J. Endocrinol. Invest. 13: 949-950, 1990
LETTER TO THE EDITOR
A case of dermatomyositis associated with hypothyroidism and hypoparathyroidism after surgery tor Graves' disease Dear sir, We read with interest the article by Sakata and colleagues about a case of Graves' disease associated with polymyositis (1). They emphasize the uncommon association of the two diseases and hypothesize a broad deterioration of immune function of the patient, rather than a common underlying mechanism. We also have observed, in 1987, a 47-year-old IMJITlan, referred to us for museie weakness and diffuse edema. No family history for autoimmune thyroid disease nor connective tissues disease was evident. Her past hystory was as follow: in 1969 she was diagnosed as hyperthyroid with mild exophthalmos and large diffuse goiter and was treated with methimazole; in 1978 for the recurrence of hyperthyroidism she underwent subtotal thyroidectomy with pathologie diagnosis of Graves' disease (Fig. 1). In May 1987 she was referred to our department for weakness of proximal museies, more evident at shoulders and
arms, associated with liIac rash on the upper eyelids, periorbital edema and ulcerative stomatitis. Concentrations of T3 and T4 were in the normal range, 123 ng/dl and 6.1 J.lQ/dl respectively, whereas TSH was 8.9 IlU/ml (normal range 0.6-4 llU/ml). Antithyroglobulin antibodies were 1: 160 (Wellcome TGHA) whereas antithyroid microsomal antibodies were in the normal range. Calcium and phosphorus blood levels were 6.9 mg/dl (normal range 8.7-10.2 mg/dl) and 5.3 mg/dl (normal range 2.5-4.9 mg/dl) respectively. Elevated concentrations of CPK (1132 lU/I) and LDH (1120 lU/I) were found. After the normalization of thyroid function with L-T4 and correction of blood values of calcium and phosphorus with calcitriol and oral calcium supplementation, CPK and LDH were immodified and weakness was persistent. Electromyographic interference pattern suggested primary disease of museies (Fig.2). Pathological findings of deltoid biopsy -necrosis of muscular fibers associated with
Fig. 1 - Thyroid: flatten follicles with tall epithelium and scalloped colloid content due to epithelial resorption are typical aspects 01 Graves' disease (EE. x 175)
949
M. Zingrillo, M. Errico, P. Simone, et a/.
in Caucasian, of association between dermat01lyositis and Graves' disease, suggest a new consideration of the question.
M. Zingrillo *, M. Errico *, P. Simone **, C. Bosman ***, and S. Fusilli *** Departments of Internal Medicine (*), Neurophysiology (**) and Pathology (***), Ospedale Generale Regionale della Fondazione "Casa Sollievo della Sofferenza· San Giovanni Rotondo, Foggia, Italy
Fig. 2 - Electromyographic interference pattern at minimal contraction with incremented motor unit potentials, small in amplitude and short in duration. (Quadriceps)
Iymphocyte infiltration of interstitium- confirmed the diagnosis of dermatomyositis (Fig.3). Oral treatment with prednisone (25 mg b.i.d.) improved muscle strenght and normalized serum enzymes in two months. At the present the patient needs a 7.5 mg daily prednisone maintenance therapy: she has anormal muscle strenght, with normal serum values of LOH and CPK, whereas there is a persistent liIac rash of the upper eyelids. No clear association was observed between autoimmune thyroid disorders and connective tissues diseases (2), but this further re port, the first
REFERENCES 1. Sakata S., Fuwa Y., Goshima E., Nakamura S., Yamakita N., Maeda M., Miura K. A case of Graves' disease associated with polymyositis. J. Endocrinol. Invest. 12837, 1989. 2. Pinchera A., Fenzi G.F., Mariotti S. Autoimmunita endocrina. In: Dammacco F. (Ed.): Immunologia in Medicina. Edi-Hermes, Milano, 1989, p. 803.
