European Journal of Endocrinology 10.1530/EJE-16-0737 complex interactionbetween thegeneticbackground genetically susceptibleindividuals ( the immuneresponseagainst thyroidantigensin and existential factors trigger the development of autoimmune disorder, inwhich environmental ( its incidencehasbeenincreasedinthelastdecades prevalent autoimmune thyroid disease at any age, and Hashimoto’s thyroiditis(HT)isworldwidethemost Introduction occurs mostfrequentlyinadults. specific NTADs indifferent agesoflife.Moreover, theassociationbetweenHTandNTADs increaseswithageand Conclusions both cohorts,vitiligobeingthemostcommon. type 1diabetesandcoeliacdiseaseinchildren/adolescents.Skindiseaseswererepresentedwithsimilarprevalence in two cohorts,themostfrequentassociateddiseasesbeingarthropathiesandconnectivetissueinadults and but wassignificantintheadults( significantly higherthanthatofchildren/adolescent( patients ( Results medical history, physicalexamination andassessmentofselectedautoantibodyprofiles. adolescents (449F, meanage11.1 Methods Design clustering inpediatric/adolescentandadultage. non-thyroidal autoimmunediseases(NTADs) inHTpatientsandtodelineate theclinicalpatternofdiseases associated withotherautoimmunediseases.Thepresentstudywasaimedtodescribethetypeandfrequency of Objective Abstract Biomedical SciencesandMorpho-FunctionalImaging, Pericolanti, 1 A Alibrandi R M Ruggeri in adulthoodandchildhood/adolescence thyroiditis: different ofassociation patterns Autoimmune comorbiditiesinHashimoto’s Division ofEndocrinology, DepartmentofClinicalandExperimentalMedicine, 1 DOI: 10.1530/EJE-16-0737 www.eje-online.orgwww.eje-online.org Clinical Study , 2 , : Cross-sectionalstudy. : TheprevalenceofassociatedNTADs wassignificantlyhigherinadults thanthatinpediatric/adolescentHT 3 ). Itrepresentsaprototypicalorgan-specific : 1053newlydiagnosedHTpatients(500adults(467F, meanage40.2 3 P : Hashimoto’s thyroiditis(HT),themostcommonautoimmunethyroid diseaseatanyage,isoften Department ofAdultandDevelopmentAgeHumanPathology‘GaetanoBarresi’,

< : AgeatHTpresentationmayinfluenceautoimmunediseasesclustering,favoringtheassociationof 5

.0001). Inaddition,thenumberofadultpatientssuffering fromtwoormoreassociatedNTADs was , FDe Luca 1 , F Trimarchi

3

and 2 , G Giuffrida © 2017EuropeanSociety ofEndocrinology © 2017EuropeanSociety ofEndocrinology M Wasniewska R MRuggeriandothers P ±

<

3.0 years)) wereevaluatedforcommonNTADs bymeansofcareful recording of

0.0001). TheepidemiologicaldistributionofNTADs wasstronglydifferent inthe 4 , 1 Printed inGreatBritain , R Certo 5 , 5 6 Economics, UniversityofMessina,Italy 3 , 7 ). The 1 , E Cama P

<

0.0001). Afemaleprevalencewasevidentinbothcohorts, 1 disorders, andtheconcept of anautoimmunediathesis ( presentation canbeevenwith transientthyrotoxicosis subclinical andthenoverthypothyroidism, althoughits by anti-thyroidautoantibodiesproduction,toward from anunderlyingautoimmunediathesis,featured the outcomeofdisease,thatgenerallyproceeds and existential/environmentalfactorsalsoinfluences 2 thyroiditis Comorbidities inHashimoto’s , Accademia Peloritanadei 1 3 Published byBioscientifica Ltd. , A Campennì , 3 HT isknowntoclusterwith otherautoimmune , 8 , 9 ). 4 Departments of 4 ± ,

13.7 years) and553children/ Downloaded fromBioscientifica.com at10/03/202112:18:30AM (2017) Endocrinology European Journal of [email protected] Email to RMRuggeri should beaddressed Correspondence 176 176 : 2 176 :2 , 133–141

133 –141

via freeaccess European Journal of Endocrinology www.eje-online.org accepted laboratory and ultrasonographic criteriaaccepted laboratory to avoidselectionbias. and type 2) were excluded, as well as were related subjects, syndrome, autoimmunepolyglandular syndromestype1 disease (i.e.Trisomy 21, Turner syndrome,Klinefelter September 2015.Subjectsaffectedbyanysyndromic of ourUniversityHospitalfromSeptember2012to Endocrinology andPaediatrics’Divisionrespectively, consecutively referredtotheoutpatientclinicof years) who and 553children/adolescentsaged3–18 years diagnosed HTpatients(500adultsaged19–80 In thiscross-sectionalstudy, weenrolled 1053newly Patients Subjects andmethods pediatric andadultage. (namely HT)byconditioningadifferentclusteringin NTADs inpatientswiththesameautoimmunedisorder presentation might study wastoascertain,forthefirsttime,ifageatHT and adults,whowereallaffectedbyHT. Theaimofour (NTADs) intwocohortsofpatients,children/adolescents clustering ofnon-thyroidalautoimmunediseases predisposed individuals( the diversityofautoimmunemanifestationsin and existentialfactorscouldbecriticalindetermining beside thesharedgeneticpredisposition,environmental 15 autoimmune diseasesratherthanthereverse( have examinedtheprevalenceofHTinnon-thyroidal 20 cutaneous conditions( for others,includingvariousrheumatologicaland ( extent thatscreeningrecommendationscanbemade for somedisorders(namelyperniciousanemia),tothe 20 association withHT( to systemicdiseaseshasbeenvariouslydescribed in endocrine ornon-endocrine organ-specific diseases spectrum ofautoimmunedisordersrangingfromeither a shared genetic predisposition ( their relatives,mainlyhighlightingtheimportanceof of otherautoimmunediseasesinsubjectswithHTand have reportedanincreasedprevalenceandrelativerisk is widely accepted ( 11 Clinical Study , ). However, moststudiesevaluatingsuchassociations ). Suchanassociationhasbeenfirmlyestablished ), whereasithasbeenreportedinvariablepercentages 16 HT wasdiagnosedaccording tothecurrently The presentstudywasaimedtoinvestigatethe , 17 , 18 , 19 , 20 per se ). Also,thisestimateindicatesthat 4 11 , 12 5 , 11 , 12 influencetheaggregationof , 7 ). 13 , , 13 10 , R MRuggeriandothers , 14 , 14 11 , 11 , 15 ). Previous studies 15 , , 12 , 16 16 , , 13 , 17 17 ). A wide , , 18 10 18 , , , 14 19 19 , , ,

