thyroid stimulator (LATS) - Europe PMC

284 Proc. roy. Soc. Med. Volume 63 March 1970

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Thyroid Acropachy Peter M Ford MB MRCP (for Professor E G L Bywaters FRCP and Dr L P J Holt mRcp) (RoyalPostgraduate Medical School, London) Mrs L C, aged 63, Shop assistant History: First attended the outpatient department with a seven-year history of pain and swelling in the thumbs and index fingers of both hands. Aged 27, exophthalmic thyrotoxicosis treated by partial thyroidectomy; became euthyroid but exophthalmos persisted. Aged 37, had further thyroidectomy for recurrence and again became euthyroid. Exophthalmos persisted for another eighteen years before resolving spontaneously. Aged 56, began to get pain and swelling in both thumbs and index fingers. Two years later, right carpal tunnel decompression afforded only slight relief. On examination: Obviously myxcedematous with small areas of fading pretibial myxcedema. No eye signs present. Clubbing of fingers and toes noted, with swelling of interphalangeal joints of both thumbs (Fig 1). Investigations: Protein-bound-iodine less than 1 pg/100 ml. 1311 uptake 6% at 48 hours. Cholesterol 198 mg/100 ml. Thyroid antibodies (Dr D Doniach): thyroglobulin tanned cell agglutination test positive at 1:320, positive immunofluorescence against cytoplasmic antibodies; gastric parietal cell antibodies positive. Long-acting thyroid stimulator (LATS) (Professor D S Munro) 2,000 units (control 108 units). Vitamin Bl 330

Fig 2 X-ray ofright index metacarpal showing typical periosteal reaction

Fig 1 Hand showingfinger clubbing and swelling of interphalangeal joints of thumbs

pg/ml. Gastric acid secretion normal. X-rays of hands showed irregular periosteal new bone along radial aspect of distal half of right index metacarpal (Fig 2). Similar change present on dorsal aspect of proximal phalanx of right thumb with soft tissue swelling of interphalangeal joints of both thumbs. Irregular new bone formation also visible on medial margin of right first metatarsal (Fig 3). Bone scan showed no local activity. Diagnosis: Myxcedema and the features of thyroid acropachy. Discussion

Thyroid acropachy is an uncommon disorder characterized clinically by clubbing of fingers and toes, exophthalmos and pretibial myxcedema in

Fig 3 X-ray ofrightfirst metatarsal showing irregular new bone formation along medial.margin

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Clinical Section

association with a past or present history of exophthalmic thyrotoxicosis. Radiologically the typical features are an irregular periosteal reaction involving the shafts of the metacarpals, metatarsals and phalanges of hands and feet. Characteristically this reaction occurs along the radial aspect of the first two or three metacarpals of the hand and the ulnar aspect of the fifth; occasionally the long bones of the limbs may be involved. The onset is insidious and the time relation with the thyrotoxic state is a very variable one often occurring many years afterwards as in the present case. The etiology is obscure, Thomas (1933) suggesting that the change from high to low peripheral blood flow with the onset of hypothyroidism might be the provocative factor. More recently the discovery of LATS and the demonstration of a high level of activity in a number of these cases of acropachy (Beighton 1968, Kinsella & Back 1968) raises the possibility that LATS may be a contributory factor in some as yet undetermined manner. Recognition of this disorder is important in that it may save wasteful screening investigations to ascertain the cause of the clubbing. Treatment of the hypothyroid state in this patient is straightforward but there appears to be no effective therapy as regards the acropachy.

tate aminotransferase (SGOT) 14 i.u./ml. Serum albumin 3 4, globulin 45 g/100 ml. Immunoglobulins: IgG 3,200, IgA 300, IgM 800 mg/ 100 ml. Wassermann and Kahn reactions: false positive. Needle liver biopsy: focal granulomata with small areas of necrosis heavily infiltrated with eosinophils. Ova of Fasciola hepatica detected in stools; fasciola complement fixation text positive to 1/160. Treatment: Emetine hydrochloride 60 mg/day subcutaneously for ten days, interrupted for 48 hours following atrial ectopic beats. Progress: She was afebrile and pain free within four days. Ova were not detected in the stools after the first week. One month later she had noted an increase in weight, but was still tired and complained of pruritus and rare abdominal pains. In April 1969, three months after treatment, she still complained of abdominal pain. Hb 11-8 g/100 ml, WBC 10,000, eosinos. 1,300, ESR 40 mm in 1 hour. Wassermann reaction negative, serum alkaline phosphatase 12 K-A units/ 100 ml, SGOT 7 i.u./ml.

REFERENCES Beighton P (1968) Postgrad. med. J. 44, 426 Kinselia R A & Back D K (1968) Med. Clin. N. Amer. 52, 393 Thomas 11 M (1933) Arch. int. Med. 51, 511

Human Fascioliasis C J D'Sa MRCP (for A W J Houghton MRcP and P L Boardman MDW MRCP)

(Royal Salop Infirmary, Shrewsbury) Mrs L G, aged 22. Housewife History: Had eaten watercress on several occasions between May and September 1968. In May 1968 she complained of slight pains in the right hypochondrium, and a feeling of fullness after meals. In September the pain was more severe, situated in right hypochondrium and epigastrium, and troublesome at night. In October she began to have rigors, evening pyrexia, malaise and loss of weight. Admitted on December 20, with temperature 39*40C (1030F), and a smooth tender liver enlarged to 9-5 cm below costal margin. Investigations: Hb 11-6 g/100 ml, WBC 12,000: eosinos. 6,480 (55%), neutros. 3,240, lymphos. 2,160, monos. 120. ESR 33 mm in 1 hour (Wintrobe). Serum bilirubin normal, alkaline phosphatase 28 K-A units/100 ml, serum aspar-

Discussion

The above patient is one of 5 infected with fascioliasis in a recent outbreak occurring in Shropshire. They lived in three houses on adjoining farms, and shared a common source of watercress from a roadside ditch bordering their gardens. Snails of the species Lymnwa truncatula were found around the site where the watercress was picked. Dissection revealed that a large number of these snails were heavily infected with redim and ceircarim. The patients all had pain in the right hypochondrium, malaise, anorexia, eosinophilia, and four had pyrexia and hepatomegaly. -The diagnosis was confirmed by detection of ova in the stools, and/or by positive serological tests. One patient had a 600 mg course of emetine hydrochloride subcutaneously, and the others were treated with bithionol 3 g/day on alternate days up to a total of 45 g. Bithionol is the drug of choice for the treatment of lung fluke infection. Dawes (1966) reported the drug to be effective in the treatment of experimentally induced fascioliasis in rats. Lienert (1962) and Swiezawska et al. (1967) reported on its effectiveness in human infection with Fasciola hepatica. At a three-month follow up of treatment, all 4 patients treated with bithionol had a complete clinical recovery with satisfactory eosinophil counts, whereas the patient treated with emetine continued to have abdominal pain, lassitude, and an eosinophil count of 1300/mmn3. All patients on bithionol had side-effects - nausea, vomiting, diarrhoea, and pruritus, and one patient had to stop treatment after 22-5 g. These preliminary results suggest that bithionol is an effective drug