Carbimazole-Resistant Grave’s Thyrotoxicosis is a Diagnostic and Therapeutic Dilemma, Case Report with Literature Review

Fateen Ata,1 Adeel Ahmad Khan,1 Shuja Tahir,2 Zaina Al Amer1 1Department of Endocrinology, Hamad Medical Corporation, Doha, Qatar; 2Department of Cardiothoracic Surgery, St James’s Hospital, Dublin, IrelandCorrespondence: Fateen AtaDepartment of Endocrinology, Hamad General Hospital, Hamad Medical Corporation, Doha, 3050, Qatar, Tel +974 66055176, Email docfateenata@gmail.com; FAta@hamad.qaBackground: Carbimazole (CBZ) (or methimazole) is the most used drug inducing and maintaining remission in thyrotoxicosis, especially Grave’s disease (GD). Rarely, situations arise when patients do not respond to recommended or even supratherapeutic doses of CBZ. It poses a challenge to diagnose drug resistance and ultimately manage hyperthyroidism, which can otherwise be fatal if left untreated. Propylthiouracil (PTU) has been used as an alternative in such patients amid increased side effect risks. Additionally, definitive therapy has been recommended with ablation or surgery. However, the best modality of inducing euthyroidism in drug-resistant patients is yet to be established. On literature search, twenty similar cases were found in the literature search. This study summarizes the past literature with addition of a new case of anti-thyroid drug resistant (ATDR) GD.Case Presentation: A 34-year-old female presented with a 5-day history of progressively worsening fatigue, heat intolerance, sweating, and palpitations. She was diagnosed with GD based on her thyroid function tests (TFTs) and started on CBZ and propranolol. Despite being compliant with CBZ 20 mg once daily and then twice daily, her TFTs remained unchanged for 4 months. However, patient revisited the emergency with continued thyrotoxicosis and unchanged TFTs. Her dose was eventually increased to 20 mg thrice daily, and administration under supervision did not improve her TFTs. The patient was shifted to PTU 150 mg thrice daily with steroids, with minimal improvement. The patient eventually underwent thyroidectomy to avoid long-term PTU use.Conclusion: ATDR GD is rare and remains a diagnostic and therapeutic challenge. Optimal management should focus on carefully excluding other possibilities and shared decision-making in its management. Most patients may require definitive therapy; hence, arrangements should be made timely with simultaneous attempts to reduce the thyrotoxic state, which otherwise poses a continued threat to patients’ life with potentially serious complications.Keywords: carbimazole, propylthiouracil, drug resistance, thyrotoxicosis, Grave’s disease