Rheumatic and autoimmune thyroid disorders: a causal or casual relationship?

The association between thyroid dysfunction, autoimmune thyroid disease, and rheumatoid arthritis disease severity

BACKGROUND

Rheumatoid Arthritis (RA) and autoimmune thyroid disease (AITD) are the two most prevalent coexisting autoimmune diseases due to their similar pathogenesis. Considering the potential effect of AITD on the severity of RA disease, this study aimed to determine the association between thyroid dysfunction, anti-thyroid peroxidase (anti-TPO) positivity, AITD, and RA disease severity in the Iranian population.

METHODS

Three hundred and fifty RA patients who presented to Shahid Beheshti tertiary care center, Qom, Iran, were included in this cross-sectional study. The data were collected through the patient's medical records, interviews, physical examinations, and laboratory tests. The RA disease activity score in 28 joints for RA with erythrocyte sedimentation rate (DAS-28-ESR) was used to divide patients into three subgroups, remission (DAS-28-ESR ⩽ 2.6), mild-to-moderate (2.6 < DAS-28-ESR ⩽ 5.1), and severe disease activity (DAS-28-ESR > 5.1).

RESULTS

Using the aforementioned method, 111, 96, and 138 patients were put into remission, mild-to-moderate, and severe disease activity groups, respectively. Anti-TPO antibody positivity rate was 2.93 times more prevalent among patients with severe disease compared to the remission subgroup (OR: 2.93; P-value < 0.001). Patients suffering from a more severe disease were almost 2.7 times more probable to have AITD (OR = 2.71; P-value < 0.001) and they were 82% more likely to have thyroid dysfunction compared to patients in remission (OR = 1.82; P-value = 0.006).

CONCLUSIONS

It was demonstrated that thyroid dysfunction, anti-TPO antibody positivity, and AITD were significantly more common among RA patients with more severe disease activity.

Autoimmune polyendocrine syndromes associated with autoimmune rheumatic diseases

Autoimmune polyendocrine syndromes (APSs), also called autoimmune polyglandular syndromes, are a group of autoimmune diseases characterized by the co-occurrence of dysfunctions of several (at least two) endocrine glands. They develop under the influence of environmental factors in genetically predisposed people. Autoimmune polyendocrine syndromes may accompany autoimmune rheumatic diseases and worsen their course - APS-2 and APS-3 are the most common. The APS-2 includes the coexistence of, e.g. Hashimoto's disease, celiac disease and rheumatoid arthritis (RA). In APS-3, rheumatic diseases such as RA, systemic lupus erythematosus, and Sjögren's syndrome may coexist with Hashimoto's disease, type 1 diabetes and hypogonadism or other endocrinopathies. Undiagnosed endocrine diseases may be the reason for the intensification of metabolic disorders observed in the course of rheumatic diseases, cause the ineffectiveness of rheumatological treatment and also increase the frequency of bone fractures due to osteoporosis, cardiovascular complications and even miscarriages when coexistent, e.g. Hashimoto's disease with hypothyroiditis, which increases the risk of pregnancy loss. It is important to be able to conduct an extensive interview, paying attention to the symptoms of possible endocrinopathy as well as the features of other autoimmune disorders in the physical examination (e.g. vitiligo or darkening of the skin in Addison's disease). Depending on the history and physical examination, screening for various APSs is advised.

The prevalence of thyroid dysfunction and autoimmune thyroid disease in patients with rheumatoid arthritis

Background

Rheumatoid arthritis (RA) is one of the most common chronic non-organ-specific autoimmune diseases; meanwhile, autoimmune thyroid disease (AITD) is the most common organ-specific autoimmune disease that can lead to hypo or hyperthyroidism. Although the etiology of both diseases is complex with a combination of genetic and environmental factors, there are overlaps in genes contributing to the pathogenesis of both diseases. Numerous studies found a correlation between thyroid abnormality and RA in different populations, yet some didn’t. This study is aimed to evaluate the prevalence of thyroid dysfunction, AITD, and anti-thyroid peroxidase (anti-TPO) positively in Iranian patients with RA.

