ESPE Abstracts

Introduction: The most common extra-thyroidal manifestation of Graves' disease is ophthalmic involvement. Pediatric Graves' ophthalmopathy (GO) occurs in approximately one-third of cases with pediatric Graves' disease. However, the frequency of severe GO is quite rare compared to adults, and in this case series, two different GO cases, one severe and one unilateral/asymmetric, are presented.

Case 1: A 14-year-old female was referred to our clinic due to symptoms persisting for six months, including hyperactivity, palpitations, and hand tremors. Physical examination revealed weight SDS: 1.39, height SDS: 0.8, and BMI SDS: 1.1, along with tachycardia, diffuse goiter and marked proptosis. The diagnosis of Graves' disease was confirmed by primary hyperthyroidism and positive thyroid-stimulating immunoglobulin levels. Ophthalmological evaluation revealed a clinical activity score (CAS) of 2, along with positive lagophthalmos and lid lag. Methimazole was initiated (0.15 mg/kg/d) and total thyroidectomy was performed due to pressure symptoms from the goiter and cosmetic concerns expressed by both the family and the patient. Orbital MRI demonstrated active myositis in all muscle groups, particularly affecting the medial and inferior rectus muscles. As a result, the patient underwent methylprednisolone treatment for active Graves' orbitopathy (GO). Following methylprednisolone therapy, orbital decompression surgery was performed due to persistent severe proptosis and ocular symptoms.

Case 2: A 13-year-old girl previously diagnosed with Graves' disease and currently euthyroid after nine months of methimazole treatment presented with drooping of the right eyelid. Initial assessment suggested ptosis, and the patient was further evaluated by ophthalmology, revealing ptosis in the right eye, exophthalmos in the left eye, a clinical activity score (CAS) of 0, negative lid lag, and negative lagophthalmos. Orbital MRI indicated bilateral Graves' orbitopathy (GO), with more pronounced involvement on the left side. Selenium supplementation was initiated for the patient, who was deemed to have mild GO.

Conclusion: Pediatric GO, while uncommon, may manifest with severe GO or atypical features such as unilateral or asymmetric ophthalmopathy. Therefore, it is crucial that every child diagnosed with Graves' disease undergoes evaluation by an experienced ophthalmologist specialized in GO for accurate diagnosis and effective management.

Keywords: Graves' ophthalmopathy, asymmetric Graves' ophthalmopathy, methylprednisolone