18 Nov - Graves

Today's case was a 33 y/o F that presented with symptoms of emotional lability and weight loss over two months.  The symptoms began shortly following a flu like illness.  Family members had noted increased tearfulness that had progressively worsened.  There was no previous history of depression.  She did have a history of low back pain managed with prescription opiates, but no recent changes in pain or med dosages were noted.  Family members had noted neck swelling.  On examination she had marked nodular thyromegaly with an audible bruit.  There was no evidence of exophthalmos.  She was tremulous.  Heart rate was 120's to 130's.  TSH was 0.02 and T4 was 4.  She was hypercalcemic.  She was diagnosed with Grave's disease with thyrotoxicosis and started on beta blockers and PTU.

Clinical Pearls:

- Imaging and antibody tests are not necessary to establish the diagnosis in typical cases such as this.
- methimazole is more convenient and probably superior to PTU in terms of effectiveness.
- PTU is the drug of choice in pregnancy
- agranulocytosis and hepatotoxicity are potential side effects of PTU
- elderly patietns with graves can present with "apathetic hyperthyroidism" with wt loss and depression.

This Clinical Practice article reviews a case remarkably similar to the one discussed in MR and provides a good diagnostic stragety for cases that are not as typical in presentation.

Hypercalcemia in graves has been linked to PTHrP (usually seen in hypercalcemia of malignancy) as a cause of non-PTH dependent hypercalcemia. 

Graves ophthalmopathy has been reviewed here and here.  It is clinically evident in ~1/3 of Graves patients, but can be seen in imaging in 70-80% of cases.  Treatment involves immunosuppressive therapy with steroids and potentially TNF inhibitors among other treatments.