Methods

A total of 250 RA patients and 248 patients with non-inflammatory rheumatologic disease were included in this case–control study. All participants underwent complete clinical and laboratory assessments. Participants were also assessed for thyroid function testing, including anti-TPO antibodies.

Results

Thyroid dysfunction was twice as common in RA patients as in controls (OR = 2.16; P-value > 0.001). Overt hypothyroidism was the most common thyroid dysfunction among RA patients (58 out of 84). Anti-TPO positivity was also significantly more common in RA compared with controls (OR = 2.65; P-value > 0.001). The proportion of controls and RA patients with AITD were 9 and 21.5%, respectively. AITD was found 2.8 times more common in RA group than controls (OR = 2.77; P-value > 0.001).

Conclusion

It was demonstrated that RA was an independent factor associated with thyroid dysfunction and AITD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00293-9.

Evaluating whole-genome expression differences in idiopathic and diabetic adhesive capsulitis

BACKGROUND

Diabetic patients have a greater incidence of adhesive capsulitis (AC) and a more protracted disease course than patients with idiopathic AC. The purpose of this study was to compare gene expression differences between AC with diabetes mellitus and AC without diabetes mellitus.

METHODS

Shoulder capsule samples were prospectively obtained from diabetic or nondiabetic patients who presented with shoulder dysfunction and underwent arthroscopy (N = 16). Shoulder samples of AC with and without diabetes (n = 8) were compared with normal shoulder samples with and without diabetes as the control group (n = 8). Shoulder capsule samples were subjected to whole-transcriptome RNA sequencing, and differential expression was analyzed with EdgeR. Only genes with a false discovery rate < 5% were included for further functional enrichment analysis.

RESULTS

The sample population had a mean age of 47 years (range, 24-62 years), and the mean hemoglobin A_1c level for nondiabetic and diabetic patients was 5.18% and 8.71%, respectively. RNA-sequencing analysis revealed that 66 genes were differentially expressed between diabetic patients and nondiabetic patients with AC whereas only 3 genes were differentially expressed when control patients with and without diabetes were compared. Furthermore, 286 genes were differentially expressed in idiopathic AC patients, and 61 genes were differentially expressed in diabetic AC patients. On gene clustering analysis, idiopathic AC was enriched with multiple structural and muscle-related pathways, such as muscle filament sliding, whereas diabetic AC included a greater number of hormonal and inflammatory signaling pathways, such as cellular response to corticotropin-releasing factor.

CONCLUSIONS

Whole-transcriptome expression profiles demonstrate a fundamentally different underlying pathophysiology when comparing diabetic AC with idiopathic AC, suggesting that these conditions are distinct clinical entities. The new genes expressed explain the differences in the disease course and suggest new therapeutic targets that may lead to different treatment paradigms in these 2 subsets.

Long Work Hours Are Associated with Hypothyroidism: A Cross-Sectional Study with Population-Representative Data

Background: Studies have highlighted the adverse effects of long work hours on workers' health; however, the association of long work hours with thyroid function has not been studied. This study aimed at assessing long work hours as a risk factor for thyroid dysfunction. Methods: This cross-sectional study was based on data obtained from the Korea National Health and Nutrition Examination Survey conducted from 2013 to 2015. A total of 2160 adults who worked 36-83 hours per week were included. Thyroid function was defined based on the population thyroid-stimulating hormone reference ranges, after excluding individuals with positive results for thyroid peroxidase antibody. The association between work hours and thyroid function was confirmed via multinomial logistic regression. Results: Hypothyroidism was more prevalent among those with longer work hours (3.5% vs. 1.4% for 53-83 and 36-42 work hours per week, respectively). Individuals who worked longer hours had an increased odds for hypothyroidism (odds ratio 1.46, confidence interval 1.12 - 1.90, per 10-hour increase in work hours per week), after adjustment for age, sex, body mass index, urine iodine concentration, smoking status, work schedule, and socioeconomic status. The association between work hours and hypothyroidism was consistent in various subgroups stratified by sex or socioeconomic status. Conclusions: To our knowledge, this study is the first to show that long work hours are associated with hypothyroidism. Further large longitudinal studies are needed to clarify causality.

