BACKGROUND: Graves\' disease (GD) is an autoimmune disorder affecting the thyroid gland, leading to systemic manifestations such as hyperthyroidism, Graves\' orbitopathy, and pretibial myxedema. Contrary to previous beliefs that hyperthyroidism protects against thyroid cancer, recent studies reveal an increased incidence of thyroid malignancies in GD patients, particularly differentiated thyroid carcinomas and, in rare cases, medullary thyroid carcinoma (MTC).
METHODS: This case series presents three female GD patients diagnosed with MTC, highlighting the complexities of diagnosis and management. All patients exhibited thyroid nodules with suspicious ultrasonographic features, elevated plasma calcitonin levels, and required total thyroidectomy. Histological examination confirmed MTC.
CONCLUSIONS: These cases underscore the importance of routine calcitonin screening in GD patients with thyroid nodules to facilitate early detection and improve prognosis. Our findings suggest that while the coexistence of GD and MTC is likely incidental, vigilant monitoring and comprehensive evaluation are crucial for timely intervention.
CONCLUSIONS: This study advocates for integrating calcitonin testing into the standard diagnostic protocol for GD patients presenting with thyroid abnormalities.

Orbital radiotherapy for Graves\' ophthalmopathy is an example of non-oncological radiotherapy. First introduced in the 1930s, this treatment has become widely used since the 1980s with several studies showing proof of both effectiveness and safety: a decrease of soft tissue involvement in 70 to 80% of patients and an improvement of ocular mobility in 30 to 80% of patients. Nowadays, it\'s one of the second line treatment options recognized by the European Group on Graves\' orbitopathy in the management of a moderate to severe and active disease after failure of glucocorticoids. In that setting, orbital radiotherapy should be combined with glucocorticoids. To our knowledge, there are no practical recommendations on how orbital radiotherapy should be planned and conducted for Graves\' ophthalmopathy. Optimal dose is not defined however the most frequent regimen consists of 20Gy in ten fractions of 2Gy, though other options may yield better results. Lastly, the use of modern technique of radiotherapy such as intensity-modulated radiation therapy may allow a better sparing of organs at risk compared to three-dimensional radiotherapy using lateral opposing fields.

OBJECTIVE: This meta-analysis aims to analyze the relationship between serum vitamin D (VD) levels and Graves\' disease (GD).
METHODS: We conducted a search for publications on VD and GD in the English language. Our search encompassed databases such as PubMed, Embase, Web of Science, and the Cochrane Library, covering publications available through August 2023. A meta-analysis was performed using Cochrane RevMan 5.4 software. The standardized mean difference (SMD) and 95% confidence interval (CI) were used for outcome calculation. We used R software to test for publication bias.
RESULTS: Twelve studies were selected, comprising 937 (22.4%) cases with GD and 3254 (77.6%) controls. The overall meta-analysis revealed that patients with GD are significantly more likely to have low VD levels (SMD = - 0.66; 95% CI: -1.05, - 0.27; p = 0.001) than those in the control group. Egger\'s test results indicated no publication bias (p = 0.0791). These studies exhibited a high degree of heterogeneity (chi-square = 205.86, p < 0.00001; I2 = 95%). Subgroup analysis was conducted based on assay method, geographic location, and mean age of the case group to explore the heterogeneity sources. Assay methods and geographic locations were identified as potential heterogeneity sources. Based on the mean age, there were no statistically significant differences found in the subgroup analysis of the included studies.
CONCLUSIONS: There is promising evidence that low serum VD levels may increase the risk of GD. Further rigorous and long-term trials are needed to explore the role of VD in the onset and treatment of GD.

