Thyroid autoimmunity may represent a predisposition for the development of fibromyalgia?

The relationship between migraine and Hashimoto's thyroiditis: a single center experience

Introduction

Hashimoto's thyroiditis (HT) is nowadays the leading cause of hypothyroidism with high and still growing prevalence in general population, but there are lack of data regarding migraine and HT connection.

Methods

The aim of this study was to analyze the prevalence of HT in migraine and to check if the presence of HT influence migraine severity. This retrospective observational cohort study involved consecutive migraine patients consulted at our Headache Center with diagnosis of migraine. Electronic charts of patients were collected, including data on migraine type, presence of cranial autonomic symptoms (CAS), monthly migraine days (MMD), medication overuse headache (MOH), and the presence of comorbidities including HT.

Results

We found 928 eligible migraine patients, 88.7% were women. The mean age was 36.09 years. 592 (63.8%) were diagnosed with episodic migraine (EM), the rest with chronic migraine (CM). MOH was additionally diagnosed in 258 (27.8%) patients. The duration of migraine was 15.99 years. 106 (11.4%) was diagnosed with HT, 148 (15.9%) with hypothyroidisms, while 84 (9.05%) had both diagnosis. Migraine patients with HT were significantly older (p < 0.001), were more frequently women (p = 0.0017), had longer duration of migraine (p < 0.001), had CAS more frequently (<0.001), developed CM (p = 0.0169) and depression more frequently (p = 0.0047) and had more MMD (p = 0.0195) as compared with individuals without HT. According to our multivariate logistic model, the presence CM was positively associated with HT (OR 1.76, p = 0.045), MOH and duration of migraine, while negatively associated with aura.

Conclusion

HT is very prevalent in migraine patients. This is the first study considering migraine and HT to be comorbid and suggesting that HT may influence the course of migraine causing its chronification.

Effect of Steroids on Patients With Fibromyalgia/Chromic Widespread Pain: An Observational Study

OBJECTIVE

Fibromyalgia causes widespread chronic pain. Pain management and treating underlying conditions are of utmost importance. Recent studies found an association of thyroid autoimmunity with fibromyalgia. Pain management of patients with anti-thyroid peroxidase antibody (anti-TPO Ab) positive was studied sparsely. To determine the effect of steroid (deflazacort) on pain management using numerical rating scale (NRS) pain score at baseline and at 3-month follow-up.

STUDY DESIGN

A retrospective observational study was undertaken, recruiting patients diagnosed with fibromyalgia as per 2010 American College of Rheumatology guidelines and treated with the steroid, deflazacort 12 mg. Patients with missing details were excluded. Patients were categorized into negative, positive, and strongly positive anti-TPO Ab groups. Baseline and follow-up (3 months) pain score was compared across the groups. Reduction in pain was considered as a primary outcome variable.

RESULTS

The study included 128 participants with 98 (76.6%) females and 30 (23.4%) males. The age of the study population was 48±13.29 years. The proportion of hyper, hypo, and euthyroid was 10 (7.81%), 42 (32.81%), and 76 (59.38%), respectively. The proportion of participants with negative, positive, and strongly positive anti-TPO Ab levels was 41 (32.03)%, 50 (39.06%), and 37 (28.91%), respectively. Baseline pain score was 7.3±1.32 and 3-month follow-up was 4.7±2.46. Steroid response was found in 66 (51.6%). Negative and positive anti-TPO Ab had a 1-point reduction in pain score from baseline, p-value <0.001. The strongly positive group had 5 points reduction, p-value<0.05.

CONCLUSION

Fibromyalgia patients with thyroid autoimmunity responded well to short courses of steroids. Greater pain relief was observed among those who are strongly positive anti-TPO Ab group.

A retrospective analysis of the prevalence and impact of associated comorbidities on fibromyalgia outcomes in a tertiary care center

Background

This retrospective study was designed to analyze the prevalence and impact of associated comorbidities on fibromyalgia (FM) outcomes (functionality, pain, depression levels) for patients who participated in an intensive multicomponent clinical program in a tertiary care center.

Methods

Participants included a sample of 411 patients diagnosed with FM at a large tertiary medical center using the 2016 ACR criteria. Patients completed an intensive 2-day cognitive behavioral treatment (CBT) program, filled out the Fibromyalgia Impact Questionnaire Revised (FIQR), the Center for Epidemiologic Studies Depression Scale (CES-D), the Pain Catastrophizing Scale (PCS), and were followed for 6 months after treatment completion. T-tests were performed to analyze differences between the presence or absence of select comorbidities for the three outcomes at follow-up. Statistically significant comorbidities (p < 0.05) were used as predictors in multivariable logistic regression models.

