Field trip to the Ischia resurgent caldera, a journey across an active volcano in the Gulf of Naples

Ischia is one of the most impressive examples of post-caldera resurgence in the world, with its almost 1,000 m of uplift in less than 30 ka. This three-days field trip will lead the participants through the geological and volcanological history of the island, illustrating the volcanic and related hazardous phenomena threatening about 50,000 inhabitants. Effusive and explosive eruptions, catastrophic earthquakes and huge debris-avalanches struck the island that, since Neolithic times, experienced a complex history of alternating human colonization and natural disasters. The field trip consists of three routes: 1) the circumnavigation of the island, aimed to outline its main volcanological, geomorphological and tectonic features and to observe the oldest volcanic rocks exposed, stimulating discussions about coastal evolution and the relationships between volcanism, volcano-tectonism and slope instability; 2) an onland excursion on peculiar aspects of the products related to Ischia more recent period of volcanic activity; 3) a route focusing on the Mt. Epomeo Green Tuff caldera forming eruptions (55-60 ka), encouraging a discussion on the dynamics of the intracalderic resurgence and the geomorphological evolution of the Mt. Epomeo slopes, with ongoing Mass Rock Creep (MRC) processes culminating in rockavalanche, debris-avalanche and lahar deposits

Support for the upregulation of serum thyrotropin by estrogens coming from the increased requirement of levothyroxine in one gynecomastic patient with excess of thyroxine-binding globulin secondary to exposure to exogenous estrogens

Thyroxine-binding globulin (TBG) is the liver-synthesized and estrogen-upregulated major plasma carrier of thyroid hormones with an affinity binding greater for T4 than T3. It is known that pregnancy, a physiologic state of estrogen-driven elevation of serum TBG, raises the requirement of L-T4 dose in hypothyroid women, especially those with no residual thyroid function. Similar increased requirement was reported for postmenopausal women during estrogen therapy. One known cause of relative hyperestrogenemia, gynecomastia and acquired TBG excess is liver disease, but very rarely chronic liver disease is mentioned as a cause of increased L-T4 requirement. One hypothyroid man with cirrhosis-associated gynecomastia and increased serum levels of both estradiol and TBG was reported recently. His requirement of L-T4 was no longer increased after liver transplantation. We now report the case of a man with primary hypothyroidism under stable replacement therapy with L-T4 until exposure to an exogenous cause of hyperestrogenemia caused increased L-T4 requirement associated to TBG excess. In addition to increased TBG, the high levels of estrogens had caused the appearance of gynecomastia. We fully corrected primary hypothyroidism upon eliminating his exposure to the source of estrogens. Hyperestrogenism can be a cause of increased L-T4 requirement through the rise of circulating levels of TBG also in man with no residual thyroid function. Keywords: Thyroxine-binding globulin, Estrogens, Thyrotropin, Levothyroxine therapy, Refractory hypothyroidis

A case of amiodarone-induced hypothyroidism in a mild to moderate iodine deficiency area

Thyroid dysfunction associated to amiodarone treatment depends on iodine intake, as thyrotoxicosis occurs more frequently in iodine deficiency areas, whereas hypothyroidism in iodine sufficient areas. We present here a case of severe overt hypothyroidism induced by prolonged treatment with amiodarone for atrial fibrillation in a man living in a low iodine intake area. The case was managed with levothyroxine (LT4) replacement and amiodarone withdrawal. Euthyroidism was restored after two months, and atrial fibrillation has not relapsed to date

Psoriasis, Psoriatic Arthritis, and Thyroid Autoimmunity

Psoriasis (PsO) is a chronic relapsing/remitting autoimmune skin disease, associated with an increased risk of other autoimmune disorders. Psoriatic arthritis (PsA) is a chronic inflammatory arthritis occurring approximately in 30% of PsO patients. Sporadic cases of association between PsO and autoimmune thyroid disorders (AITDs) have been reported. However, two different recent studies did not find any association between them. In patients with PsO and PsA, an association with AITD has been shown by most of the studies in adults, but not in the juvenile form. In PsA women and men, thyroid autoimmunity [positive antithyroid peroxidase (AbTPO) antibodies, hypoechoic thyroid pattern] and subclinical hypothyroidism were more prevalent than in the general population. An association has been shown also in patients with PsO, arthritis, and inflammatory bowel disease, who have more frequently AITD. A Th1 immune predominance has been shown in early PsO, and PsA, with high serum CXCL10 (Th1 prototype chemokine), overall in the presence of autoimmune thyroiditis. This Th1 immune predominance might be the immunopathogenetic base of the association of these disorders. A raised incidence of new cases of hypothyroidism, thyroid dysfunction, positive AbTPO, and appearance of a hypoechoic thyroid pattern in PsA patients, especially in women, has been shown recently, suggesting to evaluate AbTPO levels, thyroid function, and thyroid ultrasound, especially in PsA women. Thyroid function follow-up and suitable treatments should be performed regularly in PsA female patients at high risk (thyroid-stimulating hormone within the normal range but at the higher limit, positive AbTPO, hypoechoic, and small thyroid)

Serum thyroid hormone antibodies are frequent in patients with polyglandular autoimmune syndrome type 3, particularly in those who require thyroxine treatment

