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Sharif MW, Mungara S, Bajaj K, Amador P, Khandelwal N. Orbital Lymphoma Masquerading as Euthyroid Orbitopathy. Cureus 2023; 15:e34885. [PMID: 36925990 PMCID: PMC10011929 DOI: 10.7759/cureus.34885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/11/2023] [Indexed: 02/13/2023] Open
Abstract
Thyroid eye disease (TED), also called Graves orbitopathy (GO), is the most common diagnosis of orbital tissue inflammation. It is typically associated with the onset of hyperthyroidism, an autoimmune response to excess amounts of thyroid hormone. However, a visible and palpable lump, strictly unilateral or gross asymmetric eye involvement, non-axial (eccentric) proptosis, a lack of lid retraction or lid lag on downward gaze, or weakened muscle function (suggestive of tendon involvement) are the key features of non-TED mediated ocular involvement, as was found in the case we report here. Orbital lymphoma should always be suspected and excluded in all cases of orbital inflammation. Our patient was diagnosed with mucosa-associated lymphoid tissue (MALT) lymphoma at 27 years of age, two years after the diagnosis of euthyroid ophthalmopathy. This case highlights the need to include space-occupying lesions in the differential diagnosis of proptosis and gaze restrictions, even in younger patients.
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Affiliation(s)
- Muhammad Waqar Sharif
- Internal Medicine, Texas Tech University Health Science Center at Permian Basin, Odessa, USA
| | - Sai Mungara
- Internal Medicine, Texas Tech University Health Science Center at Permian Basin, Odessa, USA
| | - Kelash Bajaj
- Hematology and Oncology, Texas Tech University Health Science Center at Permian Basin, Odessa, USA
| | - Pablo Amador
- Internal Medicine, Texas Tech University Health Science Center at Permian Basin, Odessa, USA
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Das L, Singh U, Malhotra B, Bhadada SK, Rastogi P, Singh P, Dutta P, Tadepalli S. Thyroid eye disease with concurrent orbital lymphoma: a radiological surprise. Endocrinol Diabetes Metab Case Rep 2022; 2022:21-0109. [PMID: 35332876 PMCID: PMC9002204 DOI: 10.1530/edm-21-0109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2022] [Accepted: 03/08/2022] [Indexed: 12/04/2022] Open
Abstract
Summary Thyroid eye disease (TED) is the most common extra-thyroidal manifestation in Graves' disease (GD). Additional/concurrent/synchronous pathologies may be present, especially in elderly patients who present with atypical features such as non-axial (or eccentric) proptosis, absence of lid lag and restricted superior extra-ocular movements. A 70-year-old female presented with progressive proptosis of her left eye and diplopia. She was diagnosed with GD a year prior and initiated on carbimazole. On examination, she had eccentric proptosis, restricted superior extra-ocular movements and a palpable mass in the supero-temporal quadrant of the left eye. Her T3 (1.33 ng/mL) and T4 (8.85 µg/dL) were normal with carbimazole. Thyroid-stimulating hormone (TSH)-receptor antibody was positive (3.15 IU/L, reference range <1.75). MRI revealed an enhancing lesion infiltrating the left superior rectus, with concurrent characteristic muscle belly involvement bilaterally. Orbital biopsy showed atypical lymphoid cells (CD20+), suggesting marginal zone lymphoma. CT thorax and abdomen, fluorodeoxyglucose-positron emission tomography and bone marrow examination were normal. The patient was administered orbital radiotherapy for her localised lymphoma and carbimazole was continued. TED is the most common cause of orbital involvement overall and in GD. However, additional or alternative pathology may be present which requires evaluation. MRI can be a useful adjunct in these patients. Orbital lymphoma needs to be staged with workup for disseminated disease. Radiotherapy is the treatment of choice for localized disease. The index case provides evidence for synchronous presentation of dual pathology and highlights the importance of astute clinical examination as well as keeps a low threshold for MRI in selected cases. Learning points Thyroid eye disease can co-exist with other ocular pathology, especially in elderly individuals. Eccentric proptosis, absent lid lag and restriction of eye movements (suggesting tendon involvement) should alert towards the presence of alternative pathology. Orbital imaging using MRI not only has greater sensitivity in diagnosing radiologically bilateral disease in patients who have unilateral involvement clinically but is also useful to identify concurrent neoplasms.
