Management of Severe Graves’ Hyperthyroidism in Pregnancy Following Immune Reconstitution Therapy in Multiple Sclerosis

• Published in: Journal of the Endocrine Society Vol. 5; no. 6; p. bvab044
• Main Authors: Hammerstad, Sara Salehi, Celius, Elisabeth G, Husby, Henrik, Sørensen, Ingvild M, Norheim, Ingrid E
• Format: Journal Article
• Language: English
• Published: US Oxford University Press 01-06-2021; Oxford Academic
• Subjects: Care and treatment; Case Report; Complications and side effects; Development and progression; Multiple sclerosis; Pregnancy; Pregnant women; Thyroid diseases; Thyroid gland; Thyrotropin; Norway; alemtuzumab; Graves’ disease; neonatal thyrotoxicosis; multiple sclerosis; pregnancy
• ISSN: 2472-1972; 2472-1972
• DOI: 10.1210/jendso/bvab044

Abstract
Context
Alemtuzumab (ALZ), a CD52 monoclonal antibody, is highly efficacious in multiple sclerosis; however, side effects are common. Autoimmune thyroid disease (Graves’ disease and Hashimoto thyroiditis) is a well-known complication of ALZ. Treatment of ALZ-induced Graves’ disease can be challenging, and even more difficult during pregnancy.
Case description
We present a case of severe ALZ-induced Graves’ disease with a rapid increase in thyrotropin receptor antibodies (TRAb 240 IU/L) and thyrotoxicosis in early pregnancy. Treatment with high doses of antithyroid medication was needed. There was high risk of both fetal and neonatal thyrotoxicosis. Serial fetal sonography showed normal development. The newborn baby presented high levels of TRAb (240 IU/L) and developed neonatal thyrotoxicosis on day 8. Adequate monitoring, treatment, and follow-up of the newborn baby ensured normal thyroid function until disappearance of TRAb 6 weeks after birth.
Conclusion
Multiple sclerosis patients treated with ALZ may develop severe Graves’ disease with an increased risk of both fetal and neonatal thyrotoxicosis. Close follow-up with a multidisciplinary approach is needed to ensure a healthy outcome.