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The white butterfly
ARTICLES
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Task Force for the Diagnosis and Treatment of Chronic Heart Failure ESoC, Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22: 1527–60. Cleland JGF, Gemmel I, Khand A, Boddy A. Is the prognosis of heart failure improving? Eur J Heart Fail 1999; 1: 229–41. Davie AP, McMurray JJV. ACE inhibitors and health-care economics. Coronary Artery Disease 1995; 6: 315–19. Cleland JGF, Swedberg K, Poole-Wilson PA. Successes and failures of current treatment of heart failure. Lancet 1998; 352 (suppl): s19–28. The Task Force of the Working Group on Heart Failure of the European Society of Cardiology. The treatment of heart failure. Eur Heart J 1997; 18: 736–53. Davie AP, McMurray JJ. ACE inhibitors and heart failure in hospital: any difference between cardiologists and general physicians? Postgrad Med J 1999; 75: 219–22. Hillis GS, Al-Mohammad A, Wood M, Jennings KP. Changing patterns of investigation and treatment of cardiac failure in hospital. Heart 1996; 76: 427–29. Clark AL, Coats AJS. Severity of heart failure and dosages of angiotensin converting enzyme inhibitors. BMJ 1996; 310: 973–74. The Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. Increasing the awareness and improving the management of heart failure in Europe: the IMPROVEMENT of HF initiative. Eur J Heart Fail 1999; 1: 139–44. Rothman KJ. Modern epidemiology. Boston: Little, Brown & Co, 1986. Collett D. Modelling binary data. London: Chapman and Hall, 1991. Cleland JGF, Swedberg K. Influence of aetiology on the effects of treatment in heart failure. J Cardiovasc Risk 1999; 6: 131–39. Follath F, Cleland JGF, Klein W, Murphy R. Etiology and response to drug treatment in heart failure. J Am Coll Cardiol 1998; 32: 1167–72. Hobbs FDR, Jones MI, Allan TF, Wilson S, Tobias R. European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF). Eur Heart J 2000; 21: 1877–87. Cleland JGF, Freemantle N, McGowan J, Clark A. The evidence for beta-blockers equals or surpasses that for ACE inhibitors in heart failure. BMJ 1999; 318: 824–25. Cowie MR, Wood DA, Coats AJS, et al. Incidence and aetiology of heart failure. A population based study. Eur Heart J 1999; 20: 421–28.
21 Cleland JGF. Progression from hypertension to heart failure. Mechanisms and management. Cardiology 1999; 92 (suppl 1): 10–19. 22 Cleland JGF, Tendera M, Adamus J, et al for the PEP-CHF investigators. Perindopril for elderly people with chronic heart failure: the PEP-CHF study. Eur J Heart Fail 1999; 1: 211–17. 23 Clark AL, Coats AJ. Unreliability of cardiothoracic ratio as a marker of left ventricular impairment: comparison with radionuclide ventriculography and echocardiography. Postgrad Med J 2000; 76: 289–91. 24 Vasan RS, Benjamin EJ. Diastolic Heart Failure - No time to relax. N Engl J Med 2001; 344: 58–59. 25 Caruana L, Petrie MC, Davie AP, McMurray JV. Do patients with suspected heart failure and preserved left ventricular systolic function suffer from “diastolic heart failure” or from misdiagnosis? A prospective descriptive study. BMJ 2000; 321: 215–18. 26 Toal M, Walker R. Angiotensin converting enzyme (ACE) inhibitors in the treatment of heart failure in general practice in North Cumbria. Eur J Heart Fail 2000; 2: 201–07. 27 Philbin EF, Andreou C, Rocco TA, Lynch LJ, Baker SL. Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol 1996; 77: 832–38. 28 Philbin EF. Factors determining angiotensin-converting enzyme inhibitor underutilisation in heart failure in a community setting. Clin Cardiol 1998; 21: 103–08. 29 Yusuf S. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293–302. 30 CIBIS Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II). Lancet 1999; 353: 9–13. 31 MERIT-HF Study Group. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999; 333: 2001–07. 32 Houghton T, Freemantle N, Cleland JGF. Are beta-blockers effective in patients who develop heart failure soon after myocardial infarction? A meta-regression analysis of randomised trials. Eur J Heart Fail 2000; 2: 333–40. 33 Freemantle N, Cleland JGF, Young S, Mason J, Harrison J. Beta blockade after myocardial infarction:systematic review and meta regression analysis. BMJ 1999; 318: 1730–37.
