Dolor y edema de miembros inferiores por dermopatía tiroidea: presentación inusual de la enfermedad de Graves en una paciente adolescente / Lower limb pain and edema due to thyroid dermopathy: an unusual presentation of Graves disease in an adolescent patient

La enfermedad de Graves es un proceso inmunomediado en el que autoanticuerpos se dirigen contra el receptor de tirotrofina. Por su acción estimulante sobre la glándula tiroides, se genera crecimiento glandular difuso y aumento de la hormonogénesis. Se caracteriza por el comienzo subagudo de síntomas constitucionales, neuromusculares, cardiovasculares, gastrointestinales y oculares, seguidos en algunos casos de la aparición de manifestaciones cutáneas como la dermopatía tiroidea o mixedema. En pediatría la enfermedad de Graves es infrecuente (aunque es la causa más frecuente de hipertiroidismo), pero la cronología de aparición de los síntomas está bien descrita; es rara la aparición de dermopatía en ausencia de otros síntomas de hipertiroidismo y sin afectación ocular. Se presenta el caso de una paciente de 15 años con dermopatía tiroidea por enfermedad de Graves sin oftalmopatía ni otros síntomas de hipertiroidismo clínico asociados.

Graves disease is an immune-mediated process characterized by the presence of autoantibodies to thyrotropin receptors. Its stimulating action on the thyroid gland causes diffuse glandular growth and increased hormone production. Graves disease is characterized by a subacute onset of non-specific, neuromuscular, cardiovascular, gastrointestinal, and eye symptoms, sometimes followed by skin manifestations, such as thyroid dermopathy or myxedema. In pediatrics, Graves disease is rare (although it is the most frequent cause of hyperthyroidism). However, the chronology of symptom onset has been well described; the development of dermopathy in the absence of other symptoms of hyperthyroidism and without eye involvement is rare. Here we describe the case of a 15-year-old female patient with thyroid dermopathy due to Graves disease without eye disease or other associated clinical symptoms of hyperthyroidism.

Graves' disease, myxedema, and papillary thyroid carcinoma / Doença de Graves, mixedema e carcinoma papilífero de tireoide

Graves' disease (GD) is the leading cause of hyperthyroidism and diffuse toxic goiter in iodine-sufficient geographi-cal areas. GD is associated with classical manifestations such as ophthalmopathy and thyroid dermopathy, in addi-tion to diffuse goiter, which may be the site of carcinomas, as a complication. Case report: A 52-year-old woman presented with goiter and symptoms compatible with hyperthyroidism, such as heat intolerance, weight loss, fati-gue, increased sweat, tachycardia, fine tremors, increased intestinal transit, anxiety, emotional lability, insomnia, exophthalmos, and pretibial myxedema. A complementary investigation confirmed the diagnosis of hyperthyroidism (high free T4 and total T3 levels and low thyroid-stimulating hormone - TSH levels). Ultrasound images showed dif-fuse enlargement of the thyroid lobes by approximately 10 times and the presence of three thyroid nodules, one of which was larger than 2 cm with heterogeneous echogenicity and vascularization throughout the nodule; ultrasoun-d-guided fine needle aspiration revealed cytology compatible with Bethesda IV; scintigraphy revealed a low uptake area (cold nodule) amid a diffuse high-uptake goiter. A thyroidectomy was performed, and the anatomical specimen diagnosis revealed papillary thyroid carcinoma in the right lobe, with adjacent parenchyma compatible with GD. Histopathological examination of the skin showed the presence of myxedema compatible with Graves' dermopathy. The patient evolved with the normalization of TSH levels and a reduction of cutaneous manifestations. Conclusion:GD abnormalities may not be restricted to the classic clinical manifestations, and a careful investigation may reveal the coexistence of carcinomas. (AU)

