Category: Thyroid

Monitor: 16

16 - Graves' disease after withdrawal of Natalizumab

Friday, Apr 26
12:00 PM – 12:30 PM

Objective :

Natalizumab (NTZ) was the first monoclonal antibody approved for treatment of relapsing-remitting Multiple Sclerosis (MS). There are no notable adverse effects on thyroid described. Two cases of autoimmune hyperthyroidism have been reported after withdrawal of NTZ to date.We are presenting a case of hyperthyroidism secondary to Graves’ disease after discontinuation of NTZ.


Methods : n/a


Results : n/a


Discussion :

A 42-year-old female with MS, being treated with Interferon therapy was switched to Natalizumab due to progressive disease. Thyroid function at diagnosis of MS and before starting NTZ was normal. Six months later she tested positive for JC virus antibodies therefore the NTZ was stopped and she was started on Teriflunomide. About a year after cessation of NTZ therapy, she reported six months of progressive symptoms of palpitations, insomnia, tremors, heat intolerance, and 25 lbs. weight loss. Exam revealed a diffuse goiter and exophthalmos. She had no family history of thyroid disease. Labs revealed TSH 0.001 mIU/L, FT4 6.99 ng/ml, thyroid stimulating antibodies >500% (<122%) and TPO 348 IU/L. Thyroid ultrasound showed diffuse enlargement with no nodules. I-123 scan showed increased uptake, 43% at 4 hours and 35% at 24 hours. She was diagnosed with Graves disease and started on Methimazole with subsequent disease control.


Conclusion :

This case highlights the importance of monoclonal antibody therapy and its withdrawal on the endocrine system. With widespread use of monoclonal antibodies, clinicians should have a low threshold for checking thyroid function before, during and after such therapy. Immune reconstitution inflammatory syndrome (IRIS) is a recognized phenomenon in the context of HIV antiretroviral therapy or bone transplantation. IRIS has been reported after discontinuation of Alemtuzumab but has not been reported with NTZ. Our case may represent a manifestation of IRIS secondary to the withdrawal of NTZ. Studies with larger sample sizes are necessary to confirm our observation.

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SYED AZHAR. HASSAN

Endocrinology Fellow, PGY-5
Texas Tech University health Sciences Center, Permian Basin, Odessa Texas
Odessa, Texas

ABIM Certified 10/2017
Medical Education:
Bachelor of Medicine, Bachelor of Surgery (M.B, B.S.) Khyber Medical College, Peshawar Pakistan. December 2002-November 2008
Post-Graduate Training:
• Endocrinology Fellowship at Texas Tech University Health Sciences Center, Permian Basin, Texas. 6/26/17 – 6/30/19
• Internal Medicine Residency, Grand Rapids Medical Education Partners/Michigan State University Grand Rapids, MI. 06/2013 - 01/2017 • •
Poster Presentation, AACE 25th Annual Scientific & Clinical Congress Orlando Florida 5/2016 Exercising leading to temporary paralysis: A case of familial hypokalemic periodic paralysis. Roger Harty, Syed Azhar Hassan, Nashmia Riaz. GRMEP/MSU Internal Medicine Residency
Atypical presentation of Cushing's disease Syed Azhar Hassan MD, Roger Harty MD, Nashmia Riaz MD, Mohammad Kawji MD GRMEP/MSU IM Residency.
Recent Posters and Abstracts
Siddiqui A, Hasan S, Spellman C, Burks J. An Unusual Presentation of Graves Ophthalmopathy (Poster presented at the AACE 27th Annual Scientific and Clinical Congress at Boston, MA, May 16-20, 2018)
Chakrala J, Hasan S, Siddiqui A, Chemitiganti R, Burks J. Parathyroid Crisis in a Young Male (Poster presented at the AACE 27th Annual Scientific and Clinical Congress at Boston, MA, May 16-20, 2018)
Hasan S, Siddiqui A, Burks J. A Rare Cause of Graves Disease in HIV Infection (Poster presented at the AACE 27th Annual Scientific and Clinical Congress at Boston, MA, May 16-20, 2018)

Ayesha Siddiqui

Assistant Professor of Medicine
Penn State Health Milton S. Hershey Medical Center
Hershey, Pennsylvania

Endocrinology Fellow.

