Refractory Graves’ Disease with Ophthalmopathy in a 19-year Old Girl Managed Endoscopically: A Case Report

Graves’ disease is an autoimmune disease of the thyroid gland which results from production of thyroid stimulating immunoglobulins-TSI. These thyroid stimulating immunoglobulins bind to the thyroid stimulating hormone-TSH. This leads to overproduction of thyroid hormones, necessitating excessive functions of these hormones in the body. The commonest presentation is features of hyperthyroidism, occasionally with extra thyroidal features. Graves’ disease is rare in children and adolescents, greater numbers are seen in adults, between fifth and sixth decades of life. We report a case of 19-year-old girl who presented with anterior neck swelling of two years, associated with features of hyperthyroidism and ophthalmopathy which were present at onset. Prior to presentation had received anti thyroid treatments with drugs and radioiodine ablation one year ago and refractory to above treatment. Investigations showed raised thyroxine, tri-iodothyronine, reduced thyroid stimulating hormone and markedly raised thyroid antibody. Thyroid ultrasound showed enlargement of both lobes and isthmus with lobulated outlines, echotexture and heterogenous fibrous bands. She was treated by endoscopic total thyroidectomy (Bilateral axillary and breast approach) without postoperative complication and had since remained euthyroid with good cosmetic outcome. She is currently on outpatient follow up. Graves’ disease in teen age with ophtalmopathy is rare, and refractory with medical and RAI therapy. This can be well managed endoscopically in expert hands.