Incidence of thyroid disease in patients with forefoot deformity

BACKGROUND

Hallux valgus and lesser toe deformities are common foot disorders with substantial functional consequences. While the exact etiologies are multi-factorial, it is unknown if certain endocrine abnormalities, such as thyroid dysfunction, may be associated with these pathologies. The current study sought to investigate the prevalence of thyroid disease in patients with hallux valgus or lesser toe deformities.

METHODS

Every new patient who presented to our institution's foot and ankle clinic during a three-month time period was given a survey to determine the presence of a known thyroid disorder. The diagnosis for each visit was then recorded. Additionally, a national, publicly available database was queried for patients diagnosed with thyroid disease and concomitant hallux valgus or specific forefoot pathology. Odds ratios for the presence of thyroid dysfunction were then calculated for each patient group.

RESULTS

Three-hundred and fifty initial visit patient surveys were collected, and 74 (21.1%) patients had a known diagnosis of thyroid disease. The most common diagnoses were primary hypothyroidism (n = 61, 17.4%), secondary hypothyroidism (n = 6, 1.7%), thyroiditis (n = 4, 1.1%), and hyperthyroidism (n = 3, 0.9%). Thyroid disease was present in 16 of 26 patients (61.5%) with a diagnosis of hallux valgus (OR 7.3, CI[3.16-16.99], p < 0.0001). Lesser toe deformities, including hammertoes, mallet toes, bunionettes and crossover toes, were also significantly associated with thyroid disease (OR 5.45, CI[1.83-16.26], p < 0.002). The national database revealed 905,924 patients with a diagnosis of a specific forefoot deformity, and 321,656 of these patients (35.5%) had a concomitant diagnosis of a thyroid condition (OR 2.11, CI[2.10-2.12], p < 0.0001).

CONCLUSIONS

The current study suggests a significant association between forefoot pathology and thyroid dysfunction, especially hallux valgus and lesser toe deformities. Increased understanding of these correlations may offer an important opportunity in population health management, both in diagnosis and treatment. While further studies with long-term outcomes are necessary, the early diagnosis of thyroid disease may provide an opportunity to predict and potentially alter the course of forefoot pathology.

Thyroid disease in the time of COVID-19

The novel coronavirus disease COVID-19 is produced by SARS-CoV-2. WHO has declared COVID-19 as a public health emergency, with the most susceptible populations (requiring ventilation) being the elderly, pregnant women and people with associated co-morbidities including heart failure, uncontrolled diabetes, chronic obstructive pulmonary disease, asthma and cancer. However, such general guidance does not provide information regarding COVID-19 risks in patients with suffering from pre-existing thyroid problems, and furthermore, we do not know whether patients with COVID-19 (symptomatic or without symptoms), who have not previously had thyroid issues develop endocrine thyroid dysfunction after infection. The European Society for Endocrinology recently published a statement on COVID-19 and endocrine diseases (Endocrine, 2020); however, thyroid diseases were not mentioned specifically. We have therefore reviewed the current literature on thyroid diseases (excluding cancer) and COVID-19, including data from the previous coronavirus pandemic caused by the SARS-associated coronavirus (SARS-CoV), a member of the same family Coronaviridae leading to severe acute respiratory syndrome (SARS). At the moment there are no data suggesting that thyroid patients are at higher risk of COVID-19, but this requites further research and data analysis.

Fibromyalgia, Sjogren's & depression: linked?

