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February 5, 2024
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Teaching Video NeuroImage: Calf Hypertrophy and Myoedema Unravel a Diagnosis of Severe Hypothyroidism

A 58-year-old man presented to the outpatient clinic complaining of left-sided weakness for 5 months. He had a history of thyroidectomy for hemorrhagic goiter and was nonadherent with thyroid medication. On presentation, he had asteatotic eczema and new-onset calf hypertrophy (Figure). Motor strength examination revealed Medical Research Council grade 4/4 weakness bilaterally for shoulder abduction, elbow flexion, and hip flexion. Percussion of arm and leg muscles showed myoedema (Video 1). Laboratory investigation detected thyroid-stimulating hormone 89 mIU/mL and creatine kinase 5,428 U/L. Two months after thyroxine replacement, muscle strength improved and creatine-kinase normalized. Enlargement of the calf muscles in adults secondary to hypothyroidism was first described by Hoffman in 1897.1 Adult patients may also have myoedema and pseudomyotonia (a delay in muscle relaxation after tendon reflexes is elicited). Myoedema differs from rippling and pseudomyotonia for its rapid and localized mounding of muscles caused by delayed calcium reuptake by the sarcoplasmic reticulum following calcium release after percussion.2 Awareness of these signs can lead to a correct diagnosis, avoiding unnecessary investigations.
Figure Hypertrophy of the Calf Muscles

Footnote

MORE ONLINE For multiple-choice questions relevant to Teaching NeuroImages and Teaching Video NeuroImages, find @greenjournal on X using the hashtag #NeurologyRF

References

1.
Horak HA, Pourmand R. Endocrine myopathies. Neurol Clin. 2000;18(1):203-213.
2.
Vignesh G, Balachandran K, Kamalanathan S, Hamide A. Myoedema: a clinical pointer to hypothyroid myopathy. Indian J Endocrinol Metab. 2013;17(2):352.

Information & Authors

Information

Published In

Neurology®
Volume 102Number 5March 12, 2024
PubMed: 38315936

Publication History

Received: June 26, 2023
Accepted: December 8, 2023
Published online: February 5, 2024
Published in print: March 12, 2024

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Disclosure

The authors report no relevant disclosures. Go to Neurology.org/N for full disclosures.

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No targeted funding reported.

Authors

Affiliations & Disclosures

From the Internal Medical Department (S.C.), and Hospital das Clínicas (P.S.R., L.S.M.B.), Federal University of Minas Gerais, Belo Horizonte, Brazil.
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Served on a scientific advisory board - Michael J Fox Foundation - GP2 Steering Committee
None - Associate editor MDS Clinical Practice
None - Associate editor Arquivos de Neuropsiquiatria
None - Associate editor Parkinsonism and related disorders
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Pétala Silva Ribeiro
From the Internal Medical Department (S.C.), and Hospital das Clínicas (P.S.R., L.S.M.B.), Federal University of Minas Gerais, Belo Horizonte, Brazil.
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Luiz Sergio M. Barbosa, MD
From the Internal Medical Department (S.C.), and Hospital das Clínicas (P.S.R., L.S.M.B.), Federal University of Minas Gerais, Belo Horizonte, Brazil.
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NONE
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NONE
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NONE
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Notes

Correspondence Dr. Camargos [email protected]
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Submitted and externally peer reviewed. The handling editor was Resident & Fellow Section Editor Whitley Aamodt, MD, MPH.

Author Contributions

S. Camargos: drafting/revision of the manuscript for content, including medical writing for content; major role in the acquisition of data; study concept or design; analysis or interpretation of data. P.R. Ribeiro: analysis or interpretation of data. L.S.M. Barbosa: study concept or design; analysis or interpretation of data.

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