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Graves′ Disease With Pretibial Myxoedema  [cached]
Sood Apra,Sood Ajay,Souza Paschal D,Pandhi R K
Indian Journal of Dermatology , 1998,
Abstract: A 45 year old man presented with asymptomatic skin coloured nodules, erythmatous plaques on both legs along with features of thyrotoxicosis. Investigations confirmed the diagnosis of Gravesa€ disease with pretibial mayxoedema. The patient became euthyroid with carbimazole and the skin lesions responded partially to antithyoroid treatment and local corticosteroids.
Pretibial epidermolysis bullosa with intraepidermal split  [cached]
Singh Sanjay,Jha A,Kumar Mohan,Pandey S
Indian Journal of Dermatology, Venereology and Leprology , 1991,
Abstract: Histology of a 26 year old woman with pretibial epidermolysis bullosa (PEB) revealed intraepidermal split. Her son had dystroplaic epidermolysis bullosa.
Palmoplantar keratoderma in myxedema  [cached]
Mittal R,Jha Anju
Indian Journal of Dermatology, Venereology and Leprology , 2002,
Abstract: A 45-years-old woman came with diffuse yellowwaxy thickening, dryness and scaly skin of palms and soles and thickening of knuckles on dorsa of hands since 2 years. In addition, she had hoarseness of voice, weight gain, slow response, intolerance to cold, loss of pubic and axillary hair, generalised dryness and coarseness of skin, and mask like fades. Diagnosis of palmoplantar keratoderma and myxedema was confirmed by investigations.
Pretibial Epidermolysis Bullosa  [cached]
Joshi Arun,Sah Shatrughan P
Indian Journal of Dermatology , 2002,
Abstract: A 34 year old Nepalese male presented with 10 year history of recurrent itchy erythematous papules, plaques and vesicles healing with scarring and milia on his shins. He also had dystrophic toenails since childhood. Family and past history were not contributory. Histopathological findings were consistent with the clinical diagnosis of pretibial epidermolysis bullosa (PEB). The patient was treated with oral vitamin E with some relief.
Coma mixedematoso Myxedema coma  [cached]
Lisette Leal Curí
Revista Cubana de Endocrinología , 2012,
Abstract: El coma mixedematoso es la forma más severa y profunda del hipotiroidismo. Se presenta con mayor frecuencia en mujeres y ancianos. Entre los factores precipitantes se encuentran: la sepsis, la exposición al frío, los eventos agudos graves, el uso de anestésicos, sedantes o narcóticos, así como la descontinuación del tratamiento sustitutivo con hormonas tiroideas, entre otros. El diagnóstico clínico se realiza por la presencia de síntomas y signos característicos de un hipotiroidismo severo, con hipotermia y alteraciones de la conciencia. Apoyan este diagnóstico los hallazgos de laboratorio: hiponatremia, hipoxemia, hipercapnia, alteraciones hemoquímicas y el aumento de la tirotropina por la disminución de las hormonas tiroideas en el caso de la enfermedad primaria. El tratamiento se debe realizar en una unidad de cuidados intensivos, con monitorización, medidas de soporte respiratorio y cardiovascular, calentamiento corporal interno, hidratación, corrección de la hipotensión y de los trastornos electrolíticos. Se administrarán, además, glucocorticoides, antibióticos de amplio espectro y hormonas tiroideas. La evolución depende de la demora en el inicio del tratamiento, la edad, las comorbilidades, la hipotermia persistente y las complicaciones asociadas. Myxedema coma is the most severe and deepest form of hypothyroidism. It occurs more often in the women and the elderly. Among the unleashing factors found are sepsis, exposure to cold, acute severe events, use of anesthetic drugs, sedatives or narcotics as well as the interruption of the replacement treatment with thyroid hormones, among others. The clinical diagnosis is based on the presence of symptoms and signs that are characteristic of severe hypothyroidism, with hypothermia and altered consciousness. This diagnosis is also supported by the lab findings: hyponatremia, hypoxemia, hypercapnia, hemochemical alterations and the rise of thyrotropin due to the decrease of thyroid hormones in the case of the primary disease. The patient should be treated in an intensive care unit, by using monitoring, respiratory and cardiovascular support, internal body heating, hydration, correction of hypotension and control of electrolytic disorders. Additionally, glycocorticoids, broad-spectrum antibiotics and thyroid hormones should be administered. The progression of the disease depends on the delay in starting the treatment, the age, the comorbidities, the persistent hypothermia and the associated complications.
