Pitting oedema in hypothyroidism.

A 38 yrs old female admitted generalised swelling, puffiness of face and coarsening of features for six months. Examination revealed obesity (BMI 34.7 kg/m) with pitting pedal oedema (Figs, 1,2), normal JVP and delayed relaxation of ankle jerks. Rest of general physical examination and systemic examination was normal. On investigation, haemogram, urine examination, X-ray chest, echocardiography and serum biochemical examination were normal, except for total cholesterol which was 350 mg%. ECG showed sinus bradycardia with normal voltage with ST-T wave changes. Her thyroid function test were T3 0.41 μg/ml (0.58-1.59 μg/ml), T4 1.65 ng/ml (4.87-11.72 ng/ml) and TSH 224.20 mU/l (0.35-4.94 mU/l). She was put on 1thyroxine 25 μg per day which was increased to 100 μg per day over one month. On follow up after 3 months, she was free of symptoms and her pedal oedema had disappeared. Peripheral oedema is present in 55% patients of hypothyroidism, whereas periorbital oedema is seen in 22%. There is infiltration of mucopolysaccharides, hyaluronic acid and chondroitin sulphate in dermis giving rise to non-pitting oedema or myxoedema. Although sign and symptoms of myxoedema may suggest congestive cardiac failure but in absence of other cardiac disease, myocardial failure is rare. Pitting edema in hypothyroidism is rare and can be due to increased capillary permeability, decreased adrenergic (vasoconstrictor) tone and increase in serotonin (vasodilator) metabolism.