Elephantiasic pretibial myxedema: Insight into and a hypothesis regarding the pathogenesis of the extrathyroidal manifestations of Graves' disease

The basis for the extrathyroidal manifestations of Graves' ophthalmopathy ( GO) and dermopathy are not well understood. We describe immunohistochemical studies on the skin of a patient with an extreme, elephantiasic form of Gr aves' dermopathy that developed after periods of prolonged standing with de pendent edema. Excision of part of the lesion with subsequent skin grafting from a normal donor site resulted in recurrence of the disease at the orig inal site as well as in development of disease at the donor site. A murine monoclonal antibody reacted with the thyrotropin receptor (TSHR) or a cross -reacting protein in fibroblast-like cells in the patient's upper dermis an d, surprisingly, with dermal cells from unaffected individuals. The patient 's dermis containing lymphoid follicles comprising B cells and CD3+, CD4+ T cells, with few CD8+ T cells. CD21+ cells (most likely follicular dendriti c cells) were also present in the dermis. Based on past and present observa tions, we raise an unifying hypothesis to explain the diverse extrathyroida l manifestations of Graves' disease and their apparent lack of association with TSHR autoantibodies. As opposed to the present concept that these phen omena relate to site-specific properties on preadipocytes or fibroblasts, w e suggest that clinically evidence GO and dermopathy are primarily caused b y local factors (particularly in the orbit) superimposed on a systemic, low -grade connective tissue inflammation.