You are asked to make a diagnosis simply by observing eye movements in this 60-year-old man. What is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, do you recommend? What presenting symptoms do you think this patient might have?
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DIAGNOSIS: Grave's disease.
Note the positive eye signs for hyperthroidism - the stare, the lag of the upper lid on downward gaze (von Graefe sign), the lag of the lower lid on upward gaze (Griffith sign), and the lag of the globe behind the upper lid on upward gaze (Mean sign); all of these signs are due to lid spasm and may occur in Grave's disease and other varieties of hyperthyroidism. Other signs to be noted include Stellwag sign (infrequent blinking) and Boston sign (jerking of the lagging lid). Joffroy sign (absence of forehead wrinkling with upward gaze) is not present. Eye signs that are seen only in Grave's disease include proptosis (present), periorbital edema and ophthalmoplegia (absent). Acropatchy (nail clubbing) and dermopathy (pretibial edema) are comparatively rare findings.
Symptoms of hyperthyroidism include heat intolerance, anxiety, palpitations, weight loss, proximal muscle weakness, hyperphagia, and amenorrhea. The disease may be very subtle in the elderly and present with atrial fibrillation, heart failure, or weight loss. A diffuse, nontender goiter is characteristic of Grave's disease.
A plasma TSH level of < 0.1 microunits/mL and an elevated free T4 or, if the FT4 is normal, an elevated T3 establishes a diagnosis of hyperthyroidism. The diagnosis of Grave's disease is established by measuring plasma levels of anti-thyroid receptor antibodies.
Treatment of Grave's disease consists of a beta-adrenergic anatagonist to control anxiety and tachycardia and either radioactive iodine (the treatment of choice for most patients), thionamides, or subtotal thyroidectomy.