Patients inwhomHTwasdiscoveredadulthood, period oflife(adulthoodorchildhood/adolescence). HT, butboth diseaseswerediagnosedinthesame have already been diagnosed for the NTAD prior to selected autoantibodyprofiles.Anumberofpatients history, physical examination and assessment of (NTADs) bymeansofcarefulrecordingmedical evaluated fornon-thyroidalautoimmunediseases with elevatedfreethyroidhormones( undetectable ( mL respectively, whereasthyrotoxicosiswasdefinedas according totheTSHvaluebeingbeloworabove10 subdivided intosubclinicalandoverthypothyroid of diagnosisweredefinedhypothyroidandfurther features ( dermatological diseaseswas basedonlyonclinical with autoantibody-positive values( Oral glucosetolerancetest wasperformedinpatients autoantibodies, as well as glycosylated hemoglobin. (GADA), anti-insulin(IAA)andanti-isletcell(ICA) determination of anti-glutamicaciddecarboxylase colitis ( was mucosalbiopsyduringcolonoscopyforulcerative critical forthediagnosisofautoimmunehepatitis,as it by thesmallintestinebiopsy( positive forthespecificautoantibodieswasconfirmed Diagnosis ofcoeliacdisease(CD)inpatientswhotested (EMA) and anti-tissue transglutaminase IgA (aTTG). and anti-21-hydroxylase(21-OHAb),anti-endomysium gastric mucosa(anti-PCA),anti-adrenalcortex(ACA) the followingorgan-specificautoantibodies:anti- ( evidence, accordingtothecurrentlyacceptedcriteria diagnosed onthebasisofbothclinicalandlaboratory arthropathies andconnectivetissuediseases,were when appropriate.Rheumaticdisorders,suchas kidney microsomal (LKM), antibodies) were searched anti-centromere, anti-mitochondrial(AMA),liver– antibodies. Additionalspecificautoantibodies(i.e. DNA (nDNA)andextractablenuclearantigens(ENA) practice: antinuclear(ANA),double-stranded(native) autoantibodies, commonlyutilizedinrheumatologic were screenedforthefollowingnon-organ-specific in childhoodwereexcluded.Alltheothersubjects whereas T1DMorCD,forinstance,hadbeendiagnosed status, individualswithaTSH hypoechogenicity atUS)( heterogeneous echo-structurewithdiffuseorpatchy (serum anti-thyroidantibodiespositivityand thyroiditis Comorbidities inHashimoto’s 22 , All HTpatientsincludedinthestudywere 23 , 26 24 28 ). Type 1diabetes(T1DM)screeningincluded ). Also,weassayedseraofeachcohortfor , 29 < , 0.01 30 ). µU/mL) orlow( Downloaded fromBioscientifica.com at10/03/202112:18:30AM 1 ). Concerningthefunctional > 25 5 µIU/mL atthetime ). Liverbiopsywas 176 27 < 21 :2 Um) TSH 0.4 µU/mL) ). Diagnosisof ). 134 µIU/ via freeaccess European Journal of Endocrinology TPO-Ab (IU/L) Tg-Ab (IU/L) FT4 (pmol/L) TSH (µIU/L) Hyperthyroidism Overt Subclinical Hypothyroidism Euthyroidism Functional status( Male Female Sex Mean Age (year) Parameters specified under‘Materialsandmethods’section. Table 1 < the intra-andinter-assayCVswere of ourUniversityHospitalMessina.Forallassays, samples were processed centrally in the laboratory according tothemanufacturer’s instructions.All fluoro-enzyme immunoassaywithcommercial kits, radioimmunoassay orbyimmunofluorescence specific autoantibodieswere routinely measuredby ( adult population with an upper limit up to 6.26 forTSHarewiderthanthoseinthereference intervals However, it should be considered thatthepediatric 0–115 TSH, 0.27–4.2 wereby DasitSpA).Normalvaluesinourlaboratory radioimmunoassay (BrahmsTrak HumanRIA,supplied TSH receptorantibodies(TRAbs)weremeasuredby analytics E170suppliedbyRocheDiagnostics.Anti- using commercial kitsforElecsys1010/2010emodular electrochemiluminescence immunoassay(ECLIA), peroxidase antibodies(TPOAb),weremeasuredby as wellanti-thyroglobulin(TgAb)andanti-thyroid Serum TSHandfreethyroxine(FT4)concentrations, Methods participate. the children’s parentsgaveinformedwrittenconsentto Committee ofourhospital,andalltheadultpatients P 3 -Values typedinboldaresignificant( 10% respectively. Clinical Study F:M ratio ). Theaforementionednon-organ-andorgan- The study design was approved by the Ethics IU/mL; TPOAb,0–34 ±

General characteristicsofthestudypopulation.Dataareexpressedasmean s . d . (range) µIU/L; FT4,12.0–22.0 n (%)) P ≤0.05). IU/mL; TRAb, R MRuggeriandothers 7444.85 899.95 40.22 13.87 5.75 Adults 146 (29.2%) 467 (93.4%) 69 (13.8%) ± 215 (43%) 285 (57%) pmol/L; TgAb, 33 (6.6%) ± ± ± 92176.49, 37 (19–80) 13.72 3448.25, 14.5:1 ± 13.03, 3.55, 0 ( n =500) < 5% and < 14.0 2.48 1 IU/L. 165.0 216.50 U/L

