Graves' Disease — MCQs
Preoperative medication of thyrotoxicosis are all except?
A pregnant woman is diagnosed with Graves' disease. The most appropriate therapy for her would be:
A 40F presents with double vision, headaches, and a progressively enlarging thyroid mass. She has proptosis and limited eye movement. TSH is suppressed. Likely cause of her symptoms?
Which antibodies are primarily associated with Graves' disease?
The best marker for hyperthyroidism is
A 32-year-old female patient with Graves' disease with eye signs and enlarged thyroid planned for a total thyroidectomy. What can be given in the preoperative period to reduce intraoperative bleeding in the patient?
Which of the following conditions is the most common complication of radioiodine treatment for Graves' disease?
A 27-year-old woman presents with 26 weeks of gestation with a thyroid lesion which is found to be papillary carcinoma of thyroid. Which is the best treatment for this patient?
Surgical treatment for a 40-years old lady with 3 x 3 cm. papillary carcinoma thyroid with level III enlarged lymph nodes is :
A young adult presents 2 days after trauma to the eye with proptosis and pain in the right eye. On examination, he is found to have a bruise on the right eye and forehead. The most likely diagnosis is:
Graves' Disease Indian Medical PG Practice Questions and MCQs
Question 1: Preoperative medication of thyrotoxicosis are all except?
- A. Carbimazole
- B. PTU
- C. Propranolol
- D. Levothyroxine (Correct Answer)
Explanation: Levothyroxine - Levothyroxine is a synthetic thyroid hormone used to treat hypothyroidism, meaning it increases thyroid hormone levels, which would worsen thyrotoxicosis [1]. - Its administration would be contraindicated in a patient with thyrotoxicosis, as the goal is to reduce thyroid hormone levels preoperatively. Carbimazole - Carbimazole is a thionamide drug that inhibits the synthesis of thyroid hormones, making it a critical medication for treating hyperthyroidism and preparing patients for surgery [1]. - It reduces the amount of thyroid hormone produced by the thyroid gland, thus mitigating the risks associated with thyrotoxicosis during surgery. PTU - Propylthiouracil (PTU), like carbimazole, is a thionamide that blocks thyroid hormone synthesis and also inhibits the conversion of T4 to T3 [1]. - It is used in the preoperative management of thyrotoxicosis to achieve a euthyroid state and prevent a thyroid storm. Propranolol - Propranolol is a beta-blocker used to manage the symptoms of thyrotoxicosis, particularly the cardiovascular effects such as tachycardia, palpitations, and tremors [1]. - While it does not affect thyroid hormone levels directly, it helps control symptoms and stabilize the patient preoperatively, making them a safer candidate for surgery [1].
Question 2: A pregnant woman is diagnosed with Graves' disease. The most appropriate therapy for her would be:
- A. Radioiodine therapy
- B. Total thyroidectomy
- C. Carbimazole parenteral
- D. Propylthiouracil oral (Correct Answer)
Explanation: ***Propylthiouracil oral*** - **Propylthiouracil (PTU)** is the preferred antithyroid drug during the **first trimester** of pregnancy due to a lower risk of teratogenicity compared to methimazole/carbimazole [1]. - It works by inhibiting both the synthesis of thyroid hormones and the peripheral conversion of **T4 to T3**. *Radioiodine therapy* - **Radioactive iodine** is absolutely contraindicated in pregnancy as it can cross the placenta and cause **fetal hypothyroidism or athyreosis**. - It leads to permanent destruction of the thyroid gland and is not suitable for a temporary condition in a pregnant woman. *Total thyroidectomy* - While thyroidectomy can be considered for Graves' disease in pregnancy, it is generally reserved for cases where antithyroid drugs are not tolerated or ineffective, or for very large goiters causing compressive symptoms. - It carries risks associated with **surgery and anesthesia** during pregnancy, and requires **lifelong thyroid hormone replacement**. *Carbimazole parenteral* - **Carbimazole** (which is metabolized to methimazole) is generally avoided in the **first trimester** due to an increased risk of teratogenicity, particularly **aplasia cutis**, omphalocele, and choanal atresia [1]. - While it can be used in the second and third trimesters, **PTU is preferred in the first trimester**, and carbimazole is not typically administered parenterally.
Question 3: A 40F presents with double vision, headaches, and a progressively enlarging thyroid mass. She has proptosis and limited eye movement. TSH is suppressed. Likely cause of her symptoms?
