自體免疫甲狀腺功能低下合併自體免疫溶血性貧血

(1)

2008 19 437-440

500 135

ၡāāࢋ

27 TSH anti-TPO

(autoimmune hypothyroidism) (Hashimoto's thyroiditis) direct Comb's test

ᙯᔣෟĈϥېཛྷΑਕҲ˭ ( Hypothyroidism )

ҋវҺࠪϥېཛྷ়ঽ ( Autoimmune thyroid disease ) ҋវҺࠪ໘ҕّళҕ ( Autoimmune hemolytic anemia ) λҕ஧ّళҕ ( Macrocytic anemia)

݈֏

ళҕߏϥېཛྷΑਕҲ˭ଈ۰࠹༊૱֍۞Ъ׀

াĄϥېཛྷΑਕҲ˭͔੓ళҕ۞࡭ঽ፟ᖼޝкĈ ( 1 ) ϥېཛྷΑਕҲ˭Ξጱ࡭ࡓҕ஧Ϡј৵ ( ery- thropoietin; EPO ) ԩّĂ͔҃੓ళҕ

¹

Ą( 2 ) ᜠ৿

ͻĈΞֽҋ͡གྷณ࿅кĂ˘ొЊҋវҺࠪϥېཛྷ

়ঽ ( autoimmune thyroid disease; ATD ) ଈ۰݋

ߏЯࠎᎮѣ൑ࡤᅕা(achlohydria)Ă҃ౄјᜠӛ ќ̙։

²

Ą( 3 ) ჯϠ৵ B

¹²

ӛќ̙։Ă̈́ཧᅕ৿ͻ ඈкࢦࣧЯĄ

ϥېཛྷΑਕҲ˭۞ళҕ఼૱ߏϒҕ஧ّ ( nor- mocytic )Ăࡶߏ΍னλҕ஧ّళҕ ( macrocytic anemia )Ăྵ૱֍۞ࣧЯߏჯϠ৵ B

¹²

ăཧᅕ৿ͻ

ٕೋّళҕ

³

ĄώּಡӘ˘ЩϥېཛྷΑਕҲ˭ଈ ۰Ă΍னλҕ஧ّళҕĂݒߏҋវҺࠪ໘ҕّళ ҕ ( autoimmune hemolytic anemia; AIHA ) ٙౄ

јĄ AIHA ߏϥېཛྷΑਕҲ˭ց֍۞ళҕࣧЯĂ

זϫ݈ࠎͤΪѣ͌ณ۞ঽּಡӘĂᔵ൒ౌߏҋវ

Һ়ࠪঽĂҭ׌۰۞ᙯᓑϫ݈ᔘ̙୻຾ĂЯѩإ

ϏజᕩᙷٺЇңҋវҺࠪা࣏ཏ̚ĂटٽజᓜԖ

ᗁरٙنரĄ

(2)

ঽּಡӘ

27 ໐ّ̃Ă͹෦౵ܕೀ࣎֕͡ྮटٽಆă

͕ଙăБ֗൑˧ăࢴᇒָ̙ăᐝຶĂЯछᗁࡊᗁ र൴னϥېཛྷཚ̂҃ᖼ̶ֽ̬̰کࡊܝ෧Ą൑൴

፵Ăវࢦ൑ត̼Ă͡གྷᔘზϒ૱Ă࿅Ν֭൑׎΁

়ঽĂπॡϺ൑ڇϡᘽۏĄநጯᑭߤ൴னĈ֗੼

156 ̶̳Ăវࢦ 60 ̳͝Ă͕தϒ૱Ăҕᑅϒ૱Ă ᓚҒரࠎঙཚĂඕቯᄔϨĂ൑ࡎீĂϥېཛྷͧ̂

ؒ޽ϐ༼ர̂Ăൾർ൑ᛈ൭Ăѣќᒺഇ͕ᗔࢰĂ

൑քතཚ̂Ă൑ϩৃĂ൑ᙯ༼ূ൭Ă൑˭۳ͪ

ཚĂ൑ྻજٕຏᛇள૱ĄܐՎ۞၁រވᑭߤពϯ TSH 15.7 ɢU/mL (reference range; 0.35-4.94ɢU/mL)Ă Free T4 0.72 ɢ g/dL ( reference range; 0.70-1.48 ɢg/dL )ĂAnti-TPO 2347.30 IU/mL ( reference range;

