March 2011. Patient P. Caucasian female, 53 years. Diagnosis: severe Graves disease (GD), recurrent course. Endocrine ophthalmopathy (EO) NOSPECS 4, CAS 7. Thyrotoxic cardiomyopathy. Paroxysmal atrial fibrillation. Thyrotoxic proximal myopathy of the lower limbs. Thyrotoxic hepatitis. Type 2 diabetes mellitus. Chronic obstructive pulmonary disease.
Anamnesis: GD was first diagnosed in 2001, when she started to complain of weight lost (20 kilos in a couple months), tachycardia and general fatigue. Clinical examination revealed thyrotoxicosis. For 10 years she had been taking Thiamazole from 30 to 10 mg/daily depending on the level of hormones, because of fear of thyroidectomy and radioiodine therapy. In 2009 she was admitted to the inpatient Department of Endocrinology with ketoacidosis and blood glucose level 27 mmol/l. She was administered intensive insulin therapy. 2010 new complains of double vision, lacrimation and dry eyes appeared.
Clinical examination: TSH 0.01 ME/ml (0.4 4), fT3 20 pmol/l (2.36.3), fT4 25 ng/dl (6.815.0), Ab-rTSH 38 (00.99). C-peptide 3 pmol/l (2581758), A1C 11%. Ultrasonography of the orbits (U.S.orbits): the value ofthe retrobulbar tissue (RBT) OD\OS =18.3/17.5 mm (n<16).: Blood glucose (BG): 17.320.05.518.917.613.4 mmol/l.
Treatment: Thiamazole 40 mg/daily, oral dexamethasone 0.1 mg/kg on alternate days, dose correction of the insulin, potassium preparations, omeprazole.
After normalization of fT3, f4 levels and BG, the patient was transferred to the surgical department for thyroidectomy.After that she was administered L-thyroxin 125 mkg/daily.
Follow up: November 2011. TSH, f4, fT3 normal.U.S. orbits reveals no signs of edema. BG: 7.8 9.0 8.0 7.6 8.5 9.0 mmol/l, A1c 7.5%.
After removing the source of the autoimmune aggression weve managed to achieve stable remission of EO, GDs complications and good glycemic control.
Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.
05 - 09 May 2012
European Society of Endocrinology