Abstract Introduction The presentation, diagnosis, clinical course and treatment of a man with hyperthyroidism secondary to autoimmune thyroiditis in the setting of type 1 diabetes mellitus has not previously been described. Case presentation A 32-year-old European-American man with an eight-year history of type 1 diabetes mellitus presented with an unintentional 22-pound weight loss but an otherwise normal physical examination. Laboratory studies revealed a suppressed thyroid-stimulating hormone concentration and an elevated thyroxine level, which are consistent with hyperthyroidism. His anti-thyroid peroxidase antibodies were positive, and his thyroid-stimulating immunoglobulin test was negative. Uptake of radioactive iodine by scanning was 0.5% at 24 hours. The patient was diagnosed with autoimmune thyroiditis. Six weeks following his initial presentation he became clinically and biochemically hypothyroid and was treated with thyroxine. Conclusion This report demonstrates that autoimmune thyroiditis presenting as hyperthyroidism can occur in a man with type 1 diabetes mellitus. Autoimmune thyroiditis may be an isolated manifestation of autoimmunity or may be part of an autoimmune polyglandular syndrome. Among patients with type 1 diabetes mellitus who present with hyperthyroidism, Graves' disease and other forms of hyperthyroidism need to be excluded as autoimmune thyroiditis can progress quickly to hypothyroidism, requiring thyroid hormone replacement therapy.</p

A Chidakel

A Mohn

AW Michels

G Dimitriadis

GE Umpierrez

Irl B Hirsch

John K Amory

K Karavanaki

K Vondra

KS Leong

P Mitrou

S Crunkhorn

S Mariotti

English

PubMed

Abstract Introduction The presentation, diagnosis, clinical course and treatment of a man with hyperthyroidism secondary to autoimmune thyroiditis in the setting of type 1 diabetes mellitus has not previously been described. Case presentation A 32-year-old European-American man with an eight-year history of type 1 diabetes mellitus presented with an unintentional 22-pound weight loss but an otherwise normal physical examination. Laboratory studies revealed a suppressed thyroid-stimulating hormone concentration and an elevated thyroxine level, which are consistent with hyperthyroidism. His anti-thyroid peroxidase antibodies were positive, and his thyroid-stimulating immunoglobulin test was negative. Uptake of radioactive iodine by scanning was 0.5% at 24 hours. The patient was diagnosed with autoimmune thyroiditis. Six weeks following his initial presentation he became clinically and biochemically hypothyroid and was treated with thyroxine. Conclusion This report demonstrates that autoimmune thyroiditis presenting as hyperthyroidism can occur in a man with type 1 diabetes mellitus. Autoimmune thyroiditis may be an isolated manifestation of autoimmunity or may be part of an autoimmune polyglandular syndrome. Among patients with type 1 diabetes mellitus who present with hyperthyroidism, Graves' disease and other forms of hyperthyroidism need to be excluded as autoimmune thyroiditis can progress quickly to hypothyroidism, requiring thyroid hormone replacement therapy.</p

Hirsch Irl B

Amory John K

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Hyperthyroidism from autoimmune thyroiditis in a man with type 1 diabetes mellitus: a case report

