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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">The combination of systemic lupus erythematosus &#40;SLE&#41; and altered thyroid function has been described in several different studies&#46; The most common alteration has been described as primary hypothyroidism&#46; However&#44; the presence of central hypothyroidism in patients with SLE is very uncommon&#46; Here we present the case of a patient with SLE that&#44; in the course of an outbreak of lupus nephritis&#44; developed severe suprathyroid hypothyroidism</p><p class="elsevierStylePara">Our patient was a 33-year old male diagnosed with SLE in 2000 based on an analysis of polyarthralgia and cutaneous lesions&#46; In 2001&#44; he developed pure nephrotic syndrome&#46; A renal biopsy indicated membranous glomerulonephritis &#40;stage V&#41; that went into complete remission following immunosuppressant treatment&#46; In 2005&#44; he had another bout of nephritis in the form of impure nephrotic syndrome&#59; we performed another biopsy and detected membranous glomerulonephritis &#40;GN&#41;&#44; accompanied by necrosis and proliferation in half of the glomeruli and centres of fibrosis&#44; as well as interstitial atrophy &#40;stage 4-5&#41;&#46; He responded partially to several immunosuppressants&#44; and was stabilised at a plasma creatinine level of 1&#46;5-1&#46;8mg&#37; and proteinuria in the non-nephrotic range&#46; He then was treated with losartan&#44; prednisone &#40;5mg&#47;day&#41;&#44; and simvastatin&#46;</p><p class="elsevierStylePara">In March 2011&#44; the patient sought treatment for the appearance of tibio-malleolar oedema&#46; The physical examination revealed blood pressure of 210&#47;120mm Hg&#44; pallor of the mucosa&#44; and pitting oedema in both legs&#46; A laboratory analysis revealed&#58; haemoglobin &#40;Hb&#41;&#58; 10g&#47;dl&#59; creatinine&#58; 4&#46;3mg&#47;dl &#40;glomerular filtration rate &#91;GFR&#93;&#58; 15ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2</span>&#41;&#59; albumin&#58; 25g&#47;l&#59; antinuclear antibodies &#40;ANA&#41;&#58; 23 &#40;positive &#62;1&#41;&#59; anti-DNA&#58; 405U&#47;ml &#40;positive &#62;15&#41;&#59; C3&#58; 28mg&#47;dl &#40;76-181&#41;&#59; C4&#58; 4&#46;4mg&#47;dl &#40;12-49&#41;&#59; proteinuria&#47;24 hours&#58; 11g&#44; and sediments with haematuria&#46; We started the patient on prednisone and mycophenolate&#44; with anti-hypertensives to control the arterial hypertension&#46; We observed the progressive disappearance of the oedema&#44; as well as improved renal function &#40;creatinine&#58; 3mg&#47;dl and reduction of proteinuria to 3g&#47;24h&#41;&#46; Seven days after starting treatment&#44; the patient complained of severe asthenia that impeded mobility&#44; constipation&#44; and a constant feeling of cold&#46; The thyroid analysis revealed&#58; thyrotropin &#40;TSH&#41;&#58; 0&#46;09&#181;U&#47;ml &#40;0&#46;34-4&#46;9&#41;&#59; free T4 thyroxin&#58; 0&#46;60mg&#47;dl &#40;0&#46;69-1&#46;48&#41;&#44; free T3 triiodothyronine&#58; 1&#46;4pg&#47;ml &#40;1&#46;71-3&#46;71&#41;&#59; reverse triiodothyronine&#58; 0&#46;19ng&#47;ml &#40;0&#46;10-0&#46;34&#41;&#44; and thyroid peroxidase antibodies &#40;TPO&#41;&#58; 6&#46;92U&#47;ml &#40;0-5&#46;6&#41;&#46; The measurements of gonadotropins &#40;FSH&#44; LH&#41;&#44; prolactin&#44; human growth hormone&#44; testosterone&#44; and somatomedin C &#40;IGF-1&#41; were all normal&#46; A thyroid ultrasound and magnetic resonance of the hypophysis resulted normal&#46; We started treatment with levothyroxine&#44; observing a progressive disappearance of the hypothyroid symptoms&#44; and normalised plasma levels of free thyroxin&#46;</p><p class="elsevierStylePara">Several different studies have shown that altered thyroid function is more common in SLE patients than in the general population&#46;<span