tS1 Refer to: Levine GA, Williams DE, Hershman JM, et al: Graves hyperthyroidism following myxedema in a patient with recurrent carcinoma of the colon. West J Med 128: 240-244, Mar 1978
Graves Hyperthyroidism Following Myxedema in a Patient With Recurrent Carcinoma of the Colon GERALD A. LEVINE, MD DONALD E. WILLIAMS, MD JEROME M. HERSHMAN, MD, GILDON N. BEALL, MD Los Angeles CHRONIC LYMPHOCYTIC THYROIDITIS (Hashimoto thyroiditis) has been increasing in frequency in the United States and now is the most frequently seen thyroid disorder, probably accounting for most instances of idiopathic acquired hypothyroidism." Hypothyroidism following hyperthyroidism is not unusual, but the reverse situation, that of hyperthyroidism following hypothyroidism, is rare. We report a case we have followed during transition from idiopathic hypothyroidism to Graves disease with hyperthyroidism to a euthyroid state over a seven year period. The relationship of the development of hyperthyroidism in this man to recurrent carcinoma of the colon is also of interest. Report of a Case In a 58-year-old white man hyperthyroidism developed in 1973, four years after well-documented hypothyroidism. His illness began in 1969 with a six-month history of easy fatigability, weakness, stiffness and cramping of his muscles, and a 25-pound weight gain. He had not received goitroFrom the Endocrine Section, Medical and Research Services Veterans Administration Wadsworth Hospital Center, Los Angeles; Harbor General Hospital, Torrance, and Department of Medicine, University of California, Los Angeles, Center for the Health Sciences. Submitted, revised, June 20, 1977. Supported in part by the Medical Research Service of the Veterans Administration and USPHS Grant HD-7181. Reprint requests to: Jerome M. Hershman, MD, Endocrine Section, VA Wadsworth Hospital Center, Los Angeles, CA 90073.
240
MARCH 1978 * 128 * 3
genic drugs or iodine. There was no family history of thyroid disease; one of seven siblings died of stomach cancer and another of an unknown type of cancer. On physical examination, the pulse was 75 beats per minute and blood pressure was 110/85 mm of mercury. Dry skin, puffiness around the eyes, delayed relaxation of the deep tendon reflexes, and swelling, induration and non-pitting edema of the muscles were noted. The thyroid was not enlarged or tender and was of normal consistency. Figure 1 depicts the serum thyroxine (T4) values over a seven-year period. Initially the proteinbound iodine (PBI) was 2.0 jug per dl with two repeat values of 1.9 ug per dl, and a T3 resin uptake was 22.4 percent (hypothyroid range). Thyroid radioiodine uptake was 2 percent at 6 hours and 0 at 24 hours. Serum cholesterol was 330 mg per dl, and creatine phosphokinase was 17 sigma units (normal 0 to 12). An electrocardiogram showed low voltage of T waves in I, V5 and V6. To obtain faster improvement of his myopathy, the patient was treated with triiodothyronine (CytomelP), 75 Mug per day for eight days, along with desiccated thyroid, 180 mg per day; within ten days he noted pronounced improvement and lost 10 pounds. He remained euthyroid on 180 mg of desiccated thyroid per day. In February 1971 he complained of double vision, tearing of his eyes and limitation of upward gaze on the left, and in September 1971 he stopped the thyroid medicine because of worsening eye symptoms, nervousness and fatigue. In December 1971 proptosis measured 20 mm bilaterally. The eye symptoms subsided over the next 18 months and he remained euthyroid with no medications being given. Serum T4 iodine was 5.4 Mg per dl (normal 2.9 to 6.5) in December 1971 and 5.7 Mug per dl in March 1972, six months after thyroid therapy was discontinued. Thyroid radioiodine uptake was 8 percent at six hours (normal 5 percent to 25 percent) and 22 percent at 24 hours (normal 10 percent to 40 percent) in March 1972. In August 1973 the patient reported a twomonth history of nervousness, tremor, palpitations, weakness, easy fatigability and a 20-pound weight loss. On examination the patient was noted to be thin and nervous with a pulse of 110 beats
CASE REPORTS
per minute, fine tremor, lid lag, mild chemosis, and restricted extraocular movement with diplopia on upward and lateral gaze bilaterally. Proptosis measured 17 mm in the left eye and 15 mm in the right eye. There were proximal muscle weakness and hyperactive reflexes. The thyroid gland was minimally enlarged, nontender, and firm without nodules. Pretibial dermopathy was not TABLE 1.-Tests of Antithyrold Antibodies Date
9-10-73 ...... 10-5-73 ...... 10-11-73 ..... 12-3-73 ...... 12-14-73 ..... 12-18-73 ..... 1-4-74 ....... 3-19-74 ...... 3-29-74 ......
