IMPLICATIONS OF STEROID THERAPY IN THE MANAGEMENT OF AN IMMUNOCOMPROMISED PATIENT WITH SEVER GRAVES' OPHTHALMOPATHY (GO)

Abstract

INTRODUCTION
Severe GO is four times more common among males. Immunosuppressive therapy is aimed at combating inflammation and preserving sight. Kahaly et al found that high dose intravenous pulsed methylprednisolone for moderate to severe GO had favorable response rates compared to oral prednisolone. However, the treatment is associated with significant morbidity among diabetes, renal and liver patients. The possible complications are systemic bacterial and fungal infection, cataract, osteoporosis and hypoadrenalism.

CASE
A 42-year-old gentleman, non-smoker, with known history of diabetes, hypertension, old stroke, chronic kidney disease (CKD) stage 4 and bilateral severe non-proliferative diabetic retinopathy, presented with painful red eyes with proptosis of the left eye of 4 months’ duration. Visual Acuity (VA) and clinical activity score (CAS) assessments were 6/24 and 3/7 on the right eye and 6/36 and 6/7 on the left, respectively. He had severe GO without optic nerve compression confirmed by magnetic resistance imaging. He was clinically and biochemically euthyroid. He was started on oral prednisolone but relapsed within a month. Subsequently, he was given pulsed intravenous methylprednisolone totaling 10.25 g in combination with oral cyclosporine. During this period, he developed neutropenic sepsis, herpes zoster and deterioration of CKD requiring temporary dialysis. After initial response to steroid, his condition declined to sight-threatening left GO with optic nerve compression resulting in near blindness. He underwent orbital wall decompression followed by peribulbar triamcinolone injection. While CAS improved significantly to 0/7 on both eyes, his vision did not recover, with VA 6/24 on the right and only hand movement on the left. Orbital radiotherapy was not offered due to advanced diabetic retinopathy.

CONCLUSION
This case highlights the challenges in using steroid therapy in a patient complicated by diabetes and other comorbidities in an attempt to save sight, while taking the risk of life-threatening infection and deterioration of renal function.