A 23-year-old woman comes to the office due to palpitations, increased frequency of bowel movements, and a 4.5-kg (10-lb) weight loss despite adequate food intake. The patient's symptoms also include redness of the eyes associated with tearing, grittiness, and photophobia, as well as intermittent diplopia when reading or watching television. Medical history is unremarkable; she has never been pregnant. The patient is not sexually active. She has smoked half a pack of cigarettes a day for the last 2 years.
Blood pressure is 138/66 mm Hg and pulse is 110/min and regular. The patient appears anxious. The thyroid gland shows diffuse symmetrical enlargement without tenderness. A thyroid bruit is audible. Ocular examination shows bilateral proptosis with conjunctival injection and periorbital edema.
Laboratory evaluation shows a serum TSH level of 0.005 μU/mL and a free thyroxine level of 4.1 ng/dL (normal: 0.9-2.4). Thyroid scintigraphy shows 24-hour radioactive iodine uptake of 56% (normal: 10%-30%) with a diffuse pattern.
The patient is started on a beta blocker and oral prednisone. Which of the following additional interventions should be initiated at this time?

Question

A 23-year-old woman comes to the office due to palpitations, increased frequency of bowel movements, and a 4.5-kg (10-lb) weight loss despite adequate food intake.  The patient's symptoms also include redness of the eyes associated with tearing, grittiness, and photophobia, as well as intermittent diplopia when reading or watching television.  Medical history is unremarkable; she has never been pregnant.  The patient is not sexually active.  She has smoked half a pack of cigarettes a day for the last 2 years.
Blood pressure is 138/66 mm Hg and pulse is 110/min and regular.  The patient appears anxious.  The thyroid gland shows diffuse symmetrical enlargement without tenderness.  A thyroid bruit is audible.  Ocular examination shows bilateral proptosis with conjunctival injection and periorbital edema.
Laboratory evaluation shows a serum TSH level of 0.005 μU/mL and a free thyroxine level of 4.1 ng/dL (normal: 0.9-2.4).  Thyroid scintigraphy shows 24-hour radioactive iodine uptake of 56% (normal: 10%-30%) with a diffuse pattern.
The patient is started on a beta blocker and oral prednisone.  Which of the following additional interventions should be initiated at this time?

Quizplus · Accepted Answer

11ec193a_97d3_085d_853d_dfd4cc62e90f_MD0002_00 This patient has hyperthyroidism associated with a diffuse goiter and increased radioiodine uptake consistent with Graves disease. She also has moderate Graves ophthalmopathy, with ocular irritation, photophobia, and diplopia. Initial management of patients with hyperthyroidism should include a beta blocker (eg, propranolol) to control adrenergic symptoms. Systemic glucocorticoids are indicated for those with moderate (oral) or severe/progressive (intravenous) ophthalmopathy. Smoking cessation is also advised as smoking is associated with increased progression of ophthalmopathy. In addition, this patient should be started on an antithyroid drug (ATD) to inhibit synthesis of thyroid hormone. ATDs can be used to achieve remission in patients with mild Graves disease, or to attain a euthyroid state in preparation for more definitive treatment in those with more significant disease (such as this patient). Methimazole is usually preferred due to the risk of hepatotoxicity with propylthiouracil, although propylthiouracil is recommended in the first trimester of pregnancy due to the teratogenic effects of methimazole (Choice B). (Choice C) Radioactive iodine (RAI) ablation can be considered for definitive therapy in patients with moderate to severe Graves disease, in whom an ATD alone is unlikely to achieve remission. However, RAI can worsen ophthalmopathy and should be avoided in patients with significant ocular symptoms. (Choice D) Selenium deficiency is associated with an increased risk of Graves ophthalmopathy. Supplementation appears to reduce symptoms in patients with mild ophthalmopathy, but the benefits are uncertain in regions where selenium deficiency is uncommon, including the United States. (Choice E) Thyroidectomy is the preferred definitive therapy for patients with large goiters, obstructive symptoms, or suspected thyroid cancer. It is also recommended for those with significant ophthalmopathy, in whom RAI may cause an exacerbation of symptoms. However, thyroidectomy is usually performed with the patient in a euthyroid state on an ATD. Educational objective: Antithyroid drugs (eg, methimazole) can induce remission in patients with mild Graves disease. They are also used to attain a euthyroid state in preparation for definitive treatment with radioactive iodine or thyroidectomy in patients with moderate to severe disease. Radioactive iodine can worsen Graves ophthalmopathy and should be avoided in patients with significant ocular symptoms. __________ References: Graves' ophthalmopathy: epidemiology and natural history. (http://www.ncbi.nlm.nih.gov/pubmed/24583420) An update on the medical treatment of Graves' hyperthyroidism. (http://www.ncbi.nlm.nih.gov/pubmed/25185644) Radioiodine therapy versus antithyroid medications for Graves' disease. (http://www.ncbi.nlm.nih.gov/pubmed/26891370)

A 23-Year-Old Woman Comes to the Office Due to Palpitations