Summary of Lupus and Basedow Disease Association: The association lupus auto-immune thyroid disease is well known. Lupus is most commonly associated with Hashimoto’s thyroiditis. As for Graves’ disease, it is most often associated with pernicious anaemia, vitiligo, idiopathic purpura and myasthenia gravis. To our knowledge, we report the first case of lupus associated with Graves’ disease in sub-Saharan Africa. Observation: A female patient of 52 years old has been followed since February 2010 for systemic lupus diagnosed on biological and immunological clinical ACR criteria. There was no skin ailment and kidneys involved. Combined treatment with high-dose corticosteroids early and rapid decrease and hydroxychloroquine was established with good clinical and biological evolution. One year later the patient developed thyrotoxicosis syndrome and vascular goitre without exophthalmos associated with the presence of antibodies anti receptor of TSH leading to the diagnosis of Graves’ disease. The patient has been treated with synthetic anti-thyroid and beta blocker allowing the regression of clinical symptoms and the normalization of thyroid hormones. Since then, the patient had not shown other signs of systemic affection. Conclusion: Systemic diseases are often associated with autoimmune thyreopathies. But association of lupus with Graves’ disease has been rarely described in the literature. One should always watch out for the occurrence of thyroid disease in front of any systemic disease and vice versa.
Autoimmune thyreopathies such as Graves’ disease and more frequently Hashimoto thyroiditis can be associated with other auto immune systemic or organ specific diseases. The more frequently reported associations in these autoimmune thyreopathies are Biermer anaemia, vitiligo, myasthenia, Sjogren disease or rheumatoid polyarthritis. Graves’ disease is very often associated with Biermer disease, vitiligo, idiopathic purpura thrombopenic and myasthenia [
A 52-year-old woman was followed on an outpatient basis since February 2010, in an internal medicine department of the University Hospital of Dakar, for systemic lupus diagnosed according to the ACR criteria modified, non-erosive rheumatoid arthritis and non-deforming small joints (hands, wrists and feet), unilateral serofibrinous pleurisy without cutaneous signs. On interrogation, the history was unremarkable. There were no other systemic affections.
A full blood count showed leukopenia with bicytopenia at 3000/mm3 and anaemia (normocytic normochromic) haemolytic to 9.2 g/dl with direct Coombs test positive and anti Sm antibodies were positive at 2.9 (normal < 0.9). There were no other serous or visceral affections. The 24-hour proteinuria was zero.
The patient was put under corticosteroids (Prednisone) 1 mg/kg for one month, followed by a rapid reduction in 4 weeks of dosing, in increments of 10 mg in combination with hydroxychloroquine 400 mg/day for 6 months. The outcome was favourable with regression of signs of arthritis, loss of pleurisy and normalization of hematologic biological signs after 6 months of treatment.
In November 2011 (i.e. 22 months after taking hydroxychloroquine), she presented a syndrome of thyrotoxicosis combining weight loss despite keeping up of appetite, feelings of tachycardia with palpitations, non-neu- rological trembling of extremities, thermophobia, physical asthenia and vascular goitre without exophthalmia. There were no other signs of thyrotoxicosis.
Hormone check-up showed a collapsed TSHus rate (less than 0.005 IU/L). Anti TSH antibodies were strongly positive 124.8 IU/L (normal < 1.5).
The thyroid Doppler ultrasonography objectivised a homogeneous diffuse goitre hyper vascular. The patient was put under Carbimazole 5 mg: 45 mg/day and propranolol 120 mg/day associated with their previous treatment 10 mg/day corticosteroid and hydroxychloroquine 400 mg/day for two months, followed by 20 mg/day maintenance therapy of Carbimazole. Currently it has a maintenance involving 5 mg of Carbimazole 5 mg of Prednisone daily and 200 mg morning and evening of hydroxychloroquine treatment.
The evolution was favourable with no evidence of thyrotoxicosis signs. The thyroid check-up was also normalized. Only the rate of anti TSH receptor antibody remained still high at 27 IU/L after 14 months of treatment. There was no recurrence of signs or other systemic affections.
We report a case of lupus associated with Graves’ disease. The diagnosis of systemic lupus was placed before clinical criteria (a non-deforming non-erosive rheumatoid arthritis of the small joints, unilateral serofibrinous pleurisy) biological (a bicytopenia with leukopenia 3000/mm3 and haemolytic anaemia to 9.2 g/dl with direct Coombs test positive) and immunologic (positivity of anti Sm). Graves’ disease occurred almost two years after diagnosis of treated lupus disease.
The diagnosis of Graves’ disease was based on manifestations of hyperthyroidism on the one hand and on the other hand autoimmunity events [
Several authors have stressed the frequency of the association of systemic disease and autoimmune thyreopathies, but their actual number is unknown. In a study conducted by Gaches et al. [
The most common associations in autoimmune thyroid disease were the Gougerot syndrome, Biermer disease, and primitive biliary cirrhosis. Graves’ disease is very often associated with Biermer disease, vitiligo, idiopathic purpura, and myasthenia [
In fact, systemic lupus is more usually associated with autoimmune hypothyroidism. Appenzeller et al. [
The terms of the lupus-Basedow disease association are variable. Lupus can precede Graves’ disease that was the case in this observation. This same observation was made by Mokhtar [
In the series of Gaches et al. [
These results require a clinical, biological and immunological monitoring of thyroid function in all patients followed for lupus or other systemic disease.
This association between two autoimmune diseases guides discussions around dysimmune mechanisms. A review of the literature allows considering a common pathogenetic link. There is a genetic field predisposing to the onset of single or multiple dysimmune diseases [
Graves’ disease presents a clear female predominance in the literature [
Treatment of Graves’ disease is based on the prescription of synthetic anti thyroid loading dose, allowing a rapid normalization of thyroid hormone levels, followed four weeks after by a maintenance dose to be administered [
The autoimmune thyroid diseases are often associated with systemic diseases. Lupus is most frequently seen in autoimmune hypothyroidism. However, Graves’ disease is rarely associated with lupus. This is the first observation reported in Sub-Saharan Africa. A systematic examination of the thyroid should be practiced regularly in front of any systemic disease.