Department of Internal Medicine, Baptist Health System, Birmingham, AL 35213, USA.
Am J Med Sci. 2013 Jul;346(1):73-5. doi: 10.1097/MAJ.0b013e318288a6fa.
To report a rare case of Graves' disease without ophthalmopathy presenting with pretibial myxedema (PM) as an initial presentation.
We present the clinical history, physical findings, laboratory studies and biopsy data of a 62-year-old man with a history of uncontrolled type 2 diabetes (DM2) presenting with arm and leg skin lesions in the absence of other physical findings. Histopathology confirmed PM. Graves' disease and its association with PM without Graves' ophthalmopathy and the pertinent literature are reviewed.
A 60-year-old man with a history of uncontrolled DM2 presented for glycemic management. He described symptoms of anxiety, insomnia and fatigue for the last 5 to 6 months. He described diffuse chest pain, occasionally associated with palpitations, and a 50-pound weight loss. He also complained of severe itching and burning of his arms and legs for the past several months. Subsequent thyroid studies revealed hyperthyroidism suggestive of Graves' disease. In the interim, he was hospitalized for atrial flutter and was cardioverted. After being started on methimazole, his symptoms abated. His skin lesions were biopsied, and the leg biopsy was consistent with PM. He however had no lid lag or proptosis characteristic of Graves' disease. He subsequently underwent radioiodine ablation. His hyperglycemia was better control led after treatment of his hyperthyroidism.
PM is an autoimmune manifestation of Graves' disease. Almost all cases of thyroid dermopathy are associated with relatively severe ophthalmopathy. Usually ophthalmopathy appears first and dermopathy much later. However, this case represents a rare initial presentation of Graves' disease with PM without ophthalmologic symptoms or findings. Hyperthyroidism is typically associated with worsening glycemic control and increased insulin requirements. In patients with diabetes having hyperthyroidism, deterioration in glycemic control should be anticipated and treatment should be adjusted accordingly. Restoration of euthyroidism will lower the blood glucose level.
报告一例罕见的 Graves 病无眼病患者，以胫前黏液水肿（PM）为首发表现。
我们报告了一例 62 岁男性的临床病史、体格检查结果、实验室研究和活检数据，该患者患有未控制的 2 型糖尿病（DM2），无其他身体发现，出现手臂和腿部皮肤病变。组织病理学证实为 PM。我们回顾了 Graves 病及其与 PM 无 Graves 眼病的关联，以及相关文献。
一名 60 岁男性，患有未控制的 DM2，来进行血糖管理。他描述了过去 5 至 6 个月焦虑、失眠和疲劳的症状。他描述了弥漫性胸痛，偶尔伴有心悸，体重减轻了 50 磅。他还抱怨过去几个月手臂和腿部严重瘙痒和灼热。随后的甲状腺研究显示甲状腺功能亢进症提示 Graves 病。在此期间，他因心房颤动住院并进行了电复律。在开始使用甲巯咪唑后，他的症状减轻。他的皮肤病变进行了活检，腿部活检符合 PM。然而，他没有 Graves 病的眼睑迟滞或眼球突出等特征。他随后接受了放射性碘消融治疗。他的高血糖在治疗甲状腺功能亢进症后得到了更好的控制。
PM 是 Graves 病的一种自身免疫表现。几乎所有甲状腺皮肤病都与相对严重的眼病有关。通常眼病先出现，皮肤病后出现。然而，本例代表了 Graves 病以 PM 为首发表现而无眼部症状或表现的罕见初始表现。甲状腺功能亢进症通常与血糖控制恶化和胰岛素需求增加有关。在患有糖尿病的甲状腺功能亢进症患者中，应预计血糖控制恶化，并相应调整治疗。恢复正常甲状腺功能将降低血糖水平。
