Int J Thyroidol.  2016 Nov;9(2):190-194. 10.11106/ijt.2016.9.2.190.

A Case of Methimazole-Resistant Severe Graves' Disease: Dramatic Response to Cholestyramine

• Chae SB
• Kim ES
• Lee YI
• Min BR

• KMID: 2362357
• DOI: http://doi.org/10.11106/ijt.2016.9.2.190

Abstract

A 22-year-old woman with severe Graves' disease was referred from a local clinic because of her refractory hyperthyroidism. She presented with exophthalmos, diffuse goiter, and tachycardia. She was treated with a maximal dose of methimazole and a beta-blocker for 2 months. However, her thyroid function test (TFT) did not improve. TFT showed a free T4 level of 74.7 ng/dL and a thyroid stimulating hormone (TSH) level of 0.007 µIU/mL. She was then administered cholestyramine (4 g thrice daily), hydrocortisone (300 mg/day) and methimazole (100 mg/day) which prepared the patient for surgery by reducing the free T4 level (4.7 ng/dL). The patient underwent a total thyroidectomy without experiencing thyrotoxic crisis. This case describes the use of cholestyramine for the first time in Korea in treating Graves' disease and provides limited evidence that cholestyramine can be an effective option.

Keyword

Cholestyramine; Graves' disease; Thyrotoxicosis; Methimazole

MeSH Terms

Cholestyramine Resin*
Exophthalmos
Female
Goiter
Graves Disease*
Humans
Hydrocortisone
Hyperthyroidism
Korea
Methimazole
Tachycardia
Thyroid Crisis
Thyroid Function Tests
Thyroidectomy
Thyrotoxicosis
Thyrotropin
Young Adult
Cholestyramine Resin
Hydrocortisone
Methimazole
Thyrotropin

Figure

• 

  Fig. 1. Patients scintigraphy scan. This shows diffuse enlargement of both lobes of the thyroid gland with increased Tc-99m uptake.

• 

  Fig. 2. Interval change of free T4 level and total T3 level following administration of medications (fT4: free T4, MMI: methimazole).

• 

  Fig. 3. Histopathologic images of the patients thyroid. (A) The postoperative gross image of the patients thyroid gland. Right lobe (7.0×4.0×3.5 cm), left lobe (5.0×5.0×3.0 cm), isthmus (3.0×2.0×1.0 cm) and pyramidal lobe, weighed 78 g in total. (B) Usually histologic findings of the Graves' disease are hyperplastic, and dilated follicles of variable sizes with scalloping of the colloid, but this case showed decreased scalloping of the colloid.

Reference

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