Graves' disease and recurrence in ectopic thyroid tissue after total thyroidectomy

Recurrent Graves' Disease Following Near-Total Thyroidectomy: A Case Report and Literature Review

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.

Recurrent multinodular goitre and primary hyperparathyroidism due to adenoma arising in a parathyroid autotransplant more than 20 years after near-total thyroidectomy

The patient is a female in her 60s with a remote history of a near-total thyroidectomy in 1997 for multinodular goitre. At the initial operation, she sustained a left recurrent laryngeal nerve injury. A devascularised parathyroid gland was autotransplanted into the right sternocleidomastoid muscle. She had been off of thyroid hormone for long periods, and her most recent levothyroxine requirement had fallen to only 25 mcg daily. The patient presented more than 20 years after her thyroidectomy with hoarseness, fatigue and dyspnoea. Laboratory studies suggested primary hyperparathyroidism. Imaging demonstrated bilateral pulmonary emboli and bulky thyroid tissue extending into her mediastinum. She underwent a completion thyroidectomy with the removal of a parathyroid adenoma arising in the autotransplanted parathyroid. This case illustrates the possibility of regrowth of benign thyroid tissue after thyroidectomy. In addition, to our knowledge, this is the first case report of a parathyroid adenoma arising from autotransplantation of a normal parathyroid.