Combined Immunosuppressive Therapy for Severe Graves Dermopathy
Authors: Sriram Gubbi, Katherine Andrea Araque, Shirisha Avadhanula, Asma Azam, Roxanne Merkel, Craig Cochran, Peter Denis Burbelo, Meryl Waldman, Susanne Neumann, Marvin Carl Gershengorn, Monica Skarulis, Joanna Klubo-Gwiezdzinska
Journal: Annals of Internal Medicine (2021)

LettersOctober 2021Combined Immunosuppressive Therapy for Severe Graves DermopathySriram Gubbi, MD, Katherine Andrea Araque, MD, Shirisha Avadhanula, MD, Asma Azam, BS, Roxanne Merkel, RN, Craig Cochran, RN, Peter Denis Burbelo, PhD, Meryl Waldman, MD, Susanne Neumann, PhD, Marvin Carl Gershengorn, MD, Monica Skarulis, MD, and Joanna Klubo-Gwiezdzinska, MD, PhDSriram Gubbi, MDNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, Katherine Andrea Araque, MDNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, Shirisha Avadhanula, MDCleveland Clinic, Cleveland, OhioSearch for more papers by this author, Asma Azam, BSNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, Roxanne Merkel, RNNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, Craig Cochran, RNNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, Peter Denis Burbelo, PhDNational Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, Meryl Waldman, MDNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, Susanne Neumann, PhDNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, Marvin Carl Gershengorn, MDNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, Monica Skarulis, MDNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this author, and Joanna Klubo-Gwiezdzinska, MD, PhDNational Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandSearch for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/L21-0152 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: The extrathyroidal manifestations of Graves disease include orbitopathy, dermopathy, and acropachy (periosteal changes and clubbing of fingers and toes). Severe forms of Graves dermopathy, such as nodular dermopathy or elephantiasis nostras verrucosa, can cause significant morbidity (1). The pathophysiology of Graves dermopathy is poorly understood. A combination of factors may contribute to its development, including immunologic factors, such as infiltration of T and B lymphocytes, cytokine production, interactions between serum thyroid-stimulating hormone receptor antibodies (TRAbs) and thyroid-stimulating hormone and insulin-like growth factor I receptors in dermal tissues; cellular factors, such as glycosaminoglycan production from fibroblasts; and other factors, such ...References1. Fatourechi V. Pretibial myxedema: pathophysiology and treatment options. Am J Clin Dermatol. 2005;6:295-309. [PMID:16252929] CrossrefMedlineGoogle Scholar2. Heyes C, Nolan R, Leahy M, et al. Treatment-resistant elephantiasic thyroid dermopathy responding to rituximab and plasmapheresis. Australas J Dermatol. 2012;53:e1-4. [PMID: 22309343] doi:10.1111/j.1440-0960.2010.00693.x CrossrefMedlineGoogle Scholar3. Kotwal A, Turcu AF, Sonawane V, et al. Clinical experience with rituximab and intravenous immunoglobulin for pretibial myxedema: a case series. Thyroid. 2019;29:692-699. [PMID: 30854936] doi:10.1089/thy.2018.0706 CrossrefMedlineGoogle Scholar4. Klubo-Gwiezdzinska J, Lange M, Cochran E, et al. Combined immunosuppressive therapy induces remission in patients with severe type B insulin resistance: A prospective cohort study. Diabetes Care. 2018;41:2353-2360. [PMID: 30201849] doi:10.2337/dc18-0884 CrossrefMedlineGoogle Scholar5. Farivar SS, Cunningham WE, Hays RD. Correlated physical and mental health summary scores for the SF-36 and SF-12 Health Survey, V.I. Health Qual Life Outcomes. 2007;5:54. [PMID: 17825096] CrossrefMedlineGoogle Scholar6. Oltulu P, Ince B, Kokbudak N, et al. Measurement of epidermis, dermis, and total skin thicknesses from six different body regions with a new ethical histometric technique. Turkish Journal of Plastic Surgery. 2018;26:56–61. doi:10.4103/tjps.TJPS_2_17 CrossrefGoogle Scholar Author, Article, and Disclosure InformationAffiliations: National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MarylandCleveland Clinic, Cleveland, OhioNational Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MarylandNote: The study was approved by the Institutional Board Review at the National Institutes of Health Clinical Center and an informed consent was obtained from the patient. Drs. Gubbi and Araque contributed equally to the study and preparation of the manuscript. Dr. Burbelo performed the luciferase immunoprecipitation systems assay. Dr. Gershengorn, Dr. Neumann, and Ms. Azam performed the in vitro studies. These in vitro studies are not available in clinical laboratories. Additional details about the tests used to establish the effectiveness of therapy are available from Dr. Klubo-Gwiezdzinska (e-mail, joanna.klubo-[email protected]gov).Acknowledgment: The authors thank the physicians and nurses who played a role in taking care of this patient at the National Institutes of Health Clinical Center.Financial Support: This patient was under the functional thyroid disease protocol at the National Institutes of Health, which was funded by the intramural program of the National Institutes of Health (DK 075005 16) and National Institute of Dental and Craniofacial Research. The sponsors had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.Disclosures: Authors have reported no disclosures of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=L21-0152.Corresponding Author: Joanna Klubo-Gwiezdzinska, MD, PhD, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive, Building 10 CRC, Room 9C-103, Bethesda, MD, 20814; e-mail, joanna.[email protected]gov.This article was published at Annals.org on 22 June 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics October 2021Volume 174, Issue 10Page: 1478-1480KeywordsAntibodiesDisclosureImmunoprecipitationImmunosuppressivesInsulin resistanceMagnetic resonance imagingSoft tissuesThyroglobulinThyroid-stimulating hormoneThyroxine ePublished: 22 June 2021 Issue Published: October 2021 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...