Clinical picture The white butterfly Shehzad Basaria, Suzanne Jan de Beur A 51-year-old woman with a 3-year history of hypothyroidism was seen in the endocrine clinic. On examination, the patient had a butterfly shaped area of vitiligo on the anterior surface of the neck overlying the thyroid gland (figure). She said that the lesion had appeared 5 years before her hypothyroidism was diagnosed. She was euthyroid on levothyroxine treatment. She had no detectable anti-peroxidase or anti-thyroglobulin antibodies. Over the next 3 years the patient developed Graves’ disease with elevated titres of thyroid stimulating immunoglobulins. She was successfully treated with radioactive iodine and reverted to being euthyroid on levothyroxine. Vitiliginous lesions are more common in patients with autoimmune thyroid disease than in the general population. They are commonly located on the dorsal aspect on the hands, feet, and elbows and are usually bilateral. The lesions generally precede the development of thyroid dysfunction. The pathogenesis of vitiligo involves the autoimmune destruction of melanocytes. Some endocrinologists have recommended screening patients with vitiligo for thyroid dysfunction. Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD-21224, USA (S Basaria MD, S Jan de Beur MD)
THE LANCET • Vol 360 • November 23, 2002 • www.thelancet.com
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For personal use. Only reproduce with permission from The Lancet Publishing Group.
5
6 7 8 9
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12 13
14 15 16 17 18
19
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Task Force for the Diagnosis and Treatment of Chronic Heart Failure ESoC, Remme WJ, Swedberg K. Guidelines for the diagnosis and treatment of chronic heart failure. Eur Heart J 2001; 22: 1527–60. Cleland JGF, Gemmel I, Khand A, Boddy A. Is the prognosis of heart failure improving? Eur J Heart Fail 1999; 1: 229–41. Davie AP, McMurray JJV. ACE inhibitors and health-care economics. Coronary Artery Disease 1995; 6: 315–19. Cleland JGF, Swedberg K, Poole-Wilson PA. Successes and failures of current treatment of heart failure. Lancet 1998; 352 (suppl): s19–28. The Task Force of the Working Group on Heart Failure of the European Society of Cardiology. The treatment of heart failure. Eur Heart J 1997; 18: 736–53. Davie AP, McMurray JJ. ACE inhibitors and heart failure in hospital: any difference between cardiologists and general physicians? Postgrad Med J 1999; 75: 219–22. Hillis GS, Al-Mohammad A, Wood M, Jennings KP. Changing patterns of investigation and treatment of cardiac failure in hospital. Heart 1996; 76: 427–29. Clark AL, Coats AJS. Severity of heart failure and dosages of angiotensin converting enzyme inhibitors. BMJ 1996; 310: 973–74. The Study Group on Diagnosis of the Working Group on Heart Failure of the European Society of Cardiology. Increasing the awareness and improving the management of heart failure in Europe: the IMPROVEMENT of HF initiative. Eur J Heart Fail 1999; 1: 139–44. Rothman KJ. Modern epidemiology. Boston: Little, Brown & Co, 1986. Collett D. Modelling binary data. London: Chapman and Hall, 1991. Cleland JGF, Swedberg K. Influence of aetiology on the effects of treatment in heart failure. J Cardiovasc Risk 1999; 6: 131–39. Follath F, Cleland JGF, Klein W, Murphy R. Etiology and response to drug treatment in heart failure. J Am Coll Cardiol 1998; 32: 1167–72. Hobbs FDR, Jones MI, Allan TF, Wilson S, Tobias R. European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF). Eur Heart J 2000; 21: 1877–87. Cleland JGF, Freemantle N, McGowan J, Clark A. The evidence for beta-blockers equals or surpasses that for ACE inhibitors in heart failure. BMJ 1999; 318: 824–25. Cowie MR, Wood DA, Coats AJS, et al. Incidence and aetiology of heart failure. A population based study. Eur Heart J 1999; 20: 421–28.