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Affiliation(s)
- Liza Das
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Usha Singh
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Bhanu Malhotra
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sanjay Kumar Bhadada
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pulkit Rastogi
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Paramjeet Singh
- Department of Radiology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Pinaki Dutta
- Department of Endocrinology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sameeksha Tadepalli
- Department of Ophthalmology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Maloca PM, Faludi B, Zelechowski M, Jud C, Vollmar T, Hug S, Müller PL, de Carvalho ER, Zarranz-Ventura J, Reich M, Lange C, Egan C, Tufail A, Hasler PW, Scholl HPN, Cattin PC. Validation of virtual reality orbitometry bridges digital and physical worlds. Sci Rep 2020; 10:11815. [PMID: 32678297 PMCID: PMC7366721 DOI: 10.1038/s41598-020-68867-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 06/22/2020] [Indexed: 11/09/2022] Open
Abstract
Clinical science and medical imaging technology are traditionally displayed in two dimensions (2D) on a computer monitor. In contrast, three-dimensional (3D) virtual reality (VR) expands the realm of 2D image visualization, enabling an immersive VR experience with unhindered spatial interaction by the user. Thus far, analysis of data extracted from VR applications was mainly qualitative. In this study, we enhance VR and provide evidence for quantitative VR research by validating digital VR display of computed tomography (CT) data of the orbit. Volumetric CT data were transferred and rendered into a VR environment. Subsequently, seven graders performed repeated and blinded diameter measurements. The intergrader variability of the measurements in VR was much lower compared to measurements in the physical world and measurements were reasonably consistent with their corresponding elements in the real context. The overall VR measurements were 5.49% higher. As such, this study attests the ability of VR to provide similar quantitative data alongside the added benefit of VR interfaces. VR entails a lot of potential for the future research in ophthalmology and beyond in any scientific field that uses three-dimensional data.
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Affiliation(s)
- Peter M Maloca
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland. .,OCTlab, Department of Ophthalmology, University Hospital Basel, 4031, Basel, Switzerland. .,Department of Ophthalmology, University of Basel, 4031, Basel, Switzerland. .,Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK.
| | - Balázs Faludi
- Center for Medical Image Analysis & Navigation, University of Basel, 4031, Basel, Switzerland
| | - Marek Zelechowski
- Center for Medical Image Analysis & Navigation, University of Basel, 4031, Basel, Switzerland
| | - Christoph Jud
- Center for Medical Image Analysis & Navigation, University of Basel, 4031, Basel, Switzerland
| | - Theo Vollmar
- MRZ Medical Radiology Center, 6004, Lucerne, Switzerland
| | - Sibylle Hug
- MRZ Medical Radiology Center, 6004, Lucerne, Switzerland
| | - Philipp L Müller
- Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK
| | | | | | - Michael Reich
- Faculty of Medicine, Eye Center, Albert-Ludwigs University Freiburg, 79085, Freiburg, Germany
| | - Clemens Lange
- Faculty of Medicine, Eye Center, Albert-Ludwigs University Freiburg, 79085, Freiburg, Germany
| | - Catherine Egan
- Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK
| | - Adnan Tufail
- Moorfields Eye Hospital NHS Foundation Trust, London, EC1V 2PD, UK
| | - Pascal W Hasler
- OCTlab, Department of Ophthalmology, University Hospital Basel, 4031, Basel, Switzerland.,Department of Ophthalmology, University of Basel, 4031, Basel, Switzerland
| | - Hendrik P N Scholl
- Institute of Molecular and Clinical Ophthalmology Basel (IOB), 4031, Basel, Switzerland.,Department of Ophthalmology, University of Basel, 4031, Basel, Switzerland.,Wilmer Eye Institute, Johns Hopkins University, Baltimore, 21287, USA
| | - Philippe C Cattin
- Center for Medical Image Analysis & Navigation, University of Basel, 4031, Basel, Switzerland
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Abstract
Graves' Orbitopathy (GO) is an autoimmune orbital disorder usually presenting as a sequala of autoimmune thyroid disease. The presence of GO is associated with increased psychological burden and, in severe cases may cause blindness. While most patients with GO present with bilateral disease, asymmetric or unilateral GO may affect a significant proportion of patients diagnosed with GO. Older age, male sex, active and severe disease correlate with asymmetric disease. However, the exact mechanisms causing asymmetry remain elusive. Herein, we review the literature on asymmetric GO and highlight its differences compared with bilateral GO.
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Affiliation(s)
- Grigorios Panagiotou
- Department of Acute and Intensive Care Medicine, Northwick Park Hospital, London North West University Healthcare NHS Trust, Harrow, United Kingdom
- *Correspondence: Grigorios Panagiotou,
| | - Petros Perros
- Department of Endocrinology, Royal Victoria Infirmary, Newcastle-upon-Tyne, United Kingdom
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Thyroid-Associated Orbitopathy and Biomarkers: Where We Are and What We Can Hope for the Future. DISEASE MARKERS 2018; 2018:7010196. [PMID: 29736194 PMCID: PMC5875031 DOI: 10.1155/2018/7010196] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Revised: 12/21/2017] [Accepted: 01/30/2018] [Indexed: 01/10/2023]
Abstract
Background Thyroid-associated orbitopathy (TAO) is the most common autoimmune disease of the orbit. It occurs more often in patients presenting with hyperthyroidism, characteristic of Graves' disease, but may be associated with hypothyroidism or euthyroidism. The diagnosis of TAO is based on clinical orbital features, radiological criteria, and the potential association with thyroid disease. To date, there is no specific marker of the orbital disease, making the early diagnosis difficult, especially if the orbital involvement precedes the thyroid dysfunction. Summary The goal of this review is to present the disease and combine the available data in the literature concerning investigation of TAO biomarkers. Conclusions Despite the progress done in the understanding of TAO disease, some important pieces are still missing. Typically, for the future, major efforts have to be done in the discovery of new biomarkers, validation of the suspected candidates on multicenter cohorts with standardized methodologies, and establishment of their clinical performances on the specific clinical application fields in order to improve not only the management of the TAO patients but also the therapeutic options and follow-up.