deviation ( Numerical dataareexpressedasmeanandstandard Statistical analysis University HospitalofMessina. 10 apparatus (GeneralElectricHealthcare,UK),witha7.5– all patients at the first evaluation using areal-time 2D examined categoricalvariables,foradultsandchildren/ patients with and without associated NTADs for all the relative significance.Thesametestwasappliedtocompare and thyrotoxicosis),weestimatedchi-squaretestthe (euthyroidism, subclinicalandoverthypothyroidism such assex,typeofcomorbidityandfunctionalstatus children/adolescents) andothercategoricalvariables, percentage. alpha level.050hastobedividedbythenumberof apply Bonferroni’s correction,forwhichthesignificance Whitney test.Forthesemultiplecomparisons,wehadto comparisons between the NTADs for age using Mann– resulted tobehighlysignificant,weperformedpairwise 12 selectedNTADs usingKruskal–Wallis test;asit interquartile range.We comparedageamongthe could calculatemedianageatdiagnosisandrelative prevalence ofcomorbiditiesinbothcohorts. adolescents, separatelyand,also,tocomparetheglobal thyroiditis Comorbidities inHashimoto’s MHz lineartransducerattheRadiologyUnitofour To assesstheassociationbetweencohorts(adultsor Thyroid ultrasonography(US)wasperformedin For NTADs affectingatleast6patients,we Children/adolescents 1237.71 826.86 s . d 11.11 13.85 13.02 . ), andcategoricalvariablesasnumber 95 (17.20%) 217 (39.2%) 300 (54.3%) 104 (18.8%) 449 (81.2%) 122 (22%) 36 (6.5%) ± ± ± ± 2041.40, ± ± 2622.60,

4.3:1 s .6 (3–18) 2.96 . 6.53, 29.07, d ., medianinitalics.Normalvaluesare Downloaded fromBioscientifica.com at10/03/202112:18:30AM 13.3 4.0 237.0 ( 554.0 n =553) 176 www.eje-online.org :2 < < < P 0.0001 0.0001 0.0001 0.114 0.673 0.952 0.234 0.413 value – – 135 via freeaccess European Journal of Endocrinology www.eje-online.org results ofbothgroupsarepresentedin mean age at presentation11.1 those from553children/adolescents(449F, 104M, 33 M,meanageatpresentation40.2 We compared the data from500 adult patients (467 F, population General characteristicsofadultandpediatricstudy Results statistically significant. Window package. wascalculated. interval adult population,oddsratioandrelative95%confidence .050/78 =.0006. to equal the new‘adjusted’significancelevelforthisanalysisis comparisons, sothe possible seventy-eight pairwise Gastro-enteric diseases P urticaria, 1psoriasis,2erytemanodosum, 1multiplesclerosis,5CD,UC)andin75children/adolescents (36T1DM,29CD,8vitiligo,2alopecia); preceded thediagnosisofHTin70 adults(16SpA,14RA,7SS,4SLE,1polymyositis,5undifferentiated connectivedisease,10vitiligo, 1chronic * Multiple sclerosis Addison’s disease Type 1diabetesmellitus Lichen Alopecia Psoriasis Vitiligo Cutaneous diseases Vasculitis Polymyositis Connective tissuediseases Other SpA Psoriatic Arthrtitis Arthropathies Non-thyroidal autoimmune diseases Table 2 P < valuestypedinboldaresignificant ( Clinical Study Ulcerative colitis(UC) Autoimmune hepatitis Celiac disease(CD) Atopic dermatitis Erythema nodosum Chronic urticaria Undifferentiated connectivedisease Systemic scleroderma(SSc) Systemic LupusErythematosus(SLE) Sjogren’s syndrome(SS) Reumatoid arthritis(RA) SpondyloArthritis (SpA)

0.0001 adultsvschildren/adolescents. Statistical analyses were performed using SPSS 17.0 for Moreover, toevaluatetheriskofeachNTAD for Prevalence ofassociatednon-thyroidalautoimmunediseases(NTADs) inadultandpediatric/adolescentHTpatients. P

<

0.05 twosideswasconsideredtobe ± P ≤0.05). R MRuggeriandothers

2.9 years). The analytic ± § Forty adultsand7pediatricpatients hadtwoormoreassociatedNTAD ( 37yas with 13.7 years) Table 1 . 147/500 (29.4%) 15 (3%) 29 (5.8%) 48 (9.6%) 65 (13%) 14 (2.8%) 10 (2%) 28 (5.6%) 25 (5%) 11 (2.2%) 29 (5.8%) 40 (8%) Adults 3 (0.6%) 5 (1%) 2 (0.4%) 2 (0.4%) 4 (0.8%) 9 (1.8%) 2 (0.4%) 1 (0.2%) 3 (0.6%) 4 (0.8%) 5 (1%) 1 (0.2%) 1 (0.2%) 1 (0.2%) 7 (1.4%) 0 with no relapses.No hyperthyroid individuals were found resolution occurredspontaneouslywithin3–18 months, TPOAb serumlevelswerepositive, and hyperthyroidism undetectable duringtheoverallfollow-upperiod,whereas presentation. Insuchpatients,serumTRAbsremained (6.5%) withtransientthyrotoxicosis(Hashitoxicosis)at forpediatricageshouldbeconsidered. reference intervals in theformer( largely exceededtherateofsubclinicalhypothyroidism that inadultsbecausetherateofoverthypothyroidism TSH wassignificantlyhigherinchildren/adolescentsthan between thetwocohorts( about fortypercent werehypothyroid,withoutdifferences of thepatientswereeuthyroidatfirstevaluation,and evident intheadults( but suchafemaleprevalencewassignificantlymore in theadultcohort( thyroiditis Comorbidities inHashimoto’s § In the pediatric cohort, there were 36 patients Concerning thyroid functional status, more than half The female sex was more represented in both groups, Children/adolescent 104/553 (18.8%) P

<

0.0001). Also, thewiderserumTSH Table 1 40 (7.23%) 38 (6.9%) 25 (4.5%) 40 (7.23%) 15 (2.7%) P 4 (0.7%) 1 (0.18%) 1 (0.18%) 2 (0.36%) 5 (0.9%) 2 (0.36%) 1 (0.18%) 1 (0.18%) 1 (0.18%) 0 0 0 0 0 0 0 0 0 0 0 0 0

< Downloaded fromBioscientifica.com at10/03/202112:18:30AM 0.0001). Table 1 ). § ). However, meanserum P 176

< .01. NTAD 0.0001). :2 P <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 <0.0001 value* 0.017 0.381 0.487 0.091 0.991 0.408 0.319 0.507 0.636 0.062

