ACUTE FLARE OF PRETIBIAL MYXEDEMA AFTER RADIOACTIVE IODINE ABLATION IN PATIENT OF GRAVE'S DISEASE
AACE ePoster Library. Garg M. 05/13/15; 97816; 1025
Dr. Manisha Garg
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Abstract
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Objective: Progression of Grave’s opthalmopathy with radioactive iodine (RAI) treatment for hyperthyroidism is well known. Acute exacerbation of pretibial myxedema following RAI has not been reported in literature. We hereby report a case of worsening of pretibial myxedema and ophthalmopathy in a patient with Graves’ disease who was given RAI ablation for multifocal papillary thyroid cancer.
Methods/case--55 year old white male patient with PMH of COPD/chronic smoking presented with symptoms suggestive of thyrotoxicosis including unintentional weight loss of 100 pounds, palpitations and tremors. His physical exam was positive for mild lid lag, diffusely enlarged thyroid with bruit and fine tremors on outstretched hands. He also had mild pretibial myxedema manifested as hyperpigmented thick skin with nodules. Ocular exam was normal. Hyperthyroidism was confirmed with suppressed TSH of <0.010, elevated Free T4 5.4(0.7-1.9) and total T3 of 398(79-149). He had positive TSI of 367 % (0-139%) and increased diffuse uptake of 51% on RAI scan. Patient was treated with Methimazole and beta blocker with good control of symptoms. Two years later, patient underwent thyroidectomy for obstructive symptoms related to goiter. He was found to have multifocal papillary thyroid carcinoma with largest focus of 1.4 cm on surgical specimen with no lymph node involvement. He had RAI after surgery as adjuvant treatment for the thyroid cancer. Two weeks later, patient returned for follow up and was noted to have worsening of skin changes with hyperkeratosis and marked nodule formation. He had skin biopsy which was consistent with changes of pretibial myxedema. A trial of therapy with topical steroid was initiated without any noticeable improvement. Coincidentally, he also developed new eye symptoms of exophthalmos, double vision which on CT evaluation were found to be related to severe opthalmopathy, requiring surgical decompression and high doses of systemic steroids. Patient had marked improvement of his eye and skin symptoms. He is currently doing well on thyroxine replacement therapy.
Discussion- We report a case of Grave’s disease that developed florid pre tibial myxedema and opthalmopathy following adjuvant RAI treatment for thyroid cancer that was found incidentally during thyroidectomy. Dermopathy occurs in 5% of patients with Grave’s disease and 15% of patients with Grave’s disease and opthalmopathy. It is usually a late manifestation occurring later than thyrotoxicosis and opthalmopathy. Of all extra thyroidal manifestations, there is evidence that radio iodine therapy for Graves; disease worsens opthalmopathy. However, progression of dermopathy following RAI and worsening of Grave’s ophthalmopathy following RAI for thyroid cancer is not reported much in literature. These patients characteristically have higher serum concentrations of thyrotropin (TSH) receptor antibodies. . The implicated pathogenesis is due to expression of TSH receptor antigen in skin fibroblasts; triggering autoimmune response. The etiology of pretibial myxedema is not proven.
Conclusion-This case provides clear evidence for potential of radioiodine therapy not only to worsen eye disease but also pretibial myxedema. Interestingly, skin changes improved significantly with systemic steroids given for opthalmopathy. We suggest careful selection of RAI ablation as treatment in Grave’s disease with preexisting skin changes and high titers of TSI. We also suggest that subjects with history of Graves’ disease who are subsequently found to have thyroid cancer should be made aware of the possibility of worsening ophthalmopathy with adjuvant RAI treatment. Also, systemic steroids can be effective treatment for both Grave’s opthalmopathy and dermopathy.