class="elsevierStyleSup">1-4</span> Primary hypothyroidism&#44; both clinical and sub-clinical&#44; is the most commonly observed alteration&#46; Two recent studies compared patients with SLE with a control group and observed a prevalence of primary clinical hypothyroidism of 6&#37; and 14&#37;&#44; and sub-clinical hypothyroidism of 12&#37; and 17&#37;&#44; respectively&#46;<span class="elsevierStyleSup">5&#44;6</span> The prevalence of clinical hypothyroidism in the general Western population is less than 1&#37;&#46; Based on the presence of antithyroid antibodies in patients with SLE and hypothyroidism&#44; half of all cases have an autoimmune origin&#44; and the percentage of positivity for antithyroid antibodies in patients with SLE and euthyroidism ranges between 6&#37; and 47&#37;&#46;</p><p class="elsevierStylePara">On the other hand&#44; the majority of these studies suggest that there is no difference in the prevalence of hyperthyroidism between patients with SLE and the general population&#46; We must point out that the association between SLE and central hypothyroidism is rare&#46; The cases described have been of patients with SLE that develop lymphocytic neurohypophysis&#44; which also produces altered secretion of other hormones in addition to the thyroid hormones&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">Taking into account this prevalent association and the fact that clinical and laboratory manifestations of hypothyroidism can simulate a lupus outbreak&#44;<span class="elsevierStyleSup">8</span> we suggest performing an analysis of thyroid function in patients with SLE&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p>"
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Systemic lupus erythematosus and hypothyroidism
Lupus eritematoso sistémico e hipotiroidismo central
M.. Cuxarta, A.. Graub, M.. Picazoc, R.. Sansc
a Servicio de Nefrología, Fundació Salut Empordà. Hospital de Figueres, Figueres, Girona
b Servicio de Medicina Interna, Fundació Salut Empordà. Hospital de Figueres, Figueres, Girona,
c Servicio de Nefrología, Fundació Salut Empordà. Hospital de Figueres, Figueres, Girona,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44; </span></p><p class="elsevierStylePara">The combination of systemic lupus erythematosus &#40;SLE&#41; and altered thyroid function has been described in several different studies&#46; The most common alteration has been described as primary hypothyroidism&#46; However&#44; the presence of central hypothyroidism in patients with SLE is very uncommon&#46; Here we present the case of a patient with SLE that&#44; in the course of an outbreak of lupus nephritis&#44; developed severe suprathyroid hypothyroidism</p><p class="elsevierStylePara">Our patient was a 33-year old male diagnosed with SLE in 2000 based on an analysis of polyarthralgia and cutaneous lesions&#46; In 2001&#44; he developed pure nephrotic syndrome&#46; A renal biopsy indicated membranous glomerulonephritis &#40;stage V&#41; that went into complete remission following immunosuppressant treatment&#46; In 2005&#44; he had another bout of nephritis in the form of impure nephrotic syndrome&#59; we performed another biopsy and detected membranous glomerulonephritis &#40;GN&#41;&#44; accompanied by necrosis and proliferation in half of the glomeruli and centres of fibrosis&#44; as well as interstitial atrophy &#40;stage 4-5&#41;&#46; He responded partially to several immunosuppressants&#44; and was stabilised at a plasma creatinine level of 1&#46;5-1&#46;8mg&#37; and proteinuria in the non-nephrotic range&#46; He then was treated with losartan&#44; prednisone &#40;5mg&#47;day&#41;&#44; and simvastatin&#46;</p><p class="elsevierStylePara">In March 2011&#44; the patient sought treatment for the appearance of tibio-malleolar oedema&#46; The physical examination revealed blood pressure of 210&#47;120mm