Alopecia areata in a patient with candidiasis-endocrinopathy syndrome: unsuccessful treatment trial with diphenylcyclopropenone

The association of chronic mucocutaneous candidiasis with endocrine dysfunction (candidiasis-endocrinopathy syndrome, CES) is a complex immune disorder, in which autoimmunity is found besides selective impairment of cellular immunity. We report a case of CES associated with alopecia areata. The histology of a scalp biopsy demonstrated minor inflammation with profound atrophy of the hair follicles and sclerotic whorls in the region of the hair papillae. A treatment trial with topical immunotherapy using diphenylcyclopropenone was unsuccessful, which might be explained by both long-standing alopecia areata and the underlying immune deficiency with an impaired delayed hypersensitivity reaction. Furthermore, the patient presented with agenesis of the spleen. Atrophy of the spleen in patients suffering from CES has formerly been described in the literature, but not asplenia. Its significance in the setting of the syndrome is discussed.

Four patients with polyendocrinopathy with associated pituitary hormone deficiency

Four cases of polyglandular endocrine disorders associated with pituitary hormone secretion failure are reported. Three of them had both insulin dependent diabetes mellitus (IDDM) and Hashimoto's disease. Each of these patients (cases 1-3) showed isolated deficiency of ACTH, TSH or gonadotropin, respectively. Another patient (case 4) had both Hashimoto's disease and isolated ACTH deficiency. Anti-pituitary antibody to AtT-20 cells was detected in case 1. Serum gamma-globulins from patients 1 and 4 attenuated corticotropin releasing hormone-induced ACTH release in monolayer cultured rat anterior pituitary cells. Gamma-globulins from patients 1 and 2 decreased baseline TSH release but stimulated baseline prolactin release in pituitary cell cultures. It is possible that pituitary hormone deficiency in these patients may be caused by autoimmune disorders.

The occurrence of polyglandular autoimmune syndrome type III associated with coeliac disease in patients with sarcoidosis

OBJECTIVES

To study whether an association between polyglandular autoimmune (PGA) syndrome type III [including autoimmune thyroid disease (ATD) and insulin-dependent diabetes mellitus (IDDM)], coeliac disease and sarcoidosis, exists.

DESIGN

In patients with documented sarcoidosis, the presence of the disease constellation of ATD, IDDM and coeliac disease was examined.

SETTING

The patients were recruited at the Department of Pulmonary Medicine, and the study was conducted at the Department of Endocrinology, Lund University Clinics, General Hospital, Malmö, Sweden.

SUBJECTS

Of all patients (n = 89) with documented sarcoidosis attending the Department of Pulmonary Medicine between January 1980 and December 1991, 78 patients (44 males, 34 females: median age at the time of the study 48 years, range 22-81 years: median observation time since the diagnosis of sarcoidosis 120 months, range 1-468 months) were examined in the present study.

RESULTS

Amongst the 78 patients with documented sarcoidosis, one female patient was found with PGA syndrome type III, coeliac disease and sarcoidosis.

CONCLUSIONS

This present patient further indicates the existence of an association between polyglandular autoimmune (PGA) syndrome type III, coeliac disease and sarcoidosis. To determine whether this disease constellation might constitute a new syndrome, further studies on larger groups of patients with sarcoidosis are demanded.

[Combined endocrine autoimmune syndrome--incidence, forms of manifestation and clinical significance]

