title: Pitting type of pretibial edema in a patient with silent thyroiditis successfully treated by angiotensin ii receptor blockade.
abstract: METHODS
  Female, 56 FINAL DIAGNOSIS: Thyroiditis - silent Symptoms: Palpitations • pretibial pitting edema • short of breath • sweating
  
  
  METHODS
  - Clinical Procedure: - Specialty: Endocrinology and Metabolic.
  
  
  OBJECTIVE
  Unknown etiology.
  
  
  BACKGROUND
  Hyper- or hypothyroidism sometimes causes pretibial myxedema characterized by non-pitting infiltration of a proteinaceous ground substance. However, in those patients, the "pitting" type of pretibial edema as a result of increased sodium and fluid retention or vascular hyper-permeability rarely occurs, except in cases complicated by heart failures due to severe cardiomyopathy or pulmonary hypertension.
  
  
  METHODS
  A 56-year-old woman developed bilateral pretibial pitting edema, followed by occasional sweating, palpitations, and shortness of breath, which persisted for more than 2 months. The diagnosis of hyperthyroidism due to silent thyroiditis was supported by elevated levels of free thyroxine (T4) and triiodothyronine (T3), with a marked decrease in thyroid-stimulating hormone (TSH), and the negative results for TSH receptor antibodies with typical findings of destructive thyrotoxicosis. Despite her "pitting" type of pretibial edema, a chest radio-graph demonstrated the absence of cardiomyopathy or congestive heart failure. Oral administration of angiotensin II receptor blocker (ARB) was initiated for her systolic hypertension, with a relatively higher elevation of plasma renin activity compared to that of the aldosterone level. Although the symptoms characteristic to hyperthyroidism, such as increased sweating, palpitations and shortness of breath, slowly improved with a spontaneous resolution of the disease, ARB quickly resolved the pretibial pitting edema shortly after the administration..
  
  
  CONCLUSIONS
  In this case, increased activity of the renin-angiotensin-aldosterone system stimulated by thyroid hormone was likely responsible for the patient's pitting type of edema. The pharmacological blockade of the renin-angiotensin-aldosterone system was thought to be effective for the quick resolution of the symptom.
authors.affiliation: Department of Physiology I, Tohoku University Graduate School of Medicine, Sendai, Japan.
authors.forename: Itsuro
authors.initials: I
authors.lastname: Kazama
authors.affiliation: Mori Yoko Clinic, Sendai, Japan.
authors.forename: Yoko
authors.initials: Y
authors.lastname: Mori
authors.affiliation: Department of Physiology I, Tohoku University Graduate School of Medicine, Sendai, Japan.
authors.forename: Asuka
authors.initials: A
authors.lastname: Baba
authors.affiliation: Department of Internal Medicine, Iwakiri Hospital, Sendai, Japan.
authors.forename: Toshiyuki
authors.initials: T
authors.lastname: Nakajima
keywords: Hyperthyroidism; Renin-Angiotensin System; Thyroiditis