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CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 3  |  Page : 206-208

Psoriasis and Hashimoto's thyroiditis in a child with down syndrome


Department of Dermatology, Koç University School of Medicine, Istanbul, Turkey

Date of Web Publication5-Jul-2016

Correspondence Address:
Hilal Gokalp
Department of Dermatology, Koç University School of Medicine, Davutpaşa Caddesi No: 4 34010 Topkapı, Istanbul
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.179497

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  Abstract 

Down syndrome (DS), or trisomy 21, is the most common chromosomal disorder. DS has been associated with autoimmune diseases including autoimmune thyroiditis, Type 1 diabetes mellitus, celiac disease, autoimmune chronic active hepatitis, alopecia, vitiligo, hypoparathyroidism, psoriasis, and psoriatic arthritis. To our knowledge, we herein report the first concurrence of psoriasis and Hashimoto's thyroiditis in an individual with DS, emphasizing the predisposition of DS individuals to autoimmune diseases.

Keywords: Autoimmune diseases, autoimmunity, Down syndrome, Hashimoto's thyroiditis, psoriasis


How to cite this article:
Gokalp H, Akkaya AD. Psoriasis and Hashimoto's thyroiditis in a child with down syndrome. Indian J Paediatr Dermatol 2016;17:206-8

How to cite this URL:
Gokalp H, Akkaya AD. Psoriasis and Hashimoto's thyroiditis in a child with down syndrome. Indian J Paediatr Dermatol [serial online] 2016 [cited 2019 Oct 16];17:206-8. Available from: http://www.ijpd.in/text.asp?2016/17/3/206/179497


  Introduction Top


Down syndrome (DS), which results from the trisomy of chromosome 21, is the most common autosomal chromosome disorder and occurs in approximately one in 700 newborns. DS is also the most common chromosomal disorder and is associated with a greater prevalence of autoimmune diseases, including Hashimoto's thyroiditis, Graves' disease, Type 1 diabetes mellitus, alopecia, vitiligo, hypoparathyroidism, celiac disease, autoimmune chronic active hepatitis, psoriasis, and psoriatic arthritis, than in the general population.[1],[2],[3],[4],[5],[6] Here, we describe a 4-year-old girl with DS and concurrent psoriasis and Hashimoto's thyroiditis.


  Case Report Top


A 4-year-old girl with DS was referred by her family because of lesions on her body that had persisted for 7 months. The physical examination revealed typical DS stigmata [Figure 1]. There were erythematous-desquamative papules and plaques on her trunk, arms, and legs [Figure 2] and [Figure 3]. There was no history of infection or drug intake before the lesions began. Nail changes were noted, including pitting, subungual hyperkeratosis, and yellow discoloration. No fungal elements were detected. Clinically, she was diagnosed with psoriasis. A skin biopsy from the right leg confirmed the diagnosis [Figure 4].
Figure 1: Typical Down syndrome stigmata

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Figure 2: Desquamative papules and plaques on her arm

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Figure 3: Erythematous-desquamative papules and plaques on her legs. Subungual hyperkeratosis and yellow discoloration in the nails

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Figure 4: Histopathology of skin lesions was consistent with psoriasis

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Laboratory evaluations were normal, including blood glucose, hemoglobin A1c, and renal and liver function tests. Thyroid function tests revealed compensated hypothyroidism, with an elevated thyroid-stimulating hormone level, but normal free and total T4 levels. The serum antimicrosomal antibody level was 256 IU/mL (normal range 0–35 IU/mL), and the antithyroglobulin antibody level was 148 IU/mL (normal range 0–115 IU/mL). The patient's thyroid gland parenchyma appeared heterogeneous on ultrasonography. The patient was diagnosed with Hashimoto's thyroiditis and was referred to the department of pediatric endocrinology for thyroid hormone replacement and follow-up. No signs or symptoms of other autoimmune disorders were detected.

The psoriasis was treated topically with corticosteroids and emollients. The patient's Psoriasis Area and Severity Index score improved markedly after 3 weeks of treatment.