21 Cleland JGF. Progression from hypertension to heart failure. Mechanisms and management. Cardiology 1999; 92 (suppl 1): 10–19. 22 Cleland JGF, Tendera M, Adamus J, et al for the PEP-CHF investigators. Perindopril for elderly people with chronic heart failure: the PEP-CHF study. Eur J Heart Fail 1999; 1: 211–17. 23 Clark AL, Coats AJ. Unreliability of cardiothoracic ratio as a marker of left ventricular impairment: comparison with radionuclide ventriculography and echocardiography. Postgrad Med J 2000; 76: 289–91. 24 Vasan RS, Benjamin EJ. Diastolic Heart Failure - No time to relax. N Engl J Med 2001; 344: 58–59. 25 Caruana L, Petrie MC, Davie AP, McMurray JV. Do patients with suspected heart failure and preserved left ventricular systolic function suffer from “diastolic heart failure” or from misdiagnosis? A prospective descriptive study. BMJ 2000; 321: 215–18. 26 Toal M, Walker R. Angiotensin converting enzyme (ACE) inhibitors in the treatment of heart failure in general practice in North Cumbria. Eur J Heart Fail 2000; 2: 201–07. 27 Philbin EF, Andreou C, Rocco TA, Lynch LJ, Baker SL. Patterns of angiotensin-converting enzyme inhibitor use in congestive heart failure in two community hospitals. Am J Cardiol 1996; 77: 832–38. 28 Philbin EF. Factors determining angiotensin-converting enzyme inhibitor underutilisation in heart failure in a community setting. Clin Cardiol 1998; 21: 103–08. 29 Yusuf S. Effect of enalapril on survival in patients with reduced left ventricular ejection fractions and congestive heart failure. N Engl J Med 1991; 325: 293–302. 30 CIBIS Investigators and Committees. The Cardiac Insufficiency Bisoprolol Study II (CIBIS-II). Lancet 1999; 353: 9–13. 31 MERIT-HF Study Group. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999; 333: 2001–07. 32 Houghton T, Freemantle N, Cleland JGF. Are beta-blockers effective in patients who develop heart failure soon after myocardial infarction? A meta-regression analysis of randomised trials. Eur J Heart Fail 2000; 2: 333–40. 33 Freemantle N, Cleland JGF, Young S, Mason J, Harrison J. Beta blockade after myocardial infarction:systematic review and meta regression analysis. BMJ 1999; 318: 1730–37.
Clinical picture The white butterfly Shehzad Basaria, Suzanne Jan de Beur A 51-year-old woman with a 3-year history of hypothyroidism was seen in the endocrine clinic. On examination, the patient had a butterfly shaped area of vitiligo on the anterior surface of the neck overlying the thyroid gland (figure). She said that the lesion had appeared 5 years before her hypothyroidism was diagnosed. She was euthyroid on levothyroxine treatment. She had no detectable anti-peroxidase or anti-thyroglobulin antibodies. Over the next 3 years the patient developed Graves’ disease with elevated titres of thyroid stimulating immunoglobulins. She was successfully treated with radioactive iodine and reverted to being euthyroid on levothyroxine. Vitiliginous lesions are more common in patients with autoimmune thyroid disease than in the general population. They are commonly located on the dorsal aspect on the hands, feet, and elbows and are usually bilateral. The lesions generally precede the development of thyroid dysfunction. The pathogenesis of vitiligo involves the autoimmune destruction of melanocytes. Some endocrinologists have recommended screening patients with vitiligo for thyroid dysfunction. Division of Endocrinology and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD-21224, USA (S Basaria MD, S Jan de Beur MD)
THE LANCET • Vol 360 • November 23, 2002 • www.thelancet.com
1639
For personal use. Only reproduce with permission from The Lancet Publishing Group.