Localized Myxedema Research Articles

Graves diseases with severe progressive ophthalmopathy after thyroidectomy. Case report.

Graves’ disease is an autoimmune disease that may consist of hyperthyroidism, goiter, orbitopathy, and occasionally a dermopathy referred to as pretibial or localized myxedema. Graves’ disease is caused by autoantibodies that bind to the thyrotropin receptor, stimulating growth of the thyroid and overproduction of thyroid hormone. Clinical manifestations of Graves’ disease include diffuse goiter and symptoms and signs resulting from hyperthyroidism. Thyroid hormones excess affects several different body systems, and for this reason, signs and symptoms associated with Graves’ disease can vary strongly, and significantly influence the general well-being. Common symptoms are: tremor, heat sensitivity and warm, weight loss even if with normal eating habits, anxiety and irritability, enlargement of the thyroid gland, alterations in menstrual cycles, erectile dysfunction or decreased libido, fatigue, frequent bowel movements, palpitations, and others. Graves’ orbitopathy is present in about 30-50% of patients with Graves disease. Graves’ orbitopathy is an autoimmune disease of the retroocular tissues occurring in patients with Graves’ disease.We present the clinical case report with progressive ophthalmopathy after a total thyroidectomy. In our case after surgery his ophthalmopathy did not regress and, in fact, was progressive. In the vast majority of cases of Grave’s ophthalmopathy, the periorbital edema regresses significantly after a total thyroidectomy. This patient’s ophthalmopathy did not regress after surgery even the ophtalmopathy progressed. Only after initiation of pulsatile therapy of 500 mg of methylprednisolone weekly did the ophthalmopathy regress noticeably.

Pretibial myxedema in a euthyroid patient: a case report

BackgroundPretibial myxedema also known as localized myxedema, thyroid dermopathy, or infiltrative dermopathy and rarely as localized mucinosis is an infrequent manifestation of Graves’ disease. It can appear before, during, or after the thyrotoxic state. Euthyroid pretibial myxedema is a rare presentation with few case reports in the literature. This case highlights the importance of considering pretibial myxedema when characteristic skin lesions are observed in a euthyroid patient.Case presentationA 72-year old male Ethiopian patient with a very rare presentation of biopsy-proven pretibial myxedema in a euthyroid state without history of thyroid disease and absence of thyroid autoimmune markers. Resolution of skin lesion was achieved after topical corticosteroid application.ConclusionAbsence of history of thyroid disorder and normal thyroid function tests should not exclude the diagnosis of pretibial myxedema.

Electrosurgical debulking of pretibial myxedema of the foot

Pretibial myxedema or thyroid dermopathy constitutes dermal deposition of mucin, primarily hyaluronic acid and chondroitin sulfate. It is a manifestation of autoimmune thyroiditis, seen more in Graves disease than in Hashimoto thyroiditis. The time delay from treatment of hyperthyroidism to appearance of localized myxedema varies from one month to 16 years (mean 5.13 years). Despite a variety of therapeutic options, failure and relapse rates are high. Therapeutic options reported in the literature include compression, topical and intralesional corticosteroids, oral pentoxifylline, octreotide, rituximab, plasmapheresis, and high-dose intravenous immunoglobulin. We share our experience in two patients who were treated with electrosurgical debulking of selected longstanding myxedematous lesions, with one positive result and one negative result.

Rare site of presentation of a rare manifestation of graves’ disease

Infiltrative dermopathy is an uncommon manifestation of Graves’ disease frequently involving the lower extremities. The pretibial area is most commonly involved. Rarely the fingers, hands, elbows, arms, or face are affected. Skin thickening is the characteristic abnormality. Localized myxedema is an autoimmune manifestation of Graves’ disease. Here, we report the case of a 45-year-old who presented with thyroid-associated orbitopathy and localized myxoedema over both the shoulders. In a patient who has long-standing hyperthyroidism, the diagnosis of infiltrative dermopathy is usually confirmed by the location, non-pitting nature, and distinct borders of the lesions. As most of these lesions are asymptomatic, no specific therapy is required.