In a retrospective case finding study we collected data from patients with polyglandular autoimmune syndrome type II (PGAS Type II) who had been treated in our endocrine outpatient clinic between 1975 and 1989. 31 adult patients (25 females and 6 males) fulfilled the criteria for PGAS Type II (association of autoimmune endocrine disease with at least one other--usually endocrine--autoimmune disease or autoantibodies against another organ). Among these patients, 18 had hypothyroidism due to autoimmune thyroiditis, 8 were hyperthyroid (Graves' disease), and 4 had silent autoimmune thyroiditis (without thyroid dysfunction). Insulin dependent (type I) diabetes mellitus (IDDM) was seen in 11, Addison's disease in 7, primary hypogonadism in 5, vitiligo in 6 and pernicious anemia in 5 cases. The presence of antiparietal cell antibodies was demonstrated in 21 of 30 investigated patients. These patients also showed other evidence of autoimmune gastritis, such as increased gastrin (in 10 out of 13), diminished vitamin B12 levels (6 out of 13), atrophic gastritis (9 out of 9), pernicious anemia (6 out of 30) and funicular myelosis (2 out of 30).

CONCLUSION

The most common endocrine diseases in our patient group were autoimmune thyroid diseases (97%) followed by IDDM (35%) and Addison's disease (23%). A high percentage (70%) of our subjects had elevated titers of antiparietal cell antibodies. Polyglandular autoimmune syndrome must be suspected in all patients with autoimmune endocrine disease, especially in the presence of relatives suffering from PGAS. Patients at risk should be screened regularly by measuring thyrotropin (ultrasensitive assay), fasting blood glucose levels, and by checking red blood count and antiparietal cell antibodies.(ABSTRACT TRUNCATED AT 250 WORDS)

T-cell large granular lymphocytic leukemia and pure red cell aplasia in a patient with type I autoimmune polyendocrinopathy: response to immunosuppressive therapy

Clonal proliferations of large granular lymphocytes (LGLs) of T-cell origin characterize T-cell LGL leukemia. This disorder has been described in association with rheumatoid arthritis and other autoimmune phenomena. The presence of endocrinologic abnormalities in patients with T-cell LGL leukemia has not been previously reported, nor has T-cell LGL leukemia been described in patients with endocrinologic abnormalities. Herein we describe a young woman with type I autoimmune polyendocrinopathy, in whom pure red cell aplasia developed in association with clonal proliferation of LGLs. Immunosuppressive therapy with cyclophosphamide resulted in remission of pure red cell aplasia, transient improvement in hypocalcemia, and disappearance of the LGL clone. Clonal proliferation of LGLs may be associated with autoimmune endocrinopathies. Clinicians who are responsible for the care of such patients should be aware of this possible association.

[Autoimmune ovarian inflammation]

Autoimmune oophoritis, which is frequently associated with other autoimmune diseases including other endocrine organs (autoimmune polyglandular syndrome), may precede the associated diseases by several years. The clinical significance of this association has increasingly been emphasized. And, this should facilitate early diagnosis since early initiation of replacement therapy can be life-saving. Thus, a review article on this subject apparently is of interest not only for gynaecologists but for internists, general practitioners and others.

[Case report of sister with Duane's syndrome and PGA, or myasthenia gravis]

We report a case of polyglandular autoimmune syndrome (PGA) complicated by Duane's syndrome. The patient was 44-year-old female with marked limitation of abduction in the left eye, lethargy, nonhomogeneous facial pigmentation, goiter, and oligomenorrhea. A diagnosis of chronic thyroiditis was first made to explain the patient's symptoms. Laboratory examinations were performed. Plasma ACTH level was high and plasma cortisol was low, and there was no response to the ACTH stimulation test. The presence of primary adrenocortical deficiency was confirmed. Moreover, primary gonadal failure was also present, and the diagnosis of PGA type II was made. The patient's elder sister had myasthenia gravis which is a condition known to occur with PGA type II. Therefore, the sister was also suspected to have PGA type II, as the syndrome can occur in family members. However, since she had been receiving large doses of steroids for her myasthenia gravis, laboratory findings were inconclusive. Duane's syndrome, which is characterized by congenital oculomotor disturbance, was also seen in the sister. It is still unknown whether the familial occurrence of Duane's syndrome has a genetic basis. There have been reports of congenital disorders occurring in combination with autoimmune diseases. Further investigation into the relationship between congenital anomalies and autoimmune diseases is necessary.

