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Mona Christiansen, age

42
Department of Endocrinology
Made by Unni Syversen, 2003
Revised summer/fall 2013

Part 1
During the last year the patient has felt weak and in lack of energy. She has lost
weight, about 5 kg. She has also had a sensation of being warm and restless,
and her sleep is disturbed. Sometimes she has noticed palpitation of the heart,
and in periods, she has had frequent bowel outlets. Previously, she has
menstruated regularly, but for the last 3 months, she has had amenorrhea.

Which are the possible diagnoses?

What will you focus your physical examination on?
Which tests will you suggest?

Part 2
A 53-year-old woman whose appearance corresponds to her age. She is slender,
and seems to be restless and hectic. Cooperates well. No edemas, icterus,
cyanosis and no general lymph node enlargement. Pulse 90, regular. Blood
pressure 145/65. The thyroid gland is symmetrically enlarged on palpation - - soft
consistency without any palpable nodules. Slight tremor of the hands.

Part 3
Blood test results:
Free thyroxine: 75.0 (12-22 pmol/L)
TSH: <0.01 (0.27-4.20 mIU/L)

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The following blood tests were normal: Hb, SR, creatinine, potassium, ALAT, GT,
cortisol, prolactin, FSH, LH, estradiol and fasting glucose.

Part 4
Which preliminary diagnosis do you make in light of the physical examination and
the results of the blood tests?
Which additional tests could further specify the diagnosis?
Which physical signs should be looked for when specifying the diagnosis?
Any other investigations that could help clarify the diagnosis?

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Part 5
How would you treat the patient?

Part 6
The patient has elevated level of antibodies against TSH-receptor (TRAb) 23 IU/L
(ref < 1.0), and she has a moderate degree of exophthalmos, therefore the
diagnosis is Graves' disease. She is treated with carbimazole (Neo-Mercazole®)
10 mg 3 times daily as an initial dose.

Which information should be conveyed to the patient regarding possible side

effects of Neo-Mercazole?

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After three weeks of treatment, the level of FT4 declined from 75 to 40 pmol/L,
whereas the level of TSH was still suppressed. Clinically, she feels somewhat
better with less palpitations and less disturbed sleep.

What advice do you give as to the dose of Neo-Mercazole at this time?

How long interval before next blood test? Which follow-up tests do you order?

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At next control (6 weeks after start of treatment with Neo-Mercazole), FT4 is 25

pmol/L.

Proposals for alterations in the medication?

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How will you follow this treatment (frequency of follow-ups)?

What blood tests will you order?

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Are there any possible treatments which can help avoid worsening of her
exophthalmus?

Part 7
On “block and replace” therapy, the patient’s FT4 remains stable around 18-23
pmol/L, and TSH is no longer suppressed, but stabilizes around 1.0 mIU/L. After
9 months, Neo-Mercazole is reduced to 5 mg twice daily and Levaxin to 50 µg
once daily. Thereafter, FT4 and TSH remained stable around the same levels.

After one year of treatment you consider stopping the treatment. The patient has
read on the Internet that there is a >50 % risk of relapse. Her daughter is to be
married in 2 months, and she wants to avoid a relapse around the wedding.
Which factors may predict her risk of relapse? (Answer: there is a higher risk of
relapse in subjects who smoke, who have a large goiter and whose TRAb level is
elevated).

This patient’s TRAb has declined to 2.5 IU/L (ref < 1.0), she no longer has a
goiter, and she does not smoke. The treatment is continued for another 4 months,
and thereafter stopped.

Part 8
Two years later the patient has a relapse of Graves' disease with FT4 55 pmo/L,
suppressed TSH and elevated TRAb 18 IU/I. She doesn't want to start with
carbimazole again. She no longer has signs of endocrine ophthalmopathy. She
wants treatment with radioactive iodine (RAI).

How will you inform her concerning treatment alternatives?

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