From the Guidelines
The increase in TRAb levels to 2.1 despite total thyroidectomy suggests persistent autoimmune activity, and I recommend monitoring the patient closely with regular TRAb measurements and thyroid function tests every 3-6 months. This occurs because thyroidectomy removes the target organ but doesn't eliminate the underlying autoimmune process that produces TRAb 1. The patient's history of severe Graves' ophthalmopathy and previous response to pulse steroids suggests that the autoimmune response is still active.
Some key points to consider in this patient's management include:
- The risk factors for worsening orbitopathy, such as smoking, which should be avoided 1
- The potential for restrictive myopathy, which can cause diplopia and compensatory head posture, impacting visual function and quality of life 1
- The importance of treating thyroid eye disease in a symptom-directed manner, with targeted outcomes including recognition and prevention of primary vision loss, restoration of ocular alignment, reduction of diplopia, and improvement of compensatory head position 1
Given the patient's history and current presentation, consideration of another course of pulse steroids (methylprednisolone 500-1000mg IV for 3 consecutive days) or rituximab (1000mg IV, two doses separated by 2 weeks) to suppress the autoimmune response may be necessary if the ophthalmopathy worsens. Additionally, selenium supplementation (200mcg daily) may help improve mild eye symptoms. For persistent or severe eye symptoms, referral to an ophthalmologist specializing in thyroid eye disease is warranted for consideration of orbital decompression surgery or radiation therapy. The autoimmune nature of Graves' disease means antibodies can persist in circulation for months to years after thyroidectomy, with extrathyroidal tissues like orbital fibroblasts remaining susceptible to TRAb stimulation, explaining the continued ophthalmopathy despite thyroid removal 1.
From the Research
Possible Causes of Increased TRAB
- The increase in TRAB levels despite thyroidectomy could be due to the persistence of autoimmune stimulation, as the underlying autoimmune process is not directly addressed by surgery 2.
- Another possible cause is the presence of residual thyroid tissue, which can continue to produce thyroid hormones and stimulate the production of TRAB 3, 4.
- The increase in TRAB levels could also be related to the patient's immune response, as some patients may continue to produce TRAB even after thyroidectomy 5, 6.
Suggestions for Further Management
- Close monitoring of TRAB levels and thyroid function to assess the effectiveness of treatment and adjust the management plan as needed 3, 4.
- Consideration of targeted immunotherapies, such as rituximab or teprotumumab, to reduce TRAB levels and manage Graves' orbitopathy 5.
- Evaluation of the patient's overall health and adjustment of the treatment plan to minimize the risk of complications, such as hypoparathyroidism or laryngeal nerve damage 3, 4.
- Discussion of the potential benefits and risks of additional treatments, such as radioiodine therapy or antithyroid drugs, to manage the patient's condition 2.