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Systemic Diseases and the Skin
Published in Ayşe Serap Karadağ, Lawrence Charles Parish, Jordan V. Wang, Roxburgh's Common Skin Diseases, 2022
Jana Kazandjieva, Razvigor Darlenski, Nikolai Tsankov
Thyroid acropachy is most often occurring in patients with a long history of active hyperthyroidism disease. Thyroid acropachy is a triad consisting of digital clubbing, soft tissue swelling of the hands and feet, and periosteal new bone formation with possible pain in the digits. Thyroid acropachy is an indicator of severity of dermopathy and ophthalmopathy.
Endocrine emergencies with skin manifestations
Published in Biju Vasudevan, Rajesh Verma, Dermatological Emergencies, 2019
Warm and moist skin is the most characteristic finding of hyperthyroidism. This is because of cutaneous vasodilatation and increased diaphoresis. Scalp hair becomes fine and fragile, and in 20%–40% of the patients diffuse hair loss occurs. A characteristic but rare finding is Plummer nails, onycholysis involving the fourth and fifth fingers. A rare form of skin involvement occurs in Graves disease, called thyroid dermopathy, and it occurs in less than 1% of cases. It is also called pretibial myxedema because most commonly it occurs as hyperpigmented, nonpitting induration of skin over the shins. This is a late manifestation and almost 99% of these patients will have Graves orbitopathy. There is compression of lymphatics in dermis resulting in nonpitting edema. Later in the course of disease, there is nodule and plaque formation. Rare sites of such lesions are the face, eyebrows, elbows, or dorsa of hands. The Graves triad consists of thyrotoxicosis and goiter, orbitopathy, and dermopathy. Thyroid acropachy (painful clubbing, soft tissue swelling, and periosteal bone changes) occurs due to hypermetabolic state leading to axial bone destruction. This is presumably due to increased osteoclast activity. Vitiligo is common in autoimmune thyroid disorders [13].
The diagnostic evaluation and management of hyperthyroidism due to Graves’ disease, toxic nodules, and toxic multinodular goiter
Published in David S. Cooper, Jennifer A. Sipos, Medical Management of Thyroid Disease, 2018
Pretibial myxedema results from excessive lymphocyte infiltration in the pretibial area, with resultant mucopolysaccharide deposition by fibroblasts (33, 34). The clinical result may simply be a small area of raised discoloration in the pretibial area. Rarely, a large area of induration and nonpitting edema may develop, sometimes involving the entire lower leg. In this circumstance, the patient may have difficulty wearing shoes and the area may be pruritic and even painful (Figure 2.5). Although the cause of pretibial myxedema is unknown, it seems to be related to anti-TSH receptor antibody levels (63). Pretibial myxedema usually does not occur unless a patient has clinical evidence of ophthalmopathy, and pretibial myxedema may occur in other anatomic sites, such as the feet, face, or preradial area. Topical steroids, usually recommended to be used under an occlusive dressing, is the most effective therapy, but the response is poor in patients with more severe disease. Thyroid acropachy, which is clubbing of the fingers and toes, occurs rarely in Graves’ disease and develops almost exclusively in patients with concomitant ophthalmopathy and dermopathy (Figure 2.6). The etiology is unknown (32).
Recognizing skin conditions in patients with cirrhosis: a narrative review
Published in Annals of Medicine, 2022
Ying Liu, Yunyu Zhao, Xu Gao, Jiashu Liu, Fanpu Ji, Yao-Chun Hsu, Zhengxiao Li, Mindie H. Nguyen
Clubbing (Figure 2(g)) is the incrassation of the soft organization beneath the proximal nail plate, leading to increased curvature of the nails. Diagnostic findings include Lovibond’s angle, and the Schamroth sign [44]. This condition may indicate cyanotic congenital heart disease, pulmonary fibrosis, bronchial carcinoma, inflammatory bowel disease, cirrhosis and thyroid acropachy. Although the underlying mechanism remains elusive, several hypotheses have been proposed, including neurocirculatory reflex, growth hormone and megakaryocyte/platelet clump [45]. It is important to differentiate between clubbing and hypertrophic osteoarthropathy, which may resemble clubbing but is distinguished from clubbing by the presence of a painful nail bed, while clubbing is asymptomatic. Hypertrophic osteoarthropathy is associated with the paraneoplastic syndrome of several malignancies, including primary liver cancer [46].
