Fellow Michigan state university Okemos, Michigan, United States
Introduction : Autoimmune thyroid disease is considered to have a genetic predisposition. Graves' disease (GD) is less common in males and even rarer in twins. We report an intriguing case of identical twin brothers who developed GD at the same time and experienced an unusual parallel course of disease.
Case(s) Description : The patient is a 30 year old male who presented to the hospital with palpitations, tremors and 20 pound weight loss over the span of 6 months. In addition, he experienced muscle weakness and exercise intolerance to the extent that he had to stop playing professional hockey. Lab workup showed hypokalemia, hypomagnesemia, and elevated ALP, Free T3 and T4. TSH was undetectably low. US of the thyroid gland showed diffuse heterogenous echogenicity and hypervascularity consistent with GD. Coincidentally, the patient’s twin brother was in the exam room at the time of initial evaluation and he notified us that he had similar complaints as his brother's. Upon brief evaluation, he was asked to present to the emergency room. Clinical and laboratory workup confirmed labs consistent with GD. The patient and his brother were both treated with propylthiouracil (PTU), beta blockers and steroids during their inpatient stay and then were transitioned to methimazole and propranolol on discharge from the hospital. Surprisingly, both twin brothers developed similar diffuse skin rashes on the methimazole within 6 weeks of taking the medication and were switched to PTU on an outpatient basis. Once again, both brothers developed liver enzyme elevation within 4 weeks of PTU use. Due to medication side effects, they were both referred to surgery for total thyroidectomy. They both had surgery on the same day by the same surgeon and are both doing well on oral levothyroxine.
Discussion : We are aware of a few case reports of GD in twins. However, this case is quite unusual in its concomitant presentation, along with development of skin rash and liver toxicity as side effects to methimazole and PTU, respectively.
