PSAT353 Can Generalized Granuloma Annulare occur in patients with Graves’ disease?

Abstract

Introduction Granuloma annulare (GA) is a benign self-limiting dermatosis, typically characterized by an annular arrangement of erythematous or flesh-colored papules, affecting patients of all ages. An association between GA and autoimmune diseases (including autoimmune thyroiditis) has been reported in the literature thus suggesting that GA belongs to the spectrum of autoimmune diseases. However, only a few case reports described the unusual association of localized GA with hyperthyroidism. The definitive correlation between thyroid disease and GA hasn't been established. It was suggested that there is a common immunogenic predisposition or that both diseases share a common pathway. We present a rare case of generalized granuloma annulare in a patient with Graves’ disease. Case report A 52-year-old African American female with a past medical history of Graves’ disease with mild Graves’ ophthalmopathy was referred to the endocrinology clinic. She was diagnosed with Graves’ disease seven years ago and was medically managed ever since. Initially, she was treated with a high dose of methimazole however, for the past six years, she was on a stable dose of methimazole 5 mg daily. Two years following diagnosis of Graves’ disease, she developed serpiginous non-pruritic erythematous skin papules and patches in the right upper arm which slowly progressed over the course of years to involve bilateral inner thighs and under the breasts. She was evaluated by dermatology at that time and was empirically treated with a topical antifungal agent without any significant improvements. After establishing care with us, there was suspicion of methimazole-induced ANCA vasculitis or other autoimmune diseases. Extensive rheumatological workup including ANCA level was performed with negative results. Since her thyroid function tests (TSH and free T4) were normal on a low dose of methimazole for an extended period, we discontinued methimazole, however, skin rash didn't improve. The patient was then evaluated by dermatology and was diagnosed with GA based on clinical judgment. She was subsequently treated with an extended course of triple antibiotics therapy using rifampin, ofloxacin, and minocycline for 5 months with significant improvement of the skin rash. Currently, the patient has been off methimazole for 12 months and off triple antibiotic for 4 months with no recurrence of symptoms. Conclusion Although rare, generalized granuloma annulare can be seen in patients with autoimmune thyroid disease including Graves’ disease. Hence, endocrinologists should be aware of the different skin manifestations which can be seen in patients with autoimmune thyroid disease. Further studies are necessary to clarify the association of GA with autoimmune thyroid disease. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Immune checkpoint inhibitor-induced diabetes mellitus with nivolumab

“… 19 20 Additionally, it has been recommended that patients are informed about symptoms of hyperglycaemia to promote early recognition of ICI-DM. 2 4 Clinician awareness of this potential irAE is also important, given our patient did not present with such symptoms and hyperglycaemia was an incidental finding.…”

“… 4 Cancer cells can express PD-L1 to exploit this self-tolerance, hence the role of PD-1 and PD-L1 inhibitors in reactivating the antitumour immune response. 2 …”

“… 7 This is thought to represent a self-tolerance mechanism to reduce autoimmune destruction of islet cells and may explain why PD-1 and PD-L1 inhibitor therapy can induce diabetes mellitus. 2 …”

“… 4 11 12 HbA1c is generally lower than 10% at time of diagnosis and C-peptide levels are either undetectable or inappropriately low for the degree of hyperglycaemia. 2 4 13 There are increasing articles evaluating the role of C-peptide in aiding diagnosis and monitoring of ICI-DM given the proposed mechanism of autoimmune destruction of pancreatic islet cells. Some authors have suggested interval testing of C-peptide level to confirm which patients will require lifelong insulin therapy and one longitudinal study reported no difference in C-peptide level from baseline to diagnosis of ICI-DM between patients with and without ICI-DM.…”

“…However, they can also lead to immune-related adverse events (irAEs) in any organ system, with endocrinopathies being among those more commonly reported 1. ICI-induced diabetes mellitus (ICI-DM) is one such endocrinopathy and has particular clinical significance as the majority of patients present in diabetic ketoacidosis (DKA) and require lifelong treatment with insulin therapy 2. ICI-DM has been reported with PD-1 and PD-L1 inhibitors and rarely with CTLA-4 inhibitors 2 3…”