<12 IU/mL )Ă RBC 1.71 x 10-3/uL, Hb 6.3 g/dL Ă MCV127.5fL Ă WBC 4600/cumm Ă platelet 242,000/cumm, Urine protein: negative Ă serum al- bumin 4.1 g/dL Ă globulin 2.9 g/dL Ąϥېཛྷ෹ࢰ گពϯҲаࢰளኳّᚢႝّཚ̂Ă௑ЪҋវҺࠪ

ϥېཛྷ়ঽ̝૱֍ᇆည

⁴

Ă਒ొ X ray ൑পҾ൴ னĄ˘ฟؕАග̟ϥېཛྷ৵(eltroxine 100 ɢ g ˾ ڇĂ׌͟˘Ѩ)ڼᒚĂ TSH ˭ࢫז 3.6 ɢ U/mL Ă ҭᓜԖېڶ֭൑ԼචĄҕ୵ᑭߤ൴ன Hb ˭ࢫז 4.2 g/dL Ąซ˘Վ੫၆ళҕซҖᑭߤĂ ferritin 96.06 ng/mL ( reference range; 4.63-204 ng/mL )Ă vitamin B

¹²

372 pg/mL ( reference range;180-914 pg/mL )Ă folate 5.78 ng/mL ( reference range; >5.21 ng/mL )Ă total bilirubin 2.09 mg/dL ( reference range; 0.3-1.3 mg/dL )Ă direct bilirubin 0.86 mg/dL ( reference range; 0.1-0.5 mg/dL )Ă LDH 485 U/L ( reference range; 103-193 U/L )Ă hepatoglobin <10 mg/dL ( reference range; 30-200 mg/dL ), reticulocyte 21.4% ( reference range; 0.5-1.5% )Ă direct Comb's test:( 2+ )Ă anti-C3d:( + )Ă anti-IgG:( 4+ ) Ă ANA:1:80 ( + )Ă speckle type ĂពϯߏҋវҺࠪ໘ ҕّళҕĂ warm agglutinin ݭĄฟؕϩኳᙷ׽ዔ ڼᒚĂԸͽ̂጗ณϩኳᙷ׽ዔ ( m e t h y l p r e d - nisolone 1000 mg གྷᐖਔᕇႍᏮڦ˘Ѩගᄃ )Ă҃

ޢග̟ prednisolone Տ͟ 45 mg ˾ڇĂ˟࣎͡ޢଈ ۰۞ Hb а̿ז 9.7 mg/dL Ă MCV ࢫࠎ 110.4 fL Ą

੅ኢ

ώଈ۰ϥېཛྷӔᚢႝّཚ̂ĂϥېཛྷΑਕ݋

΍ன TSH ੼Ă̈́੼ड़ᆊ anti-TPO ԩវĂЯѩ෧ ᕝࠎҋវҺࠪϥېཛྷΑਕҲ˭( autoimmune hy- pothyroidism )Ă፜ώͩϥېཛྷۆ ( Hashimoto's thyroiditis ) ߏ౵Ξਕ۞়ঽĄλҕ஧ّళҕдҋ វҺࠪϥېཛྷΑਕҲ˭ଈ۰֗˯΍னĂ૱ឰˠۡ

ତຐזߏϥېཛྷΑਕҲ˭ώ֗ăჯϠ৵ B

¹²

ăཧ ᅕ৿ͻٕೋّళҕٙౄјĂ҃نர˞ҋវҺࠪ໘ ҕّళҕ ( autoimmune hemolytic anemia; AIHA )Ą AIHA ˵ߏͽλҕ஧ّళҕࠎ͹Ă֭΍ன indirect bilirubin ˯̿ă LDH ˯̿ă haptoglobin ˭ࢫă reticulocytosis ඈ໘ҕপᇈĄ warm agglutinin AI- HA ఼૱ߏ direct Coombs' test วّĂ҃ͷ 99% ͽ

˯ߏ anti-IgG ٕ anti-C3 วّĄώּߏ׏ݭ۞ҋ វҺّࠪ໘ҕّళҕĂ warm agglutinin ݭĄ

ҋវҺࠪϥېཛྷ়ঽ ( autoimmune thyroid disease; ATD ) т፜ώͩϥېཛྷۆ ( Hashimoto's thyroiditis ) ٕཀྵ༄܀ਬঽ ( Graves' disease )Ă૱

Ъ׀ೋّళҕăࣧ൴ّඪ˯ཛྷΑਕҲ˭ăௐ˘ݭ ᎤԌঽඈҋវҺ়ࠪঽĂజჍࠎ a u t o i m m u n e polyglandular syndrome II ĂᓜԖ˯̙֭ց֍Ąҭ ߏ AIHA Ъ׀ ATD ݒޝ͌జಡӘĂ˵إϏజᕩ ᙷٺЇңҋវҺࠪা࣏ཏ̚Ą఺ߏ˘࣎າ۞ҋវ Һࠪা࣏ཏĂٕΪߏ༥μ˘੓΍னٺώଈ۰ĉ

