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There are numerous cutaneous manifestations of hypothyroidism, the most notable of which is periorbital and facial oedema. Only upper limb oedema was present in our patient and this obscured the clinical diagnosis. Some scaling and xerosis were noted on the upper arms during the later stages but other features such as pale, cold, wrinkled skin with punctate telangiectasias, palmoplantar keratoderma and absence of sweating were not present.The noncutaneous manifestations of hypothyroidism are weight gain, cold intolerance, constipation and poor concentration. Musculoskeletal symptoms are common but reports of proximal muscle weakness and elevated creatine kinase are rare. Madariaga et al. 1 found only 32 published cases over a 25-year period between 1975 and 2000.The presence of mucin in the biopsy specimen and musculoskeletal symptoms is compatible with a diagnosis of thyroid disease, dermatomyositis, and systemic lupus erythematosus. 2 Our case is similar to that previously reported by Ohtsuka et al. 3 who described dermal mucinosis and musculoskeletal symptoms simulating polymyositis as a presenting sign of hypothyroidism. However, their patient had facial oedema, dry skin and a goitre suggesting the diagnosis.The cutaneous mucinoses can be classified into primary and secondary forms depending upon whether mucin deposition is a distinct histological feature or an indistinct feature associated with various pathologies. 4 The primary mucinoses are scleromyxoedema, acral persistent papular mucinosis, scleredema, nodular and papular mucinosis, and mucinosis associated with thyroid disease. Nodular and papular mucinosis has been associated with systemic lupus erythematosus 5 and acral persistent papular mucinosis with dermatomyositis. 6 This is an atypical presentation of hypothyroidism and highlights the importance of determining thyroid function in patients presenting with musculoskeletal symptoms and ⁄or cutaneous mucin deposition. Obvious signs of hypothyroidism may be absent. Other rare manifestations of hypothyroidism can similarly cause difficulty in diagnosis leading to a delay in treatment, 'myxoedema madness' being the well-known example. Amelioration of symptoms and normalization of creatine kinase levels in response to prednisolone and methotrexate reflects their nonspecific actions, and provides an illustration of how this can mislead the clinician.

Many studies have found that screening and treatment of latent tuberculosis (TB) before starting treatment with tumour necrosis factor (TNF)-a inhibitors reduces associated TB infections. The new T-cell interferon-a release assay (TIGRA), is more specific and sensitive for detection of latent TB compared with the tuberculin skin test (TST). We report results of TIGRA in our first 63 patients commencing TNF-a inhibitors for severe psoriasis. Of the 63 patients, 5 (7.9%) had a positive TIGRA result and were started on treatment for latent TB. We found that the only risk factor for TB associated with a positive TIGRA was a history of travel to countries with high TB incidence. To our knowledge, this is the first study to identify the background risk (7.9%) of latent TB in an endemic UK population. This result emphasizes the importance of TIGRA testing to reduce the risk of TB in patients treated with TNF-a inhibitor.

We present a case of a 50-year-old man with unusual extensive linear lesions on the right leg that had been present from the age of 2 years. As a child he had been treated with oral steroids under a working diagnosis of linear scleroderma. He went on to undergo multiple operations and skin-grafting procedures under the care of the plastic surgeons and presented to the dermatology department in 2004 because of itchy, scaly and painful lesions extending from the original area. Multiple biopsies had been taken, all showing similar histopathological features of a poorly differentiated dermal lesion composed of fibrohistiocytic cells arranged in a whorled pattern, similar to that seen in dermatofibroma. There was positive staining with vimentin and SMA, and negative staining with caldesmon, D33, CD34, S100 and factor 13a, indicating that the cell of origin was a myofibroblast. Clinically this extensive lesion does not fit the characteristics of a dermatofibroma. It also does not fit readily into any previously described fibrous tissue tumour condition, and, to our knowledge, is a unique case. The patient remains under close clinical observation given that there is no way of predicting the long-term prognosis, but to date no suspicious features have been seen.

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