Polyglandular autoimmune syndrome (PAS) type 3 consists of autoimmune thyroid disease (AITD) coexisting with ≥1 non-thyroidal autoimmune disease (NTAID) other than Addison’s disease and hypoparathyroidism. We evaluated the prevalence and repertoire of thyroid hormones antibodies (THAb) in PAS-3 patients. Using a radioimmunoprecipation technique, we measured THAb (T3IgM, T3IgG, T4IgM, and T4IgG) in 107 PAS-3 patients and 88 controls (patients with AITD without any NTAID). Based on the selective coexistence of AITD with one NTAID (chronic autoimmune gastritis, non-segmental vitiligo or celiac disease), patients were divided into group 1 (chronic autoimmune gastritis positive, n = 64), group 2 (non-segmental vitiligo positive, n = 24), and group 3 (celiac disease positive, n = 15). At least one of the four THAb was detected in 45 PAS-3 patients (42.1%) and 28 controls (31.8%, P = 0.14), with similar rates in the three PAS-3 groups. The rates of T3Ab, T4Ab, and T3 + T4Ab were similar in groups 1 and 2, while in group 3, T3Ab was undetected (P = 0.02). In PAS-3 patients, the rate of levothyroxine treatment was greater in THAb-positive patients compared to THAb-negative patients (76.7 vs. 56.1%, P = 0.03, RR = 1.4, 95% CI 1.03–1.81). Not unexpectedly, levothyroxine daily dose was significantly higher in group 1 and group 3, namely in patients with gastrointestinal disorders, compared to group 2 (1.9 ± 0.4 and 1.8 ± 0.3 vs. 1.5 ± 0.2 μg/kg body weight, P = 0.0005 and P = 0.004). Almost half of PAS-3 patients have THAb, whose repertoire is similar if chronic autoimmune gastritis or celiac disease is present. A prospective study would confirm whether THAb positivity predicts greater likelihood of requiring levothyroxine treatment

The unusual association of Graves' disease, chronic spontaneous urticaria, and premature ovarian failure: report of a case and HLA haplotype characterization

Chronic spontaneous urticaria (CSU), defined as the occurrence of spontaneous wheals for more than six weeks, has been associated with autoimmune diseases. Herein, we report the unusual association of CSU, Graves' disease, and premature ovarian failure. Human leukocyte antigen (HLA) studies were performed. A 36-year-old woman presented symptoms and signs of hyperthyroidism for three months. In the same period, the patient complained of widespread urticarial wheals, intensely itchy, and poorly responsive to therapy with antihistaminic agents. Hyperthyroidism was confirmed biochemically, and treatment with methimazole was started. As hyperthyroidism improved, a marked improvement in her urticaria was also observed. However, the patient continued to complain of amenorrhea. Endocrine evaluation, at the age 38, was consistent with premature ovarian failure. This is the first report of coexistence of GD, CSU, and POF. The genetic background of such unusual association is a specific combination of HLA

Stress-induced hashitoxicosis: case report and relative HLA serotype and genotype

SUMMARY OBJECTIVE Even though stress has been long known as a provocative factor for Graves' disease, its relationship with Hashimoto's thyroiditis is more controversial. Studies on this topic are scanty. This paper aims to report a case of stress-induced Hashitoxicosis. RESULTS Here we report a case of Hashitoxicosis induced by a psychological stressful event in a 28-year-old woman with Hashimoto's thyroiditis. She had remained stably euthyroid for 12 years. She was first observed in April 2016, while euthyroid. She came back after 11 months because of fatigue and palpitations, in the absence of neck pain. Thyroid function tests revealed moderate thyrotoxicosis (undetectable TSH; FT4 36.94 pmol/L, normal values 9.0-24.46; FT3 13.50 pmol/L, normal values 3.07-6.14) with negative TSH-receptor antibodies. In the previous three months, she had experienced a psychological stressful event. Inflammatory markers were negative, and the white cell count was normal. Thyroid ultrasound revealed a modest increase in vascularization. Transient subclinical hypothyroidism ensued after seven weeks and spontaneously recovered. On the last visit, the patient was still on euthyroidism. (TSH 1.01 mU/L; FT4 9.22 pmol/L; FT3 3.98 pmol/L). We also performed HLA serotyping and genotyping. CONCLUSION This case demonstrates that, similarly to Graves' disease, Hashitoxicosis can also be triggered by stressful life events

Gitelman syndrome disclosed by calcium pyrophosphate deposition disease: Early diagnosis by ultrasonographic study

Gitelman's syndrome is a rare autosomal-recessive tubular disorder characterized by hypomagnesemia and hypocalciuria associated to hypokalemia. The clinical spectrum is wide and usually characterized by chronic fatigue, cramps, muscle weakness and paresthesiae. We describe a case of a 43 year-old male patient with early onset of knee arthritis and no other symptoms. Ultrasound revealed diffuse and confluent hyperechoic deposits in cartilage, fibrocartilage of the menisci and synovium and calcium pyrophosphate crystals were observed in the synovial fluid of the knee. The concomitant presence of hypomagnesemia, hypocalciuria and hypokalemia made clear the diagnosis of Gitelman's syndrome associated with chondrocalcinosis