Endocrine Abstracts

JOINT2569

Introduction: Graves’ orbitopathy (GO) is an autoimmune condition characterized by inflammation of extraocular muscles and peri-orbital tissue due to overstimulation of TSH receptor autoantibodies (TRAbs). It is a key extrathyroidal manifestation of Graves’ disease (GD), often appearing at disease onset or shortly thereafter. Total thyroidectomy (TT) is one of the treatment options for GD, particularly in cases when definitive management is preferred, and radioiodine therapy is not appropriate. TT is generally considered safe regarding orbitopathy progression so prophylactic glucocorticoid therapy post-surgery is not routinely recommended.

Clinical case: This report presents a 41-year-old female patient with multiple sclerosis who, after receiving three cycles of Alemtuzumab, developed signs and symptoms suggestive of hyperthyroidism. Laboratory tests revealed: TSH <0.004 UI/mL (0.4-4.0), T4L 1.61 ng/dl (0.7-1.5), and TRAbs 16 U/l (<1.0). Treatment with thiamazole and propranolol was initiated with partial symptom improvement. The clinical course was characterized by difficult-to-control hyperthyroidism, requiring frequent dose adjustments of thiamazole (up to 30 mg daily) and continuous propranolol therapy. The patient developed other manifestations including pretibial myxedema and orbitopathy. The latter appeared approximately one year after the initial presentation, with dry eye sensation, visual acuity changes, and progressively worsening bilateral exophthalmos. The introduction of selenium therapy at 200 mg/day provided only partial relief. An orbital CT scan confirmed the diagnosis, and ophthalmology assessment classified the condition as moderate-to-severe and inactive (CAS 2). Due to the severe and poorly controlled clinical picture, the patient underwent total thyroidectomy two and a half years after symptom onset. At the time of surgery, she was on 25 mg of thiamazole and was biochemically euthyroid, with TRAbs of 76 U/l. Immediately after surgery, the patient experienced a multiple sclerosis flare, requiring a short course of corticosteroid therapy (prednisolone 1 g for 5 days). About a week post-surgery and after completing the corticosteroid cycle, she developed worsening orbitopathy with ocular pain and diplopia, requiring an emergency ophthalmology consultation. A follow-up orbital CT scan confirmed disease progression, prompting the initiation of corticosteroid therapy, of which she has completed two cycles to date. Due to only partial improvement, treatment with Tocilizumab has been proposed and is scheduled to begin soon.

Conclusion: A patient with severe, difficult-to-control hyperthyroidism and moderate-to-severe inactive orbitopathy underwent total thyroidectomy. Despite this, orbitopathy exacerbation occurred post-surgery, requiring specific treatment. This case highlights a rare complication and raises the question of whether corticosteroid prophylaxis should be considered after surgery in high-risk patients.