Fig. 3 - Deltoid museIe: mus eIe fibers invaded with macrophages, inflammatory cells in the interstitium and endomysial fibrosis are consistent with a polimyositic condition. (EE x 175 )
950
LETTER TO THE EDITOR
A case of dermatomyositis associated with hypothyroidism and hypoparathyroidism after surgery tor Graves' disease Dear sir, We read with interest the article by Sakata and colleagues about a case of Graves' disease associated with polymyositis (1). They emphasize the uncommon association of the two diseases and hypothesize a broad deterioration of immune function of the patient, rather than a common underlying mechanism. We also have observed, in 1987, a 47-year-old IMJITlan, referred to us for museie weakness and diffuse edema. No family history for autoimmune thyroid disease nor connective tissues disease was evident. Her past hystory was as follow: in 1969 she was diagnosed as hyperthyroid with mild exophthalmos and large diffuse goiter and was treated with methimazole; in 1978 for the recurrence of hyperthyroidism she underwent subtotal thyroidectomy with pathologie diagnosis of Graves' disease (Fig. 1). In May 1987 she was referred to our department for weakness of proximal museies, more evident at shoulders and
arms, associated with liIac rash on the upper eyelids, periorbital edema and ulcerative stomatitis. Concentrations of T3 and T4 were in the normal range, 123 ng/dl and 6.1 J.lQ/dl respectively, whereas TSH was 8.9 IlU/ml (normal range 0.6-4 llU/ml). Antithyroglobulin antibodies were 1: 160 (Wellcome TGHA) whereas antithyroid microsomal antibodies were in the normal range. Calcium and phosphorus blood levels were 6.9 mg/dl (normal range 8.7-10.2 mg/dl) and 5.3 mg/dl (normal range 2.5-4.9 mg/dl) respectively. Elevated concentrations of CPK (1132 lU/I) and LDH (1120 lU/I) were found. After the normalization of thyroid function with L-T4 and correction of blood values of calcium and phosphorus with calcitriol and oral calcium supplementation, CPK and LDH were immodified and weakness was persistent. Electromyographic interference pattern suggested primary disease of museies (Fig.2). Pathological findings of deltoid biopsy -necrosis of muscular fibers associated with
Fig. 1 - Thyroid: flatten follicles with tall epithelium and scalloped colloid content due to epithelial resorption are typical aspects 01 Graves' disease (EE. x 175)
949
M. Zingrillo, M. Errico, P. Simone, et a/.
in Caucasian, of association between dermat01lyositis and Graves' disease, suggest a new consideration of the question.
M. Zingrillo *, M. Errico *, P. Simone **, C. Bosman ***, and S. Fusilli *** Departments of Internal Medicine (*), Neurophysiology (**) and Pathology (***), Ospedale Generale Regionale della Fondazione "Casa Sollievo della Sofferenza· San Giovanni Rotondo, Foggia, Italy
Fig. 2 - Electromyographic interference pattern at minimal contraction with incremented motor unit potentials, small in amplitude and short in duration. (Quadriceps)
Iymphocyte infiltration of interstitium- confirmed the diagnosis of dermatomyositis (Fig.3). Oral treatment with prednisone (25 mg b.i.d.) improved muscle strenght and normalized serum enzymes in two months. At the present the patient needs a 7.5 mg daily prednisone maintenance therapy: she has anormal muscle strenght, with normal serum values of LOH and CPK, whereas there is a persistent liIac rash of the upper eyelids. No clear association was observed between autoimmune thyroid disorders and connective tissues diseases (2), but this further re port, the first
REFERENCES 1. Sakata S., Fuwa Y., Goshima E., Nakamura S., Yamakita N., Maeda M., Miura K. A case of Graves' disease associated with polymyositis. J. Endocrinol. Invest. 12837, 1989. 2. Pinchera A., Fenzi G.F., Mariotti S. Autoimmunita endocrina. In: Dammacco F. (Ed.): Immunologia in Medicina. Edi-Hermes, Milano, 1989, p. 803.
Fig. 3 - Deltoid museIe: mus eIe fibers invaded with macrophages, inflammatory cells in the interstitium and endomysial fibrosis are consistent with a polimyositic condition. (EE x 175 )
950
