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VG M, K J, APPALA A, HR N. Rare Association Between Congenital Ptosis With Hashimoto Thyroiditis.--Letter to the Editor. CJP 2025; 11 (1)
URL: http://caspianjp.ir/article-1-259-en.html
URL: http://caspianjp.ir/article-1-259-en.html
Department of Pediatrics, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, India & JSS MEDICAL COLLEGE, JSS ACADEMY OF HIGHER EDUCATION AND RESEARCH,MYSORE,INDIA , jagdishmandya@gmail.com
Abstract: (51 Views)
Dear Editor
Hashimoto's thyroiditis (HT) is an important cause of hypothyroidism and can be associated with ocular problems. Thyroid-associated ophthalmopathy (TAO) is caused by an autoimmune process affecting the orbital tissue. Although TAO is rare in HT, ptosis may be one of the manifestations.
A 9-year-old girl presented with complaints of excessive daytime sleepiness for 2 months. She also had a history of constipation for the past 2 months, passing stools once every 3 days. There was no history of weight gain, cold intolerance, or skin changes. On further inquiry, she reported a lack of interest in playing with peers, but watched television for short periods. Her academic performance was normal.
On examination, her vital signs were within normal limits. General examination did not reveal pallor, icterus, edema, cyanosis, goiter or dry of skin. On nervous system examination, the child was interactive, with no hoarseness of voice or evidence of cranial nerve palsy except for right ptosis [Fig 1], which was reportedly since birth. Motor system examination was normal with elicitable deep tendon reflexes. Examination of other systems was unremarkable. In view of her symptoms of excessive daytime sleepiness and constipation, a provisional diagnosis of juvenile acquired hypothyroidism was made.
Her investigations showed normal complete blood counts, RBS of 83mg/dl, Total T3 of 1.27 ng/ml, Total T4 of 3 µg/dl, TSH of 100µIU/ml, Serum Thyroglobulin (Tg) of 0.73 ng/ml [normal 1.70-55.60 ng/ml], Anti Thyroid Peroxidase (Anti-TPO) of 86.6 IU/ml [Up to 34 IU/ml is normal]. Ultrasound of the neck revealed a normal thyroid gland, indicating hypothyroidism with HT.
Congenital ptosis presents as drooping of the upper eyelid due to congenital underdevelopment of the levator palpebrae superioris muscle since birth [1]. The most common form of ptosis is the simple congenital type (81%), which is idiopathic according to a study by Griepentrog et al [2]. Our case presented with drooping of the right eyelid since birth. HT is characterized by destruction and eventual fibrosis of the thyroid gland due to both cell-mediated and antibody-induced immune responses, leading to hypothyroidism [3]. Females are more commonly affected, with a female-to-male ratio of 10:1 [3]. The majority of women are diagnosed between 30 and 50 years of age [3]. It is the most common cause of hypothyroidism, and the diagnosis is based on clinical symptoms, elevated levels of thyroid-stimulating hormone (TSH) with low levels of thyroxine, along with raised anti-TPO antibodies [3]. Our patient had symptoms of hypothyroidism with supporting laboratory evidence to be diagnosed as HT. HT typically presents with hypothyroidism and painless goiter [3]. However, the latter was absent in our case.
TAO is an autoimmune condition involving the orbital tissue [4]. Clinical features include eyelid retraction, proptosis, compressive optic neuropathy, and restrictive myopathy. It usually occurs in hyperthyroid patients due to Graves’ disease but can also be seen in euthyroid and hypothyroid states. TAO is rare in HT [4]. TAO typically affects both eyes but can also cause unilateral involvement 4. In a study of 120 TAO patients, the common ophthalmological findings were eyelid retraction (91%), proptosis (62%), malfunction of the extraocular muscles (42%), hyperemia of the conjunctiva (34%), edema of the eyelid (32%), and chemosis (23%) [4].
Manju et al. reported blepharoptosis as the manifesting sign of HT in a 13-year-old girl [5]. Jain et al. indicated severe hypothyroidism associated with bilateral complete ptosis in a 55-year-old woman [6]. Unilateral ptosis is diagnosed when there is palpebral fissure asymmetry of ≥ 1mm between the two upper eyelids or a marginal reflex distance (MRD) of < 2.5 mm [2]. MRD1 indicates the degree of ptosis or retraction. It is measured from the light reflex on the cornea to the margin of the upper eyelid when gazing in the primary position and is expressed in millimeters. In our case, MRD 1 in the right eye was 1mm and 6 mm in the left eye, representing right-sided ptosis. However, since the ptosis in our case was congenital, asymptomatic, unilateral, and without other ocular findings, TAO is unlikely. Instead, this may represent a rare association of congenital ptosis with Hashimoto thyroiditis. HT typically presents with hypothyroidism, and clinicians should maintain a high index of suspicion to diagnose hypothyroidism to prevent long-term complications such as dyslipidemia.
