Annals of the Rheumiiiatic Diseases 1993; 52: 839-840 839

A Arteries of head and neck are most affected in with of 7.- frequently GCA, sparing Ann Rheum Dis: first published as 10.1136/ard.52.11.839 on 1 November 1993. Downloaded from LETTERS TO the intracranial arteries. Involvement of the thyroid arteries in GCA was described in THE EDITOR 1939 by Lucien et al.' In fact this was the first histological evidence that GCA affects arteries other than the temporal vessels. Though thyroid arteritis might have caused Simultaneous onset of ischaemic thyroiditis in our patient, this giant cell arteritis and could not be proved. Giant cells were found subacute thyroiditis in material obtained by aspiration, but this can be a feature in both GCA and classical subacute or giant cell thyroiditis. Biopsy of Sir: The classical presentation of giant cell the thyroid might have helped in the arteritis (GCA) with headache, scalp differentiation, but this procedure was not sensitivity, and jaw claudication is caused by performed because of the significant risk. inflammation of the external carotid arteries B Giant cell arteritis and thyroid disease may or their branches. Giant cell arteritis is now a_ both be manifestations of autoimmunity. recognised as a systemic illness that may be Giant cell arteritis is associated with HLA associated with generalised vasculitis.' types that are also associated with several Subacute or giant cell thyroiditis is a self autoimmune disorders.4 The association of limiting inflammation of the thyroid, GCA with autoimmune thyroid disease has presenting with painful thyroid swelling, been described,5 but its significance has thyrotoxicosis, and low radioactive iodine been doubted. In our patient autoimmune uptake. We report here on a woman with the thyroid disease was not present. simultaneous onset of GCA and subacute Subacute or de Quervain's thyroiditis often thyroiditis. follows an upper airways virus infection, but An 81 year old, previously healthy, white the infectious agent can rarely be identified.' woman had noticed a swollen throat two The association with certain HLA factors weeks before admission in July 1990, suggests a role for immune mechanisms in followed by fever, night sweats, and moderate the pathogenesis.'" Both GCA and subacute weight loss. Other complaints were dry C thyroiditis might have been caused by virus cough, continuous awareness of her throat induced alteration of autologous antigen, ears, extreme and the .. and jaw pain, scalp respectively, in artery wall and thyroid, with being sensitive to hair combing. She denied an immune response to these neo-antigens headache but had noticed a thickened blood causing the clinical symptoms. As no vessel on the left lateral forehead. serological proof of a recent infection was Physical examination showed a moderately obtained in this patient, this hypothesis ill woman pressure with blood 168/85 remains speculative. We believe that the mmHg, regular pulse rate of 104 beats/min, subacute thyroiditis in the presented patient and temperature of 38-8°C. Both temporal was caused by thyroid arteritis. arteries were tender, thickened, and vigorously pulsating. The right thyroid lobe S M AREND was enlarged threefold, smoothly firm, and M L WESTEDT tender. Fundoscopy showed no vasculitis. Departm)ienit ofInitenial Medicine anid Rhenmiatologa'

Broniovo Hospital http://ard.bmj.com/ The remainder of the examination was non- Broniovolaant 5 contributory. Electrocardiography and chest 2597 AX The Hague radiograph were normal. Laboratory data The Netherlanids Technetiunm-99mn pertechnetate thyroid scanst on showed an erythrocyte sedimentation rate three different dates. (A) J7uly 1990; 71o uptake (ESR) of 120 mm/first hour, 13-8 X 109 in the thyroid at the start ofthe disease; (B) Correspondence to Dr Sandra M Arend, leucocytes/l with normal differentiation and Septemiber 1990; after two mionths' treatmiienit Department of General Internal Medicine, University Hospital Leiden, Building 1, Cl-R41, 562 X 10' thrombocytes/l. Abnormal wvith corticosteroids, there is now an irregular PO Box 9600, 2300 RC Leiden, The Netherlands. biochemical values were: alkaline phos- uptake in the thyroid; (C) November 1992;

