Thyroid MDS Case Samya

Thyrotoxicosis Case Presentation by Samya Al Rashidi History • Mr. J. M. is a 50 year old Kty gentleman presented to Mubarak hospital in May 15, 2002: 1 month: Shaky both hands & legs Nervousness & irritability Perfused sweating Heat intolerance, 6 months: 19 kg weight loss (original weight is 110), palpitation on exertion. History • No H/O : loss of appetite change in bowel habits, hair loss, bone pain, blurred vision, dizziness, headache, difficulty in getting up from sitting position (proximal m. weakness), skin changes, SOB, chest pain. History P.M.H.: • one admission in 1985 for cholecystectomy. • Known case of HTN > 10 years • no H/O IHD, CVA F.H.: • has 4 brothers one of them has hyperthyroidism under follow up, • his father died from CVA at the age of 60 yrs. • No other relevant family history History • Drug history:  Tenormin (B-blocker) 100mg OD (for HTN)  No h/o allergy to drugs • Social history:  married & has 6 healthy children  works in interior ministry  economically stable  non-smoker  Non-ethanol consumer Physical Examination On initial visit to hospital • Pt was conscious, oriented, not in pain No Jaundice, pallor, cyanosis, L L oedema, nor pre-tibial myxedema, no eye signs • Vital signs: BP: 130/70 mmHg Pulse: 110/min regular afebrile Physical Examination • Hands: warm, and had tremor, no clubbing nor palmar erythema • Neck: • mild-moderate diffuse non-tender goiter, firm in consistency with bruit on auscultation • no clinical evidence of retrosternal extension • Chest: clear, normal air entry • Heart: S1 S2, systolic murmur • Abdomen: subcostal incision scar of previous chole., soft & lax with no organomegaly • CNS: no diplopia, ophalmoplagia, hyperreflexia Investigation Plan? • • • • CBC, ESR Full Biochemistry profile fT3, fT4, TSH levels Thyroid Abs: • TSH-R Ab • Anti-microsomal • Anti-thyroglobulins • Radioisotope thyroid tests • Iodine uptake • Thyroid scan • Supplementary tests: • ECG • LFT Investigation Done • CBC: WBC: 6.5x109/L (4.8-10.8) Hb: 13.3 g/dl (14-18) plt: 272x109/L (130-400) 40 (3.3-7.2) pmol/L 68 (11-24) pmol/L 0.03 (0.3-4.2) mU/L • Free T3 Free T4 TSH • Thyroid uptake: uptake is high 54% (NR, up to 35%) • Thyroid scan: diffused goiter consistent with Graves` disease Investigation done • Biochemistry Profile: FBG: 4.6 mmol/L (3.9-6.1) Ca: 2.77 mmol/L (2.2-2.67) PO4: 1.4 mmol/L (0.8-1.4) ALP: 89 IU/L (26-88) cholestrol: 2.7 mmol/L (3-5.2) • RFT: Normal LFT: Normal Diagnosis Grave`s Disease Management ? Anti-thyroid drugs Carbimazole  B-blockers  Iodine  Radioactive Iodine therapy Surgery Very large goiter Relapse after anti-thyroid Treatment • Neomarcazole (carbimazole) 20 mg BD planned for 12 months. Already on B-blocker for HTN • TFT after 6 weeks was normalized and was kept of the titration method with a maintenance dose of 10 mg daily • After 12 months of treatment, his medications were stopped, but his repeated TFT was thyrotoxic FT4 50 (11-24) pmol/L TSH 0.04 (0.3-4.2) mU/L Treatment • He was then advocated to receive RAI, which he took on about June 2004, with a post-RAI TFT (3 months) of : – FT4 2.4, F T3 1.2, TSH of >40 – Then he was treated with thyroxine replacement (100mcg OD) and he is now euthyroid.