A doença de Graves (DG) é a principal causa de hipertireoidismo e bócio difuso tóxico em áreas geográficas com iodo suficiente. DG está associada a manifestações clínicas clássicas como oftalmopatia e dermopatia da tireoide, além do bócio difuso, que pode ser sítio de carcinomas, como uma complicação. Relato de caso: Mulher de 52 anos apresentou bócio e sintomas compatíveis com hipertireoidismo como intolerância ao calor, emagrecimento, fadiga, sudorese aumentada, taquicardia, tremores finos, trânsito intestinal aumentado, ansiedade, labilidade emocional, insônia, exoftalmia e mixedema pré-tibial. A investigação complementar confirmou o diagnóstico de hipertireoidis-mo (níveis elevados de T4 livre e T3 total; níveis baixos de hormônio estimulante da tireoide - TSH). As imagens ultrassonográficas mostraram aumento difuso dos lobos tireoidianos em aproximadamente 10 vezes e a presença de três nódulos tireoidianos, um dos quais, maior que 2 cm, com ecogenicidade e vascularização heterogêneas em todo o nódulo, cuja punção aspirativa por agulha fina guiada por ultrassom revelou citologia compatível com Bethesda IV; e a cintilografia evidenciou uma área de baixa captação (nódulo frio) em meio a um bócio difuso de alta captação. Foi realizada tireoidectomia e o diagnóstico da peça anatômica revelou carcinoma papilífero de tir-eoide em lobo direito, com parênquima adjacente compatível com DG. O exame histopatológico da pele mostrou a presença de mixedema compatível com dermopatia de Graves. A paciente evoluiu com normalização dos níveis de TSH e redução das manifestações cutâneas. Conclusão: As anormalidades da DG podem não estar restritas às manifestações clínicas clássicas, e uma investigação criteriosa pode revelar a coexistência de carcinomas, (AU)

Coma mixedematoso asociado a infección por SARS-CoV-2 / Myxedema coma associated with SARS-CoV-2 infection / Coma mixedematoso associado à infecção por SARS-CoV-2

Resumen: Aunque se sabe que la infección por SARS-CoV-2 es una causa importante de enfermedad pulmonar, se han observado múltiples manifestaciones extrapulmonares asociadas a COVID-19. Existen en la literatura reportes de tirotoxicosis secundarios a COVID-19, pero los casos de hipotiroidismo descompensado por COVID-19 son escasos. Reportamos el caso de una paciente de 37 años con obesidad que presentó coma mixedematoso asociado a infección por SARS-CoV-2. El estado proinflamatorio secundario a obesidad, el daño directo a la glándula tiroidea por SARS-CoV-2 y la elevación de mediadores inflamatorios en sangre observados durante la infección viral podrían ser mecanismos que desencadenen el coma mixedematoso. En pacientes con COVID-19 severo es importante la búsqueda intencionada de signos de coma mixedematoso y su confirmación con un perfil tiroideo al ingreso hospitalario.

Abstract: Although SARS-CoV-2 infection is known to be an important cause of lung disease, multiple extrapulmonary manifestations associated with COVID-19 have been observed. There are reports of thyrotoxicosis secondary to COVID-19 in the literature, but cases of decompensated hypothyroidism due to COVID-19 are rare. We report the case of a 37-year-old female patient with obesity who presented myxedema coma associated with SARS-CoV-2 infection. The pro-inflammatory state secondary to obesity, direct damage to the thyroid gland by SARS-CoV-2, and the elevation of inflammatory mediators in the blood observed during viral infection could be mechanisms that trigger myxedema coma. In patients with severe COVID-19, the intentional search for signs of myxedema coma and its confirmation with a thyroid profile at hospital admission is important.

Resumo: Embora a infecção por SARS-CoV-2 seja conhecida por ser uma causa importante de doença pulmonar, foram observadas várias manifestações extrapulmonares associadas ao COVID-19. Há relatos na literatura de tireotoxicose secundária à COVID-19, mas os casos de hipotireoidismo descompensado por COVID-19 são raros. Relatamos o caso de um paciente de 37 anos com obesidade que apresentou coma mixedematoso associado à infecção por SARS-CoV-2. O estado pró-inflamatório secundário à obesidade, o dano direto à glândula tireoide pelo SARS-CoV-2 e a elevação de mediadores inflamatórios no sangue observados durante a infecção viral podem ser mecanismos que desencadeiam o coma mixedematoso. Em pacientes com COVID-19 grave, é importante a busca intencional de sinais de coma mixedematoso e sua confirmação com perfil tireoidiano na admissão hospitalar.