Results

The FM associated comorbidities in this cohort that had significant impact on the measured outcome domains after treatment program completed were Obesity (FIQR p = 0.024), Hypothyroidism (CES-D p = 0.023, PCS p = 0.035), Gastroesophageal reflux disease GERD (PCS p < 0.001), Osteoarthritis (CES-D p = 0.047). Interestingly, Headache, the most frequent FM associated comorbidity in this cohort (33.6%), did not have a significant impact on the outcome domains at follow-up. Obesity (18.2%) was the only FM associated comorbidity significantly impacting all three outcome domains at follow-up.

Conclusion

The present study suggests that addressing obesity may significantly impact outcomes in FM patients.

Hashimoto's thyroiditis and coexisting disorders in correlation with HLA status-an overview

Hashimoto's thyroiditis (HT), also known as chronic lymphocytic thyroiditis, is a frequent disorder of the thyroid gland caused by autoimmune-trigged lymphocytic infiltration and destruction of the thyroid gland. With the progressive destruction of the organ, the thyroid gland shrinks in size, thus commonly leading to hypothyroidism. Therapy of HT is mainly focused on managing the thyroid dysfunction by oral substitution of L‑thyroxine. However, patients with HT often complain about a broad spectrum of symptoms, with some of them hardly explained by HT itself. Several other disorders are known to be associated with HT. The etiology of HT seems to be multifactorial, including environmental influences such as iodine supply, infections, and stress as triggers of immune modulation. In addition, also a genetic background based on changes of the human leukocyte antigen (HLA) status seems to be evident. The paper will provide an overview of diseases related to HT, including their correlation to certain HLA patterns. This presentation should give a broader view on HT-related disorders and facilitate detailed examination and management of patients with HT.

Diagnostic Challenges and Management of Fibromyalgia

The World Health Organization regards chronic pain to be a public health concern. In clinical medicine, fibromyalgia (FM) is the most prevalent chronic widespread pain disease. In terms of impairment, consumption of health and social resources, and impact on primary and speciality care systems, it has reached worrisome proportions. This disease is frequently managed by primary care providers. Because of its intricacy, fibromyalgia diagnosis and treatment can be difficult. Fibromyalgia is a controversial condition. It might appear ill-defined in comparison to other pain conditions, with no clear knowledge of pathophysiology and hence no particular targeted therapy. This invariably sparks debates and challenges. There is no obvious cut-off point that distinguishes FM from non-FM. The diagnosis of fibromyalgia has been complicated by several factors, including patients' health-seeking behaviour, symptom identification, and physician labelling of the disease. Fibromyalgia is currently considered a centralized pain condition, according to research that has improved our understanding of its etiopathology. A multidisciplinary strategy combining pharmacological and non-pharmacological therapies based on a biopsychosocial paradigm can result in effective therapy. Cultural and psychosocial variables appear to be a recent development in fibromyalgia, and they appear to have a larger influence on physician diagnosis than severe symptom levels in FM patients. Although physicians rely on FM criteria as the only way to classify FM patients in research and clinical settings, some crucial elements of the diagnostic challenge of fibromyalgia remain unsolved - invalidation, psychosocial variables, and diverse illness manifestation are some examples. Beyond the existing constructional scores, physicians' judgment gained in real communicative contexts with patients, appears to be the only dependable route for a more accurate diagnosis for fibromyalgia. We have performed an exhaustive review of the literature using the keywords "Fibromyalgia", "challenges" and "diagnosis" in PubMed and Google Scholar indexes up to September 2021. This article aims to examine the causes, diagnosis, and current treatment protocols of FM, as well as discuss some continuing debates and diagnostic challenges which physicians face in accurately diagnosing fibromyalgia.

