Das Liza, Singh Usha, Malhotra Bhanu, Bhadada Sanjay Kumar, Rastogi Pulkit, Singh Paramjeet, Dutta Pinaki, Tadepalli Sameeksha
Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.
Endocrinol Diabetes Metab Case Rep. 2022 Mar 1;2022. doi: 10.1530/EDM-21-0109.
Thyroid eye disease (TED) is the most common extra-thyroidal manifestation in Graves' disease (GD). Additional/concurrent/synchronous pathologies may be present, especially in elderly patients who present with atypical features such as non-axial (or eccentric) proptosis, absence of lid lag and restricted superior extra-ocular movements. A 70-year-old female presented with progressive proptosis of her left eye and diplopia. She was diagnosed with GD a year prior and initiated on carbimazole. On examination, she had eccentric proptosis, restricted superior extra-ocular movements and a palpable mass in the supero-temporal quadrant of the left eye. Her T3 (1.33 ng/mL) and T4 (8.85 µg/dL) were normal with carbimazole. Thyroid-stimulating hormone (TSH)-receptor antibody was positive (3.15 IU/L, reference range <1.75). MRI revealed an enhancing lesion infiltrating the left superior rectus, with concurrent characteristic muscle belly involvement bilaterally. Orbital biopsy showed atypical lymphoid cells (CD20+), suggesting marginal zone lymphoma. CT thorax and abdomen, fluorodeoxyglucose-positron emission tomography and bone marrow examination were normal. The patient was administered orbital radiotherapy for her localised lymphoma and carbimazole was continued. TED is the most common cause of orbital involvement overall and in GD. However, additional or alternative pathology may be present which requires evaluation. MRI can be a useful adjunct in these patients. Orbital lymphoma needs to be staged with workup for disseminated disease. Radiotherapy is the treatment of choice for localized disease. The index case provides evidence for synchronous presentation of dual pathology and highlights the importance of astute clinical examination as well as keeps a low threshold for MRI in selected cases.
Thyroid eye disease can co-exist with other ocular pathology, especially in elderly individuals. Eccentric proptosis, absent lid lag and restriction of eye movements (suggesting tendon involvement) should alert towards the presence of alternative pathology. Orbital imaging using MRI not only has greater sensitivity in diagnosing radiologically bilateral disease in patients who have unilateral involvement clinically but is also useful to identify concurrent neoplasms.
甲状腺眼病（TED）是格雷夫斯病（GD）最常见的甲状腺外表现。可能存在其他并存/同步的病变，尤其是在老年患者中，这些患者表现出非典型特征，如非轴性（或偏心性）突眼、无眼睑迟落和上直肌运动受限。一名70岁女性出现左眼进行性突眼和复视。她一年前被诊断为GD，并开始服用卡比马唑。检查时，她有偏心性突眼、上直肌运动受限，左眼颞上象限可触及肿块。服用卡比马唑时，她的T3（1.33 ng/mL）和T4（8.85 µg/dL）正常。促甲状腺激素（TSH）受体抗体呈阳性（3.15 IU/L，参考范围<1.75）。MRI显示一个强化病变浸润左上方直肌，同时双侧肌肉腹有特征性受累。眼眶活检显示非典型淋巴细胞（CD20+），提示边缘区淋巴瘤。胸部和腹部CT、氟脱氧葡萄糖正电子发射断层扫描及骨髓检查均正常。该患者因局限性淋巴瘤接受了眼眶放疗，卡比马唑继续服用。TED是总体上以及在GD中眼眶受累的最常见原因。然而，可能存在其他或替代的病变，需要进行评估。MRI在这些患者中可能是一种有用的辅助检查。眼眶淋巴瘤需要通过检查播散性疾病进行分期。放疗是局限性疾病的首选治疗方法。该病例为双重病变的同步表现提供了证据，并强调了敏锐临床检查的重要性，以及在特定病例中对MRI保持较低的阈值。
甲状腺眼病可与其他眼部病变共存，尤其是在老年人中。偏心性突眼、无眼睑迟落和眼球运动受限（提示肌腱受累）应警惕存在替代病变。使用MRI进行眼眶成像不仅在诊断临床上单侧受累患者的放射学双侧疾病方面具有更高的敏感性，而且对于识别并存的肿瘤也很有用。
