Norcross and colleagues point out the vagaries of photographic reproduction. The "after" picture was taken immediately after the "before" picture, and the original slides are quite faithful to the color. During the publication process, however, the "after" picture became slightly altered in darkness and color. Nevertheless, we believe it aptly demonstrates the Pemberton sign.

The authors also question the sharp line of demarcation between the suffused skin and normal skin. The only reasonable explanation is that the affected vasculature happens to supply the skin in a distribution with a sharp line of demarcation. This same appearance can be seen in some cases of superior vena cava obstruction, such as that shown in Figure 6.39 of Epstein and colleagues' book on clinical examination [1].

Dr. Auwaerter refers to another rare, and rarely demonstrated, cutaneous finding of thyroid disease. The Maroni sign is an area of redness overlying an overactive thyroid gland. Although our patient did have subclinical hyperthyroidism, the cutaneous blood vessels in the neck are probably not the result of local effects of the thyrotoxic gland but rather of chronic vascular dilatation. Consequently, we probably should not refer to this as the Maroni sign but as a "pseudo-Maroni" sign.