Rheumatic Manifestations of Endocrine Diseases

Joseph A. Markenson


Curr Opin Rheumatol. 2010;22(1):64-71. 

In This Article

Thyroid Disorders

Hypothyroidism presents often with a characteristic symmetrical arthropathy involving stiffness of the joints of the hands and knees. On palpation the joints feel 'gelatinous' and aspiration of fluid is usually noninflammatory, viscous with high levels of hyaluronic acid. CPPD crystals are often found, and hypothyroidism should be included in the differential diagnosis[1] of joints that demonstrate CPPD crystals on aspiration.[2] The conditions probably associated with calcium pyrophosphate dihydrate crystal deposition are as follows:

  1. hyperparathyroidism,

  2. familial hypocalciuric hypercalcemia,

  3. hemochromatosis,

  4. hemosiderosis,

  5. hypophosphatasia,

  6. hypomagnesemia,

  7. hypothyroidism,

  8. gout,

  9. neuropathic joints,

  10. aging

  11. amyloidosis and

  12. trauma including surgery.

A myopathy has been reported presenting with proximal weakness and fatigue normal creatinine phophokinase (CPK) levels, normal fatigue, muscle pathology on biopsy and hypercholesterolemia.[3,4]

Carpal tunnel syndrome may present as an initial manifestation of hypothyroidism present in upwards of 7% of patients.[5]

Hyperthyroidism (Graves' disease) can present with pretibial myxedema usually associated with graves ophthalmopathy. The myxedma may appear as nodules which vary in size from 1 cm to large lesions covering most of the pretibial surface and colored from pink to a light purple hue. They can appear and as erythema nodosum, but are painless and comprise hyaluronic acid.[6,7]

Nail changes, onycholysis and clubbing (thyroid acropachy) may be associated with periostitis around the metacarpal joints as well as soft tissue swelling of the digits. Unfortunately this condition may not return to normal when the patient is treated.[8]

Patients with hyperthyroidism may present with proximal muscle weakness (associated shoulder adhesive capsulitis), loss of muscle mass and weight loss. Most of these manifestations will correct with treatment.[9]

A common and serious manifestation of hyperthyroidism is osteopenia and osteoporosis. Treating to achieve a normal thyroid-stimulating hormone (TSH) level as well as adjusting the dose of thyroid replacement in hypothyroid patients is essential. Improvement in bone mineral density (as measured by densitometry) in patients with thyroid disease is important to achieve.[10,11]


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