Thyroid-associated orbitopathy in patients with Hashimoto's thyroiditis: a case report

Thyroid-associated orbitopathy is a set of ophthalmic symptoms resulting from an autoimmune process in which the swelling of extraocular tissues leads to exophthalmos either caused by hypersecretion and accumulation of glycosaminoglycans in the orbit fibroblasts or being the result of inflammatory processes in the oculomotor. These changes cause eyeball motility disturbances, keratopathy, and the pressure on the optical nerve. Thyroid-associated orbitopathy accompanies Graves' disease in most cases, whereas the Hashimoto's disease in only 5%. In the present case, other reasons for the exophthalmos such as tumors of the orbit and sinuses, intracranial tumors, aneurysms and vascular fistulas and orbit tissue inflammation of different etiology were excluded. Additional examinations showed that thyrotropin level was 26 microlU/ml (normal range 0.27-4.0), antithyroglobulin antibody level was 1763 IU/ml (normal range 0-115), antithyrotropin antibody level was 4.93 IU/l (normal range 0-1), and anti-thyroid peroxidase antibody level was 1609 lU/ml (normal range 0-35). An ultrasound examination showed a thyroid gland of 9.8 ml volume. A cytological presentation obtained by thin-needle aspiration biopsy demonstrated inflammatory infiltration of lymphocytes, indicating an autoimmune process. The iodine uptake after 24 hours was 9%. The active form of orbitopathy was diagnosed in the patient with hypothyreosis in the course of Hashimoto's disease. Moreover, the coexistence of another autoimmune disease, pernicious anemia was diagnosed. The administration of the methylprednisolone pulse therapy and levothyroxine caused remission of ophthalmic symptoms, and euthyreosis was obtained. Our report presents a rare coexistence of thyroid orbitopathy and Hashimoto's disease.