Review Question - QID 102723

This patient is presenting with a low TSH, fever, tachycardia, weight loss, and exophthalmos which is concerning for Graves disease. The definitive treatment for Graves disease in a nonpregnant patient is radioactive iodine ablation.

Graves disease is an autoimmune disease in which thyroid stimulating immunoglobulins bind to TSH receptors. There tends to be a female predominance, and symptoms are often precipitated by stress (for example childbirth or infection). Graves disease often presents with heat intolerance, tachycardia, sweating, and nontender thyroid enlargement. Exophthalmos can be seen on physical exam. Radioactive iodine uptake scans will show diffuse uptake. Indications for radioactive iodine over antithyroid agents include a large thyroid gland, multiple symptoms of thyrotoxicosis, high levels of thyroxine, and high titers of thyroid-stimulating immunoglobulins (TSI). Definitive treatment of a nonpregnant patient with Graves disease is radioactive iodine ablation (though this can worsen the patient's exophthalmos).

Figure A is the physical exam finding of exophthalmos which is commonly seen in Graves disease.

Incorrect Answers:
Answer 1: No treatment is indicated would be appropriate management of silent thyroiditis which presents with a transient hyperthyroid phase, followed by a transient hypothyroid phase, and finally, the patient returns to a euthyroid state.

Answer 2: Propranolol would be the best next step in management, after radioactive iodine ablation, for this patient as it would slow her heart rate and decrease her systemic adrenergic tone. It is symptomatic rather than definitive treatment of Graves disease.

Answer 3: Propylthiouracil is an antithyroid agent that can be given which would suppress the production of thyroid hormone; however, it generally is not definitive management of Graves disease. This patient's mild exophthalmos make her a candidate for radioactive iodine ablation.

Answer 5: Thyroidectomy is generally not the preferred treatment of Graves disease unless the patient is pregnant and symptoms cannot be controlled medically during the pregnancy. Radioactive iodine would ablate the fetus's thyroid thus it is not indicated.

Bullet Summary:
Radioactive iodine ablation is the definitive treatment of Graves disease in nonpregnant patients.