Graves' Disease Following Hypothyroidism Due To Hashimoto's Disease: Studies Of Eight Cases

Abstract

Hashimoto's and Graves' diseases represent the main two types of autoimmune thyroid disease. The combination of these two is well known. However, occurrence of Graves' disease after primary hypothyroidism is rare. We report seven patients with hypothyroidism due to Hashimoto's disease, who developed Graves' disease with hyperthyroidism. We also report one patient with hypothyroidism due to Hashimoto's disease, who continued to be hypothyroid even in the presence of TSAb (thyroid stimulating antibody). These patients were divided into three groups according to the changes in thyroid function and clinical course: (1) transient hyperthyroidism due to Graves' disease following hypothyroidism; (2) persistent hyperthyroidism due to Graves' disease following hypothyroidism; and (3) persistent hypothyroidism with positive TSAb. Such changes in thyroid function and clinical course seem to be decided by three factors: (1) TSAb and (2) TSBAb (thyroid stimulation blocking antibody) activities in the blood and (3) the responsiveness of the thyroid gland to TSAb. Seven patients had hyperthyroidism, when they had TSAb, which stimulated the thyroid gland; one of these seven patients had TSBAb during the hypothyroid state and TSAb during the hyperthyroid state, indicating that the alterations in the thyroid state related to the balance between the activities of TSAB and TSBAb. Another patient continued to be hypothyroid despite the presence of TSAb; his thyroid gland was not palpable and could not respond to TSAb.

Peculiarities of Graves' disease in children and adolescents with Down's syndrome

“…Nevertheless, the development of GD from HT has been only sporadically described until now in DS patients (7) and has been infrequently reported even in individuals without DS (8,9). An immunological mechanism that may be hypothesized to account for a change from HT to GD is alteration in the biological activity of TRABs from predominantly thyroid-blocking antibodies during the hypothyroid phase to thyroid-stimulating antibodies when GD manifests itself (10).…”

Hypothyroidism Preceding Hyperthyroidism in a Patient with Continuously Positive Thyroid Stimulating Antibody.

“…The possibility that the abnormal response of the PIP2 cascade, an alternative index of thyroid stimulation for TSHand TRAb, was somehowchanged could also be considered. Although the detection of TSAbin autoimmune hypothyroidism has been reported to be uncommon(1, 4-7, 22, 18-20, 25-3 1 ), it is important to keep in mind that hypothyroid patients with positive TSAb may quickly develop Graves' hyperthyroidism as discussed in previous reports (1,(4)(5)(6)(7)22) and in the present paper. …”

“…However, there have been few studies in which thyrotropin (TSH) receptor antibody (TRAb) was serially determined during the course of the illness from hypothyroidism to hyperthyroidism (1)(2)(3)(4)(5)(6)(7)(8). The sequential change in TRAbwas observed also in euthyroid subjects who subsequently developed hyperthyroidism due to Graves ' disease (9- 1 1 ).…”

Rapid Transition from Subclinical Hypothyroidism to Hyperthyroidism

“…However, cases of hypothyroidism followed by hyperthyroidism, such as in our patient, have also been described. Takasu et al described eight cases of autoimmune thyroid disease with an alternating pattern of thyroid function [3]. In five cases, hypothyroidism was followed by transient hyperthyroidism.…”