Graves' disease

Abstract

A 35-year-old woman presented with weight loss, heat intolerance, anxiety, sleep disturbance, oligomenorrhoea, diarrhoea, and palpitations. Her thyroid gland was enlarged about 3 fold, was smooth and soft in consistency, and there was a bruit audible on auscultation. She had eyelid lag and retraction, periorbital puffiness, conjunctival congestion (chemosis), and mild exophthalmos. The diagnosis of Graves' disease was confirmed by the finding of high concentrations of free thyroxine and free tri-iodothyronine in serum, with suppression of thyroid-stimulating hormone (TSH): antithyroid peroxidase antibodies were present in high titre. Carbimazole was introduced at a dose of 30 mg per day and she was warned about the possibility of side-effects. 4 weeks later on the basis of a fever, sore throat, and white-cell count of less than 1000×10 9 Taylor S Robert Graves: the golden years of Irish medicine. Royal Society of Medicine Services Ltd, London1989: 1-160 Google Scholar /L (<100×10 9 Taylor S Robert Graves: the golden years of Irish medicine. Royal Society of Medicine Services Ltd, London1989: 1-160 Google Scholar /L neutrophils) diagnosis of emerging carbimazole-induced agranulocytosis was made. She was admitted and given propranalol for persistent hyperthyroidism, together with broad spectrum antibiotics, and prophylaxis against fungal and viral infection byfluconazole and aciclovir. We gave recombinant human granulocyte colony-stimulating factor to expedite neutrophil recovery-even though the usefulness of this agent has not been proved in agranulocytosis induced by antithyroidal drugs. 1 Fukata S Kuma K Sugawara M Granuocyte colony-stimulating factor (G-CSF) does not improve recovery from anti-thyroid drug induced agranlocytosis: a perspective study. Thyroid. 1999; 9: 29-31 Crossref PubMed Scopus (115) Google Scholar The neutrophil count was restored to >1000×10 9 Taylor S Robert Graves: the golden years of Irish medicine. Royal Society of Medicine Services Ltd, London1989: 1-160 Google Scholar /L within 4 days. Lugol's iodine solution was given and partial thyroidectomy rendered her euthyroid. Unfortunately, her hyperthyroidism re-emerged after 6 months and she underwent treatment with radioactive iodine. She was given 30 mg prednisolone daily (0·5 mg/kg bodyweight) for 2 months for thyroid eye-signs, until she complained of excessive weight gain, and the treatment was progressively withdrawn. Shortly after administration of radioiodine, she had worsening chemosis, proptosis, together with mild diplopia. The eye signs improved, however, after 4 months. 6 months after treatment with radioactive iodine she developed hypothyroidism and was started on treatment with thyroxine. She is currently euthyroid on long-term replacement therapy.