Jahnavi Chakrala

ENDOCRINOLOGY FELLOW (PGY-5)
TEXAS TECH UNIVERSITY HEALTH SCIENCES CENTER, PERMIAN BASIN, ODESSA
Odessa, Texas

Jahnavi Chakrala, MD,
7/2017- Current- Endocrine Fellowship, TTUHSC, Permian Basin
07/2014- 2/2017- Hospitalist at Presbyterian Hospital, NM
06/2011- 06/2014 - Residency at St. John’s Episcopal Hospital, NY
09/2010-01/2011- Volunteer experience- Methodist University Hospital, Memphis, TN
06/2000-05/2006- Medical school- Narayana Medical College, India
Board Certification- Internal Medicine- 2014
Poster presentations:
Parathyroid Crisis in a Young adult- At AACE, 2017, First author,
Herpes Simplex Pneumonitis in a critically ill patient- At MSSNY, 2013, First author
Fatal Herpes Simplex Virus Hepatitis in an immunocompromised patient- At MSSNY 2013, Second author

James K. Burks

Endocrinology Fellowship Program Director
Texas Tech Health Science Center of the Permian Basin
Odessa, Texas

BIOGRAPHICAL SKETCH
Provide the following information for the key personnel and other significant contributors.
Follow this format for each person. DO NOT EXCEED TWO PAGES.

NAME
James K. Burks, MD POSITION TITLE: Professor of Medicine

EDUCATION/TRAINING (Begin with baccalaureate or other initial professional education, such as nursing, and include postdoctoral training.)
INSTITUTION AND LOCATION DEGREE
(if applicable) YEAR(s) FIELD OF STUDY
Texas Technological College, Lubbock, TX BS 1963-1967 Microbiology
Univ. Tex. Southwestern Med. School, Dallas, TX MD 1967-1971 MD
Vanderbilt, Nashville, TN Resident 1971-1973 Internal Medicine
NIH, NISMDD, Bethesda, MD Staff Assoc. 1973-1975 Admin; collagen research
Strong Mem. Hospital, Rochester, NY Fellow 1975-1976 Endocrinology
Washington Univ., St. Louis, MO Fellow 1976-1979 Endocrinology


A. Positions and Honors

Assoc. Professor of Medicine, Texas Tech of the Permian Basin, Odessa, TX 1994-2003
Program Director, Internal Medicine, Texas Tech of the Permian Basin 1996-2014
Chairman, Department of Internal Medicine, Texas Tech of the Permian Basin 2002-2004
Professor of Medicine, Texas Tech of the Permian Basin, Odessa, TX 2003-
Excellence in Teaching in Clinical Sciences, TTUHSC 1998-1999
ACGME Parker J. Palmer Courage to Teach Award 2008-2009
TTUHSC Dean’s Clinical Teaching Award 2008-2009
Program Director Endocrinology Fellowship, Texas Tech of the Permian Basin 2016-

B. Selected Publications

Adnan Haider MD, James K Burks MD, Cheema HI, MD, Angel Tejada, MD
Postprandial Hypoglycemia: Complication of peptic ulcer surgery
Am J Med 2017: 130(12); e527-529 PubMED ID 28711557

Peck, W.A., Burks, J.K., Wilkins, J., Rodan, S. B., Rodan, G.A.
Evidence for preferential effects of parathyroid hormone, calcitonin and
adenosine on bone and periosteum
Endocrinology, 1977, Volume 100(S), pp. 1357-1364

Burks, J. K., and Peck, W.A.
Bone cells: A serum-free medium supports proliferation in primary culture
Science, 1978, Volume 199, pp. 542-544

Burks, J. K., and Peck W. A,
Growth and differentiation of isolated calvarium cells in a serum-free medium
International Review of Cytology, Supplement 10, 1979, pp. 103-115:
Edited by W. W. Nichols and D. G. Murphy



C. Recent Posters and Abstracts

Haider A, Ramirez A, Siddiqui A, Burks J. Primary Adrenal Lymphoma Presenting as Bilateral Adrenal Masses (Poster presented at the AACE 26th Annual Scientific and Clinical Congress at Austin, TX, May 3-7, 2017)
Siddiqui A, Hasan S, Spellman C, Burks J. An Unusual Presentation of Graves Ophthalmopathy (Poster presented at the AACE 27th Annual Scientific and Clinical Congress at Boston, MA, May 16-20, 2018)
Chakrala J, Hasan S, Siddiqui A, Chemitiganti R, Burks J. Parathyroid Crisis in a Young Male (Poster presented at the AACE 27th Annual Scientific and Clinical Congress at Boston, MA, May 16-20, 2018)
Hasan S, Siddiqui A, Burks J. A Rare Cause of Graves Disease in HIV Infection (Poster presented at the AACE 27th Annual Scientific and Clinical Congress at Boston, MA, May 16-20, 2018)
Hassan S, Burks J. Graves' Disease and Thyroid Eye Disease in HIV Patient Due to Immune Reconstitution Inflammatory Syndrome. (100th Annual Meeting of the Endocrine Society, Chicago, IL)