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Case Reports
. 2019 Jul 24;12(2):581-588.
doi: 10.1159/000501714. eCollection 2019 May-Aug.

R-CHOP-Associated Graves' Hyperthyroidism

Natalie Mora  1 , Katherine N Vu  1 , Thanh D Hoang  1 , Vinh Q Mai  1 , Mohamed K M Shakir  1
Affiliations
Case Reports

R-CHOP-Associated Graves' Hyperthyroidism

Natalie Mora et al. Case Rep Oncol. .

Abstract

Radiation-induced thyroid dysfunction following oncologic treatment is not uncommon, however limited literature data has been found on patients that underwent chemotherapy only. A change in thyrometabolic autoimmune status is also a rare entity. We present a case of newly diagnosed Graves' thyrotoxicosis following a successful R-CHOP (Rituximab, Cyclophosphamide, Doxorubicine, Vincristine and Prednisone) treatment in a patient with concurrent abdominal and thyroid diffuse large B-cell lymphoma (DLBCL). Following chemotherapy, PET CT showed resolution of FDG-avid thyroid nodule as well as no evidence of the thyroid mass on repeat ultrasound. Her thyroid function also normalized. During her follow-up visit, patient reported significant unintentional weight loss and persistent fatigue over the past couple months. Repeat laboratory evaluation revealed TSH 0.005 mIU/mL, FT4 6.73 ng/dL and thyroid stimulating immunoglobulin (TSI) 535 (ref <140%). She was started on methimazole followed by radioactive iodine therapy. This unique case of Graves' disease following R-CHOP treatment in patients with known Hashimoto's and thyroid lymphoma is one of the first to be reported in the literature. The swing of pendulum from Hashimoto's to Graves' disease is very uncommon. As clinicians, we need to continue monitoring for clinical and biochemical thyroid dysfunction in this subset of population.

Keywords: Graves' disease; Hashimoto's thyroiditis; Hyperthyroidism; R-CHOP; Rituximab; Thyroid lymphoma.

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Conflict of interest statement

The authors have no multiplicity of interest to disclose. We had published a case report pertaining to the initial presentation of our patient [16]. Different imaging cuts were used in this article. Disclaimer: The views expressed in this article are those of the author and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government.

Figures

Fig. 1
Fig. 1
A Course of the disease, from Hashimoto's thyroiditis (blue) to thyroid lymphoma (green) and then Graves' hyperthyroidism (purple). Hyperthyroidism was treated with methimazole/ I131 and finally the patient developed hypothyroidism (brown) which was treated with levothyroxine. TSH (thyroid stimulating hormone, IU/L, shown in red color), and free T4 (free thyroxine, ng/dL, shown in blue color). B Course of the disease, from Hashimoto's thyroiditis (blue) to thyroid lymphoma (green) and then Graves' hyperthyroidism (purple). Hyperthyroidism was treated with methimazole/ I131 and finally the patient developed hypothyroidism (brown) which was treated with levothyroxine. The X axis shows time (in years) and the Y axis shows the levels of thyroid antibodies: TSI (thyroid-stimulating immunoglobulin, shown in red color), TBRAb (thyroid receptor blocking antibody, blue color), TPO (thyroid peroxidase antibody, black color), TG Ab (thyroglobulin antibody, purple color).
Fig. 2
Fig. 2
A Thyroid ultrasound showing a dominant hypervascular left thyroid mass 5.9 × 2.7 × 4.4 cm. B Fine-needle aspiration biopsy of the left dominant thyroid nodule revealing background small lymphocytes, scattered plasma cells, and neutrophils with rare, large, atypical forms with prominent nucleoli (DiffQuik).
Fig. 3
Fig. 3
A PET/CT of the chest and abdomen revealing a large retroperitoneal and mesenteric soft tissue mass, measuring 16 × 14 cm in greatest trans-axial dimension. The retroperitoneal mass encased the aorta and inferior vena cava as well as mesenteric vessels and both renal arteries. The mass also displaced the kidneys peripherally. B PET-CT scan showing resolution of fluorodeoxy-glucose (FDG) avid thyroid nodule and retroperitoneal mass.
See this image and copyright information in PMC

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