A 63-year-old woman presented with a six month history of a large pruritic plaque which was present over both her legs and feet. The lesions had first appeared over her right leg, followed by involvement of left leg. She denied fatigue, heat intolerance, hand tremor, constipation, unexplained weight gain or change in voice. Her past medical history included Type-2 diabetes mellitus, which was currently diet controlled and hypertension, of two year's duration. Her current medications included an angiotensin receptor blocker. Her physical examination revealed a non-tender, firm, nodular thyroid swelling and exophthalmos. Her cutaneous examination showed a well defined, indurated, erythematous to skin coloured non-tender plaque over both anterolateral aspects of legs. On left side, lesions extended upto middle of the leg and on the right side, just above the ankle, extending to involve bilateral feet, but sparing the toes [Table/ Fig-1]. There was no clubbing, hyperhidrosis or hypertrichosis.Thyroid function test showed thyroid-stimulating hormone (TSH)-2.25 mu/L (0.27-4.20 mu/L), free triiodothyronine (T3) -1.54 nmol/L (1.3-3.1 nmol/l), free thyroxine (T4) -93.62 nmol/l (66-181 nmol/l), thyroglobulin antibodies (AbTG) titre-190 IU/mL(0-35 IU/mL) and Anti-TPO antibody levels of >1000 IU/mL (0-35iu/ ml). Other haematological and biochemical investigations, including serum creatinine, lipid profile and plasma glucose were within normal limits. Keeping in mind PM, chronic dermatitis and lichen myxedematosus as differentials, a skin biopsy was taken from left leg. Histopathology showed a normal epidermis, collagen fibres in reticular dermis, which were mildly separated by deposits of mucin, and mild perivascular lymphocyte infiltration. These changes were suggestive of PM [Table/ Fig-2].Ultrasound examination of thyroid showed diffusely heterogeous and bulky cystic areas with increased vascularity. Few subcentimetric sized lymph nodes were noted, which were bilateral at level 2 and level 3, which suggested a possibility of Thyroiditis. Fine needle aspiration biopsy taken from thyroid swelling showed oxyphilic cells with round nuclei and moderate to marked anisocytosis, prominent nucleoli and abundant eosinophilic granular cytoplasm. Few multinucleated giant cells with occasional clusters of epitheloid histiocytes were present, which favoured changes of Hashimoto's thyroiditis. The lesions regressed after 4 sittings, with monthly intralesional triamcinolone acetonide injections, 10 mg/ml, 0.5-1.0 ml per lesion.
DisCussionPM is a well-defined cutaneous mucinosis which is characterized by increased amounts of acid glycosaminoglycans in the dermis. It is a rare clinical finding which is often referred to as localized myxedema or thyroid dermopathy. It is an autoimmune manifestation seen in 5 -10% of patients with Graves thyrotoxicosis [1]. PM has a gradual onset and it typically develops 12 to 24 months after the diagnosis of thyrotoxicosis. It tends to affect older adults, showing a peak incidence in the sixth decade of l...