Serendipitous identification of Graves' disease in identical twins with polydipsia

IDENTICAL TWIN SISTERS WITH CLOSE ONSET OF GRAVES' DISEASE AND WITH MULTIPLE HLA SUSCEPTIBILITY ALLELES FOR GRAVES' DISEASE

CONTEXT

Autoimmune thyroid disease is considered a multifactorial disorder in which autoimmunity against thyroid antigens is facilitated by exposure to endogenous and environmental factors. We present here a rare case of identical female twins who developed consecutively Graves' disease within a few months and had three HLA susceptibility alleles for the development of Graves' disease.

SUBJECTS

A 28-year-old woman was referred to our hospital complaining of thirst, sweating, palpitations, tremor and skin rash. Laboratory data showed hyperthyroidism with antibodies against the thyroid stimulating hormone receptor and ultrasonography of the thyroid revealed enlargement with hypervascularity. Her identical twin was referred to our hospital because of similar symptoms.

RESULT

We diagnosed them with Graves' disease and both were treated with methimazole. Human leukocyte antigen genotyping showed that both twins possessed the DRB1*04:05, DQB1*04:01:01, DPB1*05:01 haplotype, which confers susceptibility to Graves' disease.

CONCLUSIONS

This case supports the hypothesis that interaction of multiple human leukocyte antigen susceptibility alleles as well as genetic background and environmental factors might synergistically contribute the close timing in Graves' disease onset.

Graves' disease in monozygotic twins - a case report

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.

Detours on the road to diagnosis of Graves disease

OBJECTIVES

The aims of this study were to determine the frequency at which spurious diagnoses and unnecessary treatment occurs prior to the diagnosis of Graves disease (GD) and to evaluate the economic consequences of these events.

METHODS

Retrospective chart review of children diagnosed with GD.

RESULTS

A total of 76 children (61 girls) aged 11.9 ± 3.8 years were identified. In all, 17 (22.4%) were referred to other subspecialists prior to diagnosis of GD. Six were hospitalized, and 2 visited emergency rooms. A total of 15 (19.7%) underwent nonthyroid-related studies. Estimated cost of testing and procedures ranged from $49 to $14,000. Twelve (15.8%) were diagnosed with attention deficit/hyperactivity disorder, and 16 (21.1%) were started on medications for other conditions prior to diagnosis of GD.

CONCLUSIONS

Evaluation and treatment for presumed other disorders are common in children with GD. A high index of suspicion for hyperthyroidism by primary care providers may help to avoid clinical detours that may be costly and delay diagnosis.