- A. Pituitary adenoma
- B. Orbital cellulitis
- C. Graves' orbitopathy (Correct Answer)
- D. Thyroid carcinoma
Explanation: Graves' orbitopathy - The combination of **proptosis**, **limited eye movement (ophthalmoplegia)** causing double vision, and a suppressed TSH (indicating hyperthyroidism) is highly characteristic of **Graves' disease** with orbital involvement [1]. - An **enlarging thyroid mass** further supports Graves' disease, as it often presents with goiter and hyperthyroidism, leading to the autoimmune sequelae in the orbit [1]. *Pituitary adenoma* - While it can cause **headaches** and **double vision** due to oculomotor nerve compression, a pituitary adenoma would not typically cause a progressively **enlarging thyroid mass** or **proptosis** with suppressed TSH. - Hypersecreting pituitary adenomas (e.g., ACTH, GH) affect other endocrine axes, and non-secreting ones primarily cause mass effect. *Orbital cellulitis* - This is an **acute infection** of the orbital tissues, usually presenting with **pain, fever, rapidly progressing proptosis**, and erythema, which is not suggested by the chronic and progressive nature of this patient's symptoms. - It would not be associated with a suppressed TSH or an enlarged thyroid gland. *Thyroid carcinoma* - A thyroid carcinoma can present as an **enlarging thyroid mass** and may cause local symptoms like dysphagia or hoarseness if advanced, but it does not directly cause **proptosis**, **double vision**, or suppressed TSH. - Although some rare thyroid cancers can metastasize to the orbit, primary presentation with bilateral proptosis and ophthalmoplegia is not typical.
Question 4: Which antibodies are primarily associated with Graves' disease?
- A. TSH receptor antibodies (TRAb) (Correct Answer)
- B. Antinuclear antibodies (ANA)
- C. Thyroid peroxidase antibodies (TPO)
- D. Anti-thyroglobulin antibodies
Explanation: ***TSH receptor antibodies (TRAb)*** - **TRAb** directly stimulate the **TSH receptor** on thyroid follicular cells, leading to excessive thyroid hormone production and the characteristic features of **Graves' disease** [1], [2]. - These antibodies are highly specific for Graves' disease and are used for diagnosis, management, and prediction of remission [1]. *Antinuclear antibodies (ANA)* - **ANA** are associated with various **systemic autoimmune diseases** like lupus and scleroderma, not primarily with Graves' disease. - While ANA can be positive in a small percentage of Graves' patients due to general immune dysregulation, they are not the causative or primary diagnostic antibody. *Thyroid peroxidase antibodies (TPO)* - **TPO antibodies** are primarily associated with **Hashimoto's thyroiditis**, causing thyroid destruction and hypothyroidism. - Although they can be present in Graves' disease, they are not the main pathogenic antibodies responsible for hyperthyroidism. *Anti-thyroglobulin antibodies* - **Anti-thyroglobulin antibodies** are also mainly associated with **Hashimoto's thyroiditis** and other autoimmune thyroid conditions. - They target thyroglobulin, a precursor to thyroid hormones, but do not directly stimulate thyroid hormone synthesis as TRAb do in Graves' disease.
Question 5: The best marker for hyperthyroidism is
- A. T3
- B. T4
- C. TSH (Correct Answer)
- D. Thyroglobulin
Explanation: ***TSH*** - **TSH (Thyroid-Stimulating Hormone)** is the most sensitive and specific initial test for evaluating thyroid function. - In **hyperthyroidism**, the thyroid gland produces excess thyroid hormones (T3 and T4), which suppresses TSH release from the pituitary gland, leading to **very low or undetectable TSH levels**. *T3* - While **elevated T3 levels** are diagnostic of hyperthyroidism, TSH is a more sensitive initial screen. - Some patients, particularly those with **T3 toxicosis**, may have elevated T3 but normal T4. *T4* - **Elevated T4 levels** are a key indicator of hyperthyroidism, but TSH often reflects changes in thyroid hormone status earlier and is more sensitive for screening. - **Free T4** is preferred over total T4 as it is not affected by protein binding changes. *Thyroglobulin* - **Thyroglobulin** is a protein produced by the thyroid gland and is primarily used as a **tumor marker** in patients with differentiated thyroid cancer after thyroidectomy. - It is **not a primary diagnostic marker for hyperthyroidism**, although it can be elevated in conditions causing thyroid destruction or inflammation.
