Pretibial myxedema and nonthyrotoxic thyroid disease

A 63-year-old woman presented with a six month history of a large pruritic plaque which was present over both her legs and feet. The lesions had first appeared over her right leg, followed by involvement of left leg. She denied fatigue, heat intolerance, hand tremor, constipation, unexplained weight gain or change in voice. Her past medical history included Type-2 diabetes mellitus, which was currently diet controlled and hypertension, of two year's duration. Her current medications included an angiotensin receptor blocker. Her physical examination revealed a non-tender, firm, nodular thyroid swelling and exophthalmos. Her cutaneous examination showed a well defined, indurated, erythematous to skin coloured non-tender plaque over both anterolateral aspects of legs. On left side, lesions extended upto middle of the leg and on the right side, just above the ankle, extending to involve bilateral feet, but sparing the toes [Table/ Fig-1]. There was no clubbing, hyperhidrosis or hypertrichosis.Thyroid function test showed thyroid-stimulating hormone (TSH)-2.25 mu/L (0.27-4.20 mu/L), free triiodothyronine (T3) -1.54 nmol/L (1.3-3.1 nmol/l), free thyroxine (T4) -93.62 nmol/l (66-181 nmol/l), thyroglobulin antibodies (AbTG) titre-190 IU/mL(0-35 IU/mL) and Anti-TPO antibody levels of >1000 IU/mL (0-35iu/ ml). Other haematological and biochemical investigations, including serum creatinine, lipid profile and plasma glucose were within normal limits. Keeping in mind PM, chronic dermatitis and lichen myxedematosus as differentials, a skin biopsy was taken from left leg. Histopathology showed a normal epidermis, collagen fibres in reticular dermis, which were mildly separated by deposits of mucin, and mild perivascular lymphocyte infiltration. These changes were suggestive of PM [Table/ Fig-2].Ultrasound examination of thyroid showed diffusely heterogeous and bulky cystic areas with increased vascularity. Few subcentimetric sized lymph nodes were noted, which were bilateral at level 2 and level 3, which suggested a possibility of Thyroiditis. Fine needle aspiration biopsy taken from thyroid swelling showed oxyphilic cells with round nuclei and moderate to marked anisocytosis, prominent nucleoli and abundant eosinophilic granular cytoplasm. Few multinucleated giant cells with occasional clusters of epitheloid histiocytes were present, which favoured changes of Hashimoto's thyroiditis. The lesions regressed after 4 sittings, with monthly intralesional triamcinolone acetonide injections, 10 mg/ml, 0.5-1.0 ml per lesion. DisCussionPM is a well-defined cutaneous mucinosis which is characterized by increased amounts of acid glycosaminoglycans in the dermis. It is a rare clinical finding which is often referred to as localized myxedema or thyroid dermopathy. It is an autoimmune manifestation seen in 5 -10% of patients with Graves thyrotoxicosis [1]. PM has a gradual onset and it typically develops 12 to 24 months after the diagnosis of thyrotoxicosis. It tends to affect older adults, showing a peak incidence in the sixth decade of l...

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“…Lynch et al, [8] reported cases of PM with euthyroidism, but with thyroid gland related clinical or laboratory disorders.…”

Section: Resultsmentioning

confidence: 99%

Pretibial Myxedema Associated with Euthyroid Hashimoto’s Thyroiditis: A Case Report

Nair

Mishra

Chaudhary

2014

JCDR

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“…As shown in Table 1, most of the patients reported with hypothyroid Graves' disease in the literature had anti-TSH receptor antibodies; 10 of 19 patients had long acting thyroid stimulator (LATS) [10,[24][25][26][27][28][29][30], 9 of 12 patients had TBII [2,[31][32][33][34][35] and all 9 patients had TSAB [2,[32][33][34][35][36]. No patient had TSBAB.…”

Section: Discussionmentioning

confidence: 99%

Anti-Eye Muscle Antibodies and Hypothyroid Graves' Disease: A Case Report.

et al. 1992

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Abstract. We report the case of a 70-year-old man who developed hypothyroidism associated with TSH receptor antibodies and severe ophthalmopathy during lithium therapy. He had received lithium therapy for more than 20 years for manic depression, when ophthalmopathy (class VI of the American Thyroid Association classification) and mild hypothyroidism developed. Orbital magnetic resonance imaging indicated marked enlargement of the superior, medial and inferior rectus muscles in the left eye. He had anti-eye muscle antibodies in his serum, detected by Western blotting and quantified by chromatoscanning, as well as anti-TSH receptor antibodies. He was treated with supplementation of levothyroxine and four cycles of methylprednisolone pulse therapy. After the pulse therapy, both anti-eye muscle antibodies and anti-TSH receptor antibodies decreased and disappeared in parallel with the improvement in eye symptoms and signs. These observations suggest the importance of anti-eye muscle antibodies as clinical markers in the development of thyroid-associated ophthalmopathy.