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CASE REPORT Open Access
Hyperthyroidism from autoimmune thyroiditis
in a man with type 1 diabetes mellitus:
a case report
John K Amory1* and Irl B Hirsch2
Abstract
Introduction: The presentation, diagnosis, clinical course and treatment of a man with hyperthyroidism secondary
to autoimmune thyroiditis in the setting of type 1 diabetes mellitus has not previously been described.
Case presentation: A 32-year-old European-American man with an eight-year history of type 1 diabetes mellitus
presented with an unintentional 22-pound weight loss but an otherwise normal physical examination. Laboratory
studies revealed a suppressed thyroid-stimulating hormone concentration and an elevated thyroxine level, which
are consistent with hyperthyroidism. His anti-thyroid peroxidase antibodies were positive, and his thyroid-
stimulating immunoglobulin test was negative. Uptake of radioactive iodine by scanning was 0.5% at 24 hours. The
patient was diagnosed with autoimmune thyroiditis. Six weeks following his initial presentation he became
clinically and biochemically hypothyroid and was treated with thyroxine.
Conclusion: This report demonstrates that autoimmune thyroiditis presenting as hyperthyroidism can occur in a
man with type 1 diabetes mellitus. Autoimmune thyroiditis may be an isolated manifestation of autoimmunity or
may be part of an autoimmune polyglandular syndrome. Among patients with type 1 diabetes mellitus who
present with hyperthyroidism, Graves’ disease and other forms of hyperthyroidism need to be excluded as
autoimmune thyroiditis can progress quickly to hypothyroidism, requiring thyroid hormone replacement therapy.
Introduction
One percent of adults with type 1 diabetes mellitus will
develop hyperthyroidism, with Graves’ disease, multi-
nodular goiters and toxic adenomas being the most
common causes [1]. Infrequently, hyperthyroidism in
type 1 diabetes mellitus can be secondary to autoim-
mune thyroiditis. Autoimmune thyroiditis initially pre-
sents with signs and symptoms of hyperthyroidism and
serological evidence of thyroid autoimmunity, but with-
out evidence of the immune-mediated thyroid stimula-
tion characteristic of Graves’ disease. As autoimmune
thyroiditis often irreversibly damages the thyroid gland,
this condition frequently progresses to hypothyroidism,
requiring thyroid hormone replacement therapy [2]. In
this report, we document the initial presentation,
diagnosis, clinical course and treatment of a man with
hyperthyroidism secondary to autoimmune thyroiditis in
the setting of type 1 diabetes mellitus. We were unable
to identify a similar case report in the medical literature.
Case presentation
Our patient was a 32-year-old Caucasian man with an
eight-year history of type 1 diabetes mellitus. At the
time of his diabetes diagnosis, he was noted to be posi-
tive for both elevated levels of antibodies to glutamic
acid decarboxylase at 64 U/mL (normal, less than 1.45
U/mL) and anti-islet cell antibodies with a titer of 1:256
(normal, less than 1:4), but was otherwise healthy. His
thyroid function was normal. He had no family history
of diabetes or other autoimmune disease. Over the past
eight years, his diabetes had been treated with insulin by
using a MiniMed Paradigm 722 insulin pump (Medtro-
nic Inc., Northridge, CA, USA) as well as with pramlin-
tide 15 μg three times daily prior to meals. His average
blood glucose level was 150 mg/dL, and his hemoglobin
* Correspondence: jamory@u.washington.edu
1Division of General Internal Medicine, Department of Medicine, University of
Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195,
USA
Full list of author information is available at the end of the article
Amory and Hirsch Journal of Medical Case Reports 2011, 5:277
http://www.jmedicalcasereports.com/content/5/1/277 JOURNAL OF MEDICAL
CASE REPORTS
© 2011 Amory and Hirsch; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
A1c (HbA1c) was 7.5%. He had no evidence of retinopa-
thy, neuropathy or nephropathy.
He presented for medical care with a complaint of
unintended weight loss of 22 pounds, from 203 pounds
(body mass index (BMI) 26.1) to 181 pounds (BMI
23.2), over a period of three months. His weight loss
was not associated with abdominal pain, diarrhea, stea-
torrhea or a change in diet or exercise. He denied palpi-
tations, heat intolerance, neck soreness or other
