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Post-partum thyroiditis in women with chronic viral hepatitis
Journal of Clinical Virology 41 (2008) 318–319
Letter to the Editor
Post-partum thyroiditis in women with chronic viral hepatitis Keywords: Post-partum; Thyroiditis; Viral hepatitis
Post-partum thyroiditis (PPT) is the occurrence of transient hyperthyroidism and/or transient hypothyroidism during the first year after delivery. It is consider as a transient form of Hashimoto’s thyroiditis occurring post-partum as a consequence of the immunologic flare following the immune suppression period of pregnancy (Abalovich et al., 2007). The mean prevalence of PPT is 5–7.5%. Women with type 1 diabetes mellitus, prior episode of PPT, family history of autoimmune thyroiditis or history of being thyroid peroxidase antibody (anti-TPO) positive as well as women with prior miscarriage represent high-risk groups for PPT (Stagnaro-Green, 2002). Controversy surrounds whether to screen or not for PPT and which the optimal screening strategy should be. Universal screening for PPT is not recommended by any national organization until now, whereas some experts recommend selective screening for women at high risk for PPT. So, investigation for new high-risk groups for PPT should be the next step. Autoimmune thyroid disease represents a well-known extrahepatic manifestation in patients with chronic HCV infection (Vassilopoulos and Calabrese, 2005). Moreover, the unique immunological changes observed during pregnancy and post-partum, result in immune reconstitution syndrome and exacerbation of chronic infections in post-partum period (Elefsiniotis et al., 2004; Singh and Perfect, 2007). Despite these observations, the incidence of PPT among women with chronic viral hepatitis has not been investigated yet. During 2006, a total of 21 women with chronic HCV infection and 74 women with chronic HBV infection had delivery in our public maternal hospital, “Helena Venizelou” Hospital of Athens, Greece in which more than 7000 births per year account. All of them were prospectively evaluated for the appearance of PPT, defined as clinical hyperthyroidism or hypothyroidism and/or abnormal FT4/TSH levels with posi-
1386-6532/$ – see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.jcv.2007.12.010
tive anti-TPO titers. Chronic HCV or HBV infected pregnant women with known autoimmune or other type of thyroid disease, with coinfections (HIV/HCV, HBV/HCV, etc.) as well as women with type 1 diabetes mellitus were excluded. Sixteen chronic HCV infected women and 64 chronic HBV infected women were finally included in the study. All chronic HBV infected women had never been treated before whereas 3 of 16 chronic HCV infected women had been treated in the past with pegylated-interferon alpha plus ribavirin and two of them had been characterized as sustained virological responders. The remaining 14 chronic HCV infected women exhibited significant viremia (serum HCVRNA >700,000 IU/ml in six and 200,000–650,000 IU/ml in eight of them) during the perinatal period. Seven women presented genotype 3, four women genotype 1, two women genotype 4 and one genotype 2 HCV infections. Four of 16 chronic HCV-infected women developed PPT (25%), a percentage higher enough than the ones reported in the literature. None of 64 chronic HBV infected women developed PPT. Two chronic HCV-infected women exhibited overt hyperthyroidism during the third and the sixth month post-partum, respectively, clinically (fatigue, tachycardia, sleep disorders and mild depression) and laboratory (suppressed TSH levels and high anti-TPO titers) confirmed. The rest two women who developed PPT were presented with hypothyroidism (TSH levels 6.5 and 61 mIU/ml, respectively, as well as high anti-TPO titers). Those women were treated with thyroxin and were followed-up in an outpatient basis in order to evaluate if they develop permanent hypothyroidism. Our findings are suggestive of a new high risk group for PPT, women with chronic HCV infection, in whom screening for PPT might be beneficial. Prospectively designed, controlled studies, with large number of chronic HCV infected pregnant women are needed in order to clarify a possible relationship between chronic HCV infection and PPT.
Letter to the Editor / Journal of Clinical Virology 41 (2008) 318–319
References Abalovich M, Amino N, Barbour LA, et al. Management of thyroid dysfunction during pregnancy and post-partum: an endocrine society clinical practice guidelines. J Clin Endocrinol Metab 2007;92(Suppl. 8):S1–47. Elefsiniotis IS, Pantazis K, Magaziotou I, et al. Virological response in postpartum treated chronic hepatitis C women with pegylated interferonalpha plus ribavirin. A case-control study. J Clin Virol 2004;31(4): 314–5. Singh N, Perfect JR. Immune reconstitution syndrome and exacerbation of infections after pregnancy. CID 2007;45:1192–9. Stagnaro-Green A. Postpartum thyroiditis. J Clin Endocrinol Metab 2002;87(9):4042–7. Vassilopoulos D, Calabrese L. Extrahepatic immunological complications of hepatitis C virus infection. AIDS 2005;19(3):S123–7.
