Endocrinologist Trinity Health Rochester Hills, Michigan, United States
Disclosure(s):
Bhavya Mody, MD: No financial relationships to disclose
INTRODUCTION
Hashimoto’s thyroiditis (HT) may present with various extrathyroidal manifestations, reflecting its systemic autoimmune nature. We report three cases of HT with unusual mucocutaneous and ocular manifestations—eyelid retraction with brow ptosis, recurrent urticaria, and transient lingual papillitis (TLP). In two cases, ocular findings and recurrent urticaria were the only presenting manifestations of HT.
CASE DESCRIPTIONS
Case 1- A 37-year-old woman presented with a recurrent pruritic maculopapular rash on the extremities since 1 month, partially responsive to steroids. She was diagnosed with chronic urticaria, and no specific triggers were identified. 9 months later, lab work revealed hyperthyroidism with markedly elevated anti-TPO antibodies, mildly elevated anti-thyroglobulin and thyrotropin receptor antibodies, and negative thyroid stimulating immunoglobulin (TSI). Thyroid hypervascularity was seen on ultrasound. She experienced mild, self-limited symptoms, and her laboratory values normalized within two weeks, consistent with a diagnosis of the transient hyperthyroid phase of HT (hashitoxicosis).
Case 2 - A 40-year-old woman with Hashimoto’s thyroiditis (elevated anti-TPO antibodies, normal TSI and thyroid function tests) complained of right upper eyelid retraction and relative right brow ptosis for 6 months, with no other symptoms of thyroid disease. Thyroid ultrasound showed mild hypervascularity. She was diagnosed with eye disease likely due to HT by ophthalmology.
Case 3 - A 36-year-old woman with hypothyroidism due to HT presented with episodes of glossitis for 6 months, unresponsive to antibiotics, antiviral and antifungal treatments. She was referred to allergy and immunology and was diagnosed with TLP, with no identifiable risk factors, including local irritation, infection, etc., and likely due to HT.
DISCUSSION
These cases highlight atypical manifestations of Hashimoto's thyroiditis, which in some cases may be the sole presenting features, as in our cases with ocular findings and urticaria. Proposed mechanisms linking chronic urticaria with HT include mast cell activation mediated by thyroid autoantibodies, antigen release from thyroid inflammation, and TSH-driven cytokine release. Thyroid eye disease is classically associated with Graves’ disease and typically linked to TSAb positivity; ocular involvement in HT is rare. Although TLP is often inflammatory, there is evidence to suggest non inflammatory etiologies. The absence of triggers in this case suggests a possible association with HT. Hence, thyroid testing should be considered in patients presenting with these symptoms with no clear identifiable non-thyroidal etiology.
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