Endocrine Abstracts

A 53-year-old caucasian female presented with tremor, palpitations, sweating, breathlessness and chest discomfort. Examination revealed a non-tender, large diffuse goitre and TFT showed an elevated T₄ and undetectable TSH. Thyroid antibodies were elevated; 115 IU/ml (NR <35) and thyroid ultrasound confirmed diffuse vascular goitre. Patient was diagnosed with thyrotoxicosis with a likely aetiology of Grave’s disease.

Carbimazole was commenced which normalised the thyroid function, but was stopped when the patient developed agranulocytosis. Neutrophil count recovered, however symptoms returned with the addition of thyroid eye disease and deranged liver function (contraindicating treatment with propythiourocil). Abdominal ultrasound revealed no hepatobiliary tract abnormality. Virology, immunoglobulins, ferritin, PT, autoantibody and infection screens were negative. Echocardiogram demonstrated moderate tricuspid regurgitation, dilated right atrium and elevated pulmonary artery pressure. CXR showed bulky hilar, reported as not clinically significant. The patient was pre-treated with B-blockers and lugol’s iodine. She underwent uncomplicated total thyroidectomy once TFT’s had normalised. Histology showed diffuse hyperplasia, areas of fibrosis and several non-caseating granulomas. Post-operatively, liver function normalised spontaneously. Despite normal thyroid function and thyroxine replacement, breathlessness persisted. Serum ACE level was elevated at 114 U/l (NR11–55). Ultimately, the patient was referred to the respiratory team for management of pulmonary sarcoidosis.

This case raises the following points: A rare but well recognised case of thyroid gland sarcoidosis coexisting with Grave’s disease. Liver dysfunction can be explained by thyrotoxicosis, thionamide treatment and sarcoidosis. Although the symptoms aligned with Grave’s hyperthyroidism, this was not the sole cause of the patient’s symptoms, particularly the breathlessness. Post-thyroidectomy, patient remained breathless and disabled. The initial hilar adenopathy was discounted, however was one of the missing pieces of the puzzle in the underlying diagnosis.

Lesson; even though a symptom appears to be explained by one diagnosis there may be more than one condition contributing to symptom complex!