ଂ 1959 ѐ܆ᜋ Curt Wasastjerna ಡӘ፜ώͩ

ϥېཛྷۆ׀൴ AIHA ͽֽ

⁵

Ăಶౙᜈѣ఺ᙷঽּ

జಡӘ

^6-8

Ă઼̚˵ѣᇴּಡӘ

^9-11

Ą఺ֱଈ۰ѐ᛬

ଂ 16 ໐ז 60 ໐ౌѣĂҭБొౌߏّ̃Ą఺ֱଈ ۰̂ొЊТॡЪ׀ѣ AIHA ̈́ҋវҺࠪҕ̈ڕഴ

͌া ( autoimmune thrombocytopenia; ATP )Ă˵ಶ ߏ Evans' syndrome

^5-8

ĄтώּΪѣಏ৷ّ۞ AI- HA ҃إϏ΍ன ATP ۞˵ѣĂҭߏྵ͌

^9-11

Ąຍ̂

Ӏጯ۰അ̶ژ AIHA ă Evans' syndrome ׶ϥېཛྷ Αਕள૱۞ᙯܼ

¹²

Ă൴ன 44 ࣎ AIHA ঽଈ̚ѣ 5

ּߏԩϥېཛྷԩវ ( Antimicrosomal ٕ antithy- roglobulin antibody ) วّĂ׎̚׌ּѣֲᓜԖّ

ϥېཛྷΑਕҲ˭ ( subclinical hypothyroidism)ć 20

࣎ Evans' syndrome ঽଈ̚ѣ 4 ּԩϥېཛྷԩវว

ّĂ׎̚ˬּѣֲᓜԖّϥېཛྷΑਕҲ˭Ą΁ᄮ

438

(3)

ࠎ AIHA ̈́ Evans' syndrome ଈ۰Ъ׀ϥېཛྷΑਕ ள૱தቁ၁ઐ੼ĂপҾߏ Evans' syndrome Հځ ពĄ

ཀྵ༄܀ਬঽЪ׀ AIHA ٕ Evans' syndrome ˵ ѣ̙͌ঽּಡӘ

^13,14

Ąᄂ៉ϺഅಡӘ˘ּ ITP ଈ ۰ޢֽౙᜈ΍ன Graves' disease ̈́ AIHA

¹⁵

ĄЯѩ ATD ׶ AIHA ۞Вх̙֭ߏઊ൒۞Ąᔵ൒ϫ݈إ

൑ڱቁᄮ׎В఼۞࡭ঽ፟ᖼࠎңĂҭкᇴᄮࠎ AIHA ă ITP ̈́ ATD ׍ѣВТ۞Һࠪ౉शĄ˵ѣ ˠ೩΍઄ᄲĈ AIHA ă ITP ٕ Evans' syndrome ۞ ٽຏૄЯ ( ּт HLA-B8/DR3 ඈ ) Ξਕົٸ̂ϥ ېཛྷ۞ҋវҺࠪͅᑕ҃ౄј ATD Ăҭזϫ݈֭

