Thyroid Dermopathy and Ophthalmopathy Secondary to Autoimmune Hypothyroidism: A Rare Entity

Dear Editor, Thyroid dermopathy and ophthalmopathy are among the most prevalent extrathyroidal manifestations of Graves’ disease, whereas these findings are uncommon in hypothyroidism.[1,2] This report presents a case of pretibial myxoedema accompanied by ophthalmopathy associated with autoimmune hypothyroidism. A 53-year-old male presented with fatigue, insomnia, restlessness, asymptomatic swelling of both legs, periorbital puffiness, and proptosis for six months. During the same period, he experienced dryness and thickening of the skin on both lower legs with generalized dryness over other body areas. Two months prior, he was diagnosed with hypothyroidism with serum TSH at 14.2 μIU/ml and was prescribed daily L-thyroxine 50 μg. Although there was a slight improvement in symptoms, the skin lesions and eye complaints persisted. The patient gave a 20-year history of smoking with an intake of approximately eight cigarettes per day. Dermatological examination showed ichthyotic hyperpigmented skin with non-tender, non-pitting edema on the lower legs and non-tender bulbous swelling of the posterior calcaneum [Figure 1a and b]; the patient also had dry skin over the face and hands. An ophthalmological examination revealed bilateral proptosis, periorbital puffiness, reduced tear film height, bilateral scleral show, and superficial punctate keratoses [Figure 1c]. Finger and toenails were discolored and clubbed [Figure 1d], while oral and other mucosa appeared normal. The thyroid gland was not palpable, and there was no neck swelling; no abnormality was detected in the neck ultrasound. A skin biopsy from the shin and heel showed abundant mucinous material in the dermis and subcutis, causing the separation of dermal collagen bundles, indicative of pretibial myxedema [Figure 2a]. The slide demonstrated mucin staining with alcian blue [Figure 2b]. Laboratory results revealed elevated TSH (28.64 μIU/ml), low free T4 (0.612 ng/dl), high anti-thyroid peroxidase antibodies (427.5 IU/ml), and high anti-TSH receptor antibodies (>50 IU/L). The patient’s lipid profile showed elevated cholesterol and LDL, with normal renal and liver function tests. The patient was diagnosed with autoimmune hypothyroidism, dermopathy, ophthalmopathy, and acropachy. Treatment included 88 μg of L-thyroxine daily, methylcellulose eye drops, goggles, compression bandages, and a topical steroid with moisturizer for skin lesions. A follow-up was scheduled in two months.Figure 1: (a and b) showed ichthyotic hyperpigmented skin with non-tender, non-pitting edema on the lower legs and non-tender bulbous swelling of the posterior calcaneum, (c) Showing bilateral proptosis, periorbital puffiness, (d) Fingernails were discolored and clubbedFigure 2: (a) Histopathology (H and E, 100x) shows Skin biopsy from the shin and heel showed abundant mucinous material in the dermis and subcutis, causing the separation of dermal collagen bundles, (b) Histopathology (H and E, 400x) shows mucin staining with alcian blueAutoimmune thyroid disorders can cause extra-thyroidal manifestations like ophthalmopathy, dermopathy, and acropachy.[1,2] These occur in 95% of autoimmune hyperthyroidism (Graves’ disease) cases and only 5% of autoimmune hypothyroidism (Hashimoto’s thyroiditis) cases. Ophthalmopathy is seen in 40–50% of Graves’ disease patients, and dermopathy in 3–5%. In Hashimoto’s thyroiditis, 3–5% have infiltrative ophthalmopathy, and dermopathy is rare.[3] Dermopathy and acropachy indicate the severity of the autoimmune process, with tobacco intake being a major risk factor.[1] The patient, in this case, has been addicted to tobacco for 20 years. The pathogenesis of ophthalmopathy and dermopathy is influenced by various factors, primarily involving fibroblast differentiation, proliferation, and glycosaminoglycan synthesis. Lymphatic obstruction also contributes to lymphedema. The accumulation of glycosaminoglycans leads to fluid retention, fiber separation, and connective tissue expansion.[1,4] The severity of extrathyroidal manifestations is related to TSH receptor antibody level. However, recent evidence indicates that autoimmunity against the IGF-I receptor may also play a role in Graves’ ophthalmopathy and dermopathy.[1] TSH receptor antibodies can be stimulating, blocking, or neutral.[5] Blocking antibodies are commonly seen in Hashimoto thyroiditis. Rarely, it may also be associated with TSHR-stimulating antibodies, which results in thyroid eye disease. This might also explain why few individuals with Hashimoto thyroiditis switch to Graves’ disease.[4] The index case has thyroid-associated ophthalmopathy, dermopathy, and acropachy associated with autoimmune hypothyroidism, which is a rare event. A previous case report by Walia et al. showed a 31-year-old man with infiltrative ophthalmopathy and dermopathy in association with hypothyroidism due to Hashimoto’s thyroiditis.[3] Our case had no history of hyperthyroidism, and his USG neck did not reveal any nodularity or fibrosis and was normochromic in contrast to Hashimoto’s thyroiditis. We believe our patient has developed hypothyroidism along with cutaneous, ophthalmic, and nail findings due to thyroid-blocking antibodies. Extrathyroidal manifestations, like ophthalmopathy and dermopathy, are rarely seen in autoimmune hypothyroidism in comparison with Graves’ disease. Avoiding trauma and tobacco use and managing thyroid dysfunction effectively and promptly are all ways to prevent extrathyroidal symptoms. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.