136 via freeaccess European Journal of Endocrinology NTADs asawholeandthatofpatientswithoutanycomorbidity ( NTADs, thedifference inmedianagewassignificant( autoimmune comorbiditieswerealso displayed.Comparingpatientsaffected byeachoftheaforementionedrheumaticdisorderswith patientswithout ( vitiligo, CDandT1DM( The followingstatisticallysignificantcomparisonswererecorded:Psoriatis arthritisvsvitiligo,CD,T1DM,psoriasisandalopecia( None Alopecia Psoriasis Type 1diabetesmellitus(T1DM) Coeliac disease(CD) Chronic urticaria Vitiligo Undifferentiated connectivetissuedisease Systemic LupusErythematosus(LES) Sjogren syndrome(SS) Rheumatoid arthritis(RA) Psoriatic arthritis autoimmune diseases Coexisting non-thyroidal relationship withthemostprevalentcomorbidities.* Table 3 range. AccordingtoBonferroni’s correction,the‘adjusted’significance levelis0.050/78 affected bydifferent NTADs usingMann–Whitney test.OnlyNTADs affecting sixormore patientswereincluded,toallowcalculationofinterquartile were diagnosedinbothcohortswithasimilarprevalence, represented byCDandT1DM( and themostprevalentautoimmunecomorbiditieswere population, thesedisorders were absentorrarelyfound, Sjögren syndrome(SS).Inthepediatric/adolescent arthritis (RA), and connective tissue diseases, mostly arthropathies, mostly psoriatic arthritis and rheumatoid adult patientsthemostfrequentassociateddiseaseswere strongly differentinthetwocohorts.Infact, adolescents (40vs7; NTAD wassignificantlyhigherthanthatofchildren/ of adult patients who suffered from two or more associated cohort: 29.4vs18.8%( significantly higher in adults than that inthe pediatric the prevalenceofpatientswithassociatedNTADs was and theirfrequencies,arereportedin found inassociationwithHTourstudypopulation, The wholespectrumofautoimmunedisordersthatwere Association withNTADs inadultsandchildren pediatric group. thyrotoxicosis wasdefinitelymorefrequentinthe overt hypothyroidismweresignificantlydifferent,and two cohorts,buttheproportionsofsubclinicaland and hypothyroidismwereequallyfrequentinthe P

= Clinical Study 0.0001); LESvsT1DM( The epidemiologicaldistributionofNTADs was In summary, atHTpresentation,botheuthyroidism Median ageatHTpresentationandinterquartilerange(years)inallpatients(adultspluschildren/adolescents), P

(NTADs) < P 0.0001), andalopecia( P

=

0.0001); undifferentiated connectivetissuediseasevsCDand T1DM( < P 0.0001).

<

0.0001). Moreover, thenumber R MRuggeriandothers al 2 Table P Table 2

= 0.0004); SSvsLES( ). Skindiseases P

<

0.0001). Itwashighlysignificantalso thecomparisonbetweenmedianageofpatientswith . Asshown, Patients n P 802

< 40 49 29 10 28 26 29 6 6 6 7

0.0001). *We performedpairwisecomparisonsbetweenmedianagesofpatients P

= 0.0004), vitiligo,CDandT1DM( those withoutanyotherautoimmunedisease( patients withcomorbidities,asawhole,wereolderthan coexisting T1DMorCD( autoimmune disease( were oldercomparedtocaseswithoutanyassociated Similarly, subjectsaffectedbyconnectivediseases suffering fromT1DM,vitiligo,alopeciaorCD( diseases ( compared withpatientsnocoexistingautoimmune with coexistingarthropathiesweresignificantlyolder between caseswithdifferentautoimmunediseases,those ( range) inrelationtothetypeofassociatedcomorbidity stratified allHTpatientsbyage(medianandinterquartile in relation with age was even more evident when we ( occurred inthetwocohortswithasimilarprevalence vitiligo beingthemostcommon.Also,Addison’s disease adults ( preceded the diagnosis of connective tissue diseases in diagnosed beforeHT( pediatric/adolescent group, T1DM and CD were usually children/adolescents ( diagnosis ofNTAD in77(52%)adultsand29(28%) the presentingautoimmunedisease.HTpreceded on age,therewasalsoadifferentpatterninregardto thyroiditis Comorbidities inHashimoto’s al 3 Table Table 2 Such adifferentclusteringofautoimmunedisorders In additiontothedifferencesinaggregationbased Median ageatpresentation = P 0.0006. ).

). Whencomparingmedianageatdiagnosis = P 0.0041). Inouradultcohort,arthropathieswere

<

0.00001), aswellcomparedtothose P <

14.6 12 15.5 11.9 14.6 33 12.9 41.5 32 49 50.5 46 0.0001). Dataforpatientswithnoother P < χ

0.0001), psoriasis( 2 P =14.98; Downloaded fromBioscientifica.com at10/03/202112:18:30AM P

<

<

P 0.0001), whereasHTusually

0.001) andtothosewith

< .0) ( 0.001) P

< Interquartile range

0.0001). Within the P 176 .0) alopecia =0.002), P al 3 Table

< www.eje-online.org :2 10.8–36 10.2–14.8 11.4–16.8 18.4–46 42.2–60.5 40.7–63

0.0001); RAvs 9.4–21 9.2–38 35–50 20–34 37–57 9–14 ). Also,HT P P

< < 0.0001). 0.0001). 137 via freeaccess European Journal of Endocrinology TSH (µIU/L)* Thyrotoxicosis Overt Hypothyroidism Euthyroidism Functional status( Male Female Sex Mean Age (year) Tg-Ab (IU/L)* FT4 (pmol/L)* www.eje-online.org significant ( *Data areexpressedasmean TPO-Ab (IU/L)* Subclinical Patients withNTAD Parameters autoimmune diseases(NTADs). Table 4 subdividing thesepatients according totheirpubertal children/adolescents with comorbidities.Moreover, P ratio wassignificantlylower intheformer(2.8:1vs4.9:1; between subjects with or without NTADs, but the F:M cohort, therewerenodifferencesinageatpresentation than thosewithoutNTADs. Inthepediatric/adolescent comorbidities were more frequently females and older the formerand12:1inlatter. Thus, adultswith 38.9 than those without comorbidities (43.40 subjects with associated NTADs were significantly older without NTADs, somedifferencesemerged.Inadults, P children/adolescents withcomorbidities(41.5%vs26.9%; was foundinahigherpercentage ofadultscomparedto Concerning thyroidfunctionalstatus,hypothyroidism tends toinvolvemainlywomenwithincreasingage. in theadultcohort,indicatingthatautoimmunity once again,suchafemaleprevalencewasmoreevident two subgroupsofpatientswithassociatedNTADs, but found thatthefemalesexwasmorerepresentedin adolescent patientswithassociatedNTADs ( between agegroups( ( before orafterHTatthesameextentbothinchildren as wellCD( diagnosed before or after HT at the same extent ( P =0.025). = F:M ratio

