Graves disease - goiter and thyroid eye disease

Case contributed by Dr Henry Knipe

Presentation

Palpitations, tremor, anxiety, sweating and recurrent headaches.

Patient Data

Age: 40 years
Gender: Female

The thyroid is enlarged (i.e. a goiter) with heterogeneous echotexture and a few thyroid nodules. No enlarged cervical nodes. 

99mTc Sodium Pertechnetate

Nuclear medicine

There is diffusely increased uptake throughout the thyroid gland. No discrete hyper- or hypofunctioning nodules are detected. There is no retrosternal extension. Uptake = 27% (normal 1-4%).

Thyroid function tests demonstrate hyperthyroidism (elevated thyroid hormones with suppressed TSH).

Strongly positive results for thyroid peroxidase antibody (Thy Per Abs) and TSH receptor antibody (TSH R Abs) in keeping with Graves disease. 

Mild bilateral proptosis. Enlargement of inferior, medial and superior rectus muscle bellies bilaterally, which is mildly asymmetrically larger on the left. 

Case Discussion

This is a case Graves disease with classic presentation of thyrotoxicosis confirmed with laboratory results. Ultrasound findings are non-specific and typically demonstrate an heterogeneous goiter. 99m Tc pertechnetate demonstrates homogeneously increased uptake. 

Thyroid associated orbitopathy affects up to 25% of patients, can can develop after hyperthyroidism has been treated. 

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