Unusual problems in the management of hyperthyroid graves’ disease

Abstract

Graves’ disease is a common endocrine disorder and the various permutations inherent in it’s management are usually straightforward for the practicing endocrinologist. However, we recently saw a 22 year old female with active Graves’ disease who displayed two striking and unusual features which significantly impacted her management. The patient was diagnosed with the classic features of hyperthyroid Graves’ disease with multiple symptoms and physical findings consistent with the diagnosis, including a very large, homogeneous 200-300g goiter with an audible bruit and moderate opthalmopathy. She was treated with high doses of methimazole (MMI, 40mg daily) and atenolol (50mg daily) for over 10 weeks as an outpatient with no improvement in her thyroid function tests or clinical findings. Serum total T3 remained >800ng/dl (83- 160ng/dl), total T4 >24 ng/dl (5.1-11.4 mcg/dl) and TSH <0.001mIU/L (0.35-4.9 mIU/L) after 2 months of therapy with MMI. Graves’ disease almost always responds appropriately to high doses of MMI within 2 to 3 months of therapy. She was a well educated college student who adhered to her medications, yet she remained clinically and biochemically thyrotoxic, with persistent tremor, palpitations, marked proximal muscle weakness, audible bruit, a huge goiter and markedly elevated peripheral thyroid hormone levels.