Unusual onset of thyroid associated orbitopathy during pregnancy: case report and review of literature
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CASE REPORT
Open Access
Unusual onset of thyroid associated orbitopathy during pregnancy: case report and review of literature Janos K. Aranyosi1, Tamas Deli2, Annamaria Erdei3, Geza Toth4, Attila Jakab2, Mariann Fodor1, Endre V. Nagy3 and Bernadett Ujhelyi1*
Abstract Background: Thyroid associated orbitopathy (TAO) is the most common extrathyroidal complication of Graves’ disease. The disease course ranges from mild, where symptomatic therapy is sufficient, to severe, where high dose steroid administration or orbital decompression surgery is required. Women of their reproductive age are more likely to be affected. Although pregnancy is a state of enhanced immune tolerance, TAO may develop or worsen in 0.2–0.4% of pregnant women. Case presentation: We present the case of a 19-year-old woman who has developed hyperthyroidism and progressive TAO during the second trimester of her third pregnancy, which has improved postpartum. The possible mechanisms and the importance of follow up in pregnancy is discussed. Conclusions: Expectant mothers with Graves’ disease require follow up of eye signs throughout pregnancy, preferably in the setting of a thyroid-eye clinic. Keywords: TAO, Graves’ disease, Pregnancy, Orbitopathy, Smoking, Case report
Background Graves’ disease (GD) and Hashimoto’s thyroiditis (HT) are autoimmune disorders, that may affect around 2% of the population [1]. GD occurs more frequently in women, smokers, patients suffering from other autoimmune diseases and those with a positive family history for thyroid autoimmunity [2]. GD is the most common cause of hyperthyroidism in women of reproductive age. It occurs before and during pregnancy in 0.4–1% and 0.2–0.4% of the cases, respectively [3, 4]. According to a recent review by Chin et al. in approximately 40% of the cases GD is accompanied by thyroid associated orbitopathy (TAO) [5]. In 5%, deterioration of visual acuity may * Correspondence: [email protected] 1 Department of Ophthalmology, Faculty of Medicine, University of Debrecen, Nagyerdei krt 98, Debrecen H-4032, Hungary Full list of author information is available at the end of the article
occur [6]. In mild cases local therapy such as artificial tears, ointments, sunglasses and higher pillows at night are sufficient. Severe cases require systemic immunosuppressive therapy, usually with high dose corticosteroids [7]. Additional options are retrobulbar irradiation and orbital wall decompression surgery [8]. During pregnancy the therapeutic options are limited. The majority of autoimmune diseases tend to improve during gestation due to the state of enhanced immune tolerance. Thyroid autoimmune diseases, multiple sclerosis and rheumatoid arthritis show improvement during pregnancy [9, 10]. There are a few exceptions; SLE and type 1 diabetes deteriorate [11]. In GD, humoral immune response predominates. Stimulating antibodies against the TSH receptor (TRAb) result in the clinical manifestations of the disease, including hyperthyroidism, goiter, orbitopathy and
© The Author(s). 2020 Open Acces
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