Thyroid eye disease with concurrent orbital lymphoma: a radiological surprise

Area of Science:

• Ophthalmology
• Endocrinology
• Oncology

Background:

• Thyroid eye disease (TED) is a common manifestation of Graves' disease (GD).
• Elderly patients with GD may exhibit atypical TED features, necessitating evaluation for concurrent pathologies.
• Eccentric proptosis, absent lid lag, and restricted eye movements can signal alternative diagnoses.

Purpose of the Study:

• To highlight the importance of considering concurrent orbital pathology in elderly patients with atypical TED.
• To emphasize the role of MRI and biopsy in diagnosing dual pathologies.
• To present a case of synchronous TED and orbital marginal zone lymphoma.

Main Methods:

• Case report of a 70-year-old female with GD presenting with proptosis and diplopia.
• Clinical examination, thyroid function tests, TSH-receptor antibody levels, orbital MRI, and orbital biopsy.
• Staging workup including CT, FDG-PET, and bone marrow examination.

Main Results:

• The patient presented with eccentric proptosis and restricted eye movements, suggestive of atypical TED.
• Orbital MRI revealed an enhancing lesion infiltrating the superior rectus muscle.
• Orbital biopsy confirmed marginal zone lymphoma; staging workup was negative for disseminated disease.

Conclusions:

• Atypical TED features in elderly GD patients warrant investigation for concurrent neoplasms.
• MRI is valuable for diagnosing orbital pathologies and identifying concurrent neoplasms.
• Orbital lymphoma requires staging, and radiotherapy is the treatment of choice for localized disease.