Systemic vasculitis and hyperthyroidism in a patient with myasthenia gravis

Granulomatosis with polyangiitis: Possible endocrine manifestations

Granulomatosis with polyangiitis (GPA), formerly known as Wegener's granulomatosis, is a necrotizing vasculitis of small and medium-sized blood vessels characterized by diffuse inflammation of vascular structures and perivascular and extravascular granulomatosis. In its systemic form, GPA predominantly affects the ear, nose and throat, with lung and kidney involvement with typically rapidly progressive necrotizing glomerulonephritis with extracapillary crescents, while the absence of kidney damage at the time of diagnosis is defined as a limited form of GPA with a more favorable prognosis (1, 2). Antineutrophil cytoplasmic antibodies (c-ANCA) with specificity for proteinase 3 (PR3) represent a biochemical diagnostic criterion. They are detected in 90% of generalized forms and in about 50% of limited forms of granulomatosis with polyangiitis (1, 2). In the absence of treatment, GPA is a disease of progressive evolution. Systemic corticosteroid therapy and immunosuppressive therapy significantly changed the prognostic aspect of the disease. Only a few sporadic observations have been published on endocrine disorders associated with GPA. We present a case of a man, 39 years old, with Wegener's granulomatosis who developed autoimmune thyroiditis 8 years after the initial diagnosis.

Central nervous system vasculitis after starting methimazole in a woman with Graves' disease

BACKGROUND

Graves' disease (GD), a prototypical autoimmune disorder, is associated with other autoimmune diseases, including vasculitis. Antithyroid drugs, despite their postulated immunosuppressive effects, may cause several autoimmune disorders. Here we describe the first patient with central nervous system (CNS) vasculitis that developed shortly after the start of methimazole (MMI) treatment for GD.

PATIENT FINDINGS

CNS vasculitis was suspected on the basis of the clinical features and neurologic examination, showing a reinforcement of deep reflexes, especially of the left knee and Achilles reflexes. The diagnosis was confirmed by a brain magnetic resonance imaging (MRI), which showed some hyperintensive spots in the subcortical substantia alba and in the parietal area bilaterally, and by a single-photon emission computed tomography (SPECT) imaging, which showed a nonhomogenous distribution of the blood flow in the brain, with a reduced perfusion on the left side of the frontotemporal and parietal regions, and on the right side of the frontotemporal area. MMI was stopped before total thyroidectomy, and symptoms resolved in the next 5 weeks. Six months after MMI was stopped, the brain MRI and SPECT had become normal.

SUMMARY

To our knowledge, this is the first report of CNS vasculitis related to MMI therapy.

Myasthenia gravis with cutaneous polyarteritis nodosa

Cutaneous polyarteritis nodosa presents with typical cutaneous lesions of polyarteritis nodosa without visceral involvement at the time of diagnosis. We report a 32-year-old woman with a 12-year history of myasthenia gravis under immunosuppressive treatment, who presented with tender, erythematous nodules 20 mm in diameter on her shins. A diagnosis of cutaneous polyarteritis nodosa was made, based on the clinical and histopathological findings. Myasthenia gravis, an antibody-mediated disease, is occasionally accompanied by other autoimmune diseases, but we found no previous report in the literature associating it with polyarteritis nodosa.