Thyroid Ophthalmopathy, Dermopathy, and Acropachy
A 56-year-old man was referred to a dermatologist for assessment of the progression of his thyroid dermopathy. Three years earlier he had received a diagnosis of Graves’ disease with thyroid-associated ophthalmopathy and dermopathy. He was treated with radioactive iodine ablation. Photographs taken 1 year after treatment showed proptosis (Panel A) and pretibial myxedema (Panel B). Shortly thereafter he underwent orbital decompression in both eyes. At the time of the current presentation, his physical examination showed progression of the dermopathy, which was functionally limiting and resembled elephantiasis (Panel C). In addition, his hands were enlarged and coarsened, and his fingers had a clublike shape (Panel D). Radiography of the hand showed periostitis of multiple phalangeal and metacarpal bones (Panel E, arrowheads), with diffuse swelling of the soft tissue, changes that were consistent with thyroid acropachy, a rare manifestation of Graves’ disease. Laboratory results showed that levels of thyrotropin-receptor antibodies were in excess of 40 IU per liter (normal range, ≤1.75 IU per liter); the test did not allow for more precise measurement. The patient was started on a combination treatment with intravenous immune globulin and rituximab. which appeared to halt the progression of his condition. At follow-up several months later there was no disease progression.