Hashimoto's thyroiditis (HT) is an important cause of hypothyroidism and can be associated with ocular problems. Thyroid-associated ophthalmopathy (TAO) is caused by an autoimmune process affecting the orbital tissue. Although TAO is rare in HT, ptosis may be one of the manifestations.
A 9-year-old girl presented with complaints of excessive daytime sleepiness for 2 months. She also had a history of constipation for the past 2 months, passing stools once every 3 days. There was no history of weight gain, cold intolerance, or skin changes. On further inquiry, she reported a lack of interest in playing with peers, but watched television for short periods. Her academic performance was normal.
On examination, her vital signs were within normal limits. General examination did not reveal pallor, icterus, edema, cyanosis, goiter or dry of skin. On nervous system examination, the child was interactive, with no hoarseness of voice or evidence of cranial nerve palsy except for right ptosis [Fig 1], which was reportedly since birth. Motor system examination was normal with elicitable deep tendon reflexes. Examination of other systems was unremarkable. In view of her symptoms of excessive daytime sleepiness and constipation, a provisional diagnosis of juvenile acquired hypothyroidism was made.
Her investigations showed normal complete blood counts, RBS of 83mg/dl, Total T3 of 1.27 ng/ml, Total T4 of 3 µg/dl, TSH of 100µIU/ml, Serum Thyroglobulin (Tg) of 0.73 ng/ml [normal 1.70-55.60 ng/ml], Anti Thyroid Peroxidase (Anti-TPO) of 86.6 IU/ml [Up to 34 IU/ml is normal]. Ultrasound of the neck revealed a normal thyroid gland, indicating hypothyroidism with HT.
Congenital ptosis presents as drooping of the upper eyelid due to congenital underdevelopment of the levator palpebrae superioris muscle since birth [1]. The most common form of ptosis is the simple congenital type (81%), which is idiopathic according to a study by Griepentrog et al [2]. Our case presented with drooping of the right eyelid since birth. HT is characterized by destruction and eventual fibrosis of the thyroid gland due to both cell-mediated and antibody-induced immune responses, leading to hypothyroidism [3]. Females are more commonly affected, with a female-to-male ratio of 10:1 [3]. The majority of women are diagnosed between 30 and 50 years of age [3]. It is the most common cause of hypothyroidism, and the diagnosis is based on clinical symptoms, elevated levels of thyroid-stimulating hormone (TSH) with low levels of thyroxine, along with raised anti-TPO antibodies [3]. Our patient had symptoms of hypothyroidism with supporting laboratory evidence to be diagnosed as HT. HT typically presents with hypothyroidism and painless goiter [3]. However, the latter was absent in our case.
TAO is an autoimmune condition involving the orbital tissue [4]. Clinical features include eyelid retraction, proptosis, compressive optic neuropathy, and restrictive myopathy. It usually occurs in hyperthyroid patients due to Graves’ disease but can also be seen in euthyroid and hypothyroid states. TAO is rare in HT [4]. TAO typically affects both eyes but can also cause unilateral involvement 4. In a study of 120 TAO patients, the common ophthalmological findings were eyelid retraction (91%), proptosis (62%), malfunction of the extraocular muscles (42%), hyperemia of the conjunctiva (34%), edema of the eyelid (32%), and chemosis (23%) [4].
Manju et al. reported blepharoptosis as the manifesting sign of HT in a 13-year-old girl [5]. Jain et al. indicated severe hypothyroidism associated with bilateral complete ptosis in a 55-year-old woman [6]. Unilateral ptosis is diagnosed when there is palpebral fissure asymmetry of ≥ 1mm between the two upper eyelids or a marginal reflex distance (MRD) of < 2.5 mm [2]. MRD1 indicates the degree of ptosis or retraction. It is measured from the light reflex on the cornea to the margin of the upper eyelid when gazing in the primary position and is expressed in millimeters. In our case, MRD 1 in the right eye was 1mm and 6 mm in the left eye, representing right-sided ptosis. However, since the ptosis in our case was congenital, asymptomatic, unilateral, and without other ocular findings, TAO is unlikely. Instead, this may represent a rare association of congenital ptosis with Hashimoto thyroiditis. HT typically presents with hypothyroidism, and clinicians should maintain a high index of suspicion to diagnose hypothyroidism to prevent long-term complications such as dyslipidemia.
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