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Graves' disease (GD) is the leading cause of hyperthyroidism and diffuse toxic goiter in iodine-sufficient geographi-cal areas. GD is associated with classical manifestations such as ophthalmopathy and thyroid dermopathy, in addi-tion to diffuse goiter, which may be the site of carcinomas, as a complication. Case report: A 52-year-old woman presented with goiter and symptoms compatible with hyperthyroidism, such as heat intolerance, weight loss, fati-gue, increased sweat, tachycardia, fine tremors, increased intestinal transit, anxiety, emotional lability, insomnia, exophthalmos, and pretibial myxedema. A complementary investigation confirmed the diagnosis of hyperthyroidism (high free T4 and total T3 levels and low thyroid-stimulating hormone - TSH levels). Ultrasound images showed dif-fuse enlargement of the thyroid lobes by approximately 10 times and the presence of three thyroid nodules, one of which was larger than 2 cm with heterogeneous echogenicity and vascularization throughout the nodule; ultrasoun-d-guided fine needle aspiration revealed cytology compatible with Bethesda IV; scintigraphy revealed a low uptake area (cold nodule) amid a diffuse high-uptake goiter. A thyroidectomy was performed, and the anatomical specimen diagnosis revealed papillary thyroid carcinoma in the right lobe, with adjacent parenchyma compatible with GD. Histopathological examination of the skin showed the presence of myxedema compatible with Graves' dermopathy. The patient evolved with the normalization of TSH levels and a reduction of cutaneous manifestations. Conclusion:GD abnormalities may not be restricted to the classic clinical manifestations, and a careful investigation may reveal the coexistence of carcinomas. (AU)

A doença de Graves (DG) é a principal causa de hipertireoidismo e bócio difuso tóxico em áreas geográficas com iodo suficiente. DG está associada a manifestações clínicas clássicas como oftalmopatia e dermopatia da tireoide, além do bócio difuso, que pode ser sítio de carcinomas, como uma complicação. Relato de caso: Mulher de 52 anos apresentou bócio e sintomas compatíveis com hipertireoidismo como intolerância ao calor, emagrecimento, fadiga, sudorese aumentada, taquicardia, tremores finos, trânsito intestinal aumentado, ansiedade, labilidade emocional, insônia, exoftalmia e mixedema pré-tibial. A investigação complementar confirmou o diagnóstico de hipertireoidis-mo (níveis elevados de T4 livre e T3 total; níveis baixos de hormônio estimulante da tireoide - TSH). As imagens ultrassonográficas mostraram aumento difuso dos lobos tireoidianos em aproximadamente 10 vezes e a presença de três nódulos tireoidianos, um dos quais, maior que 2 cm, com ecogenicidade e vascularização heterogêneas em todo o nódulo, cuja punção aspirativa por agulha fina guiada por ultrassom revelou citologia compatível com Bethesda IV; e a cintilografia evidenciou uma área de baixa captação (nódulo frio) em meio a um bócio difuso de alta captação. Foi realizada tireoidectomia e o diagnóstico da peça anatômica revelou carcinoma papilífero de tir-eoide em lobo direito, com parênquima adjacente compatível com DG. O exame histopatológico da pele mostrou a presença de mixedema compatível com dermopatia de Graves. A paciente evoluiu com normalização dos níveis de TSH e redução das manifestações cutâneas. Conclusão: As anormalidades da DG podem não estar restritas às manifestações clínicas clássicas, e uma investigação criteriosa pode revelar a coexistência de carcinomas, (AU)

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Introducción: en el presente reporte de caso se presenta una urgencia endocrinológica, el coma mixedematoso. Se considera una descompensación del hipotiroidismo y su mortalidad es alta alcanzando hasta 52% en algunas series de casos. Puede desencadenarse por múltiples factores y su presentación clínica es muy variada ya que comprende la afección de diversos sistemas. Presentación del caso: se presenta el caso de una paciente femenina de 42 años de edad que consultó al servicio de urgencias del Hospital de San José de Bogotá con sospecha inicial de una de falla cardiaca descompensada, sin embargo, cursó con pobre mejoría ante el manejo instaurado, por lo cual se realizaron estudios de extensión en donde se encontró una función tiroidea deprimida. Discusión y conclusiones: en este momento se consideró que la paciente padecía un coma mixedematoso, se instauró manejo con dosis altas de levotiroxina oral con lo cual evolucionó de manera favorable y se logró dar de alta a los pocos días.

