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A patient with stress-related onset and exacerbations of Graves disease

Nature Clinical Practice Endocrinology & Metabolism volume 5, pages 55–61 (2009)Cite this article

Abstract

Background An 18-year-old, nonsmoking woman presented to her general practitioner with a 1-week history of weakness, fatigue, palpitations, nervousness, tremors, insomnia, heat intolerance, and sudden enlargement of a thyroid goiter that had been detected 2 years earlier. The patient's symptoms had started shortly after she experienced emotional stress. Diagnostic work-up disclosed an avid radioactive iodine uptake by the goiter. On ultrasound examination, the thyroid gland was enlarged with a diffusely hypoechogenic structure and intense vascularization.

Investigations Thyroid scintigraphy with 131I; ultrasonography of the thyroid gland; and measurements of serum free T3, free T4, TSH levels and thyroid autoantibodies, including autoantibodies against thyroglobulin (TgAb), thyroperoxidase (TPOAb) and TSH receptor (TRAb).

Diagnosis Graves disease, with stress-related onset and subsequent stress-related exacerbations.

Management The patient was treated with methimazole to normalize levels of thyroid hormone and thyroid autoantibodies, and with bromazepam to help her cope with stress. The daily dose of methimazole was kept low during pregnancy. Over the 4 year period when the patient was taking methimazole, exacerbations of hyperthyroidism occurred twice: during her first pregnancy and 9 months after her first delivery. On all three occasions, symptoms were preceded by stressful life events. Further exacerbations were avoided by starting bromazepam treatment soon after the patient experienced stressful events.

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Figure 1: Stressful life events (indicated by arrows), changes in serum free T3 and free T4 levels, thyroid autoantibodies (TgAb, TPOAb, TRAb) and pharmacological treatment in the patient described.
Figure 2: Most frequent symptoms and signs of hyperthyroidism.5

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Acknowledgements

Written consent for publication was obtained from the patient. Désirée Lie, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Authors and Affiliations

  1. R Vita is enrolled at the Postgraduate School of Endocrinology; D Lapa is a Research Fellow at the Section of Endocrinology; G Vita is Master of Science at the Department of Pathology and Experimental Microbiology; F Trimarchi is Professor of Medicine and Chair at the Section of Endocrinology; and S Benvenga is Professor of Medicine at the Section of Endocrinology, Department of Clinical and Experimental Medicine at the University of Messina, Italy.,

    Roberto Vita, Daniela Lapa, Giuseppe Vita, Francesco Trimarchi & Salvatore Benvenga

  2. D Lapa is a Research Fellow at the Section of Endocrinology,

    Roberto Vita, Daniela Lapa, Giuseppe Vita, Francesco Trimarchi & Salvatore Benvenga

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Correspondence to Salvatore Benvenga.

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Vita, R., Lapa, D., Vita, G. et al. A patient with stress-related onset and exacerbations of Graves disease. Nat Rev Endocrinol 5, 55–61 (2009). https://doi.org/10.1038/ncpendmet1006

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