A 58-year-old woman comes to the office due to recent-onset tremor, palpitations, weight loss, and fatigue. She has no other medical conditions and takes no medications or over-the-counter supplements. The patient's mother had hypothyroidism and osteoporosis. Blood pressure is 144/80 mm Hg, pulse is 110/min, and respirations are 18/min. On examination, there is diffuse, nontender enlargement of the thyroid gland. Ocular examination shows bilateral proptosis, lid lag, and periorbital puffiness. The patient has diplopia and ocular discomfort on extremes of lateral gaze. Laboratory tests show a suppressed TSH and elevated thyroid hormone levels. Which of the following treatment options is most likely to worsen this patient's eye disease?

Question

A 58-year-old woman comes to the office due to recent-onset tremor, palpitations, weight loss, and fatigue.  She has no other medical conditions and takes no medications or over-the-counter supplements.  The patient's mother had hypothyroidism and osteoporosis.  Blood pressure is 144/80 mm Hg, pulse is 110/min, and respirations are 18/min.  On examination, there is diffuse, nontender enlargement of the thyroid gland.  Ocular examination shows bilateral proptosis, lid lag, and periorbital puffiness.  The patient has diplopia and ocular discomfort on extremes of lateral gaze.  Laboratory tests show a suppressed TSH and elevated thyroid hormone levels.  Which of the following treatment options is most likely to worsen this patient's eye disease?

Quizplus · Accepted Answer

11ec25c8_d3bd_064f_bc81_59e2a4a0019c_MD0003_00 This patient has hyperthyroidism with a diffuse goiter, consistent with Graves disease. In addition, she has signs of Graves ophthalmopathy, including proptosis, swelling of the periorbital tissues, and involvement of the extraocular muscles (eg, diplopia, discomfort with ocular movements). Graves ophthalmopathy is due to the effects of activated T cells and thyrotropin receptor antibodies (TRAB) on TSH receptors on retro-orbital fibroblasts and adipocytes. The 3 primary treatment options for Graves disease include radioactive iodine (RAI), antithyroid drugs (eg, propylthiouracil, methimazole), and thyroidectomy. Patients with mild disease often achieve permanent remission with antithyroid drugs alone, but those with more severe disease require definitive treatment with thyroidectomy or RAI. However, titers of TRAB increase significantly following RAI therapy, and RAI can cause worsening of ophthalmopathy. For this reason, administration of glucocorticoids with RAI is often advised to prevent complications in patients with mild ophthalmopathy (Choice A); thyroidectomy is preferred over RAI for those with moderate or severe ophthalmopathy (Choice E). (Choice B) Beta blockers (eg, propranolol) are usually given to minimize the cardiovascular effects (eg, hypertension, tachycardia) of hyperthyroidism. (Choice C) Destruction of thyroid follicles by RAI can cause unregulated release of thyroid hormone, temporarily worsening the hyperthyroid state. Younger patients without cardiovascular disease usually tolerate RAI without major problems. However, elderly patients and those with cardiovascular disease may not tolerate the temporary increase in thyroid hormone and often are given an antithyroid drug to deplete existing thyroid hormone stores prior to RAI. Educational objective: Graves ophthalmopathy is due to the effects of activated T cells and thyrotropin receptor antibodies (TRAB) on TSH receptors on retro-orbital fibroblasts and adipocytes. Radioactive iodine (RAI) treatment can raise titers of TRAB and worsen the ophthalmopathy. Glucocorticoids and antithyroid drugs can be used to minimize the effects of RAI. References: Thyroid-associated ophthalmopathy after treatment for Graves' hyperthyroidism with antithyroid drugs or iodine-131. (http://www.ncbi.nlm.nih.gov/pubmed/19723755) Immunopathogenesis of Graves' ophthalmopathy: the role of the TSH receptor. (http://www.ncbi.nlm.nih.gov/pubmed/22632365)

A 58-Year-Old Woman Comes to the Office Due to Recent-Onset