Introduction: herein we present an endocrine emergency, myxedema coma, which is a form of decompensated hypothyroidism, whose mortality may be as high as 52% as evidenced in some case series. It may be triggered by multiplefactors and has varied clinical presentations for it affects diverse organ systems. Case presentation:we present the case of a 42-year-old female who presented to the emergency department of Hospital de San José in Bogotá with clinical suspicion of decompensated heart failure upon admission, however, her response was poor to the treatment she received. Extension studies were performed which showed low thyroid function. Discussion and conclusions: at this point the patient was diagnosed with myxedema coma, and was started on high doses of oral levothyroxine, with which she evolved favorably and was discharged a few days later.

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RESUMEN El coma mixedematoso es la complicación más grave de un hipotiroidismo. Ocurre, por lo general, en mujeres ancianas con hipotiroidismo conocido sin un adecuado manejo y en presencia de un evento desencadenante. El diagnóstico es difícil y debe realizarse en forma oportuna para disminuir el riesgo de muerte. El coma es una de las presentaciones neurológicas de esta urgencia endocrinológica y no es necesario su presencia para el diagnóstico. En este reporte de caso se presentan varías manifestaciones inusuales en un paciente masculino con hipotiroidismo profundo que, al diagnóstico, debutó con coma mixedematoso con predictores de mal pronóstico durante la hospitalización, pero debido al abordaje temprano y el manejo integral, se dio una resolución satisfactoria a esta urgencia endocrinológica infrecuente.

SUMMARY Myxedema coma is the most serious complication of hypothyroidism. It usually occurs in the context of elderly women, with known hypothyroidism without proper management and in the presence of a triggering event. The diagnosis is challenging and must be made in a timely manner to prevent the development of adverse outcomes. Coma is one of the neurological manifestations of the entity, not being necessary for its diagnosis. This case report presents a constellation of unusual manifestations of a male patient with myxedema coma at the debut of severe hypothyroidism with predictors of poor prognosis during hospitalization, but due to the early approach and comprehensive management, this uncommon endocrinological emergency was satisfactorily resolved.

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Abstract Localized pretibial myxedema is a dermopathy whose treatment is a challenge in dermatology, occurring in 0.5-4% of patients with Graves' disease. This autoimmune thyroid condition stimulates the production of hyaluronic acid and glycosaminoglycans that are deposited particularly in the pretibial region. Clinically, it presents as a localized, circumscribed, and non-depressible infiltrate in plaques. Several treatment modalities have been proposed, and their results vary, with worse response observed in severe cases. This report presents the case of a patient with elephantiasic pretibial myxedema who was subjected to intralesional corticosteroid applications, resulting in an excellent and encouraging therapeutic response that was maintained.

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Localized pretibial myxedema is a dermopathy whose treatment is a challenge in dermatology, occurring in 0.5-4% of patients with Graves' disease. This autoimmune thyroid condition stimulates the production of hyaluronic acid and glycosaminoglycans that are deposited particularly in the pretibial region. Clinically, it presents as a localized, circumscribed, and non-depressible infiltrate in plaques. Several treatment modalities have been proposed, and their results vary, with worse response observed in severe cases. This report presents the case of a patient with elephantiasic pretibial myxedema who was subjected to intralesional corticosteroid applications, resulting in an excellent and encouraging therapeutic response that was maintained.

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Resumen Se presenta un caso de una paciente de 69 años de edad y sin antecedentes personales o familiares de patología tiroidea alguna, que asiste con un estado convulsivo de aparición súbita, de hemicuerpo derecho y relajación esfinteriana, asociado, además, a trastornos del estado de conciencia, bradicardia, bradipnea y edema de difícil Godet en miembros inferiores. Los exámenes complementarios mostraron acidosis respiratoria, hiposecreción de T4 y elevación de la hormona estimulante de la tiroides por retroalimentación negativa. Estos resultados corroboraron el diagnóstico presuntivo de coma mixedematoso. Se emprendió el tratamiento hormonal correspondiente con levotiroxina, al cual respondió satisfactoriamente y fue egresada a los 24 días de su ingreso, pendiente de valoración por el especialista de endocrinología.

