Autoimmune Hyperthyroidism, Vitiligo, Halo Nevus and Lupus.

CASE PRESENTATION A 43-year-old female patient presented with a 6-year history of increased appetite, weight loss, heat intolerance, sweating, tremor and goiter, when she was diagnosed with hyperthyroidism and received methimazole (Tapazole). This patient developed vitiligo, 3 years before (Figure A, on the fingers), and halo nevus (Figure B, on the chest), involving face, limbs and trunk. She experienced malar erythema, 8 months before (Figure C, on bilateral cheeks, mainly involving the right cheek) and photosensitivity, with no arthritis or oral ulcers. Laboratory tests showed anemia and high titers of autoimmune antibodies, including anti–double-stranded DNA, antinuclear, antinucleosome, antithyroid peroxidase and antithyroglobulin antibodies, without evident proteinuria. However, the test for antihistone antibody showed negative result. A biopsy specimen from the erythematous lesion on the cheek showed basal cell liquefaction degeneration and lymphocytic infiltration in the superficial layer of dermis (Figure D, hematoxylin and eosin; original magnification, 100 and 400). Immunofluorescence of epidermal basement membrane demonstrated deposits of IgG, IgA, IgM and C3, consistent with the changes in lupus erythematosus. Thus, the diagnosis of autoimmune polyglandular syndrome type 3 was confirmed. The malar erythema, vitiligo and lupus disease activity were controlled with methylprednisolone, hydroxychloroquine and topical tacrolimus treatment. The frequencies of autoimmune disorders were significantly elevated in vitiligo probands and their 1st-degree relatives, including vitiligo itself, autoimmune thyroid disease (particularly hypothyroidism), pernicious anemia, Addison's disease and systemic lupus erythematosus. To the authors' knowledge, there is only 1 case report of discoid lupus erythematosus complicated with vitiligo and hypothyroidism. Of interest, this is the first case report of autoimmune hyperthyroidism, vitiligo, halo nevus and lupus.