Clinical Study = 0.046); thus, males were more represented among 0.2363) andadults( Comparing in each cohort the HT patients with and Comparing the two subgroups of adult and pediatric/ ± 33 year; 13.35 ±

Demographic andclinicalparametersofadultschildren/adolescentswithHTassociatednon-thyroidal s P . ≤0.05). d . (range) P n

= (%)) 0.8531). Skin diseaseswerediagnosed P

< P

0.0001), with a F:M ratio 28:1 in =0.3899). ±

s . d P . , medianinitalics.Normalvaluesarespecifiedunder‘Materialsandmethods’section. .44, ihu differences without =0.9484), R MRuggeriandothers 340.66 43.40 325.41 13.10 147/500 (29.4%) 5.54 18 (12.25%) 43 (29.25%) 142 (96.6%) 61 (41.5%) 86 (58.5%) Table 4 ± ± 28:01:00 5 (3.4%) ± ± ± 41 (18–80) 14.13 489.69, ± Adults 11.79, P 41 vs 14.13 4.76, 973.09, =0.403), 0 ), we 13.72 2.38 187.75 113 represented inbothgroups. *OR wascalculatedforallautoimmune comorbidities,whichwere pediatric/adolescent cohort(forprevalencevalues autoimmune disease,comparingprevalenceinadultvs Table 5 Alopecia Psoriasis Coeliac disease(CD) Type 1diabetesmellitus(T1DM) Chronic urticaria Vitiligo Vasculitis Rheumatoid arthritis(RA) Two ormoreNTAD Any NTAD autoimmune disease Coexisting non-thyroidal when datawereavailableeitherfromthecurrent compared tothosereportedintheItalianpopulation, 21.107), suggestingastrongdiseaseassociation( NTADs, therelativeriskwasgreatestforRA(OR OR ofhavingmorethantwoNTADs. Amongthevarious adolescents, andinadulthooditwasevenhigherthanthe disorder wasgreaterinadultsthanchildren/ odds ratio(OR)ofdevelopinganadditionalautoimmune and pre-pubertal(35/190or18%)subjects( prevalence of NTADs betweenpubertal (69/363 or 19%) status, we did not find any significant difference in the thyroiditis Comorbidities inHashimoto’s Also, the observed prevalencerates of NTADsAlso, the observed were As shownin Relative risk(oddsratio)ofthesinglenon-thyroidal 1103.20 1359.80 11.13 Children/adolescent 15.24 104/553 (18.8%) 8.56 13 (12.5%) 15 (14.4%) 28 (26.9%) 69 (66.4%) 27 (26%) 77 (74%) al 5 Table 7 (6.7%) ± (NTAD) ± ± ± ± 24.85, 2.8:1 . (2.8–18) 3.4 4.98, 4255.29, 3830.98,

Downloaded fromBioscientifica.com at10/03/202112:18:30AM 14.75 , therelativerisk,expressedas 2.92 175 386 P valuestypedinboldare 21.107 Odds ratio 0.136 1.427 0.104 0.024 3.627 0.625 0.705 5.18 1.798 176

:2 95% Confidence 0.016–1.179 0.256–7.937 0.048–0.228 0.006–0.102 0.417–31.511 0.287–1.357 0.044–11.409 2.811–158.465 2.217–12.105 1.349–2.396 P < < < =0.866). P 0.019 0.0001 0.025 0.0001 0.0001 0.004 0.2 0.188 0.256 interval > value – – – 0).* Table 5

138 via freeaccess ).

European Journal of Endocrinology same manner, nodifferencesinage at diagnosiswere of associated NTADs betweenmenandwomen. Inthe there werenosignificant differences intheprevalence women definitelyoutnumbered men(2744Fand542M), were significantly increased in both. In this cohort, even if relative risksofallothercoexistingautoimmunedisorders 14.3% inHTand9.67%Graves’diseasecases,the ( age 43 years) suffering from HT ( characterized cohortofadultCaucasiansubjects(mean relative risk of other autoimmune diseases in a well- coworkers ( and adultage. a differentclusteringofdiseasesinpediatric/adolescent same autoimmune disorder (namely HT) by conditioning influence theaggregationofNTADs inpatientswiththe ascertain whether the age at HT presentation might autoimmune diseases.Thepresentstudywasaimedto on theirpossibleroleinconditioningtheaggregationof autoimmune disorders( gender areassociatedwithincreasingriskofdeveloping patients alongwithadultsHT. the literature,whichincludesevenpediatric/adolescent our knowledge,thisisthelargestcohortsofarreportedin diseases aggregationinrelationwithage.To thebestof at anyageoflifetodelineatetheclinicalpatterns 1000 well-characterized,newlydiagnosedHTpatients between HT and other autoimmune diseases in more than In the present study, we have evaluated the association Discussion pediatric ageandforCDvitiligoinbothgroups. for connectivetissuediseasesinadultage,T1DM of otherautoimmunediseaseinHTpatients,mainly non-casual diseaseassociationandanincreasedrisk prevalence data,ourdatasupportthepresenceofatrue, population limited by the paucity of contemporary adolescents vs2.0%inthegeneralpopulation.Although adolescents; vitiligo, 2.8% inadultsand2.7%children/ CD 1.8%vs0.7%inadults,7.2%1.25%children/ vs 0.07%;T1DMinchildren/adolescents,6.8%1.5%; population; RA,5%vs1%;SS,5.6%3%;LES,1.4% population: psoriaticarthritis,5.8%vs1%inthegeneral more frequentlyinourHTsubjectsthanthegeneral ( literature ( www.salut n Clinical Study