symptoms referable to his thyroid. His physical exami-
nation revealed a well-developed, well-nourished man in
no apparent distress. He had a normal blood pressure
level of 130/80 mmHg, and his pulse was within the
normal range at 72 beats/minute. There was no lid lag
or proptosis. His thyroid gland was not enlarged and
was non-tender. There was no cervical lymphadenopa-
thy or appendicular tremor. The remainder of his physi-
cal examination was within normal limits.
His laboratory assessment revealed normal blood
counts, electrolytes and liver and kidney function. His
serum thyroid-stimulating hormone (TSH) level was sup-
pressed at 0.033 mIU/L (normal range, 0.4 to 5.0 mIU/L),
and his free thyroxine level was elevated at 33 pmol/L
(normal range, 7.7 to 15.4 pmol/L). An anti-thyroid per-
oxidase antibody was elevated at 13.2SD (normal, <
2.0SD), and the results of a thyroid-stimulating immuno-
globulin (TSI) assay were undetectable. His serum thyro-
globulin was normal, arguing against thyroid hormone
self-administration (thyrotoxicosis factitia) [3]. A radioac-
tive iodine update scan was performed to exclude the
possibility of TSI-negative Graves’ disease. The uptake of
radioactive iodine at four hours was 1.3% (normal, 4% to
20%) and 0.5% at 24 hours (normal, 10% to 30%), consis-
tent with thyroiditis. Notably, his HbA1c improved to
6.9% without any change in his insulin regimen.
The patient was diagnosed with autoimmune thyroidi-
tis and instructed to watch carefully for signs or symp-
toms of hypothyroidism. Six weeks after his diagnosis he
developed fatigue, cold intolerance and had regained all
of the weight he had lost earlier. His TSH level was ele-
vated to11 mIU/L, and his free thyroxine concentration
was below the lower limit of the normal range at 5.4
pmol/L. Therefore, given the combination of his bio-
chemistry and symptomatic hypothyroidism, the deci-
sion was made to initiate thyroid hormone replacement
therapy at a dose of 1.5 μg/kg (137 μg daily for a 91 kg
individual), which normalized his serum TSH and free
thyroxine values and alleviated his symptoms of
hypothyroidism (Figure 1). The patient has remained
euthyroid on a stable dose of thyroxine for over 12
months without recurrence of his hyperthyroid symp-
toms. His glycemic control has returned to baseline
values.
Discussion
This case nicely illustrates the dynamic nature of thyroi-
ditis with an initial hyperthyroid phase due to the
release of pre-formed thyroid hormone from the injured
thyroid gland followed by a hypothyroid phase due to
glandular dysfunction. In addition to the usual symp-
toms of hyperthyroidism, our patient experienced a
transient improvement in his glycemic control, as evi-
denced by a reduction in his HgA1C level early in his
illness. In this patient, the diagnosis of autoimmune
thyroiditis was made on the basis of the presence of
anti-thyroid peroxidase antibodies and the absence of
evidence of another etiology for hyperthyroidism, such
as Graves’ disease, multi-nodular goiter or toxic ade-
noma. As expected, six weeks after he presented and
was diagnosed with hyperthyroidism, his serum thyrox-
ine concentration fell below the normal range and he
began to manifest symptoms of hypothyroidism, necessi-
tating thyroid hormone replacement therapy.
The evaluation of a patient who presents with
hyperthyroidism frequently includes a radioiodine
uptake scan as well as testing for anti-thyroid antibodies,
specifically thyroid-stimulating receptor antibodies and
anti-thyroid peroxidase antibodies, to make the differen-
tial diagnosis between Graves’ disease, multi-nodular
goiter, toxic adenoma and thyroiditis. Distinguishing
these conditions is desirable, as the treatment of these
entities differs. Graves’ disease, goiters and adenomas
are treated with thionamide medications (such as methi-
mazole or propylthiouracil), radioactive iodine or surgi-
cal resection. In contrast, thyroiditis can be managed
prospectively, as many patients with this disease return
to normal over time or develop hypothyroidism, as was
the case in our patient. An alternative approach to treat-
ing a patient such as the one described in this report
could have been the empirical use of a thionamide med-
ication, without the use of scanning or testing for anti-
thyroid antibodies, as therapy for a presumptive diagno-
sis of Graves’ disease. This approach would save some
