Unprecedented complexity of six coexisting autoimmune diseases: A case report

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Published Feb 18, 2024
https://doi.org/10.62438/tunismed.v102i2.4647
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Vol. 102 No. 2 (2024): Tunis med feb 2024

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Jihed Anoun
Department of Internal Medicine, Sahloul University Hospital, Faculty of Medicine, University of Sousse, Sousse, Tunisia
https://orcid.org/0000-0002-5441-6867
Nourhen Guedri
Department of Internal Medicine, Sahloul University Hospital, Faculty of Medicine, University of Sousse, Sousse, Tunisia
https://orcid.org/0009-0005-5342-7010
Imen Ben Hassine
Department of Internal Medicine, Sahloul University Hospital, Faculty of Medicine, University of Sousse, Sousse, Tunisia
https://orcid.org/0000-0001-5459-3460
Wafa Baya
Department of Internal Medicine, Sahloul University Hospital, Faculty of Medicine, University of Sousse, Sousse, Tunisia
https://orcid.org/0000-0003-1358-5266
Anis Mzabi
Department of Internal Medicine, Sahloul University Hospital, Faculty of Medicine, University of Sousse, Sousse, Tunisia
https://orcid.org/0009-0000-1277-9494
Fatma Ben Fredj
Department of Internal Medicine, Sahloul University Hospital, Faculty of Medicine, University of Sousse, Sousse, Tunisia
https://orcid.org/0000-0002-2850-816X

Abstract

Introduction. Autoimmune disorders often exhibit interconnectedness, although encountering multiple autoimmune conditions in a single patient is uncommon. Multiple autoimmune syndrome is characterized by the presence of at least three distinct autoimmune diseases in an individual. This report outlines the case of a middle-aged woman diagnosed with autoimmune thyroiditis, Sjögren’s syndrome, scleroderma, autoimmune hepatitis, primary biliary cirrhosis, and antisynthetase syndrome. Additionally, it includes a literature review encompassing multiple autoimmune syndromes involving five or more autoimmune diseases.


Observation. A 57-year-old woman, with no previous medical history, presented with fever, extensive muscle weakness, progressive exertional dyspnea, inflammatory polyarthralgia, dysphagia, and dry mouth. Clinical examination revealed muscular deficit in the scapular and pelvic girdles, distal muscular deficit, synovitis in the wrists, and features indicative of “mechanic’s hand”. Laboratory examinations showed cytolysis, cholestasis, elevated muscle enzymes, hypergammaglobulinemia and elevated thyroid stimulating hormone. Immunoassays showed positive results for antinuclear antibodies, anti-histidyl-t-RNA synthetase, anti–Sjögren's-syndrome-related antigen A, anti-ribonucleic-acid-polymerase-III-RP155, anti-fibrillarin, anti-mitochondrial, anti-liver/kidney microsomal type 1, anti-glycoprotein 210, and anti-thyroid peroxidase antibodies. Further investigations led to the diagnosis of a multiple autoimmune syndrome involving autoimmune thyroiditis, Sjögren’s syndrome, scleroderma, autoimmune hepatitis, primary biliary cirrhosis, and antisynthetase syndrome. The patient received treatment with intravenous immunoglobulins, corticosteroids, azathioprine, and ursodeoxycholic acid, which resulted in favorable clinical and biological outcomes.


Conclusion. This patient presented with six concurrent distinct autoimmune disorders, categorizing this case as a type two multiple autoimmune syndrome. The identification of antisynthetase syndrome notably distinguishes this case.

Keywords:

Autoimmune hepatitis, Autoimmune thyroiditis, Myositis, primary biliary cirrhosis, Sjogren’s syndrome

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