Late relapse of severe graves

Hamdi Frikha; Mona Rekik; Sonda Kammoun; Jemaa Yoldez Ben; Khouloud Boujelben; Salah Dhoha Ben; Fatma Mnif; Mouna Mnif; Mohamed Abid; Amira Trigui; Majdoub Nabila Rekik

doi:10.1530/endoabs.99.EP581

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Endocrine Abstracts (2024) 99 EP581 | DOI: 10.1530/endoabs.99.EP581

ECE2024 Eposter Presentations Thyroid (198 abstracts)

Late relapse of severe graves’ ophthalmopathy: a case report

Hamdi Frikha ¹ , Mona Rekik ² , Sonda Kammoun ² , Yoldez Ben Jemaa ² , Khouloud Boujelben ¹ , Dhoha Ben Salah ¹ , Fatma Mnif ¹ , Mouna Mnif ¹ , Mohamed Abid ¹ , Amira Trigui ² & Nabila Rekik Majdoub ¹

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Author affiliations

¹Hedi Chaker University Hospital, Department of Endocrinology, Tunisia; ²Habib Bourguiba University Hospital, Department of Ophtalmology, Tunisia

Introduction: Graves’ disease (GD) is an autoimmune disorder characterized by hyperthyroidism, and it often involves the development of Graves’ ophthalmopathy (GO). The latter occurs in a significant percentage (25-50%) of Graves’ disease cases. Active and severe ophthalmopathy can lead to a worsened prognosis and, in extreme cases, result in blindness. Reports about late ocular manifestation of GD have become scarce due to improved management.

Case Report: A 68-year-old woman with a 25-year history of Graves’ disease presented a unique case of late relapse of GO. Remission had initially been achieved using thyroid synthesis blockers. However, sudden hypothyroid state due to overdose of treatment led to the development of severe active ophthalmopathy, with an activity score of 6 and significant sight impairment. Concomitant Thyrotropin Receptor Antibody (TRAK) levels were remarkably high at 43 UI. The patient underwent methylprednisolone boluses followed by a course of mycophenolate mofetil, resulting in a partial remission of inflammatory phenomena. Decompressive surgery was subsequently performed, leading to partial improvement in sight.

Discussion: This case highlights the challenges associated with late relapses of Graves’ ophthalmopathy, even after an extended period of disease management. The importance of caution in thyroid-blocking treatments is underscored, as treatment overdose in this case contributed to the severe manifestation of ophthalmopathy. TRAK play a significant role in the assessment and management of the patient as they correlate with the severity of ophthalmopathy and could therefore guide the use of immunosuppressive therapies like methylprednisolone and mycophenolate mofetil. The successful outcome following decompressive surgery suggests its potential role in ameliorating sight impairment in severe cases of Graves’ ophthalmopathy. In conclusion, this case emphasizes the importance of vigilant management in Graves’ disease, considering the potential for late relapses of ophthalmopathy. Clinicians should exercise caution in thyroid-blocking therapies to prevent exacerbation of ophthalmic complications. Regular monitoring, prompt intervention, and a multidisciplinary approach are essential in optimizing outcomes for patients with Graves’ ophthalmopathy.