money in terms of diagnostic testing but could lead to
unnecessary medication-induced side effects or greater
hypothyroidism six to eight weeks later at follow-up. To
our knowledge, a formal risk-benefit analysis comparing
these diagnostic approaches has not been published in
the medical literature. With either approach, the correct
diagnosis of thyroiditis in our patient would have been
made when he re-presented at follow-up with symptoms
of weight gain, hypothyroidism and an elevated TSH
level. Therefore, the risk of initial misdiagnosis based on
the conservative testing strategy is not great, unless the
patient were to receive radioactive iodine or were to
experience an unnecessary side effect of methimazole
treatment.
Amory and Hirsch Journal of Medical Case Reports 2011, 5:277
http://www.jmedicalcasereports.com/content/5/1/277
Page 2 of 4
Evidence of thyroid autoimmunity is common in indi-
viduals with type 1 diabetes mellitus, with up to 27% of
young adults with type 1 diabetes mellitus having
detectable titers of anti-thyroid peroxidase antibodies
[4]. Many of these individuals eventually manifest clini-
cal thyroid disease, which is almost always hypothyroid-
ism. It is uncommon for these patients to present with
symptomatic signs and symptoms of hyperthyroidism,
which may be mild enough to be asymptomatic or
could be missed by clinicians. Symptomatic thyroid dis-
ease is more common in women but can occasionally
occur in men, as demonstrated by our present case.
Furthermore, clinically evident thyroid disease is more
common in children with antibodies to glutamic acid
decarboxylase [5], suggesting a common immune patho-
physiology between the development of type 1 diabetes
mellitus and autoimmune thyroid disease. Indeed, some
individuals may develop other manifestations of autoim-
munity, such as adrenal dysfunction, celiac disease or
pernicious anemia, due to an underlying autoimmune
polyglandular syndrome [6]. To exclude the possibility
of an autoimmune polygladular syndrome, our patient
underwent testing for pernicious anemia and celiac dis-
ease, but no evidence of either condition was found.
The most common form of autoimmune polyglandular
syndrome is associated with specific haplotypes of class
II human leukocyte antigen alleles, but this test is not
commonly performed in a clinical setting. It is possible
that the co-occurrence of autoimmune thyroiditis and
type 1 diabetes mellitus in our patient was coincidental;
however, the elevated risk of other types of autoimmune
diabetes in individuals with type 1 diabetes mellitus sug-
gests that a causal link between these conditions is
more likely than not.
The effect of hyperthyroidism on diabetes is complex
[7]. Hyperthyroidism stimulates increased metabolism in
many tissues, leading to an increased demand for glu-
cose [8]. This in turn triggers stimulation of gluconeo-
genesis and lipolysis, leading to weight loss. Overall, the
increased uptake of glucose from the circulation,
coupled with reductions in weight, can result in
improvements in markers of glycemic control such as
0
2
4
6
8
10
12
14
16
5
10
15
20
25
30
35
0 1 2 3 4
TSH (mIU/ml) Free Thyroxine
Serum 
TSH 
(mIU/ml)
Free 
Thyroxine
(pmol/L)
Time (months)
Thyroxine 137μg po daily 
Figure 1 Thyroid-stimulating hormone (TSH) and free thyroxine in a man with autoimmune thyroiditis. Initially, our patient presented
with hyperthyroidism (elevated thyroxine and suppressed TSH levels), which evolved to hypothyroidism (elevated TSH and low thyroxine levels)
at month two. His thyroid indices normalized with thyroid hormone replacement therapy (indicated by arrow) four months after his initial
presentation. The dotted lines represent the upper and lower limits of the normal ranges for TSH and free thyroxine.
Amory and Hirsch Journal of Medical Case Reports 2011, 5:277
http://www.jmedicalcasereports.com/content/5/1/277
Page 3 of 4
those we observed in our patient. Conversely, hypothyr-
oidism appears to increase insulin resistance indepen-
dently of weight gain [9,10] and has been associated
with an increased risk of symptomatic hypoglycemia
[11]. Protracted hypoglycemia can lead to increases in
weight, which exacerbate insulin resistance and worsen
glycemic control.
Conclusion
In conclusion, in this case report, we have described the
presentation, diagnosis, clinical course and treatment of
a man with hyperthyroidism secondary to autoimmune