First case of bilateral localized myxedema of the feet in a hypothyroid patient

First case of bilateral localized myxedema of the feet in a hypothyroid patient

Pretibial Myxedema in Hypothyroidism – A Clinical Paradox

Pretibial myxedema, also known as localized myxedema, is an infiltrative dermopathy. It most often presents as asymptomatic, bilateral diffuse nonpitting edema in the pretibial area. Pretibial myxedema is nearly always associated with Graves’ disease. It is seen approximately in 4% of patients with Graves’ thyrotoxicosis and usually follows ophthalmopathy. Rarely it has been reported in Hashimoto’s thyroiditis and euthyroid patients. Pretibial myxedema may undergo partial or complete remission and is primarily a cosmetic concern. Apart from treatment of the primary thyroid abnormality, topical or intralesional steroids remain the mainstay of treatment. We report a case of a 64 year old man who presented with asymptomatic indurated plaques on both legs. His thyroid function tests were suggestive of primary idiopathic hypothyroidism. Histopathology of the lesion was consistent with pretibial myxedema. A paradox of pretibial myxedema in a patient with primary idiopathic hypothyroidism is a clinical rarity.

Preradial myxedema in a euthyroid male: A distinct rarity

Localized or pretibial myxedema is one of the signs of Graves disease (along with goiter, exophthalmus, thyroid acropathy, and high circulating levels of long-acting thyroid-stimulating hormone) and usually tends to occur at a later stage of the disease or even after the patient becomes euthyroid post treatment. Very rarely has it been reported in euthyroid patients. We report a euthyroid man presenting with localized myxedema on the extensor surface of his forearm with clinical and histopathological features consistent with pretibial myxedema. He responded partially to topical clobetasol propionate cream and tacrolimus ointment 0.1 percent for about 7 months. To the best of our knowledge, this is the first case of preradial myxedema in a euthyroid patient in the English international dermatological literature.

Pretibial Myxedema

Pretibial myxedema or localized myxedema or thyroid dermopathy is an autoimmune manifestation of Graves' disease. It also occasionally occurs in Hashimoto's thyroiditis. Lesions of thyroid dermopathy are usually asymptomatic and have only cosmetic importance. Advanced forms of dermopathy are associated with elephantiasis or thyroid acropachy. Almost all cases of thyroid dermopathy are associated with relatively severe ophthalmopathy. Usually ophthalmopathy appears first and dermopathy much later. All patients with localized myxedema have high serum concentrations of thyroid-stimulating hormone receptor antibodies, indicating the severity of the autoimmune condition. Occurrence of thyroid dermopathy in areas other than pretibial skin indicates a systemic process. Similar to Graves' ophthalmopathy, thyroid-stimulating hormone receptors in the connective tissue may be the antigen responsible for the immune process. Both humoral and cellular immune mechanisms are involved in the stimulation of fibroblasts and the production of large amounts of glycosaminoglycans. Localization in the pretibial area relates to mechanical factors and dependent position. Diagnosis of thyroid dermopathy is based on signs and typical pretibial skin lesions in association with a history of Graves' hyperthyroidism and ophthalmopathy. In some cases, skin biopsy is needed for confirmation. The lesions are usually mild and are overshadowed by more symptomatic ophthalmopathy. Most cases of thyroid dermopathy do not require any therapy. In mildly severe symptomatic cases and when there is cosmetic concern, topical corticosteroids applied under occlusive dressing are beneficial. In more severe cases, systemic immunomodulation may be necessary; however, conclusive evidence for long-term efficacy of these modalities is lacking. When significant edema and elephantiasis are present, local compressive therapy may have added benefit. In mild cases that do not require treatment, 50% of patients achieve complete remission after several years. Severe cases that receive topical corticosteroids or other therapies do not have a better outcome than untreated milder cases. Current treatment modalities for thyroid dermopathy and acropachy are at best palliative. Better and safer means of immunomodulation are needed.

Graves’ Disease presenting as localized myxedema in a thigh donor graft site

Pretibial myxedema, exophthalmus, and thyroid acropachy are the classic manifestations of Graves’ Disease. However, myxedema in Graves’ Disease can occur in locations other than the pretibial surfaces. Furthermore, with systemic symptoms, localized myxedema may occur at sites of trauma or scarring. We describe a patient with localized myxedema on the thigh at the site of a donor skin graft as the initial presentation of Graves’ Disease. (J Am Acad Dermatol 1998;39:846-9.)

