The patient in the above vignette is experiencing symptoms associated with Graves' disease. In the US, the definitive treatment for Graves' with mild or no ophthalmopathy is radioactive iodine ablation.
Graves' disease is an autoimmune disease in which thyroid stimulating immunoglobulins bind to TSH-receptors. There tends to be female predominance, and symptoms are often precipitated by stress (e.g. childbirth, infection). Graves' often presents with heat intolerance, tachycardia, sweating, and a non-tender thyroid enlargement. Some characteristic physical exam findings are demonstrated in Illustrations A-C. Radioactive iodine uptake scans will show diffuse uptake. Indications for radioactive iodine over antithyroid agents include a large thyroid gland, multiple symptoms of thyrotoxicosis, high levels of thyroxine, and high titers of TSI. Additionally, anti-thyroid medication use alone has been shown to result in a higher rate of relapse when compared with radioactive iodine ablation.
Reid et al. explore hyperthyroidism causes and treatment options. Graves' disease is the most common cause of hyperthyroidism. Graves' can be treated with radioactive iodine, anti-thyroid medications, or surgery, but in the US, radioactive iodine ablation is the treatment of choice in patients without contraindications. Of note, an infiltrative ophthalmopathy is noted in approximately 50% of these patients.
Marinò et al. report on the genetic and non-genetic factors of Graves'. Some of the environmental factors that have been shown to be associated with this pathology are female gender, periods of immune reconstitution, immune modulation, iodine, smoking, and physiologic stress. The major genes that have been found to predispose patients to Graves' disease are: HLA complex, CD40, CTLA-4, PTPN22, FCRL3, Thyroglobulin, & TSH-R. With further study, the goal is to establish a causal treatment pattern based on the defining etiology and genetics involved.
Figure A demonstrates an image of a radioactive iodine uptake scan with the characteristic pattern of diffuse uptake seen in patients with Grave's disease.
Illustration A depicts a clinical photograph of a patient with pre-tibial myxedema, which is often associated with Graves' disease.
Illustration B is a clinical photograph of exophthalmos, an abnormal connective tissue deposition in the orbit.
Illustration C is a clinical photograph of the typical goiter seen in Grave's disease.
Answer 1: Watchful waiting is not an appropriate treatment option for an individual with symptomatic Graves' disease.
Answer 2: Beta-blockade alone would help with some of the hyper-sympathetic symptoms of Graves' disease (e.g. tachycardia), but is not considered a definitive treatment.
Answer 3: In the US, anti-thyroid mediations alone would not be considered an appropriate treatment option for a patient with Graves' disease and associated symptomatic tachycardia that could be treated with beta-blockers as well. When methimazole or propylthiouracil is used alone, there is an increased risk of relapse of hyperthyroidism at a later time.
Answer 5: Radioactive iodine ablation with prophylactic glucocorticoids would be an appropriate treatment option for someone with moderate to severe exophthalmos as thyroid destruction during ablation can cause worsening of symptoms.
Reid JR, Wheeler SF. Hyperthyroidism: diagnosis and treatment. Am Fam Physician. 2005 Aug 15;72(4):623-30. Review. PubMed PMID: 16127951.
PMID:16127951 (Link to Abstract)
Marinò M, Latrofa F, Menconi F, Chiovato L, Vitti P. Role of genetic and non-genetic factors in the etiology of Graves' disease. J Endocrinol Invest. 2014 Nov 25. [Epub ahead of print] PubMed PMID: 25421156.
PMID:25421156 (Link to Abstract)