TSH receptor inhibitory antibody(TBAb) promotes extracellular accumulation of hyaluronic acid in pretibial myxedema primary fibroblasts via PI3K-AKT pathway / 中华内分泌代谢杂志

Objective:Pretibial myxedema (PTM) is a localized myxedema characterized by excessive dermal hya-luronan (HA) deposition and elevated serum TSH receptor antibody (TRAb). In this study, we investigated the effects of TRAb and its subtypes, stimulating antibody [TSAb (M22)] and inhibitory antibody[TBAb (K1-70)], on the synthesis of hyaluronic acid produced by PTM primary dermal fibroblasts.Methods:Normal and PTM dermal fibroblasts were isolated and stimulated with M22, K1-70, and IgG from patients respectively. HA concentration in the supernatant before and after stimulation was tested by ELISA. The protein level and phosphorylation variation of CEMIP, HAS2 and PI3K-AKT pathway were detected by Western blot.Results:IgG from patients (TRAb 8.4 IU/L) significantly stimulated the extracellular accumulation of HA in PTM primary fibroblasts. Similarly, both M22 and K1-70 also upregulated HA level in the supernatant, though K1-70 seemed much more effecitve. After treatment with IgG, M22, and K1-70, the expression of HAS2 increased and the expression of CEMIP decreased; meanwhile, p-PI3K and p-AkT increased. Among them, further study on K1-70, promoting HA production by regulating PI3K-AkT signal pathway could be inhibited by PI3K inhibitor (LY294002).Conclusion:TSAb (M22) and TBAb (K1-70), especially TBAb, increase HAS2 and inhibit CEMIP expression by activating PI3-AKT signaling pathway in PTM fibroblasts, leading to increased extracellular HA level.

Myxedema coma as a cause associated with multiple etiologies of heart failure

ABSTRACT Introduction: Myxedema coma is the rarest and most extreme manifestation of hypothyroidism in adults. It is more frequent in older women and is associated with various clinical manifestations including diseases with systemic involvement, such as heart failure, pulmonary thromboembolism, and atrial fibrillation in unstable patients. Case presentation: A 73-year-old female patient with a history of heart failure, hypertension and overweight, presented functional deterioration, dyspnea at rest, tachypnea, tachycardia, desaturation, generalized edema, distal cyanosis, and jugular venous pressure. Laboratory tests showed mild anemia, normal blood glucose and electrolytes, azotemia with impaired renal function, TSH: 100 μUI/ml, free T4: 0.21 ng/dL, atrial fibrillation with accelerated ventricular rhythm and high lactate level in blood. Based on the findings, heart failure associated with de novo myxedema coma was diagnosed, as well as pulmonary thromboembolism associated with signs of right systolic dysfunction. The patient's condition gradually improved with hormone replacement therapy, heart failure treatment, and anticoagulation. Conclusion: Myxedema coma is a rare and extreme form of hypothyroidism. It is associated with high mortality and morbidity rates because it has severe systemic manifestations. Timely diagnosis and early implementation of supportive and specific treatment, especially with aggressive thyroid hormone replacement therapy and intensive care unit monitoring, help improve the prognosis of patients.

