Secondary hypothyroidism following the Resolution of Graves’ Disease: A Case Report
This is the case report of a 39-year-old lady who presented with clinical and laboratory features of secondary hypothyroidism two years after achieving clinical and biochemical resolution of Graves' disease and cessation of anti-thyroid medications. The thyroid function tests at presentation revealed: Serum T3 1.33ng/ml (normal range 0.8-1.7ng/ml), Serum T4 2.92 (normal range 4.5-12.0µg/dl), and TSH 0.2mIU/l (normal range 0.5-5.0mIU/l). Thyroid-related autoantibodies could not be assayed in the patient due to financial constraints. However, pointers to the possible autoimmune nature of secondary hypothyroidism include the recurrence of exophthalmos, dating of symptoms back to puerperium, relative lymphocytosis, and moderately elevated erythrocyte sedimentation rate (ESR). The patient was subsequently placed on levothyroxine and low-dose steroids, and the patient achieved clinical and biochemical euthyroidism in the sixth, ninth, and twelfth months of follow-up. This report is to demonstrate the development of secondary hypothyroidism following Graves' disease, and it also serves to highlight the judicious use of clinical acumen in the face of limited laboratory support to diagnose and treat endocrine disorders in resource-poor settings.
Ginsberg J. Diagnosis and management of Graves' disease. CMAJ 2003;168:575-585.
McLachlan SM, Rapoport B. Thyrotropin-blocking autoantibodies and thyroid-stimulating autoantibodies: potential mechanisms involved in the pendulum swinging from hypothyroidism to hyperthyroidism or vice versa. Thyroid 2013;23:14-24. https://doi.org/10.1089/thy.2012.0374
Takasu N, Matsushita M. Changes of TSH-Stimulation Blocking Antibody (TSBAb) and Thyroid Stimulating Antibody (TSAb) Over 10 Years in 34 TSBAb-Positive Patients with Hypothyroidism and in 98 TSAb-Positive Graves' Patients with Hyperthyroidism: Reevaluation of TSBAb and TSAb in TSH-Receptor-Antibody (TRAb)-Positive Patients. J Thyroid Res 2012;2012:182176. https://doi.org/10.1155/2012/182176
Wood LC, Ingbar SH. Hypothyroidism as a late sequela in a patient with Graves' disease treated with anti-thyroid agents. J Clin Invest 1979;64:1429-36. https://doi.org/10.1172/JCI109601
Kasagi K, Hidaka A, Endo K, Miyamoto S, Takeuchi R, Misaki T, et al. Fluctuating thyroid function depending on the balance between stimulating and locking types of TSH receptor antibodies: a case report. Thyroid 1993;3:315–318. https://doi.org/10.1089/thy.1993.3.315
Evans M, Sanders J, Tagami T, Sanders P, Young S, Roberts E, et al. Monoclonal autoantibodies to the TSH receptor, one with stimulatory activity and one with blocking activity obtained from the same blood sample. Clin Endocrinol 2010;73:404–412. https://doi.org/10.1111/j.1365-2265.2010.03831.x
Frohlich E, Wahl R. Thyroid Autoimmunity: Role of Anti-thyroid Antibodies in Thyroid and Extra-Thyroidal Diseases. Front Immunol2017; 8:521. https://doi.org/10.3389/fimmu.2017.00521
Furqan S, Haque NU, Islam N. Conversion of autoimmune hypothyroidism to hyperthyroidism. BMC Res Notes 2014;7:489. https://doi.org/10.1186/1756-0500-7-489
Wuqiang F, Prabhat T, Mahesh K. Oscillating hypothyroidism and hyperthyroidism - a case-based review. J Community Hosp Intern Med Perspect 2014;4:25734. https://doi.org/10.3402/jchimp.v4.25734 Fr
Yamasaki H, Takeda K, Nakauchi Y, Suehiro T, Hashimoto K. Hypothyroidism preceding hyperthyroidism in a patient with continuously positive thyroid-stimulating antibody. Intern Med 1995;34:247–250. https://doi.org/10.15605/jafes.033.02.12
Gupta Y, Singh S, Ammini AC. Development of Graves' disease after long-standing hypothyroidism on treatment, with acute toxicity to thionamides and lithium. BMJ Case Rep. 2012;2012:bcr2012006433. https://doi.org/10.1136/bcr-2012-006433
Ekpebegh C, Elmezughi K, Mtingi L. Graves' disease following hypothyroidism due to Hashimoto's thyroiditis in a black South African lady: A case report. Pan Afr Med J. 2019;32:186. https://doi.org/10.11604/pamj.2019.32.186.18713
Kamath C, Young S, Kabelis K, Sanders J, Adlan MA, Furmaniak J, et al. Thyrotropin receptor antibody characteristics in a woman with long-standing Hashimoto's who developed Graves' disease and pretibial myxedema. Clin Endocrinol 2012;77:465–470. https://doi:10.1111/j.1365-2265.2012.04397.x
Pak S, Valencia D, Fershko A. Transformation of Hashimoto's thyroiditis to Graves' disease. Res Rev Insights 2017;1:1–2. https://doi.org/10.15761/RRI.1000117
Thomsen H, Li X, Sundquist K, Sundquist J, Försti A, Hemminki K. Familial risks between Graves disease and Hashimoto thyroiditis and other autoimmune diseases in the population of Sweden. J Transl Autoimmun 2020;3:100058. https://doi.org/10.1016/j.jtauto.2020.100058
Champion B, Gopinath B, Ma G, El-Kaissi S, Wall JR. Conversion to Graves’ hyperthyroidism in a patient with hypothyroidism due to Hashimoto's thyroiditis documented by real-time thyroid ultrasonography. Thyroid 2008;18:1135–1137. https://doi.org/10.1089/thy.2008.0142
Dasari S, Naha K, Hande M, Vivek G. Hot and cold: coexistent Graves' disease and Hashimoto's thyroiditis in a patient with Schmidt's syndrome. BMJ Case Rep 2014;2014:bcr2013010432. https://doi.org/10.1136/bcr-2013-010432
Ahmad E, Hafeez K, Arshad MF, Isuga J, Vrettos A. Hypothyroidism conversion to hyperthyroidism: it's never too late. Endocrinol Diabetes Metab Case Rep 2018;2018:18-0047. https://doi.org/10.1530/EDM-18-0047
Amino N, Tada H, Hidaka Y. Postpartum autoimmune thyroid syndrome: a model of aggravation of the autoimmune disease. Thyroid 1999;9:705-713. https://doi.org/10.1089/thy.1999.9.705
Kim WB, Chung HK, Park YJ, Park DJ, Lee HK, Cho BY. Clinical significance of classification of Graves' disease according to the characteristics of TSH receptor antibodies. Korean J Intern Med 2001;16:187-200. https://doi.org/10.3904/kjim.2001.16.3.187
Hallengren B, Planck T, Åsman P, Lantz M. Presence of Thyroid-Stimulating Hormone Receptor Antibodies in a Patient with Subacute Thyroiditis followed by Hypothyroidism and Later Graves' Disease with Ophthalmopathy: A Case Report. Eur Thyroid J. 2015;4:197-200. https://doi.org/10.1159/000435915
Copyright (c) 2022 Annals of Health Research
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
The articles and other materials published in the Annals of Health Research are protected by the Nigerian Copyright laws. The journal owns the copyright over every article, scientific and intellectual materials published in it. However, the journal grants all authors, users and researchers access to the materials published in the journal with the permission to copy, use and distribute the materials contained therein only for academic, scientific and non-commercial purposes.