Analytical and clinical performance of newly developed immunoassay for detecting thyroid-stimulating immunoglobulin, the Immulite TSI assay
Published in Scandinavian Journal of Clinical and Laboratory Investigation, 2019
Jin Ju Kim, Soon-Ho Jeong, Byungkwang Kim, Dokyun Kim, Seok Hoon Jeong
GD is the most common cause of hyperthyroidism, and the lifetime risk of GD is approximately 3% for women and 0.5% for men [18]. The diagnosis of GD is usually based on clinical features of hyperthyroidism, including palpitations and heat intolerance with GD-specific features, such as orbitopathy and thyroid acropachy [19]. Considering the pathogenesis of GD, testing for detection of TRAb could be a useful tool and should be considered to be included in the diagnostic criteria along with thyroxine (T4), triiodothyronine (T3) and TSH. Nevertheless, testing for TRAb in the initial diagnosis is still controversial, probably due to cost effectiveness and the low clinical sensitivity of old immunoassays [9,19]. Since the early 2000s, third-generation immunoassays for measuring TRAb have been introduced, and they have shown an improvement in clinical sensitivity and specificity up to 97.4% and 99.2%, respectively [20]. Some studies have reported that TRAb could be applied to clinical fields as a screening tool for GD diagnosis [9,20–22]; however, measuring TRAb is still recommended only for assessing the treatment response of GD patients, not for their initial diagnosis [22,23].
Touraine–Solente–Gole syndrome
Published in Orbit, 2018
Minor criteria: hyperhidrosis, arthralgia, gastric ulcer, cutis verticis gyrate, blepharoptosis, joint effusion, column-like legs, seborrhea and acne.8 Our patient had all three major criteria, i.e., periostosis, finger clubbing and pachydermia along with blepharoptosis, joint effusion and seborrhea. The pathogenesis of PDP is unclear. A pathogenic role of the vascular endothelial growth factor has been suggested. Mutations in the HPGD gene which codes for 15-hydroxyprostaglandin dehydrogenase, the key enzyme which is responsible for prostaglandin degradation, which is located on chromosome 4q33 4q34, which would lead to high concentrations of prostaglandin E2, a mediator which is involved in the processes of clubbing, skin thickening and periostosis have been described.9 Mutations in SLCO2A1 gene causing PDP in Japanese and African patients have been described.10 SLCO2A1 gene encodes a prostaglandin transporter that is a member of the 12-membrane-spanning organic anion-transporting polypeptide superfamily of transporters. The encoded protein may be involved in mediating the uptake and clearance of prostaglandins in numerous tissues.10 Thickening of both eyelids, which gives rise to the mechanical ptosis which is seen in PDP, has been aptly termed as “Blepharoptosis”, to differentiate this kind of ptosis from that which results from neurologic causes. Sebaceous gland hyperplasia and dermal mucin deposition contribute to eyelid thickening and the development of ptosis.7–11 Differential diagnosis includes acromegaly, secondary hypertrophic osteoarthropathy following lung, liver and intestinal malignancy, thyroid acropachy and syphilitic periostosis.7–11 At present, there is no effective disease-modifying therapy. NSAIDs and corticosteroids are used in symptomatic patients to alleviate the polyarthritis. Pamidronate, tamoxifen citrate, octreotide, colchicine and bisphosphonates have been reported as effective therapies in refractory cases.7–9 Plastic surgery is indicated for cosmetic reasons, to change the facial and scalp appearances. Bilateral blepharoplasty, tarsal wedge resection and excision of skin furrows can be done to achieve a good cosmetic improvement.