Long-term evaluation of temporomandibular disorders in association with cytokine and autoantibody status in young women

Temporomandibular disorders (TMD) is a chronic pain disease affecting 4-60% of general population. Its suggested etiology includes mechanical overloading to related structures, psychosocial factors, and genetic vulnerability. However, its pathogenesis is yet to be fully understood, especially in cases with a higher level of pain and more associated comorbidities. Recently chronic systemic inflammation and possible autoimmunity has been indicated in several pain conditions as the underlying mechanism of chronicity but this aspect has not been rigorously investigated in TMD. This article focuses on analyzing the levels of cytokines, chemokines, autoantibodies and nonspecific inflammatory markers and comparing their levels according to pain severity and duration in 66 female TMD patients in their 20 s and investigating their association with clinical indices of TMD and comorbidities. The high pain disability group showed decreased range of jaw function and more pain on palpation of capsule areas compared to the low pain disability group. Comorbidities such as anxiety and sleep disturbance were also significantly more prevalent. The level of IL-8 and IgG were significantly higher in the high pain disability group. IL-2, -8, -13, IFN- γ, RANTES, PGE2, and thrombopoietin levels showed a significant effect on indices reflecting jaw function, generalized pain intensity, and health related quality of life. Such results imply that longer pain duration and higher pain intensity is associated with higher levels of systemic inflammation suggesting the possible role of immunologic disturbance as an underlying factor of chronic TMD pain and warranting further investigation for its consideration in diagnosis and treatment.

Persisting symptoms in patients with Hashimoto's disease despite normal thyroid hormone levels: Does thyroid autoimmunity play a role? A systematic review

OBJECTIVE

Patients with hypothyroidism due to Hashimoto's disease (HD) may experience persisting symptoms despite normal serum thyroid hormone (TH) levels. Several hypotheses have been postulated to explain these persisting symptoms. We hypothesized that thyroid autoimmunity may play a role.

DESIGN

A systematic literature review.

METHODS

A PubMed search was performed to find studies investigating the relation between the presence of thyroid autoimmunity and (persisting) symptoms. Included studies were critically appraised by the Newcastle - Ottawa Scale (NOS) and then subdivided into (A) disease-based studies, comparing biochemically euthyroid patients with HD, and euthyroid patients with non-autoimmune hypothyroidism or euthyroid benign goitre, and (B) (general) population-based studies. Due to different outcome measures among all studies, meta-analysis of data could not be performed.

RESULTS

Thirty out of 1259 articles found in the PubMed search were included in this systematic review. Five out of seven disease-based studies found an association between thyroid autoimmunity and symptoms or lower quality of life (QoL). Sixteen of 23 population-based studies found a comparable positive association. In total, the majority of included studies reported an association between thyroid autoimmunity and persisting symptoms or lower QoL in biochemically euthyroid patients.

CONCLUSION

(Thyroid) autoimmunity seems to be associated with persisting symptoms or lower QoL in biochemically euthyroid HD patients. As outcome measures differed among the included studies, we propose the use of similar outcome measures in future studies. To prove causality, a necessary next step is to design and conduct intervention studies, for example immunomodulation vs. placebo preferably in the form of a randomized controlled trial, with symptoms and QoL as main outcomes.

Fibromyalgia: Pathogenesis, Mechanisms, Diagnosis and Treatment Options Update

Fibromyalgia is a syndrome characterized by chronic and widespread musculoskeletal pain, often accompanied by other symptoms, such as fatigue, intestinal disorders and alterations in sleep and mood. It is estimated that two to eight percent of the world population is affected by fibromyalgia. From a medical point of view, this pathology still presents inexplicable aspects. It is known that fibromyalgia is caused by a central sensitization phenomenon characterized by the dysfunction of neuro-circuits, which involves the perception, transmission and processing of afferent nociceptive stimuli, with the prevalent manifestation of pain at the level of the locomotor system. In recent years, the pathogenesis of fibromyalgia has also been linked to other factors, such as inflammatory, immune, endocrine, genetic and psychosocial factors. A rheumatologist typically makes a diagnosis of fibromyalgia when the patient describes a history of pain spreading in all quadrants of the body for at least three months and when pain is caused by digital pressure in at least 11 out of 18 allogenic points, called tender points. Fibromyalgia does not involve organic damage, and several diagnostic approaches have been developed in recent years, including the analysis of genetic, epigenetic and serological biomarkers. Symptoms often begin after physical or emotional trauma, but in many cases, there appears to be no obvious trigger. Women are more prone to developing the disease than men. Unfortunately, the conventional medical therapies that target this pathology produce limited benefits. They remain largely pharmacological in nature and tend to treat the symptomatic aspects of various disorders reported by the patient. The statistics, however, highlight the fact that 90% of people with fibromyalgia also turn to complementary medicine to manage their symptoms.

