Autoimmune Thyroiditis Shifting from Hashimoto's Thyroiditis to Graves' Disease

Abstract

In 15-20% of cases, Graves' disease (GD) shifts to Hashimoto's thyroiditis (HT), while the shift from HT to GD is rare. We present a case of a patient in whom HT shifted to GD, along with a literature review. A 50-year-old woman with myxedema was diagnosed with Hashimoto's disease due to hypothyroidism and the presence of antibodies against thyroid peroxidase (TPOAb) and thyroglobulin (TgAb); she also had thyroid stimulating antibodies (TSAb) without any signs of GD. Although thyroid hormone replacement therapy improved her thyroid function, 2 months later, hyperthyroidism appeared and did not improve after discontinuation of the replacement therapy. The patient was diagnosed with GD, which improved with antithyroid agent administration. To date, only 50 cases regarding conversion from HT to GD have been reported. The median age is 44 years (range, 23-82 years), and the median time of conversion is 7 years (range, 0.1-27 years). The male-to-female ratio of HT conversion to GD is 1:9, closer to that of regular GD (1:10) than that of general HT (1:18). All patients received thyroid hormone replacement therapy for hypothyroidism due to HT. Continuous evaluation of TSAb levels is recommended in HT, particularly in cases of TSAb-positive and those under replacement, since it may help predict conversion to GD. Evaluating the clinical characteristics of patients with HT preceding GD is crucial to ensure appropriate treatment and reduce the risk of adverse events.

Keywords: Graves’ disease; Hashimoto thyroiditis; autoimmune disease; thyroid antibodies.

Figure 1

Thyroid US at the onset of GD. The right lobe in the sagittal view shows normal echogenicity and mild hypervascularity. The size of the right lobe was 1.18 × 1.31 × 4.32 cm (volume 3.5 cm³) and within normal range.

Figure 2

The image of thyroid gland in 99mTc scan. No remarkable accumulation of 99mTc was observed focally or in the whole thyroid gland. The uptake ratio was 0.76% at 30 min, which was within normal range.