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In addition to GO, patients with Graves’ disease may have localized myxedema and thyroid acropachy [20]. Myxoedema is characterized by a usually restricted and well-delimited area of skin thickening, colouration (from red to brown) (Fig. 2a), pruritus, and occasionally pain. In addition to the pretibial area, its most typical location, the lesion can be rarely seen also on the feet, toes and upper extremities as well as on the forehead and ear. In severe, proliferative cases, the skin can assume an elephantiasic aspect (Fig. 2b). Myxoedema can be treated with local steroids, being quite responsive in the non-proliferative, fortunately most common, variants. Treatments with systemic steroids and other immunosuppressive medications, or with surgery, have also been used, although no clear-cut data on the outcomes are available. Thyroid acropachy is characterized by digital clubbing of fingers (but not toes) and swelling of digits and toes together with a periosteal reaction of extremity bones. Both myxoedema and acropachy are due to proliferation of fibroblasts and deposition of glycosaminoglycans, somehow resembling GO, and are believed to have the same pathogenesis as GO. Both myxoedema and acropachy are rare, as they are observed in 0.5–5 and 0.07–1% of patients with Graves’ disease, respectively [4], and both are almost invariably associated with the presence of GO.

Fig. 2. a Diffuse pretibial myxoedema. b Elephantiasic pretibial myxoedema. c Thyroid acropachy.