Physical fatigability and muscle pain in patients with Hashimoto thyroiditis

Introduction

Hashimoto thyroiditis (HT) may lead to muscle weakness due to hypothyroid dysfunction. However, clinical experience treating patients with HT suggests that neuromuscular symptoms may develop in these patients despite long-standing euthyroidism.

Methods

In 24 euthyroid patients with HT and 25 healthy controls, physical fatigability was assessed using the arm movement test (AMT) and 6-min walk test (6MWT). Fatigability was based on calculation of linear trend (LT) reflecting dynamic performance within subsequent constant time intervals. Perception of physical fatigue and muscle pain was analyzed using fatigue (FSMC) and pain questionnaires. Obtained results were correlated with clinical, neurophysiological and lab findings.

Results

HT patients showed a negative LT in 6MWT significantly differing from stable performance in controls. LT in AMT did not differ between HT and controls. FSMC scores and pain perception revealed significantly higher levels in HT patients than in controls. Physical FSMC score was primarily influenced by pain perception (standardized regression coefficient, beta = 0.633, p = 0.002). Neither pain score nor physical fatigue score showed a correlation with LT in 6MWT nor did mood, or anti-TPO antibody titer.

Conclusion

A significant physical fatigability could be shown in euthyroid HT patients despite missing obvious neuromuscular deficits in routine testing. Further, elevated pain and fatigue perception in HT patients seem to contribute to nonspecific muscle complaints in these patients. A possible pathogenic role of thyroid autoimmunity in hidden neuromuscular involvement may be suggested.

Metabolic Dysfunction in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome Not Due to Anti-mitochondrial Antibodies

Metabolic profiling studies have recently indicated dysfunctional mitochondria in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). This includes an impaired function of pyruvate dehydrogenase complex (PDC), possibly driven by serum factor(s), which leads to inadequate adenosine triphosphate generation and excessive lactate accumulation. A reminiscent energy blockade is likely to occur in primary biliary cholangitis (PBC), caused by anti-PDC autoantibodies, as recently proposed. PBC is associated with fatigue and post-exertional malaise, also signifying ME/CFS. We herein have investigated whether ME/CFS patients have autoreactive antibodies that could interfere with mitochondrial function. We found that only 1 of 161 examined ME/CFS patients was positive for anti-PDC, while all PBC patients (15/15) presented significant IgM, IgG, and IgA anti-PDC reactivity, as previously shown. None of fibromyalgia patients (0/14), multiple sclerosis patients (0/29), and healthy blood donors (0/44) controls showed reactivities. Anti-mitochondrial autoantibodies (inner and outer membrane) were negative in ME/CFS cohort. Anti-cardiolipin antibody levels in patients did not differ significantly from healthy blood donors. In conclusion, the impaired mitochondrial/metabolic dysfunction, observed in ME/CFS, cannot be explained by presence of circulating autoantibodies against the tested mitochondrial epitopes.

Infection Elicited Autoimmunity and Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: An Explanatory Model

Myalgic encephalomyelitis (ME) often also called chronic fatigue syndrome (ME/CFS) is a common, debilitating, disease of unknown origin. Although a subject of controversy and a considerable scientific literature, we think that a solid understanding of ME/CFS pathogenesis is emerging. In this study, we compiled recent findings and placed them in the context of the clinical picture and natural history of the disease. A pattern emerged, giving rise to an explanatory model. ME/CFS often starts after or during an infection. A logical explanation is that the infection initiates an autoreactive process, which affects several functions, including brain and energy metabolism. According to our model for ME/CFS pathogenesis, patients with a genetic predisposition and dysbiosis experience a gradual development of B cell clones prone to autoreactivity. Under normal circumstances these B cell offsprings would have led to tolerance. Subsequent exogenous microbial exposition (triggering) can lead to comorbidities such as fibromyalgia, thyroid disorder, and orthostatic hypotension. A decisive infectious trigger may then lead to immunization against autoantigens involved in aerobic energy production and/or hormone receptors and ion channel proteins, producing postexertional malaise and ME/CFS, affecting both muscle and brain. In principle, cloning and sequencing of immunoglobulin variable domains could reveal the evolution of pathogenic clones. Although evidence consistent with the model accumulated in recent years, there are several missing links in it. Hopefully, the hypothesis generates testable propositions that can augment the understanding of the pathogenesis of ME/CFS.

