Graves’ dermopathy and acropachy

Excerpt

A 57-year-old woman was referred to hospital with verrucous nodules on her shins. Approximately 30 years ago, she underwent near-total thyroidectomy for hyperthyroidism and goiter diagnosed as Graves’ disease. Postoperatively, she had normal thyroid function with levothyroxine for 30 years, but her pretibial nodules were enlarged. Physical examination showed huge verrucous nodules on her shins and dorsa of the foot (Fig. 1a) and exophthalmos. Foot X-ray showed lobular lesions on bilateral shins (Fig. 1b, arrowheads). Hand X-ray showed fluffy periosteal reaction of bones (Fig. 1c, arrowheads), soft tissue swelling (Fig. 1c, asterisks), and digital clubbing which are compatible with thyroid acropachy. Laboratory examinations showed thyroid-stimulating hormone receptor antibody levels of 380 IU/L (normal, <2.0 IU/L), thyroid-stimulating antibody values of 3,758 % (normal, ≤180 %), and thyroid-stimulating hormone blocking antibody values of 100 % (normal, ≤45.6 %). Histological examination of the nodules showed epidermal acanthosis and mucinous degeneration. She was diagnosed with pretibial myxedema associated with Graves’ disease. Localized or pretibial myxedema is an infrequent extrathyroidal manifestation of Graves’ disease (along with goiter, exophthalmus, thyroid acropachy, and high circulating levels of long-acting thyroid-stimulating hormone), with late onset, often occurring after thyroidectomy or radioisotope therapy [1]. It is generally considered that thyroid dermopathy and acropachy occur with Graves’ ophthalmopathy, and appear to be markers of severe ophthalmopathy [2]. Subcutaneous injections of steroids were initiated with modest improvement of myxedema after 8 months.

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