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Diagnosis and Treatment > Intervention > Orbital decompression

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Kingsley Okolie National Health Coop, Canberra, Australian Capital Territory, Australia

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Daniel Chen St. Vincent’s Hospital, Darlinghurst, Sydney, New South Wales, Australia

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Raf Ghabrial University of Sydney Medical School, Sydney, New South Wales, Australia

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Robert Schmidli Canberra Hospital, Woden, Canberra, Australian Capital Territory, Australia

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Summary

Multinodular goitre is not associated with eye disease, unless in a rare case of Marine–Lenhart syndrome where it coexists with Grave’s disease. Therefore, other causes of exophthalmos need to be ruled out when the eye disease is seen in a patient with multinodular goitre. Confusion can arise in patients with features suggestive of Graves’ ophthalmopathy in the absence of thyroid-stimulating hormone receptor autoantibodies and no evidence of other causes of exophthalmos. We present a case of multinodular goitre in a patient with exophthalmos which flared up after iodine contrast-based study. A 61-year-old Australian presented with a pre-syncopal attack and was diagnosed with toxic multinodular goitre. At the same time of investigations, to diagnose the possible cause of the pre-syncopal attack, computerised tomographic (CT) coronary artery angiogram was requested by a cardiologist. A few days after the iodine contrast-based imaging test was performed, he developed severe eye symptoms, with signs suggestive of Graves’ orbitopathy. MRI of the orbit revealed features of the disease. Although he had pre-existing eye symptoms, they were not classical of thyroid eye disease. He eventually had orbital decompressive surgery. This case poses a diagnostic dilemma of a possible Graves’ orbitopathy in a patient with multinodular goitre.

Learning points:

  • Graves’ orbitopathy can occur in a patient with normal autothyroid antibodies. The absence of the thyroid antibodies does not rule out the disease in all cases.

  • Graves’ orbitopathy can coexist with multinodular goitre.

  • Iodine-based compounds, in any form, can trigger severe symptoms, on the background of Graves’ eye disease.

Taxonomy:
Clinical Overview, Gland/Organ, Thyroid, Topic, Thyroid, Hormone, IGF1, Thyroxine (T4), Triiodothyronine (T3), TSH, Condition/ Syndrome, Goitre (multinodular), Graves' ophthalmopathy, Patient Demographics, Age, Adult, Gender, Male, Ethnicity, White, Country of Treatment, Australia, Diagnosis and Treatment, Signs and Symptoms, Diplopia, Eyes - inflammation, Eyes - redness, Eyes - watering, Fatigue, Goitre, Heat intolerance, Photophobia, Proptosis, Syncope, Vision - blurred, Investigation, Angiography, CT scan, Fine needle aspiration biopsy, FT3, FT4, IGF1, MRI, Thyroid antibodies, Thyroid function, Thyroid scintigraphy, TSH, Ultrasound scan, Intervention, Eye surgery, Orbital decompression, Medication, Carbimazole, Glucocorticoids, Prednisolone, Publication Details, Case Report Type, Unique/unexpected symptoms or presentations of a disease
DOI:
https://doi.org/10.1530/EDM-18-0138
Volume/Issue:
Volume 2019: Issue 1
Open access