A tale to tell: how lupus led to Graves' disease
Madalina Musat1,2, Camelia Giurca2, Daniela Aflorei2, Anca Lupu2, Anda Dumitrascu2, Mihaela Milicescu1,3, Rucsandra Danciulescu1,4 & Catalina Poiana1,2
Introduction: Despite the presence of antinuclear (ANA) and anti DNA antibodies in Graves disease, the association with Systemic Lupus Erythematosus (SLE) is rare. Responsible for this association seem to be mutations in the PTPN22 gene.
Case Report: We report a case of a 27-year-old woman, who presented in January 2009 in our department, at 6 months postpartum, after extensive investigations for autoimmune disease. She had negative results for polymyositis and SLE, but positive for TSHR antibodies.
At presentation the patient had no signs or symptoms of Graves disease, only a mild rash of the zygomatic region, neck and anterior thorax, and hyperemic oedema of the infrapalpebral region. Laboratory showed suppressed TSH, normal FT3, FT4, and positive TSHR-antibody, ATPO and antitiroglobulin antibodies). There were no CT signs of Graves orbitopathy, but infiltrative aspect of the bilateral inferior palpebral regions.
At this point the patient was diagnosed with subclinical Graves disease and commenced on antithyroid drug (methymazole) and continued with oral glucocorticoids previously recommended.
Corticotherapy was tapered in 3 months and the patient returned after a pause of 2 more months, with an exacerbation of facial and thoracic rush during the summertime.
She was rescreened for SLE (ANA, Ac antiADN ds) and found positive.
A diagnosis of SLE with multiple organ involvement was made and treatment with methylprednisolone, hydroxichlorochine and azathioprine was started.
Conclusion: Screening for Graves disease in young women suspected of SLE should be more largely used, while facial rash in young women with controlled Graves disease could be relevant of SLE.