Slow metabolic deterioration towards diabetes in islet cell antibody positive patients with autoimmune polyendocrine disease

We studied metabolic progression to IDDM in a cohort of adults who are ICA-positive and have associated autoimmune endocrine disease or circulating organ-specific autoantibodies (the Polyendocrine Study). Of the 186 individuals recruited 27 developed overt diabetes after a median follow-up of 4.5 years (range 0.4-12). Of these, eight patients did not require insulin treatment until at least 6 months after clinical diagnosis, with an interval of 1.8 years (1.2-5.7). An IVGTT was performed in 38 subjects and 23 had sequential studies. Of the initial 38 subjects six developed diabetes and only three showed a loss of FPIR to glucose (below the first percentile of a normal control group) before clinical onset of the disease. An additional three subjects showed a loss of the FPIR, and all still have normal glucose tolerance after median follow-up of 28 months (22-95). A "whole" or "mixed" pattern of islet cell staining was found in five of the six patients who developed diabetes and antibodies against an islet 37 k-antigen were detectable in four patients, all of whom required insulin soon after diagnosis. A beta-cell "selective" ICA staining pattern was seen in 14 of 17 subjects who did not develop diabetes and the "mixed" pattern in only three. None of this group had detectable 37 k-antibodies. We conclude that metabolic deterioration is slow in polyendocrine patients, and that the IVGTT has less prognostic significance in this group than in first degree relatives of patients with IDDM.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic active hepatitis in the type I polyglandular autoimmune syndrome

Type I polyglandular autoimmune syndrome is characterized by the triad of hypoparathyroidism, Addison's disease and chronic mucocutaneous candidiasis. Chronic active hepatitis has been associated with this syndrome but its incidence and severity have not been well documented. We describe a sibship of two patients with type I polyglandular autoimmune syndrome who presented with autoimmune chronic active hepatitis. The first patient presented to us with advanced disease and died despite an emergent liver transplant, while the second patient responded to steroids. Autoimmune chronic active hepatitis, a major cause of mortality in this syndrome, can present without symptoms or physical signs of liver disease. We suggest periodic screening of liver enzymes in subjects with this syndrome.

Diffuse alveolar hemorrhage due to antibasement membrane antibody disease appearing with a polyglandular autoimmune syndrome

We describe a patient with type 3-C polyglandular autoimmune syndrome who presented with diffuse alveolar hemorrhage and normal renal function. The diagnosis of antibasement membrane antibody disease was established by immunofluorescent staining of transbronchial biopsy specimens. We suggest the incorporation of antibasement membrane antibody disease into the spectrum of diseases that define the polyglandular autoimmune syndromes.

Autoimmune polyglandular failure associated with malabsorption and gastric carcinoid tumour

A 21-year-old female with autoimmune polyglandular failure (APG) manifested by insulin-dependent diabetes mellitus (IDDM), hypothyroidism and pernicious anaemia developed severe malabsorption due to exocrine pancreatic insufficiency. Supplemental pancreatic enzymes resulted in marked improvement of steatorrhea. There was also an incidental finding of gastric carcinoid tumour. We identified only 13 other patients in our institution with either type 2 or 3 APG, one of which had significant steatorrhoea. Another patient with IDDM, hypothyroidism and pernicious anaemia had an asymptomatic gastric carcinoid tumour. The possible mechanisms for malabsorption in APG are discussed.

