Problem 1

Natasha Schick is a 19-year-old aspiring model who has always dieted to keep her weight in
an “acceptable” range. However, within the past 3 months, she has lost 20 lb despite a
voracious appetite. She complains of nervousness, sleeplessness, heart palpitations, and
irregular menstrual periods. She notes that she is “always hot” and wants the thermostat set
lower than her apartment mates. On physical examination, Natasha was restless and had a
noticeable tremor in her hands. At 5 feet, 8 inches tall, she weighed only 110 lb. Her
arterial blood pressure was 160/85, and her heart rate was 110 beats/min. She had a wide-
eyed stare, and her lower neck appeared full; these characteristics were not present in
photographs taken 1 year earlier. Based on her symptoms, the physician suspected that
Natasha had thyrotoxicosis, or increased circulating levels of thyroid hormones. However, it
was unclear from the available information why her thyroid hormone levels were elevated.
Laboratory tests were performed to determine the etiology of her condition

Total T4 6–3 Natasha’s Laboratory Results

Tree T4 increased

Total T4 Increased

TSH Decreased (undetectable)

Questions

Based on her symptoms, Natasha’s physician suspected thyrotoxicosis (elevated levels of

thyroid hormone). Why is each of the following symptoms consistent with increased levels of
thyroid hormones?

(i) Weight loss

(ii) Heat intolerance

(iii) Increased heart rate

(iv) Increased pulse pressure

(v) Increased arterial blood pressure

The physician considered the following possible causes of thyrotoxicosis, based on

his understanding of the hypothalamic–anterior pituitary–thyroid axis: (i) increased
secretion of thyrotropinreleasinghormone(TRH) from the hypothalamus; (ii)
increased secretion of thyroid-stimulating hormone (TSH) from the anterior
pituitary; (iii) primary hyperactivity of the thyroid gland (e.g., Graves’ disease); and
(iv) ingestion of exogenous thyroid hormones (factitious hyperthyroidism). Using the
laboratory findings and your knowledge of the regulation of thyroid hormone
secretion, include or exclude each of the four potential causes of Natasha’s
thyrotoxicosis.

Natasha’s physician performed a radioactive I− uptake test to measure the activity

of her thyroid gland. When her thyroid was scanned for radioactivity, I− uptake
was increased uniformly throughout the gland. How did this additional information
help refine the diagnosis? Which potential cause of thyrotoxicosis discussed in
Question 2 was ruled out by this result?
Problem 1

Based on Natasha’s symptoms and laboratory findings, Natasha’s physicians

concluded that she had Graves’ disease. Why did they reach this conclusion?
Describe the etiology and pathophysiology of this disease.