Psychological stress and soft-tissue manifestations of Graves disease: a potential link?

Objective: Although a higher prevalence of psychiatric disease has been reported in patients with Graves disease, the nature of this association is unclear. Biologically plausible mechanisms have been described to link severe psychological stress with dysregulation of the immune system and loss of self-tolerance. Methods: We describe a 53-year-old female with Graves disease who developed acute, painful finger swelling during a state of heightened psychological distress. The Graves disease had been treated definitively with radioactive iodine several years prior to the onset of these symptoms. There was a clear temporal relation between the onset of the patient's acute manic episode, which was sufficently severe to lead to admission to an inpatient psychiatric ward, and the subsequent development of finger swelling about 1 week later. Results: Hand radiographs demonstrated erosion and thickening of the periosteum in the proximal phalanges of both hands and new cortical bone formation at these sites. These changes are consistent with thyroid acropachy, a connective-tissue manifestation of Graves disease. The patient was also noted to have marked nail clubbing and pretibial myxedema, characterised by a violaceous eruption overlying both shins. Conclusion: The pathogenesis of soft-tissue manifestations of Graves disease are incompletely understood. This case supports the possibility that severe psychological stress may exacerbate thyroid autoimmunity and specifically, rare soft-tisse manifestations of this condition.