Endocrine Abstracts

Graves’ disease (GD) is an autoimmune disease that can affect other tissues in addition to the thyroid gland. Depending on the intensity of the immune response, in addition to hyperthyroidism, orbitopathy, dermatopathy and acropachy can also occur. Extrathyroidal manifestations of GD are most often the result of a more pronounced immune response. Thyroid dermatopathy (TD) is a rare extrathyroidal manifestation of GD, almost always associated with Graves’ orbitopathy (96%) and usually appears after ocular changing. About 0.5%–4.3% of patients with a history of thyrotoxicosis and 15% of patients with severe Graves’ orbitopathy have this cutaneous manifestation. Presence of dermopathy and acropachy are indicators of severity of autoimmune process and a risk factor for severe orbitopathy. It is more common in older patients and women. TD represents diffuse mucinosis, with typical accumulation of glycosaminoglycans in the dermis and hypodermis. The most common form is diffuse non-pitting edema, followed by plaque and nodular forms and rarely the elephantiasic form. Clinically, TD presents as light-colored, sometimes yellowish-brown skin lesions, frequently with an orange peel texture, mostly in the pretibial region. Hyperpigmentation and hyperkeratosis may also occur. The appearance of dermopathy is related to the duration of the autoimmune disease and is seen less often today, since the diagnosis of GD is made earlier. We present four patients that came to our hospital in short period of time with different forms and different time of onset of TD. Two patients had severe form of dermopathy - elephatiasis, that appeared concurrently with hyperthyroidism and orbitopathy in one patients, and concurrently with hyperthyroidism, but before orbitopathy in second patient. In this patient, orbitopathy appeared one year after dermopathy. In the other two patients TD presented as the third manifestation of GD, after onset of hyperthyroidism and orbitopathy in one patient and after orbitopathy and hypothyroidism in second patient, as the plaque-type lesions, and elastic edema. In the last patient, GD started with Graves’ orbitopathy, and after a year, hypothyroidism was diagnosed. TD appeared three years later in the form of pretibial plaque and swell of the toe. In all patients TD was associated with very high levels of TRAb >40 IU/l (Table1). TD is a rare manifestation of GD and is characteristic of long lasting disease and an intense autoimmune response. It is not often seen today, which makes the appearance of four patients with TD in a short period of time all the more interesting.