DR [Dermatology Reports 2011; 3:e19] [page 43] A new combination of multiple autoimmune syndrome? Coexistence of vitiligo, autoimmune thyroid disease and ulcerative colitis Firdevs Topal,1 Engin Senel,2 Sabiye Akbulut,3 Fatih Topal,4 Yasemin Dölek5 1Clinics of Gastroenterelogy; 2Dermatology, Çankiri State Hospital, Çankiri; 3Department of Gastroenterology, Kartal Kosuyolu High Specialty Education and Research Hospital, Istanbul; 4Clinics of Emergency Medicine; 5Pathology, Çankiri State Hospital, Çankiri, Turkey Abstract The occurrence of three or more autoim- mune disorders in one patient defines multiple autoimmune syndrome. The pathogenesis of multiple autoimmune syndrome is not known yet and environmental triggers and genetic susceptibility have been suggested to be in- volved. Herein, we report a 47-year-old woman who had Hashimoto’s thyroiditis, vitiligo and newly diagnosed ulcerative colitis. Diagnosis of ulcerative colitis was confirmed with histopathologic examination. This case pres- ents a new combination of multiple autoim- mune syndrome. Introduction A multiple autoimmune syndrome (MAS) consists of three or more well-defined autoim- mune conditions in the same patient. It was first proposed by Humbert in 1988 and de- scribed with increasing frequency.1 Although exact pathogenesis of the syndrome is ob- scure, environmental triggers and genetic sus- ceptibility may be involved.2 Case Report A 47-year-old woman who had Hashimoto’s thyroiditis for 26 years and vitiligo for 37 years presented to gastroenterology service of our hospital with bloody diarrhea for three months. Dermatological examination showed multiple depigmented macules and patches on her trunk and extremities (Figure 1). Colonoscopy revealed a hemorrhagic edematous mucosa of the colon. Histopathological examination dis- closed superficial ulceration and numerous crypt abscesses, and mixed leukocytic infil- trates in lamina propria (Figure 2). A diag- nosis of rectosigmoid ulcerative colitis was es- tablished by colonoscopy and histopathological examination. Discussion Autoimmune disorders are conditions in which there is the development of antibodies against self-cells. Multiple autoimmune syn- drome is defined as a combination of at least three autoimmune diseases in the same pa- tient. MAS can be classified into three subtypes in which certain disorders frequently occur to- gether (Table 1).2,3 HLA-B8, -DR3 or -DR5 have been suggested to be an important factor for subtype 3. Acquired primary hypogonadism, hy- pophysitis, romatoid arthritis, relapsing poly- chondritis, multiple sclerosis, CAH, ulcerative colitis, and scleroderma have been reported to be associated with MAS subtype 3.1,2 The pathogenesis of MAS is not clear yet. En- vironmental triggers and genetic susceptibility have been proposed to be involved.2,4,5 Autoim- munity has been proposed to be a prominent factor for inflammatory bowel diseases.6 Snook et al. found that at least one autoimmune dis- order was present in 7% of the patients with ul- cerative colitis and 2% of the controls.7 Our patient had autoimmune thyroid dis- ease, vitiligo and ulcerative colitis. Although this combination of autoimmune disorders has Dermatology Reports 2011; volume 3:e19 Correspondence: Engin Senel, Çankiri State Hospital, Clinic of Dermatology, Aksu Mah. Ogretmenler Sokak, 18200 Çankiri, Turkey. Tel. +90.376.2131098. E-mail: enginsenel@enginsenel.com Key words: multiple autoimmune syndrome, autoimmunity, vitiligo, ulcerative colitis, autoim- mune thyroiditis. Received for publication: 15 July 2011. Accepted for publication: 15 July 2011. This work is licensed under a Creative Commons Attribution NonCommercial 3.0 License (CC BY- NC 3.0). ©Copyright F. Topal et al., 2011 Licensee PAGEPress, Italy Dermatology Reports 2011; 3:e19 doi:10.4081/dr.2011.e19 Figure 1. Depigmented patches on the back. Table 1. Classification of multiple autoimmune syndrome. MAS Type 1 MAS Type 2 MAS Type 3 Thymoma Rheumatoid arthritis Autoimmune thyroid disease Myasthenia gravis Sjögren’s syndrome Myasthenia Polymyositis Pemphigus vulgaris Thymoma Giant cell myocarditis Primary biliary cirrhosis Sjögren’s syndrome, pernicious anemia Pemphigus vulgaris Scleroderma Idiopathic thrombocytopenic purpura Bullous pemphigoid Autoimmune thyroid disease Addison’s disease Insulin-dependent diabetes Vitiligo Autoimmune Hemolytic anemia Systemic lupus erythematosus Dermatitis herpetiformis Figure 2. Crypt abscesses and mixed leukocyt- ic infiltrates in lamina propria (H&E, x10).No n- co mm er cia l u se on ly [page 44] [Dermatology Reports 2011; 3:e19] not been reported before this case presents a new association that meets the requirements for the diagnosis of MAS. We suggest that this com- bination should be included in MAS subtype 3. References 1. Humbert P, Dupond JL. [Multiple autoim- mune syndromes]. Ann Med Interne (Paris) 1988;39:159-68. 2. Mohan MP, Ramesh TC. Multiple autoim- mune syndrome. Indian J Dermatol Venereol Leprol 2003;69:298-9. 3. Tirado-Sanchez A, Montes-de-Oca G. Coex- istence of bullous pemphigoid, vitiligo, and thyroid disease: a multiple autoim- mune syndrome? Dermatol Online J 2005;11:20. 4. Humbert P, Dupond JL, Vuitton D, Agache P. Dermatological autoimmune diseases and the multiple autoimmune syndromes. Acta Derm Venereol Suppl (Stockh) 1989; 148:1-8. 5. Pasic A, Ljubojevic S, Lipozencic J, et al. Coexistence of psoriasis vulgaris, bullous pemphigoid and vitiligo: a case report. J Eur Acad Dermatol Venereol 2002;16:426-7. 6. Thompson DM, Robinson TW, Lennard- Jones J. Alopecia areata, vitiligo, sclero- derma and ulcerative colitis. Proc R Soc Med 1974;67:1010-2. 7. Snook JA, de Silva HJ, Jewell DP. The asso- ciation of autoimmune disorders with in- flammatory bowel disease. Q J Med 1989; 72:835-40. Case Report No n- co mm er cia l u se on ly