General Surgery · Year 3 · from General Surgery

Case 3: Graves' Disease Requiring Surgery

Patient Demographics

  • Age: 32 years
  • Sex: Female
  • Occupation: Elementary school teacher

Chief Complaint

"I can't control my thyroid with medications and I don't want radioactive iodine."

History of Present Illness

The patient was diagnosed with Graves' disease 18 months ago after presenting with weight loss, palpitations, heat intolerance, and tremor. She was started on methimazole and initially achieved euthyroid state. However, she has had two relapses requiring dose escalation. She developed elevated liver enzymes (AST/ALT 3x normal) on higher dose methimazole, requiring dose reduction. She remains symptomatic with difficulty controlling heart rate. She desires definitive treatment and prefers surgery over radioactive iodine as she is planning pregnancy in the next year.

Past Medical History

  • Graves' disease (18 months)
  • Graves' ophthalmopathy (mild - lid retraction, no proptosis)
  • No other medical problems

Family History

  • Mother: Hypothyroidism
  • Maternal grandmother: "Thyroid problems"

Medications

  • Methimazole 10 mg daily (reduced from 20 mg due to hepatotoxicity)
  • Propranolol 20 mg TID

Physical Examination

  • Vitals: BP 128/70 mmHg, HR 98 bpm (on beta-blocker), fine tremor
  • Eyes: Lid lag present, mild lid retraction, no proptosis, no diplopia
  • Neck:
  • Diffusely enlarged thyroid (approximately 40g)
  • Smooth, non-tender
  • No nodules palpated
  • Audible bruit over thyroid
  • No lymphadenopathy
  • Cardiovascular: Tachycardic, regular rhythm, no murmurs
  • Skin: Warm, moist

Laboratory Results

  • TSH: 0.08 mIU/L (suppressed)
  • Free T4: 2.8 ng/dL (elevated, normal 0.8-1.8)
  • Free T3: 5.2 pg/mL (elevated)
  • TSH receptor antibodies (TRAb): Positive
  • Thyroid peroxidase antibodies: Positive
  • AST: 68 U/L (elevated)
  • ALT: 72 U/L (elevated)

Imaging

Thyroid Ultrasound:

  • Diffusely enlarged thyroid gland
  • Increased vascularity ("thyroid inferno")
  • No discrete nodules
  • Total thyroid volume: 45 mL

Radioiodine Uptake (if performed):

  • Elevated 24-hour uptake consistent with Graves' disease

Treatment Options Discussed

  1. Continue ATDs: Limited by hepatotoxicity, ongoing symptoms
  2. Radioactive iodine: Effective but delays pregnancy 6-12 months, may worsen ophthalmopathy
  3. Total thyroidectomy: Definitive, allows immediate pregnancy planning, appropriate for ophthalmopathy

Patient chose surgery given desire for pregnancy and concern about ophthalmopathy.

Preoperative Preparation

  • Goal: Achieve euthyroid state before surgery
  • Continue low-dose methimazole (10 mg) with liver monitoring
  • Add potassium iodide (SSKI) 5 drops TID starting 10 days before surgery to reduce vascularity
  • Beta-blocker continued
  • Preoperative labs: T4 normalized, liver enzymes stable

Operative Procedure

  • Total thyroidectomy
  • Capsular dissection technique
  • Bilateral recurrent laryngeal nerve identification and preservation
  • All four parathyroid glands identified and preserved in situ
  • One parathyroid inadvertently devascularized - autotransplanted to sternocleidomastoid muscle

Pathology

  • Diffuse thyroid hyperplasia consistent with Graves' disease
  • No malignancy
  • Total thyroid weight: 52 grams

Postoperative Course

  • Voice normal postoperatively
  • POD 1 calcium: 7.8 mg/dL, PTH: 12 pg/mL (low)
  • Symptomatic hypocalcemia (perioral tingling, Chvostek's sign positive)
  • Started on IV calcium gluconate, then oral calcium carbonate 1g TID and calcitriol 0.5 mcg BID
  • Calcium improved to 8.4 mg/dL
  • Started levothyroxine 112 mcg daily
  • Discharged POD 2

Follow-up

  • 2 weeks: Calcium 9.0 mg/dL on supplements, weaning
  • 6 weeks: Off calcium supplements, PTH recovered to 28 pg/mL
  • TSH normalized on levothyroxine
  • Ophthalmopathy stable
  • Cleared for pregnancy planning

Teaching Points

  1. Surgery is preferred for Graves' with ophthalmopathy, large goiter, or pregnancy planning
  2. Preoperative preparation essential: euthyroid state, iodine to reduce vascularity
  3. Total thyroidectomy preferred to lobectomy (lower recurrence)
  4. Transient hypocalcemia common (20-30%); permanent hypoparathyroidism rare (<2%)
  5. RLN injury risk ~1% with experienced surgeon
  6. Lifetime levothyroxine replacement required

Clinical Image

Image Description: Thyroid ultrasound with Doppler imaging demonstrating the "thyroid inferno" pattern characteristic of Graves' disease. The markedly increased blood flow throughout the diffusely enlarged gland creates the characteristic appearance of intense color Doppler signal.

Attribution: Image from Wikimedia Commons. Source: https://commons.wikimedia.org/wiki/Category:Thyroid_nodules

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