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Elephantiasis in a patient with thyroid eye disease

A 29-year-old man with Graves disease presented with a 6-month history of bulging eyes and upper and lower extremity skin changes. The patient previously underwent radioactive iodine ablation and at the time of presentation was receiving levothyroxine and was euthyroid. There was no family history of Graves disease or thyroid eye disease (TED) and the patient was a non-smoker. Visual acuity was 20/20 bilaterally. There was no afferent pupillary defect. Ocular motility was moderately impaired in depression and abduction on the right and in elevation and abduction on the left. There was bilateral proptosis and upper and lower eyelid retraction with superior and inferior scleral show (Figure 1a). A computed tomography scan of the orbits demonstrated significantly enlarged extra-ocular muscles in a fusiform pattern (Figure 1b). Humphrey visual field testing was within normal limits. The patient’s fingers were uniformly swollen (Figure 1c), and the patient’s feet demonstrated non-pitting edema and cobblestone-appearing hyperkeratotic papulonodules (Figure 1d). A diagnosis of TED with associated