SAT-332 - Rising from the Grave: A Resurrection of Graves' Disease.

Background:
Total thyroidectomy is definitive therapy for Graves’ disease, with recurrence rates of 2.4%¹. Recurrence is usually due to incomplete resection, residual thyroid tissue in difficult anatomical locations (particularly above the hyoid bone), or ectopic thyroid tissue². Ophthalmopathy may progress independently of thyroidectomy or biochemical control³.

Case Presentation:
A 33-year-old woman was diagnosed with Graves’ disease in 2016 during pregnancy and underwent total thyroidectomy in 2019. She later developed persistently low, then suppressed, TSH levels despite decreasing levothyroxine doses, suggesting recurrent hyperthyroidism. In 2023, she developed an anterior neck mass with compressive symptoms; ultrasound showed a 2.5 × 1.2 × 3.6 cm hypervascular soft-tissue mass, and thyroglobulin was elevated at 27.9 ng/mL, indicating functioning thyroid tissue. CT confirmed recurrent thyroid tissue. She underwent completion thyroidectomy in 2023. Postoperatively, TSH increased, levothyroxine requirements rose to a weight-based dose, and she achieved hypothyroid status, supporting successful removal of hyperfunctioning tissue. She remained euthyroid throughout 2024. Despite biochemical control, in September 2025 she developed dry, gritty eyes, bilateral periorbital edema, and mild–moderate proptosis, consistent with thyroid eye disease.

Discussion:
This case illustrates rare recurrence of Graves’ hyperthyroidism following apparent total thyroidectomy, most likely due to residual or ectopic thyroid tissue in surgically challenging regions, particularly along the thyroglossal duct tract or superior to the hyoid bone². Persistent thyroid-stimulating immunoglobulins may activate these remnants. Progression of ophthalmopathy after surgical cure highlights its independence from thyroid hormone status³.

Conclusion:
Recurrent Graves’ disease should be suspected when decreasing levothyroxine requirements are accompanied by rising thyroglobulin levels after total thyroidectomy. Imaging and thyroglobulin measurement are essential for identifying functioning remnants⁴. High preoperative TRAb titers increase recurrence risk, and thyroid eye disease may progress despite complete thyroid resection, requiring long-term surveillance³.

References:
1. Liu X et al. Ann Surg. 2021;273:1197–1206. PMID: 33914484.
2. Vaz-Pereira R et al. BMJ Case Rep. 2022;15:e248166.
3. Jang SY et al. Yonsei Med J. 2015;56:1389–94. PMID: 26256985.
4. Menon LP et al. Cureus. 2024;16:e52260. PMID: 38352081.

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