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Vasseur V, Farah E, Zmuda M, Galatoire O. [Orbital lymphoma masquerading in a young patient with Graves ophthalmopathy]. J Fr Ophtalmol 2017; 40:e273-e275. [PMID: 28889905 DOI: 10.1016/j.jfo.2016.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 05/30/2016] [Accepted: 06/06/2016] [Indexed: 11/29/2022]
Affiliation(s)
- V Vasseur
- Service d'oculoplastique, Fondation ophtalmologique Adolphe-de-Rothschild, 25, rue Manin, 75019 Paris, France.
| | - E Farah
- Service d'oculoplastique, Fondation ophtalmologique Adolphe-de-Rothschild, 25, rue Manin, 75019 Paris, France
| | - M Zmuda
- Service d'oculoplastique, Fondation ophtalmologique Adolphe-de-Rothschild, 25, rue Manin, 75019 Paris, France
| | - O Galatoire
- Service d'oculoplastique, Fondation ophtalmologique Adolphe-de-Rothschild, 25, rue Manin, 75019 Paris, France
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Jakobiec FA, Homer N, Zakka FR, Curtin HD, Fay A. Clinicopathologic and Magnetic Resonance Imaging Analysis of a Multifocal Orbital Lymphoid Tumor. Ocul Oncol Pathol 2017; 4:82-89. [PMID: 30320086 DOI: 10.1159/000478731] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 06/14/2017] [Indexed: 01/21/2023] Open
Abstract
Objective To distinguish between a multifocal orbital lymphoid tumor and a major simulator represented by a diffuse lymphaticovenous malformation. Methods We performed a comparison of clinical and radiographic (magnetic resonance imaging [MRI]) findings of these two disparate entities and demonstrated how a misdiagnosis can be prevented. Results Orbital lymphoid tumors develop in adults at around 60 years of age, whereas extensive lymphaticovenous malformations are generally detected in the first decade. Despite these differences, this is the first description of clinical confusion between them. MRI with gadolinium injection in the current lymphoid tumor displayed a low signal on T2-weighted images, rapid and uniform enhancement, and reduced diffusion. Lymphaticovenous malformations are heterogeneous, display poor or only focal perfusion, and fail to exhibit diminished diffusion. Newer techniques such as diffusion-weighted imaging and dynamic contrast-enhanced imaging may be able to provide additional differential diagnostic information. The final pathologic diagnosis was an extranodal marginal zone lymphoma. Conclusions Despite the obvious distinctions between orbital lymphoid tumors and lymphaticovenous malformations, several clinical radiologic specialists misdiagnosed the present orbital lesion as a vascular lesion. A combined clinicoradiographic analysis should obviate such errors and facilitate the correct diagnosis in the future.
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Affiliation(s)
- Frederick A Jakobiec
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, USA
| | - Natalie Homer
- Orbital and Oculoplastics Service, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, USA
| | - Fouad R Zakka
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, USA.,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, USA
| | - Hugh D Curtin
- Department of Radiology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, USA
| | - Aaron Fay
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary and Harvard Medical School, Boston, MA, USA
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Monteiro MLR, Gonçalves ACP, Bezerra AMPS. Isolated primary amyloidosis of the inferior rectus muscle mimicking Graves' orbitopathy. EINSTEIN-SAO PAULO 2017; 14:553-556. [PMID: 28076605 PMCID: PMC5221384 DOI: 10.1590/s1679-45082016rc3744] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2016] [Accepted: 08/21/2016] [Indexed: 01/27/2023] Open
Abstract
The diagnosis of Graves’ orbitopathy is usually straightforward. However, orbital diseases that mimick some clinical signs of Graves’ orbitopathy may cause diagnostic confusion, particularly when associated to some form of thyroid dysfunction. This report describes the rare occurrence of localized inferior rectus muscle amyloidosis in a patient with autoimmune hypothyroidism, who was misdiagnosed as Graves’ orbitopathy. A 48-year-old man complained of painless progressive proptosis on the left side and intermittent vertical diplopia for 6 months. The diagnosis of Graves’ orbitopathy was entertained after magnetic resonance imaging revealing a markedly enlarged, tendon-sparing inferior rectus enlargement on the left side, and an autoimmune hypothyroidism was disclosed on systemic medical workup. After no clinical improvement with treatment, the patient was referred to an ophthalmologist and further investigation was performed. The presence of calcification in the inferior rectus muscle on computed tomography, associated with the clinical findings led to a diagnostic biopsy, which revealed amyloid deposition. This report emphasizes that a careful evaluation of atypical forms of Graves’ orbitopathy may be crucial and should include, yet with rare occurrence, amyloidosis in its differential diagnosis.
