Thyroidectomy in Graves’ Disease With Unusually 4-Fold High Thyroid Hormone Levels: Clinical Challenges and Management
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This report describes the successful management of a 20-year-old woman with Graves’ disease (GD) who presented with extremely elevated thyroid hormone levels (free T4 up to 9.5 pg/mL, over 5-fold the upper limit of normal) and was resistant to conventional medical therapy. Due to severe Graves’ ophthalmopathy, radioactive iodine therapy was contraindicated. Despite high-dose methimazole, her condition worsened. A rapid and intensive multidisciplinary preoperative protocol was implemented, incorporating 3 sessions of plasmapheresis (PP) and combined with inorganic iodine, corticosteroids, and beta-blockers. This regimen dramatically reduced free T4 levels by over 65% within 6 days, bridging the patient to surgery. Emergent total thyroidectomy was safely performed without intra- or postoperative complications, such as a thyroid storm. This case suggests that emergent thyroidectomy, facilitated by aggressive hormonal control via PP, is a viable life-saving strategy for selected patients with severe, drug resistant GD who are ineligible for other definitive therapies.
Abstract
This report describes the successful management of a 20-year-old woman with Graves’ disease (GD) who presented with extremely elevated thyroid hormone levels (free T4 up to 9.5 pg/mL, over 5-fold the upper limit of normal) and was resistant to conventional medical therapy. Due to severe Graves’ ophthalmopathy, radioactive iodine therapy was contraindicated. Despite high-dose methimazole, her condition worsened. A rapid and intensive multidisciplinary preoperative protocol was implemented, incorporating 3 sessions of plasmapheresis (PP) and combined with inorganic iodine, corticosteroids, and beta-blockers. This regimen dramatically reduced free T4 levels by over 65% within 6 days, bridging the patient to surgery. Emergent total thyroidectomy was safely performed without intra- or postoperative complications, such as a thyroid storm. This case suggests that emergent thyroidectomy, facilitated by aggressive hormonal control via PP, is a viable life-saving strategy for selected patients with severe, drug resistant GD who are ineligible for other definitive therapies.