facial edema

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.

Vitals: T 38.6°C; BP 135/78; HR 90; RR 18

General: Lying in bed, somewhat anxious appearing

HEENT:

  • Significant edema of bilateral cheeks and periorbital areas
  • Thinning of hair along scalp and lateral aspect of eyebrows
  • Mild macroglossia

Skin:

  • Yellow tinge to patient’s skin
  • Horizontal scar noted on the anterior aspect of the neck

TSH: 31.27 mU/L

Free T4: 0.20 pmol/L

Myxedema facies

This patient has a history of thyroidectomy, as indicated by her neck scar, and a history of noncompliance with levothyroxine.

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.

Take-Home Points

  • 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.
  1. Safer JD. Thyroid hormone action on skin. Dermatoendocrinol. 2011 Jul;3(3):211-5. doi: 10.4161/derm.3.3.17027. Epub 2011 Jul 1. PMID: 22110782; PMCID: PMC3219173.
  2. Wiersinga WM. Adult Hypothyroidism. 2014 Mar 28. In: Feingold KR, Anawalt B, Boyce A, Chrousos G, de Herder WW, Dhatariya K, Dungan K, Grossman A, Hershman JM, Hofland J, Kalra S, Kaltsas G, Koch C, Kopp P, Korbonits M, Kovacs CS, Kuohung W, Laferrère B, McGee EA, McLachlan R, Morley JE, New M, Purnell J, Sahay R, Singer F, Stratakis CA, Trence DL, Wilson DP, editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000–. PMID: 25905416.

 

 

Michael Sternberg, MD

Michael Sternberg, MD

Professor
Department of Emergency Medicine
University of South Alabama
Michael Sternberg, MD

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Chris Evers

Chris Evers

Medical Student
University of South Alabama
Chris Evers

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