UNASSIGNED: Thyrotoxicosis is not uncommon after immunization. It is known as \'autoimmune/autoinflammatory syndrome by adjuvants (ASIA syndrome)\' and is caused by immunological reaction to adjuvants. However, there is insufficient information on thyrotoxicosis after COVID-19 vaccination in the Indian subcontinent.
UNASSIGNED: To investigate the spectrum of thyrotoxicosis after COVID-19 immunization.
UNASSIGNED: A single-centre retrospective study was conducted at a tertiary care academic institute in India.
UNASSIGNED: We studied the clinical symptoms, biochemical markers, imaging characteristics and treatment of every patient who was diagnosed with thyrotoxicosis within 60 days of receiving the COVID-19 vaccine.
UNASSIGNED: Following COVID-19 vaccination, we diagnosed ten people (mean age 39.9 years, range 22-63 years) with thyrotoxicosis [Graves\' disease (GD, n-6) and subacute thyroiditis (SAT, n-4)]. The typical duration for symptoms to appear was 2 to 60 days. The majority of patients (n-9) received the COVISHIELD™ vaccine, whereas only one received the COVAXIN® vaccine. After vaccination, two patients with GD developed mildly severe Graves\' orbitopathy, with symptoms emerging two days and sixty days later, respectively. Anti-thyroid drugs (methimazole or carbimazole) were required for all GD patients. All SAT patients were treated conservatively with nonsteroidal anti-inflammatory medications and had positive outcomes.
UNASSIGNED: SAT, GD and GO may occur as a manifestation of ASIA syndrome, following immunization with COVISHIELD™ and COVAXIN®. Despite the obvious benefits of the COVID-19 vaccine, clinicians should be aware of any potential autoimmune and inflammatory thyroid problems.

Recurrent Graves\' disease due to regrowth of thyroid tissue is a rare complication of near-total thyroidectomy, which can be challenging to recognize and manage. Here, we present the case of a 30-year-old woman with Graves\' disease and thyroid eye disease who underwent near-total thyroidectomy with resultant hypothyroidism. Her levothyroxine dose requirement gradually decreased and thyroglobulin level increased, which led to the diagnosis of recurrent Graves\' disease. A neck ultrasound showed regrowth of thyroid tissue. The treatment options in such cases are repeat thyroid surgery and radioactive iodine ablation. The patient had moderate-severe active thyroid eye disease, so radioactive iodine ablation was contraindicated. Repeat surgery was deemed high risk due to the location of the residual thyroid tissue near the recurrent laryngeal nerve. Watchful waiting with serial thyrotropin (TSH) receptor antibody monitoring was chosen, and her levothyroxine dose was adjusted based on her thyroid function tests. There was a normalization of her TSH receptor antibody level over the next two and half years and stabilization of levothyroxine dose requirement. Recurrent Graves\' disease must be considered when there is an ongoing decrease in the levothyroxine dose requirement associated with a rise in the serum thyroglobulin level following near-total thyroidectomy. Conservative management with medical therapy can induce remission in the case of recurrent Graves\' disease following near-total thyroidectomy, without the need for radioactive iodine ablation or repeat thyroid surgery.

BACKGROUND: Coexistence of TSH-secreting pituitary adenoma (TSHoma) and Graves\' disease (GD) is rare and complicates the management decision.
METHODS: We present a case of the co-existence of TSHoma and GD. In addition, we systematically searched articles describing TSHoma and GD in the same patient published until 20th March 2023, using Pubmed, Scopus and Embase.
METHODS: A 46-year-old man presented with symptoms of thyrotoxicosis. His thyroid function tests showed serum TSH 3.35 (reference range 0.3-4.2) mIU/L, FT3 19.7 (3.7-6.4) pmol/L, and FT4 68.9 (11-23.3) pmol/L. The serum TSH receptor antibody was 11.5 mIU/L (positive at ≥ 1.75 mIU/L). Pituitary magnetic resonance imaging showed macroadenoma compressing the optic chiasm. The patient underwent trans-sphenoidal resection of pituitary adenoma. Postoperatively, he remained on maintenance carbimazole and octreotide.
RESULTS: Fourteen articles comprising 15 patients were identified from the systemic search. A total of 16 patients (including the current case) were included in the systematic review. The mean (± SD) age at diagnosis was 41 ± 13.6 years. The majority were females (75%). The median (IQR) TSH was 1.95 (0.12-5.5) mIU/L, the median (IQR) free T3 was 11.7 (7.6-19.7) pmol/L and the median (IQR) free T4 level was 47.6 (33.3-64.4) pmol/L. Ten (76.9%) patients had positive TSH receptor antibody levels. 84.6% had pituitary macroadenoma. Pituitary surgery was performed in 12 (75%) patients. At the last follow-up, 4 (25%) patients had complete resolution of symptoms after pituitary surgery, 3 (18.7%) were on maintenance treatment with thionamides for GD, 1 (6.25%) on beta-blockers and 1 (6.25%) on somatostatin analog.
CONCLUSIONS: TSHoma and GD can co-exist, and it is essential to identify this rare association as it can significantly impact treatment strategies.