RESUMEN Introducción. El coma mixedematoso representa la máxima y más rara expresión del hipotiroidismo en los adultos. Esta complicación es más frecuente en mujeres ancianas y tiene diversas formas clínicas asociadas como enfermedades con compromiso sistémico, entre ellas la falla cardíaca, el tromboembolismo pulmonar y la fibrilación auricular en pacientes inestables. Presentación del caso. Paciente femenina de 73 años con antecedentes de insuficiencia cardíaca, hipertensión arterial y sobrepeso, quien presentó deterioro funcional, disnea en reposo, taquipnea, taquicardia, desaturación, edemas generalizados, cianosis distal e ingurgitación yugular. Los exámenes paraclínicos mostraron anemia leve, glucemia y electrolitos normales, azoados con deterioro de la función renal, TSH: 100 μUI/mL, T4 libre: 0.21 ng/dL, ritmo de fibrilación auricular con respuesta ventricular rápida e hiperlactatemia. A partir de los hallazgos se diagnosticó falla cardíaca asociada a coma mixedematoso de novo, que requirió soporte inotrópico y vasopresor, y tromboembolismo pulmonar asociado a signos de disfunción sistólica derecha. Finalmente, la paciente tuvo evolución lenta hacia la mejoría con la suplencia hormonal, optimización de falla cardíaca y anticoagulación. Conclusión. El coma mixedematoso es una forma extrema e infrecuente de hipotiroidismo que se asocia con altos niveles de morbimortalidad dado que implica manifestaciones sistêmicas graves. El diagnóstico oportuno y la implementación temprana de un tratamiento de soporte y específico, sobre todo con suplencia agresiva de hormonas tiroideas y vigilancia en unidad de cuidados intensivos, ayudan a mejorar el pronóstico de los pacientes con esta complicación.

Convulsiones, derrame pericárdico y rabdomiólisis en debut de coma mixedematoso / Myxedema coma presenting with seizures, pericardial effusion, and rhabdomyolysis

RESUMEN El coma mixedematoso es la complicación más grave de un hipotiroidismo. Ocurre, por lo general, en mujeres ancianas con hipotiroidismo conocido sin un adecuado manejo y en presencia de un evento desencadenante. El diagnóstico es difícil y debe realizarse en forma oportuna para disminuir el riesgo de muerte. El coma es una de las presentaciones neurológicas de esta urgencia endocrinológica y no es necesario su presencia para el diagnóstico. En este reporte de caso se presentan varías manifestaciones inusuales en un paciente masculino con hipotiroidismo profundo que, al diagnóstico, debutó con coma mixedematoso con predictores de mal pronóstico durante la hospitalización, pero debido al abordaje temprano y el manejo integral, se dio una resolución satisfactoria a esta urgencia endocrinológica infrecuente.

SUMMARY Myxedema coma is the most serious complication of hypothyroidism. It usually occurs in the context of elderly women, with known hypothyroidism without proper management and in the presence of a triggering event. The diagnosis is challenging and must be made in a timely manner to prevent the development of adverse outcomes. Coma is one of the neurological manifestations of the entity, not being necessary for its diagnosis. This case report presents a constellation of unusual manifestations of a male patient with myxedema coma at the debut of severe hypothyroidism with predictors of poor prognosis during hospitalization, but due to the early approach and comprehensive management, this uncommon endocrinological emergency was satisfactorily resolved.

Successful therapeutic approach in a patient with elephantiasic pretibial myxedema

Abstract Localized pretibial myxedema is a dermopathy whose treatment is a challenge in dermatology, occurring in 0.5-4% of patients with Graves' disease. This autoimmune thyroid condition stimulates the production of hyaluronic acid and glycosaminoglycans that are deposited particularly in the pretibial region. Clinically, it presents as a localized, circumscribed, and non-depressible infiltrate in plaques. Several treatment modalities have been proposed, and their results vary, with worse response observed in severe cases. This report presents the case of a patient with elephantiasic pretibial myxedema who was subjected to intralesional corticosteroid applications, resulting in an excellent and encouraging therapeutic response that was maintained.

