Clinical case. Graves’ ophtalmopathy

Abstract

Introduction: Graves’ ophthalmopathy (GO) is an autoimmune inflammatory disorder Associated with thyroid disease which affects ocular and orbital tissues.The objective was to present a clinical case of patient with Graves’ disease and GO. Clinical case: Patient V.P. (45 years) was hospitalize in the Department of Endocrinology on the 16.03.16, with clinical manifestations: painful feeling behind the globe, redness of the conjunctiva, hyperlacrimation, exophthalmos and diplopia. In July 2014, patient was diagnosed with Graves’ disease, treatment with ATS was initiated. In April 2015, supports a viral infection that leads to worsening general appearance of exophthalmos, decreased eyes motility, sensation of "sand" in the eyes, hyperlacrimation and decreased visual acuity. Patient diagnosed with GO and oral Prednisone was given in decreasing doses: 30 mg for the first week, after the dose was tapered off by 5 mg per week and GO ameliorates. In September 2015, after a virosis, clinical signs of GO becomes more severe and the patient resumes treatment with Prednisone. As a result of recently appeared flu (2-3 weeks), GO worsens and patient is hospitalized for pulse therapy. Clinical activity score was appreciated according to CAS=6. Family history: patient’s sister and brother have Graves disease with severe GO. Hormonal tests: 05.15 FT4-16,8 pmol/L (normal values range = 12-22 pmol/L); 07.15 FT4-33,2 pmol/L; TSH <0,005 mIU/L (normal values range 0,27- 4,2 mIU/L); 09.15 FT4-10,8 pmol/L; TSH 0,011 mIU/L; 11.15 FT4-12 pmol/L; TSH 0,185 mIU/L; 01.16 FT4-58,5 pmol/L; TSH <0,005 mIU/L; 03.16 TSH 0,011 mIU/L; FT4 11,24 pmol/L; FT3 4,32 pmol/L (normal values range 3,1-6,8). MRI of the orbit: diffuse thickening of: m.rectus inferior to 1,0 cm (normal values range 0,49-0,57 cm), m. rectus medial to 0,85 cm (normal values range 0,41-0,46 cm), m. rectus laterale to 0,7 cm (normal values range 0,29-0,35 cm), m. rectus superior to 0,75 cm (normal values range 0,38-0,45 cm) with signs of edema.The CAS wasn’t determinate before and after Prednisone treatment and we can’t appreciate the success of suppressive treatment. In etiology an important role has genetic predisposition (20-60% of affected individuals have a positive family history of thyroid disease), 21 % of the risk for developing GD is attributable to environmental factors (infectious agents). To confirm the genetic predisposition it would be ideal to identify the cytokines: HLA-DR3, CTLA4, PTPN22, CD40, IL-2RA, FCRL3, and IL- 23R. Also, we can’t ignore the influence of other factors in the pathogenesis of GO, such as female gender and the age 45 years. Conclusion: 1. It is important to appreciate the clinical activity score of Graves' ophthalmopathy before and after the suppressive treatment. 2. Environmental factors, like viral infections had an important role in the evolution and severity of Graves' ophthalmopathy.