Case and Research letter
Bilateral Eyelid Swelling Associated With Acute Hypothyroidism
Edema palpebral bilateral asociado a crisis hipotiroidea
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Salazar-Nievas, S. Arias-Santiago" "autores" => array:2 [ 0 => array:3 [ "nombre" => "M." "apellidos" => "Salazar-Nievas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 1 => array:4 [ "nombre" => "S." "apellidos" => "Arias-Santiago" "email" => array:1 [ 0 => "salvadorarias@hotmail.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario San Cecilio, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Virgen de las Nieves, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Edema palpebral bilateral asociado a crisis hipotiroidea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 733 "Ancho" => 550 "Tamanyo" => 83863 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Eyelid swelling 24<span class="elsevierStyleHsp" style=""></span>hours after onset. The lesion was neither warm to the touch nor painful and was more pronounced on the right.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The eyelid is subject to considerable deformity owing to the particular laxity of the subcutaneous cellular tissue, which is caused by infiltration of the interstitial spaces. The degree of swelling can range from simple tumefaction of the ciliary margin to a considerable increase in periocular tissue volume, which in some cases can lead to narrowing, or even closure, of the palpebral fissure. Differential diagnosis of eyelid swelling is complex. It requires a meticulous physical examination and inclusion of both inflammatory and noninflammatory causes. The main noninflammatory cause is acute hypothyroidism, as in the present case.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the case of a 52-year-old woman who presented with a 1-week history of sudden-onset bilateral eyelid swelling that was neither painful nor pruriginous. Her personal history was remarkable for autoimmune hypothyroidism (Hashimoto thyroiditis) that first appeared 5 years previously and for which she was receiving hormone replacement therapy (levothyroxine 75<span class="elsevierStyleHsp" style=""></span>μg/d). She also had a 1-year history of autoimmune hepatitis, which was treated with prednisone (7.5<span class="elsevierStyleHsp" style=""></span>mg/d po), and hypertension, which was treated with enalapril (20<span class="elsevierStyleHsp" style=""></span>mg/d po). She attended our clinic with bilateral eyelid swelling that had begun 24<span class="elsevierStyleHsp" style=""></span>hours earlier. The patient had not ingested new drugs, experienced injury, received insect bites or stings, or applied cosmetic products to the area. Examination revealed soft bilateral edema that was more pronounced on the right side with discrete erythema and no crepitus, vesicles, or desquamation (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Her visual acuity and eye movement were unaltered, and she had no skin lesions at other sites. The results of a full laboratory workup were normal, although thyroid-stimulating hormone (TSH) was 50.3<span class="elsevierStyleHsp" style=""></span>mIU/L and free thyroxine was diminished (0.5<span class="elsevierStyleHsp" style=""></span>ng/dL). The dose of levothyroxine was increased considerably (500<span class="elsevierStyleHsp" style=""></span>μg/d), as was that of oral prednisone (15<span class="elsevierStyleHsp" style=""></span>mg/d), to reduce inflammation. Seven days after the first visit, her TSH level had fallen to 35<span class="elsevierStyleHsp" style=""></span>mIU/L, thyroid hormone levels had returned to normal, and the swelling had improved considerably. A week later, the skin complaint was in total remission (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and the TSH concentration had fallen to 20<span class="elsevierStyleHsp" style=""></span>mIU/L.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The characteristics of the lesion and the clinical course confirmed a diagnosis of bilateral eyelid swelling associated with acute hypothyroidism.