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Yasuda S, Suzuki S, Yanagisawa S, Morita H, Haisa A, Satomura A, Nakajima R, Oikawa Y, Inoue I, Shimada A. HLA typing of patients who developed subacute thyroiditis and Graves' disease after SARS-CoV-2 vaccination: a case report. BMC Endocr Disord 2023; 23:54. [PMID: 36879263 PMCID: PMC9988595 DOI: 10.1186/s12902-023-01287-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 01/27/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND Cases of subacute thyroiditis (SAT) after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination have been reported. A human leukocyte antigen (HLA) allele, HLA-B*35, appears to be involved in the pathogenesis of SAT. CASE PRESENTATION We conducted HLA typing of one patient with SAT and another with both SAT and Graves' disease (GD), which developed after SARS-CoV-2 vaccination. Patient 1, a 58-year-old Japanese man, was inoculated with a SARS-CoV-2 vaccine (BNT162b2; Pfizer, New York, NY, USA). He developed fever (38 °C), cervical pain, palpitations, and fatigue on day 10 after vaccination. Blood chemistry tests revealed thyrotoxicosis and elevated serum C-reactive protein (CRP) and slightly increased serum antithyroid-stimulating antibody (TSAb) levels. Thyroid ultrasonography revealed the characteristic findings of SAT. Patient 2, a 36-year-old Japanese woman, was inoculated twice with a SARS-CoV-2 vaccine (mRNA-1273; Moderna, Cambridge, MA, USA). She developed fever (37.8 °C) and thyroid gland pain on day 3 after the second vaccination. Blood chemistry tests revealed thyrotoxicosis and elevated serum CRP, TSAb, and antithyroid-stimulating hormone receptor antibody levels. Fever and thyroid gland pain persisted. Thyroid ultrasonography revealed the characteristic findings of SAT (i.e., slight swelling and a focal hypoechoic area with decreased blood flow). Prednisolone treatment was effective for SAT. However, thyrotoxicosis causing palpitations relapsed thereafter, for which thyroid scintigraphy with 99mtechnetium pertechnetate was conducted, and the patient was diagnosed with GD. Thiamazole treatment was then initiated, which led to improvement in symptoms. CONCLUSION HLA typing revealed that both patients had the HLA-B*35:01, -C*04:01, and -DPB1*05:01 alleles. Only patient 2 had the HLA-DRB1*11:01 and HLA-DQB1*03:01 alleles. The HLA-B*35:01 and HLA-C*04:01 alleles appeared to be involved in the pathogenesis of SAT after SARS-CoV-2 vaccination, and the HLA-DRB1*11:01 and HLA-DQB1*03:01 alleles were speculated to be involved in the postvaccination pathogenesis of GD.
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Affiliation(s)
- Shigemitsu Yasuda
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan.
| | - Seiya Suzuki
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Shinnosuke Yanagisawa
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Hideo Morita
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Akifumi Haisa
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Atsushi Satomura
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Ritsuko Nakajima
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Yoichi Oikawa
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Ikuo Inoue
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
| | - Akira Shimada
- Department of Endocrinology and Diabetes, Saitama Medical University, Morohongo 38, Moroyama, Iruma-gun, Saitama, 350-0495, Japan
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Tan G, Wang X, Zheng G, Du J, Zhou F, Liang Z, Wei W, Yu H. Meta-analysis reveals significant association between FOXP3 polymorphisms and susceptibility to Graves' disease. J Int Med Res 2021; 49:3000605211004199. [PMID: 33858251 PMCID: PMC8054215 DOI: 10.1177/03000605211004199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE This meta-analysis aimed to determine the associations between the rs3761547, rs3761548, and rs3761549 single-nucleotide polymorphisms (SNPs) of the forkhead box P3 (FOXP3) gene and susceptibility to Graves' disease (GD). METHODS Case-control studies with information on the associations between the rs3761547, rs3761548, and rs3761549 FOXP3 SNPs and GD published before 01 May 2020 were identified in the PubMed, Embase, Web of Science, and China National Knowledge Infrastructure databases. Data from the studies were analyzed using RevMan version 5.3. RESULTS Seven independent case-control studies including 4051 GD patients and 4569 controls were included in the meta-analysis. The overall pooled analysis indicated that FOXP3/rs3761548 and FOXP3/rs3761549 polymorphisms were significantly associated with GD susceptibility (rs3761548: A vs. C, odds ratio [OR] = 1.32, 95% confidence interval [CI] 1.05-1.67; rs3761549: TT vs. CC, OR = 1.98, 95%CI 1.49-2.65; (TT + TC) vs. CC, OR = 1.44, 95%CI 1.11-1.88). In contrast, the FOXP3/rs3761547 polymorphism was not associated with GD susceptibility. Subgroup analysis according to ethnicity showed that rs3761548 was associated with GD in Asians but not in Caucasians, whereas rs3761549 was associated in both Asians and Caucasians. CONCLUSION This meta-analysis demonstrated that FOXP3/rs3761548 and FOXP3/rs3761549 SNPs were significantly associated with susceptibility to GD, at least in Asian populations.