A narrative review on the difficulties associated with fibromyalgia diagnosis

Fibromyalgia presents a clinical enigma as its pathophysiology is not well understood and its symptoms are nonspecific and overlap with many disorders, making its diagnosis a challenge for clinicians and researchers. Efforts have been made to develop a set of diagnostic criteria for this disorder. However, these criteria rely heavily on expert clinician opinion and produce a large heterogeneity within the diagnosed population. With no present specific technique reflecting the underlying pathophysiology of fibromyalgia, a definitive diagnosis of fibromyalgia remains elusive. This review discusses some problems and challenges associated with fibromyalgia diagnosis and presents some novel findings on the pathophysiological nature of fibromyalgia.

Fibromyalgia in patients with thyroid autoimmunity: prevalence and relationship with disease activity

Fibromyalgia (FM) is a syndrome characterised by chronic musculoskeletal pain, tenderness and other somatic symptoms. The prevalence of FM is approximately 2-7% in the general global population and is 30-40% in the population of Hashimoto thyroiditis (HT) with a structural pathology. In 2010, new classification criteria for FM were proposed, as an alternative to the American College of Rheumatology (ACR) 1990 criteria. The objectives of the present study were to identify the prevalence of FM in the HT population and evaluate the associated features by using the new diagnostic criteria. The study group included 79 consecutive patients with HT with or without FM. Recorded data included age, gender, laboratory parameters, sociodemographic features and clinical findings, presence of somatic symptoms, and disease activity indices. The prevalence of FM in patients with HT was 62%. Antithyroid peroxidase antibody (TPOAb) positivity, duration of disease, and waist circumference were significantly associated with concomitant FM (p = 0.000, p = 0.000, and p = 0.015, respectively). A strong positive correlation was noted between fibromyalgia impact questionnaire (FIQ) scores and disease duration, age, values of thyroid-stimulating hormone (TSH) and TPOAb, waist circumference and marital status. TPOAb was found to be independent of body mass index, age and TSH. Concomitant FM is a common clinical problem in HT and its recognition is important for the optimal management of the disease. The new set of diagnostic criteria for FM reinforces this situation. Consideration of the FM component in the management of HT increases the likelihood of treatment success.

Rheumatic symptoms in autoimmune thyroiditis

Autoimmune thyroiditis (ATD) is generally regarded as a classic example of single organ autoimmunity with a high association with endocrine thyroid disorders. However, it is closely associated with several autoimmune diseases including rheumatologic syndromes and has long been known to have several rheumatic manifestations particularly in association with hypothyroidism. More recently, it has also been implicated in rheumatologic syndromes in the absence of hypothyroidism or subclinical hypothyroidism. There is also an emerging body of evidence that ATD is highly linked to chronic generalized pain syndromes including fibromyalgia. This review examines the rheumatic symptoms of ATD described in the current literature and discusses the clinical relevance of ATD in general rheumatology.

Assessing the prevalence of autoimmune, endocrine, gynecologic, and psychiatric comorbidities in an ethnically diverse cohort of female fibromyalgia patients: does the time from hysterectomy provide a clue?

Background

This retrospective chart review investigated differences in the prevalence of medical comorbidity between women with fibromyalgia (FM) (n=219) and a control group women with chronic pain (CP) without FM (n=116). The specific aims were to compare the prevalence of autoimmune, psychiatric, endocrine, gynecologic pathology, the relationship between timing of gynecologic surgery, and pain onset. We additionally sought to compare the number of comorbidities in an ethnically diverse cohort.

Methods

This was a retrospective chart review of patients seen in FM or CP clinics at an academic medical center in 2009–2010.

Results

Logistic regression modeling found that gynecologic, endocrine, and autoimmune diagnoses were independently associated with a diagnosis of FM. Detailed analyses showed that thyroid disease (P<0.01) and gynecologic surgery (P<0.05) were significantly more common in FM. Women with FM were more likely to have multiple autoimmune, endocrine, gynecologic, or psychiatric pathologies. A relationship was observed between the timing of gynecologic surgery and pain onset in FM, with more surgeries observed in the years just prior to pain onset or in the year after pain onset. A similar pattern was not found in the control group.

