Exophthalmos and multinodular goitre, an unusual combination. (3rd May 2019)

• Record Type: Journal Article
• Authors: Okolie, Kingsley; Chen, Daniel; Ghabrial, Raf; Schmidli, Robert
• Is Part Of: Endocrinology, diabetes & metabolism case reports. (2019)
• Publication Date: 2019-05-03
• Subjects: Adult -- Male -- White -- Australia; Thyroid -- Thyroid -- Triiodothyronine (T3) -- TSH -- Thyroxine (T4) -- IGF1 -- Graves' ophthalmopathy -- Goitre (multinodular); Proptosis -- Goitre -- Syncope -- Heat intolerance -- Eyes - redness -- Eyes - watering -- Eyes - inflammation -- Photophobia -- Vision - blurred -- Diplopia -- Fatigue -- CT scan -- Angiography -- MRI -- Thyroid function -- FT3 -- FT4 -- TSH -- Thyroid antibodies -- Thyroid scintigraphy -- Ultrasound scan -- IGF1 -- Fine needle aspiration biopsy -- Orbital decompression -- Eye surgery -- Carbimazole -- Prednisolone -- Glucocorticoids; Unique/unexpected symptoms or presentations of a disease -- May -- 2019; Endocrinology -- Periodicals; Diabetes -- Periodicals; Diabetes Mellitus; Endocrinology; Diabetes; Endocrinology; Case Reports; Periodicals; Periodicals; 616.4
• DOI: 10.1530/EDM-18-0138
• Languages: English
• ISSNs: 2052-0573

Abstract

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.