Reversible hyperkinesia in a patient with autoimmune polyglandular syndrome type I

Autoimmune polyglandular syndrome is characterized by a failure of multiple endocrine organs and the presence of circulating organ-specific autoantibodies targeted against the failing organs. Here we describe a patient with autoimmune polyglandular syndrome type I with the endocrine manifestations of hypoparathyroidism, adrenocortical insufficiency, and insulin-dependent diabetes mellitus. Long-standing hypoparathyroidism led to extensive calcification of the basal ganglia which resulted in the clinical presentation of an extrapyramidal movement disorder (choreoathetotic and hemiballistic hyperkinesia of the left extremities). Interestingly, parallel to rehydration and the initiation of cortisol replacement therapy a complete reversion of the hyperkinetic signs was achieved. This case shows a rare multiendocrine organ failure with complex metabolic interactions resulting in marked neurological signs. Furthermore, this case demonstrates for the first time that a hyperkinetic syndrome--most likely due to hypoparathyroidism-induced basal ganglia calcification--can be reversed solely by adequate treatment of the concomitant endocrine failures.

Dental manifestations of autoimmune hypoparathyroidism

The histopathologic changes in three permanent molars from two siblings with autoimmune hypoparathyroidism as part of candida endocrinopathy syndrome are described. These teeth developed after the diagnosis of hypoparathyroidism and while each subject was receiving vitamin D and calcium supplementation. The pathogenesis of the dental changes is unknown, but it is possible that parathormone may directly influence tooth development independent of its role in calcium and phosphorous homeostasis.

Polyglandular autoimmune syndrome type III associated with coeliac disease and sarcoidosis

A female patient demonstrating a previously not reported constellation of polyglandular autoimmune syndrome type III (including autoimmune thyroiditis, Graves' ophthalmopathy, insulin-dependent diabetes mellitus and vitiligo), coeliac disease and sarcoidosis is described. This may be a random association but might also indicate a common immunological and/or genetic disturbance.

[A case of autoimmune polyglandular deficiency associated with progressive myopathy]

We reported a 29-year-old woman with autoimmune polyglandular deficiency (APGD) type 1 accompanied by progressive myopathy. She had chronic mucocutaneous candidiasis at the age of 3, primary hypothyroidism at 12, insulin dependent diabetes mellitus at 27, and adrenal insufficiency at 29 years. Laboratory findings indicated an underlying defect in cell mediated immunity. Meanwhile, she had progressive muscular weakness and wasting at the age of 22 years which brought her to our hospital at 29 years. On admission, she could not walk without support and raise her arms up to the level of shoulders. Moderate to severe muscle wasting as well as weakness was observed in the limb girdle muscles. Serum CK levels were mildly elevated. A needle EMG examination disclosed short-duration and low-amplitude polyphasic motor units at voluntary contraction with few fibrillations and positive sharp waves at rest. On muscle CT examination, decreased density was detected in the neck extensor, paravertebral, rectus femoris, vastus intermedius, biceps femoris and soleus muscles. Muscle biopsy was performed on the biceps brachii and rectus femoris muscles. The former showed chronic dystrophic changes including marked variation in fiber size with necrotic and degenerating process, interstitial fibrosis, and lobulated and right fibers. In the latter, in addition to variation in fiber size with some necrotic fibers and occasional multi-core structures, nemaline bodies were seen in approximately 30% of muscle fibers. The progressive muscle involvement in our patient might be induced from 1) endocrine abnormality, 2) autoimmune disorder, and/or 3) coincidental complication of nemaline myopathy or limb girdle muscular dystrophy. The clinical and laboratory examinations, however, failed to support any of them.(ABSTRACT TRUNCATED AT 250 WORDS)

[Addison's disease in the framework of poly-glandular autoimmune syndromes: 3 case reports]

Case reports of three patients with idiopathic Addison's disease combined with other associated autoimmune endocrine and non-endocrine disorders are presented. In the first patient, a young man with a long-standing history of mucocutaneous candidiasis, latent Addison's disease was discovered by diagnostic screening tests. In the two other patients, women aged 39 and 20 respectively, overt Addison's disease combined with primary hypothyroidism was diagnosed. One of them also had a pre-existing ovarian failure. The polyglandular autoimmune syndromes with Addison's disease are classified into two different subtypes, on the basis of characteristic patterns of disease combinations and on different modes of inheritance. Patients with autoimmune Addison's disease are at relatively high risk for other endocrine disorders or non-endocrine autoimmune diseases. Therefore, these patients--and in some instances also their relatives--need lifelong supervision and advice to ensure timely recognition of any associated diseases.

