Schmidt's syndrome in a Saudi family

We present 3 patients from a Saudi family who are presented with polyglandular autoimmune syndrome type 2. They have Addison's disease with either autoimmune thyroid disease or insulin dependent diabetic mellitus. Although this syndrome is rare, the incidence among Saudi Arabia or the Arab population is not known.     

Association of Addison's disease with autoimmune disorders--a long-term observation of 180 patients.

This study aimed at evaluating the frequency of autoimmune disorders in Addison's disease. We have observed 180 patients (113 females, 67 males, aged 9-74 years) for 1 to 26 years. Tuberculosis was noted in 54 patients. Autoimmune disorders were found in 80 patients (44%); however, 125 (69%) patients were believed to have an autoimmune origin of adrenocortical insufficiency. In 20 patients two or more autoimmune disorders were found to coexist with Addison's disease.     

Prevalence of hypothyroidism and importance of cholesterol estimation in patients suffering from major depressive disorder

The coexistence of hypothroidism and depression is already reported and both of these conditions are known to share some common clinical symptoms. Serum cholesterol level is known to be altered in either condition considered separately. But, no report is obtained regarding serum cholesterol level when both the conditions coexist. In this study, 78 patients (61 females and 17 males, age ranged 19 to 67 years) suffering from major depressive disorder were included. Serum T3, T4, TSH and cholesterol levels were estimated in all of them. Sixty-two patients were found to be euthyroid and 16 patients (11 females, 5 males) were found to be hypothyroid. Among female patients, 6 had subclinical hypothyroidism and 5 had overt hypothyroidism. Among male patients 3 had subclinical hypothyroidism and 2 had overt hypothyroidism. The overall prevalence of hypothyroidism in major depressive disorder was estimated as 20.5%. Mean serum cholesterol level in 62 euthyroid patients was found to be 150.9% +/- 16 mg% and that of 16 hypothyroid patients to be 190.7 +/- 12 mg% showing a significant difference (p < 0.01). Thus estimation of cholesterol in major depressive disorder patients may give an idea regarding their thyroid status and vice-versa.     

A Case of Painful Hashimoto Thyroiditis that Mimicked Subacute Thyroiditis

Hashimoto thyroiditis (HT) is an autoimmune thyroid disorder that usually presents as a diffuse, nontender goiter, whereas subacute thyroiditis (SAT) is an uncommon disease that is characterized by tender thyroid enlargement, transient thyrotoxicosis, and an elevated erythrocyte sedimentation rate (ESR). Very rarely, patients with HT can present with painful, tender goiter or fever, a mimic of SAT. We report a case of painful HT in a 68-year-old woman who presented with pain and tenderness in a chronic goiter. Her ESR was definitely elevated and her thyroid laboratory tests suggested subclinical hypothyroidism of autoimmune origin. (99m)Tc pertechnetate uptake was markedly decreased. Fine needle aspiration biopsy revealed reactive and polymorphous lymphoid cells and occasional epithelial cells with Hürthle cell changes. Her clinical symptoms showed a dramatic response to glucocorticoid treatment. She became hypothyroid finally and is now on levothyroxine therapy.     

1型糖尿病患者临床特点与胰岛素剂量关系的研究

目的研究胰岛素剂量与1型糖尿病患者的临床特点是否相关。方法94例初诊1型糖尿病(DM)病人随诊4a,记录每日胰岛素剂量、家族史,定期测量血糖、糖化血红蛋白、血脂、血尿酸、尿蛋白排泄量、体重指数、腰臀比等指标。结果胰岛素剂量、总胆固醇、甘油三酯、低密度脂蛋白与1型糖尿病病程的相关系数有统计意义(P<0.05)。确诊后4a胰岛素剂量与各自变量的相关系数中,腰臀比、甘油三酯、2型糖尿病家族史与胰岛素剂量的相关系数有统计意义(P<0.01)。结论在1型DM患者,胰岛素剂量与腰臀比、甘油三酯、2型糖尿病家族史相关。     

