Thyroid dermopathy and acropachy in pediatric patients

Graves' disease thyroid dermopathy: a case report

BACKGROUND

Graves' disease is the autoimmune activation of the thyroid gland causing diffuse enlargement and hyperfunction of the gland. Manifestations of Graves' disease are multisystemic and include thyroid orbitopathy; pretibial myxedema, also referred to as thyroid dermopathy; and thyroid acropachy, described as a severe form of thyroid dermopathy. Our paper focuses on an atypical case of thyroid dermopathy.

CASE PRESENTATION

An 11-year-old Saudi male presented with a prominent diffuse goiter and exophthalmos. Investigations were consistent with a diagnosis of Graves' disease. The physical exam showed diffuse, non-pitting swelling of the ankle and penis, mimicking a lymphatic malformation. Further, multiple nodules were found on the hands and feet. Treatment of the nodules with cautery resulted in more severe nodules.

CONCLUSION

This report describes rare presentations of thyroid dermopathy mimicking lymphatic malformation. The Koebner phenomenon can explain this patient's atypical presentations. Intralesional injections of triamcinolone and total thyroidectomy showed clear improvement.

Update on Pediatric Hyperthyroidism

Typical symptoms which should lead to suspicion of hyperthyroidism are unintentional weight loss, tachycardia, and palpitations, heat intolerance, and hyperactivity. It is diagnosed by suppressed thyroid-stimulating hormone (TSH) with elevated thyroid hormone (TH) levels. Graves' disease (GD) due to antibodies stimulating the TSH receptor is the leading cause, and first-line treatment is with methimazole (MMI). Emerging data suggest MMI treatment, up to 8 years is effective and safe in improving the rate of remission. Radioactive iodine (RAI) and thyroidectomy offer definitive treatment and induce permanent hypothyroidism. Thyroid storm is a life-threatening condition with systemic decompensation and hyperpyrexia. Neonates of mothers with current or past GD are at risk for neonatal hyperthyroidism (NH). Appropriate identification and follow-up of at-risk neonates will reduce complications.

Thyroid-Stimulating Hormone Receptor Autoimmunity and Local Factors in Multiple Risk Factors Are Mainly Involved in the Occurrence of Pretibial Myxedema

Background

Pretibial myxedema (PTM) is a local mucinous dermopathy associated with thyroid diseases. Since the etiology of PTM is unclear, the aim of this study is to identify the risk factors for PTM and their etiological roles in PTM occurrence.

Methods

A large-scale case-control study (n = 1,200) was performed to identify risk factors for PTM by calculating odds ratio (OR) values and 95% confidential intervals. The PTM group entered a glucocorticoid treatment trial. Patients with complete response were followed up to the first relapse in a cohort study. The relative risk (RR) values of the main risk factors were calculated for PTM relapse to test their etiological roles.

Results

Among the 19 factors, six risk factors were identified: thyroid-stimulating hormone (TSH) receptor antibody (TRAb) (OR 42.93), autoimmune thyroid disease (AITD) or AITD history (OR 10.30), local trauma (OR 6.55), venous stasis posture (OR 6.16), cigarette smoking (OR 4.48), and age (OR 1.05). Serum TRAb levels were positively correlated with the severity of PTM. Of note, 371/400 patients received glucocorticoid treatment, and 330 achieved complete response. The serum TRAb levels after treatment decreased dramatically compared with those before treatment. After stopping glucocorticoid treatment, serum TRAb levels increased significantly when PTM relapsed (P < 0.001). In 165 relapse cases, an increase in serum TRAb levels occurred first, followed by persistent venous stasis posture or local trauma and finally PTM. The RR of elevated serum TRAb levels was 6.73 in PTM relapse cases. In the elevated serum TRAb level group, the RRs of local trauma, venous stasis posture, and local trauma plus venous stasis posture were 8.81, 6.5, and 8.84, respectively, for PTM relapse cases.

Conclusions

TSHR autoimmunity and local factors in the six identified risk factors are the main causes of PTM occurrence.