A Euthyroid Patient with Orbitopathy and Negative Graves' Serologic Markers

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 449-497-Thyroid Neoplasia & Case Reports
Clinical
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-452
Nisha Vinod Jayani*1, Roshni Shah1, Craig Stephen Stump2 and Stephen P Thomson2
1University of Arizona Medical Center, Tucson, AZ, 2University of Arizona Department of Endocrinology, Tucson, AZ
Background: Thyroid-associated orbitopathy is usually associated with thyroid disease and presence of thyroid antibodies.  Women are affected 2.5-6 times more frequently than men.  However, severe cases occur more often in men.  Affected patients are usually 30-50 years old, with severe cases appearing to be more frequent in those older than 50 years. (1)(2)

Clinical case: 65-year-old man with history of prostate cancer presented with two-year duration of bilateral orbital edema, conjunctival injection and epiphora to his primary care physician. He was initially treated for suspected glaucoma, which did not alleviate his symptoms. Subsequently, he developed ophthalmalgia and diplopia, which prompted imaging studies.  He had no proptosis and denied xerophthalmia, palpitations, tremors, hyperdefecation, or weight loss.  CT and MRI of the orbits showed significant enlargement of rectus muscles, more pronounced in the lateral rectus, which was associated with orbital apex compression.  Based on MRI findings, differential diagnoses included dysthyroid orbitopathy, orbital psuedotumor and infiltrative disease including metastasis or lymphoma.  He was evaluated by Ophthalmology and underwent extraocular muscle and orbital fat biopsy.  Pathology reported reactive lymphocytic infiltrate with atypical features, which did not meet diagnostic criteria for lymphoma.  There was no evidence of lymphadenopathy based on CT scan and bone marrow biopsy was negative for lymphoma.  He then received a two month course of prednisone for suspected Graves’ orbitopathy with no improvement.   He had TSH receptor antibody level <0.90IU/L (≤1.75IU/L), ANA not detected, anti-thyroperoxidase antibodies 0.5IU/mL (0.0-9IU/mL), thyroglobulin antibodies <0.9IU/mL(0.0-4.0IU/mL), thyroid stimulating immunoglobulin 78%(≤122%), total thyroxine 5.7μg/dL(4.8-11.7μg/dL), and thyroid stimulating hormone 1.16μIU/mL(0.35-4μIU/mL).  Serological markers and clinical evidence of Graves’ disease continued to be negative one month later.

Conclusion: Euthyroid Grave’s ophthalmopathy is defined as ophthalmopathy with no present or past history of hyperthyroidism and is reported in 0.7% of patients in a large series of Graves’ ophthalmopathy (3).  This atypical presentation of euthyroid Graves’ orbitopathy with negative serological markers can be challenging with respect to management.  Surgery, radiation, and rituximab are all potential treatment options.

(1) Perros P, Kendall-Taylor P. Natural history of thyroid eye disease. Thyroid. 1998;8:423–5.(2) Bartley GB, Fatourechi V, Kadrmas EF, Jacobsen SJ, Ilstrup DM, Garrity JA, et al. The incidence of Graves’ ophthalmopathy in Olmsted County, Minnesota. Am J Ophthalmol. 1995;120:511–7.(3) Khoo DH, Eng PH, Ho SC, et al. Graves’ ophthalmopathy in the absence of elevated free thyroxine and triiodothyronine levels: prevalence, natural history, and thyrotropin receptor antibody levels.  Thyroid 2000;10: 1093-1100

Nothing to Disclose: NVJ, RS, CSS, SPT

*Please take note of The Endocrine Society's News Embargo Policy at http://www.endo-society.org/endo2013/media.cfm