A study of serum thyroid stimulating hormone levels, and its correlation with clinical features and delayed diagnosis of hypothyroidism in central India

Background: The clinical manifestations of hypothyroidism are variable, depending upon its cause, duration and severity. The spectrum extends from subclinical to overt hypothyroidism to myxedema coma. A high degree of suspicion is thus required in order to appreciate the clinical manifestation of the disorder to reach a diagnosis. Purpose of this study was to correlate serum TSH level with severity of clinical manifestations and evaluate possible cause of delay in the diagnosis.Methods: A cross section observational and descriptive study for the assessment of severity of primary hypothyroidism at presentation and evaluation of the causes of delay in diagnosis in 86 patients was done from December 2012 to November 2013 in the Department of Medicine, MGM Medical College, Indore, MP, India.Results: Illiterate patients had significantly (p value 0.002) higher TSH values at presentation. 34.8% of patients presented as severe hypothyroidism with TSH value >100 mIU/L. Delay of as much as 7 years was noted. Majority of patients had a delay of around 1 to 3 years in diagnosis. Only 4.6% patients were diagnosed without any delay due to high level of suspicion at presentation.Conclusions: Due to non-specific symptomatology of hypothyroidism diagnosis is often delayed. Therefore, high index of suspicion is required at the physician抯 level and test of thyroid function is available at subsided cost therefore it should be offered to all such patients.

Coma mixedematoso como presentación de hipotiroidismo / Myxedema coma as presentation of hypothyroidism

Resumen Se presenta un caso de una paciente de 69 años de edad y sin antecedentes personales o familiares de patología tiroidea alguna, que asiste con un estado convulsivo de aparición súbita, de hemicuerpo derecho y relajación esfinteriana, asociado, además, a trastornos del estado de conciencia, bradicardia, bradipnea y edema de difícil Godet en miembros inferiores. Los exámenes complementarios mostraron acidosis respiratoria, hiposecreción de T4 y elevación de la hormona estimulante de la tiroides por retroalimentación negativa. Estos resultados corroboraron el diagnóstico presuntivo de coma mixedematoso. Se emprendió el tratamiento hormonal correspondiente con levotiroxina, al cual respondió satisfactoriamente y fue egresada a los 24 días de su ingreso, pendiente de valoración por el especialista de endocrinología.

Abstract We present the case of a 69-year-old female patient with no personal or family history of any thyroid disease, who attends with a convulsive state of sudden onset, right hemibody and sphincter relaxation, also associated with disorders of the state of consciousness, bradycardia, bradypnea and edema of difficult godet in lower limbs. Complementary analyses showed respiratory acidosis, hyposecretion of T4 and elevation of the thyroid stimulating hormone by negative feedback. These results corroborated the presumptive diagnosis of myxedema coma. The corresponding hormonal treatment with levothyroxine was undertaken, to which it responded satisfactorily and was discharged 24 days after admission, pending evaluation by the endocrinology specialist for an outpatient hormone replacement therapy.

Three Fibrotic Conditions Treated with 5% Topical Imiquimod Cream as an Antifibrotic Agent / 대한피부과학회지

Imiquimod, a toll-like receptor agonist, is a topical immunomodulator that induces the production of several cytokines including interferon-alpha, which shows antifibrotic properties. We hypothesized that the antifibrotic effect of imiquimod would soften fibrotic skin lesions. Therefore, we applied topical imiquimod with topical tacrolimus or systemic acitretin in patients with refractory lesions of myxedema, angiolymphoid hyperplasia, and generalized discoid lupus erythematosus and confirmed improvement in fibrotic lesions in these patients. Thus, we conclude that use of imiquimod improves fibrotic skin lesions. This report describes our experience with the treatment of this condition along with a review of the related literature.

Treatment of pretibial myxedema with local subcutaneous injection of glucocorticoid: Three cases report / 中华内分泌代谢杂志

To investigate the treatment of hyperthyroidism complicated with pretibial myxedema. Three patients with hyperthyroidism complicated with pretibial myxedema were treated with topical injection of corticosteroid at the skin lesion. All 3 patients were cured with pretibial mucous edema by local injection of corticosteroids. Multi-point injection of glucocorticoid combined with maintaining euthyroid state is effective and has little side effect.

