International Journal of Clinical Case Reports 2017, Vol.7, No.1, 1-3
1
A Letter Open Access
Multiple Autoimmune Syndrome: Celiac Disease, Hashimoto’s Thyroiditis, and
Systemic Lupus Erythematosus
Nabil Belfeki
1
, Souheil Zayet
2
, Imed Ben Ghorbel
1
, Mohamed Habib Houman
1
1 Department of Internal Medicine, University Hospital of La Rabta, Tunis, Tunisia
2 Department of Infectious Disease, University Hospital of La Rabta, Tunis, Tunisia
Corresponding author email
International Journal of Clinical Case Reports 2017, Vol.7, No.1 doi
Received: 24 Feb., 2017
Accepted: 15 Mar., 2017
Published: 05 Apr., 2017
Copyright © 2017
Belfeki et al., This is an open access article published under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Preferred citation for this article:
Belfeki N., Zayet S., Ghorbel I.B., and Houman M.H., 2017, Multiple autoimmune syndrome: celiac disease, hashimoto’s thyroiditis, and systemic lupus
erythematosus, International Journal of Clinical Case Reports, 7(1): 1-3 (doi
Abstract
Multiple autoimmune syndrome is the association of three or more autoimmune diseases in the same patient. We report
the case of a 24-year-old woman with a medical past history of celiac disease since the age of 3. She
complained of fatigue, malar
rash, and paresthesia of the lower limbs. Physical examination objectified fever at 38°C and butterfly rash. Cell blood count showed
leucopenia and lymphopenia. Thyroid tests concluded to primary hypothyroidism. Immunological investigations revealed positive
antinuclear antibodies (1/3200), anti-DNA, and thyroperoxydase antibodies. The HLA haplotype typing was A1 A26 B50 B16 DR3
DR52 DQ2. The diagnosis of multiple autoimmune syndrome associating systemic lupus erythematosus, celiac diasese, and
Hashimoto’s thyroiditis was retained. The patient was treated with hydroxychloroquine 400 mg/day and L-thyroxine 100 µg/day. The
global outcome was favorable and the patient was free of symptoms. The decline is 10 years. The current case is unique in this aspect
that the combination of these three autoimmune disorders has rarely been reported in the past.
Keywords
Multiple autoimmune syndrome; Systemic Lupus Erythematosus; Celiac disease; Hashimoto’s thyroiditis
Background
Autoimmune diseases are known to have association with each other but it is very rare to see multiple
autoimmune diseases in one patient. The combination of at least three autoimmune diseases in the same patient is
referred to as multiple autoimmune syndrome (MAS) (Humbert and Dupond, 1988).We report a case of MAS in a
24-year old girl who was diagnosed to be suffering from Hashimoto's thyroiditis, celiac disease, and systemic
lupus erythematosus (SLE).
1 Case Report
A 24-year-old woman had a family past history of celiac disease with her brother and personal past history of
celiac disease since the age of 3. The diagnosis of celiac disease was retained at the age of 3 since the patient had
abdominal pain, subtotal villous atrophy on jejunal biopsy, and positive Ig A anti transglutaminase and Ig A anti
endomysium antibodies. The patient’s symptoms improved after a gluten-free diet. At the age of 24, she
complained of fatigue, malar rash, and joint pain on wrists and fingers. On examination, she had fever at 38°C.
Her weight was 51 kg for a height of 152 cm. She had a smooth non tender goiterous swelling in the front of her
neck, measuring about 5×6 cm. She presented a butterfly malar rash and reported photosensitivity.
Musculoskeletal and abdominal examinations were unremarkable and urine sticks were negative. First hour
laboratory tests showed leucopenia (3 800/mm
3
), lymphopenia (800/mm
3
), and an erythrocyte sedimentation rate
of 57 mm. Serum protein electrophoresis showed hypergammaglobulinemia (25 g/l). Thyroïd profile showed high
thyroid stimulating hormone (TSH) (65 µUI/ml) and low T4 (4 ng/L). Immunological investigations showed that
antinuclear antibodies (1/3200), anti-DNA, and anti-thyroperoxydase antibodies were all positive. Complements
fractions (C3, C4, and CH50) were normal. Thyroid echography showed diffuse nontoxic goiter. The HLA
haplotype typing was A1 A26 B50 B16 DR3 DR52 DQ2. Based on clinical and laboratory findings, the diagnosis
retained was of multiple autoimmune syndrome associating systemic lupus erythematosus (according to the
American College of Rheumatology criteria for classification of systemic lupus erythematosus (Hocheberg,
