Letters to the Editor 3.
4.
5.
Strotmeyer ES, Cauley JA. Diabetes mellitus, bone mineral density, and fracture risk. Curr Opin Endocrinol Diabetes Obes 2007;14:429‑35. Mølgaard C, Thomsen BL, Prentice A, Cole TJ, Michaelsen KF. Whole body bone mineral content in healthy children and adolescents. Arch Dis Child 1997;76:9‑15. Warner JT, Cowan FJ, Dunstan FD, Evans WD, Webb DK, Gregory JW. Measured and predicted bone mineral content in healthy boys and girls aged 6‑18 years: Adjustment for body size and puberty. Acta Paediatr 1998;87:244‑9.
Thyroid acropachy: Frequently overlooked finding Sir, Thyroid acropachy is an uncommon manifestation of autoimmune thyroid disorder, which has been reported recently in the journal of Indian Journal of Endocrinology and Metabolism[1] and in other Indian journals. It usually presents with clubbing and swelling of digits along with periosteal reaction of extremity bones. It is almost associated with ophthalmopathy and thyroid dermopathy. Thyroid acropachy is the least common manifestation of autoimmune thyroid disease. An epidemiological‑based study showed that about 4% of patients with ophthalmopathy have dermopathy, and that one of five patients with dermopathy has acropachy. Acropachy is mostly associated with dermopathy and ophthalmopathy, although an isolated case of acropachy without dermopathy has been reported.[2] It can occur in all form of autoimmune thyroid disorder whether euthyroid, hypothyroid or hyperthyroid patients.[2] Patients first develop thyroid dysfunction, followed by ophthalmopathy, then dermopathy, and finally, acropachy.[2] However, the reports suggest that thyroid acropachy may be more common. The ubiquitous prevalence of clubbing secondary to pulmonary causes may lead primary care physicians to miss the diagnosis of thyroid acropachy in India. This letter highlights some differences between clubbing and periostitis seen in thyroid acropachy and clubbing and pulmonary osteoarthropathy seen in lung and other systemic and paraneoplastic conditions.[Table 1] Thyroid acropachy is distinguished by the uniform presence of thyroid dermopathy and ophthalmopathy. Radiological features are also somewhat different; in patients with thyroid acropachy, there is less involvement of the long bones. In pulmonary osteoarthropathy, periosteal reaction usually is symmetric; in acropachy, it can be asymmetric. In acropachy, radiographs show a characteristic sub‑periosteal spiculated, frothy, or lacy 590
Access this article online Quick Response Code: Website: www.ijem.in DOI: 10.4103/2230-8210.137505
Table 1: Difference between thyroid acropachy and other disorder associated with clubbing and pulmonary osteoarthropathy Associated signs Pain Radiological sign Periosteal reaction
Thyroid acropachy
Other systemic disorders
Ophthalmopathy, and dermopathy Rarely Involvement of long bones rare Symmetrical
Depends upon system involved Frequently Common
Characteristic subperiosteal spiculated, frothy, or lacy appearance Pathogenesis Tsh receptor antibodies in high titer Pathology Autoimmune, trapping of platelets, increase glycosaminoglycan and fibroblast proliferation Spontaneous Upto 50% remission Treatment No specific treatment
Asymmetrical Laminal periosteal proliferation absent Trapping of platelets
Infrequent Specific treatment available depends upon pathology
TSH: Thyroid-stimulating hormone
appearance,[3] quite different from the laminal periosteal proliferation of classic pulmonary osteoarthropathy. However, in thyroid acropachy, other mechanisms (such as autoimmune phenomena and increased glycosaminoglycan and fibroblast proliferation similar to changes in thyroid ophthalmopathy and dermopathy) may be at work.[1,4] It is usually believed that the periosteal reaction in thyroid acropachy, unlike that in pulmonary osteoarthropathy does not occur in the long bones of the forearms or the legs. Dermopathy is indicative of a severe autoimmune thyroid disease; acropachy is likely to indicate an even more severe form. In patients with thyroid acropachy, skin biopsy demonstrates typical findings of pretibial myxedema, including fibroblast activation and glycosaminoglycan deposition. Similar findings have been noted in skin overlying periosteal changes of acropachy.[4] No specific treatment for acropachy of thyroid disease is available, other than systemic immunosuppressive therapy and local corticosteroid therapy. These treatments usually are directed at associated ophthalmopathy and dermopathy. For persistent pulmonary osteoarthropathy, local octreotide
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2014 / Vol 18 | Issue 4
Letters to the Editor
injection and local radiotherapy have been tried. Whether these measures would help the patients with thyroid acropachy are unclear.[1,5]
2.