Question 6: A 32-year-old female patient with Graves' disease with eye signs and enlarged thyroid planned for a total thyroidectomy. What can be given in the preoperative period to reduce intraoperative bleeding in the patient?
- A. Propylthiouracil
- B. Potassium iodide (Correct Answer)
- C. Betamethasone
- D. Propranolol
Explanation: ***Potassium iodide*** - **Potassium iodide** (e.g., Lugol's solution) is given preoperatively to patients with Graves' disease undergoing thyroidectomy because it **decreases the vascularity** of the thyroid gland, thereby reducing intraoperative bleeding. - It also helps to **block the release of thyroid hormones** from the thyroid gland, stabilizing the patient's thyroid function. *Propylthiouracil* - **Propylthiouracil (PTU)** is an **antithyroid drug** that prevents the synthesis of thyroid hormones by inhibiting the organification of iodine and the coupling of iodotyrosines. - Although it helps to achieve a **euthyroid state** before surgery, it does not directly reduce the vascularity of the thyroid gland to decrease intraoperative bleeding. *Betamethasone* - **Betamethasone** is a corticosteroid used for its **anti-inflammatory** and immunosuppressive effects. - It is not typically used preoperatively in Graves' disease to reduce thyroid vascularity or bleeding; its primary role might be in managing severe **ophthalmopathy** or thyroid storm, not surgical bleeding. *Propranolol* - **Propranolol** is a **beta-blocker** used to control the adrenergic symptoms of hyperthyroidism, such as **tachycardia**, palpitations, and tremors. - While it helps to achieve a more stable cardiac state for surgery, it does not directly impact the **vascularity** of the thyroid gland or reduce surgical bleeding.
Question 7: Which of the following conditions is the most common complication of radioiodine treatment for Graves' disease?
- A. Hypothyroidism (Correct Answer)
- B. Thyroid cancer
- C. Thyroid storm
- D. Subacute thyroiditis
Explanation: ***Hypothyroidism*** - **Radioiodine (RAI) therapy** destroys overactive thyroid cells, making it highly effective for Graves' disease but often leading to a permanent state of **hypothyroidism** post-treatment. - The goal of RAI is to eliminate the source of excess hormone production, and while effective, it frequently necessitates lifelong **thyroid hormone replacement**. *Thyroid storm* - **Thyroid storm** is a rare, life-threatening complication, usually seen in untreated or undertreated hyperthyroidism or during acute stress, not typically a direct outcome of effective RAI. - While a transient increase in thyroid hormones can occur shortly after RAI, a full-blown thyroid storm is infrequent with proper preparation and management. *Thyroid cancer* - There is no significant evidence to suggest an increased risk of **thyroid cancer** in adults following therapeutic doses of radioiodine for Graves' disease [1]. - The radiation dose is targeted primarily at the thyroid gland, and studies have shown no clear link to increased malignancy [1]. *Subacute thyroiditis* - **Subacute thyroiditis** (also known as de Quervain's thyroiditis) is typically a post-viral inflammatory condition of the thyroid, characterized by pain and tenderness in the thyroid gland [2]. - It does not directly result from radioiodine treatment; however, some patients may experience a transient inflammatory response (radiation thyroiditis) after RAI, which is usually mild and self-limiting, not true subacute thyroiditis.
Question 8: A 27-year-old woman presents with 26 weeks of gestation with a thyroid lesion which is found to be papillary carcinoma of thyroid. Which is the best treatment for this patient?
- A. Hemi-thyroidectomy
- B. Total thyroidectomy
- C. Thyroid ablation using radioactive Iodine
- D. Observation (Correct Answer)
Explanation: ***Observation*** - For **papillary thyroid carcinoma** diagnosed at **26 weeks of gestation**, **observation with close monitoring** is the best management approach. - At 26 weeks (late second trimester/approaching third trimester), the optimal surgical window (14-24 weeks) has passed, and surgery in the third trimester carries increased risk of preterm labor and maternal complications. - **Papillary thyroid carcinoma** has an **indolent course**, and delaying definitive treatment by 3-4 months until after delivery poses **minimal risk** to the mother. - **Close monitoring with ultrasound** should be performed, and **total thyroidectomy** should be planned for **after delivery**. - Surgery during pregnancy is only indicated for **rapidly growing tumors** or evidence of **aggressive features**, which are not mentioned in this case. *Total thyroidectomy* - While **total thyroidectomy** is the definitive treatment for papillary thyroid carcinoma, the **timing is critical** during pregnancy. - Surgery is ideally performed in the **second trimester (14-24 weeks)** to minimize risks to both mother and fetus. - At **26 weeks**, the patient is beyond the optimal surgical window, and performing surgery at this stage or in the third trimester increases the risk of **preterm labor** and other obstetric complications. - Definitive surgery should be **deferred until after delivery** unless there are aggressive features requiring urgent intervention. *Hemi-thyroidectomy* - **Hemi-thyroidectomy** is inadequate for papillary thyroid carcinoma and is only considered for very low-risk papillary microcarcinomas (<1 cm). - It does not provide adequate oncological control for diagnosed papillary carcinoma. *Thyroid ablation using radioactive Iodine* - **Radioactive iodine ablation** is absolutely **contraindicated during pregnancy** due to the risk of fetal thyroid destruction, leading to congenital hypothyroidism or cretinism. - While it is used as adjuvant therapy post-thyroidectomy in non-pregnant patients, it must be delayed until after delivery and cessation of breastfeeding.