American Thyroid Association guidelines for use of laboratory tests in thyroid disorders

Selection of appropriate laboratory determinations will enable the clinician to diagnose thyroid dysfunction readily in the majority of patients. At the present time, estimation of free thyroxine and a "sensitive" thyrotropin assay are recommended as the principal laboratory tests for thyroid disease. A decrease in serum free thyroxine estimate and a raised level of serum thyrotropin confirm the diagnosis of hypothyroidism caused by thyroid gland failure. An increase in free thyroxine estimate combined with a serum sensitive thyrotropin level suppressed to less than 0.1 mU/L establishes the diagnosis of thyrotoxicosis. In sick patients, a normal or raised serum free thyroxine estimate together with a normal level of serum thyrotropin suggests that the patient has neither hypothyroidism nor thyrotoxicosis. Patients with severe illnesses, generally in the intensive care unit, and those treated with certain drugs, as well as individuals with unusual thyroid disorders, may present with confusing laboratory findings. An understanding of the regulation of the thyroid hormone system and/or judicious consultation with an endocrinologist should enable the clinician to diagnose thyroid disease, if present, in such patients.     

32-year old patient presenting with autoimmune polyglandular syndrome

A 32-year-old student reported fatigue and malaise since two months in the absence of specific symptoms. Clinical examination and extensive laboratory testing revealed no abnormalities at his first presentation. Some weeks thereafter, on re-admission, hyperpigmentation suggestive of Addison's disease was observed and pathognomonic autoantibodies directed against the thyroid gland and the adrenal cortex were detected. Further evaluation led to the diagnosis autoimmune polyglandular deficiency syndrome, also named "Schmidt syndrome", comprising adrenocortical insufficiency (Addison's disease) and lymphocytic thyroiditis (Hashimoto thyroiditis). The diagnosis of polyglandular insufficiency is often delayed due to non-specific symptoms at early disease stages and progression may be rapid, culminating in Addisonian crisis under physical stress or infection, requiring immediate high-dose hormone replacement therapy. Hence, careful re-examination is mandatory to ensure adequate treatment before life-threatening complications occur. Nowadays this type of disease is classified as autoimmune polyglandular syndrome type II (APS type II) with an increased risk of developing insulin-dependent diabetes mellitus (IDDM), vitiligo, alopecia, pernicious anaemia, coeliac disease, myasthenia gravis and primary hypogonadism. The cause of the disease remains obscure but in addition to an autosomal dominant trait with variable penetrance some hints at viral infection triggering the disease process exist.     

Hyperthyroidism after propranolol withdrawal

Classic features of thyrotoxicosis developed in three patients with no prior history of thyroid disease shortly after the discontinuation of therapy with or decrease in doseage of propranolol hydrochloride. Graves' disease probably developed fortuitously after propranolol therapy was instituted, but the beta-adrenergic blockade masked the clinical features of hyperthyroidism. On discontinuation of propranolol therapy or decrease in propranolol dosage, previously latent thyrotoxicosis became manifest. If hyperthyroidism masked by beta-blockade is not recognized before withdrawal of propranolol therapy in patients with ischemic heart disease, the sudden appearance of thyrotoxicosis may lead to symptoms of increased myocardial ischemia.     

Detection of familial dysalbuminaemic hyperthyroxinaemia

A simple test of in vitro thyroxine binding to serum proteins was used to screen serum samples from euthyroid patients with unexplained increases in the free thyroxine index. A diagnosis of familial dysalbuminaemic hyperthyroxinaemia was presumed in 14 unrelated subjects and six first degree relatives. Increased binding of thyroxine to thyroxine binding prealbumin was diagnosed in one woman with four unaffected relatives. Seven patients with familial dysalbuminaemic hyperthyroxinaemia had been treated for presumed thyrotoxicosis: two had typical Graves' disease and one subacute thyroiditis. Four other patients had been mistakenly treated with radioactive iodine or antithyroid drugs. In previously treated patients familial dysalbuminaemic hyperthyroxinaemia was suspected from the combination of a high serum thyroid stimulating hormone concentration and a normal but invalid free thyroxine index. Physicians should be cautious in accepting a diagnosis of thyrotoxicosis based mainly on a raised serum thyroxine concentration.     

