Endocrine Abstracts

JOINT1207

Introduction: Graves’ disease is an autoimmune thyroid disorder characterized by hyperthyroidism and elevated thyroid-stimulating antibodies (TRAbs). Management can be particularly challenging in patients with residual thyroid tissue post-thyroidectomy, especially when complicated by Graves’ orbitopathy.

Case Report: A 48-year-old woman with a history of Graves’ disease was referred to the endocrinology consultation for the recurrence of her condition. She had undergone total thyroidectomy in 2015 due to diagnosis of Graves’ disease, followed by levothyroxine replacement therapy. In 2022, she developed tremors, anxiety, palpitations, and bilateral exophthalmos. Laboratory tests confirmed thyrotoxicosis with markedly elevated thyroid-stimulating hormone receptor antibodies (TRAbs) (>40 IU/l). Following this, she underwent a progressive reduction in levothyroxine dosage, ultimately stopping the medication. Despite being off levothyroxine for the six months prior to referral, she remained euthyroid on subsequent thyroid function tests. The patient had a significant history of smoking (20 UMAs) and presented with marked bilateral exophthalmos on examination. Ultrasounds showed a hypoechoic, heterogeneous nodule at the left and right surgical sites. Thyroid scintigraphy confirmed the presence of hyperfunctioning nodules in the surgical site and additional ectopic tissue in the thyroglossal duct/submental region. Given her euthyroid state, antithyroid drugs were not initiated, and radioactive iodine was avoided due to her significant Graves’ orbitopathy. Recent laboratory tests, performed without any directed therapy, revealed thyroid-stimulating hormone (TSH) 1.05 µIU/ml, free thyroxine (FT4) 0.82 ng/dl (N: 0.70–1.48), free triiodothyronine (FT3) 3.15 pg/ml (N: 1.71–3.71), and TRAbs 47 IU/l. Surgical intervention was considered the best option to remove the residual thyroid tissue and prevent further progression of orbitopathy and thyroid autoimmunity. Smoking cessation was also strongly encouraged. The patient has surgery scheduled soon.

Conclusion: This case underscores the challenges in managing Graves’ disease when residual thyroid tissue persists post-thyroidectomy, even in euthyroid patients. The persistence of elevated TRAbs and the risk of exacerbating orbitopathy highlight the need for a tailored treatment approach, involving careful monitoring and surgical intervention to prevent disease recurrence and minimize complications.