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Elephantiasic Pretibial Myxedema, Chronic and Recalcitrant Thyroid Dermopathy
EP26857
Poster Title: Elephantiasic Pretibial Myxedema, Chronic and Recalcitrant Thyroid Dermopathy
Submitted on 08 Feb 2018
Author(s): Alisha Agrawal, BA, Anna Kim, MD, Erfon Ekhlassi, MD, Lucia Seminario-Vidal, MD, PhD
Affiliations: University of South Florida
This poster was presented at USF Research Day 2018
Poster Views: 961
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Poster Information
Abstract: Patients afflicted with autoimmune thyroiditis, specifically Graves’ disease, can have extrathyroidal manifestations such as exophthalmos, thyroid dermopathy, and acropachy. Thyroid dermopathy usually presents as pretibial myxedema (PTM) due to its predilection for the pretibial area. In severe forms of PTM, it can present as the elephantiasic form, which is notoriously resistant to conventional treatment. Due to the disease rarity, only a few case reports of elephantiasic PTM exist in the literature. In fact, only 1 out of 7671 patients with Graves’ Disease presented with a elephantiasic form of PTM in the 20 year experience of Mayo Clinic. These patients had persistent and progressively worsening dermopathy despite achieving an euthyroid state and applying conventional compressive and topical therapies. Novel treatment approaches including complete decongestive physiotherapy; radiotherapy; plasmapheresis alone and in combination with immunosuppressive agents (such as corticosteroids, rituximab, or azathioprine); intravenous immunoglobulin; pentoxifylline; melphalan; surgical therapy; and somatostatin analogue (octreotide) have shown promising, albeit mixed results. We present a 62-year-old patient with past medical history significant for Graves’ disease now status post thyroidectomy and surgical intervention for exophthalmos who presented to our clinic with a 5-year history of painful disabling bilateral lower extremity swelling. She had been treated with compression bandages, compression stockings, and topical steroids under occlusion without improvement. Physical examination revealed edematous flesh colored cobblestoned plaques with serosanguinous drainage distributed over the bilateral shins, mainly over the pretibial area and dorsal feet. In addition, the patient demonstrated notable bilateral eye proptosis and enlarged, coarsened hands with clubbing of her digits. Biopsies were obtained and demonstrated dermal mucinosis compatible with pretibial myxedema. Based on the chronicity of the patient’s dermopathy and dramatic clinical presentation, our patient was diagnosed with elephantiasic PTM. Summary: Patients afflicted with autoimmune thyroiditis can have extrathyroidal manifestations such as exophthalmos, thyroid dermopathy, and acropachy. Thyroid dermopathy usually presents as pretibial myxedema (PTM) due to its predilection for the pretibial area. In severe forms of PTM, it can present as the elephantiasic form, which is notoriously resistant to conventional treatment. Due to the disease rarity, only a few case reports of elephantiasic PTM exist in the literature.References: 1. Antonelli A, Navarranne A, Palla R, et al. Pretibial myxedema and high-dose intravenous immunoglobulin treatment. Thyroid. 1994;4(4):399-408. doi:10.1089/thy.1994.4.399.

2. Dhaille F, Dadban A, Meziane L, et al. Elephantiasic pretibial myxoedema with upper-limb involvement, treated with low-dose intravenous immunoglobulins. Clin Exp Dermatol. 2012;37(3):307-308. doi:10.1111/j.1365-2230.2011.04175.x.

3. di Meo N, Nan K, Noal C, et al. Polypoid and fungating form of elephantiasic pretibial myxedema with involvement of the hands. Int J Dermatol. 2016;55(7):e413-e415. doi:10.1111/ijd.13259.

4. Engin B, Gumusel M, Ozdemir M, Cakir M. Successful combined pentoxifylline and intralesional triamcinolone acetonide treatment of severe pretibial myxedema. Dermatol Online J. 2007;13(2):16.

5. Fatourechi V, Pajouhi M, Fransway AF. Dermopathy of Graves disease (pretibial myxedema). Review of 150 cases. Medicine (Baltimore). 1994;73(1):1-7.

6. Fatourechi
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