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Affiliation(s)
- Guiqin Tan
- Department of Immunology, Special Key Laboratory of Gene Detection and Therapy of Guizhou Province, Zunyi Medical University, Zunyi, China
| | - Xin Wang
- Department of Basic Medical Education, Zunyi Medical University, Zunyi, China
| | - Guangbing Zheng
- Department of Immunology, Special Key Laboratory of Gene Detection and Therapy of Guizhou Province, Zunyi Medical University, Zunyi, China
| | - Juan Du
- Department of Immunology, Special Key Laboratory of Gene Detection and Therapy of Guizhou Province, Zunyi Medical University, Zunyi, China
| | - Fangyu Zhou
- Department of Immunology, Special Key Laboratory of Gene Detection and Therapy of Guizhou Province, Zunyi Medical University, Zunyi, China
| | - Zhongzhi Liang
- Department of Immunology, Special Key Laboratory of Gene Detection and Therapy of Guizhou Province, Zunyi Medical University, Zunyi, China
| | - Wenwen Wei
- Department of Immunology, Special Key Laboratory of Gene Detection and Therapy of Guizhou Province, Zunyi Medical University, Zunyi, China
| | - Hongsong Yu
- Department of Immunology, Special Key Laboratory of Gene Detection and Therapy of Guizhou Province, Zunyi Medical University, Zunyi, China
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So S, Tawara F. Risk factors of subclinical hypothyroidism and the potential contribution to miscarriage: A review. Reprod Med Biol 2020; 19:232-242. [PMID: 32684822 PMCID: PMC7360962 DOI: 10.1002/rmb2.12325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Revised: 02/28/2020] [Accepted: 03/03/2020] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND There is no clear cutoff value for thyroid-stimulating hormone (TSH) level that defines subclinical hypothyroidism (SCH). Moreover, TSH levels can be affected by numerous factors. Although mild SCH has been implicated in miscarriage, the relationship between TSH levels and miscarriage remains unelucidated. METHODS We reviewed nine known risk factors affecting TSH levels and 28 studies investigating the potential association between mild SCH and miscarriage, examining whether these factors were considered. MAIN FINDINGS Among 28 studies that examined whether mild SCH (TSH > 2.5 mIU/L) contributed to miscarriage, thyroid antibodies were measured in only 15. TSH measurement methods were described in 18 studies. Although the iodinated contrast medium used in hysterosalpingography (HSG) is stored in the body for a long time and is a risk factor for mild SCH, only one study described its potential impact on TSH levels. Nine studies, which concluded that mild SCH contributed to miscarriage, had thyroid status evaluated only after the onset of pregnancy, but not before. CONCLUSION TSH levels can be significantly affected by patient demographics and health history, country of origin, and fertility treatment. It is important to consider these factors while evaluating mild SCH. It remains unclear how mild SCH contributes to miscarriage.