Methods/case--55 year old white male patient with PMH of COPD/chronic smoking presented with symptoms suggestive of thyrotoxicosis including unintentional weight loss of 100 pounds, palpitations and tremors. His physical exam was positive for mild lid lag, diffusely enlarged thyroid with bruit and fine tremors on outstretched hands. He also had mild pretibial myxedema manifested as hyperpigmented thick skin with nodules. Ocular exam was normal. Hyperthyroidism was confirmed with suppressed TSH of <0.010, elevated Free T4 5.4(0.7-1.9) and total T3 of 398(79-149). He had positive TSI of 367 % (0-139%) and increased diffuse uptake of 51% on RAI scan. Patient was treated with Methimazole and beta blocker with good control of symptoms. Two years later, patient underwent thyroidectomy for obstructive symptoms related to goiter. He was found to have multifocal papillary thyroid carcinoma with largest focus of 1.4 cm on surgical specimen with no lymph node involvement. He had RAI after surgery as adjuvant treatment for the thyroid cancer. Two weeks later, patient returned for follow up and was noted to have worsening of skin changes with hyperkeratosis and marked nodule formation. He had skin biopsy which was consistent with changes of pretibial myxedema. A trial of therapy with topical steroid was initiated without any noticeable improvement. Coincidentally, he also developed new eye symptoms of exophthalmos, double vision which on CT evaluation were found to be related to severe opthalmopathy, requiring surgical decompression and high doses of systemic steroids. Patient had marked improvement of his eye and skin symptoms. He is currently doing well on thyroxine replacement therapy.
Discussion- We report a case of Grave’s disease that developed florid pre tibial myxedema and opthalmopathy following adjuvant RAI treatment for thyroid cancer that was found incidentally during thyroidectomy. Dermopathy occurs in 5% of patients with Grave’s disease and 15% of patients with Grave’s disease and opthalmopathy. It is usually a late manifestation occurring later than thyrotoxicosis and opthalmopathy. Of all extra thyroidal manifestations, there is evidence that radio iodine therapy for Graves; disease worsens opthalmopathy. However, progression of dermopathy following RAI and worsening of Grave’s ophthalmopathy following RAI for thyroid cancer is not reported much in literature. These patients characteristically have higher serum concentrations of thyrotropin (TSH) receptor antibodies. . The implicated pathogenesis is due to expression of TSH receptor antigen in skin fibroblasts; triggering autoimmune response. The etiology of pretibial myxedema is not proven.
Conclusion-This case provides clear evidence for potential of radioiodine therapy not only to worsen eye disease but also pretibial myxedema. Interestingly, skin changes improved significantly with systemic steroids given for opthalmopathy. We suggest careful selection of RAI ablation as treatment in Grave’s disease with preexisting skin changes and high titers of TSI. We also suggest that subjects with history of Graves’ disease who are subsequently found to have thyroid cancer should be made aware of the possibility of worsening ophthalmopathy with adjuvant RAI treatment. Also, systemic steroids can be effective treatment for both Grave’s opthalmopathy and dermopathy.
Objective: Progression of Grave’s opthalmopathy with radioactive iodine (RAI) treatment for hyperthyroidism is well known. Acute exacerbation of pretibial myxedema following RAI has not been reported in literature. We hereby report a case of worsening of pretibial myxedema and ophthalmopathy in a patient with Graves’ disease who was given RAI ablation for multifocal papillary thyroid cancer.
Methods/case--55 year old white male patient with PMH of COPD/chronic smoking presented with symptoms suggestive of thyrotoxicosis including unintentional weight loss of 100 pounds, palpitations and tremors. His physical exam was positive for mild lid lag, diffusely enlarged thyroid with bruit and fine tremors on outstretched hands. He also had mild pretibial myxedema manifested as hyperpigmented thick skin with nodules. Ocular exam was normal. Hyperthyroidism was confirmed with suppressed TSH of <0.010, elevated Free T4 5.4(0.7-1.9) and total T3 of 398(79-149). He had positive TSI of 367 % (0-139%) and increased diffuse uptake of 51% on RAI scan. Patient was treated with Methimazole and beta blocker with good control of symptoms. Two years later, patient underwent thyroidectomy for obstructive symptoms related to goiter. He was found to have multifocal papillary thyroid carcinoma with largest focus of 1.4 cm on surgical specimen with no lymph node involvement. He had RAI after surgery as adjuvant treatment for the thyroid cancer. Two weeks later, patient returned for follow up and was noted to have worsening of skin changes with hyperkeratosis and marked nodule formation. He had skin biopsy which was consistent with changes of pretibial myxedema. A trial of therapy with topical steroid was initiated without any noticeable improvement. Coincidentally, he also developed new eye symptoms of exophthalmos, double vision which on CT evaluation were found to be related to severe opthalmopathy, requiring surgical decompression and high doses of systemic steroids. Patient had marked improvement of his eye and skin symptoms. He is currently doing well on thyroxine replacement therapy.
