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The New Zealand Medical Journal

 Journal of the New Zealand Medical Association, 21-January-2011, Vol 124 No 1328

A young male with gradual onset of bilateral calf swelling and generalised weakness
Sumit Chatterjee, Susmita Chatterjee

Case history

A 36-year-old male presented with generalised weakness, loss of appetite, hoarseness of voice and gradual onset of bilateral calf swelling during the previous 2 months. He also complained of symptoms suggestive of proximal muscle weakness of both his lower limbs, an excessive cold sensation and constipation during the same period.
There is no significant past history of any ailment nor any contributory family history.
General examination revealed mild pallor, facial puffiness and dry coarse skin. Pulse and blood pressure were 64/min and 120/90 mmHg respectively. Cardiac and respiratory system examination was normal. CNS examination showed hypotonia in all the four limbs, power grade 3/5 in both lower limbs proximally and 4/5 distally. Power in upper limbs was normal.
Deep tendon reflexes were normal throughout except for the ankle jerk which revealed delayed relaxation. Rest of the examination was normal.
Relevant investigations revealed the following:
  • Anaemia (haemoglobin 8.9 gm/dL), hypertriglyceridaemia (TG 350 mg/dL), hypercholesterolaemia (Sr. LDL–C 300mg/dL)
  • Serum T4–1.0 microgram/dl (normal value is 4.5 to 12 microgram/dl), serum T3–21 microgram /dl (normal value is 60 to 200 microgram /dl), serum TSH–99 U/ml (normal value is 0.3 to 5.5 U/ml).
  • Creatine phosphokinase was 1565 U/L (normal value is less than 140 U/L).
  • Chest X-ray was normal study, ECG showed low voltage complexes in all the leads.
  • Electromyography (EMG) was suggestive of mild spontaneous activity, polyphasic myopathic motor unit potentials (MUAPs) along with small amplitude and duration in proximal muscles consistent with hypothyroidism.
  • Nerve conduction studies of the nerves of both the extremities were normal.
  • Anti TPO (thyroperoxidase) antibodies were strongly positive.
Relevant photographs are shown below.
Photographs showing calf hypertrophy, loss of hairs and shiny skin over the affected area
Figure 1

Figure 2
Question—Name the complete diagnosis
Answer and Discussion
Author information: Sumit Chatterjee, Senior Resident, Department of Medicine, Calcutta National Medical College, Kolkata, India; Susmita Chatterjee, Medical Officer, Department of Medicine, CGHS, Mumbai, India
Correspondence:Dr. Sumit Chatterjee, E7/003, Peerless Nagar, P.O. Panihati, Kolkata, West Bengal, India 700114. Email: chatterjeesum@yahoo.co.in
References:
  1. Fessel WJ. Myopathy of hypothyroidism. Ann Rheum Dis. 1968 Nov;27(6):590-6.
  2. McKeran RO, Slavin G, Ward P, et al. Hypothyroid myopathy. A clinical and pathologaical study.J Pathol. 1980 Sep;132(1):35-54
  3. Vasconcellos LF, Peixoto MC, de Oliveira TN, et al. Hoffman's syndrome: pseudohypertrophic myopathy as initial manifestation of hypothyroidism. Case report. Arq Neuropsiquiatr. 2003 Sep;61(3B):851-4.
  4. Larsen PR, Davies TF, Hay ID. the thyroid gland. In Williams textbook of endocrinology, 9th ed. Philadelphia: WB Saunders Company, 1998:401-406.
     
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