454 Indian Journal of Dermatology 2011; 56(4)

Correspondence
PARANEOPLASTIC
ERYTHRODERMA COMPLICATED
BY HYPOTHERMIA AND
HYPOTHYROIDISM
Shrutakirthi D Shenoi, Shubha Seshadri
1
,
Smitha Prabhu, Rohith Valsalan
1
,
Vinay Pandit
1
, Sathish Pai B
From the Department of Skin and STD, Kasturba Medical
College,
1
Department of General Medicine, Kasturba Medical
College, Manipal University, Manipal, Karnataka, India. E-mail:
drsmithaprabhu@yahoo.com
Indian J Dermatol 2011:56(4):454
Sir,
A 67-year-old male with no premorbid illness presented
to us with generalized itchy lesions of 20-days duration
associated with drowsiness, dizziness and loss of appetite.
He had cold extremities with rectal temperature of 95 F.
Pulse rate, blood pressure and respiratory rate were
56/minute, 86/56 mmHg and 16/min, respectively. There
was generalized hyperpigmentation and thickening of
skin with loss of body hair. We diagnosed him as chronic
erythroderma with hypothermia. Baseline investigations
were normal except for hypoglycemia (40 mg/dL) and
hypoalbuminemia (1 gm/dl). ECG showed Osborn J waves,
which are seen in mild hypothermia. Patient was passively
warmed and given intravenous prewarmed dextrose normal
saline, fresh frozen plasma and antibiotics along with
ionotropic support. Thyroid function tests showed features
of primary hypothyroidism (TSH 51.9 IU/ml, T3 normal,
T4 decreased, 3.3 mg/dl). Patient was started on thyroxine.
In 72 hours, patients sensorium improved, oral temperature
rose to 98 F and repeat ECG showed normal sinus rhythm.
Histopathology of skin showed a hyperplastic irregularly
acanthotic epidermis with follicular plugging and elongated
branching rete ridges. Dermis showed periadnexal and
perivascular lymphohistiocytic infltrate with pigment
incontinence, suggestive of dermatitis. He was treated
with emollients and tapering course of oral prednisolone.
Subsequently he developed herpes zoster and inguinal
abscess. In addition as he had obstructive urinary voiding
complaints a urology consultation revealed a frm, enlarged
prostate with a prostatic biopsy specimen revealing
adenocarcinoma. The prostate specifc antigen level was
markedly elevated. Bilateral orchidectomy and transurethral
resection of the prostate was done. Skin condition and
pruritus has signifcantly improved at 2 months followup.
Paraneoplastic erythroderma occurs as a response to solid
and hematological malignancies, characterized by dramatic
increase in the epidermal turnover rate leading to erythema
and scaling involving more than 90% body surface area,
and impaired cutaneous functions like barrier function and
thermoregulation. In hypothermia, the body temperature
falls to an abnormally low level, incompatible with normal
metabolism and functions. Other common causes for
hypothermia include hypothyroidism, low environmental
temperature and drug overdosage with phenothiazines,
ethanol and sedative hypnotics.
[1]
Erythroderma can predate, accompany or postdate the
detection of malignancy. Hypothermia in erythroderma
has been previously described and is seen in
approximately 1% cases. Hypothermia can be classifed
according to severity as mild (90-95 F), moderate
hypothermia (82-90* F) and severe (<82*F). Our
patient had both erythroderma and hypothyroidism as
contributing factors for his mild hypothermia.
Heat loss in erythroderma accompanies a defective barrier
and impaired vasoconstriction along with decreased
shivering refex, further loss of body heat occurs via
evaporation of oozing liquid from the surface. Normally
25% of the heat loss is by evaporation, but in extensive skin
lesions, it increases. The increased transepidermal loss
[2]

and increased blood fow lead to heat loss by radiation,
conduction and evaporation compounded by defects in
vascoconstriction and activation of cold receptors.
[3]
Our
patient possibly developed erythroderma as a paraneoplastic
response to the prostatic malignancy. Hypothyroidism
was later detected which was a major contributor for
hypothermia. The role of thyroid hormone in thermogenesis
is well known. In hypothyroidism, hypothermia is
secondary to peripheral vasoconstriction.
[4]
Moreover,
myxoedemic coma is a potentially fatal complication of
hypothyroidism precipitated by any physical stress or
illness and results in an altered mental status, hypothermia,
bradycardia, hypercarbia and hyponatremia.
[5]
References
1. McCullough L, Arora S. Diagnosis and treatment of hypothermia.
Am Fam Phy 2004;70:2325-32.
2. Grace KA, Bettley FR. Skin water loss and accidental
hypothermia in psoriasis, ichthyosis and erythroderma. Br Med J
1967;28:195-8.
3. Yaffee HS. Hypothermic coma and exfoliative dermatitis. J Am
Med Assoc 1969;207:367.
4. Edelman IS. Thyroid thermogenesis. N Eng J Med 1974;290:
1303-8.
5. Bharaktiya S, Orlander PR, Davis AB. Hypothyroidism. Available
from: http://emedicine.medscape.com/article/122393-overview
[Last accessed on 2009 Apr 23].
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DOI: 10.4103/0019-5154.84720
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