Ϗѣ˘࡭ّ۞ᙋፂ̈́ඕኢ

^7,12,14,15

Ą

൴ঽ۞ॡมАޢѨԔĂѣֱߏА A I H A Г ATD

^8,9

ćѣֱߏ AIHA ׶ ATD ˘੓జ൴ன

^5,6,10,11

Ă тώּć˵ѣֱߏА AT D Г A I H A ൒ޢ΍ன ITP

⁷

Ą఺ֱ९ּଂϥېཛྷΑਕϒ૱

¹¹

ĂϥېཛྷΑ

ਕҲ˭

^6,7,9,10

ĂࠤҌϥېཛྷΑਕ̤ซౌѣ

⁸

ĂЯѩ

ϥېཛྷΑਕ੼Ҳ׶ AIHA ൴Ϡ۞࠹ᙯّ̪ޞՀк

۞ࡁտֽᗃ୻Ą

ր௚ّࡓ೹ّফስ ( systemic lupus erythe- matosus; SLE ) ׶ҋវҺࠪϥېཛྷ়ঽ۞ᙯܼܕ ѐᅲкঽּಡӘ׶ࡁտ

^16,17,18

ĄдҋវҺࠪϥېཛྷ

়ঽ۞ԩ८ԩវ ( anti-nuclear antibody; ANA ) ว

ّதፂҤࢍΞ੼྿ 3 5 % Ăҭ׎ᓜԖຍཌྷ̙֭୻

຾

^{1 9}

Ąώঽּ˵ѣҲड़ᆊ ANA Ăҭϫ݈֭Ϗѣ

௑Ъ SLE ۞׎΁াېĂߏӎώּ૟ֽົϤ AIHA

൴णј Evans' syndrome ࠤҌ SLE Ăࣃ଀Гڦ ຍĄ

ϥېཛྷΑਕҲ˭࠹ᙯ̝ళҕдྃ·ϥېཛྷ৵

̈́࠹ᙯ̝ᒉዳ৵ޢĂдˬ̰࣎͡ళҕӮΞᒔ଀Լ චĂ MCV ˘ਠ˵ົ˭ࢫ

²⁰

Ą˵അѣঽּಡӘᙷ ࢲᒅّᙯ༼ۆЪ׀ϥېཛྷΑਕҲ˭̈́ᚑࢦళҕ

̝ଈ۰Ăགྷϥېཛྷ৵ڼᒚޢĂళҕᒔ଀ځពԼ ච

²¹

Ąҭߏညώঽּ఺჌ ATD Ъ׀ AIHA Ă၆ϥ ېཛྷ৵Ъ׀ᒉዳ৵۞ڼᒚߏ൑ड़۞Ăϥېཛྷ৵۞

ྃ·ࠤҌΞਕЯࠎᆧΐ௡ᖐਈউณ҃ೋ̼׎ళҕ

াېĄЯࠎڼᒚ͞ё׶׎΁ళҕၟ൒̙ТĂٙͽ

̈́ॡϒቁ෧ᕝ AIHA ၆ঽଈ۞ڼᒚޝࢦࢋĄ ϩኳᙷ׽ዔߏ AIHA ۞૱ϡڼᒚᘽۏĂҭߏ ϩኳᙷ׽ዔώ֗ݒົԺטϥېཛྷΑਕĄ෹࿅Ϡந

጗ณ۞ϩኳᙷ׽ዔ ( ּт hydrocortisone Տ͟ 100 mg ͽ˯ ) ົԺט TSH ̶کĂՀ̂጗ณ۞ϩኳᙷ

׽ዔ ( ּт dexamethasone Տ͟ 4 mg ͽ˯ ) ݋ົ

ซ˘ՎԺט T

⁴

ᖼೱј T

³

Ăౄјҕ୻ T

³

፧ޘ˭

ࢫĄٙض఺ֱԺטүϡΪߏൺഇ۞Ăତצܜഇϩ ኳᙷ׽ዔڼᒚ۞ଈ۰Ă̙֭ົጱ࡭ᚑࢦ۞ϥېཛྷ ΑਕҲ˭

²²

Ą

ඕኢ

ϥېཛྷΑਕҲ˭׶ళҕдᓜԖাې˯ѣޝк ࢦᝑ̝఍ĂΒ߁֕ྮटٽಆă͕ଙăБ֗൑˧ࢽ

ަăᐝຶඈĂ൑ኢд෧ᕝళҕٕϥېཛྷΑਕҲ˭

ॡౌᑕপҾڦຍ׌჌়ঽགྷ૱֭хćϥېཛྷΑਕ Ҳ˭ᑕТॡᑭߤళҕĂ̝ͅϺТĄᔵ൒ϫ݈ AI- HA إϏజЕˢ Autoimmune polyglandular syn- drome Ăҭߏ၆ٺҋវҺࠪϥېཛྷΑਕҲ˭ଈ۰

΍ன̝λҕ஧ّళҕ۞ᝥҾ෧ᕝᑕΐ˯ AIHA Ă

̖ਕϒቁ෧ڼѩ়ঽĄ

ણ҂͛ᚥ

1.Dilek M, Akpolat T, Cengiz K. Hypothyroidism as a cause of resistance to erythropoietin. Nephron 2002; 92: 248.

2.Fein HG, Rivlin RS. Anemia in thyroid diseases. Med Clin N Am 1975; 59: 1133-45.

3.Lu JY, Huang TS. Pernicious anemia in two cases of subclinical hypothyroidism. J Intern Med Taiwan 2000; 11: 126-31.

4.Pedersen OM, Aardal NP, Larssen TB, Varhaug JE, Myking O, Vik-Mo H.The value of ultrasonography in predicting autoim- mune thyroid disease. Thyroid 2000; 10: 251-9.

