Pretibial myxedema (PTM), an uncommon manifestation of Graves’ disease (GD), is a local autoimmune reaction in the cutaneous tissue. The treatment of PTM is a clinical challenge. We herein report on a patient with PTM who achieved complete remission by multipoint subcutaneous injections of a long-acting glucocorticoid and topical glucocorticoid ointment application for a self-controlled study. A 53-year-old male presented with a history of GD for 3.5 years and a history of PTM for 1.5 years. Physical examination revealed slight exophthalmos, a diffusely enlarged thyroid gland, and PTM of both lower extremities. One milliliter of triamcinolone acetonide (40 mg) was mixed well with 9 mL of 2% lidocaine in a 10 mL syringe. Multipoint intralesional injections into the skin lesions of the right lower extremity were conducted with 0.5 mL of the premixed solution. A halometasone ointment was used once daily for PTM of the left lower extremity until the PTM had remitted completely. The patient’s PTM achieved complete remission in both legs after an approximately 5-mo period of therpy that included triamcinolone injections once a week for 8 wk and then once a month for 2 mo for the right lower extremity and halometasone ointment application once daily for 8 wk and then once 3-5 d for 2 mo for the left lower extremity. The total dosage of triamcinolone acetonide for the right leg was 200 mg. Our experience with this patient suggests that multipoint subcutaneous injections of a long-acting glucocorticoid and topical glucocorticoid ointment application are safe, effective, and convenient treatments. However, the topical application of a glucocorticoid ointment is a more convenient treatment for patients with PTM.

• Intralesional injection
• Pretibial myxedema
• Glucocorticoid
• Halometasone
• Triamcinolone acetonide
• Case report

Exophthalmos, myxedema, and osteoarthropathy syndrome is a very rare condition that is associated with Graves’ disease. The presence of dermopathy and the involvement of joint/bone tissues indicate that it seems to be related with the severity of the autoimmune process. Owing to its low incidence, there is a lack of information regarding its treatment and clinical follow-up. Some cases improved after use of high doses of steroids; however, some patients do not respond to this treatment. Recently, the effectiveness of rituximab for treatment of Graves’ ophthalmopathy resistant to corticosteroids has been demonstrated. However, it has never been used for the treatment of exophthalmos, myxedema, and osteoarthropathy syndrome (particularly for the treatment of osteoarticular manifestations).

We present the case of a 54-year-old Mexican woman previously treated for Graves’ disease who developed post-iodine hypothyroidism and exophthalmos, myxedema, and osteoarthropathy that did not improve after high doses of steroids (intravenous and oral). Her exophthalmos, myxedema, and osteoarthropathy syndrome symptoms improved as early as 6 months after treatment with rituximab.

Exophthalmos, myxedema, and osteoarthropathy syndrome is a non-classical presentation of Graves’ disease, whose clinical manifestations could improve after treatment with rituximab, particularly in those patients with lack of response to high doses of corticosteroids.

• Exophthalmos
• Myxedema
• Primary hyperthyroidism
• Rituximab

• EMO syndrome
• Graves' disease
• exophthalmos
• myxedema
• osteoarthropathy
• radiotherapy

• Adult
• Dermis/pathology
• Exophthalmos/complications
• Female
• Graves Disease/complications
• Humans
• Myxedema/complications
• Myxedema/pathology

• Adrenal Cortex Hormones/therapeutic use
• Adult
• Aged
• Aged, 80 and over
• Autoimmune Diseases/complications
• Autoimmune Diseases/diagnostic imaging
• Autoimmune Diseases/drug therapy
• Autoimmune Diseases/physiopathology
• Elephantiasis/etiology
• Extremities/diagnostic imaging
• Female
• Graves Disease/etiology
• Graves Disease/surgery
• Humans
• Male
• Middle Aged
• Myxedema/etiology
• Periosteum/diagnostic imaging
• Pulmonary Disease, Chronic Obstructive/complications
• Radiography
• Retrospective Studies
• Severity of Illness Index
• Smoking
• Thyroid Diseases/complications
• Thyroid Diseases/diagnostic imaging
• Thyroid Diseases/drug therapy
• Thyroid Diseases/physiopathology
• Thyroid Gland/physiopathology
• Time Factors
• Treatment Outcome