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The differential diagnosis of eyelid swelling should include various clinical entities (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>). A careful evaluation should be made of the intensity, location (one or both eyelids), and coloring of the swelling. The initial examination first makes it possible to rule out swelling caused by trapped air, with its characteristic crunching snow sensation, and blood pooling in the case of hematoma. Finally, it is necessary to define whether the swelling is inflammatory or noninflammatory and analyze the possible causes.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Eyelid swelling associated with hypothyroidism is uncommon and can occasionally mimic other conditions such as angioedema, bites and stings, and contact dermatitis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In the case we describe, the absence of induration, vesicles, and pruritus make a diagnosis of eczema or angioedema unlikely; in addition, the patient's clinical condition improved considerably when the acute hypothyroidism resolved. The causes of swelling are not well known, although mucopolysaccharide deposits play a role. Case reports show that eyelid swelling is a clinical sign of severe acute hypothyroidism. It is sometimes more subtle, is associated with thinning of the eyebrows,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> and, in some cases, can manifest as palpebral redundancy resulting from laxity of the eyelid.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The swelling resolves gradually with treatment of hypothyroidism.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4,5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Eyelid swelling is not the only dermatologic manifestation associated with hypothyroidism, and other more common presentations sometimes go unnoticed. In more than 80% of cases the epidermis is thin, dry, rough, hyperkeratotic, and covered with fine superficial scales.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The hair is opaque, rough, and brittle, partly owing to reduced secretion of sebum. Alopecia has been reported in up to 50% of patients and can be diffuse or partial; the nails are thin and fragile with striations and horizontal and longitudinal ridges.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Finally, in the case of sudden-onset asymptomatic bilateral soft swelling in which dermatitis and angioedema can be ruled out, systemic causes such as hypothyroidism should be suspected. Therefore, eyelid swelling can be a sign of numerous local and systemic diseases and requires a meticulous clinical workup in order to determine the cause and enable appropriate treatment to be started.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Salazar-Nievas M, Arias-Santiago S. Edema palpebral bilateral asociado a crisis hipotiroidea. Actas Dermosifiliogr. 2014;105:427–429.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 733 "Ancho" => 550 "Tamanyo" => 83863 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Eyelid swelling 24<span class="elsevierStyleHsp" style=""></span>hours after onset. The lesion was neither warm to the touch nor painful and was more pronounced on the right.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 666 "Ancho" => 888 "Tamanyo" => 95203 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Bilateral palpebral swelling involving the nasal root 72<span class="elsevierStyleHsp" style=""></span>hours after onset.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 294 "Ancho" => 750 "Tamanyo" => 46109 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Swelling resolved after improvement of acute hypothyroidism.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1279 "Ancho" => 1829 "Tamanyo" => 255205 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Diagnostic algorithm for palpebral swelling.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Alonso Caviedes S, Collado Hornillos JA, Gómez Dacasa A. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 25 | 8 | 33 |
