Graves disease

Case contributed by Ammar Ashraf
Diagnosis certain

Presentation

Neck swelling, weight loss (10 kg in 4 months) and heat intolerance.

Patient Data

Age: 40 years
Gender: Female

Baseline ultrasound

ultrasound

Mildly enlarged thyroid gland with heterogeneous parenchymal echogenicity; right thyroid lobe measures 2.1 x 1.6 x 5.1 cm and left thyroid lobe measures 1.8 x 1.7 x 5.1 cm. No focal solid or cystic abnormality is seen in either thyroid lobe. Increased vascularity (thyroid inferno) is seen in both lobes on color Doppler ultrasound examination. 

Tc-99m thyroid scan D3 later

Nuclear medicine

Enlarged thyroid gland with homogeneously increased radiotracer activity in both lobes. Small pyramidal lobe is also noted. No focal areas of increased or decreased radiotracer activity to suggest focal pathology. Thyroid uptake function: 16% (normal 0.4-4%). 

FU thyroid US 3yr post Rx I131

ultrasound

Heterogeneous thyroid gland without any obvious focal solid or cystic nodule in either lobe. An interval reduction is seen in its size when compared with the previous ultrasound examination.

Case Discussion

  • free T4 = 44.2 pmol/L (reference range = 9-19). 
  • TSH = 0.015 mIU/L (reference range = 0.35-4.94).
  • TPO IgG (thyroid peroxidase antibodies) = 366.51 units (reference range: <100 units is negative and >100 units is positive).
  • anti-hTg IgG (anti-human thyroglobulin antibodies) IgG = 970.49 units (reference range: <0.6 unit is negative and >0.6 unit is positive).

Based on the clinical history, and baseline laboratory and imaging (thyroid ultrasound and Tc-99m pertechnetate scan) findings, diagnosis of Graves disease was made, which was subsequently treated with radioactive I-131 (393 MBq)..

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