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14 March 2014 : Case report  Japan

Pitting type of pretibial edema in a patient with silent thyroiditis successfully treated by angiotensin II receptor blockade

Unknown etiology, Challenging differential diagnosis

Itsuro KazamaABCDEF, Yoko MoriB, Asuka BabaF, Toshiyuki NakajimaB

DOI: 10.12659/AJCR.889854

Am J Case Rep 2014; 15:111-114

Abstract

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.

CASE REPORT: 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 radiograph 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.

Keywords: Renin-Angiotensin System, hyperthyroidism, Thyroiditis

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American Journal of Case Reports eISSN: 1941-5923
American Journal of Case Reports eISSN: 1941-5923