Case 2-2012: A 38-year-old female with weigh loss, leg edema and hand tremor

Volke, V., & Matjus, S.

doi:10.1186/1752-1947-6-258

17 Case 2-2012: A 38-year-old female with weigh loss, leg edema and hand tremor

Unilateral pitting edema of the leg as a manifestation of Graves’ disease: a case report. Journal Of Medical Case Reports, 2012,6(1). doi: 10.1186/1752-1947-6-258

Volke, V., & Matjus, S.

Case Summary ¹

A 38-year-old Caucasian female had been experiencing symptoms of hyperthyroidism for five months and had developed pitting edema of the left leg four months prior to. The patient had lost approximately 3 kilograms and had mild hand tremors. The patient’s physical examinations revealed tachycardia (95 beats per minute) and a smooth thyroid – with a slightly increased volume. Laboratory investigations revealed normal D-dimer levels and suppressed thyroid-stimulating hormone levels (less than 0.001 mlU/L, local reference of 0.4 mlU/L to 4 mlU/L).

Learning Objectives

Investigating the clinical history of the patient with symptoms of hyperthyroidism and selecting appropriate examinations for further analysis and diagnosis.
Familiarizing and defining new medical terminology associated with the endocrinological disease while understanding the purpose of each lab investigation.
Extrapolating key lifestyle factors that have contributed to the disease and correlating the diagnosis to the laboratory results.

Clinical History ¹

Age: 38 years old
Sex: Female
Ethnicity: Caucasian

Medical History ¹

No history of taking oral contraceptive pills.

Symptoms ¹

Symptoms of hyperthyroidism lasting for ~five months.
- Weight loss (3 kg)
- Irritability
- Mild hand tremor
She developed painless pitting edema of the left leg four months before
No history of trauma

Examinations (Clinical Assays/Tests/Imaging) ¹

Physical Examination ¹

Signs of thyrotoxicosis were moderate: hand tremor, tachycardia (95 beats per minute)
Warm skin was apparent.
Thyroid was smooth, slightly increased volume, and was not tender on palpation.
No eye involvement except mild periorbital edema of her left eye
The skin of both legs was of normal color and the pitting edema on her left leg was of a diffuse nature and spread to two-thirds of her leg.
The skin surface was smooth and had no elevations or discoloration, whereas her right leg appeared normal.

Laboratory Investigations ¹

Thyroid-stimulating hormone level (less than 0.001 mlU/L, local reference of 0.4 to 4).
Free T4 (75 pmol/L, local reference of 10.3 to 24.5)
Anti-thyroid receptor antibodies (13.5 U/L, local reference of less than one and a half)
Antithyroid peroxisomal antibodies are normal (26 IU/L, local reference of less than 35).
Normal D-dimer levels.

Doppler Ultrasound ¹

Had normal findings of her leg veins.

Question & Answers Leading to Diagnosis:

Question 1: Based on the patient physicals symptoms, such as mild hand tremors, weight loss and edema, what lab investigations should be conducted to determine the diagnosis?

Question 2: Thyroid-stimulating hormones levels were low while free T4 levels were high, what immediate diagnosis could be suggested?

Question 3: Hyperthyroidism can be the by-product of difference illnesses; what lab investigations would support a specific diagnosis and what is that diagnosis?

Question 4: How could we correlate this diagnosis with the patient’s demographic?

** For answers please check the next chapter.

Medical terminology/Abbreviations:

Anti-thyroid peroxisomal antibodies – Antibodies that are associated with a thyroid disease due to an autoimmune disorder.⁹
Anti-thyroid receptor antibodies – Antibodies responsible for blocking, neutralizing, and activating thyroid receptors, associated with autoimmune thyrotoxicosis. ^{10, 11}
Congestive heart failure – A condition where the heart muscles don’t pump blood as efficiently as they should. ⁵
D-dimer – Small protein fragment found in the blood post blood clot degradation by fibrinolysis. ¹²
Hyperthyroidism – An overactive thyroid, occurring when the thyroid gland produces an excess amount of hormone thyroxine.²
Periorbital edema – Swelling around the eye. ¹³
Pretibial myxedema – Describes localized lesions of the skin due to the deposition of hyaluronic acid, a rare thyroid disease. ⁴
Tachycardia – A condition where a pulse exceeds 100 beats per minute. ⁸
Thyroid acropachy – A rare autoimmune thyroid disease. ³
Thyroid dermopathy – Thickening of the skin usually in the pretibial area, a symptom of hyperthyroidism. ¹⁴
Thyroid-stimulating hormone – A hormone made in the pituitary gland to regulate your weight, body temperature, muscle strength, and mood. 7
Thyrotoxicosis – Excess thyroid hormone in the body. ⁶