International Journal of Surgery Case Reports 114 (2024) 109138

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International Journal of Surgery Case Reports

journal homepage: www.elsevier.com/locate/ijscr

Case report

Graves' disease with only unilateral involvement; a case report

Mohammed Saad Bu Bshait *
Department of Surgery, College of Medicine, King Faisal University, Saudi Arabia

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Graves' disease characteristically presents with a diffuse goiter secondary to the autoantibodies that
Hyperthyroidism target the thyrotropin receptors of the thyroid gland. Few cases have been reported of only one of the two lobes
Unilateral Graves' disease being affected. The cause of this phenomenon is still uncertain. Here we report on another case of unilateral
Case report
Graves' disease.
Case presentation: A 43-year-old female patient presented with a history of weight loss, palpitations and right
sided neck swelling for 4 months. Clinical examination showed an enlarged right thyroid lobe. Laboratory in­
vestigations yielded evidence of thyrotoxicosis with suppressed thyroid stimulating hormone. In addition, anti-
TSH receptor and anti-thyroperoxidase antibodies were positive. Neck Ultrasound showed an enlarged right
thyroid lobe with increased vascularization. The isthmus and left lobe were both normal in size. A Tc99m per­
technetate thyroid scan demonstrated enlargement of the right thyroid lobe with diffuse intense uptake, whereas
the left lobe was suppressed. A diagnosis of unilateral Graves' disease was made. The thyrotoxicosis was treated
and maintained with methimazole.
Discussion: Unilateral Graves' disease is a rare manifestation of Graves' disease, sharing the same autoimmune
background and the symptoms of thyrotoxicosis. Enlargement of only one lobe was evident on clinical exami­
nation. The distinctive feature was unilateral uptake during thyroid scintigraphy. The exact pathophysiology of
this condition has yet to be elucidated. Management options and responses are similar to those of classical
Graves' disease.
Conclusion: Unilateral uptake during thyroid scintigraphy and/or unilateral lobar goiter in the setting of hy­
perthyroidism can be the presentation of unilateral Graves' disease.

1. Introduction 2. Case presentation

Graves' disease is an autoimmune condition in which the thyrotropin

receptor is stimulated by circulating autoantibodies, leading to excessive
release of thyroid hormones. The homogeneous exposure of the gland to
these circulating antibodies characteristically affects it in a diffuse
manner. This broad involvement is evident as diffuse goiter, with
sonographic hypervascularity, and universally intense uptake on scin­
tigraphy [1]. In contrast, Graves' disease with unilateral involvement in
a bilobed gland has been reported only occasionally. Here we describe
another rare case of unilateral Graves' disease. This work has been re­
ported in accordance with the SCARE criteria [2].
2.1.1. Patient information
A 43-year-old female patient presented with a history of weight loss
despite an increase in appetite, palpitations and a right sided neck
swelling of four months' duration. The patient denied compression
symptoms or a family history of thyroid cancer.
2.1.2. Clinical findings
There was enlargement of the right thyroid that moved with deglu­
tition. There was no retrosternal extension nor lymph node enlargement.
The patient had no exophthalmos or pretibial myxedema.

* King Faisal University, College of Medicine, Alahsa 36377, Saudi Arabia.

E-mail address: mbubshait@kfu.edu.sa.

