P-I-11. Endocrine disorder, Case 3

Anamnesis: 28-year-old woman visits her GP because she has been experiencing an increasing number of unpleasant symptoms. Her symptoms are: despite a good appetite, she has lost 9-10 kg in the last 3 months. Her diet is mixed, and she does not follow any diet. She feels that food “passes through her” because she has bowel movements and diarrhoea several times a day. Her “heart is racing”, she feels her heart beating almost all the time, but she is also anxious and distressed. She wakes up several times a night, sleeps badly. Last summer was very hard on her, she could not stand the heat. She says her muscle strength has decreased and she feels generally weak. Her concentration has also decreased and her attention wanders. Her periods have been less than usual for the last 3 months, and she has had only 2 spotting episodes. Her home pregnancy test from a pharmacy was negative. Her mother and one of her cousins also have some thyroid disease.

She does not take any medication regularly but has occasionally taken 1-2 tablets of a non-prescription sedative sleep aid (containing catnip extract). No known drug allergy.

Physical examination: Female patient of medium physical development, height: 168 cm, weight: 49 kg. BMI: 17. Exophthalmos visible, skin sweaty, it feels warm to touch. Blood pressure 158/88 mm Hg, resting pulse 98/min. Respiratory rate: 20/min. Vivid reflexes, mild bilateral quadriceps weakness. Both hands tremor. Abdominal examination: no abnormalities, hypermotility of the bowels on auscultation of the abdomen. Peripheral pulses well palpable, aa. dors. pedis mko. well palpable. The thyroid gland is diffusely enlarged, insensitive to palpation, a small soft lesion about 1 cm in diameter in the left lobe is palpable.

Laboratory tests: From the laboratory results it should be noted that the patient’s blood sedimentation rate was 32 mm/h, fasting blood glucose: 6.8 mmol/l, total cholesterol: 3.6 mmol/l, fT4 and fT3 were significantly elevated, while TSH was extremely low: 0.001 mIU/l (norm.: 0.4-4 mIU/l). Anti TPO: ↑↑; TRAb –Trak: ↑↑

Ultrasound: The thyroid gland is diffusely enlarged, with a cystic lesion 5-7 mm in diameter in the right lobe and in the isthmus, and a 1.2 cm diameter lesion in the left lobe, also appearing to be a cyst. No other abnormalities are observed.

Scintigraphy: The thyroid gland is diffusely enlarged, with a cold nodule in the areas of the gland as seen on ultrasound. Other areas show uniformly increased isotope enrichment.

Results of a fine needle aspiration biopsy: A 1.2 cm diameter image of the left lobe was sampled. No evidence of malignancy was observed in the cells obtained by aspiration cytology. Opinion: thyroid cyst.

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Key Quotes & What They Tell Us

Quote / Value	Interpretation
“despite a good appetite, she has lost 9–10 kg”; “food passes through her … diarrhoea several times a day”	Hypermetabolic state with gut hypermotility → thyroid hormone excess
“heart is racing”; pulse 98/min; “both hands tremor”; vivid reflexes; anxiety	Sympathetic/adrenergic overactivity from hyperthyroidism
“could not stand the heat”; skin “sweaty … warm to touch”	Heat intolerance and increased thermogenesis
“Exophthalmos visible”	Graves’ ophthalmopathy — specific to autoimmune Graves’ disease
“thyroid gland is diffusely enlarged”	Diffuse goitre (whole-gland stimulation, not a single nodule)
fT4 and fT3 elevated; TSH 0.001 mIU/L (extremely low)	Primary hyperthyroidism — high free hormones suppress TSH via negative feedback
Anti-TPO ↑↑; TRAb (TRAK) ↑↑	TSH-receptor stimulating antibodies confirm Graves’ disease (autoimmune)
Scintigraphy: “cold nodule” but FNA → benign “thyroid cyst”	Incidental benign cyst on a background of diffusely overactive gland — not the cause of the hyperthyroidism

Key Points

• Diagnosis: Graves’ disease — autoimmune hyperthyroidism.
• Pathophysiology: TSH-receptor stimulating antibodies (TRAb) drive diffuse gland overactivity → excess fT4/fT3 → suppressed TSH.
• Clinical picture: Hypermetabolism (weight loss, diarrhoea, heat intolerance) plus adrenergic features (tachycardia, tremor, anxiety).
• Specific sign: Exophthalmos and diffuse goitre point to Graves’ rather than a toxic nodule.
• Incidental finding: The “cold” nodule is a benign cyst on FNA — a separate, non-malignant issue.