Classic Grave’s hyperthyroidism with anterior mediastinal mass

Stimulating discussion at Intern Report of a case of classic Grave’s hyperthyroidism. 21 yo F presenting with 40 lbs weight loss, palpitation, SOB/DOE, neck swelling, diarrhea, irregular menses for 6 months. On further evaluation was found to be hyperthyroid per labs and diagnosed with Grave’s disease (TSI/ thyroid stimulating immunoglobulins- elevated). She was also found to have an anterior mediastinal mass. She was started on beta blockers and methimazole and discharged with outpatient follow up appointments.

Take home points:

– when suspecting Grave’s hyperthyroidism, evaluate for ophthalmopathy as this can change management (requires pre treatment with steroids if considering radioiodine ablation)

– as per guidelines TSI test is indicated for confirmation of Grave’s disease only for; euthyroid patients with ophthalmopathy and pregnant patients. Otherwise TSI is not needed routinely to confirm diagnosis

– obilteration of retrosternal shadow could be anterior mediastinal mass or RV enlargement. In this patient is possibly thymic hyperplasia (paper stating association between Grave’s and thymic hyperplasia)

– radioiodine ablation has low recurrence rates and lower cost (NEJM review paper on radioiodine for hyperthyroidism)

Also: NEJM review paper on Grave’s.