319
Ioannis S. Elefsiniotis ∗ Elena Vezali Konstantinos D. Pantazis George Saroglou University Department of Internal Medicine, Hepatology Unit, Maternal Hospital “Helena Venizelou”, Athens, Greece ∗ Corresponding
author at: Carchidonos 9, A. Glyfada GR-16562, Greece. Tel.: +30 210 9630312; fax: +30 210 7787807. E-mail address: [email protected] (I.S. Elefsiniotis) 7 December 2007
Letter to the Editor
Post-partum thyroiditis in women with chronic viral hepatitis Keywords: Post-partum; Thyroiditis; Viral hepatitis
Post-partum thyroiditis (PPT) is the occurrence of transient hyperthyroidism and/or transient hypothyroidism during the first year after delivery. It is consider as a transient form of Hashimoto’s thyroiditis occurring post-partum as a consequence of the immunologic flare following the immune suppression period of pregnancy (Abalovich et al., 2007). The mean prevalence of PPT is 5–7.5%. Women with type 1 diabetes mellitus, prior episode of PPT, family history of autoimmune thyroiditis or history of being thyroid peroxidase antibody (anti-TPO) positive as well as women with prior miscarriage represent high-risk groups for PPT (Stagnaro-Green, 2002). Controversy surrounds whether to screen or not for PPT and which the optimal screening strategy should be. Universal screening for PPT is not recommended by any national organization until now, whereas some experts recommend selective screening for women at high risk for PPT. So, investigation for new high-risk groups for PPT should be the next step. Autoimmune thyroid disease represents a well-known extrahepatic manifestation in patients with chronic HCV infection (Vassilopoulos and Calabrese, 2005). Moreover, the unique immunological changes observed during pregnancy and post-partum, result in immune reconstitution syndrome and exacerbation of chronic infections in post-partum period (Elefsiniotis et al., 2004; Singh and Perfect, 2007). Despite these observations, the incidence of PPT among women with chronic viral hepatitis has not been investigated yet. During 2006, a total of 21 women with chronic HCV infection and 74 women with chronic HBV infection had delivery in our public maternal hospital, “Helena Venizelou” Hospital of Athens, Greece in which more than 7000 births per year account. All of them were prospectively evaluated for the appearance of PPT, defined as clinical hyperthyroidism or hypothyroidism and/or abnormal FT4/TSH levels with posi-
1386-6532/$ – see front matter © 2007 Elsevier B.V. All rights reserved. doi:10.1016/j.jcv.2007.12.010
tive anti-TPO titers. Chronic HCV or HBV infected pregnant women with known autoimmune or other type of thyroid disease, with coinfections (HIV/HCV, HBV/HCV, etc.) as well as women with type 1 diabetes mellitus were excluded. Sixteen chronic HCV infected women and 64 chronic HBV infected women were finally included in the study. All chronic HBV infected women had never been treated before whereas 3 of 16 chronic HCV infected women had been treated in the past with pegylated-interferon alpha plus ribavirin and two of them had been characterized as sustained virological responders. The remaining 14 chronic HCV infected women exhibited significant viremia (serum HCVRNA >700,000 IU/ml in six and 200,000–650,000 IU/ml in eight of them) during the perinatal period. Seven women presented genotype 3, four women genotype 1, two women genotype 4 and one genotype 2 HCV infections. Four of 16 chronic HCV-infected women developed PPT (25%), a percentage higher enough than the ones reported in the literature. None of 64 chronic HBV infected women developed PPT. Two chronic HCV-infected women exhibited overt hyperthyroidism during the third and the sixth month post-partum, respectively, clinically (fatigue, tachycardia, sleep disorders and mild depression) and laboratory (suppressed TSH levels and high anti-TPO titers) confirmed. The rest two women who developed PPT were presented with hypothyroidism (TSH levels 6.5 and 61 mIU/ml, respectively, as well as high anti-TPO titers). Those women were treated with thyroxin and were followed-up in an outpatient basis in order to evaluate if they develop permanent hypothyroidism. Our findings are suggestive of a new high risk group for PPT, women with chronic HCV infection, in whom screening for PPT might be beneficial. Prospectively designed, controlled studies, with large number of chronic HCV infected pregnant women are needed in order to clarify a possible relationship between chronic HCV infection and PPT.
Letter to the Editor / Journal of Clinical Virology 41 (2008) 318–319
References Abalovich M, Amino N, Barbour LA, et al. Management of thyroid dysfunction during pregnancy and post-partum: an endocrine society clinical practice guidelines. J Clin Endocrinol Metab 2007;92(Suppl. 8):S1–47. Elefsiniotis IS, Pantazis K, Magaziotou I, et al. Virological response in postpartum treated chronic hepatitis C women with pegylated interferonalpha plus ribavirin. A case-control study. J Clin Virol 2004;31(4): 314–5. Singh N, Perfect JR. Immune reconstitution syndrome and exacerbation of infections after pregnancy. CID 2007;45:1192–9. Stagnaro-Green A. Postpartum thyroiditis. J Clin Endocrinol Metab 2002;87(9):4042–7. Vassilopoulos D, Calabrese L. Extrahepatic immunological complications of hepatitis C virus infection. AIDS 2005;19(3):S123–7.
319
Ioannis S. Elefsiniotis ∗ Elena Vezali Konstantinos D. Pantazis George Saroglou University Department of Internal Medicine, Hepatology Unit, Maternal Hospital “Helena Venizelou”, Athens, Greece ∗ Corresponding
author at: Carchidonos 9, A. Glyfada GR-16562, Greece. Tel.: +30 210 9630312; fax: +30 210 7787807. E-mail address: [email protected] (I.S. Elefsiniotis) 7 December 2007