Journal List > J Korean Endocr Soc > v.23(5) > 1003457

TOOLS
Jeong, Kim, Kim, Kim, Lee, Yim, Kim, Kim, and Shong: A Case of Painful Graves' Disease
Case Report
Journal of Korean Endocrine Society

Journal of Korean Endocrine Society 2008; 23(5): 337-341.

Published online: 31 October 2008

DOI: https://doi.org/10.3803/jkes.2008.23.5.337

A Case of Painful Graves' Disease

Ji Yun Jeong, Tae Yong Kim, Eun Hee Kim, Eui Young Kim, Sang Ah Lee, Ji Hye Yim, Kyung Min Kim, Won Bae Kim, Young Kee Shong

Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Korea.

Received 8 April 2008       Accepted 13 August 2008

Copyright © 2008 Korean Endocrine Society

Abstract

Graves' disease rarely presents as pain and tenderness of goiter, with only a few cases reported in the literature. We describe a case of painful Graves' disease presenting as 2 episodes of painful goiter.
A-25-yr-old male was referred to our hospital because of pain in the anterior neck, palpitations, and muscle weakness. His heart rate was 122 beat/min and body temperature was normal. The thyroid gland was enlarged and tender. His thyroid function test showed thyrotoxicosis with high TSH binding inhibitory immunoglobulin (TBII) and thyroid peroxidase antibody (TPO Ab). A 99mTc-pertechnate thyroid scan showed diffuse increased uptake with no focal defects. He was started on propranolol, methimazole, Lugol's solution, and prednisolone. He was discharged 7 days later with improved painful symptoms. The prednisolone was tapered out for 2 months. Eight months after the initial pain, he experienced one more episode of thyroid pain and hyperthyroidism, with an increase in TBII. He was treated with methimazole and prednisolone, and responded well.

Keywords: Graves' disease, painful goiter, painful Hashimoto's thyroiditis

Figures and Tables

Fig. 1
99mTechnetium pertechnate thyroid scans shows increased uptake in both lobe and diffuse enlargement.
jkes-23-337-g001
Fig. 2
Thyroid ultrasonography reveals a diffusely enlarged gland with heterogeneous echogenecity without focal abnormality. (A) Right lobe (B) Left lobe.
jkes-23-337-g002
Fig. 3
Changes in symptom, signs, thyroid function, and treatment. Total T3: normal range, 98-180 ng/dL. Free T4: normal range, 0.8-1.9 ng/dL. TSH: Thyroid stimulating hormone, normal range, 0.4~5.0 µIU/mL. TBII: TSH-binding inhibitor immunoglobulin measured by BRAHMS DYNOtest® TRAK human, normal range, 0~2.0 IU/L. d: day. m: month.
jkes-23-337-g003

References

1. Meier DA, Nagle CE. Differential diagnosis of a tender goiter. J Nucl Med. 1996. 37:1745–1747.
2. Shigemasa C, Ueta Y, Mitani Y, Taniguchi S, Urabe K, Tanaka T, Yoshida A, Mashiba H. Chronic thyroiditis with painful tender thyroid enlargement and transient thyrotoxicosis. J Clin Endocrinol Metab. 1990. 70:385–390.
3. Alves C, Eidson MS, Zakarija M, McKenzie JM. Graves disease presenting as painful thyroiditis. Eur J Pediatr. 1989. 148:603–604.
4. Chao CS, Lin SY, Sheu WH. Graves' disease presented as painful goiter. Horm Res. 2002. 57:53–56.
5. Stanley JM, Najjar SS. Painful thyroid gland: an atypical presentation of Graves\' disease. Clin Endocrinol (Oxf). 1992. 37:468–469.
6. Iitaka M, Kakinuma S, Yamanaka K, Fujimaki S, Oosuga I, Wada S, Katayama S. Induction of autoimmune hypothyroidism and subsequent hyperthyroidism by TSH receptor antibodies following subacute thyroiditis: a case report. Endocr J. 2001. 48:139–142.
7. Bartalena L, Bogazzi F, Pecori F, Martino E. Graves' disease occurring after subacute thyroiditis: report of a case and review of the literature. Thyroid. 1996. 6:345–348.
8. Shigemasa C, Mitani Y, Taniguchi S, Adachi T, Ueta Y, Urabe K, Miyazaki S, Tanaka T, Yoshida A, Mashiba H. Three patients who spontaneously developed persistent hypothyroidism during or following treatment with antithyroid drugs for Graves' hyperthyroidism. Arch Intern Med. 1990. 150:1105–1109.
9. Fukata S, Matsuzuka F, Kobayashi A, Hirai K, Kuma K, Sugawara M. Development of Graves' disease after subacute thyroiditis: two unusual cases. Acta Endocrinol (Copenh). 1992. 126:495–496.
10. Mitani Y, Shigemasa C, Kouchi T, Taniguchi S, Ueta Y, Yoshida A, Mashiba H. Detection of thyroid-stimulating antibody in patients with inflammatory thyrotoxicosis. Horm Res. 1992. 37:196–201.
11. Zimmerman RS, Brennan MD, McConahey WM, Goellner JR, Gharib H. Hashimotos thyroiditis. An uncommon cause of painful thyroid unresponsive to corticosteroid therapy. Ann Intern Med. 1986. 104:355–357.
12. Kon YC, DeGroot LJ. Painful Hashimoto's thyroiditis as an indication for thyroidectomy: clinical characteristics and outcome in seven patients. J Clin Endocrinol Metab. 2003. 88:2667–2672.
13. Kasagi K. Painful Hashimoto's thyroiditis. Intern Med. 2006. 45:351–352.
14. Ohye H, Nishihara E, Sasaki I, Kubota S, Fukata S, Amino N, Kuma K, Miyauchi A. Four cases of Graves' disease which developed after painful Hashimoto's thyroiditis. Intern Med. 2006. 45:385–389.
15. Konno S, Konno N, Yokobori M, Kazui K, Hase T, Uematsu T, Nishimura M. Autoimmune thyroid disease accompanied by recurring episodes of painful thyroid ameliorated by thyroidectomy. J Endocrinol Invest. 2002. 25:996–1000.
16. Ohye H, Fukata S, Kubota S, Sasaki I, Takamura Y, Matsuzuka F, Amino N, Kuma K, Miyauchi A, Kakudo K. Successful treatment for recurrent painful Hashimotos thyroiditis by total thyroidectomy. Thyroid. 2005. 15:340–345.
17. Fukata S, Matsuzuka F, Hara T, Mukuta T, Kuma K, Sugawara M. Rapidly progressive thyroid failure in Graves\' disease after painful attack in the thyroid gland. Arch Intern Med. 1993. 153:2157–2161.
18. Shigemasa C, Shirota K, Urabe K, Kouchi T, Mitani Y, Ueta Y, Yoshida A, Mashiba H. Onset of subacute aggravation of chronic thyroiditis followed immediately by transient hypothyroidism during antithyroid drug therapy for Graves' hyperthyroidism. Horm Res. 1991. 35:208–212.
TOOLS
Similar articles