title: A patient with stress-related onset and exacerbations of Graves disease.
abstract: BACKGROUND
  An 18-year-old, nonsmoking woman presented to her general practitioner with a 1-week history of weakness, fatigue, palpitations, nervousness, tremors, insomnia, heat intolerance, and sudden enlargement of a thyroid goiter that had been detected 2 years earlier. The patient's symptoms had started shortly after she experienced emotional stress. Diagnostic work-up disclosed an avid radioactive iodine uptake by the goiter. On ultrasound examination, the thyroid gland was enlarged with a diffusely hypoechogenic structure and intense vascularization.
  
  
  METHODS
  Thyroid scintigraphy with (131)I; ultrasonography of the thyroid gland; and measurements of serum free T(3), free T(4), TSH levels and thyroid autoantibodies, including autoantibodies against thyroglobulin (TgAb), thyroperoxidase (TPOAb) and TSH receptor (TRAb).
  
  
  METHODS
  Graves disease, with stress-related onset and subsequent stress-related exacerbations.
  
  
  RESULTS
  The patient was treated with methimazole to normalize levels of thyroid hormone and thyroid autoantibodies, and with bromazepam to help her cope with stress. The daily dose of methimazole was kept low during pregnancy. Over the 4 year period when the patient was taking methimazole, exacerbations of hyperthyroidism occurred twice: during her first pregnancy and 9 months after her first delivery. On all three occasions, symptoms were preceded by stressful life events. Further exacerbations were avoided by starting bromazepam treatment soon after the patient experienced stressful events.
authors.affiliation: Department of Pathology and Experimental Microbiology, University of Messina, Messina, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Vita
authors.forename: Daniela
authors.initials: D
authors.lastname: Lapa
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Vita
authors.forename: Francesco
authors.initials: F
authors.lastname: Trimarchi
authors.forename: Salvatore
authors.initials: S
authors.lastname: Benvenga
mesh_terms: D000293:Adolescent; D005260:Female; D006111:Graves Disease / Q000175:diagnosis* / Q000378:metabolism / Q000473:pathology*; D006801:Humans; D006980:Hyperthyroidism / Q000175:diagnosis / Q000378:metabolism / Q000473:pathology; D013315:Stress, Psychological / Q000503:physiopathology*