simultaneous occurrence of hashimoto 's thyroiditis ( ht ) , and graves disease ( gd ) is rare . a 60-year - old lady presented with tremulousness of hands , palpitation , and excessive sweating . her weight was 46 kg , bmi 17 , afebrile , regular pulse rate of 110/min with fine tremor in hands . thyroid gland was symmetrically enlarged , firm , without any bruit , but mildly tender with lobular surface . initial thyroid function tests ( tft ) revealed : t3 : 3.80 ng / ml ( 0.80 - 2.10 ) , t4 : 12.40 ug / dl ( 5.10 - 12 ) , thyroid stimulating hormone ( tsh ) : 0.20 u / l ( 0.70 - 5 ) . her anti thyroperoxidase ( tpo ) antibody : 374 iu / ml ( normal [ nl . ] < 35 ) and tsh receptor antibody : 15 u / l ( nl . < 1 ) were both strongly positive . 99mtc pertechnetate scan showed an enlarged gland with increased uptake of radiocontrast : 17% ( nl . thyroid fine needle aspiration cytology ( fnac ) showed sheets of hurthle cells with abdunce of lymphocytes indicating ht . repeat tft , 3 months later showed : t3 : 4.20 ng / ml , t4 : 14.40 ug / dl , tsh : 0.001 u / l , with increased uptake on repeat scan . our case of an elderly lady with no eye signs , lobular , firm tender goiter with patchy uptake in both lower poles on tc99 m scan were odd points in diagnosing isolated gd . hashimoto 's thyroiditis ( ht ) and graves disease ( gd ) are the two main types of autoimmune thyroid disease . ht rarely occurs following gd . but combined occurrence of gd and ht are rare . a 60-year - old lady , presented with tremulousness of hands for 1 month and palpitation with excessive sweating for 3 months . she had a history of weight loss for 6 months , and gradually enlarging neck swelling for 3 years . her weight was 46 kg , bmi 17 , afebrile , pulse rate : 110/min / regular , blood pressure : 140/56 mm of hg . her thyroid gland was symmetrically enlarged , firm in consistency , nodular / lobular surface and mildly tender without any bruit . initial thyroid function tests ( tft ) revealed high t3 : 3.80 ng / ml ( 0.80 - 2.10 ) , t4 : 12.40 ug / dl ( 5.10 - 12 ) with a low tsh : 0.20 mu / l ( 0.70 - 5 ) . her tsh receptor antibody ( tsab ) : 25 u / l ( normal [ nl . ] < 1 ) , anti tpo antibody : 374 iu / ml ( nl . < 35 ) and thyroglobulin antibody : 268 iu / ml ( nl . < 65 ) were all strongly positive . ultrasonogram of thyroid revealed an enlarged gland with hypoechoic parenchyma with fibrous septa.tc pertechnetate scan ( tc99 m scan ) revealed enlarged thyroid gland with diffusely increased uptake of radiocontrast : 17% ( nl . thyroid fnac showed sheets of hurthle cells with abdunce of lymphocytes and sheets of regular follicular cells , indicating ht . repeat tft , 3 months later showed : t3 : 4.20 ng / ml , t4 : 14.40 ug / dl , tsh : 0.001 u . repeat tc pertechnetate scan was done , which again revealed enlarged thyroid gland with diffusely increased uptake of radiocontrast : 21% ( nl . our patient presented with clinical symptoms and signs of thyrotoxicosis along with slightly raised t4 , t3 and low tsh with positive tsab , and diffusely increased uptake on tc99 m scan , all in favor of a diagnosis of gd . however , there were some odd features such as elderly age , absence of eye signs , nodular , firm mildly tender goiter , hypoechoic parenchyma in ultrasonography ( usg ) , and patchy uptake in both lower poles on tc99 m scan . fnac of the thyroid gland was suggestive of ut fnac of thyroid gland suggested ht . so we adopted a wait and watch policy , and put the patient on beta blockers . repeat tft , 3 months later showed persistent thyrotoxicosis and repeat tc99 m scans revealed an enlarged thyroid gland with diffusely increased uptake of radiocontrast . diffusely increased uptake on tc99 m scan rules out hashitoxicosis , which mostly resolves within 3-months time - frame . a diagnosis of combined occurrence of hyperthyroid gd and hd was established and anti - thyroid medication started . reported four cases of ht in previously diagnosed patients with gd hyperthyroidism . in three cases , ht occured 7 - 25 years after gd treatment ; in one , it developed in a few months of gd treatment . the diagnosis of ht was based on clinical manifestation , positive tpo and thyroglobulin antibody , and fnac . all were middle - aged women , who had high titers of anti - thyroid antibodies and thyrotoxicosis at the onset of painful ht . reported seven patients with hypothyroidism due to hashimoto 's disease , who developed hyperthyroid gd . some had transient , some persisistent hyperthyroidism due to gd following hypothyroidism due to ht . ht and gd represent the main two types of autoimmune thyroid disease . gd is caused due to hyperplasia and hyperfunction of the thyroid gland by stimulating tsab . on the contrary , ht is thought to be due to a tsh stimulation - blocking antibody ( tsbab ) which blocks the action of tsh hormone and subsequently brings damage and atrophy to the thyroid gland . alterations in the thyroid state related to the balance between the activities of tsab and tsbab . moreover , approximately 15 - 20% of patients with gd have been reported to have spontaneous hypothyroidism resulting from the chronic ht . patients with gd who have achieved remission on anti - thyroid drugs may also experience ht or hashitoxicosis or intermittent transient hyperthyrodism . they may have both ht and gd since antibodies associated with both diseases may be present . to distinguish from relapsed gd a wait and see approach is beneficial . a definitive diagnosis can be made by fnac biopsy , that is , fine - needle aspiration . hashimoto 's disease , which occurs following gd may be due to extended immune response to endogenous thyroid antigens , i.e. thyroid peroxidase and thyroglobulin , which may enhance lymphocyte infiltration and finally cause ht . in conclusion , ht rarely occurs following gd . in our case of an elderly lady , absence of eye signs , lobular - firm tender goiter with patchy uptake in both lower poles on tc99 m scan were odd points in diagnosing isolated gd .
introduction : simultaneous occurrence of hashimoto 's thyroiditis ( ht ) , and graves disease ( gd ) is rare.aims and objectives : we report a case of simultaneous occurrence of gd and hd , at presentation.case report : a 60-year - old lady presented with tremulousness of hands , palpitation , and excessive sweating . 
 she had a history of weight loss and neck - swelling . 
 her weight was 46 kg , bmi 17 , afebrile , regular pulse rate of 110/min with fine tremor in hands . 
 thyroid gland was symmetrically enlarged , firm , without any bruit , but mildly tender with lobular surface . 
 there were no occular manifestations . 
 initial thyroid function tests ( tft ) revealed : t3 : 3.80 ng / ml ( 0.80 - 2.10 ) , t4 : 12.40 ug / dl ( 5.10 - 12 ) , thyroid stimulating hormone ( tsh ) : 0.20 u / l ( 0.70 - 5 ) . her anti thyroperoxidase ( tpo ) antibody : 374 iu / ml ( normal [ nl . ] 
 < 35 ) and tsh receptor antibody : 15 u / l ( nl . 
 < 1 ) were both strongly positive . 
 ultrasonogram of thyroid revealed a hypoechoic enlarged gland . 
 99mtc pertechnetate scan showed an enlarged gland with increased uptake of radiocontrast : 17% ( nl . 
 0.4 - 4% ) with some patchy defects in both lower poles . 
 thyroid fine needle aspiration cytology ( fnac ) showed sheets of hurthle cells with abdunce of lymphocytes indicating ht . 
 she was observed on beta blockers . 
 repeat tft , 3 months later showed : t3 : 4.20 ng / ml , t4 : 14.40 ug / dl , tsh : 0.001 u / l , with increased uptake on repeat scan.conclusion:ht rarely occurs following gd . 
 our case of an elderly lady with no eye signs , lobular , firm tender goiter with patchy uptake in both lower poles on tc99 m scan were odd points in diagnosing isolated gd . 
 fnac confirmed simultaneous hd with gd .