Session: SAT 449-497-Thyroid Neoplasia & Case Reports
Poster Board SAT-452
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.
Nothing to Disclose: NVJ, RS, CSS, SPT
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