TRC-Tg
Graves Hyperthyroidism Following Myxedema in a Patient With Recurrent Carcinoma of the Colon GERALD A. LEVINE, MD DONALD E. WILLIAMS, MD JEROME M. HERSHMAN, MD, GILDON N. BEALL, MD Los Angeles CHRONIC LYMPHOCYTIC THYROIDITIS (Hashimoto thyroiditis) has been increasing in frequency in the United States and now is the most frequently seen thyroid disorder, probably accounting for most instances of idiopathic acquired hypothyroidism." Hypothyroidism following hyperthyroidism is not unusual, but the reverse situation, that of hyperthyroidism following hypothyroidism, is rare. We report a case we have followed during transition from idiopathic hypothyroidism to Graves disease with hyperthyroidism to a euthyroid state over a seven year period. The relationship of the development of hyperthyroidism in this man to recurrent carcinoma of the colon is also of interest. Report of a Case In a 58-year-old white man hyperthyroidism developed in 1973, four years after well-documented hypothyroidism. His illness began in 1969 with a six-month history of easy fatigability, weakness, stiffness and cramping of his muscles, and a 25-pound weight gain. He had not received goitroFrom the Endocrine Section, Medical and Research Services Veterans Administration Wadsworth Hospital Center, Los Angeles; Harbor General Hospital, Torrance, and Department of Medicine, University of California, Los Angeles, Center for the Health Sciences. Submitted, revised, June 20, 1977. Supported in part by the Medical Research Service of the Veterans Administration and USPHS Grant HD-7181. Reprint requests to: Jerome M. Hershman, MD, Endocrine Section, VA Wadsworth Hospital Center, Los Angeles, CA 90073.
240
MARCH 1978 * 128 * 3
genic drugs or iodine. There was no family history of thyroid disease; one of seven siblings died of stomach cancer and another of an unknown type of cancer. On physical examination, the pulse was 75 beats per minute and blood pressure was 110/85 mm of mercury. Dry skin, puffiness around the eyes, delayed relaxation of the deep tendon reflexes, and swelling, induration and non-pitting edema of the muscles were noted. The thyroid was not enlarged or tender and was of normal consistency. Figure 1 depicts the serum thyroxine (T4) values over a seven-year period. Initially the proteinbound iodine (PBI) was 2.0 jug per dl with two repeat values of 1.9 ug per dl, and a T3 resin uptake was 22.4 percent (hypothyroid range). Thyroid radioiodine uptake was 2 percent at 6 hours and 0 at 24 hours. Serum cholesterol was 330 mg per dl, and creatine phosphokinase was 17 sigma units (normal 0 to 12). An electrocardiogram showed low voltage of T waves in I, V5 and V6. To obtain faster improvement of his myopathy, the patient was treated with triiodothyronine (CytomelP), 75 Mug per day for eight days, along with desiccated thyroid, 180 mg per day; within ten days he noted pronounced improvement and lost 10 pounds. He remained euthyroid on 180 mg of desiccated thyroid per day. In February 1971 he complained of double vision, tearing of his eyes and limitation of upward gaze on the left, and in September 1971 he stopped the thyroid medicine because of worsening eye symptoms, nervousness and fatigue. In December 1971 proptosis measured 20 mm bilaterally. The eye symptoms subsided over the next 18 months and he remained euthyroid with no medications being given. Serum T4 iodine was 5.4 Mg per dl (normal 2.9 to 6.5) in December 1971 and 5.7 Mug per dl in March 1972, six months after thyroid therapy was discontinued. Thyroid radioiodine uptake was 8 percent at six hours (normal 5 percent to 25 percent) and 22 percent at 24 hours (normal 10 percent to 40 percent) in March 1972. In August 1973 the patient reported a twomonth history of nervousness, tremor, palpitations, weakness, easy fatigability and a 20-pound weight loss. On examination the patient was noted to be thin and nervous with a pulse of 110 beats
CASE REPORTS
per minute, fine tremor, lid lag, mild chemosis, and restricted extraocular movement with diplopia on upward and lateral gaze bilaterally. Proptosis measured 17 mm in the left eye and 15 mm in the right eye. There were proximal muscle weakness and hyperactive reflexes. The thyroid gland was minimally enlarged, nontender, and firm without nodules. Pretibial dermopathy was not TABLE 1.-Tests of Antithyrold Antibodies Date
9-10-73 ...... 10-5-73 ...... 10-11-73 ..... 12-3-73 ...... 12-14-73 ..... 12-18-73 ..... 1-4-74 ....... 3-19-74 ...... 3-29-74 ......
TRC-Tg