Treatment of pretibial myxedema with local subcutaneous injection of glucocorticoid:Three cases report / 中华内分泌代谢杂志

To investigate the treatment of hyperthyroidism complicated with pretibial myxedema. Three patients with hyperthyroidism complicated with pretibial myxedema were treated with topical injection of corticosteroid at the skin lesion. All 3 patients were cured with pretibial mucous edema by local injection of corticosteroids. Multi-point injection of glucocorticoid combined with maintaining euthyroid state is effective and has little side effect.[Summary] To investigate the treatment of hyperthyroidism complicated with pretibial myxedema. Three patients with hyperthyroidism complicated with pretibial myxedema were treated with topical injection of corticosteroid at the skin lesion. All 3 patients were cured with pretibial mucous edema by local injection of corticosteroids. Multi-point injection of glucocorticoid combined with maintaining euthyroid state is effective and has little side effect.

Pretibial Myxedema Presenting as Severe Elephantiasis

Elephantiasis is a symptom characterized by the thickening of the skin and underlying tissues in the legs. Pretibial myxedema (PTM) is a non-frequent manifestation of autoimmune thyroiditis, particularly Graves' disease. Lesions of myxedema occur most commonly on the pretibial surfaces, also develop at sites of previous injury or scars and other areas. A 49-year-old male presented with severe elephantiasis on the both pretibial areas, dorsum of the feet, ankles and toes. Twenty years previously, he had received radioactive iodine treatment for thyrotoxicosis. Laboratory tests showed that the patient's thyroid function was normal, but the level of thyroid stimulating hormone (TSH) receptor antibodies was very high (>40 IU/L). The biopsy confirmed PTM. Interestingly, the connective tissue was stained with the TSH receptor antibodies in the deep dermis. Elephantiasic PTM is a severe form of the myxedema and there is few reported case. We report a rare case of PTM with appearance of severe elephantiasis.

Coma mixedematoso e trombo de veia cava superior. Relato de caso e revisão da literatura / Myxedema coma and superior vena cava thrombus: case report and literature review

O coma mixedematoso é uma emergência endocrinológica rara e consiste na máxima expressão do hipotireoidismo, com alta mortalidade por suas complicações hemodinâmicas e ventilatórias, podendo ser agravadas por distúrbios da coagulação. Relatamos o caso de uma paciente diagnosticada com coma mixedematoso e trombo de veia cava superior. Buscamos salientar os distúrbios de coagulação frequentes no hipotireoidismo grave, que contribuem para o aumento da mortalidade deste grupo de pacientes. O diagnóstico e o tratamento precoce do coma mixedematoso, aliados à instituição imediata da terapia para o fenômeno trombótico encontrado, permitiram a evolução favorável do quadro. O relato, juntamente da bibliografia pesquisada, orientou o raciocínio sobre a relação dos distúrbios de coagulação, que ocorrem no hipotireoidismo descompensado. Apesar de poucos relatos, estes distúrbios podem ser frequentes e devem ser pesquisados, pois contribuem com o aumento da mortalidade.(AU)

Myxedema coma is a rare endocrinological emergency, consisting of the highest expression of hypothyroidism with high mortality due to hemodynamic and ventilatory complications, which may be aggravated by coagulation disorders. We report the case of a patient diagnosed with myxedema coma and superior vena cava thrombus. We sought to emphasize the frequent coagulation disorders in severe hypothyroidism, which contribute to increased mortality in this group of patients. The diagnosis and early treatment of myxedema coma, together with the immediate institution of therapy for the thrombotic phenomenon found, allowed the favorable evolution of the condition. The report, together with the literature, has guided the rationale for the influence of coagulation disorders that occur in decompensated hypothyroidism. Despite the few number of reports, these disorders can be frequent and should be investigated because they contribute to the increase in mortality.(AU)

Coma mixedematoso / Myxedema coma

El hipotiroidismo es una enfermedad frecuente, de diagnóstico y tratamiento simples. Si no es detectada a tiempo puede progresar a la forma más grave conocida como coma mixedematoso. El término "coma mixedematoso" es considerado generalmente engañoso, ya que la mayoría de los pacientes no se presenta inicialmente en estado de coma. La progresión típica es la letargia, evolucionando al estupor y eventualmente al coma, con insuficiencia respiratoria e hipotermia. Es relativamente infrecuente, afecta fundamentalmente a mujeres ancianas, y a menudo ocurre en invierno. Esta entidad debe ser considerada una forma de hipotiroidismo descompensado, desencadenada a partir de una variedad de enfermedades o condiciones no tiroideas que provocan un compromiso sistémico generalizado de extrema gravedad, con desenlace fatal de no mediar un diagnóstico precoz y un tratamiento intensivo.