A Case Report of EMO Syndrome Showing Localized Hyperhidrosis in Pretibial Myxedema

We describe here a case of EMO syndrome, which is defined as a combination of exophthalmos, pretibial or localized myxedema, and hypertrophic osteoarthropathy. A 34-year-old Japanese man with Graves' disease developed the characteristic eye changes. He showed 22 mm protrusion of both eyes and hypertrophy of the right lateral rectus muscle as well as both superior rectus muscles by computerized tomography. He subsequently developed lightly erythematous, indurated, nonpitting, peau d'orange plaques and nodules on his lower legs. Finally, he developed Graves' acropathy with hypertrophic osteoarthropathy in the metacarpal bones. Histological examination of myxedematous skin showed typical deposition of mucin accompanied by changes in the amount and distribution of elastic fibers. In addition, the lesional skin showed localized hyperhidrosis, a rarely reported complication of pretibial myxedema. We speculate that this hyperhidrosis of the lesional skin was brought about by stimulation of peripheral sympathetic nerves by surrounding mucin deposition, in the setting of poorly controlled hyperthyroidism.

Localized myxedema on the nasal dorsum in a patient with Graves’ disease: Report of a case

We report the case of a 56-year-old Japanese female with Graves' disease associated with localized myxedema on the nasal dorsum. The patient developed localized myxedema concomitantly with hyperthyroidism before antithyroid therapy was given. The lesion was totally removed surgically, as it was small and well circumscribed. Although unusual locations of localized myxedema have been reported elsewhere, there is to date no case of localized myxedema on the nasal dorsum without involvement of the pretibial area reported in the literature. We discuss this unique feature of our patient.

Unusual Locations of Localized Myxedema in Graves' Disease

Three patients with Graves' disease had very unusual locations of localized myxedema. One patient had localized myxedema on the pretibial and shoulder areas after sodium iodide I 131 therapy. The second patient had localized myxedema on his neck, shoulders, and upper part of the back as well as on the pretibial area. The third patient had localized myxedema on the pinnae, also following sodium iodide I 131 therapy. After surgical removal followed by intralesional triamcinolone acetonide injections, the first patient's lesions recurred. The lesions in the second case did not respond to topical steroid cream. The third patient had a partial response to intralesional steroid injections.

Unusual locations of localized myxedema in Graves' disease. Report of three cases

Unusual locations of localized myxedema in Graves' disease. Report of three cases

Serum long acting thyroid stimulator (LATS) and LATS-protector (LATS-P) in Graves' disease associated with localized myxedema.

When localized myxedema occurs in Graves' disease, there is often very high serum long acting thyroid stimulator (LATS) activity. However, this association is not invariable and no pathogenetic role for this IgG associated activity is known. Serum LATS protector (LATS-P) is a closely related IgG activity which is present in the majority of cases of untreated Graves' disease. It usually coexists in LATS positive sera in a substantially greater concentration. Its association with localized myxedema has not been studied, nor have serial studies been performed on this activity during the clinical course of the disease. Fourteen patients (13 females, 1 male) with localized myxedema and a history of Graves' disease were examined. In 13 serum LATS was detectable with a wide range of activity from 2.4 to 1,000 units/ml. Serum LATS-P was detected in all including the LATS negative patient with a range of activity from 46 to 4,068 units/ml. Serial studies for at least 2 years were conducted in 8 patients. In two there was no change in either skin lesions or in serum LATS and LATS-P. In 6 the skin lesions partially or completely resolved. In 5 this was associated with statistically significant falls in serum LATS and LATS-P but in one no significant change occurred. The study demonstrated the high prevalence of LATS and LATS-P in localized myxedema. In the sole LATS negative patient there was a high concentration of LATS-P. The role of these activities in the pathogenesis of the disease remains unknown but in serial studies falls in activity were usually associated with clinical improvement.

Serum Long Acting Thyroid Stimulator (Lats) and Lats-Protector (LATS-P) in Graves' Disease Complicated by Localized Myxoedema