Health care has become increasingly fragmented, partly due to advancing medical technology. Patients are often managed by various specialty teams when presenting with symptoms that could be manifestations of different diseases. Approximately one third of them are referred to specialists, at over half for outpatient appointments. Fatigue, pain, depression, dry mouth, headaches, and arthralgia are common complaints and frequently require referral to specialist physicians. Differential diagnoses include fibromyalgia (FM), Sjogren's syndrome (SS), and depression. Evaluations involve various sub-specialist especially physicians like those practicing pain management, rheumatology, and psychiatry. Thresholds for referring vary. Patients sometime feel lost in a 'medical maze'. Disagreement is frequent between specialties regarding management. Each discipline has its own diagnostic and treatment protocols and there is little consensus about shared decision-making. Communication between doctors could improve continuity. There are many differences and similarities in the pathophysiology, symptomatology, diagnosis, and treatment of fibromyalgia, Sjogren's syndrome, and depression. Understanding the associations between fibromyalgia, Sjogren's syndrome and depression should improve clinical outcome via a common holistic approach.

Assessment of the relationship between knee ultrasound and clinical symptoms in patients with thyroid dysfunction

Objective

To determine whether musculoskeletal ultrasound (MSUS) abnormalities were associated with thyroid dysfunction.

Methods

This study included 109 patients with thyroid diseases, including thyroid dysfunction or autoimmune thyroid disease. Patients were categorized as euthyroid, hypothyroid, or hyperthyroid based on their recent thyroid function tests. To evaluate MSUS, an experienced rheumatologist examined the presence of synovial fluid, synovial hypertrophy, and grade of inflammation in both gray-scale and power Doppler scans of the knee joint. Associations between MSUS abnormalities, thyroid status, visual analog scale (VAS) score for knee pain, and presence of thyroid autoantibodies were investigated.

Results

MSUS abnormalities were more frequently associated with hyperthyroid or hypothyroid states than with a euthyroid state. High knee VAS score was significantly associated with overall MSUS severity score regardless of knee osteoarthritis. However, there was no difference in MSUS abnormalities based on the presence of thyroid autoantibodies.

Conclusions

Both hypothyroid and hyperthyroid states were associated with MSUS abnormalities and knee arthralgia. MSUS examination may be helpful in uncontrolled thyroid dysfunction and knee arthralgia.

Children Born by Women With Rheumatoid Arthritis and Increased Susceptibility for Chronic Diseases: A Nationwide Cohort Study

OBJECTIVE

Fetal exposure to maternal rheumatoid arthritis (RA) might impact the long-term risk of disease in the offspring. We examined a possible association between maternal RA and 15 selected groups of chronic diseases in the offspring.

METHODS

This nationwide cohort study was based on the Danish health registries and included data on all children born alive in Denmark between January 1, 1989 and December 31, 2013. The cohort comprised 2,106 children born by women with RA (exposed), and 1,378,539 children born by women without RA (unexposed). Cox proportional hazards regression models were used, taking a large range of confounders into consideration, and the hazard ratios (HRs) of child and adolescent diseases were calculated.

RESULTS

In children exposed to maternal RA in utero, the HR of thyroid diseases was 2.19 (95% confidence interval [95% CI] 1.14-4.21), epilepsy 1.61 (95% CI 1.16-2.25), and RA 2.89 (95% CI 2.06-4.05). The HRs for anxiety and personality disorders and chronic lung disease including asthma were in the range of 1.15-1.16, but these were not statistically significant associations.

CONCLUSION

Our results suggest that in utero exposure to maternal RA is associated with an increased risk of thyroid disease and epilepsy in childhood and adolescence, and in particular an increased risk of RA, compared to children born to mothers without RA. These important findings should encourage pediatricians and general practitioners to have an increased awareness of certain chronic diseases in children exposed to RA in utero.