Conclusion

This study demonstrates that autoimmune, endocrine, and gynecologic pathologies occur more commonly in women with FM than in those with CP, which is consistent with findings in less ethnically diverse samples. Moreover, a relationship was found between timing of pain onset and gynecologic surgery. A larger prospective study of the relationship between gynecologic surgery and pain onset in FM is warranted.

Longitudinal medical records as a complement to routine drug safety signal analysis

Purpose

To explore whether and how longitudinal medical records could be used as a source of reference in the early phases of signal detection and analysis of novel adverse drug reactions (ADRs) in a global pharmacovigilance database.

Methods

Drug and ADR combinations from the routine signal detection process of VigiBase® in 2011 were matched to combinations in The Health Improvement Network (THIN). The number and type of drugs and ADRs from the data sets were investigated. For unlabelled combinations, graphical display of longitudinal event patterns (chronographs) in THIN was inspected to determine if the pattern supported the VigiBase combination.

Results

Of 458 combinations in the VigiBase data set, 190 matched to corresponding combinations in THIN (after excluding drugs with less than 100 prescriptions in THIN). Eighteen percent of the VigiBase and 9% of the matched THIN combinations referred to new drugs reported with serious reactions. Of the 112 unlabelled combinations matched to THIN, 52 chronographs were inconclusive mainly because of lack of data; 34 lacked any outstanding pattern around the time of prescription; 24 had an elevation of events in the pre‐prescription period, hence weakened the suspicion of a drug relationship; two had an elevated pattern of events exclusively in the post‐prescription period that, after review of individual patient histories, did not support an association.

Conclusions

Longitudinal medical records were useful in understanding the clinical context around a drug and suspected ADR combination and the probability of a causal relationship. A drawback was the paucity of data for newly marketed drugs with serious reactions. © 2015 The Authors. Pharmacoepidemiology and Drug Safety published by John Wiley & Sons, Ltd.

Vestibular disorders in euthyroid patients with Hashimoto's thyroiditis: role of thyroid autoimmunity

INTRODUCTION

A relationship between vestibular disorders and thyroid autoimmunity independently from thyroid function has been postulated.

AIM

To shed more light on the actual relationship between vestibular lesions and Hashimoto's thyroiditis (HT) regardless of thyroid function.

METHODS

Forty-seven patients with HT (89·4% F; aged 48·3 ± 12·7 years), 21 with multinodular goitre (MNG; 57·1% F; 54·1 ± 9·8 years) and 30 healthy volunteers (56·7% F; 50·7 ± 13·9 years) were enrolled. Inclusion criteria were the presence of normal thyroid function tests and no clinical history of vestibular dysfunction. Each subject was submitted to complete vestibular evaluation [Caloric Test, Vestibular evoked myogenic potentials (VEMPs), Head Shaking Test (HST)].

RESULTS

52·2% of HT patients showed an alteration of VEMPs and 44·7% of caloric test (P < 0·0001 for both). None of the MNG patients showed any vestibular alteration, while one healthy control showed an altered caloric test. A correlation was found between vestibular alterations of HT patients and the degree of serum TPOAb level, not affected by age and serum TSH value. By logistic regression analysis, the absence of thyroid autoimmunity significantly reduced the risk of vestibular alterations: HR 0.19 (95%CI: 0·003-0.25, P = 0·0004) for caloric test; HR 0·07 (95%CI: 0·02-0·425, P < 0·0001) for VEMPs; and HR 0·22 (95%CI: 0·06-0·7, P = 0·01) for HST.

CONCLUSION

In euthyroid HT patients, a significant relationship between subclinical vestibular damage and the degree of TPOAb titre was documented. This finding suggests that circulating antithyroid autoantibodies may represent a risk factor for developing vestibular dysfunction. An accurate vestibular evaluation of HT patients with or without symptoms is therefore warranted.

Rheumatologic manifestations in Iranian patients with autoimmune thyroid diseases

BACKGROUND

Autoimmune thyroid diseases (ATDs) are the most common endocrine diseases which result in rheumatologic manifestations. Some studies have shown association between rheumatologic disorders and ATDs. Thus, the aim of this study was to assess the frequency of rheumatologic manifestations in patients with ATDs.

