Endocrine Abstracts

Subacute thyroiditis is a painful disease of the thyroid gland characterized with granulomatous inflammation. Adalimumab is a human monoclonal anti TNF antibody used in the treatment of several autoimmune diseases. Here we report a case of subacute thyroiditis associated with adalimumab treatment for ankylosing spondylitis. A 42 year old female patient was admitted to the hospital for fever, chills and neck pain radiating to the right ear. She was diagnosed with ankylosing spondylitis 9 years ago and was on adalimumab treatment (40 mg every 15 days) for the last 7 years. On physical examination her body temperature was 38.2 °C. Thyroid was diffusely enlarged and tender to palpation. Laboratory evaluation of the patient is summarized in table 1. A thyroid scintigraphy showed a diffusely supressed gland. Ultrasonography of the thyroid revealed diffuse enlargement of the gland with interspersed hypoechoic areas (figures A and B). The patient was diagnosed with subacute thyroditis. Serum Ig M for CMV and EBV were negative. Adalimumab treatment was stopped and prednisolone 32 mg/day was started. Four weeks later, she consulted again with relapse of fever and neck pain due to noncompliance with the steroid treatment. She was hospitalized and 48 mg/day prednisolone was given. Her neck pain subsided and her fever responded dramatically to steroid treatment. She was discharged on steroid treatment. When the patient came for a control at 6 weeks her thyroid function tests were normal and CRP decreased to 5.6 mg/dl. Adalimumab is a biologic agent used in the treatment of autoimmune diseases. To date three cases of subacute thyroiditis are reported with adalimumab. Subacute thyroiditis is histopathologically characterized with granuloma formation. TNF-α plays an important role in regulation of T cell function and granuloma formation. Adalimumab is implied in the paradoxical development of pulmonary sarcoidosis and granulomatous skin reactions.The precise mechanism underlying the association between adalimumab and the onset of subacute thyroiditis remains unclear.