Autoimmune thyroid disease may present with a wide range of symptoms. When the presentation is hyperthyroidism due to Graves’ Disease the symptoms generally subside over the subsequent two years but may recur at any time months to years later. When the initial presentation is hypothyroidism that person usually remains hypothyroid, requiring thyroid hormone replacement therapy for the rest of their life.
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Case report of a 67 year old woman presenting with hyperthyroidism after 25 years of stable dose thyroid hormone replacement therapy. Her symptoms persisted after stopping the Armour Thyroid. Evaluation for causes of hyperthyroidism revealed the presence of both TRAb and TSI antibodies that have decreased in titer but are still present more than 4 years after the diagnosis of hyperthyroidism. TPO antibody was not present at the time of the diagnosis of the Graves’ Disease. Symptoms have been controlled over this time period with low dose (5-10 mg/day) methimazole.
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Hypothyroidism is very common in women with Hashimoto’s Thyroiditis as the usual etiology. When patients on thyroid hormone replacement therapy (THRT) present with symptoms of hyperthyroidism they are usually managed with dose reduction. However, complete cessation of THRT is unusual, especially after more than 10-20 years of therapy. Dose reduction of more than 50% without contributing factors such as significant weight loss should prompt measurement of TRAb and/or TSI to evaluate for Graves’ Disease regardless of the duration of the THRT.
Assistant Professor of Clinical Medicine
The Ohio State University Wexner Medical Center
Dr. Lubna Bashir Munshi completed her fellowship in Endocrinology at the Mount Sinai Health System in New York City. She is currently an assist professor at The Ohio State University where her interests include type 2 diabetes and thyroid disease management.
Associate Professor of Clinical Medicine
The Ohio State University Wexmer Medical Center
Dr. Kathleen Wyne is an Associate Professor of Clinical Medicine in the Division of Endocrinology at The Ohio State University in Columbus, Ohio, where she is the Director of the Adult Type 1 Diabetes Program.
She completed an MD and a PhD while working in the Atehrosclerosis SCOR at the University of Chicago.
She then completed an Internal Medicine residency at Baylor in Houston Texas followed by Endocrinology at the University of Texas Southwestern in Dallas.
She has served on the National Board of Directors for AACE and the National Lipid Association.
She has written guidelines for the Texas Diabetes Council and, most recently, the AACE 2017 Lipid Guideline.