= 2791). TheestimatedprevalenceofanotherNTAD was A previous multicenter study by Boelaert and It iscurrentlyknownthatincreasingageandfemale 31 e.gov.it). MostoftheNTADs werereported 13 , 32 ) haveestimatedtheprevalenceand , 33 , 34 7 ) orfromourHealthDepartment , 10 ), butscantydataareavailable n R MRuggeriandothers

= 495) or Graves’ disease per se

pediatric/adolescent (553 cases, aged sex andagetothestudybyBoelaertcoworkers) consisted ofbothadults (550 cases,comparable by number, Furthermore, unlikepreviousstudies,ourHTpopulation the participantsforcommonautoimmunediseases. just collectedtheclinicalrecordsbutalsoscreenedall the study. age onsuchanassociationasitwasbeyondtheaimof no additionalinformationaboutthepossibleinfluenceof provided strongevidencefortruediseasesassociation,but study ( without anyassociatedNTAD wasnotprovidedinthe whole groupofpatientswithdifferentNTADs andthose any associatedNTADs. However, comparisonbetweenthe RA and pernicious anemia were older than cases without NTADs, whereasGraves’s diseasecaseswithcoexisting reported betweenHTcaseswithorwithoutassociated This hasanimportantsignificanceforthediseases and firsthighlightthatthere aresignificantdifferences about theirepidemiological distributionandclustering, the literature,presentdata providenovelinformation present studyhavealready been reportedindividuallyin their pubertalstatus. prevalence whensubdividingthesesubjectsaccording to Accordingly, wedidnotfindanydifference inNTADs autoimmune diseasesaggregationatyoungerage. that sex-relatedfactorsarelessimportantinconditioning compared tothosewithoutcomorbidities,suggesting ratio wassignificantlylowerinHTpatientswithNTADs adolescents. Under theageofeighteen,female: male such a female preponderance was not evident in children/ autoimmune comorbiditieswithincreasingage.However, one ormoreotherautoimmunedisorders. coexisting NTADs withage,aswellanincreasedORfor adolescents. Thus,wereportanincreasingprevalenceof as adultshadanearlytwofoldriskcomparedtochildren/ The relativeriskofdevelopingNTADs increasedwithage were significantlyolderthanthosewithoutcomorbidities. adolescents. Moreover, subjectswithassociatedNTADs was significantlyhigherinadultsthanchildren/ patients sufferingfromtwoormoreassociatedNTADs was significantlyhigherinadults.Alsothenumberof in thewholecohortofHTsubjectswas23.8%,andit others tendtooccurlater(i.e.RA). tend tooccurearlyinlife(i.e.T1DMandCD),whereas prevalence estimatesassomeoftheNTADs investigated thyroiditis Comorbidities inHashimoto’s In thepresentstudy on alargecohort,wenotonly Although mostdiseaseassociations describedinthe Female subjectsweremorefrequentlyaffectedby In our study, the prevalence of associated NTADs 13 ). Thus,thestudyfromBoelaertandcoworkers Downloaded fromBioscientifica.com at10/03/202112:18:30AM 176 < 18 years) patients. 18 years) www.eje-online.org :2 139 via freeaccess European Journal of Endocrinology www.eje-online.org compared withthosereportingT1DM,vitiligo,alopecia and/or connectivediseasesweresignificantlyolder different NTADs, patientswithcoexistingarthropathies comparing medianageatdiagnosisbetweencaseswith vitiligo beingthemostcommon.Accordingly, when represented withsimilarprevalenceinbothcohorts, prevalent oneswereT1DMandCD.Skindiseases disorders wereabsentorrarelyfound,andthemost the contrary, inthepediatric/adolescentcohort,these the ORwasgreatestforRA(morethan20-folds). On and RA)connectivetissuediseases(mostlySS), associated diseaseswerearthropathies(psoriaticarthritis different in thetwocohorts. In adults, the mostfrequently different ages.Infact,theNTADs distributionwasstrongly in theprevalenceandpeculiaraggregationsofNTADs in diseases clustering,favoring theassociationofsome Age atpresentationofHT may influenceautoimmune autoimmune disordersinrelation toageinthesepatients. time, delineatesdifferent patterns ofaggregation prevalence ofNTADs inHTpatients,andfor thefirst rheumatic diseaseswithincreasingageinourcohort. account forthehighrateofassociationbetweenHTand arthritis and spondyloarthritis ( in variousage-relateddisorders,includingrheumatoid there isgrowingevidenceontheroleofmicrobiome intensely debatedatpresent( microbiota dysbiosis,whoseroleinautoimmunity is increased oxidative stress, improved hygiene and intestinal progression ofthedisease,suchasvitaminDdeficiency, factors potentiallyinvolvedinthedevelopmentand autoimmune disordersmaysharecommonexogenous occurrence ofotherautoimmunedisorders( thus possiblyprolongedinflammation,mayfavorthe authors hypothesizedthatCDdiagnosislaterinlife, of having a concomitant autoimmune disorder. The or the disease duration, was an independent predictor the timeofCDdiagnosis,andnotfollow-up compared tothosewithCDalone( in patientswithacoexistingautoimmunedisorder and theageofCDdiagnosiswassignificantlyhigher microscopic colitisandautoimmunethyroiddiseases), of thepatients(themostprevalentbeingT1DM, of another autoimmune disease was reported in 25.2% including morethan400CDpatients,theoccurrence clusters withHT, i.e.CD( another organ-specific autoimmune disease that often or CD. Clinical Study In conclusion,thepresentstudyconfirmsahigh It isconceivablethat,besidethegeneticbackground, Very recently, similarfindingshavebeenreportedin 20 ). Inaretrospectivestudy 6 , 37 R MRuggeriandothers 7 , ). This hypothesis may P 35