Prevalence of antithyroid microsomal antibody in thyroid patients of endemic goitre area

The region of greater Mymensingh known for iodine endemicity, recently came under iodine supplementation as a result of mandatory universal iodination of salt program. Autoimmune thyroid diseases (AITD) are among the most common human autoimmune disorders & presence of autoantibodies to the microsomal antigen (AntiMCAb) is a hallmark of disease activity. Both iodine deficiency & iodine supplementation precipitate increase rate of autoimmunity to the thyroid gland. Study was undertaken to determine prevalence of AntiMCAb positive cases among patients with various thyroid diseases. High resolution ultrasound (HRUS), serum thyroid hormone assays & scintiscan were used to classify the thyroid patients into 8 categories. 221 patients were studied during the stipulated period of 3 months. Male patients were 60 & female patients were 161. Age ranged from 11 to 65 years with median age 29.4 years. AntiMCAb test were done with radioimmunoassay (RIA). 126 patients had antimicrosomal antibody (57.01%). All form of hypothyroid (atrophic, goitrous, Hashimoto's) have very high rate of AntiMCAb positive cases. Highest 89.28% were seen in patients showing feature of Hashimoto's thyroiditis or generalized feature of AITD in HRUS with hypothyroidism, followed had 61.29% positive cases, However, antithyroid antibody was found in all form of thyroid disorders. Nodular goiter had 21.73% antiMCAb positive cases. AntiMCAb found positive at the rate of 33.33% in euthyroid patients with HRUS feature of AITD & diffuse euthyroid goiter, 40% in subclinical hypothyroid, 40% in subclinical hyperthyroid. Female rated higher in range of antimicrosomal antibody positivism. 59% of all thyroid patients among female subjects were AntMCAb positive, where as 51.67% male thyroid patients were positive. Highest number of positive cases found in the 30-35 age group. No definite pattern, however, was observed among age distribution. 20 age matched sample from patients unsuspected of thyroid disease shows 10% AntiMCAb positive compared to 73.33% of the same among same age group of thyroid patients. Frank Hashimoto's thyroiditis with positive antiMCAb and hypothyroidism were all detected by HRUS.     

A case of graves’ disease associated with autoimmune haemolytic anaemia

This report describes simultaneous autoimmune thyrotoxicosis and autoimmune haemolytic anaemia. Autoimmune haematological abnormalities should be excluded in patients with Graves’ disease and thyroid function and thyroid antibody status should be evaluated in patients with autoimmune haemolytic anaemia.     

Addison's disease in type 1 diabetes presenting with recurrent hypoglycaemia

Primary adrenal insufficiency (Addison's disease) often develops insidiously. Although a rare disorder, it is more common in type 1 diabetes mellitus. A 19 year old male with type 1 diabetes and autoimmune hypothyroidism experienced recurrent severe hypoglycaemia over several months, despite a reduction in insulin dose, culminating in an adrenal crisis. Recurrent severe hypoglycaemia resolved after identification and treatment of the adrenocortical insufficiency. In type 1 diabetes, undiagnosed Addison's disease can influence glycaemic control and induce severe hypoglycaemia.     

202例白癜风临床类型与构成特点分析

目的：总结白癜风的临床类型与构成特点,以期为白癜风的临床防治提供依据。方法回顾性分析我院皮肤科2015年1~12月期间诊治的202例白癜风患者的临床资料。结果202例白癜风患者中男女比例为1：1.04;头面部是最常见的发病部位(占44.06%);临床分型中非节段型最常见(占84.65%),且以散发型多见(占49.01%);46例(占22.77%)患者伴发自身免疫性疾病或内分泌疾病,最多见者为甲状腺疾病(占8.91%);有家族史者占12.38%,有家族史者年龄为(19.16±7.75)岁,明显低于无家族史者的(22.28±8.16)岁,节段型、进展期比例分别为36%、92%,均高于无家族史者12.43%、71.75%,差异均有统计学意义(P<0.05);57例(28.22%)患者发病前存在明确的诱发因素。结论白癜风多以非节段型发病,皮损部位以头面部多见,常伴发自身免疫性疾病,精神心理因素是其发病的常见诱因,而有家族史的白癜风患者发病早、病情相对严重。     

