Endocrine Abstracts

Introduction: Pretibial Myxedema(PM) and acropachy(AP) are rare extrathyroidal manifestations of Graves’ disease observed only in 0.5–4% of all cases. These extrathyroidal manifestations are generally associated to severe ophtalmopathy. Only few cases of severe thyroid dermopathy and achropachy occurring with moderate ophtalmopathy were reported.

Observation: We present a 60years old female patient who developed grave’s disease on a pre-existing goiter associated to extrathyroidal manifestations. Physical examination revealed; some signs of hyperthyroidism, moderate exophthalmos measured by hertel’s exophtalmometer at 20 for right eye and 19 for Left eye, bilateral severe PM manifested by elephantiasis, severe AP manifested by clubbing and finger deformations, compressive goiter with 3 palpated nodules (a 5 and 4 cm nodules occupying the totality of the right and left lobe respectively, and a 2 cm left lobo-isthmic nodule) which were confirmed by ultrasound of the neck that showed hypervascularization of the normal parenchyma. Thyroid function tests before treatment showed FT3 predominating hyperthyroidism: TSHus<0.005, FT4=4.11 ng/dl (N:0.7–1.4), FT3>30 pmol/l (N:3.0–8.3 pmol/l). Anti-thyroid peroxidase antibodies were positive 149.6 UI/ml (N:<12 UI/ml). Total thyroidectomy was performed after normalization of thyroid function under 60 mg of neomercazol, and this goiter was benignant on pathology. PM was stabilized after surgery and management of hypothyroidime by levothyroxine.

Conclusion: PM and AP are very rare. They reflect the severity of autoimmunity and long duration of hyperthyroidism. These signs are often observed in severe hyperthyroidism and are constantly associated to ophtalmopathy which is generally severe. Infiltration corresponds to the accumulation of GAG in the 3 conditions. Moderate ophtalmopathy occurring with severe PM(elephantiasis) and AP(clubbing and deformations) is not habitually reported.