Elephantiasic pretibial myxoedema

摘要

A 33-year-old man presented in the outpatient department of Internal Medicine, Tri-service General Hospital, Taipei, Taiwan, with two weeks of fatigue and progressive dyspnoea. Physical examination revealed tachycardia, diaphoresis, ophthalmopathy, resting tremor and a diffusely enlarged thyroid gland. Laboratory tests showed elevated serum thyroxine (24.2 mug/dl, reference range: 5.4 to 11.7 mug/dl), free thyroxine level (4.49 ng/ dl, reference range: 0.7 to 1.24 ng/dl) and thyrotrophin receptor antibody level (52 IU/ml, reference range: <35 IU/ml), and a decreased serum thyrotropin level (0.03 muIU/ml, reference range: 0.34 to 4.25 muIU/ml). The patient was diagnosed as a case of Graves' disease. Propranolol and methimazole were administered as initial treatment He subsequently developed multiple waxy, indurated, nonpitting plaques and nodules with peau d'orange appearance and hyperpigmentation on both legs' (Fig.) within 6 months. A skin biopsy specimen from the pretibial skin showed that the dermis was thickened and mucin staining demonstrated abundant deposition of mucin in dermis separating the collagen fibers. A diagnosis of pretibial myxoedema was confirmed. During the two year of follow up and treatment with topical corticosteroids under occlusive dressings three times daily, pretibial myxoedema remained and he continued to reveice treatment.