Onset of Graves' disease during long-term immunosuppressive therapy in a patient with membranous nephropathy

[摘要] A 67-year-old man was referred to our department for thyrotoxicosis with intermittent palpitation and 4-kg weight lossduring the previous month. At the first visit, the patient was treated with cyclosporine A (CyA) for membranous nephropathyduring the last 3 years and 8 months. Laboratory studies revealed that the serum TSH level was !0.005 mU/ml, and freethyroxine (fT4) and triiodothyronine (fT3) levels were elevated at 2.76 ng/dl and 5.96 pg/ml respectively. Anti-TSH receptorantibody (TRAb) level was increased at 26.4%. A clinical diagnosis of Graves’ hyperthyroidism was given, and thenthyrostatic treatment with thiamazole (MMI) at a dose of 10 mg daily was initiated after CyA withdrawal. After the initiationof MMI therapy, serum fT4 and fT3 attained the normal level within 1.5 months, with relief of symptoms followed by aremarkable decrease in urinary protein excretion from 2.0–5.2 g/day to %0.03 g/day. The patient maintained euthyroid witha low titre of TRAb for the succeeding 2 years and then MMI was finally stopped. Neither a relapse of hyperthyroidism nora flare-up of nephrotic syndrome was observed for 3 years after MMI discontinuation. CyA has conflicting effects onimmunologic self-tolerance by modulation of self-reactive T cells and natural CD4CCD25CFoxp3C regulatory T cell (Treg)functions, and possibly becomes a triggering factor in the development of autoimmune disorders. This case may beinteresting when considering the effect of each T cell subset on the development of Graves’ disease.

[学科分类] 血液学

[关键词] Adult;Male;Asian - Japanese;Japan;Kidney;Thyroid;Thyroid;TSH;Thyroxine (T4);Triiodothyronine (T3);Graves' disease;Hyperthyroidism;Thyrotoxicosis;Membranous nephropathy;Dyspnoea;Palpitations;Sweating;Weight loss;Proteinuria;Dyslipidaemia;Immunohistochemistry;FT3;FT4;Urinalysis;Renal biopsy;Blood pressure;Thyroglobulin;Thyroid ultrasonography;Thyroid antibodies;LDL cholesterol;Methimazole;Ciclosporin;Atorvastatin;Losartan;Unusual effects of medical treatment;September;2015