(BMJ)—A 26-year-old woman with Graves' disease and ophthalmopathy presented with progressive bilateral leg swelling for 3 months. Exam: gross thickening and folding of skin on feet, and edema of shins. What’s the dx?
Lymphatic filariasis
Milroy syndrome
Lichen amyloidosis
Pretibial myxedema
Lichen myxedematosus
You are correct. Pretibial myxedema affects 0.5% to 4.3% of patients with Graves' disease; the elephantiasic form is rare. The hx of autoimmune thyroid disease, an acute presentation within 3 months, and the classical appearance were consistent with pretibial myxedema. Tx consists of topical or intralesional steroids, occlusive dressing, and comfortable footwear. Resolution is variable, based on severity at presentation, and can take months.

BMJ 2018;360:k945
(BMJ)—An otherwise healthy 29-year-old parachutist presented with sudden-onset facial flushing, dizziness, and a diffuse rash that began on a hot day, 1 hour after eating tinned tuna. The symptoms appeared while she was ascending in an aircraft, before a parachute jump from 10,000 feet. She completed the jump uneventfully. What's the dx?
Heat-related eruption
Decompression sickness
Fish allergy
Stress-induced urticaria
Scombrotoxin poisoning
You are correct. The urticarial rash without hx of fish allergy suggested scombrotoxin poisoning. Presentation mimics an allergic response, with s/sx including flushing, sweating, a burning taste, dizziness, nausea, tachycardia, fever, and urticaria without wheals. Tongue swelling, respiratory distress, and hypotension may occur, but rarely. Scombrotoxin poisoning is caused by ingestion of histamine-containing fish. The principal risk is with fresh fish, but it can also result from eating frozen, cured, or canned fish. After tx with antihistamines, symptoms usually improve rapidly. Epinephrine may be required for severe cases.

Emerg Med J 2018;35:184