Hypothyroidism is a frequently diagnosed and simply treated disease. If not recognised, however, in time it may develop into the most severe manifestation of hypothyroidism known as myxedema coma. The term "myxedema coma" is generally seen as misleading since most patients do not initially present in a coma. The typical progression is lethargy evolving into stupor and, eventually, into coma with respiratory failure and hypothermia. It mainly affects elderly women, often occurring in winter and is relatively rare. It can be considered a form of decompensated hypothyroidism often triggered by a variety of non-thyroid conditions or diseases provoking an extremely severe condition of multiple system failure with lethal consequences unless an early diagnosis is made and an aggressive treatment is administered.

Coma mixedematoso y síndrome de Ogilvie asociado a aripiprazol, memantina y venlafaxina. Reporte de caso / Myxedema and syndrome Ogilvie associated at aripiprazole, memantine and venlafaxine. Case report / Coma mixedematoso e síndrome de ogilvie associada à aripropazol, memantina e venlafaxina. Relato de caso

Resumen: El coma mixedematoso es la complicación más severa del hipotiroidismo que puede manifestarse en diversos aparatos y sistemas. La etiología más frecuente se asocia a deficiencias nutricionales, inmunológicas, infecciones o fármacos, las claves del diagnóstico son el déficit neurológico y un perfil tiroideo con elevación de la hormona estimulante de la tiroides, en algunas ocasiones es necesaria la intubación orotraqueal por insuficiencia respiratoria. El tratamiento consiste en corregir el déficit hormonal y proporcionar medidas de sostén cuando el paciente se encuentre intubado. Reportamos el caso de un paciente con antecedentes psiquiátricos tratado con antipsicóticos por largo tiempo, el cual inició con un cuadro de oclusión intestinal que fue manejado de manera conservadora; durante su estancia hospitalaria se reinició tratamiento antipsicótico y se presentaron datos de insuficiencia respiratoria, lo que indujo a intubarlo e ingresarlo a la Unidad de Cuidados Intensivos. Durante su estancia se solicitaron enzimas tiroideas, las cuales mostraron elevación de hormona estimulante de tiroides, por lo que se manejó con hormonas tiroideas y esteroides según la literatura actual, con evolución neurológica favorable y protocolo de Weaning exitoso, egresando a las dos semanas posteriores a su ingreso.

Abstract: The myxedema is the most severe complication of hypothyroidism that can be manifested in various organs and systems. The most common cause is associated with nutritional deficiencies, immune, infection or drugs, diagnostic keys are neurological deficit and a thyroid profile with elevated thyroid stimulating hormone, sometimes endotracheal intubation for respiratory failure is necessary. The treatment involves correcting the hormonal deficit and give supportive care when the patient is intubated. We report a patient with a psychiatric history treated with anti-psychotic drugs, which debuts with an intestinal occlusion was managed conservatively, while staying anti-psychotic treatment is restarted and presents data of respiratory insufficiency leading to intubate thus entering at Intensive Care Unit. Thyroid enzymes were processed had high titles of Stimulating Hormone Thyroid gave manage thyroid and steroid hormones according to the current literature, evolving favorably neurologically and accomplished Protocol of Weaning succesful, go out two weeks of their income.