Frequent occurrence of asplenism and cholelithiasis in patients with autoimmune polyglandular disease type I

PURPOSE

This study assesses the occurrence of asplenism and gallstones in patients with autoimmune polyglandular disease type I (APG I).

PATIENTS AND METHODS

Nine patients with APG I (ages 14 to 48) were studied at the National Institutes of Health. Each patient received endocrine testing, a careful examination of his or her peripheral blood smear, lymphocyte immunophenotyping, a liver-spleen scan, and either an upper abdominal ultrasound or a computer-assisted tomogram to evaluate the spleen and gallbladder.

RESULTS

We documented asplenism in four patients and cholelithiasis in four patients, with two patients having both conditions. The patients with asplenism had Howell-Jolly bodies on peripheral blood smears, lack of splenic uptake by liver-spleen scan, and absent spleens by abdominal computed tomographic scan or ultrasound evaluation. The clinical presentation of the patients with cholelithiasis ranged from acute symptoms requiring surgery to asymptomatic gallstones. Lymphocyte immunophenotyping did not reveal consistent changes in either B- or T-cell subpopulations in the patients studied.

CONCLUSION

Asplenism and gallstones occur frequently in patients with APG I. In addition to careful examination of the peripheral blood smear for Howell-Jolly bodies to screen for asplenism, we recommend an abdominal ultrasound to detect asplenism and/or gallstones in all patients with APG I. Appropriate immunizations and antibiotic coverage may be helpful in those patients with absent spleens.

Antisperm antibodies in the polyglandular autoimmune (PGA) syndrome type I: response to cyclical steroid therapy

OBJECTIVE

To determine if cyclical intermediate dose steroid therapy could improve semen parameters in an infertile man with sperm autoimmunity associated with the polyglandular autoimmune (PGA) syndrome.

DESIGN

Sperm agglutination studies performed before, during and after three courses of cyclical intermediate dose prednisolone therapy.

PATIENT

A twenty-six-year old man with polyglandular autoimmune syndrome, consisting of Addison's disease, hypoparathyroidism, chronic mucocutaneous candidiasis and alopecia totalis, presented with infertility. He had normal endocrine testicular function but severe exocrine failure evidenced by a low sperm count (4.5 x 10(6)/ml), zero motility and universal sperm agglutination.

MEASUREMENTS

Sperm agglutination tests.

RESULTS

At presentation the gelatin agglutination test (GAT) was strongly positive in serum (1/1204) and seminal plasma (1/64) as was the tray agglutination test (TAT) (1/32). The patient's wife had a regular menstrual cycle with normal luteal phase progesterone levels. Following three courses of cyclical prednisolone (20 mg twice daily on days 1-10 of wife's cycle, and 5 mg on days 11 and 12), sperm quantity and motility improved considerably (12 x 10(6)/ml, 40% respectively) and sperm agglutination tests became negative. After a fourth course of therapy the patient's wife became pregnant. Three months post-treatment sperm motility was very low again and agglutinating activity in serum and seminal plasma increased.

CONCLUSIONS

This is the first case of male infertility due to sperm autoimmunity in association with the PGA syndrome type 1. The immunosuppressive action of cyclical intermediate dose steroid therapy led to a significant quantitative and qualitative improvement in semen parameters.

[Auto-immune polyglandular syndrome in an adult with chronic active hepatitis]

We present a case report with IgA deficiency, pernicious anemia, chronic active hepatitis, insulino-dependent diabetes mellitus and hypogonadism. A diagnosis of Polyglandular Auto-immune Syndrome was done and we discuss the difficulty in including this particular case in any of the types of the Neufeld's classification of Polyglandular Auto-immune Disease.