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Affiliation(s)
- Shuhei So
- Department of Reproductive and Perinatal MedicineHamamatsu University School of MedicineHigashi‐kuHamamatsu‐shiShizuokaJapan
- Tawara IVF ClinicSuruga‐kuShizuoka‐shiShizuokaJapan
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Kalantar K, Khansalar S, Eshkevar Vakili M, Ghasemi D, Dabbaghmanesh M, Amirghofran Z. ASSOCIATION OF FOXP3 GENE VARIANTS WITH RISK OF HASHIMOTO'S THYROIDITIS AND CORRELATION WITH ANTI-TPO ANTIBODY LEVELS. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2019; 15:423-429. [PMID: 32377237 PMCID: PMC7200107 DOI: 10.4183/aeb.2019.423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
CONTEXT Regulatory T cells (Tregs) have critical roles in preventing autoimmune diseases such as Hashimoto's thyroiditis (HT). Forkhead box P3 (Foxp3), the master transcription factor of Tregs, plays a pivotal role in Treg function. OBJECTIVE Herein, we investigated the association of two single nucleotide polymorphisms (SNPs) of the Foxp3 gene with HT development. METHODS AND STUDY DESIGN A total of 129 HT patients and 127 healthy subjects were genotyped for rs3761548 (-3279 A/C) and rs3761549 (-2383 C/T) in the Foxp3 gene, using polymerase chain reaction-restriction fragment length polymorphism. RESULTS Genotypic and allelic distribution of rs3761548 SNP showed a significant association with HT. The CC genotype was observed in 37.2% of patients versus 22.1% of the controls [P<0.008, odds ratio (OR): 2.1; 95% confidence interval (CI): 1.2-3.6] and the AC genotype in 41.1% of patients compared to 54.3% of the controls (P<0.025, OR: 2.1; CI: 1.2-3.6). In addition, higher frequency of C allele in patients compared to controls (P=0.05, OR: 1.4; 95% CI: 0.9-2) suggested that patients with the CC genotype and C allele had increased susceptibility to HT. There were significantly higher serum levels of anti-thyroid peroxidase (ATPO) antibody in patients with the rs3761548 CC genotype (1156±163 IU/mL) compared to the other genotypes (≈582-656 IU/mL; P<0.004). We observed a greater frequency of the AC genotype in patients who had decreased ATPO antibody levels (P=0.02). CONCLUSIONS The association of the rs3761548 SNP with risk of HT and its influence on ATPO antibody levels suggested an important role for Foxp3 in the biology and pathogenesis of HT.
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Affiliation(s)
- K. Kalantar
- Shiraz University of Medical Sciences, School of Medicine, Department of Immunology, Shiraz, Iran
| | - S. Khansalar
- Shiraz University of Medical Sciences, School of Medicine, Department of Immunology, Shiraz, Iran
| | - M. Eshkevar Vakili
- Shiraz University of Medical Sciences, School of Medicine, Department of Immunology, Shiraz, Iran
| | - D. Ghasemi
- Shiraz University of Medical Sciences, School of Medicine, Department of Immunology, Shiraz, Iran
| | - M.H. Dabbaghmanesh
- Shiraz University of Medical Sciences, School of Medicine, Department of Immunology, Shiraz, Iran
| | - Z. Amirghofran
- Shiraz University of Medical Sciences, School of Medicine, Department of Immunology, Shiraz, Iran
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Minamitani K, Sato H, Ohye H, Harada S, Arisaka O. Guidelines for the treatment of childhood-onset Graves' disease in Japan, 2016. Clin Pediatr Endocrinol 2017; 26:29-62. [PMID: 28458457 PMCID: PMC5402306 DOI: 10.1297/cpe.26.29] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Accepted: 12/02/2016] [Indexed: 12/12/2022] Open
Abstract
Purpose behind developing these guidelines: Over one decade ago, the “Guidelines for the
Treatment of Graves’ Disease with Antithyroid Drug, 2006” (Japan Thyroid Association
(JTA)) were published as the standard drug therapy protocol for Graves’ disease. The
“Guidelines for the Treatment of Childhood-Onset Graves’ Disease with Antithyroid Drug in
Japan, 2008” were published to provide guidance on the treatment of pediatric patients.
Based on new evidence, a revised version of the “Guidelines for the Treatment of Graves’
Disease with Antithyroid Drug, 2006” (JTA) was published in 2011, combined with the
“Handbook of Radioiodine Therapy for Graves’ Disease 2007” (JTA). Subsequently, newer
findings on pediatric Graves’ disease have been reported. Propylthiouracil (PTU)-induced
serious hepatopathy is an important problem in pediatric patients. The American Thyroid
Association’s guidelines suggest that, in principle, physicians must not administer PTU to
children. On the other hand, the “Guidelines for the Treatment of Graves’ Disease with
Antithyroid Drug, 2011” (JTA) state that radioiodine therapy is no longer considered a
“fundamental contraindication” in children. Therefore, the “Guidelines for the Treatment
of Childhood-Onset Graves’ Disease with Antithyroid Drug in Japan, 2008” required
revision.
