ThyroidCases專業(yè)知識(shí)課件

MeganChan,PGY-1UHCMC2023ThyroidCasesGuesstheDiagnosis?TSHFreeT4T3Diagnosis↓↑↑Primaryhyperthyroidism↑↑↑Centralhyperthyroidism↓NormalNormalSubclinicalhyperthyroidism↓Normal↑T3thyrotoxicosis↑↓↓Primaryhypothyroidism↓↓↓Centralhypothyroidism↑NormalNormalSubclinicalhypothyroidismNormal↑↑ExogenousthyroidhormoneCase144y/omaleisinvolvedinamotorvehiclecollisionandsustainsmultipleinjuriestotheface,chestandplevis.Heisunresponsiveonthefieldandisintubatedforairwayprotection.PtisadmittedtotheICU,stabilizedandundergoessuccessfulopenreduction&internalfixationoftherightfemurandrighthumerus.AfterhereturnstotheICU,hisTSHis0.3mU/LandthetotalT4levelisnormal.T3is0.6μg/dL.Whatisthemostappropriatenextmanagementstep?InitiationoflevothyroxineRadionucleotideuptakescanThyroidultrasoundObservationInitiationofprednisoneCase1Whatisthemostappropriatenextmanagementstep?InitiationoflevothyroxineRadionucleotideuptakescanThyroidultrasoundObservationInitiationofprednisoneSick-euthyroidsyndromecanoccurinanyacute,severeillness.TSH/T4/T3abnormalitiesarethoughttoresultfromreleaseofcytokinesinresponsetoseverestress.ThemostcommonhormonepatternislowtotalandunboundT3asperipheralconversionofT4toT3isimpaired.Thisisthoughttobeevolutionarilyhelpfulasloweringthemostactivethyroidhormonewouldlimitcatabolisminstarvedorillpatients.T4maybedecreasedinverysickpatients.Thyroidfunctionwillreturntonormalinweekstomonthsasthepatientrecovers.Case229y/owomanpresentstoyourcliniccomplainingofdifficultyswallowing,sorethroat,andtenderswellinginherneck.Shehasalsonotedfeversintermittentlyoverthepastweek.SeveralweekspriortohercurrentsymptomssheexperiencedsymptomsofanURI.ShehasnoPMHx.Onexam,sheisnotedtohaveasmallgoiterthatispainfultothetouch.Heroropharynxisclear.LabsshowWBCof14.1withnormaldiff,ESR53,TSHof21.Thyroidantibodiesarenegative.Whatisthemostlikelydiagnosis?AutoimmunehypothyroidismCat-scratchfeverLudwig’sanginaSubacutethyroiditisCase2Whatisthemostlikelydiagnosis?AutoimmunehypothyroidismCat-scratchfeverLudwig’sanginaSubacutethyroiditisWhatisthemostappropriatetreatmentforthispatient?IodineablationofthethyroidLargedosesofAspirinLocalradiationtherapyNotreatmentnecessaryPropylthiouracilCase2Whatisthemostappropriatetreatmentforthispatient?IodineablationofthethyroidLargedosesofAspirinLocalradiationtherapyNotreatmentnecessaryPropylthiouracilSubacuteThyroiditisAkaQuervain’sthyroiditis,granulomatousthyroiditis,viralthyroiditisPresentswithfever,constitutionalsymptoms,&painfulenlargedthyroids.Peakincidence:30-50y/o,females>malesMultipleviruseshavebeenimplicated,butnoneidentifiedasthetrigger3phaseillness:1st–ThyroidinflammationfollicledestructionreleaseofthyroidhormonesThyrotoxicosisLowTSH,highT4&T3,radioiodineuptakeislow/undetectable.2nd—ThyroidisdepletedofhormoneHypothyroidismElevatedTSH,lowfreeT4,radioiodineuptakereturnstonormal.3rd—Recoveryphase:decreasedinflammationfolliclesheal®eneratethyroidhormone(4-6monthslater)Usuallyself-limited,benignTreatment:Mildsxs:LargedosesofAspirin(600mgq4-6hrs),NSAIDsSeveresxs:SteroidtaperMayrequirelow-doselevothyroxineCase362y/omanpresentstotheEDwithchestpressureandfeeling“l(fā)ikemyheartisflutteringinsidemychest.”Heexperiencedsimilarsymptoms1monthagothatresolvedspontaneously.Hedidnotseekmedicalattentionatthattime.HehasnosignificantPMHx.OnROShenotessomerecentweightlossdespiteanincreaseinappetiteandexcessivesweating.Onexam,HRisirregularat140-150beats/min.BPis135/55.HeisadmittedandscreeningtestsrevealandundetectableTSHlevel.Case3Whichofthefollowingstatementsistrue?50%ofhyperthyroidpatientswillconvertfromAfibtoNSRwiththyroidmanagementalone.Afirm,smallthyroidonexamwouldbecompatiblewithadiagnosisofGraves’disease.Afibisthemostcommoncardiacmanifestationofhyperthyroidism.Hisexcessivesweatingislikelynotrelatedtohyperthyroidisim.Hyperthyroidismleadstoahigh-outputstatefortheheart,narrowingthepulsepressure.Case3Whichofthefollowingstatementsistrue?50%ofhyperthyroidpatientswillconvertfromAfibtoNSRwiththyroidmanagementalone.Afirm,smallthyroidonexamwouldbecompatiblewithadiagnosisofGraves’disease.Afibisthemostcommoncardiacmanifestationofhyperthyroidism.Hisexcessivesweatingislikelynotrelatedtohyperthyroidisim.Hyperthyroidismleadstoahigh-outputstatefortheheart,narrowingthepulsepressure.Commonsignsofthyrotoxicosisincludetachycardia(mostcommoncardiacabnormality),Afib,tremor,goiter,andwarm,moistskin.Commonsymptomsincludehyperactivity,dysphoria,irritability,heatintolerance,excessivesweatingandfatigue.Weightlossoccursfrequently;however,someptswillgainweightastheytypicallyhavemarkedincreaseinappetite.Thearrhythmiasareamanifestationofahigh-outputstate,whichfrequentlyleadstoawidenedpulsepressureandasystolicmurmur.ThiscanexacerbateunderlyingheartfailureorCAD.Case3Thesamepatientisstartedonatenololandhisheartrateslowsto80beats/min.Whichofthefollowingadditionaltherapiesismostindicated?DiltiazemMethimazoleLevothyroxineLiothyroninePhenoxybenzamineCase3Whichofthefollowingadditionaltherapiesismostindicated?DiltiazemMethimazoleLevothyroxine—sometimesusedincombinationwithantithyroiddrugs(block-replaceregimen)toavoiddrug-inducedhypothyroidism.Liothyronine(oralformofT3)SurgicalresectionHyperthyroidismistreatedwithantithyroiddrugs,radioactiveiodine,orthyroidectomy.MethimazoleandPTUinhibitthyroidperoxidaseandthusdecreaseproductionofT4&T3.InGraves’disease,theyalsoreducethyroidantibodylevels.Thyroidfunctiontests&clinicalmanifestationsarereviewedevery3-4weekswithdosetitratedbasedonunboundT4.Euthyroidismusuallytakes6-8weeks.Case440y/ofemalewithGrave’sdiseasewasrecentlystartedonmethimazole.Onemonthlatershecomestoclinicforaroutinefollowup.Shenotessomelow-gradefevers,arthralgia,andgeneralmalaise.Labsshowmildtransaminitisandglucoseof150.Allofthefollowingareknownsideeffectsofmethimazoleexcept:AgranulocytosisRashArthralgiasHepatitisInsulinresistanceCase4Allofthefollowingareknownsideeffectsofmethimazoleexcept:AgranulocytosisRashArthralgiasHepatitisInsulinresistanceMethimazoleandPTUbothinhibitthefunctionofthyroidperoxidase,reducingoxidationandorganificationofiodide.Rash,urticaria,fever&arthralgiasarecommonsideeffects.Majorsideeffectsarerarebutincludehepatitis,agranulocytosis(<1%)&SLE-likesyndrome.Case5Apatientspresentstoclinicwithcomplaintsoffatigue&hairloss.Hehasgained6.4kgsincehislastclinicvisit6monthsagobutnotesmarkedlydecreasedappetite.OnROS,hereportsnotsleepingwell&feelscoldallthetime.Heisstillabletoenjoyhishobbiesanddoesnotbelievethatheisdepressed.Examrevealsdiffusealopeciaandsloweddeeptendonreflexrelaxation.Case5Whichofthefollowingstatementsregardingthemostlikelydiagnosisiscorrect?AnormalTSHexcludessecondary,butnotprimaryhypothyroidism.T3measurementisnotindicatedtomakethediagnosis.TheT3/T4ratioisimportantfordeterminingresponsetotherapy.Thyroidperoxidaseantibodiesdistinguishbetweenprimaryandsecondaryhypothyroidism.UnboundT4isabetterscreeningtestthanTSHforsubclinicalhypothyroidism.Case5Whichofthefollowingstatementsregardingthemostlikelydiagnosisiscorrect?AnormalTSHexcludessecondary,butnotprimaryhypothyroidism.T3measurementisnotindicatedtomakethediagnosis.TheT3/T4ratioisimportantfordeterminingresponsetotherapy.Thyroidperoxidaseantibodiesdistinguishbetweenprimaryandsecondaryhypothyroidism.UnboundT4isabetterscreeningtestthanTSHforsubclinicalhypothyroidism.Whilehypothyroidismmaybestronglysuspectedfromhistory&physicalexam,itisdefinitivelydiagnosedwithlabs.TSHshouldbethefirsttestsent.AnormalTSHexcludesprimary,butnotsecondary,hypothyroidism.T3levelsarenormalin~25%ofpatientswithclinicalhypothyroidismandnotindicatedfordiagnosis.T3/T4ratioisnothelpfulfordiagnosisorprognosis.IfTSHislowornormal&pituitarydiseaseissuspected,afreeT4shouldbesent.IfT4islow,DDxincludesanteriorpituitarydysfxn,sickeuthyroidsyn,&drugeffects.Insubclinicalhypothyroidism,TSHisthetestofchoiceasTSHiselevatedandT4innormal.Thyroidperoxidaseantibodiesarepresentin>90%ofpatientswithautoimmunehypothyroidism.Case6A75y/owomanisdiagnosedwithhypothyroidism.Shehaslong-standingCADandiswonderingaboutthepotentialconsequencesforhercardiovascularsystem.WhichofthefollowingstatementsistrueregardingtheinteractionofhypothyroidismandtheCVsystem?Myocardialcontractilityisincreasedwithhypothyroidism.Areducedstrokevolumeisfoundwithhypothyroidism.Pericardialeffusionsareraremanifestationsofhypothyroidism.Reducedperipheralresistanceisfoundinhypothyroidismandmaybeaccompaniedbyhypotension.Bloodflowisdivertedtowardtheskininhypothyroidism.Case6WhichofthefollowingstatementsistrueregardingtheinteractionofhypothyroidismandtheCVsystem?Myocardialcontractilityisincreasedwithhypothyroidism.Areducedstrokevolumeisfoundwithhypothyroidism.Pericardialeffusionsareraremanifestationsofhypothyroidism.Reducedperipheralresistanceisfoundinhypothyroidismandmaybeaccompaniedbyhypotension.Bloodflowisdivertedtowardtheskininhypothyroidism.Hypothyroidismisassociatedwithbradycardia&reducedmyocardialcontractility,therebyreducingstrokevolume.Increaseperipheralresistancemaybeaccompaniedbydiastolichypertension.Pericardialeffusionsarefoundinupto30%ofpatients.Bloodflowisdirectedawayfromtheskin&thusproducecoolextremities.Case738y/owomanpresentstocliniccomplainingoffatigue&irritabilitythathavebeenworseningoverthepastseveralmonths.Shehasahistoryofmildintermittentasthmaandhypertriglyceridemia.ExamrevealsHR105,BP136/72,bilateralproptosisandwarm,moistskin.ScreeningtestsaresentandrevealaTSHlevelthatisundetectableandanormalfreeT4.Whatshouldbethenextstepindiagnosis?RadionuclidescanofthethyroidThyroid-stimulatingantibodyscreenThyroidperoxidaseantibodyscreenTotalT4UnboundT3Case7Whatshouldbethenextstepindiagnosis?RadionuclidescanofthethyroidThyroid-stimulatingantibodyscreenThyroidperoxidaseantibodyscreenTotalT4UnboundT3InpatientswiththyrotoxicosisduetoGraves’disease,theTSHislowandtotal&unboundthyroidhormonelevelsareincreased.In2-5%ofpatients,onlytheT3levelswillbeincreased.Inthispatientwithahighpre-testprobabilityofGraves’disease,asuppressedTSH&normalT4supportsGraves’;however,T3shouldbetestedtodefinitivelymakethediagnosis.MeasuringthyroidantibodieswillhelpconfirmthediagnosisofGraves’butthediagnosiscanbemadewithoutthem.Radionuclidescanisusedtoevaluatefortoxicmultinodulargoiterandtoxicadenoma.Case8Whichofthefollowingismostconsistentwithadiagnosisofsubacutethyroiditis?38y/ofemalewith2-wkhistoryofpainfulthyroid,elevatedT4&T3,lowTSH,andanelevatedradioactiveiodineuptakescan.42y/omalewithhistoryofpainfulthyroid4monthsago,fatigue,malaise,lowfreeT4&T3,andelevatedTSH.31y/ofemalewithapainlessenlargedthyroid,lowTSH,elevatedT4&freeT4,andanelevatedradioactiveiodineuptakescan.50y/omalewithapainfulthyroid,slightlyelevatedT4,normalTSH,andanultrasoundshowingamass.46y/ofemalewith3weeksoffatigue,lowT4&T3,andlowTSH.Case8Whichofthefollowingismostconsistentwithadiagnosisofsubacutethyroiditis?38y/ofemalewith2-wkhistoryofpainfulthyroid,elevatedT4&T3,lowTSH,andanelevatedradioactiveiodineuptakescan.42y/omalewithhistoryofpainfulthyroid4monthsago,fatigue,malaise,lowfreeT4&T3,andelevatedTSH.31y/ofemalewithapainlessenlargedthyroid,lowTSH,elevatedT4&freeT4,andanelevatedradioactiveiodineuptakescan.50y/omalewithapainfulthyroid,slightlyelevatedT4,normalTSH,andanultrasoundshowingamass.46y/ofemalewith3weeksoffatigue,lowT4&T3,andlowTSH.Recallthe3stagesofsubacutethyroiditis:1)Thyrotoxicosis—LowTSH,highT4&T3,radioiodineuptakeislow/undetectable.2)Hypothyroidism—ElevatedTSH,lowfreeT4,radioiodineuptakereturnstonormal.3)Recovery(4-6monthslater)PatientBisinthehypothyroidstageofsubacutethyroiditis.PatientAisconsistentwiththethyrotoxicphaseexcepttheradioiodineuptakescanshouldbedecreased,notelevated.PatientCismoreconsistentwithGraves’disease.PatientDisconsistentwithneoplasm.PatientEisconsistentwithcentralhypothyroidism.Case9Ahealthy53y/omancomestoyourofficeforanannualphysicalexam.Hehasnocomplaintsandhasnosignificantmedicalhistory.HeistakinganOTCmultivitaminandnoothermedications.Onexamheisnotedtohaveanontenderthyroidnodule.HisTSHisfoundtobelow.Whatisthenextstepinhisevaluation?Closefollow-upandmeasureTSHin6months.Fine-needleaspirationLow-dosethyroidreplacementPETfollowedbysurgeryRadionuclidethyroidscanCase9Whatisthenextstepinhisevaluation?Closefollow-upandmeasureTSHin6months.Fine-needleaspirationLow-dosethyroidreplacementPETfollowedbysurgeryRadionuclidethyroidscanThyroidnodulesarefoundin5%ofpatientsandaremorecommonwithage,inwomen,andiniodine-deficientareas.TSHshouldbethefirsttestafterdetectionofathyroidnodule.InthecaseofnormalTSH,FNAorUS-guidedbiopsyshouldbepursued.IftheTSHislow,aradionuclidescanshouldbeperformedtodetermineifthenoduleisthesourceofthyroidhyperfunction.“Hot”nodulescanbetreatedmedically,resectedorablatedwithradioactiveiodine.“Cold”nodulesshouldundergoFNA.4%ofnoduleswillbemalignant,10%suspiciousformalignancy&86%areindeterminateorbenign.Case1038y/omotherofthreepresentstoherPCPwithcomplaintsoffatigueandlowenergyfor3months.Shewaspreviouslyhealthyandwastakingnomedications.Shedoesreporta5kgweightgainandsevereconstipation,forwhichsheisnowtakinglaxatives.ATSHiselevatedat25mU/L.FreeT4islow.Sheiswonderingwhyshehashypothyroidism.Whichofthefollowingtestsismostlikelytodiagnosetheetiology?AntithyroglobulinantibiodyAntithyroidperoxidaseantibodyRadioiodineuptakescanSerumthyroglobulinlevelThyroidultrasoundCase10Whichofthefollowingtestsismostlikelytodiagnosetheetiology?AntithyroglobulinantibiodyAntithyroidperoxidaseantibody(TPO)RadioiodineuptakescanSerumthyroglobulinlevelThyroidultrasoundThemostcommoncauseofhypothyroidismintheUSisautoimmunethyroiditis,asitisaiodine-repletearea.Althoughearlierinthedisease,aradiooidineuptakescanmayhaveshowndiffuselyincreaseduptakefromlymphocyticinfiltration,atthispointinthediseasewhentheinfiltrateis“burnedout”thereislikelytobelittlefoundonthescan.Likewise,athyroidultrasoundwouldonlybeusefulforpresumedmultinodulargoiter.

