Primary biliary cirrhosis and Graves disease combination rarely found
Alexandra Vieira1, Sandra Paiva1, Cristina Ribeiro1, Jacinta Santos1, Mariana Martinho2, Márcia Alves1, Sofia Gouveia1, Francisco Carrilho1 & Manuela Carvalheiro1
Introduction: The association of autoimmune diseases in the same individual is common. It is well documented that Graves disease (GD) is associated to various autoimmune diseases, including: pernicious anemia, vitiligo, type 1 diabetes, Addisons disease, systemic sclerosis, myasthenia gravis, Sjogrens syndrome, rheumatoid arthritis and systemic lupus erythematosus. In addition, primary biliary cirrhosis (PBC) may be associated with rheumatoid arthritis, Sjogrens syndrome, Raynauds phenomenon and autoimmune thyroiditis, often observed the presence of hypothyroidism. However, the association of PBC and GD is rare. It is described in the literature only 5 cases.
Case report: Female, 63 years old, sent to the endocrinologist for hyperthyroidism. The patient had a history of cholecystectomy and PBC diagnosed 9 years ago. She was treated with ursodeoxycholic acid 500 mg twice a day. She reported palpitations, excessive sweating, irritability and weight loss.
Physical examination: heart rate of 80 bpm, coarse tremor, bosselated thyroid and non-pulsatile. Laboratory findings: TSH 0.01 μUI/ml (0.274.20), free T4 3.76 ng/dl (0.931.7), antiTPO 244 UI/ml (<34) and TRAbs 4.2 U/l (<1.5).
Thyroid ultrasonography showed an enlarged, lobulated, slightly heterogeneous gland and a nodule with 1 cm in diameter in the left lobe. Fine-needle aspiration biopsy was performed: colloid nodule. The patient was treated with methimazole 15 mg/day and propranolol 10 mg twice a day. For persistence of hyperthyroidism, although the increasing of methimazole dose, the patient underwent radioiodine therapy (7.4 mCi). The patient developed hypothyroidism, therefore was treated with levothyroxine. She is currently euthyroid.
Conclusions: Despite frequent association of autoimmune diseases in the same individual, the authors present this case for the rare association between PBC and GD.