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Affiliation(s)
| | - Kanshi Minamitani
- Department of Pediatrics, Teikyo University Chiba Medical Center, Chiba, Japan
| | | | - Hidemi Ohye
- Department of Internal Medicine, Ito Hospital, Tokyo, Japan
| | - Shohei Harada
- Division of Neonatal Screening, National Center for Child Health and Development, Tokyo, Japan
| | - Osamu Arisaka
- Department of Pediatrics, Dokkyo Medical University, Tochigi, Japan
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Zeng R, Shou T, Yang KX, Shen T, Zhang JP, Zuo RX, Zheng YQ, Yan XM. Papillary thyroid carcinoma risk factors in the Yunnan plateau of southwestern China. Ther Clin Risk Manag 2016; 12:1065-74. [PMID: 27418831 PMCID: PMC4935083 DOI: 10.2147/tcrm.s105023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Objective This study investigated clinical and pathological characteristics and risk factors in papillary thyroid carcinoma (PTC) patients’ native to Yunnan plateau in southwestern China. Methods Clinical data from 1,198 patients diagnosed with PTC (n=578) and control subjects (n=620) with benign thyroid disease (ie, thyroid nodule disease, benign thyroid diseases [BTD]) in Yunnan province were analyzed retrospectively. Results The mean patient age was lower for PTC than for BTD. Positive ratios of thyroid peroxidase antibody, thyroglobulin antibody (TGAb), and thyrotrophin receptor antibody (TRAb) were higher in PTC than in BTD patients. The ratio of PTC coexisting with Hashimoto’s thyroiditis (HT) or with lymphocytic thyroiditis was higher than that of BTD. The number of patients whose age at menarche was ≤13 years, who had given birth to less than or equal to two children, or who were in premenopause were higher in the PTC than in the BTD group. Multivariate conditional logistic regression analyses revealed that age >45 years, nodal size >1 cm, and elevated TG levels were protective factors against PTC. Abnormally elevated TGAb and TRAb levels were independent risk factors for PTC in females. Conclusion HT was not an independent risk factor for but was associated with PTC. TRAb is a risk factor for PTC in individuals living in the Yunnan plateau, but not for those in the plains region.
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Affiliation(s)
- Rong Zeng
- Faculty of Environmental Science and Engineering, Kunming University of Science and Technology, Kunming, People's Republic of China; Faculty of Life Science and Technology, Kunming University of Science and Technology, Kunming, People's Republic of China; Medical Oncology, The First People's Hospital of Yunnan Province, Kunming, People's Republic of China
| | - Tao Shou
- Medical Oncology, The First People's Hospital of Yunnan Province, Kunming, People's Republic of China
| | - Kun-Xian Yang
- Surgical Oncology, The First People's Hospital of Yunnan Province Kunming, People's Republic of China
| | - Tao Shen
- Institute of Clinical and Basic Medicine Research, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Jin-Ping Zhang
- Institute of Clinical and Basic Medicine Research, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Rong-Xia Zuo
- Institute of Clinical and Basic Medicine Research, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Yong-Qing Zheng
- Institute of Clinical and Basic Medicine Research, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, People's Republic of China
| | - Xin-Ming Yan
- Institute of Clinical and Basic Medicine Research, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, People's Republic of China
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Association of single nucleotide polymorphism rs3792876 in SLC22A4 gene with autoimmune thyroid disease in a Chinese Han population. BMC MEDICAL GENETICS 2015; 16:76. [PMID: 26329403 PMCID: PMC4557484 DOI: 10.1186/s12881-015-0222-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/28/2014] [Accepted: 08/20/2015] [Indexed: 12/04/2022]
Abstract
Background The autoimmune thyroid diseases (AITD), including Graves’ disease (GD) and Hashimoto’s thyroiditis (HT), are caused by interactions between susceptibility genes and environmental triggers. Single nucleotide polymorphisms (SNPs) of Solute carrier family 22, member 4 (SLC22A4) have been shown to be associated with several autoimmune diseases, including Crohn’s disease (CD) and rheumatoid arthritis (RA). The aim of this study is to investigate whether SNP rs3792876 in the SLC22A4 gene is associated with GD, HT and AITD in a Chinese Han population. Methods In this study, we collected specimens from 553 Chinese Han individuals of 92 AITD pedigrees in 10 cities in Liaoning province, China (80 GD pedigrees, 478 members; 12 HT pedigrees, 75 members). SNP rs3792876 was genotyped using the TaqMan allelic discrimination assay. Hardy-Weinberg Equilibrium tests were performed among founders of the pedigrees using Haploview software. Family-based association tests performed using FBAT software. Results No deviation from Hardy-Weinberg equilibrium was observed (p > 0.05). There were not significant association between the SLC22A4 gene polymorphism (rs3792876) and GD, HT and AITD was found. Conclusions These results suggest a lack of association between the SLC22A4 gene polymorphism rs3792876 and susceptibility to GD, HT and AITD in a Chinese Han population.