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“…Localized myxedema may be observed in hypo/hyperthyroidism [1]. However, the affected sites are usually pretibial area and the lesion on the eye lid is rare.…”

Section: Lettermentioning

confidence: 99%

Localized Myxedema on the Upper Eyelids in a Patient of Hypothyroidism

Takahashi¹

2016

Int J Dermatol Clin Res

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018eyelashes and eyebrows, especially on the temporal side, and puffiness of eyelids are the main features [2]. Mahto described the puffiness of eyelids as a significant complication of myxedema [2]. However, the reports of the eyelid myxedema in thypothroidsm are few and Ohtsuka et al., reported myxedema on the skin including both eyelids in hypothyroidism [3]. Our case is the second of localized myxedema with lesions restricted on the upper eyelids. Clinical differential diagnosis may include dermatomyositis, which was negated by laboratory findings of normal muscle enzyme activity, no increase in anti-nuclear antibody, and no liquefaction degeneration of basal cell layer of epidermis in histopathology.We report a case of myxedema on the upper eyelids, which may be a clue of diagnosis of hypothyroidsm. LetterLocalized myxedema may be observed in hypo/hyperthyroidism [1]. However, the affected sites are usually pretibial area and the lesion on the eye lid is rare. We report a case of myxedema on the bilateral upper eyelids, which was a diagnostic clue of hypothyroidism associated with Hashimoto disease.A 42-year-old Japanese woman presented with upper eyelid swelling of 2 months duration ( Figure 1a). She did not complain muscle weakness or myalgia. She showed no dry coarse skin, tremors of the hands, thick tongue, or loss of hair. Histopathology of the skin biopsy revealed swelling of the collagen bundles with splitted individual fibers accompanied with pale material (Figure 1b), which was stained with blue with colloidal iron (Figure 1c). Laboratory investigation revealed decreased free T4 (0.88 ng/ml (1-1.8)), decreased free T3 (1.12 pg/ml (2.73-4.5)), and increased TSH (10.34 IU/ml (0.27-4.29). Anti-thyroid, anti-microsome, antithyrogloblin and anti-thyroid peroxidase antibodies were positive. Total cholesterol (286 mg/dl) and triglyceride (342 mg/dl) were elevated. Other laboratory findings including anti-nuclear antibody, aldolase, creatine kinase, and angiotensin-converting enzyme showed normal results. Echo examination disclosed slight but diffuse swelling of thyroid gland. Chest X-rays showed no abnormality and no malignant disease was detected in CT. The patient was diagnosed as localized myxedema with hypothyroidism due to Hashimoto disease. After three months of thyroid hormone replacement therapy, the skin lesions gradually improved accompanied with euthyrodic state. We got the informed consent form the patient.Localized myxedema tends to be observed in hyperthyroidism on the anteriolateral aspect of lower legs as pretibial myxedema. In hypothyroidism, generalized myxedema is usually observed with hair loss, dryness of the skin, and hoarseness. In hypothyroidism loss of 3. Ohtsuka A, Yamakage A, Yamazaki S (1999) Deram mucinosis and musculoskeletal symptoms simulating polymyositis as a presenting sign of hypothroidsm. Eur J Dermatol 9: 227-229.

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Pretibial myxedema and nonthyrotoxic thyroid disease

Cited by 19 publications

References 0 publications

Pretibial Myxedema Associated with Euthyroid Hashimoto’s Thyroiditis: A Case Report

Pretibial Myxedema Associated with Euthyroid Hashimoto’s Thyroiditis: A Case Report

Anti-Eye Muscle Antibodies and Hypothyroid Graves' Disease: A Case Report.

Localized Myxedema on the Upper Eyelids in a Patient of Hypothyroidism

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