Rheumatoid arthritis and thyroid dysfunction: A cross-sectional study and a review of the literature

Thyroid dysfunction appears to show increased prevalence in many autoimmune diseases; however, this comorbidity has not been properly investigated in patients with RA. This issue was addressed in this cross-sectional study. Using the database of the Clalit Health Services (CHS) in Israel, RA patients were paired with age- and sex-matched controls to compare the prevalence of hypothyroidism and hyperthyroidism. Chi-squared and t-tests were used for univariate analysis and a logistic regression model was used for multivariate analysis. The study included 11,782 patients with RA and 57,973 controls. The rate of thyroid dysfunction diseases in RA patients was increased compared with the prevalence in controls (16.0% and 11.7%, p < 0.001, for hypothyroidism; and 2.33% and 1.81%, p < 0.001 in hyperthyroidism, respectively). In a multivariate analysis, RA was associated with hypothyroidism (OR = 1.42, 95% CI 1.34-1.50) and hyperthyroidism (OR = 1.26, 95% CI 1.10-1.45). RA is associated with thyroid dysfunction. Therefore, physicians treating patients with RA should be aware of the possibility of comorbid thyroid dysfunction and treat accordingly.

Retrospective cohort study on risk of hearing loss in patients with rheumatoid arthritis using claims data

OBJECTIVES

Population studies on hearing loss (HL) associated with rheumatoid arthritis (RA) are lacking. This study investigated the risk of developing HL in patients with RA using a nationwide population cohort.

SETTING

The population-based insurance claims data in the Taiwan National Health Insurance Research Database.

DESIGN

Retrospective cohort study followed up RA cohort and control cohort without RA frequency matched by sex, age and diagnosis year.

STUDY POPULATION

18 267 patients with RA newly diagnosed in 2000-2006 and 73 068 controls without RA.

MAIN OUTCOMES

Incidences of HL by the end of 2011 and the RA cohort to non-RA cohort HRs after adjusting for sex, age and comorbidities.

RESULTS

The HL incidence was higher in the RA cohort than in the non-RA cohort (3.08 vs 1.62 per 1000 person-years), with an adjusted HR (aHR) of 1.91 (95% CI 1.70 to 2.14) for the RA cohort relative to the non-RA cohort after controlling for age, sex and comorbidities. Men and the elderly are at a higher risk. Cardiovascular comorbidities were associated with a further increased HL risk for patients with RA. Medications were associated with reduced HL incidence; patients with RA who used non-steroidal anti-inflammatory drugs (NSAIDs) had an aHR of 0.12 (95% CI 0.07 to 0.20), compared with non-users.

CONCLUSIONS

This study demonstrates that patients with RA are at an increased risk of developing HL. Findings highlight the need of disease-modifying treatment and scheduled auditory examinations for HL prevention and early detection for patients with RA.

The Association of Sjögren Syndrome and Autoimmune Thyroid Disorders

Sjögren's syndrome (SS) and autoimmune thyroid diseases (AITD) may frequently coexist in clinical practice, resulting in a complex overlapping disorder that represents a particular example of the expression of heterogeneity in patients with autoimmune disorders. Objective of this review was to describe the prevalence of the SS-AITD association in the most recent literature, exploring in particular to what extent the presence of AITD might influence the clinical expression of SS and vice versa. Moreover, we summarized some of the proposed genetic, biologic, and molecular mechanisms implied in the pathogenesis of AITD-SS association. Finally, we explored risk factors for lymphoma development in both AITD and SS. We performed a Medline search of English language articles published in the PubMed database in order to provide a critical overview of the recent literature on pathogenesis and clinical features of AITD-SS overlapping disease. All the articles were critically analyzed to select the most relevant contributions.

Association between giant cell arteritis and thyroid dysfunction in a "real life" population

PURPOSE

Giant cell arteritis is a systemic autoimmune disorder which involves inflammation of medium to large vessels. The association between giant cell arteritis and autoimmune thyroid disorders has been investigated numerous times in the literature with inconsistent results. Our objective was to evaluate whether a genuine association exists between giant cell arteritis and thyroid dysfunction, which is often due to immune-mediated thyroid disease.

METHODS

Utilizing the medical database of Clalit Health Services, we compared the proportion of hypo and hyperthyroidisim between patients with giant cell arteritis and age-matched and gender-matched controls in a cross-sectional study. Univariate analysis was performed using Chi-square and student t-test and a multivariate analysis was performed using a logistic regression model.

