Multidisciplinary management of thyroid eye disease (TED) in patients with latent tuberculosis or chronic hepatitis B

BACKGROUND: Intravenous methylprednisolone (IVMP) is a first-line treatment for active moderate-severe or sight-threatening thyroid eye disease (TED), but the presence of systemic infections such as latent tuberculosis (TB) or chronic hepatitis B virus (HBV) act as relative contraindications due to the risk of reactivation. There is limited data to guide clinicians in this high-risk group. METHODS: A retrospective case series was conducted involving five TED patients with relative contraindications to immunosuppression. Each patient included had a EUGOGO severity of moderate-to-severe. Multidisciplinary team (MDT) input guided treatment planning. Patients either received IVMP with or without mycophenolate mofetil (MMF) alongside management of their systemic infection or were observed. TED outcomes, infection status, and adverse events were monitored. RESULTS: Three patients had latent TB and received isoniazid ± rifampicin prophylaxis with two having conservative TED management, due to high-risk features of their TB, and one receiving IVMP with MMF. Two patients had chronic HBV and underwent IVMP therapy with tenofovir or entecavir. No systemic infection progression or adverse events were observed during follow-up. All treated patients showed improvement in Clinical Activity Score (CAS) and improved or stable Graves' Ophthalmopathy Quality of Life (GO-QOL) scores. CONCLUSIONS: Immunosuppression can be safely initiated in TED patients with systemic infections using a multidisciplinary approach. Early screening, judicious patient selection, coordinated care, and prophylactic treatment are key to balancing efficacy with risk mitigation.