Endocrine Abstracts

Background: Graves’ orbitopathy (GO), also known as thyroid eye disease, is an autoimmune condition and is one of the main extrathyroidal manifestations of Graves’ disease. GO is relatively rare and usually accompanies the onset or develops soon after the Graves’ disease. We present a case of GO that developed 18 years later from total thyroidectomy.

Case report: A 64-year-old men presented at the ophthalmology clinic with one-month history of gradual bilateral vision impairment with inability to walk independently, exophthalmos, pain in the eyes, swelling of eyelids, and excessive tearing. From past medical history, 18 years ago, patient underwent a subtotal thyroidectomy due to Graves’ disease. 4 years following surgery, his vision started to deteriorate; however, he has not seen a specialist or done any investigations. 4 years ago, he was diagnosed with cataract in both eyes and underwent surgery. Patient was smoker (30 cigarettes/day), BMI=21 kg/m2. His only regular medication was for hypertension. Physical examination revealed the presence of pretibial myxoedema on both legs and thyroid acropathy. Ophthalmological examination revealed swelling of periorbital tissue, eyelid retraction, and exophthalmos of both eyes. Clinical activity score (CAS) was 6. Moderate-to-severe and active GO was diagnosed. Laboratory tests were consistent with overt hypothyroidism (TSH=29µIU/ml, FT4=0.56ng/dl) and positive TSH receptor antibody (TRAB) titter (7.11U/l). Cerebral and orbital CT scan was also done, which revealed an infiltration of the orbital fat and enlargement of the extraocular muscles. Neck ultrasound revealed 3 nodules in the thyroid bed. FNA cytology of the dominant nodule (33x26x10mm) was performed, which showed follicular neoplasia. Patient was started on 50 mg levothyroxine, he quitted smoking, and a pulse-therapy with methylprednisolone (cumulative dose 4.5 g) was done. After 12 weeks of pulse-therapy, repeated ophthalmological examination revealed moderate and inactive GO, vision significantly improved, pretibial myxoedema completely resolved, patient’s quality of life also significantly improved. Biochemically, he was euthyroid and TRAB decreased to 4.63U/l. Thyroid remnant surgery was recommended, but patient refused to undergo the surgery.

Conclusions: Although GO usually presents soon after the onset of Graves’ disease, late presentation can also occur, even after long-standing thyroidectomy. Raising awareness among both patients and clinicians in terms of diagnosing GO in time can reduce the severity of complications and ensure better quality of life for such patients.