When localized myxedema occurs in Graves’ disease, there is often very high serum long acting thyroid stimulator (LATS) activity. However, this association is not invariable and no pathogenetic role for this IgG associated activity is known. Serum LATS protector (LATS-P) is a closely related IgG activity which is present in the majority of cases of untreated Graves’ disease. It usually coexists in LATS positive sera in a substantially greater concentration. Its association with localized myxedema has not been studied, nor have serial studies been performed on this activity during the clinical course of the disease. Fourteen patients (13 females, 1 male) with localized myxedema and a history of Graves’ disease were examined. In 13 serum LATS was detectable with a wide range of activity from 2.4 to 1,000 units/ml. Serum LATS-P was detected in all including the LATS negative patient with a range of activity from 46 to 4,068 units/ml. Serial studies for at least 2 years were conducted in 8 patients. In two there was no change in either skin lesions or in serum LATS and LATS-P. In 6 the skin lesions partially or completely resolved. In 5 this was associated with statistically significant falls in serum LATS and LATS-P but in one no significant change occurred. The study demonstrated the high prevalence of LATS and LATS-P in localized myxedema. I n the sole LATS negative patient there was a high concentration of LATS-P. The role of these activities in the pathogenesis of the disease remains unknown but in serial studies falls in activity were usually associated with clinical improvement.

Pretibial Myxedema

Pretibial myxedema is recognized as a type of localized myxedema that usually occurs on the anterior lower part of the legs and is often associated with thyroid disease. The lesions have been known to occur or become worse after thyroid surgery or radiation. We present here a case of a patient who sought surgical intervention for his disease. Report of a Case A 28-year-old man's condition was diagnosed as hyperthyroidism in 1974, and he received subsequent iodine 131 thyroid ablation. Three years later, the patient noted single, painless, pink nodules in the pretibial areas of each leg. Excisional biopsy specimens of the lesions were reported as myxomas of the skin. The lesions recurred, and the patient was referred to a plastic surgeon for wide excision and splitthickness skin grafting of both pretibial areas. Three months after excision and grafting, there was evidence of recurrence of leg lesions within the graft

Ultrastructure of localized myxedema

Five biopsies from three patients with localized myxedema were studied by electron microscopy. The dermis showed an overwhelming accumulation of microfibrils with knobs (acid glycosaminoglycans) and an amorphous material containing glycoprotein. Furthermore, evidence of degradation without new formation of collagen fibrils was found. Considerable numbers of mast cells with various types of granules, fibroblasts with dilated granular endoplasmic reticulum, and macrophages were seen in the mucinous areas.

Hyaluronic acid in localized myxedema.

The localized myxedema lesions of Graves' disease contained acid mucopolysaccharides which were 6–16 times the normal skin concentration, and which were composed almost completely, if not entirely, of hyaluronic acid. This observation contrasts with previous reports which have suggested that other mucopolysaccharide polymers were important constituents in this disorder. It is proposed that the manifestations of Graves' disease, other than those induced by hyperthyroidism, have a common biochemical disturbance resulting in increased tissue hyaluronic acid.

The long-acting thyroid stimulator.

When iniected into suitably prepared guinea pigs or mice, the serum of some patients with thyrotoxicosis causes a prolonged discharge of radioiodine from the thyroid. There is chemical and immunological evidence that the long‐acting thyroid stimulator (LATS) responsible for this effect is distinct from pituitary thyroid‐stimulating hormone, and that the activity is inherent in specific immunoglobulin G molecules. The distribution of thyroid‐stimulating activity in the polypeptide chains of the IgG parallels antigen‐binding activity in known antibodies. As a result of these findings and the specific absorption of LATS by human thyroid endoplasmic reticulum, it has been suggested that LATS is an autoantibody to a thyroid component. This hypothesis is discussed. Using suitable concentration methods LATS can be detected in the serum of 85 per cent of thyrotoxic patients, and the level correlates with several parameters of thyroid activity. High levels of LATS are also frequently associated with localized myxedema, but the relation of LATS to the eye signs associated with thyrotoxicosis is less clear.

Myxedema in Hyperthyroidism

Myxedema, strictly speaking, is a boggy swelling of the skin and subcutaneous tissue which results from the deposition of mucin. It traditionally occurs in hypothyroid states, and recognition of this generalized nonpitting edema provides the physician with a reason to suspect hypothyroidism. The lesions of localized myxedema which usually occur in the pretibial areas are also collections of mucin in the skin, as the name implies. These circumscribed lesions develop not in the hypothyroid patient as one might expect, but rather in the hyperthyroid individual who almost invariably has exophthalmos. The lesions usually appear after medical or surgical suppression of thyroid activity. Mucin in either type of myxedema appears to be the same. It represents an increase of the mucin normally present in the ground substance of the dermal connective tissue, and it can be demonstrated histochemically with a stain for acid mucopolysaccharides, such as Alcian blue, methylene blue, or