| 2024 October | 219 | 63 | 282 |
| 2024 September | 214 | 48 | 262 |
| 2024 August | 243 | 87 | 330 |
| 2024 July | 174 | 59 | 233 |
| 2024 June | 201 | 45 | 246 |
| 2024 May | 163 | 45 | 208 |
| 2024 April | 140 | 33 | 173 |
| 2024 March | 177 | 38 | 215 |
| 2024 February | 235 | 36 | 271 |
| 2024 January | 210 | 45 | 255 |
| 2023 December | 267 | 47 | 314 |
| 2023 November | 340 | 56 | 396 |
| 2023 October | 315 | 48 | 363 |
| 2023 September | 349 | 75 | 424 |
| 2023 August | 236 | 45 | 281 |
| 2023 July | 284 | 70 | 354 |
| 2023 June | 234 | 50 | 284 |
| 2023 May | 256 | 91 | 347 |
| 2023 April | 256 | 56 | 312 |
| 2023 March | 292 | 59 | 351 |
| 2023 February | 225 | 44 | 269 |
| 2023 January | 230 | 64 | 294 |
| 2022 December | 267 | 51 | 318 |
| 2022 November | 225 | 53 | 278 |
| 2022 October | 221 | 62 | 283 |
| 2022 September | 185 | 77 | 262 |
| 2022 August | 107 | 54 | 161 |
| 2022 July | 155 | 71 | 226 |
| 2022 June | 155 | 39 | 194 |
| 2022 May | 217 | 86 | 303 |
| 2022 April | 183 | 77 | 260 |
| 2022 March | 163 | 113 | 276 |
| 2022 February | 144 | 58 | 202 |
| 2022 January | 138 | 67 | 205 |
| 2021 December | 150 | 82 | 232 |
| 2021 November | 164 | 103 | 267 |
| 2021 October | 134 | 84 | 218 |
| 2021 September | 117 | 79 | 196 |
| 2021 August | 97 | 82 | 179 |
| 2021 July | 98 | 53 | 151 |
| 2021 June | 76 | 66 | 142 |
| 2021 May | 77 | 82 | 159 |
| 2021 April | 180 | 83 | 263 |
| 2021 March | 81 | 46 | 127 |
| 2021 February | 61 | 45 | 106 |
| 2021 January | 43 | 56 | 99 |
| 2020 December | 60 | 41 | 101 |
| 2020 November | 40 | 38 | 78 |
| 2020 October | 47 | 43 | 90 |
| 2020 September | 47 | 24 | 71 |
| 2020 August | 33 | 28 | 61 |
| 2020 July | 36 | 32 | 68 |
| 2020 June | 39 | 16 | 55 |
| 2020 May | 32 | 30 | 62 |
| 2020 April | 31 | 30 | 61 |
| 2020 March | 29 | 29 | 58 |
| 2020 February | 6 | 16 | 22 |
| 2020 January | 6 | 12 | 18 |
| 2019 December | 8 | 14 | 22 |
| 2019 November | 4 | 12 | 16 |
| 2019 October | 0 | 9 | 9 |
| 2019 September | 4 | 11 | 15 |
| 2019 August | 4 | 11 | 15 |
| 2019 July | 4 | 28 | 32 |
| 2019 June | 4 | 17 | 21 |
| 2019 May | 6 | 20 | 26 |
| 2019 April | 2 | 18 | 20 |
| 2019 March | 4 | 8 | 12 |
| 2019 February | 0 | 3 | 3 |
| 2019 January | 2 | 1 | 3 |
| 2018 December | 2 | 8 | 10 |
| 2018 November | 1 | 0 | 1 |
| 2018 October | 2 | 0 | 2 |
| 2018 September | 4 | 3 | 7 |
| 2018 August | 0 | 15 | 15 |
| 2018 July | 0 | 6 | 6 |
| 2018 June | 0 | 8 | 8 |
| 2018 May | 0 | 12 | 12 |
| 2018 March | 31 | 8 | 39 |
| 2018 February | 129 | 6 | 135 |
| 2018 January | 108 | 9 | 117 |
| 2017 December | 144 | 15 | 159 |
| 2017 November | 131 | 10 | 141 |
| 2017 October | 113 | 5 | 118 |
| 2017 September | 100 | 11 | 111 |
| 2017 August | 103 | 17 | 120 |
| 2017 July | 110 | 13 | 123 |
| 2017 June | 112 | 39 | 151 |
| 2017 May | 116 | 17 | 133 |
| 2017 April | 65 | 12 | 77 |
| 2017 March | 42 | 27 | 69 |
| 2017 February | 179 | 13 | 192 |
| 2017 January | 70 | 14 | 84 |
| 2016 December | 86 | 19 | 105 |
| 2016 November | 153 | 17 | 170 |
| 2016 October | 142 | 18 | 160 |
| 2016 September | 224 | 16 | 240 |
| 2016 August | 228 | 12 | 240 |
| 2016 July | 82 | 5 | 87 |
| 2016 June | 15 | 6 | 21 |
| 2016 May | 4 | 4 | 8 |
| 2016 April | 6 | 6 | 12 |
| 2016 March | 9 | 15 | 24 |
| 2016 February | 14 | 8 | 22 |
| 2016 January | 10 | 1 | 11 |
| 2015 December | 11 | 3 | 14 |
| 2015 November | 7 | 0 | 7 |
| 2015 October | 8 | 2 | 10 |
| 2015 September | 9 | 0 | 9 |
| 2015 August | 13 | 1 | 14 |
| 2015 July | 116 | 4 | 120 |
| 2015 June | 76 | 5 | 81 |
| 2015 May | 79 | 9 | 88 |
| 2015 April | 79 | 14 | 93 |
| 2015 March | 74 | 1 | 75 |
| 2015 February | 46 | 3 | 49 |
| 2015 January | 54 | 9 | 63 |
| 2014 December | 45 | 12 | 57 |
| 2014 November | 49 | 10 | 59 |
| 2014 October | 31 | 12 | 43 |
| 2014 September | 31 | 9 | 40 |
| 2014 August | 30 | 17 | 47 |
| 2014 July | 13 | 7 | 20 |
| 2014 June | 38 | 10 | 48 |
| 2014 May | 24 | 6 | 30 |
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