Acknowledgment
3.
We owe thanks to the patient and her relatives for having patience and their contribution to this undertaking.
4.
Manish Gutch, Saran Sanjay, Syed Mohd Razi, Keshav Kumar Gupta
5.
Clinico‑pathological correlation. Indian J Endocrinol Metab 2012;16:460‑2. Fatourechi V, Ahmed DD, Schwartz KM. Thyroid acropachy: Report of 40 patients treated at a single institution in a 26‑year period. J Clin Endocrinol Metab 2002;87:5435‑41. Vanhoenacker FM, Pelckmans MC, De Beuckeleer LH,Colpaert CG, De Schepper AM. Thyroid acropachy: Correlation of imaging and pathology. Eur Radiol 2001;11:1058‑62. Fatourechi V. Thyroid dermopathy and acropachy. Expert Rev Dermatol 2011;6:75‑905. Rotman‑Pikielny P, Brucker‑Davis F, Turner ML, Sarlis NJ, Skarulis MC. Lack of effect of long‑term octreotide therapy in severe thyroid‑associated dermopathy. Thyroid 2003;13:465‑70.
Department of Endocrinology, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh, India
Access this article online
Corresponding Author: Dr. Manish Gutch, D‑15, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh ‑ 250 004, India. E‑mail: [email protected]
Quick Response Code: Website: www.ijem.in
References 1.
DOI: 10.4103/2230-8210.137507
Reddy SB, Gupta SK, Jain M. Dermopathy of Graves’ disease:
Interventional endocrinology: A futuristic Perspective Sir, I thoroughly enjoyed your article on Interventional endocrinology: A futuristic perspective. I am currently an internal medicine resident in Mexico, but my plan is to go into endocrinology in two more years. This specialty is amazing in my opinion, but has been labelled as a “passive” one by many. Few procedures, usually limited to thyroid biopsies (which nowadays are done more by interventional radiologists) are available (or so I thought!). I was very interested by,[1] where you list the currently available endocrine interventions. You clearly state that interventions can be either surgical or medical, but I would like to focus on the surgical ones. The pituitary cavernous sinus and internal jugular vein sampling are usually done by neurosurgeons, but I was wondering in India, how much of the other procedures are done by endocrinologists (or should be done by endocrinologists), specially the invasive ones. Maybe a new subspecialty should be born called interventional endocrinology!
Maybe we need to become more aggressive and more “hands on”; less theoretical and more practical. Thanks again for a wonderful article. Best regards from Mexico. Amado Jiménez Ruiz Department of Internal Medicine, Hospital Civil Fray Antonio Alcalde, Guadalajara, México Corresponding Author: Dr. Amado Jiménez Ruiz, PGY3, Department of Internal Medicine, Hospital Civil Fray Antonio Alcalde,Guadalajara, México. E‑mail: [email protected]
Reference 1.
Singla R, Singla S. Interventional endocrinology: A futuristic perspective. Indian J Endocrinol Metab 2014;18:422-4.
Access this article online Quick Response Code:
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2014 / Vol 18 | Issue 4
Website: www.ijem.in DOI: 10.4103/2230-8210.137509
591
Copyright of Indian Journal of Endocrinology & Metabolism is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
4.
5.