TPOAbsarecommonlyfoundinautoimmunethyroditis,whileantithyroglobulinAbsarelesscommonlyfound.AntithyroglobulinAbsarealsofoundinotherthyroiddisorders(Graves’disease,thyrotoxicosis)andsystemicautoimmunediseases(SLE).Thyroglobulinisreleasedfromthethyroidinalltypesofthyrotoxicosiswiththeexceptionofthyroiddisease.Thispatient,however,ishypothyroid.Case11A54y/owomanwithlong-standinghypothyroidismisseenbyherPCPforaroutineevaluation.Shereportsfeelingfatiguesandsomewhatconstipated.Sinceherlastvisit,herothermedicalconditions,whichincludehypercholesterolemia&systemicHTN,arestable.Shewasdiagnosedwithuterinefibroidsandstartedonironrecently.Herothermedsincludelevothyroxine,atorvastatin,andHCTZ.HerTSHisfoundtobeelevatedat15mU/L.

WhichofthefollowingisthemostlikelyreasonforherelevatedTSH?CeliacdiseaseColoncancerMedicationnoncompliancePoorabsorptionoflevothyroxineduetoferroussulfateTSH-secretingpituitaryadenomaCase11WhichofthefollowingisthemostlikelyreasonforherelevatedTSH?CeliacdiseaseColoncancerMedicationnoncompliancePoorabsorptionoflevothyroxineduetoferroussulfateTSH-secretingpituitaryadenomaAnincreaseinTSHinapatientwithhypothyroidismthatwaspreviouslystableindosingformanyyearssuggestseitherafailureoftakingthemedication,difficultywithabsorptionfromboweldisease,ormedicationinteraction.Ptswithnormalbodyweighttaking>200μgoflevothyroxineperdaywithcontinuedelevatedTSHstronglysuggestsnoncompliance.Othercausesofincreasedthyroxinerequirementsincludemalabsorption(celiacdisease,smallbowelresection),estrogentherapy,&drugsthatinterferewithT4absorption(ferroussulfate,cholestyramine)orclearance(lovastatin,amiodarone,carbamazepine,phenytoin).Case1287y/owomanisadmittedtotheMICUwithdepressedlevelofconsciousness,hypothermia,sinusbradycardia,hypotensionandhypoglycemia.ShewaspreviouslyhealthywiththeexceptionofhypothyroidismandsystemicHTN.Herfamilymendsthatshewasnottakinganyofhermedicationsduetofinancialdifficulties.Thereisnoevidenceofinfectiononexam,urinemicroscopy,orCXR.Herlabsarenotableformildhyponatremiaandglucoseof48.TSHis>100mU/L.Case12AllofthefollowingstatementsregardingthisconditionaretrueEXCEPT:Externalwarmingisacriticalfeatureoftherapyinpatientswithatemperatureabove34oC.HypotonicIVsolutionsshouldbeavoided.IVlevothyroxineshouldbeadministeredwithIVglucocorticoids.Sedationshouldbeavoidedifpossible.Thisconditionoccursalmostexclusivelyintheelderlyandoftenisprecipitatedbyanunrelatedmedicalillness.Case12AllofthefollowingstatementsregardingthisconditionaretrueEXCEPT:Externalwarmingisacriticalfeatureoftherapyinpatientswithatemperatureabove34oC.HypotonicIVsolutionsshouldbeavoided.IVlevothyroxineshouldbeadministeredwithIVglucocorticoids.Sedationshouldbeavoidedifpossible.Thisconditionoccursalmostexclusivelyintheelderlyandoftenisprecipitatedbyanunrelatedmedicalillness.Thepatienthasmyxedemacoma.Thisconditionofprofoundhypothyroidismmostcommonlyoccursintheelderly,oftenwithaprecipitatingcondition(e.g.MI,infection).ManagementincludesIVlevothyroxineandglucocorticoidsduetoimpairedadrenalreserveinseverehypothyroidism.Caremustbetakenwithrewarmingasitmayprecipitatecardiovascularcollapse.Therefore,externalwarmingisindicatedonlyiftemperatureisbelow30oC.Hypertonicsaline&glucosemaybeusedifhyponatremiaorhypoglycemiaissevere;howeverhypotonicsolutionsshouldbeavoidedasthismayworsenfluidretention.Case1329y/owomanisevaluatedforanxiety,palpitations,anddiarrheaandisfoundtohaveGraves’disease.Beforeshebeginstherapyforherthyroidcondition,shehasanepisodeofacutechestpainandpresentstotheED.AlthoughaCTangiogramisordered,theradiologistcallstonotifythetreatingphysicianthatthisispotentiallydangerous.Case13Whichofthefollowingbestexplainstheradiologist’srecommendation?PulmonaryembolismisexceedinglyrareinGraves’disease.Radiationexposureinpatientswithhyperthyroidismisassociatedwithincreasedriskofsubsequentmalignancy.IodinatedcontrastexposureinpatientswithGraves’diseasemayexacerbatehyperthyroidism.TachycardiawithGraves’diseaselimitstheimagequalityofCTangiographyandwillnotallowaccurateassessmentofpulmonaryembolism.Theradiologistwasmistaken;CTangiographyissafeinGraves’disease.Case13Whichofthefollowingbestexplainstheradiologist’srecommendation?PulmonaryembolismisexceedinglyrareinGraves’disease.Radiationexposureinpatientswithhyperthyroidismisassociatedwithincreasedriskofsubsequentmalignancy.IodinatedcontrastexposureinpatientswithGraves’diseasemayexacerbatehyperthyroidism.TachycardiawithGraves’diseaselimitstheimagequalityofCTangiographyandwillnotallowaccurateassessmentofpulmonaryembolism.Theradiologistwasmistaken;CTangiographyissafeinGraves’disease.PtswithGraves’diseaseproducethyroid-stimulatingimmunoglobulins.TheysubsequentlyproducehigherlevelsofT4comparedwiththenormalpopulation.Asaresult,manypatientswithGraves’diseasearemildlyiodinedeficient,andT4productionissomewhatlimitedbytheavailabilityofiodine.Exposuretoiodinatedcontrastthusreverseiodinedeficiencyandmayprecipitateworseninghyperthyroidism.Additionally,thereversalofmildiodinedeficiencymaymakeI-125therapyforGraves’diseaselesssuccessfulbecausethyroidiodineuptakeislessenedintheiodine-repletestate.Case14WhichofthefollowingstatementsbestdescribesGraves’ophthalmopathy?Althoughacosmeticproblem,Graves’ophthalmopathyisrarelyassociatedwithmajorocularcomplications.Diplopiamayoccurfromperiorbitalmuscleswelling.Itisneverfoundwithoutconcomitanthyperthyroidism.Themostseriouscomplicationiscornealabrasion.Unilateraldiseaseisnotfound.Case14WhichofthefollowingstatementsbestdescribesGraves’ophthalmopathy?Althoughacosmeticproblem,Graves’ophthalmopathyisrarelyassociatedwithmajorocularcomplications.Diplopiamayoccurfromperiorbitalmuscleswelling.Itisneverfoundwithoutconcomitanthyperthyroidism.Themostseriouscomplicationiscornealabrasion.Unilateraldiseaseisnotfound.Althoughlidretractioncanoccurinanytypeofhyperthyroidism,Graves’diseaseisassociatedwithspecificeyesignsthatarethoughttobeduetotheinteractionofautoantibodieswithintheperiorbitalmuscles.TheonsetofGraves’ophthalmopathymayoccurbeforeorafterhyperthyroidism,andrarelymaynotbeassociatedwithhyperthyroidismatall.Proptosisoccursi