MATERIALS AND METHODS

In this cross-sectional descriptive study during 2010 to 2011, 65 patients with ATDs referred to the Rheumatology clinic of 5 Azar Hospital in Gorgan (North of Iran) were studied via systematic random sampling and patients with positive antithyroid peroxides (anti-TPO) were included in the study. These patients were examined by a rheumatologist for diagnosis of rheumatologic manifestations and tested for serum levels of TSH, Free T3 and T4, Anti-Nuclear Antibodies (ANAs) and Rheumatoid Factor (RF). SPSS software (version 16) and descriptive statistics were used for data analysis.

RESULTS

Nine males (14.8%) and 56 females (86.2%) with mean age of 38.81±1.44 years were studied. Overall, Rheumatologic manifestations were seen in 86.2 % (n=56). In this study, the most frequent rheumatologic manifestations were Carpal Tunnel Syndrome (36.1%) and Osteoarthritis (23%). Reynaud's phenomenon (RP) (10.7%), Discopathy (8.9%), Fibromyalgia (5.3%), Myopathy (3.6%), Rheumatoid arthritis (3.6%) and trigger finger (3.6%) were other manifestations, respectively.

CONCLUSION

In this region, there is a high frequency of rheumatologic manifestations in patients with ATDs. Thus, initial evaluation and regular checkings are recommended.

Autoimmune thyroid disease in ankylosing spondylitis

Although autoimmune thyroid disease is well known to be associated with primary Sjögren's syndrome (SjS) and with various autoimmune diseases, it is less clear whether a similar association also exists for ankylosing spondylitis (AS). Therefore, we investigated the frequency of autoimmune thyroid disease in patients with AS. In this cross sectional study, 80 patients with AS fulfilling the 1984 Modified New York Criteria and 80 healthy subjects, age and sex-matched with AS patients, were included. As the positive control group, 62 female patients with primary SjS were also studied. All cases underwent thyroid ultrasonography (USG) by a single endocrinologist. Thyroid function tests and thyroid autoantibodies were measured. The diagnosis of Hashimoto's thyroiditis (HT) was made if the patient had thyroid autoantibody positivity plus at least one of the following criteria: diffuse goiter with physical examination, abnormality in thyroid function tests, and parenchymal heterogeneity with USG. The chi-squared test and Fisher's exact test were used to compare cases and controls. The p values <0.05 were considered statistically significant. The frequencies of parenchymal heterogeneity with USG (30 vs 11.3 %, p = 0.045), thyroid autoantibody positivity (13.8 vs 2.5 %, p = 0.017), and concomitant diagnosis of HT (10 vs 1.3 %, p = 0.034) were significantly higher in AS group compared to healthy controls. Among AS patients having HT, subclinical hypothyroidism was detected only in a single patient. Frequency of autoimmune thyroid disease was significantly higher in AS group, compared to healthy controls. Prospective studies are needed to see the clinical relevance of these findings and outcome in the long term.

Pain and thyroid hormones

The role of endocrine systems in chronic pain mechanisms is slowly getting increasing experimental and clinical consideration. Many painful conditions appear to be directly and/or indirectly induced, reduced or, in some cases, modulated by hormones. We have done much work in trying to understand the relationship between hormones and pain, with particular attention to the hypothalamus-pituitary-gonadal axis. To expand our knowledge of this field, we have directed our attention to another axis, the hypothalamus-pituitary-thyroid (HPT). The literature on thyroid functions is vast but very few studies have focused on the HPT axis and pain. The few available data are considered in the present review to stimulate interest in the possible interactions between the HPT axis and pain.

Adipocytokines mark insulin sensitivity in euthyroid Hashimoto's patients

The relationship between inflammation, Hashimoto's thyroiditis (HT) and insulin resistance is still controversial. In this regard, a pretty complete evaluation of adipocytokines levels in patients with HT has not been performed so far. We assessed retinol binding protein-4 (RBP4), adipocyte-fatty acid binding protein (A-FABP), neutrophil gelatinase-associated lipocalin (NGAL) and tumor necrosis factor-α (TNFα) levels in 93 euthyroid HT patients and 51 healthy controls (CTL), also evaluating the possible correlation between adipocytokines levels and markers of insulin resistance. No significant differences between HT patients and CTL in fasting plasma glucose and insulin levels, and HOMA index were observed. HT patients had significantly higher RBP4, NGAL and A-FABP levels than CTL, while TNFα levels did not differ between the two groups. In HT patients, RBP4 was significantly related with fT3 and fT4 levels, while A-FABP with fT4 only. Moreover, in HT patients, either RBP4 or A-FABP was directly associated with plasma insulin and HOMA index. Circulating levels of these adipocytokines were not influenced by the presence of antithyroid peroxidase or antithyroglobulin autoantibodies or only one of them, neither by autoantibodies titer. In conclusion, euthyroid HT patients are characterized by a peculiar inflammatory response of the adipose tissue, apparently related to an early reduction in insulin sensitivity and to serum thyroid hormone levels, although within the normal range. These results suggest that HT patients with high RBP4 and A-FABP levels might deserve a particular attention, being potentially more exposed to develop insulin resistance and increased cardiovascular risk.

