Endgames Case Report

A 42 year old man with bilateral exophthalmos and weight loss

BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1105 (Published 23 March 2011) Cite this as: BMJ 2011;342:d1105
  1. Stelios Tigas, assistant professor of endocrinology,
  2. Agathocles Tsatsoulis, professor of medicine and endocrinology
  1. 1Department of Endocrinology, University of Ioannina, Greece
  1. Correspondence to: S Tigas stigas{at}cc.uoi.gr

A 42 year old white man who was concerned about a recent change in the appearance of his eyes was referred to the outpatient clinic for evaluation and treatment. He reported weight loss of more than 15 kg during the preceding six months, even though his appetite had been good. He was a smoker. Apart from alopecia universalis since childhood, he did not report any other significant medical history, and he was not taking any medication.

On examination he appeared restless. His body weight was 98 kg and height 168 cm. He was afebrile, with a resting tachycardia of 100 beats/min, and his blood pressure was 140/80 mm Hg. His skin was moist and warm, and there was fine tremor of the outstretched hands. He had marked bilateral exophthalmos associated with swelling and erythema of the eyelids and redness of the conjunctivae, as well as punctate keratopathy (corneal epithelial erosions). His eye movements were restricted, particularly upward gaze. His thyroid gland was diffusely enlarged with no tenderness on palpation.

Questions

  • 1 What is the diagnosis on the basis of the clinical information provided?

  • 2 What further investigations would you request?

  • 3 What is the appropriate initial management of this condition?

  • 4 How should the patient’s eye disease be managed?

Answers

1 What is the diagnosis on the basis of the clinical information provided?

Short answer

The presence of symptoms and signs of thyrotoxicosis in a patient with bilateral exophthalmos and a diffusely enlarged thyroid gland indicate a diagnosis of hyperthyroidism caused by Graves’ disease.

Long answer

The clinical diagnosis of Graves’ hyperthyroidism is relatively straightforward when a patient presents with the typical symptoms and signs of thyrotoxicosis—that is, a diffuse goitre and one or more of the features that are specific to Graves’ disease such as ophthalmopathy or, more rarely, dermopathy (pretibial myxoedema) or thyroid acropachy (finger clubbing). Although lid retraction and lid lag due to sympathetic overactivity may …

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