A 32-year-old female presented with symptoms of low energy level, weight gain, cold intolerance, increased bowel movements, flaking, and itchy scalp in the year 2014. On examination, she was found to have a palpable goiter. Her family history was significant for thyroid disease affecting her sibling. Neck ultrasound demonstrated diffusely enlarged thyroid with mild heterogeneous echotexture and left hypoechoic solid nodule measuring 0.75 cm []. Thyroid function test (TFT) was within the normal limits (TSH: 3.4 μIU/mL and FT4: 1.1 ng/dL; normal laboratory values of TSH 0.350–4.940 uIU/mL and FT4: 0.7–1.5 ng/dL respectively) however, antithyroid peroxidase (1446.0 IU/ml; reference range 0.0–5.6 IU/ml) and Tg antibodies (95.4 IU/ml; reference range 0.0–4.1 IU/ml) were high. A diagnosis of euthyroid Hashimoto's disease was made, and the patient was followed up on ultrasound and TFT.\nIn the year 2016, the patient presented with irritability and anxiety. Repeat ultrasound showed status quo. However, there was a surge in thyroid antibodies and an increase in TSH levels (7.2 μIU/mL). The clinical impression was consistent with Hashimoto's thyroiditis and the patient was started on low-dose thyroxine, which she tolerated well for 3 years. On yearly follow-up, there was a downtrend in thyroid antibodies, TSH returned to normal range, and findings on ultrasound remained stable.\nIn October 2019, the patient presented with syncopal episode. Evaluation of TFT demonstrated low TSH of 0.003 μIU/mL and raised FT4 of 2.4 ng/dL. The patient was asked to stop thyroxine tablets and to repeat TFTs in 4 weeks. Repeat TSH was <0.002 μIU/mL and FT4 of 2.6 ng/dL. I-123 thyroid uptake and the scan was performed, which demonstrated findings consistent with Graves' disease [] with 24 h uptake of 63.6% (normal range 10%–25%). The patient was subsequently treated with 15.9 mCi of radioiodine (I-131). Follow-up in 6 weeks of radioiodine therapy, the patient was clinically stable.
A 36 years old female presented with a 3 months history of easy fatigability, cold intolerance, polymenorrhagia, constipation and weight gain in the beginning of year 2005. On examination she had bradycardia and dry skin. The thyroid gland was palpable, non-tender mostly diffuse but some nodular feeling at upper pole of left lobe. Clinical suspicion of primary hypothyroidism was made and it was confirmed by TSH value of greater than 50 uIU/ml with FT4 of less than 0.30 ng/dl and positive thyroid antibodies. Thyroxine was started at a dose of 100 mcg/day. Gradually the requirement of thyroxine decreased and by the end of 2005 onwards she maintained her TSH within normal range on 50 mcg/day of thyroxine. In the beginning of 2008 the dose was further reduced to 25 mcg/day but again towards the end of 2009 thyroxine dose was increased to 50 mcg/day because of slightly increased TSH of 8.86 uIU/ml. Slightly more than a year later in the beginning of 2011, she presented with weight loss of 3 kg with a feeling of anxiety and associated tremors of hands. TSH at this time was less than 0.005 uIU/ml with a FT4 of 2.4 ng/dl, confirming the state of thyrotoxicosis. Thyroxine was stopped and patient was observed intermittently over a period of 6 months. She remained clinically and biochemically hyperthyroid with a repeat TSH of <0.005 uIU/ml and an FT4 of 2.66 ng/dl. Thyroid scintigraphy with technetium 99 was done and it showed an increased homogenous tracer uptake. Finally she was started on Neomercazole in mid of 2011and remains on it till to date.