A study on prevalence of thyroid auto-immunity in type 1 diabetes mellitus

Type 1 diabetes mellitus is an auto-immune disease. It is associated with other auto-immune endocrine disorders and auto-immune impairment of non-endocrine tissue. Auto-immune thyroid disease is one of the most frequent auto-immune diseases associated with it. Hypothyroidism can decrease insulin requirement in such patients and hyperthyroidism may cause glucose intolerance. This study attempts to review this concept and detect overt and subclinical forms of auto-immune thyroid disease in type 1 diabetics and to find its correlation with age, sex and duration of diabetes. Fifty type 1 diabetes mellitus patients were selected from SSG Hospital, Vadodara between April 2007 and September 2008. After detailed history and examination, haemogram, urine analysis, fasting and 2-hour postprandial blood glucose level, serum free T4, TSH and antithyroid peroxidase antibody level were performed. The prevalence of auto-immune thyroid disease in type 1 diabetics was 60% with 40% having thyroid disorders (24% overt hypothyroidism, 8% subclinical hypothyroidism and 8% hyperthyroidism). Patients who were females (70% versus 53% in males), older (53.3% in 15-20 years age group versus 71% in 25-30 years age group), had a longer duration of diabetes (25% in those with the disease for <2 years and 100% in those >6 years) were more likely to have auto-immune thyroid disease than their counterparts. Thyroid auto-immunity is frequently associated with type 1 diabetes mellitus and patients should undergo antibody screening to detect the same and to find out assosiated undiagnosed thyroid dysfunction.     

Remission of hyperthyroidims and oral contraceptive therapy. [Answer to question

There is no endocrine contraindication to the use of oral contraceptives (OCs) in a 31-year-old nulliparous woman who presumably is in remission from hyperthyroidism. Yet, several important physiological and pathophysiological alterations must be appreciated to evaluate properly thyroid function in persons taking estrogen-containing preparations. Estrogens induce increased hepatic synthesis and release of thyroxine binding globulins (TBGs). Increased serum TBG concentrations result in a new thyroid hormone equilibrium characterized by an elevated serum thyroxine (T4) level and a reduced resin triiodothyronine (T3 uptake) level but a persistently normal serum-free T4 (FT4) level if the patient is euthyroid. When a patient with an increased serum TBG concentration becomes thyrotoxic, the T4 level rises further and the resin T3 uptake increases from low into the normal range. The calculated FT4 level increases into the thyrotoxic range. Thus, in patients with increased serum TBG levels, the calculated FT4 level is the critical serum determinant for laboratory assessment of thyroid function. If the FT4 level is equivocal in evaluating thyrotoxicosis in the presence of increased serum TBG values, then other clinical and laboratory parameters should be used. A thyroid suppression test or a thyrotropin-releasing hormone test might be useful when the serum parameters are not definitive. It is unnecessary to stop the use of OC preparations to evaluate thyroid function. At this time it is unclear whether the use of estrogen-containing medications influences the nature and extent of an autoimmune remission in Graves' disease. There is some evidence that autoimmune thyrotoxicosis is ameliorated or modified by factors in pregnancy.     

Serum long acting thyroid stimulator protector in pregnancy complicated by Graves' disease

Activities of serum long acting thyroid stimulator protector were measured in a series of nine pregnancies in eight mothers who had Graves' disease, one of whom had been successfully treated by surgery. In all but two instances the activities tended to decline as pregnancy progressed. After delivery activities rose in three out of five patients in whom these had disappeared in pregnancy and, as this occurred, the patients relapsed. In the two patients whose activities did not decline thyrotoxicosis persisted throughout pregnancy and after delivery. None of the nine babies in this study suffered from neonatal thyrotoxicosis because maternal activities of the thyroid stimulator protector, though high enough to induce Graves' disease in adults, were not above the threshold for the induction of thyroid overactivity in neonates.     