https://doi.org/10.1016/j.ijscr.2023.109138
Received 24 October 2023; Received in revised form 21 November 2023; Accepted 1 December 2023
Available online 9 December 2023
2210-2612/© 2023 The Author. Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This is an open access article under the CC BY license
(http://creativecommons.org/licenses/by/4.0/).
M.S. Bu Bshait
3. Diagnostic assessment
3.1.1. # Thyroid function test
T3 and T4 were elevated with suppressed TSH. T3 was 17.1 pmol/L
(Reference range: 3–6.9), T4 was 37.5 pmol/L (Reference range: 12–22),
and TSH was <0.005 uIU/ml (Reference range: 0.35–4.9).
Anti-TSH receptor (TRAb) and anti-thyroperoxidase (TPO-Ab) anti­
bodies were positive.
3.1.2. # Neck ultrasonography
This showed an enlarged right thyroid lobe with a normal isthmus
and left lobe. Both lobes were hypervascular but this was more evident
on the right. (Fig. 1a–b).
3.1.3. # Thyroid scintigraphy
A Tc99m pertechnetate thyroid scan showed diffuse hyperemia and
enlargement of the right thyroid lobe. Uptake was homogeneously dense
with a smooth outline. In contrast, the left thyroid lobe was normal in
size with homogeneous radiotracer suppression. Total thyroid uptake
was 8.4 %. Right and left lobe uptake was 7.1 % and 1.3 % respectively.
(Fig. 2).
Fig. 1. a. Neck ultrasound showing enlarged right thyroid lobe.
b. Color doppler neck ultrasound demonstrating the greater hypervascularity of right thyroid lobe.
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International Journal of Surgery Case Reports 114 (2024) 109138
3.2. Therapeutic intervention
The patient was started on antithyroid medication (Methimazole) to
control thyrotoxicosis.
3.3. Follow-up and outcome
Thyrotoxicosis regressed and patient stayed in normal status for the
next four months. Based on the patient preference, she was referred to
surgery clinic for considering the option of surgical management.
However, surgical intervention has not yet been carried out due to pa­
tient hesitancy.
4. Discussion
Unilateral involvement of thyroid lobes is a rare presentation of
Graves' disease. Skata and colleagues reported the first two cases of
unilateral Graves' disease [3]. The first case presented with right nodular
goiter and euthyroid status but with positive antimicrosomal antibodies.
Thyroid ultrasound revealed an enlarged right thyroid lobe with a
hypoechoic nodule. Thyroid scintigraphy with Tc99m showed intensive
uptake in the right lobe. The patient underwent right hemi­
thyroidectomy on suspicion of malignancy. Surprisingly, histopatho­
logical evaluation was concordant with Graves' disease. Subsequently,
the patient presented after 27 months with symptoms of thyrotoxicosis,
an enlarged contralateral lobe, elevated thyroid function tests, low TSH
and positive TRAb which had been negative preoperatively. A thyroid
M.S. Bu Bshait
Fig. 2. Tc99m pertechnetate thyroid scan demonstrated enlarged right thyroid lobe with diffuse homogeneous dense uptake. Left thyroid expressed radiotracer
suppression. Total thyroid uptake was 8.4 %. Right and left lobe uptake were 7.1 % and 1.3 % respectively.
scintigram with 123I-uptake showed an increase in uptake in the
remaining left thyroid lobe. The second case was a 61-year-old female
patient who presented with weight loss, palpitations and elevated thy­
roid function tests but negative TRAb. Ultrasound excluded the presence
of nodules, with a normal gland size. Thyroid 123I-uptake showed diffuse
unilateral uptake in the right lobe. Given the possibility of a diffuse hot
nodule, the patient underwent right hemithyroidectomy. Histopatholo­
gy was compatible with Graves' disease. Eight months following surgery,
thyrotoxic symptoms developed, with laboratory findings and increased
thyroid scintigraphy uptake in the left lobe comparable with the first
case.
Since then, few other cases have been reported [4–8]. In these,
clinical symptoms of thyrotoxicosis are similar to those in ordinary
Graves' disease, including ophthalmopathy. It might be different in se­
lective lobe enlargement which may mimic toxic adenoma or Plummer's
disease. This distinctive presentation was seen in the current case as well
as others [3–8]. On the other hand, one reported case showed no dif­
ference in the size of both lobes [3]. All reported cases demonstrated
high thyroid function tests with low TSH, except for one case of Saka
et al. in whom thyroid function tests and TSH were initially normal.
Thyroid autoantibodies displayed disparate results. This is consistent
with what is found in classical Graves' disease. In the current patient,
both TPO-Ab and TRAb were positive in a manner comparable to several
other cases of unilateral Graves' disease [4–6]. Cytological evaluation
was carried out in two of the reported cases, showing lymphocytic
infiltration of the affected right lobe but not the left [4,5]. Unilateral
uptake on scintigraphy was the distinctive feature of unilateral Graves'
disease. All except one [7] involved the right lobe in a manner identical
to our patient. A larger right thyroid lobe in a normal gland, and a
preponderance of left lobe involvement in thyroid hemiagenesis, sug­
gests the possibility of predominant right lobe organogenesis and func­
tional advantages over the left [5]. Furthermore, a study evaluating
lobar activity in Graves' disease with diffuse intense TC99m uptake
showed that the right thyroid lobe expressed a higher uptake than the
left [9].
The cause of unilateral Graves' disease is not yet known. Various
possibilities have been suggested. Since TSH stimulation affects thyroid
gland function and growth, a variable lobar reaction may be present in
unilateral Graves' disease [10]. This functional and/or structural vari­
ation might be caused by a pre-existing congenital condition (such as
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International Journal of Surgery Case Reports 114 (2024) 109138
bilobed isolated lymphatic drainage) or by acquired conditions (such as
previous bacterial or viral thyroid inflammation) [11]. Impaired
thyroidal radioiodine uptake as a result of local suppression of sodium
iodide symporter gene expression is another speculation [12]. Lobar
differences in sensitivity to TSH stimulation is another possibility.
Muller-Gartner and colleagues evaluated the resistance of TSH receptors
to TSH autoantibodies in 256 patients with Graves' disease. They found
single or several foci of resistance to TSH-receptor autoantibodies in
about 5 % [13]. The relationship of the aforementioned ideas to the
development of unilateral Graves' disease is uncertain and further
investigation is needed.
In spite unilateral lobar involvement, management should be guided
in the same way as with ordinary Graves' disease. As in the current
patient, most of the cases reported in the literature were treated and
responded well to antithyroid medication [4–7]. Bolognesi and Rossi [6]
reported the findings of a Tc99m scan carried out after two years of
medical treatment. This showed almost identical scanning pattern of the
affected right lobe but a trace of weak uptake in the left lobe which had
initially been suppressed. Chen et al. [8] had managed their patient with
radioiodine ablation. Following ablation, 131I uptake revealed a homo­
geneous normal uptake in the initially suppressed right thyroid lobe
with small amount seen in the affected left lobe. Hemithyroidectomy
was performed by Saka et al. for reasons other than Graves' disease. The
remaining lobe was diseased, as shown by clinical, laboratory and thy­
roid scintigraphy findings. Nevertheless, disease regression was suc­
cessfully achieved with antithyroid medication. Thus, when surgical
management is selected for unilateral Graves' disease, the optimal sur­
gical intervention and possibility of recurrence should be taken into
consideration.
5. Conclusion
Unilateral uptake on thyroid scintigraphy and/or selective lobar
goiter in the context of hyperthyroidism could be the presentation of
unilateral Graves' disease. Collection of clinical, laboratory and imaging
results are needed to distinguish this rare manifestation of the disease.
Management procedures are identical to those adopted in the classical
form of Graves' disease including the extent of surgery.
M.S. Bu Bshait International Journal of Surgery Case Reports 114 (2024) 109138

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Conflict of interest is denied.