Graves’ disease, myxedema and papillary thyroid carcinoma

Abstract

Graves’ disease (GD) is the leading cause of hyperthyroidism and diffuse toxic goiter in iodine-sufficient geographical areas. GD is associated with classical manifestations such as ophthalmopathy and thyroid dermopathy, in addition to diffuse goiter, which may be the site of carcinomas, as a complication. Case report: A 52-year-old woman
presented with goiter and symptoms compatible with hyperthyroidism, such as heat intolerance, weight loss, fatigue, increased sweat, tachycardia, fine tremors, increased intestinal transit, anxiety, emotional lability, insomnia, exophthalmos, and pretibial myxedema. A complementary investigation confirmed the diagnosis of hyperthyroidism
(high free T4 and total T3 levels and low thyroid-stimulating hormone - TSH levels). Ultrasound images showed diffuse enlargement of the thyroid lobes by approximately 10 times and the presence of three thyroid nodules, one of which was larger than 2 cm with heterogeneous echogenicity and vascularization throughout the nodule; ultrasound-
guided fine needle aspiration revealed cytology compatible with Bethesda IV; scintigraphy revealed a low uptake area (cold nodule) amid a diffuse high-uptake goiter. A thyroidectomy was performed, and the anatomical specimen diagnosis revealed papillary thyroid carcinoma in the right lobe, with adjacent parenchyma compatible with GD.
Histopathological examination of the skin showed the presence of myxedema compatible with Graves’ dermopathy. The patient evolved with the normalization of TSH levels and a reduction of cutaneous manifestations. Conclusion: GD abnormalities may not be restricted to the classic clinical manifestations, and a careful investigation may reveal the coexistence of carcinomas.