Successful treatment of hypothyroid Graves' disease with a combination of levothyroxine replacement, intravenous high-dose steroid and irradiation to the orbit.

A 46-year-old woman with hypothyroid Graves' disease (EMO syndrome) is reported. The patient had bilateral exophthalmos, conjunctival chemosis, periorbital edema and limitation of lateral gaze. Laboratory examination revealed the presence of primary hypothyroidism with positive thyroid-stimulating hormone (TSH) binding inhibitory immunoglobulin and thyroid stimulation antibody. These findings indicated a diagnosis of hypothyroid Graves' disease or EMO syndrome. She received levothyroxine replacement and steroid pulse therapy followed by radiotherapy. Her visual symptoms showed marked improvement and pretibial myxedema disappeared. Although several studies indicate that hypothyroid Graves' disease is a different entity from hyperthyroid Graves' disease, this report suggests that steroid pulse therapy combined with radiotherapy may be effective to treat ophthalmopathy in both diseases.