= , .002). Olderageat 36 , 37 20 ). Specially, ). 10 the public,commercialornot-for-profit sector. This research did not receive any specific grant from any funding agency in Funding perceived asprejudicingtheimpartialityofresearchreported. The authorsdeclarethatthereisnoconflictofinterestcouldbe Declaration ofinterest the pathogenesisofcoexistingautoimmunediseases. related autoimmunemechanismsmaycontributeto comparison withchildren/adolescents.Common age- increased prevalenceandriskofconcomitantNTADs in increases withage,andadultHTsubjectshaveboth Moreover, theassociationbetweenHTandNTADs investigated/suspected inrelationwithpatient’s age. a consequence,differenttypesofNTADs shouldbe adolescents andrheumaticdiseasesinadulthood.As specific NTADs, suchasT1DMandCDinchildren/ References thyroiditis Comorbidities inHashimoto’s 8 9 7 6 5 4 3 2 1 Weetman AP. Non-thyroidautoantibodiesinautoimmune thyroid 2005 disease. (doi:10.1159/000334640) hashitoxicosis. Capalbo D, DeLuca F&Valenzise M. Outcomesofchildrenwith 014-0054-0) Endocrinological Investigation Metabolic Research thyroiditis: furtherdevelopmentsinourunderstanding. ( thyroiditis: firstreportonitsnaturalhistory. when presentingasinitialmanifestationofjuvenileHashimoto’s Salzano G, DeLuca F&Wasniewska M. Subclinicalhyperthyroidism in Hashimoto’s thyroiditis. receptor genepolymorphisms/haplotypesandserum25(OH)D3levels Campennì A, Cannavò S,Trimarchi F &Ruggeri RM.Vitamin D Endocrinology autoimmune thyroiddisease:oldandnewplayers. Metabolic Research (doi:10.1159/000343815) patients’ age. in childhoodandadolescencearemainlyconditionedby Thyroid functionpatternsatHashimoto’s thyroiditispresentation Messina MF, Aversa T, Bombaci S,DeLuca F&Valenzise M. 9703-2) autoimmunity. (doi:10.1016/j.autrev.2014.01.007) and diagnosticcriteria. Wasniewska M, Corrias A,Salerno M,Lombardo F, Aversa T, Mussa A, Ajjan RA &Weetman AP. ThepathogenesisofHashimoto’s Aversa T, Valenzise M, Corrias A,Salerno M,Mussa A,Capalbo D, Giovinazzo S, Vicchio TM, Certo R,Alibrandi A,Palmieri O, Effraimidis G &Wiersinga WM. Mechanisms inendocrinology: Weetman AP. Thegeneticsofautoimmunethyroiddisease. Wasniewska M, Corrias A,Salerno M,Mussa A,Capalbo D, McLeod DS &Cooper DS.Theincidenceandprevalenceofthyroid Caturegli P, DeRemigis A&Rose NR.Hashimotothyroiditis:clinical doi:10.1007/s12020-016-0942-5 19 Best PracticeandResearch ClinicalEndocrinologyandMetabolism 17–32. 2014 Hormone ResearchHormone inPaediatrics Hormone ResearchHormone inPaediatrics Endocrine (doi:10.1016/j.beem.2004.11.004) 2015 2009 170 R241–R252. Autoimmunity Reviews 47 41 2015 702–710. 421–425. Endocrine Downloaded fromBioscientifica.com at10/03/202112:18:30AM 2014 42 ) 252–265. 37 (doi:10.1530/EJE-14-0047) 2016.(Epubaheadofprint) (doi:10.1055/s-0035-1548832) (doi:10.1055/s-0029-1214415) 303–308. (doi:10.1007/s12020-012- 176 2012 2014 2012 Journal ofJournal (doi:10.1007/s40618- :2 78 13 European Journal of European Journal 77 232–236. 391–397. 36–40. Hormone Hormone Hormone Hormone 140 via freeaccess

European Journal of Endocrinology 24 23 22 21 20 19 18 17 16 15 14 13 12 11 Clinical Study Brito-Zerón P, Theander E,Baldini C, Seror R,Retamozo S, Aletaha D, Neogi T, Silman AJ,Funovits J,Felson DT, Firestein GS, Budd RC,Gabriel SE,McInnes IB&O’Dell JR. Biondi B &Cooper DS.Theclinicalsignificanceofsubclinicalthyroid Spijkerman M, Tan IL, Kolkman JJ,Withoff S, Wijmenga C, Alpigiani MG, Cerboni M,Bertini I,d’Annunzio G,Haupt R,Iester A Kakourou T, Kanaka-Gantenbein C,Papadopoulou A,Kaloumenou E Doyle EA. Autoimmuneconditionsassociatedwithtype1diabetes. Acay A, Ulu MS,Ahsen A,Eroglu S,Ozuguz U,Yuksel S & Biró E, Szekanecz Z,Czirják L,Dankó K,Kiss E,Szabó NA,Szucs G, Punzi L &Betterle C.Chronicautoimmunethyroiditisandrheumatic Boelaert K, Newby PR,Simmonds MJ,Holder RL,Carr-Smith JD, Cooper GS, Bynum ML&Somers EC.Recentinsightsinthe Weetman AP. Diseasesassociatedwiththyroidautoimmunity: Quartuccio L, Bootsma H,Bowman SJ,Dörner T, Gottenberg JE 2569–2581. Rheumatism collaborativeinitiative. American CollegeofRheumatology/EuropeanLeagueAgainst Cohen MD Bingham CO 3rd,Birnbaum NS,Burmester GR,Bykerk VP, Saunders, 2013. Textbook ofRheumatology 0043) dysfunction. (doi:10.1016/j.dld.2016.01.006) the Netherlands. and concomitantdisordersinceliacdisease–acohortstudy Visschedijk MC &Weersma RK. Alargevarietyofclinicalfeatures 565–568. chronic arthritis. & Lorini R.Endocrineautoimmunityinyoungpatientswithjuvenile (doi:10.1016/j.jaad.2005.03.032) oftheAmericanAcademyDermatology Journal (Hashimoto’s) thyroiditisinchildrenandadolescentswithvitiligo. & Chrousos GP. Increasedprevalenceofchronicautoimmune ofPediatricNursing Journal 66140626113111) patients withrheumaticdiseases. Acarturk G. Assessmentofthyroiddisordersandautoimmunityin 240–245. thyroid autoimmunediseases. Zeher M, Bodolay E,Szegedi G jbspin.2003.06.005) manifestations. 123 with autoimmunethyroiddisease. Prevalence andrelativeriskofotherautoimmunediseasesinsubjects Heward JM, Manji N,Allahabadia A,Armitage M,Chatterjee KV Autoimmunity estimates andunderstandingofclusteringdiseases. epidemiology ofautoimmunediseases:improvedprevalence 74 explanations fortheexpandingspectrum. Disorders: Drug TargetsDisorders: Drug 411–418. 183.e1–183.e9. ( doi:10.1007/s10067-005-1165-y et al (doi:10.1002/art.27584) (doi:10.1111/j.1365-2265.2010.03855.x) Endocrine Reviews 2009 . Rheumatoidarthritisclassificationcriteria:an Joint BoneSpine Digestive andLiverDisease Clinical andExperimentalRheumatology 33 (doi:10.1016/j.amjmed.2009.06.030) 2014 197–207. , 9thEdition.Philadelphia,PA, USA: 2015 14 2008 Clinical Rheumatology et al 2004 182–186. 41 (doi:10.1016/j.jaut.2009.09.008) Endocrine, MetabolicandImmune 89–91. American Journal ofMedicine American Journal . Associationofsystemicand 29 Arthritis Rheumatoid Arthritis 71 R MRuggeriandothers 76–131. 275–283. (doi:10.2174/18715303146 ) Clinical Endocrinology 2016 2005 (doi:10.1210/er.2006- 48 (doi:10.1016/j. 499–505. 2006 53

