case_images: PMC11775584_01
case_images: Clinical course of Graves disease and orbitopathy. On first admission, diplopia improved dramatically after methylprednisolone pulse therapy and orbital radiotherapy. Ocular symptoms reexacerbated after SARS-CoV-2 infection. On second admission, pyridostigmine was quite effective for the ptosis, despite the limited effects of the combination therapy for Graves orbitopathy. CyA, cyclophosphamide; fT4, free thyroxine; LT4, levothyroxine; MMI, methimazole; mPSL, methylprednisolone; PSL, prednisolone; Tac, tacrolimus; TSH, thyrotropin.
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case_images: PMC11775584_01_luaf019f1.jpg
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case_images: We therefore diagnosed Graves disease and orbitopathy and started methimazole 15 mg/day (Fig. 1). Hyperthyroidism rapidly improved after starting methimazole, the diplopia and swollen eyelids markedly improved, and the clinical activity score decreased to 2 of 10 points within 6 weeks after starting the combination therapy (see Fig. 1).
case_images: Short tau inversion recovery images of orbital magnetic resonance imaging during treatment for Graves orbitopathy. Enlarged extraocular muscles with high signal intensities (A, yellow arrows) improved after treatment with steroid pulse therapy and ocular radiotherapy (B, yellow arrows) on first admission. Enlargement of the right inferior rectus muscle with high signal intensities after SARS-CoV-2 infection (C, a red arrow), which improved after the combination therapy (D, a red arrow) on second admission.
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case_images: Magnetic resonance imaging (MRI) revealed bilateral enlargement of the extraocular muscles, and short tau inversion recovery (STIR) images showed high signal intensities of the muscles, suggesting active inflammation (Fig. 2A). Orbital MRI had shown enlarged bilateral extraocular muscles with high signal intensity on STIR image (Fig. 2A). These abnormal MRI findings improved after combination treatment with MPT and orbital radiotherapy (Fig. 2B). Orbital MRI showed predominant enlargement of right inferior rectus muscles with high signal intensity on STIR image (Fig. 2C), compatible with the exacerbation of GO. The second course of MPT and orbital radiotherapy was effective for the enlargement and inflammatory MRI findings of the ocular muscles (Fig. 2D), but the patient reported continued ptosis, which was especially enhanced in the afternoon.