In most patients with Graves' hyperthyroidism the eye signs are self-limiting and mostly subclinical. However, about one-third of the patients have clinically relevant ophthalmopathy, which can be disabling and disfiguring. The mechanical causes of the symptoms and signs of the eye disease are largely understood, but the best way to manage the ophthalmopathy is still a matter of much debate. Adequate treatment of hyperthyroidism can aleviate the eye symptoms to some extent, but it is less clear which kind of antithyroid treatment is to be preferred in patients with ophthalmopathy. There is particular controversy about the possibly deleterious effect of radioiodine therapy on the ophthalmopathy; in view of the present evidence it seems prudent to refrain from using 131I and to prefer antithyroid drugs in patients with clinical ophthalmopathy. Further medical management can include immunosuppressive treatment (such as corticosteroids) that results in improvement in roughly two-thirds of the patients. Orbital irradiation appears to be the first choice for treatment in moderately severe ophthalmopathy because it is equally effective and much better tolerated than classical corticosteroid treatment. However, to really improve the efficacy of such interventions we should be able to select those patients that are likely to respond to immunomodulatory therapy. Disease activity is probably the prime determinant of response and it is a challenge for the future to develop reliable parameters of disease activity on the basis of which patients can be selected for further medical treatment, or can be subjected to rehabilitative surgery without prior immunosuppression.
SUMMARY Infections have been implicated in the pathogenesis of a number of autoimmune diseases, and Yersinia enterocolitica (YE) might play a role in the development of autoimmune thyroid disease (AITD). Clinical evidence in support of this hypothesis has been inconclusive. We reasoned that looking earlier in the natural course of AITD might enhance chances of finding evidence for YE infection. Consequently, we determined seroreactivity against YE in subjects at risk of developing AITD, i.e. in 803 female relatives of AITD patients in self-proclaimed good health. As a comparison group we used 100 healthy women who participated in a program for reference values. IgG and IgA antibodies to virulence-associated outer membrane proteins (YOPs) of YE were measured by a specific assay. Serum thyroid peroxidase antibodies (TPO-Ab) as indicators of AITD were considered to be positive at levels of> 100 kU/l. The prevalence of YOP IgG-Ab was higher in AITD relatives than in controls (40·1% vs. 24%, P = 0·002), and the same was true for YOP IgA-Ab (22% vs. 13%, P < 0·05). Of the 803 AITD relatives, 44 had an increased or decreased plasma TSH, and 759 were euthyroid as evident from a normal TSH; the prevalence of YOP-Ab did not differ between these three subgroups. TPO-Ab were present in 10% of controls and in 27% of the AITD relatives (P < 0·001). The prevalence of TPO-Ab in the euthyroid AITD relatives was not different between YOP IgG-Ab positive and negative subjects (23·3% vs. 24·7%, NS), nor between YOP IgA-Ab positive and negative subjects (21·2% vs. 24·9%, NS). In conclusion, healthy female relatives of AITD patients have an increased prevalence of YOP antibodies, which, however, is not related to the higher prevalence of TPO antibodies in these subjects. The findings suggest a higher rate of persistent YE infection in AITD relatives. Susceptibility genes for AITD may also confer a risk for YE infection.
A 53-year-old woman presented with fever accompanied by chills and an extremely painful swelling of her right thyroid lobe. She was initially diagnosed as having subacute thyroiditis, but after 14 days her disease appeared to be caused by a destructive suppurative thyroiditis due to Salmonella group C. A pre-existing hyperplastic nodule in the right thyroid lobe was the predisposing factor. Antibiotics were given for several weeks and surgical drainage was performed. Finally a hemithyroidectomy was done to eliminate the predisposing factor.