Strotmeyer ES, Cauley JA. Diabetes mellitus, bone mineral density, and fracture risk. Curr Opin Endocrinol Diabetes Obes 2007;14:429‑35. Mølgaard C, Thomsen BL, Prentice A, Cole TJ, Michaelsen KF. Whole body bone mineral content in healthy children and adolescents. Arch Dis Child 1997;76:9‑15. Warner JT, Cowan FJ, Dunstan FD, Evans WD, Webb DK, Gregory JW. Measured and predicted bone mineral content in healthy boys and girls aged 6‑18 years: Adjustment for body size and puberty. Acta Paediatr 1998;87:244‑9.
Thyroid acropachy: Frequently overlooked finding Sir, Thyroid acropachy is an uncommon manifestation of autoimmune thyroid disorder, which has been reported recently in the journal of Indian Journal of Endocrinology and Metabolism[1] and in other Indian journals. It usually presents with clubbing and swelling of digits along with periosteal reaction of extremity bones. It is almost associated with ophthalmopathy and thyroid dermopathy. Thyroid acropachy is the least common manifestation of autoimmune thyroid disease. An epidemiological‑based study showed that about 4% of patients with ophthalmopathy have dermopathy, and that one of five patients with dermopathy has acropachy. Acropachy is mostly associated with dermopathy and ophthalmopathy, although an isolated case of acropachy without dermopathy has been reported.[2] It can occur in all form of autoimmune thyroid disorder whether euthyroid, hypothyroid or hyperthyroid patients.[2] Patients first develop thyroid dysfunction, followed by ophthalmopathy, then dermopathy, and finally, acropachy.[2] However, the reports suggest that thyroid acropachy may be more common. The ubiquitous prevalence of clubbing secondary to pulmonary causes may lead primary care physicians to miss the diagnosis of thyroid acropachy in India. This letter highlights some differences between clubbing and periostitis seen in thyroid acropachy and clubbing and pulmonary osteoarthropathy seen in lung and other systemic and paraneoplastic conditions.[Table 1] Thyroid acropachy is distinguished by the uniform presence of thyroid dermopathy and ophthalmopathy. Radiological features are also somewhat different; in patients with thyroid acropachy, there is less involvement of the long bones. In pulmonary osteoarthropathy, periosteal reaction usually is symmetric; in acropachy, it can be asymmetric. In acropachy, radiographs show a characteristic sub‑periosteal spiculated, frothy, or lacy 590
Access this article online Quick Response Code: Website: www.ijem.in DOI: 10.4103/2230-8210.137505
Table 1: Difference between thyroid acropachy and other disorder associated with clubbing and pulmonary osteoarthropathy Associated signs Pain Radiological sign Periosteal reaction
Thyroid acropachy
Other systemic disorders
Ophthalmopathy, and dermopathy Rarely Involvement of long bones rare Symmetrical
Depends upon system involved Frequently Common
Characteristic subperiosteal spiculated, frothy, or lacy appearance Pathogenesis Tsh receptor antibodies in high titer Pathology Autoimmune, trapping of platelets, increase glycosaminoglycan and fibroblast proliferation Spontaneous Upto 50% remission Treatment No specific treatment
Asymmetrical Laminal periosteal proliferation absent Trapping of platelets
Infrequent Specific treatment available depends upon pathology
TSH: Thyroid-stimulating hormone
appearance,[3] quite different from the laminal periosteal proliferation of classic pulmonary osteoarthropathy. However, in thyroid acropachy, other mechanisms (such as autoimmune phenomena and increased glycosaminoglycan and fibroblast proliferation similar to changes in thyroid ophthalmopathy and dermopathy) may be at work.[1,4] It is usually believed that the periosteal reaction in thyroid acropachy, unlike that in pulmonary osteoarthropathy does not occur in the long bones of the forearms or the legs. Dermopathy is indicative of a severe autoimmune thyroid disease; acropachy is likely to indicate an even more severe form. In patients with thyroid acropachy, skin biopsy demonstrates typical findings of pretibial myxedema, including fibroblast activation and glycosaminoglycan deposition. Similar findings have been noted in skin overlying periosteal changes of acropachy.[4] No specific treatment for acropachy of thyroid disease is available, other than systemic immunosuppressive therapy and local corticosteroid therapy. These treatments usually are directed at associated ophthalmopathy and dermopathy. For persistent pulmonary osteoarthropathy, local octreotide
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2014 / Vol 18 | Issue 4
Letters to the Editor
injection and local radiotherapy have been tried. Whether these measures would help the patients with thyroid acropachy are unclear.[1,5]
2.
