A 28-year-old female was found to have an undetectable TSH level, which was drawn as part of a workup for palpitations. On further questioning, the patient complained of easy fatigability, loss of scalp hair, insomnia, increased irritability, and at times heat intolerance. She also admitted to an unexplained 20-lb weight loss and a feeling as if a mass were pressing on the front of her windpipe. She denied any difficulty with shortness of breath, dysphagia, or dysphonia, and was unaware of any muscle weakness or a change in bowel habits. She had a positive family history of Graves' disease in her mother and one cousin. The patient denied any iodine exposure and had no history of head or neck irradiation. She was on no medications, had no allergies, and her review of systems was unremarkable except for the symptoms listed above.
The patient was in no acute distress, was 5'6" all weighed 252 lbs. Her blood pressure was 170/86 with a large cuff and her pulse 96/minute. Her skin and hair texture appeared normal, however, scalp alopecia was noted. Her eye exam was unrevealing with her OD = 17 mm and OS = 19 mm, with no limitation of extraocular motion, chemosis, conjunctival injection or periorbital edema. Her thyroid gland was diffusely enlarged, normal in consistency, and approximately two times normal size. Her gland was mobile, non tender, non nodular and had no associated cervical adenopathy. On neurologic testing she had a fine tremor of her outstretched hands, normal deep tendon reflexes and muscle strength, and the remainder of her exam was unrevealing.