A 35 Year Old Woman With Weight Loss And Protruding Eyes

A 35 year old woman comes to the clinic with the complains of 15 lb weight loss over the past 2 months, despite a good appetite, as well as difficulty sleeping, palpitations and feeling anxious all the time. She says she feels hot although it is cold weather nowadays. On examination her pulse was 112 beats per minute and she was noticed to have protruding eyes. The photo taken in the clinic is shown below:

Her palms were sweaty and she had a fine tremor in her hands.

What workup will you advice for the suspected diagnosis?

• TSH
• Serum free T4
• Serum electrolytes
• Complete blood count
• Urine toxicology

What is the Diagnosis?

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Hyperthroidism with Graves Opthalmopathy. 

Case Discussion:

• Hyperthyroidism or overactive thyroid is a condition in which the thyroid gland produces excess hormone thyroxine.
• The excess hormone in the body leads to hyperactive body metabolism.
• Patients usually present with symptoms of weight loss. increased appetite, rapid heart beat, sweating, anxiety, increased sensitivity to heat, difficulty sleeping, diarrhea, menstrual problems, fine brittle hair, fatigue, etc. 

Graves Opthalmopathy is an uncommon problem that effects the eyes. The eye balls protrude beyond their normal protective orbits when the tissues and the muscles behind the eyes swell up. This pushes the eye balls forward so far that they actually bulge out of the orbits. This leads to dryness of the eye, excessive tearing and discomfort in the eyes as well as redness.

Diagnosis:
Along with the clinical history and physical examination following tests helps in diagnosis:

• Decreased TSH
• Increased serum T3 and T4 
• Antithyroid antibodies are increased in Graves disease. 

Treatment:

Excess thyroid hormone production can be suppressed by:

1. Radioactive Iodide treatment: 

2. Antithyroid medications: Methimazole, proplythyouracil

3. Surgery