title: Graves' disease presenting as elephantiasic pretibial myxedema and nodules of the hands.
abstract: A 67-year-old man presented with a 2-year history of asymptomatic, firm, multiple nodules and plaques and cerebriform hypertrophy of both lower legs and feet, and well-defined, skin-colored, firm nodules and tumors on both hands. He had been diagnosed as having Graves' disease 3 years previously, and had been treated with 10 mg of methimazole and 100 microg of thyroxin (T4) daily for 2 years. Physical examination revealed nonpitting edema, flesh-colored to erythematous, firm, confluent, polypoid nodules and fissured plaques extending from the shins to the dorsa of both feet (Fig. 1), and round to oval, firm, skin-colored, walnut-to-egg-sized tumors on all 10 fingers and the ulnar side of the dorsum of the right hand (Fig. 2). The thyroid gland was diffusely enlarged; however, there was no exophthalmos, and extraocular movements were normal. There was no weight loss, loss of appetite, tremor, heat intolerance, diarrhea, or fatigue. On laboratory evaluation, thyroid-stimulating hormone (TSH) had a markedly low titer of < 0.05 microU/mL (normal: 0.4-5.0), and the TSH receptor antibody was extremely high at 73.8% (normal: < 15%). Serum free triiodothyronine (T3), T4, antimicrosome, and antithyroglobulin antibodies were normal or negative. Skin biopsy samples from the shin and hand disclosed extensive mucin deposition throughout the dermis.
authors.affiliation: Department of Dermatology, Asan Medical Center, College of Medicine, University of Ulsan, 388-1 Poongnap-dong, Songpa-gu, Seoul 138-736, South Korea. vickycho@hanmail.net
authors.forename: S
authors.initials: S
authors.lastname: Cho
authors.forename: J H
authors.initials: JH
authors.lastname: Choi
authors.forename: K J
authors.initials: KJ
authors.lastname: Sung
authors.forename: K C
authors.initials: KC
authors.lastname: Moon
authors.forename: J K
authors.initials: JK
authors.lastname: Koh
mesh_terms: D000368:Aged; D003937:Diagnosis, Differential; D006111:Graves Disease / Q000150:complications*; D006229:Hand Dermatoses / Q000209:etiology / Q000473:pathology*; D006801:Humans; D007868:Leg Dermatoses / Q000209:etiology / Q000473:pathology*; D008297:Male; D009230:Myxedema / Q000209:etiology / Q000473:pathology*; D012867:Skin / Q000473:pathology