Journal of Journal 220–223. 2002 2010 25 Kelley’s

20 2010 62 et al 2011

et al

. . 37 36 35 34 30 29 Accepted 8November2016 Revised versionreceived18October2016 Received 29August2016 33 32 31 28 27 26 25 thyroiditis Comorbidities inHashimoto’s Costello ME, Robinson PC,Benham H&Brown MA.Theintestinal Rosser EC &Mauri C.Aclinicalupdateonthesignificanceofgut Ruggeri RM, Vicchio TM, Cristani M,Certo R,Caccamo D, Bruno G, Maule M,Merletti F, Novelli G,Falorni A,Iannilli A,Iughetti L, Ruggeri RM, Imbesi S,Saitta S,Campennì A,Cannavò S,Trimarchi F Islam N, Leung PS,Huntley AC&Gershwin ME.Theautoimmune Mustalahti K, Catassi C,Reunanen A,Fabiani E,Heier M,McMillan S, Benucci M, DelRosso A,LiGobbi F, Manfredi M,Cerinic MM Ciocci A, Buratti L,DiFranco M&Mauceri MT. L’epidemiologia delle Ezzedine K, Eleftheriadou V, Whitton M&vanGeel N.Vitiligo. Pietropaolo M, Peakman M,Pietropaolo SL,Zanone MM,Foley Qiu D, Wang Q, Wang H, Xie Q,Zang G,Jiang H,Tu C, Guo J, Editors InternalClinicalGuidelinesTeam (UK)CoeliacDisease: 29 spondyloarthritis. microbiome inhumandiseaseandhowitrelatestoarthritis 29 microbiota insystemicautoimmunity. thyroiditis. Oxidative stressandadvancedglycationendproductsinHashimoto’s Alibrandi A, Giovinazzo S,Saija A,Campennì A,Trimarchi F study. 1990-2003 incidencetimetrendsofchildhooddiabetesinItaly:theRIDI Altobelli E, d’Annunzio G,Piffer S 2010 ( ofEndocrinologicalInvestigation Journal & Gangemi S.ChronicidiopathicurticariaandGraves’disease. 2015 basis ofalopeciaareata:acomprehensivereview. 2015 clinical recommendations. Sjögren’sEarly diagnosisofprimary syndrome:EULAR-SStaskforce centralized, internationalmassscreeningproject. Epidemiology. TheprevalenceofceliacdiseaseinEurope:resultsa Murray L, Metzger MH,Gasparin M&CoeliacEUCluster, Project CR420–CR425. of Florence(ScandicciLeSigne). Italian prevalencestudybasedonatwo-stepstrategyinanarea (SLE)inItaly:an& Salvarani C.Systemiclupuserythematosus Reumatismo malattie reumatiche:confrontofraidatiitalianiequellistranieri. jaut.1997.0170) diabetes mellitus. autoimmune diseasesconfershighspecificityforinsulin-dependent ICA512(IA-2) autoantibodiesinorganandnon-organ-specific TP Jr, Becker DJ&Trucco M. CombinedanalysisofGAD65and Hepatology diagnosis ofautoimmunehepatitisinChinesepatients. Zhang S, Wang J Health andCareExcellence:ClinicalGuidelines,2015. Institute forHealthandCareExcellence(UK).National Recognition, AssessmentandManagement.Source London:National 12 doi:10.3275/8940 202–212. S0896-8411(16)30087-7. 137–156. 14 42 386 Diabetes 587–595. 81–89. 74–84. 2011 1999 Thyroid (doi:10.1016/j.berh.2015.08.001) (doi:10.1586/1744666x.2016.1109449) 2010 (doi:10.1016/j.autrev.2014.10.014) 54 et al (doi:10.1016/S0140-6736(14)60763-7) 51 Journal ofAutoimmunity Journal ) Best PracticeandResearch ClinicalRheumatology (doi:10.3109/07853890.2010.505931) 2016 340–347. 59 (Supplement2)201. . Validation ofthesimplifiedcriteriafor 2281–2287. 26 Expert ReviewofClinicalImmunology Expert Downloaded fromBioscientifica.com at10/03/202112:18:30AM 504–511. ( doi:10.1016/j.jaut.2016.06.009 (doi:10.1016/j.jhep.2010.06.032) et al Medical ScienceMonitor (doi:10.2337/db10-0151) . Age-period-cohort analysis of . Age-period-cohortanalysisof 2013 (doi:10.1089/thy.2015.0592) Journal ofAutoimmunity Journal 2008 36 176 531–536. www.eje-online.org 11 :2 Autoimmune Reviews Annals ofMedicine 1–10. Journal of Journal (doi:10.1006/

2005 ) et al 2016 2016 141 11 Lancet 2015 . via freeaccess