Hg&#44; pallor of the mucosa&#44; and pitting oedema in both legs&#46; A laboratory analysis revealed&#58; haemoglobin &#40;Hb&#41;&#58; 10g&#47;dl&#59; creatinine&#58; 4&#46;3mg&#47;dl &#40;glomerular filtration rate &#91;GFR&#93;&#58; 15ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2</span>&#41;&#59; albumin&#58; 25g&#47;l&#59; antinuclear antibodies &#40;ANA&#41;&#58; 23 &#40;positive &#62;1&#41;&#59; anti-DNA&#58; 405U&#47;ml &#40;positive &#62;15&#41;&#59; C3&#58; 28mg&#47;dl &#40;76-181&#41;&#59; C4&#58; 4&#46;4mg&#47;dl &#40;12-49&#41;&#59; proteinuria&#47;24 hours&#58; 11g&#44; and sediments with haematuria&#46; We started the patient on prednisone and mycophenolate&#44; with anti-hypertensives to control the arterial hypertension&#46; We observed the progressive disappearance of the oedema&#44; as well as improved renal function &#40;creatinine&#58; 3mg&#47;dl and reduction of proteinuria to 3g&#47;24h&#41;&#46; Seven days after starting treatment&#44; the patient complained of severe asthenia that impeded mobility&#44; constipation&#44; and a constant feeling of cold&#46; The thyroid analysis revealed&#58; thyrotropin &#40;TSH&#41;&#58; 0&#46;09&#181;U&#47;ml &#40;0&#46;34-4&#46;9&#41;&#59; free T4 thyroxin&#58; 0&#46;60mg&#47;dl &#40;0&#46;69-1&#46;48&#41;&#44; free T3 triiodothyronine&#58; 1&#46;4pg&#47;ml &#40;1&#46;71-3&#46;71&#41;&#59; reverse triiodothyronine&#58; 0&#46;19ng&#47;ml &#40;0&#46;10-0&#46;34&#41;&#44; and thyroid peroxidase antibodies &#40;TPO&#41;&#58; 6&#46;92U&#47;ml &#40;0-5&#46;6&#41;&#46; The measurements of gonadotropins &#40;FSH&#44; LH&#41;&#44; prolactin&#44; human growth hormone&#44; testosterone&#44; and somatomedin C &#40;IGF-1&#41; were all normal&#46; A thyroid ultrasound and magnetic resonance of the hypophysis resulted normal&#46; We started treatment with levothyroxine&#44; observing a progressive disappearance of the hypothyroid symptoms&#44; and normalised plasma levels of free thyroxin&#46;</p><p class="elsevierStylePara">Several different studies have shown that altered thyroid function is more common in SLE patients than in the general population&#46;<span class="elsevierStyleSup">1-4</span> Primary hypothyroidism&#44; both clinical and sub-clinical&#44; is the most commonly observed alteration&#46; Two recent studies compared patients with SLE with a control group and observed a prevalence of primary clinical hypothyroidism of 6&#37; and 14&#37;&#44; and sub-clinical hypothyroidism of 12&#37; and 17&#37;&#44; respectively&#46;<span class="elsevierStyleSup">5&#44;6</span> The prevalence of clinical hypothyroidism in the general Western population is less than 1&#37;&#46; Based on the presence of antithyroid antibodies in patients with SLE and hypothyroidism&#44; half of all cases have an autoimmune origin&#44; and the percentage of positivity for antithyroid antibodies in patients with SLE and euthyroidism ranges between 6&#37; and 47&#37;&#46;</p><p class="elsevierStylePara">On the other hand&#44; the majority of these studies suggest that there is no difference in the prevalence of hyperthyroidism between patients with SLE and the general population&#46; We must point out that the association between SLE and central hypothyroidism is rare&#46; The cases described have been of patients with SLE that develop lymphocytic neurohypophysis&#44; which also produces altered secretion of other hormones in addition to the thyroid hormones&#46;<span class="elsevierStyleSup">7</span></p><p class="elsevierStylePara">Taking into account this prevalent association and the fact that clinical and laboratory manifestations of hypothyroidism can simulate a lupus outbreak&#44;<span class="elsevierStyleSup">8</span> we suggest performing an analysis of thyroid function in patients with SLE&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p>"
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