RESULTS

Five thousand six hundred and sixty three giant cell arteritis patients and 23,308 age-matched and gender-matched controls were included in the study. The proportion of hypothyroidism amongst giant cell arteritis patients was increased in comparison with controls (18.2 vs. 6.91%, respectively, p-value < 0.001), as was hyperthyroidism (2.56 and 1.19% respectively, p-value < 0.001). Giant cell arteritis demonstrated an independent association with hypothyroidism on multivariate analysis (Odd Ratios 1.297, 95% Confidence Intervals 1.19-1.42), yet not with hyperthyroidism.

CONCLUSIONS

Giant cell arteritis patients have a higher proportion of hypothyroidism in comparison with matched controls. Physicians treating giant cell arteritis patients should consider screening for thyroid dysfunction on a regular basis.

Prevalence, incidence and associated comorbidities of treated hypothyroidism: an update from a European population

OBJECTIVE

Estimates of the prevalence of hypothyroidism in unselected populations date from the late 1990s. We present an update on the prevalence and incidence of overt hypothyroidism in Piedmont, northwest Italy and examine the association between hypothyroidism and multiple chronic comorbidities.

DESIGN AND METHODS

Data were obtained from drug prescription and hospital discharge databases. Individuals who had received at least two levothyroxine prescriptions in 2012 were defined as having hypothyroidism; those who had undergone thyroidectomy or I¹³¹ irradiation in the previous 5 years were defined as having iatrogenic hypothyroidism and those who had either obtained exemption from treatment co-payment or had been discharged from hospital with a chronic comorbidity (diabetes and connective tissue diseases) were identified as having one of these conditions.

RESULTS

The overall crude prevalence was 31.1/1000 (2.3/1000 for iatrogenic hypothyroidism) and the overall crude incidence was 7/1000. The average daily dose of thyroxine (122 µg) roughly corresponded to 1.7 µg/kg. There was a strong association between hypothyroidism and diabetes (type 1, type 2 or gestational) and with autoimmune diseases, with the odds ratio ranging from 1.43 (1.02-1.99) for psoriatic arthritis to 4.99 (3.06-8.15) for lupus erythematosus.

CONCLUSIONS

As compared with previous estimates, the prevalence of hypothyroidism rose by about 35%, driven mainly by non-iatrogenic forms. The increase may be due to either population aging or improved diagnostic capability or both. The frequent co-occurrence of hypothyroidism with other multiple chronic conditions characterizes it more as a comorbidity rather than an isolated chronic disease.

Association of antithyroid peroxidase antibody with fibromyalgia in rheumatoid arthritis

To investigate how autoimmune thyroiditis (ATD) affects the clinical presentation of established rheumatoid arthritis (RA) with particular reference to fibromyalgia and chronic widespread pain (CWP). A cohort of 204 patients with RA for whom the presence or absence of autoimmune thyroid antibodies was documented was examined for the relationships between thyroid autoantibodies and fibromyalgia or CWP. We identified 29 % who tested positive for antithyroid peroxidase antibodies (TPOAb). The anti-thyroglobulin antibody (TgAb) was found in 24 %. Among the thyroid autoantibody-positive patients, 40 % had a diagnosis of fibromyalgia or CWP versus 17 % for antibody negative patients. Logistic regression analyses (adjusted by age, sex, diabetes and BMI) indicated that TPOAb-positive patients were more likely to have fibromyalgia or CWP, with an odds ratio (OR) of 4.641, 95 % confidence interval (CI) (2.110-10.207) P < .001. Adjusting for spinal degenerative disc disease did not change the association with fibromyalgia, OR 4.458, 95 % CI (1.950-10.191), P < .001. The OR between TgAb and fibromyalgia was not significant (P > .05). Additional logistic regression analyses (adjusted by age, sex and BMI) indicated a significant relationship between TPOAb and fibromyalgia or CWP in patients without diabetes and those without hypothyroidism (OR of 4.873, 95 % CI (1.877-12.653), P = .001 and OR of 4.615 95 % CI (1.810-11.770), P = .001, respectively). There may be a positive association between the ATD antibody TPOAb, and fibromyalgia syndrome and CWP in patients with established RA.