Pretibial Myxedema

Author(s): 
Arun Chakrabarty, MD; Catherine M. Stefanato, MD; Tania J. Phillips, MD, FRCPC

Department Editor: Tania Phillips, MD, FRCPC

Overall Learning Objectives: The physician or podiatrist participant will develop a rational approach to the evaluation and treatment of a variety of uncommon wounds and will have an increased awareness of the differential diagnosis of cutaneous wounds and the systemic diseases associated with these wounds.

Submissions: To submit a case for consideration in Diagnostic Dilemmas, e-mail or write to: Executive Editor, WOUNDS, 83 General Warren Blvd., Suite 100, Malvern, PA 19355, eklumpp@hmpcommunications.com

Completion Time: The estimated time to completion for this activity is 1 hour.

Target Audience: This CME/CPME activity is intended for dermatologists, surgeons, podiatrists, internists, and other physicians who treat wounds.

At the conclusion of this activity, the participant should be able to:
1. Recognize the associations of pretibial myxedema with thyroid disease
2. Recognize the lack of specific laboratory values for pretibial myxedema
3. Describe the treatment modalities of pretibial myxedema.

Disclosure: All faculty participating in Continuing Medical Education programs sponsored by HMP Communications are expected to disclose to the program audience any real or apparent conflict(s) of interest related to the content of their presentation. Drs. Chakrabarty, Stefanato, and Phillips disclose no financial conflicts.

Accreditation: HMP Communications is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. HMP Communications is approved by the Council on Podiatric Medical Education as a sponsor of continuing education in podiatric medicine.

Designation: HMP Communications designates this continuing medical education activity for 1 credit hour in Category 1 of the Physician’s Recognition Award of the American Medical Association. Each physician should claim only those hours he/she spent in the educational activity. HMP Communications designates this continuing education activity for .1 CEUs available to participating podiatrists.

Method of Participation: Read the article, take, submit, and pass post-test by December 15, 2003.

This activity has been planned and produced in accordance with the ACCME Essential Areas and Policies.

Release date: December 15, 2002
Expiration date: December 15, 2003

Presentation

A 55-year-old Caucasian woman presented to the clinic complaining of skin lesions on both shins. During the course of the year, the patient traumatized her leg, which resulted in several chronic, tender wounds. She had been applying hydrocolloid dressings without improvement. The patient also mentioned a history of peripheral neuropathy of the distal feet bilaterally. She denied symptoms of heat intolerance, anxiety, change in appetite, and fatigue.

Her past medical history was significant for type 2 diabetes, hypercholesterolemia, hypertension, peptic ulcer disease, gout, severe asthma, and chronic back pain. She had a past surgical history of hysterectomy, osteomyelitis resection, and necrotizing fasciitis of the right leg with debridement and skin grafting. The patient’s medications included rosiglitazone, atorvastatin, hydrochlorothiazide, omeprazole, allopurinol, montelukast, salmeterol inhaler, mometasone nasal spray, prednisone, and tramadol. She was allergic to aspirin and sulfa drugs. There was no personal or family history of thyroid disorders.

Physical Examination

Physical examination revealed an obese woman with a scar over the right calf with loss of muscle bulk from surgical debridement due to necrotizing fasciitis.

References: 

References 1. Schwartz KM, Fatourechi V, Ahmed DD, et al. Dermopathy of Graves’ disease (pretibial myxedema): Long-term outcome. J Clin Endocrinol Metab 2002;87:438–46. 2. Georgala S, Katoulis AC, Georgala C, et al. Pretibial myxedema as the initial manifestation of Graves’ disease. J Eur Acad Dermatol Venereol 2002;16:380–3. 3. Omohundro C, Dijkstra JW, Camisa C, et al. Early onset pretibial myxedema in the absence of ophthalmopathy: A morphologic evolution. Cutis 1996;58:211–4. 4. Wu SL, Chang TC, Chang TJ, et al. Cloning and sequencing of complete thyrotropin receptor transcripts in pretibial fibroblast culture cells. J Endocrinol Invest 1996;19:365–70. 5. Cheung HS, Nicoloff JT, Kamiel MB, et al. Stimulation of fibroblast biosynthetic activity by serum of patients with pretibial myxedema. J Invest Dermatol 1978;71:12–7. 6. Peacey SR, Flemming L, Messenger A, et al. Is Graves’ dermopathy a generalized disorder? Thyroid 1996;6:41–5. 7. Wortsman J, Dietrich J, Traycoff RB, et al. Preradial myxedema in thyroid disease. Arch Dermatol 1981;117:635–8. 8. Somach SC, Helm TN, Lawlor KB, et al. Pretibial mucin. Histologic patterns and clinical correlation. Arch Dermatol 1993;129:1152–6. 9. Kriss JP. Pathogenesis and treatment of pretibial myxedema. Endocrinol Metab Clin North Am 1987;16:409–15. 10. Chang CC, Chang TC, Kao SC, et al. Pentoxifylline inhibits the proliferation and glycosaminoglycan synthesis of cultured fibroblasts derived from patients with Graves’ ophthalmopathy and pretibial myxedema. Acta Endocrinol 1993;129:322–7. 11. Antonelli A, Navarranne A, Palla R, et al. Pretibial myxedema and high-dose intravenous immunoglobulin treatment. Thyroid 1994;4:399–408. 12. Chang TC, Kao SC, Huang KM. Octreotide and Graves’ ophthalmopathy and pretibial myxedema. BMJ 1992;304:158.



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