Review Question - QID 215110

This patient likely has hyperthyroidism as evidenced by her weight loss, anxiety, tremulousness, and atrial fibrillation. Her goiter and proptosis are concerning for Graves disease, and she should be first treated with a beta-blocker such as propranolol to relieve her sympathetic symptoms.

Graves disease is caused by autoantibodies that activate the thyroid-stimulating hormone (TSH) receptor, leading to thyroid hormone overproduction. This can cause hyperthyroidism, goiter, thyroid eye disease, and myxedema. Patients can present with anxiety, fatigue, weight loss, palpitations, hypertension, tremors, heat intolerance, and other signs of hyperthyroidism. Orbital involvement may include proptosis, eye irritation, blurry vision, double vision, or painful eye movements. Initial management involves beta-blockers such as propranolol to reduce the symptoms caused by increased beta-adrenergic tone (e.g., atrial fibrillation). In addition, patients with significant symptoms should start a thionamide such as propylthiouracil or methimazole to decrease thyroid hormone synthesis. Forms of definitive treatment include radioactive thyroid ablation and surgical thyroidectomy.

Smith et al. study the use of teprotumumab, an insulin-like growth factor I receptor inhibitor, for the treatment of thyroid eye disease. The authors find that teprotumumab lead to improvement in active thyroid-associated ophthalmopathy, proptosis, and quality-of-life questionnaires. The authors recommend the use of teprotumumab in patients with active thyroid eye disease.

Figure/ Illustration A shows an electrocardiogram with atrial fibrillation, which is characterized by an irregularly irregular tachyarrhythmia (yellow box) with absent P waves (blue box).

Incorrect Answers:
Answer 1: Lorazepam, a benzodiazepine, may be used to treat anxiety. However, it does not directly address the underlying cause of hyperthyroid symptoms that are due to increased sympathetic tone. Benzodiazepines should be avoided due to their sedating effects and the risk of dependency.

Answer 3: Propylthiouracil inhibits thyroid hormone synthesis. While it can be used to achieve a euthyroid state, in this case, the patient's arrhythmia needs to be addressed more urgently with a beta-blocker prior to initiation of an anti-thyroid medication.

Answer 4: Radioiodine ablation causes destruction of the thyroid follicular cells through uptake of radioactive iodine. Following treatment, patients require life-long thyroid hormone replacement therapy. Radioiodine ablation is contraindicated in pregnancy and breastfeeding.

Answer 5: Surgical resection of the thyroid gland may be indicated for those who fail or cannot tolerate medical therapy and have a large goiter. Complications include hypothyroidism, laryngeal nerve palsy, hypoparathyroidism, and hypocalcemia.

Bullet Summary:
Initial management for Graves disease includes beta-blockers such as propranolol for symptom management.