Endocrine Abstracts

Introduction: Thyroid eye disease (TED) is an autoimmune inflammatory disorder affecting the orbital tissues. It occurs with thyroid dysfunction notably Graves’ disease. TED exhibits different severity patterns and has a lot of risk factors. We, herein, report a rare case of a severe TED developing after COVID-19 infection in a patient initially treated for hyperthyroidism without ocular manifestations.

Observation: A 48-year-old female with a history of hyperthyroidism and toxic nodule treated by radioiodine therapy in 2017 was addressed to the endocrinology department for TED symptoms with inflammatory features. In 2017, at the initial diagnosis of thyrotoxicosis, the patient had a toxic thyroid nodule diagnosed by thyroid ultrasound and scintigraphy. Thyroid peroxidase antibodies (TPOAb) and thyroid stimulating hormone (TSH) receptor antibodies (TRAb) were both negatives. She was treated with Benzyl thiouracil then radioactive iodine (RAI) therapy. After developing hypothyroidism post-RAI, she was on 100 mg of levothyroxine daily. In 2021, she was diagnosed with COVID-19 infection and ten days later, she developed eye redness, eye fullness and diplopia. On physical examination, she had active TED with clinical activity score (CAS) of 4/7 points, asymmetric exophthalmia and a restrictive ocular dysmotility. Ocular computed tomography (CT) confirmed the diagnosis of a severe Graves’ orbitopathy (GO). Laboratory tests showed elevated TRAb 2.5 mIU/l (<2) and TSH 8.17 mIU/l (0.4-4). The patient was treated with 1 mg of levothyroxine daily and received intravenous methylprednisolone (1 g/day for 3 days) then oral prednisone during three months. Though inflammatory symptoms improved, diplopia worsened and heavily impacted the patient’s quality of life. A decompressive eye surgery then a strabismus surgery were ultimately performed. No complications occurred after surgery and the symptoms improved significantly.

Conclusion: In conclusion, we reported a very uncommon case of a TED presenting after COVID-19 infection. It was also a severe case of a restrictive dysmotility caused by Graves’s orbitopathy that was treated by surgery. It reinforces the eventual link between COVID-19 and autoimmunity.