Isolated periorbital edema – A sign to suspect hypothyroidism

A 57-year-old farmer was admitted to the medicine department for evaluation of generalized weakness of 6 months duration. He was referred to the dermatology department for evaluation of lower eyelid edema, which started 5 months back, predominantly on the right side and progressed to involve the left side for the past 1 month. On examination, there was a diffuse, soft, non-tender, symmetric lower eyelid swelling [Figure 1]. The swelling was mild, erythematous in hue. There were no associated textural changes on the eyelid skin. Rest of the examination was unremarkable except for diffuse dryness of the trunk and extremeties. There was no history of itching, oozing, seasonal variation, or environmental or gravitational exacerbation. The ophthalmological consultation was normal. Fine needle aspiration cytology was suggestive of subcutaneous edema. An elevated level (21.5 mIU/L) of thyroid-stimulating hormone and lower levels of free thyroxine (triiodothyronine = 97 pg/dL and thyroxine = 0.4 ng/dL) were identified. The patient was referred to the endocrinology department for further evaluation and management.

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Figure 1:

Diffuse, soft, non-pitting edema involving bilateral lower eyelids (right > left), in a patient with severe hypothyroidism.

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Periorbital edema, a hallmark feature in various systemic diseases, can arise from both local (infections, injuries, and allergies) and systemic (thyroid, renal, and cardiac) causes. The basic patho-mechanism is increased capillary permeability, decreased adrenergic tone, and an increase in serotonin metabolism. Hypothyroidism presents with various non-specific dermatological findings such as xerosis, dry and brittle hair, nail fragility, and cutaneous pigmentation. Myxedema is a manifestation of severe hypothyroidism, resulting from mucopolysaccharide deposition in the dermis, leading to non-pitting edema.^[1] Almost 90% of patients with periorbital myxedema are diagnosed with hypothyroidism.^[2] Hence, periorbital edema, a remarkably visible sign, warrants a high index of suspicion for thyroid dysfunction, as in our case.