Visual Vignette

Abstract

A 54-year-old African American man with history of renal transplant for nephrosclerosis in 2002 was admitted for acute maxillary sinusitis. For the past 8 years, he was taking long-term immunosuppressant therapy, including prednisone, 10 mg daily. He had a sister with lupus and thyroid disease. In the past 2 years, he noticed progressive bulging of his eyes and marked periorbital edema. He reported no double vision, but noticed difficulty adapting vision to far distance after reading. His eyes felt “tight” and dry. He intentionally lost approximately 6.8 kg in the last year. He noticed increased sweats, but reported no palpitations, insomnia, heat or cold intolerance, or changes in skin texture. Records showed several low thyrotropin values in the past, with normal free thyroxine and triiodothyronine in repeated measures. The patient was referred for evaluation of proptosis. On physical examination, he appeared euthyroid, with a normal thyroid gland. He had a round face and thick neck, mild conjunctival congestion, and normal extraocular movements. There was noticeable upper and lower eyelid edema with symmetric appearance and increased resistance to retropulsion bilaterally. Exophthalmometry: 27 mm left eye; 28 mm right eye. Slight clubbing was noted on extremities bilaterally. He had no areas of vitiligo or pretibial myxedema. Head computed tomography revealed that the posterior aspect of the sclerae was 3 mm anterior to the zygomatic line of both globes (fine horizontal lines), and the proptosis, as measured by computed tomography, was 32 mm (Fig. 1). Panel A shows the axial image of the patient. Panel B shows an axial image from a patient with normal anatomy. Panel C shows an axial image from a patient with Graves disease. Values from repeated thyroid tests were all normal including thyrotropin, free thyroxine, thyroperoxidase and thyroglobulin antibodies, thyroid-stimulating immunogloblin, and thyrotropin receptor antibodies. What is the diagnosis?