Thyrotoxicosis in Nigeria--a study of forty-six patients

In a review of 874 Nigerian patients with various types of thyroid gland disorders, forty-six patients were found to be thyrotoxic (5·3%), supporting the common observation of many authors that thyrotoxicosis is rarer in the African than in Europe and North America where thyrotoxicosis accounts for 20-50% of all thyroidectomies. The incidence of thyrotoxicosis is higher in the female than male though there is a higher proportion of males in this series than in the United Kingdom. There is a higher incidence of secondary thyrotoxicosis than has been reported elsewhere.     

Postpartum thyroiditis

Three women presented 4-6 months after delivery with a goitre and spontaneously changing thyroid function believed to be due to autoimmune thyroiditis. All three patients had transient hypothyroidism and one initially had evidence of thyrotoxicosis. Hypothyroidism in autoimmune thyroiditis is generally regarded as permanent. However, evidence is now accumulating, and is reviewed here, to suggest that relapses or onset with transient thyrotoxicosis and hypothyroidism followed by spontaneous, more or less complete, remission occur in one or more varieties of thyroiditis in the postpartum period.     

Coronary artery disease in young patients: clinical review and risk factor analysis

Fifty consecutive younger patients (< or = 40 years) with coronary artery disease, who underwent coronary angiography in National Institute of Cardiovascular Diseases were evaluated clinically and coronary risk factors were analyzed and compared with those of fifty older patients with coronary artery disease. Mean age of younger and older patients were 37.31 and 54.58 years respectively and myocardial infarction was the most common presenting complain in both the groups. Smoking and family history of premature coronary artery disease were more common in younger patients but the older patients were more diabetic and hypertensive. Central obesity and dyslipidemia did not vary between the two groups. Fifty percent of younger patients had one or two modifiable risk factors where sixty four percent of older patients had three or more modifiable risk factors. Forty four percent younger patients had hypercholesterolemia but a majority of patients had either isolated hypertriglyciredemia or decrease high density lipoprotein cholesterol or both with normal total cholesterol level but the total cholesterol and high density lipoprotein cholesterol index were more than 4.5. Younger patients had more number of normal coronary or single vessel diseases but older group had more number of triple vessel diseases. So the higher incidence of non-insulin dependent diabetes mellitus with central obesity suggesting insulin resistance along with unique profile of dyslipidemia, higher incidence of smoking and familial predisposition of premature coronary artery disease may be responsible for higher incidence of coronary artery disease at a premature younger age in this population.     

INDIRECT FLUORESCENCE ANTIBODY TES''T IN DIAGNOSIS OF IDIOPATHIC ADDISON''S DISEASE

By using indirect immunofluorescence antibody test, we detected adrenal, thyroid and antinuclear antibo;dies in 40 patients with Addison's disease and 91 patients with other endocrinopathies. In 25 patients with idiopathic Addison's disease antiadrenal autoantibody (AA) was found to be positive in 68To, whereas in 15 patients with tuberculous Addison's disease it was positive in 13%. There was significant difference between the two. In 91 patients with other endocrinopathies, AA was positive in only l.10lo. The antibody detected in all the positive cases was IgG. AA positivity in patients with idiopathic Addison's disease was unrelated to agc, sex, duration o;f disease and treatment. In patients with idiopathic Addison's disease the titcr of thyroid and antinuclear antibodies was significantly higher than that in those with tuberculous Addison's disease, particularly in the female. We believe that positive AA in some degree is l_elpful in the diagnosis of idiopathic Addison's disease, particularly in suspected cases. Besides, in patients with Addison's disease but no evidence of tuberculosis positive AA indicates that anti tuberculous therapy might not be used as conven- tionarlly.