Question 9: Surgical treatment for a 40-years old lady with 3 x 3 cm. papillary carcinoma thyroid with level III enlarged lymph nodes is :
- A. Total thyroidectomy with radical neck dissection
- B. Total thyroidectomy with post-operative radio-iodine ablation
- C. Total thyroidectomy with excision of involved nodes
- D. Total thyroidectomy with functional neck dissection (Correct Answer)
Explanation: ***Total thyroidectomy with functional neck dissection*** - For **papillary thyroid carcinoma** with **level III lymph node involvement**, the standard approach is **total thyroidectomy** with **therapeutic lateral neck dissection** (functional/modified radical neck dissection). - **Level III nodes** are part of the **lateral compartment** (levels II-IV), requiring formal **compartment-oriented dissection** rather than selective node excision for adequate oncological clearance. *Total thyroidectomy with excision of involved nodes* - **"Excision of involved nodes"** is not standard terminology in thyroid surgery and **"berry-picking"** individual nodes is generally not recommended for therapeutic purposes. - **Compartment-oriented dissection** is preferred over selective node removal as it provides better oncological outcomes and staging accuracy. *Total thyroidectomy with radical neck dissection* - **Radical neck dissection** involves removal of cervical lymph node levels I-V along with the **sternocleidomastoid muscle**, **internal jugular vein**, and **spinal accessory nerve**. - This extensive procedure is reserved for cases with **extensive extranodal extension** or when these structures are directly involved, causing significant morbidity. *Total thyroidectomy with post-operative radio-iodine ablation* - **Radioiodine ablation** is an **adjuvant therapy** used after thyroidectomy to destroy remaining thyroid tissue and microscopic disease. - This option doesn't address the **surgical management** of enlarged lymph nodes, which is specifically what the question asks about.
Question 10: A young adult presents 2 days after trauma to the eye with proptosis and pain in the right eye. On examination, he is found to have a bruise on the right eye and forehead. The most likely diagnosis is:
- A. Cavernous sinus thrombosis
- B. Carotico-cavernous fistula (Correct Answer)
- C. Internal carotid artery aneurysm
- D. Fracture sphenoid bone
Explanation: ***Carotico-cavernous fistula*** - The presentation of **proptosis**, **pain**, and a **bruise on the eye and forehead** following trauma is highly suggestive of a carotico-cavernous fistula. - This condition involves an abnormal connection between the **carotid artery** and the **cavernous sinus**, often resulting from trauma, leading to increased venous pressure and orbital congestion. *Cavernous sinus thrombosis* - This condition is typically associated with **infection** spreading from the face or sinuses, rather than direct trauma. - While it can cause proptosis and pain, the presence of a distinct bruise and forehead involvement post-trauma points away from an infectious etiology. *Internal carotid artery aneurysm* - An aneurysm itself usually does not immediately present with **proptosis** and **ecchymosis** unless it has ruptured or is causing direct compression. - While an aneurysmal rupture could cause hemorrhage, the specific cluster of symptoms post-trauma strongly favors a vascular shunting issue. *Fracture sphenoid bone* - A sphenoid bone fracture can occur with head trauma, but it would typically present with symptoms such as **cranial nerve deficits** (especially optic nerve or oculomotor nerve dysfunction), **CSF leak**, or **hemorrhage** into surrounding structures. - While a fracture could indirectly contribute to other issues, it doesn't directly explain the combination of proptosis, pain, and orbital bruising as a primary diagnosis in this context.
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