QJM: An International Journal of Medicine, 2018, 193 doi: 10.1093/qjmed/hcx205 Advance Access Publication Date: 28 November 2017 Clinical picture CLINICAL PI CTURE Clinical signs in hypothyroidism—myoedema and Woltman sign A 30-year-old gentleman presented with malaise and fatigue to of a muscle belly elicits a non-tender swelling or ridge that re- our clinic. Examination revealed dry, coarse skin, dull affect and solves completely in few seconds. The proposed mechanism is bradycardia. Neurological examination revealed bilateral con- thought to be due to local release of calcium ions on percussion ductive deafness, slow speech and delayed relaxation of bilat- along with delayed reaccumulation in the sarcoplasmic reticulum. eral ankle reflexes and biceps reflexes (Figure 1, Supplementary Woltman sign is defined as delayed relaxation phase of an Video S1). Myoedema was demonstrable in all limbs (Figure 2, elicited deep tendon reflex. The pathophysiology of delayed Supplementary Video S2). muscle relaxation has been postulated to be a result of Investigations revealed severe primary hypothyroidism. decreased myosin ATPase activity and decreased rate of reaccu- Thyroid hormone replacement under the cover of steroids mulation of calcium in the sarcoplasmic reticulum. Other con- resulted in complete resolution of all neurological signs. ditions which can present with delayed relaxation are advanced Myoedema is a rare clinical sign described typically in hypothy- age, pregnancy, anorexia nervosa, diabetes mellitus, sarcoid- roidism, maybe seen in hypoalbuminemia, rabies, severe osis, pernicious anemia and drugs. cachexia, hyponatremia and renal failure. Percussion or flicking We present in these videos clinical discriminators of hypo- thyroidism, identification of which led to timely requisition of thyroid function test and prompt treatment. Simple bedside clinical signs like these reaffirm our faith in the dying art of clinical examination. Supplementary material Supplementary material is available at QJMED online. Photographs and text from: A. Krishnamurthy, Department of Endocrinology and Metabolism, All India Institute of Medical Figure 1. Screen capture from the Supplementary Video S1 showing Woltman’s Sciences, New Delhi, India; V.Y. Vishnu, Department of Sign during elicitation of ankle reﬂex in a young man with severe primary Neurology, All India Institute of Medical Sciences, New Delhi, hypothyroidism. India; A. Hamide, Department of General Medicine, Jawaharlal Institute of Post Graduate Medical Education and Research, Puducherry, India. email: email@example.com Conflict of interest: None declared. References 1. Hornung K, Nix WA. Myoedema. A clinical and electrophysio- logical evaluation. Eur Neurol 1992; 32:130–3. 2. Houston CS. The diagnostic importance of the myxoedema Figure 2. Screen Capture from Supplementary Supplementary Video S2 showing reﬂex (Woltman’s sign). CMAJ 1958; 78:108–12. elicitation of myoedema in the biceps muscle belly in a young man with severe 3. Burkholder DB, Klaas JP, Kumar N, Boes CJ. The origin of primary hypothyroidism. Woltman‘s sign of myxedema. J Clin Neurosci 2013; 20:1204–6. V C The Author 2017. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: firstname.lastname@example.org Downloaded from https://academic.oup.com/qjmed/article-abstract/111/3/193/4669729 by Ed 'DeepDyve' Gillespie user on 16 March 2018
QJM: An International Journal of Medicine – Oxford University Press
Published: Mar 1, 2018
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