  Discussion Top


DS patients have a characteristically altered immunological state,[7] characterized by multiple immunological abnormalities, including mild to moderate B and CD4+ T-cell lymphopenia with a marked decrease in naive lymphocytes, increase in CD8+ T-cells, and impaired mitogen-induced T-cell proliferation.[1],[8] Reduced specific antibody responses to immunizations, defects in neutrophil chemotaxis, expansion of natural killer cells, and overexpressed interferon-δ and tumor necrosis factor-α have also been observed in individuals with DS.[1],[7],[8],[9] These multiple immunological abnormalities result in impairment of both the humoral and cellular immune responses. However, Pellegrini et al. reported that natural T regulatory cells (nTregs) could play the primary role in controlling immune responses in DS individuals.[1] They suggested that overexpression of the peripheral nTreg population with defective inhibitory activity could underlie the increased frequency of autoimmune diseases.[1] The most common autoimmune disease in children with DS is autoimmune thyroiditis, with an estimated prevalence of 5–54%.[1],[7],[8],[9],[10] The reported prevalences of other autoimmune diseases in DS are 1–10.6% for Type 1 diabetes mellitus,[1],[2],[4] 4.5–10% for celiac disease,[1],[8] 2.4–8.9% for alopecia areata,[2],[3],[4] and 0.5–8% for psoriasis.[1],[10] There are only a few reported cases of co-existing autoimmune diseases in patients with DS; to our knowledge, this is the first reported concurrence of psoriasis and Hashimoto's thyroiditis in an individual with DS. Our patient developed psoriasis 7 months earlier with no history of infection or drug intake before lesion appearance. As DS patients are predisposed to autoimmune diseases, a diagnostic workup was performed, and the patient was diagnosed with Hashimoto's thyroiditis. The patient's family was counseled about the clinical signs of other autoimmune disorders, including weight loss, persistent diarrhea, and unstable blood sugar with polydipsia and frequent urination, and the patient was screened for these diseases annually during routine check-ups.


  Conclusion Top


Autoimmune diseases become increasingly frequent as DS patients grow older, and the presence of one autoimmune disease often leads to the development of others. This case emphasizes the predisposition of DS individuals to co-existing autoimmune diseases. Even if no signs of autoimmunity are present, children with DS who develop autoimmune diseases in early childhood should be screened regularly because of the risk of developing other related conditions.

Declaration of Patient Consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Pellegrini FP, Marinoni M, Frangione V, Tedeschi A, Gandini V, Ciglia F, et al. Down syndrome, autoimmunity and T regulatory cells. Clin Exp Immunol 2012;169:238-43.  Back to cited text no. 1
    
2.
Pirgon O, Atabek ME, Sert A. Diabetic ketoacidosis, thyroiditis and alopecia areata in a child with Down syndrome. Indian J Pediatr 2009;76:1263-4.  Back to cited text no. 2
    
3.
Schepis C, Barone C, Lazzaro Danzuso GC, Romano C. Alopecia areata in Down syndrome: A clinical evaluation. J Eur Acad Dermatol Venereol 2005;19:769-70.  Back to cited text no. 3
    
4.
Taniyama M, Kushima K, Ban Y, Kaihara M, Nagakura H, Sekita S, et al. Simultaneous development of insulin dependent diabetes mellitus and alopecia areata universalis. Am J Med Sci 1991;301:269-71.  Back to cited text no. 4
    
5.
Ram G, Chinen J. Infections and immunodeficiency in Down syndrome. Clin Exp Immunol 2011;164:9-16.  Back to cited text no. 5
    
6.
Murphy M, Friend DS, Pike-Nobile L, Epstein LB. Tumor necrosis factor-alpha and IFN-gamma expression in human thymus. Localization and overexpression in Down syndrome (trisomy 21). J Immunol 1992;149:2506-12.  Back to cited text no. 6
    
7.
Murphy M, Insoft RM, Pike-Nobile L, Epstein LB. A hypothesis to explain the immune defects in Down syndrome. Prog Clin Biol Res 1995;393:147-67.  Back to cited text no. 7
    
8.
Kinik ST, Ozçay F, Varan B. Type I diabetes mellitus, Hashimoto's thyroiditis and celiac disease in an adolescent with Down syndrome. Pediatr Int 2006;48:433-5.  Back to cited text no. 8
    
9.
Nebesio TD, Eugster EA. Unusual thyroid constellation in Down syndrome: Congenital hypothyroidism, Graves' disease, and hemiagenesis in the same child. J Pediatr Endocrinol Metab 2009;22:263-8.  Back to cited text no. 9
    
10.
Madan V, Williams J, Lear JT. Dermatological manifestations of Down's syndrome. Clin Exp Dermatol 2006;31:623-9.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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