Images of Memorable Cases: Case 144 This 33-year-old woman presented with painless swelling of her fingers and lower legs of about four months’ duration. 144. Pretibial myxedema and thyroid acropachy accompanying hyperthyroidism On physical examination, this patient was thyrotoxic with bilateral exophthalmos and a diffusely enlarged thyroid gland (image below). Localized myxedema—disposition of mucopolysaccharides in the skin—typically occurs in the pretibial area. Rarely, however, such deposits can affect the hands, arms, face, ears, shoulders, back, or abdomen. The myxedema ordinarily develops after the diagnosis of thyrotoxicosis has been established but occasionally occurs before or with other clinical signs of hyperthyroidism. Associated ophthalmopathy is almost invariable. Treatment with plasmapheresis, cytotoxic agents, and topically applied corticosteroids is moderately effective, but complete remission occurs in only about 10% of the cases. Acropachy is a rare manifestation of thyroid disease and nearly always is associated with past or present hyperthyroidism, exophthalmos, and pretibial myxedema. It is characterized by soft-tissue swelling of phalanges, clubbing of terminal phalanges, and periosteal new bone formation in the hands and feet. This condition usually causes no pain or disability and requires no specific treatment.