Resumo: O coma mixedematoso é a complicação mais grave do hipotireoidismo que pode manifestar-se em vários orgão e sistemas. A etiologia mais frequente está associada com deficiências nutricionais, imunológica, infecções ou drogas, o diagnóstico é fortemente determinado pelo déficit neurológico e um perfil de tireóide com elevação do Hormônio Estimulante da Tireóide, em algumas ocasiões é necessário intubação orotraqueal por insuficiência respiratória. O tratamento consiste na correção do défice hormonal e outorgar medidas de apoio quando o paciente está entubado. Relatamos o caso de um paciente com um histórico psiquiátrico tratado com anti-psicóticos por um longo tempo, que debuta com um quadro de obstrução intestinal tratado de manera conservadora, durante sua estadia no hospital se reinicia tratamento anti-psicótico, apresenta dados de insuficiência respiratória que nos leva a entubá-lo, ingresando na unidade de terapia intensiva. Durante sua internação se solicitaram enzimas de tireoidianas que apresentaram elevação do Hormônio Estimulante da Tireóide, pelo que se começa tratamento com hormônios tireoidianos e esteróides de acordo com a literatura atual, evoluindo neurologicamente de manera favorável e protocolo de Weaning bem sucedido, dando-se de alta 2 semanas depois de seu ingresso.

Pretibial mucinosis in an euthyroid patient

Abstract A case of exuberant pretibial mucinosis in a patient with normal thyroid function is reported. A review of literature on possible etiologies other than thyroid disease for the accumulation of mucin in the pretibial area is presented. In the patient described, it is possible that vascular insufficiency is involved. However, this is not the only factor responsible for the accumulation of mucin, since there are still unidentified causes and many patients with vascular diseases do not develop similar injuries.

Coexistence of Myxedema Ascites and Tuberculous Peritonitis: a Case Report and Literature Review / 대한내과학회지

Some patients have ascites without having liver disease, so it is important to analyze the cause of these ascites. Tuberculous peritonitis is an infectious disease characterized by lymphocyte-dominant exudative ascites. In contrast, myxedema ascites is a very rare disease characterized by a high serum/ascites albumin gradient (SAAG) with hypothyroidism. We herein report a case involving a 48-year-old woman with both diseases simultaneously. She was hospitalized because of massive ascites, generalized edema, and a puffy face. Hypothyroidism was confirmed by thyroid function tests. Her ascitic fluid had a high SAAG; no other specific findings were identified by cytology, culture, or computed tomography. Three months after initiating drug therapy for the hypothyroidism, the patient's systemic edema improved but the ascites recurred. Accordingly, diagnostic laparoscopy was performed, and tuberculous peritonitis was confirmed. As seen in this case, when myxedema ascites is associated with tuberculous peritonitis, an accurate diagnosis may be challenging.

Pre-tibial myxedema: treatment with intralesional corticosteroid

The pretibial myxedema is a manifestation of Graves' disease characterized by accumulation of glycosaminoglycans in the reticular dermis. The dermopathy is self-limiting but in some cases may cause cosmetic and functional damage. Conventional treatment is use of topical steroids under occlusive dressing, however the intralesional application has shown good results. We present a case of pretibial myxedema treated with single injection of intralesional corticosteroid.

Hyperthyroid-associated EMA syndrome:four cases report and review of literature / 中华内分泌代谢杂志

[Summary] Four patients with hyperthyroid-associated exophthalmos, myxedema, acropachy ( EMA ) syndrome, including three male patients and one female patient were diagnosed with Graves′diseases and treated by 131 I therapy. Complaints of thyrotoxicosis were presented at the onset. Tibia myxedema and acropathy appeared, and eye symptoms aggravated in two patients after anti-thyroid drug therapy and 131 I therapy. Four cases were all given clobetasol propionate, miconazole nitrate, neomycin sulfate and urea cream alone or in combination with compound betamethasone local injection treatment, and three cases were given low-dose oral prednisone treatment. Complaints of tibia myxedema and eye symptoms were significantly improved after the treatment. Therefore, we should be wary of the occurrence of hyperthyroid-associated EMA syndrome after 131 I therapy. Corticosteroid might be the effective therapy for myxedema and eye symptoms of EMA syndrome.