Acknowledgment
3.
We owe thanks to the patient and her relatives for having patience and their contribution to this undertaking.
4.
Manish Gutch, Saran Sanjay, Syed Mohd Razi, Keshav Kumar Gupta
5.
Clinico‑pathological correlation. Indian J Endocrinol Metab 2012;16:460‑2. Fatourechi V, Ahmed DD, Schwartz KM. Thyroid acropachy: Report of 40 patients treated at a single institution in a 26‑year period. J Clin Endocrinol Metab 2002;87:5435‑41. Vanhoenacker FM, Pelckmans MC, De Beuckeleer LH,Colpaert CG, De Schepper AM. Thyroid acropachy: Correlation of imaging and pathology. Eur Radiol 2001;11:1058‑62. Fatourechi V. Thyroid dermopathy and acropachy. Expert Rev Dermatol 2011;6:75‑905. Rotman‑Pikielny P, Brucker‑Davis F, Turner ML, Sarlis NJ, Skarulis MC. Lack of effect of long‑term octreotide therapy in severe thyroid‑associated dermopathy. Thyroid 2003;13:465‑70.
Department of Endocrinology, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh, India
Access this article online
Corresponding Author: Dr. Manish Gutch, D‑15, Lala Lajpat Rai Memorial Medical College, Meerut, Uttar Pradesh ‑ 250 004, India. E‑mail: [email protected]
Quick Response Code: Website: www.ijem.in
References 1.
DOI: 10.4103/2230-8210.137507
Reddy SB, Gupta SK, Jain M. Dermopathy of Graves’ disease:
Interventional endocrinology: A futuristic Perspective Sir, I thoroughly enjoyed your article on Interventional endocrinology: A futuristic perspective. I am currently an internal medicine resident in Mexico, but my plan is to go into endocrinology in two more years. This specialty is amazing in my opinion, but has been labelled as a “passive” one by many. Few procedures, usually limited to thyroid biopsies (which nowadays are done more by interventional radiologists) are available (or so I thought!). I was very interested by,[1] where you list the currently available endocrine interventions. You clearly state that interventions can be either surgical or medical, but I would like to focus on the surgical ones. The pituitary cavernous sinus and internal jugular vein sampling are usually done by neurosurgeons, but I was wondering in India, how much of the other procedures are done by endocrinologists (or should be done by endocrinologists), specially the invasive ones. Maybe a new subspecialty should be born called interventional endocrinology!
Maybe we need to become more aggressive and more “hands on”; less theoretical and more practical. Thanks again for a wonderful article. Best regards from Mexico. Amado Jiménez Ruiz Department of Internal Medicine, Hospital Civil Fray Antonio Alcalde, Guadalajara, México Corresponding Author: Dr. Amado Jiménez Ruiz, PGY3, Department of Internal Medicine, Hospital Civil Fray Antonio Alcalde,Guadalajara, México. E‑mail: [email protected]
Reference 1.
Singla R, Singla S. Interventional endocrinology: A futuristic perspective. Indian J Endocrinol Metab 2014;18:422-4.
Access this article online Quick Response Code:
Indian Journal of Endocrinology and Metabolism / Jul-Aug 2014 / Vol 18 | Issue 4
Website: www.ijem.in DOI: 10.4103/2230-8210.137509
591
Copyright of Indian Journal of Endocrinology & Metabolism is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