5.Wasastjerna C. Two auto-immune diseases in one patient: A case of hemolytic anemia and Hashimoto's thyroiditis. Acta Med Scand 1959; 165: 299-304.

6.Hennemann HH, Kloss A. Autoimmune haemolytic anemia, thrombocytopenia and thyroiditis: an immunopathological triad. Dtsch Med Wochenschr 1978; 103: 609-12.

7.Kang MY, Hahm JR, Jung TS, Lee GW, Kim DR, Park MH. A 20-year-old woman with Hashimoto's thyroiditis and Evans' syndrome. Yonsei Med J 2006; 47: 432-6.

8.Geissler D, Ogriseg M, Fill H, Wolf H. Plasmapheresis treat- ment of three simultaneous autoimmune processes: Hashimoto's thyroiditis with hyperthyroidism, autoimmune thrombocytope- nia and autoimmune hemolytic anemia: a case report. Wien Klin Wochenschr 1987; 99: 351-5.

9.੼̠ᅦăॷჴ៣Ąҋ֗Һّࠪ໘ҕّళҕЪ׀ϥېཛྷ፟ਕ ഴੜ˘ּĄਝ۩ਝ͇ᗁᘽ 1996; 7: 229-30 Ą

10.ౘָ׶ăইཇ␰Ąҋ֗Һّࠪ໘ҕّళҕЪ׀፜ώͩϥې ཛྷۆᚶ൴ϥഴ˘ּĄᓜԖ̰ࡊᗔᄫ 1996; 13: 26 Ą

439

(4)

11.͍ှăͳึ୻Ąၙّ୽͐௟ࡪّϥېཛྷۆЪ׀ҋ֗Һّࠪ

໘ҕّళҕ˘ּĄщᑔᗁጯ 1997; 18: 51 Ą

12.Lio S, Albin M, Girelli G, Perrone MP, Gandolfo G, Conti L, et al. Abnormal thyroid function test results in patients with Fisher- Evans' syndrome. J Endocrinolol Invest 1993; 16: 163-7.

13.Branehog I, Olsson KS, Weinfeld A, Domellof L. Association of hyperthyroidism with idiopathic thrombocytopenic purpura and haemolytic anemia. Acta Med Scand 1979; 205: 125-31.

14.Ikeda K, Muruyama Y, Yokoyama M, et al. Association of Graves' disease with Evans' syndrome in a patient with IgA nephropathy. Intern Med 2001; 40: 1004-10.

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17.Pyne D, Isenberg DA. Autoimmune thyroid disease in systemic lupus erythematosus. Ann Rheum Dis 2002; 61: 70-2.

18.Sheu YT, Su YC, Li DK, Lai NS. Systemic lupus erythmatosus with autoimmune hemolytic anemia and pure red cell aplasia. J Intern Med Taiwan 2004; 15: 134-38.

19.Tektonidou MG, Anapliotou M, Vlachoyiannopoulos P, Moutsopoulos HM. Presence of systemic autoimmune disorders in patients with autoimmune thyroid diseases. Ann Rheum Dis 2004; 63: 1159-61.

20.Horton L, Coburn RJ, England JM, Himsworth RL. The haema- tology of hypothyroidism. Quar J Med 1976; 45: 101-23.

21.McCrea AP, Bell AL. Profound anaemia responding to correc- tion of hypothyroidism in a patient with rheumatoid arthritis. J Roy Soc Med 1989; 82: 633.

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440

Autoimmune Hypothyroidism with

Autoimmune Hemolytic Anemia Ĉ A Case Report

Hon-Ke Sia, Cheng-Shyong Chang

¹

, and Shih-Te Tu

A 27-year-old woman had shortness of breath upon walking, palpitation, generalized weakness, poor ap- petite and dizziness of several months' duration. Clinical examination revealed a diffuse goiter, hyperthy- rotropinemia, and a high titer of anti-TPO antibody. She was diagnosed to have autoimmune hypothyroidism com- patible with Hashimoto's thyroiditis. In addition, she also had severe macrocytic anemia with a strongly positive direct Coomb's test, which suggested autoimmune hemolytic anemia (AIHA). Her anemia responded to steroid therapy, but not to thyroxine replacement alone. Up to now there have been few reports of autoimmune hy- pothyroidism associated with AIHA. The two autoimmune disorders have not been grouped together as an au- toimmune syndrome. Since the management of AIHA is vastly different from that of the more common hypothy- roidism-related anemias, prompt and accurate diagnosis is crucial for treatment. ( J Intern Med Taiwan 2008; 19:

437-440 )

Division of Endocrinology and Metabolism,

¹