title: A patient with Graves' disease showing only psychiatric symptoms and negativity for both TSH receptor autoantibody and thyroid stimulating antibody.
abstract: BACKGROUND
  Both thyroid stimulating hormone (TSH) and thyroid stimulating antibody (TSAb) negative Graves's disease (GD) is extremely rare. Here we present such a patient.
  
  
  METHODS
  The patient was a 76-year-old woman who was diagnosed as having schizophrenia forty years ago. She did not show characteristic symptoms for hyperthyroidism, such as swelling of thyroid, exophthalmos, tachycardia and tremor, however, she showed only psychomotor agitation. Serum free triiodothyronine and free thyroxine levels were elevated and TSH level was suppressed, suggesting the existence of hyperthyroidism. However, both the first generation TSH receptor autoantibody (TRAb1) and the thyroid stimulating autoantibody (TSAb) were negative. Slightly increased blood flow and swelling was detected by thyroid echography. Thyroid scintigraphy demonstrated diffuse and remarkably elevated uptake of 123I uptake. Finally, we diagnosed her as having GD. She was treated by using methimazole, and hyperthyroidism and her psychiatric symptoms were promptly ameliorated.
  
  
  CONCLUSIONS
  We experienced a patient with GD who did not show characteristic symptoms except for psychiatric symptoms, and also showed negativity for both TRAb1 and TSAb. Thyroid autoantibody-negative GD is extremely rare. Thyroid scintigraphy was useful to diagnose such a patient.
authors.affiliation: Department of Internal Medicine, National Center for Global Health and Medicine Kohnodai Hospital, Chiba, Japan. dyanai@hospk.ncgm.go.jp.
authors.forename: Hidetaka
authors.initials: H
authors.lastname: Hamasaki
authors.forename: Taro
authors.initials: T
authors.lastname: Yoshimi
authors.forename: Hidekatsu
authors.initials: H
authors.lastname: Yanai