暂无摘要。

Graves\' ophthalmopathy (GO) affects up to 50% of patients with Graves\' disease (GD) ranging from mild ocular irritation to vision loss. The initial diagnosis is based on clinical findings and laboratory tests. Orbital imaging, such as magnetic resonance imaging (MRI) and computed tomography (CT), is an important tool to assess orbital changes, being also useful for understanding disease progression and surgical planning. In this narrative review, we included 92 studies published from 1979 to 2020 that used either MRI and/or CT to diagnose and investigate GO, proposing new methods and techniques. Most of the methods used still need to be corroborated and validated, and, despite the different methods and approaches for thyroid eye disease (TED) evaluation, there is still a lack of standardization of measurements and outcome reports; therefore, additional studies should be performed to include these methods in clinical practice, facilitating the diagnosis and approach for the treatment of TED.

OBJECTIVE: Thyroid eye disease (TED) is the foremost extrathyroidal manifestation of Graves\' disease (GD). Currently, available treatments do not entirely prevent the long-term consequences of TED and have distinct disadvantages. Therefore, this systematic review explored available evidence regarding the efficacy of statins in preventing and treating TED.
METHODS: Relevant studies investigating statin usage in patients with GD or TED were identified by searching Medline (Pubmed and Ovid), Scopus, Web of Science, ProQuest, and Cochrane Library databases (from the database inception to September 2023). The review was done according to the PRISMA statement. Web searching was done independently by two investigators. Two researchers independently extracted the data, and any disagreement was adjudicated by consensus. Based on the study design, the studies\' quality appraisal was done using the Newcastle-Ottawa Scale (NOS) and Version 2 of the Cochrane risk-of-bias tool (RoB2).
RESULTS: The literature search identified 145 publications, of which four met the inclusion criteria (Three retrospective cohort studies and one randomized clinical trial) and were reviewed in full text. The two retrospective cohort studies demonstrated the beneficial effects of statins on TED in newly diagnosed GD Stein et al. showed that statins, regardless of the type, prevent or delay TED (HR: 0.74 (0.65-0.84)), especially in men or treatment duration of more than one year. Nilsson et al. fascinatingly revealed that at least 60 days of statin usage in the preceding year could decrease the risk of TED development by around 40%. One RCT showed a higher treatment response for active moderate-to-severe TED in patients with hypercholesterolemia who took atorvastatin 20 mg in addition to ivGC for 24 weeks without any increase in serious side effects. The retrospective study revealed that the need for reconstructive surgery was reduced in patients with severe TED who received statin therapy.
CONCLUSIONS: Statin therapy could be a potential adjunctive modality for preventing and treating TED.
BACKGROUND: PROSPERO registration number: CRD42022315522.

Hypokalaemic periodic paralysis (HPP) is an uncommon complication of corticosteroid therapy, which may also be seen in thyrotoxicosis. It was mostly described in the Asian population, and it is rare in other ethnic groups. We present the case of a poorly controlled thyrotoxic Caucasian male with thyroid eye disease (TED) who suffered an acute quadriplegic episode caused by severe hypokalaemia and was admitted to the intensive care unit (ITU) within 24 hours of initiating intravenous methylprednisolone (IVMP) infusion. Once his potassium blood levels were repleted, he completely recovered from the episode. Although HPP is rare in the Caucasian population, it can be precipitated in thyrotoxic patients by systemic steroids. Caution should be exercised when administering IVMP in poorly controlled thyrotoxic patients, and we suggest monitoring the potassium levels at regular intervals with ECG monitoring for at least 24 hours in at-risk individuals.