Working Diagnosis:
Graves' Disease

Treatment:
The patient was prescribed metoprolol for tachycardia, which made him especially fatigued during training. Leukopenia made this patient a poor candidate for methimazole, as it is a mild immunosuppressant. As a result, radioactive iodine (RAI) was recommended. On follow-up two months after the patient received RAI, T4 levels were elevated (2.8) and TSH was low (0.01). When his T4 levels normalize, he will be started on levothyroxine.

Outcome:
The patient returned home the day of the radioablation, and was informed of the need for good radiation hygiene. He was advised to avoid sweating for 48 hours, and avoid close contact with other people for at least 4 days. He began feeling better after RAI and resumed physical activity by weight-lifting and jogging over the next 4 to 6 weeks. The patient has puffiness around his eyes, and occasionally becomes short of breath and nauseous with intense exercise. The patient was advised on the expected outcome of hypothyroidism that will require lifelong hormone replacement and periodic monitoring of TSH levels.

Author's Comments:
This case demonstrates the importance of the team physician in the care of the student athlete. It would be easy to assume that the patient had an acute GI condition. However, the key finding was the loss of weight despite increasing appetite. Common primary care findings may present slightly different in the athletic population and that is why we chose to present this case. This patient was able to be treated and returned to collegiate sports.

Editor's Comments:
Graves' disease is an autoimmune disease cause by thyrotropin receptor antibodies causing hyperthyroidism. In addition to hyperthyroidism, Graves' disease can also cause proptosis (orbitopathy) and pretibial myxedema. Graves' disease is the most common form of hyperthyroidism. Risk factors for Graves' disease includes genetic susceptibility, female sex, certain infections (hepatitis C), stress, smoking, iodine containing drugs such as amiodarone and CT contrast, Interferon alfa, and aletuzumab.
Treatment includes beta blockers for symptoms management (tachycardia), antithyroid drugs (thionamides), radioiodine, and surgery. Medication can result in permanent remission, but greater chance of permanent remission with radioiodine or surgery. Medication side effects include arthralgias, gastrointestinal symptoms, agranulocytosis, vasculitis, hepatitis. Surgery risks include iatrogenic hypoparathyroidism, recurrent laryngeal nerve injury, and permanent hypothyroidism. Radioiodine also produces permanent hypothyroidism and risks include rare radiation thyroiditis and worsening of Graves' ophthalmopathy. In addition, radioiodine requires a period of isolation usually 48 hours.
This case highlights the importance of taking a full history as the report of trouble with weight gain could direct to the correct diagnosis. Graves' disease increases after puberty, so can be seen in young athletes.

References:
1.Ross DS, Burch HB, Cooper DS, et al. 2016 American Thyroid Association Guidelines for Diagnosis and Management of Hyperthyroidism and Other Causes of Thyrotoxicosis. Thyroid 2016; 26:1343.
2.Ross DS. Radioiodine therapy for hyperthyroidism. N Engl J Med 2011; 364:542.

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