Thyrotoxicosis

Abstract

A 23-year-old female presented with heat intolerance, anxiety, tremor, and palpitation for 4 years. She also complained of weight loss despite increased appetite for 3 years. There was history of proptosis with grittiness in eyes for the past 2 years. She had regular menstrual cycles. There was no family history of thyroid disorder or autoimmune disease. On examination, her pulse rate was 124/min and regular, blood pressure was 160/60 mm Hg, and she had fine tremors with warm and moist palms. She had grade II soft and diffuse goiter with presence of a bruit. Ophthalmic examination revealed proptosis (22 mm) with a clinical activity score of 0/7 and severity score was moderate to severe. There was no dermopathy or acropachy. On investigation, serum T₃ was 5.4 ng/ml (0.8–1.8), T₄ 23.4 μg/dl (4.8–12.6), and TSH 0.001 μIU/ml (0.45–4.2). She was diagnosed to have Graves’ disease with inactive thyroid-associated orbitopathy and treated with carbimazole 30 mg once a day and propranolol 40 mg thrice daily. She was also advised artificial teardrops, sunglasses with side cover, and head-end elevation while sleeping. After 6 weeks, she had improvement in clinical symptoms and her body weight stabilized. Repeat thyroid function test revealed T₃ 2.4 ng/ml, T₄ 16.2 μg/dl (4.8–12.6), and TSH 0.001 μIU/ml (0.45–4.2), and she was continued with 30 mg carbimazole and propranolol. Subsequently at 3 months, she had resolution of clinical symptoms and normalization of T₃ and T₄; however, TSH remained suppressed. The dose of carbimazole was decreased to 10 mg and continued for 2 years with 3 monthly monitoring of thyroid function tests. Later, she was subjected to decompressive eye surgery for severe proptosis. On follow-up she is doing fine.