Stress-Induced Graves Disease: Spontaneous Recovery After Stress Relief

Jeresa I A Willems; Daan J L van Twist; Robin P Peeters; Guy J M Mostard; Roderick F A Tummers-de Lind van Wijngaarden

doi:10.1210/jendso/bvad157

Stress-Induced Graves Disease: Spontaneous Recovery After Stress Relief

J Endocr Soc. 2023 Dec 13;8(1):bvad157. doi: 10.1210/jendso/bvad157. eCollection 2023 Dec 1.

Authors

Jeresa I A Willems¹, Daan J L van Twist¹, Robin P Peeters², Guy J M Mostard¹, Roderick F A Tummers-de Lind van Wijngaarden¹

Affiliations

¹ Department of Internal Medicine, Zuyd Thyroid Center, Zuyderland Medical Center, 6162 BG Sittard-Geleen, The Netherlands.
² Department of Internal Medicine, Academic Center for Thyroid Diseases, Erasmus Medical Center, 3015 GD Rotterdam, The Netherlands.

Abstract

Purpose: Emotional stress is a precipitating factor for Graves disease (GD). However, the influence of stress relief on the course of GD is unknown. Here, we present a series of patients diagnosed with stress-induced GD in whom stress relief alone led to remission of GD.

Cases: We report on 11 patients in whom hyperthyroid symptoms started just after severe emotional stress. All patients had suppressed thyroid-stimulating hormone (TSH) levels and elevated free thyroxine (FT4; 22.2-49.5 pmol/L) and TSH-receptor antibody (TRAb; 0.57-40 U/L) levels and were subsequently diagnosed with stress-induced GD. However, all patients declined antithyroid drug treatment. Surprisingly, clinical and biochemical remission was observed in 9 out of 11 patients after 1 to 3 and 2 to 7 months of self-reported stress relief, respectively. Five patients showed long-lasting remission (median follow-up 2.3 years). In 4 patients, remission was initially achieved, but GD relapsed 1 to 4 years afterwards. In 2 patients, treatment with antithyroid drugs was initiated because of rapidly increasing FT4 levels. Baseline FT4 and TRAb levels tended to be higher in patients who did not achieve remission. Furthermore, patients without long-lasting remission were more frequently known to have prior thyroid disease.

Conclusion: We report on a series of patients with stress-induced GD in whom stress relief alone led to remission of GD (thus without antithyroid drugs). This may indicate that clinicians could consider stopping antithyroid drug treatment or at least shortening the treatment period after stress relief in patients with stress-induced GD.

Keywords: Graves’ disease; remission; stress; stress relief.