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Dr. Abid
Dr. Abid, Doctor
Category: Medical
Satisfied Customers: 5964
Experience:  MBBS, FCPS(R)
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I have Graves' disease with a very gh level of

Customer Question

I have Graves' disease with a very high level of thyroid-stimulating immunoglobulins. The resultant hyperthyroidism is actually relatively mild. My most distressing symptom is recurrent skin ulcers that are triggered by very minor trauma to my skin (pathergy). Biopsies have ruled out bacteria, mycobacteria, and fungi but are otherwise inconclusive. All that can be seen is a dense infiltrate of inflammatory cells (no vasculitis, although I do get petechiae frequently). I am convinced that the ulcers (occurring on my face and shoulders) are an atypical variant of pyoderma gangrenosum, but no one can say for sure, and I've seen every kind of specialist that exists. The ulcers do respond to topical steroids. In any case, could these inflammatory ulcers be caused by thyroid antibodies? There's a very complex relationship between the skin and the thyroid. I'm convinced that excess thyroid hormone is not blame for the ulcers, especially since my thyroid hormones are not particularly elevated. I think the ulcers are being caused by the antibodies/underlying immune system dysfunction. Is there anything at all, even experimentally, that can target the antibodies/immune dysfunction? Does RAI have a predictable effect on the antibodies? I've read that it can increase them, decrease them, or have no effect on them at all.
Submitted: 10 months ago.
Category: Medical
Expert:  Dr. Abid replied 10 months ago.

Hi there ...

Thank you for your question ...

Please tell me have you had test to rule out the possibility of associated other autoimmune disease with Graves disease which could be the cause of ulcers like scleroderma ?

Regards .

Customer: replied 10 months ago.
I've ruled out all inflammatory bowel diseases through a colonoscopy with biopsy and rheumatological diseases through a full rheumatological panel (HLA B27, sedimentation rate, cardiolipin antibody, C3 complement, rhuematoid factor, cyclic citrul peptide AB, c-ANCA and p-ANCA, extractable nuclear antigen, and c-reactive protein). I have been tested for anti-neutrophil antibodies, and the test was only positive once (titer 1:80 with a speckled pattern). I was told that was not significant. I've also been tested for immunodeficiencies, and there are none. I do have chronic idiopathic neutropenia, but it has always been mild. It may or may not be associated with the Graves' disease. I don't have any symptoms of scleroderma.
Expert:  Dr. Abid replied 10 months ago.

Ok thats fine , if everything is normal than it is highly likely that antibodies like thyroid stimulating antibodies have negative effect against skin and skin vessels leading to cutaneous vasculitis associated with ulcer formation .

Suppression of immune system with steroids can be helpful to reduce the frequency and occurrence of ulcers .

I will suggest you to ask your Endocrinologist to have immunosuppresive therapy along with anti-thyroid drugs to see response , if ulcers heal than this is indication that underlying immune hyper function is the reason of skin ulcers .

Because in hyperthyroidism hyperfunctioning of vasomotor center is also associated with skin issues.

Regards .

Positive feedback will be appreciated .

Thanks .

Customer: replied 10 months ago.
My skin biopsies have not shown vasculitis, as I said earlier, but they didn't rule it out either.To clarify, is it the antibodies themselves that would cause the vasculitis or the excess thyroid hormones (T3 and T4)? Anti-thyroid medications have been known to cause pyoderma gangrenosum, so I do not want to take those and exacerbate my skin condition.Are there any other useful immunomodulating agents besides steroids, which have horrible side effects. What about intravenous immunoglobulin? I know it's expensive, but theoretically couldn't it work?
Expert:  Dr. Abid replied 10 months ago.

Yes there are other immune modulators but they are not directly indicated once if steroids are not beneficial than those agents are indicated .

So I wish you should start steroids .

Good luck .

Positive feedback will be appreciated .

Thanks .

Expert:  Dr. Abid replied 10 months ago.

Even if biopsy are not suggestive of inflammation or vasculitis but still once you should have trial of steroids .

Regards .

Positive feedback will be appreciated .

Thanks .