Exophtalmoses due to a bilateral lacrymal gland MALT lymphoma in first occurrence of Gravesdisease
C. Solmon1, O. Gisserot2 & D. Hammoutène1
Introduction: Bilateral exophtalmoses is common at Graves disease diagnosis, but context and clinical abnormalities lead sometimes to consider other diagnosis.
Case report: A 52-year-old man had a previous history of pulmonary MALT lymphoma in complete remission and Hashimotos thyroiditis, which were diagnosed simultaneously 6 years before. He presented recently with hyperthyroidism (TSH <0.001 mUI/l; T4=25 pmol/l) after 2 months of L-thyroxine discontinuation, associated with mild goiter, bilateral exophtalmoses and periorbital edema. TSH receptor antibodies (13 UI/l) were positives, which confirmed Graves disease. Thiamazole were started (5 mg/J) with low dose because of renal failure but led to hypothyroidism in the following 2 weeks. Exophtalmoses worsened with major edema and palpable masses of the orbits despite correction of hypothyroidism. A MRI showed bilateral severe infiltration of both lacrimal glands, without abnormalities of ocular muscles. Biopsy revealed bilateral mucosa-associated lymphoid tissue (MALT) lymphoma (CD 20+). Tumor staging showed no other location. Chemotherapy using weekly Rituximab and chlorambucil with progressive dose during 6 weeks led to an important improvement of the lymphoma. Maintenance treatment is on going.
Conclusion: In this case, the two occurrences of MALT lymphoma were coincident with thyroid auto immunity diseases, which emphasizes the possible relation between these two conditions. To our knowledge, it is the first reported case of bilateral lacrymal gland lymphoma diagnosed silmutaneously with Graves disease. The presence of palpable lacrymal glands could suggest this differential diagnosis of Graves ophtalmopathy.
Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.