A Patient With Graves Disease in Whom Presenting Eye Signs Were Associated With Antibodies to the Thyrotropin Receptor and Later Eye Muscle Damage With Antibodies to G2s and Flavoprotein

Wwith Graves hyperthyroidism andmild eye signs in whom ophthalmopathyworsened after several monthsof treatment with Methimazole and thyroxin. Serumantibodies against the eye muscle antigensG2s, flavoprotein (Fp), succinate dehydrogenase(SDH) and flavine adenine Dinucleotide (FAD),and human TSH receptor, were measured retrospectivelyin serum taken from the patient over a3 yr period. High levels of serum antibodiesagainst the TSH receptor [TSH receptor antibody(TRAb)) were detected in the first sample, whenmild proptosis, chemosis and diplopia on extremegaze were noted. TRAb levels then declinedand became negative after 15 months.Twelve months after the initial assessment shedeveloped eye grittiness and excess tearing and,two wk later, antibodies against G2s becamepositive. Six months later she complained of severeupward- gaze double vision and increasedproptosis was noted. At that time antibodiesagainst Fp and SDH became positive. This is thefirst report correlating a patient s autoantibodylevels with clinical symptoms and signs of ophthalmopathy.Autoimmunity against the TSH receptormay be the initial event in the developmentof ophthalmopathy in patients withGraves hyperthyroidism while antibodiesagainst G2s and Fp are produced later, in associationwith worsening inflammatory changesand eye muscle damage. Despite the close relationshipbetween eye muscle antibodies andclinical eye signs in this pat ient the antibodiesare likely to be secondary to the eye muscle reaction,rather than its cause.