Discussion- We report a case of Grave’s disease that developed florid pre tibial myxedema and opthalmopathy following adjuvant RAI treatment for thyroid cancer that was found incidentally during thyroidectomy. Dermopathy occurs in 5% of patients with Grave’s disease and 15% of patients with Grave’s disease and opthalmopathy. It is usually a late manifestation occurring later than thyrotoxicosis and opthalmopathy. Of all extra thyroidal manifestations, there is evidence that radio iodine therapy for Graves; disease worsens opthalmopathy. However, progression of dermopathy following RAI and worsening of Grave’s ophthalmopathy following RAI for thyroid cancer is not reported much in literature. These patients characteristically have higher serum concentrations of thyrotropin (TSH) receptor antibodies. . The implicated pathogenesis is due to expression of TSH receptor antigen in skin fibroblasts; triggering autoimmune response. The etiology of pretibial myxedema is not proven.
Conclusion-This case provides clear evidence for potential of radioiodine therapy not only to worsen eye disease but also pretibial myxedema. Interestingly, skin changes improved significantly with systemic steroids given for opthalmopathy. We suggest careful selection of RAI ablation as treatment in Grave’s disease with preexisting skin changes and high titers of TSI. We also suggest that subjects with history of Graves’ disease who are subsequently found to have thyroid cancer should be made aware of the possibility of worsening ophthalmopathy with adjuvant RAI treatment. Also, systemic steroids can be effective treatment for both Grave’s opthalmopathy and dermopathy.
Methods/case--55 year old white male patient with PMH of COPD/chronic smoking presented with symptoms suggestive of thyrotoxicosis including unintentional weight loss of 100 pounds, palpitations and tremors. His physical exam was positive for mild lid lag, diffusely enlarged thyroid with bruit and fine tremors on outstretched hands. He also had mild pretibial myxedema manifested as hyperpigmented thick skin with nodules. Ocular exam was normal. Hyperthyroidism was confirmed with suppressed TSH of <0.010, elevated Free T4 5.4(0.7-1.9) and total T3 of 398(79-149). He had positive TSI of 367 % (0-139%) and increased diffuse uptake of 51% on RAI scan. Patient was treated with Methimazole and beta blocker with good control of symptoms. Two years later, patient underwent thyroidectomy for obstructive symptoms related to goiter. He was found to have multifocal papillary thyroid carcinoma with largest focus of 1.4 cm on surgical specimen with no lymph node involvement. He had RAI after surgery as adjuvant treatment for the thyroid cancer. Two weeks later, patient returned for follow up and was noted to have worsening of skin changes with hyperkeratosis and marked nodule formation. He had skin biopsy which was consistent with changes of pretibial myxedema. A trial of therapy with topical steroid was initiated without any noticeable improvement. Coincidentally, he also developed new eye symptoms of exophthalmos, double vision which on CT evaluation were found to be related to severe opthalmopathy, requiring surgical decompression and high doses of systemic steroids. Patient had marked improvement of his eye and skin symptoms. He is currently doing well on thyroxine replacement therapy.
Discussion- We report a case of Grave’s disease that developed florid pre tibial myxedema and opthalmopathy following adjuvant RAI treatment for thyroid cancer that was found incidentally during thyroidectomy. Dermopathy occurs in 5% of patients with Grave’s disease and 15% of patients with Grave’s disease and opthalmopathy. It is usually a late manifestation occurring later than thyrotoxicosis and opthalmopathy. Of all extra thyroidal manifestations, there is evidence that radio iodine therapy for Graves; disease worsens opthalmopathy. However, progression of dermopathy following RAI and worsening of Grave’s ophthalmopathy following RAI for thyroid cancer is not reported much in literature. These patients characteristically have higher serum concentrations of thyrotropin (TSH) receptor antibodies. . The implicated pathogenesis is due to expression of TSH receptor antigen in skin fibroblasts; triggering autoimmune response. The etiology of pretibial myxedema is not proven.
Conclusion-This case provides clear evidence for potential of radioiodine therapy not only to worsen eye disease but also pretibial myxedema. Interestingly, skin changes improved significantly with systemic steroids given for opthalmopathy. We suggest careful selection of RAI ablation as treatment in Grave’s disease with preexisting skin changes and high titers of TSI. We also suggest that subjects with history of Graves’ disease who are subsequently found to have thyroid cancer should be made aware of the possibility of worsening ophthalmopathy with adjuvant RAI treatment. Also, systemic steroids can be effective treatment for both Grave’s opthalmopathy and dermopathy.
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