Is Thyroid Autoimmunity per se a Determinant of Quality of Life in Patients with Autoimmune Hypothyroidism?

PURPOSE

To evaluate the relationship between thyroid variables and health-related quality of life (QoL) in patients with autoimmune hypothyroidism, using the thyroid-specific QoL questionnaire ThyPRO.

METHODS

In a cross-sectional study, responses to the ThyPRO from 199 outpatients with autoimmune hypothyroidism were analyzed in relation to thyroid volume, thyroid function and markers of thyroid autoimmunity. Based on a classical QoL framework, we hypothesized that physiological dysfunction caused specific physical and psychological symptoms, which affected functioning and well-being, and consequently participation in life and QoL. These hypotheses were tested through multiple regression and multivariate path analysis models.

RESULTS

None of the thyroid function tests were associated with QoL scores. However, in the pairwise regression, the thyroid peroxidase antibody (TPOAb) level was associated with several QoL outcomes: Goitre Symptoms (p = 0.024), Depressivity (p = 0.004), Anxiety (p = 0.004), Emotional Susceptibility (p = 0.005) and Impaired Social Life (p = 0.047). In the multivariate model, the TPOAb level was related to Goitre Symptoms (r = 0.17, p = 0.019), Depressivity (r = 0.24, p = 0.001), and Anxiety (r = 0.23, p = 0.002), but no longer to Emotional Susceptibility or Impaired Social Life, indicating that the effect on these were mediated through an effect on the symptom scales (i.e. Goitre Symptoms, Depressivity and Anxiety).

CONCLUSION

Health-related QoL, evaluated with state-of-the-art QoL methodology, was related to TPOAb level but not to thyroid function. This raises the hypothesis that autoimmunity, independent of thyroid function, impacts on QoL in patients with autoimmune hypothyroidism, especially in terms of psychological symptoms. Longitudinal studies, in initially untreated patients, are needed to test this hypothesis.

Rheumatic Manifestations of Autoimmune Thyroid Disease: The Other Autoimmune Disease

Autoimmune thyroid disease (AITD) is an inflammatory thyroiditis that in some cases is characterized by lymphocytic infiltration of the thyroid gland, also referred to as chronic lymphocytic thyroiditis or Hashimoto thyroiditis. Hashimoto thyroiditis is one of the commonest causes of hypothyroidism. Hypothyroidism has been associated with osteoarthritis (OA) and inflammatory forms of arthritis and with several well defined connective tissue diseases, which in turn can cause arthritis. The presence of arthritis in patients with AITD with normal thyroid function is now being increasingly recognized. There is also considerable evidence to suggest that AITD is highly associated with fibromyalgia syndrome. We review the current literature on the rheumatologic manifestations of AITD and describe the features in its presentation that set it apart from other forms of autoimmune arthritis.

Hashimoto's thyroiditis in patients with normal thyroid-stimulating hormone levels

Hashimoto's thyroiditis (HT) is one of the most common autoimmune endocrine disorders and often leads to hypothyroidism. It has been shown to substantially affect a patient's quality of life. Associated conditions and diseases were thought to be attributable to hypothyroidism. Yet, many patients still suffer from various symptoms even though all thyroid parameters are within the normal range. Independently of thyroid gland function, HT is associated with a wide range of organ-specific and non-organ-specific autoimmune disorders, as well as other diseases, including neuropsychological/psychiatric deficits, decreased left ventricular performance, disorders of the gut, fibromyalgia and reproductive health issues, among others. The underlying pathomechanisms remain unclear. Future treatment options might include thyroidectomy, selenium administration, prophylactic levothyroxine supplementation and dehydroepiandrosterone. However, further research is warranted to clarify the main pathophysiologic implications of thyroid autoimmunity and also to establish treatment options for euthyroid patients who suffer from HT-related symptoms and diseases.