A 44-year-old female presents to the emergency department after noticing swelling of her tongue and face, specifically the cheeks and periorbital area. She states the swelling began two weeks ago and has progressively worsened. She also complains of redness.
Myxedema is a term used to describe the appearance of nonpitting edema in patients with severe hypothyroidism. While the exact mechanism is not completely understood, this edema is thought to be secondary to increased deposition of dermal hyaluronic acid, a glycosaminoglycan that can grow up to 1000x its normal size when hydrated. Carotenemia is another possible manifestation of hypothyroidism and is secondary to impaired conversion of carotenoids to retinol in the setting of low levels of thyroid hormone. Additionally, patients may exhibit patchy alopecia, fatigue, cold intolerance, goiter, coarsening of the skin, and macroglossia.
The presentation of hypothyroidism is widely variable and may be subtle or atypical. Classically, hypothyroidism presents with pretibial myxedema, hyporeflexia, and cold intolerance. In some cases, facial edema may be the predominant feature, as seen in this patient.
Brittle, thinning hair on the scalp and eyebrows is a common feature. Thinning of the hair along the lateral eyebrows is called madarosis, also known as “Queen Anne’s Sign.”
In a patient with Grave’s disease, maintain a high index of suspicion for hypothyroidism, either as part of the natural history of the disease or as a sequela of treatment.