phatase 275 U/1 (normal value <100 UA), iionoral nodularpattern. on September 30, 2021 by guest. Protected copyright. aspartate aminotransferase 42 U/I (<20 U/1), 1 Sonnenblick M, Nesher G, Rosin A. alanine Nonclassical organ involvement in temporal aminotransferase 51 U/I (<20 UA), arteritis. Semin Arthritis Rheunin 1989; 19: and y-glutamyltransferase 100 U/I (<25 U/1). biochemistry tests were normalised by four 183-90. Thyroid function test showed moderate weeks and at eight weeks the thyroid function 2 Malmvall B E, Bengtsson B A. Giant cell primary thyrotoxicosis: thyroxine 148 nmol/l was normal, with moderately active uptake of arteritis; clinical features and involvement of different organs. Sca7nd J Rheumiiatol 1978; 7: (normal value 75-135 nmol/l), triiodo- isotope on a thyroid scan (figure B). 154-8. thyronine uptake 0 99 (0-85-1-15), free Treatment with prednisone was stopped in 3 Lucien M, Mathieu L, Verain M. Art&rite thyroxine index 1-46 (0-75-1-45), and 1992. Since then the patient has had no nodulaire de la tete et du cou. Arch Mal Coenxr hormone 0-2 relapse, her ESR is 14 mm/first 1939;32: 603-5. thyroid stimulating mUA hour, and the 4 Lowenstein M B, Bridgeford P H, Vasey F B, (0 3-4 0 mU/l). Antibodies to thyroid could thyroid scan now shows a normal uptake Germain B F, Espinoza L R. Increased not be demonstrated. Virus serology was (figure C). frequency of HLA-DR3 and DR4 in positive for anti-hepatitis B surface antigen The simultaneous onset of GCA and polymyalgia rheumatica-giant cell arteritis. Arthritis Rheuwi 1983; 26: 925-7. only. The thyroid scan failed to show uptake subacute thyroiditis has to the best of our 5 Thomas R D, Croft D N. Thyrotoxicosis and of technetium-99m pertechnetate in the knowledge not been presented as a case giant-cell arteritis. BMJ 1974; ii: 408-9. thyroid area, consistent with subacute report before. Malmvall et al mention two 6 How J, Bewsher P D, Walker W. Giant-cell thryoiditis (figure of cases of subacute a arteritis and hypothyroidism. BMJ 1977; ii: A). Biopsy the left thyroiditis during follow 99. temporal artery showed characteristic GCA. up of 68 patients with GCA, without giving 7 Dent R G, Edwards 0 M. Autoimmune thyroid Samples obtained by thyroid aspiration detailed information of these cases.2 The disease and the polymyalgia rheumatica-giant showed an inflammatory infiltrate comprising combination of GCA with subacute thy- cell arteritis syndrome. Clint Endocnnol 1978; 9: 215-9. macrophages, lymphocytes, granulocytes, roiditis may be a coincidence of two non- 8 Whitby M, Hobson D. Simultaneous onset of and multinucleate giant cells. related disorders, but the simultaneous onset thyrotoxicosis and temporal arteritis. Med J Giant cell arteritis and concomitant sub- and, furthermore, the similarities in clinical Aust 1982; 2: 483-4. acute thyroiditis were diagnosed. Treatment presentation, histological picture, and 9 Acute and subacute thyroiditis. In: DeGroot L J, Larsen P R, Refetoff S, Stanbury J B, eds. consisted of prednisone 30 mg twice daily, striking response to steroids point to a more The thy,roid anid its diseases. New York: Wiley, with rapid improvement of all symptoms. than chance relation. Either subacute 1984; 717-31. Two weeks after starting treatment her ESR thyroiditis might be a manifestation of GCA 10 Bech K, Nerup J, Thomsen M, et al. Subacute had fallen to 27 mm/first hour, and the or some thyroiditis de Quervain: a disease associated common causative and pathogenetic with HLA-B antigen. Acta Entdoc'ntol 1977; prednisone dose was gradually tapered. Liver pathway might lead to both entities. 86: 504-9.