thyroiditis in the setting of type 1 diabetes mellitus.
Clinicians caring for patients with diabetes should be
aware of hyperthyroidism secondary to autoimmune
thyroiditis so that they can distinguish it from other,
more common forms of hyperthyroidism, such as
Graves’ disease, toxic adenomas or multi-nodular goi-
ters. In a patient with type 1 diabetes mellitus such as
ours, the most common etiology is Graves’ disease.
Many clinicians would not have considered obtaining
such a comprehensive work-up, including a radioactive
iodine uptake, in this setting. However, a thorough eva-
luation was essential in our patient, as the diagnosis of
thyroiditis prevented unnecessary treatment with medi-
cations, radioactive iodine or surgery. Indeed, the treat-
ment strategy was completely altered when it was
determined that the etiology of our patient’s hyperthyr-
oidism was autoimmune thyroiditis, and there was no
indication for the use of anti-thyroid medications.
Patient’s perspective
“My initial symptoms were weight loss, highly increased
energy level, and lack of sleep (also a lack of feeling the
need for sleep). Anecdotally, during this time (roughly
one month leading up to diagnosis) I worked my normal
nine to 12 hour days and then spent an additional four
to eight hours in the evenings remodeling my kitchen. I
did this without undue feelings of exhaustion. When the
hyperthyroidism finally slowed down, it was remarkable
how quickly I transitioned to hypothyroidism. As I
remember it, in the course of a week or two I went
from having a healthy, controlled energy level to sleep-
ing 10 hours, waking up still exhausted, and exhibiting
symptoms of mild depression. The change in symptoms
was both stark and rapid. As the hypothyroidism pre-
sented, my doctors were able to quickly get me to a
balanced dose of thyroxine, and my energy levels have
been in a good place for the last year.”
Consent
Written informed consent was obtained from the patient
for publication of this case report and any accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Author details
1Division of General Internal Medicine, Department of Medicine, University of
Washington School of Medicine, 1959 NE Pacific Street, Seattle, WA 98195,
USA. 2Division of Metabolism, Endocrinology and Nutrition, Department of
Medicine, University of Washington School of Medicine, 1959 NE Pacific
Street, Seattle, WA 98195, USA.
Authors’ contributions
JKA and IBH both cared for the patient as primary care provider and
endocrinologist, respectively. Both authors contributed to the drafting of the
article, and both approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 30 October 2010 Accepted: 3 July 2011 Published: 3 July 2011
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doi:10.1186/1752-1947-5-277
Cite this article as: Amory and Hirsch: Hyperthyroidism from
autoimmune thyroiditis in a man with type 1 diabetes mellitus:
a case report. Journal of Medical Case Reports 2011 5:277.
Amory and Hirsch Journal of Medical Case Reports 2011, 5:277
http://www.jmedicalcasereports.com/content/5/1/277
Page 4 of 4

Crossref

Autoimmune polyglandular syndromes. Nat Rev Endocrinol

F: The effect of subclinical hypothyroidism on metabolic control in children and adolescents with type 1 diabetes mellitus. Diabet Med

FS: Peripheral metabolism of thyroid hormone and glucose homeostasis. Thyroid

I: Clinical presentation of thyroid dysfunction and Addison’s disease in young adults with type 1 diabetes. Postgrad Med J

Insulin action in hyperthyroidism: a focus on muscle and adipose tissue. Endocr Rev

Kitabchi AE: Thyroid dysfunction in patients with type 1 diabetes: a longitudinal study. Diabetes Care

Links between thyroid hormone action, oxidative metabolism and diabetes risk. Thyroid

Pashali E: Screening for associated autoimmunity in children and adolescents with type 1 diabetes mellitus. Horm Res

Pinchera A: Low serum thyroglobulin as a clue to the diagnosis of thyrotoxicosis factitia.

SA: Insulin action in adipose tissue and muscle in hypothyroidism.

Thyroid autoantibodies and their clinical relevance in young adults with type 1 diabetes during the first 12 years after diabetes onset.

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Hyperthyroidism from autoimmune thyroiditis in a man with type 1 diabetes mellitus: a case report

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