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Gavard-Perret A, Lagier J, Delmas J, Delas J, Adenis JP, Robert PY. [Rationale for a diagnostic approach in non-Graves' orbital inflammation--Report of 61 patients]. J Fr Ophtalmol 2015; 38:912-23. [PMID: 26604081 DOI: 10.1016/j.jfo.2015.04.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2015] [Revised: 04/13/2015] [Accepted: 04/29/2015] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Orbital inflammatory syndromes include a wide variety of inflammatory intraorbital processes which are very different in terms of clinical presentation and prognosis. We currently prefer to differentiate so-called "specific" inflammations, for which an etiology is able to be identified, from idiopathic orbital inflammatory syndromes (IOIS), for which the etiology remains unknown and the histology is nonspecific. PURPOSE To propose an efficient diagnostic approach for clinicians managing patients with non-Graves' orbital inflammations. MATERIALS AND METHODS This is a retrospective and prospective study concerning 61 patients managed by the medical team for non-Graves' orbital inflammations between May, 1999 and May, 2013 in the ophthalmology departments of Nice and Limoges university hospitals in France. Seventeen specific inflammations, 19 orbital lymphomas and 25 idiopathic orbital inflammatory syndromes were included. Patients were divided into two groups. Thirty-six patients (group 1) underwent primary biopsy, while for the other 25 (group 2), therapy was begun empirically without biopsy. We could therefore compare both approaches in terms of diagnostic efficiency and time until identification of a specific etiology. RESULTS Our statistical results show that an approach without primary biopsy leads to a number of specific diagnoses statistically much lower than that obtained by the approach with primary biopsy. Also, the risk of missing a specific inflammation (with as a consequence an inappropriate treatment and a risk of functional sequelae as well as a fatal risk of missing a lymphoproliferative pathology) is very clearly higher in the case of not performing primary biopsy. Finally, the average time elapsed between the initial consultation with the ophthalmologist and a specific diagnosis was one month in the case of the first approach, while this delay was almost three times higher with the second approach, with a mean of 2.91 months (P<0.01). DISCUSSION Our study shows that biopsy should be the mainstay of diagnostic management. A trial of empiric treatment is only performed first in myositis or in locations where biopsy could jeopardize functional prognosis. It should only be done after biopsy in all other cases. Of course, in all cases of relapse or recurrence after treatment, biopsy should be performed or repeated. CONCLUSION The diagnostic work-up of a patient with an orbital inflammatory process must of course include blood testing and orbital imaging, but also a systematic primary biopsy for histological examination in the vast majority of cases. It must be repeated at least in the case of any doubt about the diagnosis or in the case of any recurrence or resistance to treatment.
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Affiliation(s)
- A Gavard-Perret
- Ophtalmologie pédiatrique, hôpital Robert-Debré, 48, boulevard Sérurier, 75019 Paris, France.
| | - J Lagier
- CHU de Nice, 30, voie Romaine, 06001 Nice, France
| | - J Delmas
- CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - J Delas
- CHU de Nice, 30, voie Romaine, 06001 Nice, France
| | - J-P Adenis
- CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
| | - P-Y Robert
- CHU de Limoges, 2, avenue Martin-Luther-King, 87000 Limoges, France
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Thyroid Eye Disease With Significant Levator Involvement and Ptosis. Ophthalmic Plast Reconstr Surg 2015; 31:e153-4. [DOI: 10.1097/iop.0000000000000192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Thyroid-associated ophthalmopathy is the most common cause of proptosis in adult female, especially those with positive thyroid antibody. Sometimes, other diagnoses should be considered. A 45-year-old female presented with progressive right proptosis and mild diplopia for 2 years. One year earlier, she had been diagnosed with thyroid-associated ophthalmopathy because of abnormal thyroid autoantibody. Computed tomography scan showed a 2.4- × 1.9- × 1.6-mm heterogeneous soft-tissue density lying above the left eye. Excisional biopsy of this mass revealed the histopathologic diagnosis of pleomorphic adenoma. This case highlights the need for including other diagnoses such as pleomorphic adenoma in the differential diagnosis of patients with proptosis, diplopia and abnormal thyroid antibody.
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