Myxedema Coma: A New Look into an Old Crisis  [PDF]
Vivek Mathew,Raiz Ahmad Misgar,Sujoy Ghosh,Pradip Mukhopadhyay,Pradip Roychowdhury,Kaushik Pandit,Satinath Mukhopadhyay,Subhankar Chowdhury
Journal of Thyroid Research , 2011, DOI: 10.4061/2011/493462
Abstract: Myxedema crisis is a severe life threatening form of decompensated hypothyroidism which is associated with a high mortality rate. Infections and discontinuation of thyroid supplements are the major precipitating factors while hypothermia may not play a major role in tropical countries. Low intracellular T3 leads to cardiogenic shock, respiratory depression, hypothermia and coma. Patients are identified on the basis of a low index of suspicion with a careful history and examination focused on features of hypothyroidism and precipitating factors. Arrythmias and coagulation disorders are increasingly being identified in myxedema crisis. Thyroid replacement should be initiated as early as possible with careful attention to hypotension, fluid replacement and steroid replacement in an intensive care facility. Studies have shown that replacement of thyroid hormone through ryles tube with a loading dose and maintenance therapy is as efficacious as intravenous therapy. In many countries T3 is not available and oral therapy with T4 can be used effectively without major significant difference in outcomes. Hypotension, bradycardia at presentation, need for mechanical ventilation, hypothermia unresponsive to treatment, sepsis, intake of sedative drugs, lower GCS and high APACHE II scores and Sequential Organ Failure Assessment (SOFA) scores more than 6 are significant predictors of mortality in myxedema crisis. Early intervention in hypothyroid patients developing sepsis and other precipitating factors and ensuring continued intake of thyroid supplements may prevent mortality and morbidity associated with myxedema crisis. “No decision is easy, Sue. It only looks that way when you're young. When you're older, everything is complicated. There is no black and white, only grey.” —Dr. George A. Harris in the movie Coma 1978. 1. Introduction Myxedema coma is a severe and life-threatening form of decompensated hypothyroidism with an underlying precipitating factor. The mortality rates may be as high as 25–60% even with best possible treatment [1–5]. The term myxedema coma is a misnomer, and myxedema crisis may be an apt term as quite a few patients are obtunded, rather than frankly comatose. As the disease is rare and unrecognized, we only have a few isolated case reports and case series, and there is a dearth of randomized controlled trials in the field of myxedema crisis. At present there are over 300 cases reported in literature [6–8]. In this paper we discuss the standard clinical presentation, treatment, predictors of mortality, and controversies that overshadow the
Reconstruction of Pretibial Defect Using Pedicled Perforator Flaps  [PDF]
In Soo Shin,Dong Won Lee,Dong Kyun Rah,Won Jai Lee
Archives of Plastic Surgery , 2012, DOI: http://dx.doi.org/10.5999/aps.2012.39.4.360
Abstract: Background Coverage of defects of the pretibial area remains a challenge for surgeons. Thedifficulty comes from the limited mobility and availability of the overlying skin and soft tissue.We applied variable pedicled perforator flaps to overcome the disadvantages of local flaps andfree flaps on the pretibial area.Methods Eight patients who had the defects in the anterior tibial area were enrolled.Retrospective data were obtained on patient demographics, cause, defect location, defectsize, flap dimension, originating artery, pedicle length, pedicle rotation, complication, andpostoperative result. The raw surface created following the flap elevation was covered with asplit thickness skin graft.Results Posterior tibial artery-based perforator flaps were used in five cases and peronealartery-based perforator flaps in three cases. The mean age was 54.3 and the mean period offollow-up was 6 months. The average size of the flaps was 63.8 cm2, with a range of 18 to135 cm2. There were no major complications. No patients had any newly developed functionaldeficit of the lower leg.Conclusions We suggest that pedicled perforator flaps can be an alternative treatment modalityfor covering pretibial defects as a simple, safe and versatile procedure.
Elephantiasic Pretibial Myxoedema in a Patient with Graves’ Disease  [PDF]
Ruzhi Zhang, Yuhua Yang, Wenyuan Zhu
Journal of Cosmetics, Dermatological Sciences and Applications (JCDSA) , 2015, DOI: 10.4236/jcdsa.2015.54036
Abstract: Pretibial myxoedema (PM) is a late and rare manifestation of autoimmune thyroiditis, particularly in patients with Graves’ disease. It occurs in 0.5% to 4.3% of patients [1], and is usually associated with high levels of thyroid hormones. The classification of PM includes four forms: non-pitting edema; plaque; nodular; or elephantiasis [1]. Mild PM often regresses spontaneously, but the severe, elephantiasic variant is typically progressive and refractory to treatment. Elephantiasic pretibial myxoedema (EPM) is characterized by massive edema, skin fibrosis and verrucous nodule formation, and it clinically resembles lymphedema. Herein, we describe a man with Graves’ disease presenting with EPM for nearly 2 years. Although advanced cases have been described in the literature, to our knowledge, none have reached this level of severity.
A Review on Post-Puberty Hypothyroidism: A Glance at Myxedema  [PDF]
A.R. Mansourian
Pakistan Journal of Biological Sciences , 2010,
Abstract: Hypothyroidism, is a thyroid disorder accompanied by serum thyroid hormone reduction when thyroxin T4, the main thyroid hormone, reduced, it is followed by disruption of a negative-feed back auto regulatory mechanism on pituitary gland and subsequent thyroid stimulating hormone (TSH) which is released into the blood circulation to stimulate the thyroid gland to produce enough thyroid hormone to compensate for the body hormone requirements. Therefore, reduced serum thyroxin(T4) in principle, triidothyronine (T3) and elevated TSH are laboratory indices for the diagnosis of hypothyroidism. At early stage of hypothyroidism although laboratory measurements of thyroid function test are manifest the thyroid disorder but the patient clinical signs and symptoms may remain unnoticed. If the patient undiagnosed and untreated the condition of hypothyroidism worsen and the clinical manifestation begin to show itself and myxedema is a definition given to the whole picture of untreated hypothyroidism at very end stage the patients enter into myxedema comma with eventual death due to the sever symptoms of hypothyroidism. Among important causative factors leading to catastrophic events in myxedema is life threatening hypothermia, heart and cerebral dysfunctions.
Cutaneous Manifestations of Thyroid Disease: A Case of Thyroid-Induced Myxedema
Anjali Shroff,Gregory Simpson
Case Reports in Dermatological Medicine , 2011, DOI: 10.1155/2011/386081
Abstract: The cutaneous manifestations of thyroid disease can be present in the hair, nails, and local or diffuse locations throughout the skin. Traditionally, thyroid-associated mucin deposition is present in a pretibial location on bilateral lower legs. We present a case of a growing plaque on the lower back of a 10-year-old girl, whose appearance coincided with a recent diagnosis of Hashimoto's thyroiditis.
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