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Martin S, Dutescu MI, Sirbu A, Barbu C, Albu A, Florea S, Fica S. The clinical value of human leukocyte antigen HLA-DRB1 subtypes associated to Graves' disease in Romanian population. Immunol Invest 2014; 43:479-90. [PMID: 24661105 DOI: 10.3109/08820139.2014.886261] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The aim of this study was to identify the primary susceptibility HLA-DRB1 alleles associated with GD in Romanian population and to seek whether specific HLA-DRB1 haplotypes are associated with differences in the clinical presentation of GD at diagnosis. Molecular typing of HLA-DRB1 alleles was performed in 77 Romanian Caucasian GD patients and 445 racially matched controls. In GD patients, age, presence of eye disease, goiter grade, autoantibody status and titer, TSH, FT4, FT3, TT3 levels were recorded at diagnosis. The allelic frequencies of HLA-DRB1*03 (41.55% vs. 17.75%, p < 0.0001, χ(2) = 20.81) and DRB1*11 (42.85% vs. 30.56%, p = 0.045, χ(2) = 3.98)were higher, whereas those of HLA-DRB1*01(3.89% vs. 16.40%, p = 0.007, χ(2) = 7.281) and DRB1*15 (10.38% vs. 21.34%, p = 0.038, χ(2) = 4.309)were lower in GD patients than in controls. FT4/TT3 ratio (p = 0.015) and anti-thyroglobulin antibodies (p = 0.024) were higher in *03/11 patients compared to *X/X, *11/Z, *03/Y patients (where X is any other allele than *03 and *11, Y is any other allele than *11, Z is any other allele than *03). In conclusion, HLA-DRB1*03 and DRB1*11 may be the primary susceptibility HLA-DRB1 alleles associated with GD in Romanian population, whereas HLA-DRB1*01 and DRB1*15 seem to be protective. At diagnosis, HLA-DRB1*03/11 GD patients had higher FT4/TT3 ratio and anti-thyroglobulin antibody levels.
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Affiliation(s)
- Sorina Martin
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy , 020021 Bucharest , Romania
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Rüst CA, Knechtle B, Rosemann T. Graves' disease in monozygotic twins - a case report. BMC Endocr Disord 2013; 13:17. [PMID: 23705898 PMCID: PMC3672004 DOI: 10.1186/1472-6823-13-17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2013] [Accepted: 05/23/2013] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Autoimmune thyroid diseases including Graves' disease and Hashimoto's thyroiditis are caused by immune response to self-thyroid antigens. The rare situation of hyperthyroidism with Graves' disease in twins has been reported in a very few case reports in literature. CASE PRESENTATION We present monozygotic female twins developing consecutively Graves' disease within five years. One year before the diagnosis of Graves' disease was established in the first twin, the mother developed a toxic thyroid nodule with hyperthyroidism leading to hemi thyroidectomy. Both the mother and the twins were cigarette smokers. The twins were treated with carbamizole and this therapy led to normalization of thyroid stimulating hormone and thyroxine. CONCLUSION This case report supports the hypothesis that a genetic factor as well as an environmental factor (cigarette smoking) might be of great importance in the aetiology of Graves' disease.
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Affiliation(s)
- Christoph A Rüst
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
| | - Beat Knechtle
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
- Gesundheitszentrum St. Gallen, Vadianstrasse 26, St. Gallen, 9001, Switzerland
| | - Thomas Rosemann
- Institute of General Practice and Health Services Research, University of Zurich, Zurich, Switzerland
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