tachycardic and sweaty. There were no features of thyroid eye disease. Lab investigations:TSH:>0.01, fT4:>100, TRabs:550(reference range<0.9) The patient was started on Carbimazole and propranolol with up titration of the dose, but she failed to improve both clinically and biochemically. Medication script frequency & reported concordance with treatment were assessed at this & each subsequent step. High dose corticosteroids were added to the regime. Despite that, there was no improvement. Cholestyramine was started in addition. A decision was made that the patient should go for total thyroidectomy as very resistant to medical therapy. The high positive titre of antibodies pointed to difficult and relapsing pattern of disease. The problem was the severe thyrotoxic state she was in which made it very difficult for anaesthetics and surgeons. In fact, she had surgery cancelled twice because of concern about precipitating thyrotoxic storm. The patient was started on Lithium in addition to the other medications. With close monitoring and achievement of therapeutic levels we managed to control her T4 and T3 levels to prepare for surgery. She had total thyroidectomy complicated with hypocalcaemia (hypoparathyoiroidism)which is under control now. Learning points: -Very high positive antibodies titre can predict the difficulty in controlling GD -While non-concordance with treatment is a common issue very resistant disease is also an explanation for poor clinical responses. -Using multiple concurrent agents, as described, including Lithium is uncommon in practice but may be required in resistant cases. -Early consideration of definitive treatment should be considered.