Endocrine Abstracts

Introduction: Rheumatoid arthritis is an inflammatory disease characterized by joint destruction, the erosion being caused by invasion of articular cartilage by the synovial pannus. This chronic systemic disease affects approximately 0.5–1% of the adult population, occurring more often in women than in men (3:1). The etiology is thought to be multifactorial, environmental factors or infectious agents being suggested to play a role, but their contribution is yet to be defined. Acromegaly is a chronic endocrinopathy characterized by hypersecretion of growth hormone (GH) and insulin-like growth factor-1 (IGF-1), most likely caused by a pituitary adenoma. Primary hyperparathyroidism is a disorder of one or more of the parathyroid glands, characterized by an elevated PTH that causes hypercalcemia.

Case report: A 57 year old female patient, Caucasian, with no significant family history, non-smoker, diagnosed in 2007 with rheumatoid arthritis (treated with sulfasalazine, methrotrexate and leflunomide) and acromegaly (caused by a pituitary macroadenoma of 1.5/1.5/1.4 cm, treated with surgery, gamma-knife, lanreotide and octreotide – medical treatment interrupted 5 years ago), was admitted to our department with recent history of thoracocentesis (rheumatoid pleural effusion with low glucose level and present rheumatoid factor). The medical history included hypertension, osteoporosis, total histerectomy, sleep apnea and multinodular goiter with hypothyroidism. Clinical examination showed acromegaloid facial appearance, bilateral ulnar deviation of fingers, morning stiffness, swollen and painful joints, swan neck finger deformity, absent breath sounds in the lower 1/3 left hemithorax and a small goiter. Blood tests depicted normal TSH, elevated PTH (80.15 pg/ml), slightly elevated calcium (10.0 mg/dl), insufficient 25-OH-Vitamin D levels (14.75 ng/ml) and a normal IGF-1 (167 ng/ml). Thyroid ultrasonography revealed multiple micronodules with calcification and a hypoechoic mass lesion of 0.7/0.5 cm at the posterior aspect of the right thyroid lobe, resembling a parathyroid adenoma. A small-medium left pleural effusion was noted on chest X-ray without drainage recommandation. Thus, we confirmed the current inactive status of the acromegaly and the absence of pituitary gonadotropin and thyrotropin insufficiency. Treatment was initiated with Zolendronic acid and Vitamin-D 2000 UI/day.

Conclusion: Although genetic testing for multiple endocrine neoplasia syndrome type 1 and type 4 could not be performed, the simultaneously diagnosis of acromegaly and rheumatoid arthritis, associated with the latter presence of primary hyperparathyroidism, arise questions about the occurence of both autoimmune and neuroendocrine pathogeny in the same patient.