Kawashima Junji, Naoe Hideaki, Sasaki Yutaka, Araki Eiichi
Department of Metabolic Medicine, Faculty of Life Sciences, Kumamoto University , 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 , Japan.
Department of Gastroenterology and Hepatology, Faculty of Life Sciences, Kumamoto University , 1-1-1 Honjo, Chuo-ku, Kumamoto, 860-8556 , Japan.
Endocrinol Diabetes Metab Case Rep. 2015;2015:140117. doi: 10.1530/EDM-14-0117. Epub 2015 May 1.
Anti-tumor necrosis factor (TNF)-α therapy is established as a new standard for the treatment of various autoimmune inflammatory diseases. We report the first case showing subacute thyroiditis-like symptoms with an amyloid goiter after anti-TNF-α therapy. A 56-year-old man with Crohn's disease presented with fever and a diffuse, tender goiter. To control the diarrhea, anti-TNF therapy (infliximab) was administered 4 weeks before the thyroid symptoms emerged. The patient reported a swollen neck with tenderness on the right side and fever 4 days after the second infliximab injection. An elevated serum C-reactive protein (CRP) and serum thyroid hormone level with suppressed serum thyrotropin were observed. The thyroid-stimulating antibody was not elevated. An ultrasonograph of the thyroid revealed an enlarged goiter with posterior echogenicity attenuation and a low echoic region that was tender. The thyroid uptake value on technetium-99m scintigraphy was near the lower limit of the normal range. The patient was initially diagnosed with thyrotoxicosis resulting from subacute thyroiditis. Administration of oral prednisolone improved the fever, thyroid pain, and thyroid function, but his thyroid remained swollen. The patient developed diarrhea after prednisolone withdrawal; therefore, adalimumab, another TNF inhibitor, was administered. After three injections, his abdominal symptoms were alleviated, but the thyroid pain and fever recurred. Elevated serum CRP levels in the absence of thyroid dysfunction were observed. The patient's symptoms resolved after prednisolone retreatment, but an elastic, firm goiter persisted. A fine-needle biopsy revealed amyloid deposition in the thyroid.
Many cases with thyroid dysfunction accompanied by amyloid goiter have been reported.There are cases that develop amyloid goiter with subacute thyroiditis-like symptoms after anti-TNF therapy.When the thyroid remains swollen after improvement of thyrotoxicosis following treatment with prednisolone, it should be assessed to differentiate between an amyloid goiter and common subacute thyroiditis.
抗肿瘤坏死因子（TNF）-α疗法已成为治疗各种自身免疫性炎症性疾病的新标准。我们报告了首例抗TNF-α治疗后出现亚急性甲状腺炎样症状并伴有淀粉样甲状腺肿的病例。一名56岁克罗恩病男性患者出现发热及弥漫性压痛性甲状腺肿。为控制腹泻，在甲状腺症状出现前4周给予抗TNF治疗（英夫利昔单抗）。患者在第二次注射英夫利昔单抗4天后报告右侧颈部肿胀伴压痛及发热。观察到血清C反应蛋白（CRP）升高、血清甲状腺激素水平升高及血清促甲状腺素受抑制。甲状腺刺激抗体未升高。甲状腺超声显示甲状腺肿大，后方回声衰减，有压痛的低回声区。99m锝闪烁扫描的甲状腺摄取值接近正常范围下限。患者最初被诊断为亚急性甲状腺炎所致甲状腺毒症。口服泼尼松龙改善了发热、甲状腺疼痛及甲状腺功能，但甲状腺仍肿大。停用泼尼松龙后患者出现腹泻；因此，给予另一种TNF抑制剂阿达木单抗。三次注射后，其腹部症状缓解，但甲状腺疼痛和发热复发。观察到在无甲状腺功能障碍情况下血清CRP水平升高。泼尼松龙再次治疗后患者症状缓解，但弹性硬的甲状腺肿持续存在。细针穿刺活检显示甲状腺有淀粉样沉积。
已报道许多伴有淀粉样甲状腺肿的甲状腺功能障碍病例。有病例在抗TNF治疗后出现伴有亚急性甲状腺炎样症状的淀粉样甲状腺肿。用泼尼松龙治疗甲状腺毒症改善后若甲状腺仍肿大，应进行评估以鉴别淀粉样甲状腺肿和普通亚急性甲状腺炎。
