Occupational Stress and its Relation to Grave’s Disease

Background: Graves’ disease is an autoimmune thyroid gland disease that causes increased activity of the thyroid hormones. But, the mechanism by which the autoantibodies are generated is still unclear. Some theory suggests that daily life stress may be a risk factor that triggers Graves’ disease. The aim of this report is to enrol a systematically searching in order to get an answer about the risk factor of the Grave’s disease and the prevention measure.Methods: In this case report, a 47-year-old career woman with prominent occupational stress was diagnosed with Graves’ disease. Literature searching was done on database such as Pubmed, Cochrane Library, and Science Direct with occupational stress, stressful life event, and Graves’ disease as the keywords. One article was selected and critically appraised. Results: One case-control study showed that patients with Graves’ disease had odds ratio (OR) of having stressful life events as big as 8.59; 95%CI = 2.35-20.80, and the number needed to harm (NNH) is 2.35.Conclusion: Occupational stress is a prominent risk factor for developing Graves’ disease. However, this is based on one article

Helena

This chapter describes Helena Schilizzi, a London-based member of the widespread and prosperous Schilizzi family, who met Venizelos during the peace negotiations of late 1912-1913 and became devoted to him. It is based in part on her memoir A l'Ombre de Veniselos. The Schilizzis originated in the Byzantine empire, spread to Chios and later to London and other European cities. Helena, troubled for a period by Grave's disease, came across Venizelos by reading his 1910 speech in Athens, and was captivated. She took every opportunity to get close to him, starting with his contacts with the London Greek community during the peace negotiations. She realized that the way to attach herself to him was to devote herself to the cause of Greece. With her money she was able to do so.

Hyperthyroidism Times 2: Dual Cause of Thyroid Hormone Excess

The most common etiology of Hyperthyroidism is due to circulating antibodies that are directed against the thyroid-stimulating hormone (TSH) receptor, known as Grave’s Disease (GD). Another cause is an autonomously functioning thyroid nodule over-producing hormones or Toxic Adenoma. The mechanism of these two pathologies are very distinct, but the question that arises is, can they coexist? This is a case of 44-year-old female who comes to the clinic referred by her ophthalmologist after been diagnosed with severe thyroid-associated orbitopathy currently on steroid therapy. Thyroid ultrasound has done previously showed enlarged homogenous thyroid gland with a single isoechoic nodule of 2.2x1.6x1.9cm with faint peripheral calcifications and vascularity. The patient was presenting with palpitations, heat intolerance, sweating, and discriminatory features such as double vision and left eye exophthalmos. On physical examination, there was no goiter or palpable thyroid nodules, but it was remarkable for left eyelid lag retraction and mild proptosis. Evaluation showed clinical and biochemical hyperthyroidism with TSH: 0.068 mU/ml (n:0.5-5.0mU/ml), FT4: 1.39ng/dl (n:0.87-1.85ng/dl), TSH receptor antibody: <1.10IU/L and thyroid-stimulating immunoglobulin: 0.54IU/L (borderline high). The patient was placed in antithyroid drugs and B-blockers for disease control. Afterward, the patient underwent a thyroid uptake scan reporting toxic adenoma on the left lobe, however even when the biochemical workup of GD is inconclusive, patient clinical findings are highly suggestive of it. Due to the risk of worsening orbitopathy with radioactive iodine therapy, patient was referred for surgical excision of toxic adenoma and total thyroidectomy was decided since residual thyroid tissue may expose the patient to circulating thyroid-stimulating immunoglobulin leading to hyperthyroidism recurrence and put her at risk of associated thyroid excess detrimental complications. Surgical specimen gross pathology biopsy reported the thyroid gland with hyperplastic changes of Grave’s Disease. Severe thyroid-associated orbitopathy was managed with decompression surgery but did not improve, for which an alternative therapeutic approach is decided with novel immunomodulatory agent and recent approved therapy, Teprotumumab. A monoclonal antibody that works on TSHR/IGF-1R signaling complex involved in Thyroid Eye Disease. Is unusual to see two different superimposing thyroid pathologies, but disease presentations can be atypical and can be present concomitantly. In this scenario, several factors must be taken into consideration when choosing an adequate therapy approach. Our case is an example that we need to individualize management options based on guidelines recommendations, patient’s clinical settings and decreased risks of future complications.