Abstract We present the case of a 69-year-old female patient with no personal or family history of any thyroid disease, who attends with a convulsive state of sudden onset, right hemibody and sphincter relaxation, also associated with disorders of the state of consciousness, bradycardia, bradypnea and edema of difficult godet in lower limbs. Complementary analyses showed respiratory acidosis, hyposecretion of T4 and elevation of the thyroid stimulating hormone by negative feedback. These results corroborated the presumptive diagnosis of myxedema coma. The corresponding hormonal treatment with levothyroxine was undertaken, to which it responded satisfactorily and was discharged 24 days after admission, pending evaluation by the endocrinology specialist for an outpatient hormone replacement therapy.

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BACKGROUND: Exophthalmos, myxedema, and osteoarthropathy syndrome is a very rare condition that is associated with Graves' disease. The presence of dermopathy and the involvement of joint/bone tissues indicate that it seems to be related with the severity of the autoimmune process. Owing to its low incidence, there is a lack of information regarding its treatment and clinical follow-up. Some cases improved after use of high doses of steroids; however, some patients do not respond to this treatment. Recently, the effectiveness of rituximab for treatment of Graves' ophthalmopathy resistant to corticosteroids has been demonstrated. However, it has never been used for the treatment of exophthalmos, myxedema, and osteoarthropathy syndrome (particularly for the treatment of osteoarticular manifestations). CASE PRESENTATION: We present the case of a 54-year-old Mexican woman previously treated for Graves' disease who developed post-iodine hypothyroidism and exophthalmos, myxedema, and osteoarthropathy that did not improve after high doses of steroids (intravenous and oral). Her exophthalmos, myxedema, and osteoarthropathy syndrome symptoms improved as early as 6 months after treatment with rituximab. CONCLUSION: Exophthalmos, myxedema, and osteoarthropathy syndrome is a non-classical presentation of Graves' disease, whose clinical manifestations could improve after treatment with rituximab, particularly in those patients with lack of response to high doses of corticosteroids.

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O coma mixedematoso é uma emergência endocrinológica rara e consiste na máxima expressão do hipotireoidismo, com alta mortalidade por suas complicações hemodinâmicas e ventilatórias, podendo ser agravadas por distúrbios da coagulação. Relatamos o caso de uma paciente diagnosticada com coma mixedematoso e trombo de veia cava superior. Buscamos salientar os distúrbios de coagulação frequentes no hipotireoidismo grave, que contribuem para o aumento da mortalidade deste grupo de pacientes. O diagnóstico e o tratamento precoce do coma mixedematoso, aliados à instituição imediata da terapia para o fenômeno trombótico encontrado, permitiram a evolução favorável do quadro. O relato, juntamente da bibliografia pesquisada, orientou o raciocínio sobre a relação dos distúrbios de coagulação, que ocorrem no hipotireoidismo descompensado. Apesar de poucos relatos, estes distúrbios podem ser frequentes e devem ser pesquisados, pois contribuem com o aumento da mortalidade.(AU)

Myxedema coma is a rare endocrinological emergency, consisting of the highest expression of hypothyroidism with high mortality due to hemodynamic and ventilatory complications, which may be aggravated by coagulation disorders. We report the case of a patient diagnosed with myxedema coma and superior vena cava thrombus. We sought to emphasize the frequent coagulation disorders in severe hypothyroidism, which contribute to increased mortality in this group of patients. The diagnosis and early treatment of myxedema coma, together with the immediate institution of therapy for the thrombotic phenomenon found, allowed the favorable evolution of the condition. The report, together with the literature, has guided the rationale for the influence of coagulation disorders that occur in decompensated hypothyroidism. Despite the few number of reports, these disorders can be frequent and should be investigated because they contribute to the increase in mortality.(AU)

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Hypothyroidism is a frequently diagnosed and simply treated disease. If not recognised, however, in time it may develop into the most severe manifestation of hypothyroidism known as myxedema coma. The term "myxedema coma" is generally seen as misleading since most patients do not initially present in a coma. The typical progression is lethargy evolving into stupor and, eventually, into coma with respiratory failure and hypothermia. It mainly affects elderly women, often occurring in winter and is relatively rare. It can be considered a form of decompensated hypothyroidism often triggered by a variety of non-thyroid conditions or diseases provoking an extremely severe condition of multiple system failure with lethal consequences unless an early diagnosis is made and an aggressive treatment is administered.

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