Rheumatology Advance Access originally published online on March 23, 2007
Rheumatology 2007 46(5):894; doi:10.1093/rheumatology/kem035
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An unusual association with Raynaud's phenomenon
Southport and Ormskirk NHS Trust, Liverpool University, UK
Correspondence to: Dr K. A. Binymin, Southport, DGH Kew Southport, Mersyside PR8 2HT, UK. E-mail: Khalid.binymin{at}southportandormskirk.nhs.uk
SIR, We read with interest the report by AL-Deiri et al. [1]. There is little doubt that the clinical scenario suggests an association of possible Raynauds phenomenon (RP) and pituitary insufficiency. It again raises the question whether the association of hypothyroidism and RP is a direct hormonal influence or an indirect immune process. We would like to comment on certain aspect in the reporting of this case.
A 36-yr-old lady presenting for the first time with RP should always raise suspicion of a possible secondary cause. The diagnosis of RP is often dependent on patient account and description of the event. Patients often cannot differentiate a cold hand from biphasic colour change. A normal immune profile does not exclude any rheumatological cause for RP. An abnormal nail-fold capillaroscope [2] (not done in this case), however, would have suggested an autoimmune rheumatic disorder that might be brought to light by thyroxin deficiency [3]. This is a fundamental issue in this case as we need to prove a causal relation between a reversible RP and hormone deficiency, and in the mean time demonstrate the absence of structural vascular damage related to other causes such an unrelated immune process.
The abnormal short synacthen test indicates adrenal insufficiency and is not a discriminatory test between a primary adrenal or pituitary disorder. The association of primary adrenal and primary thyroid insufficiency is well established. A long synacthen test would be mandatory to confirm a possible pituitary insufficiency.
Atrophy of the pituitary gland on the MR scan is not diagnostic of any specific disorder unless pituitary hormone deficiency is confirmed using provocation test rather than spot check of pituitary hormone levels as reported in this case. Hormonal studies should be performed in pairs of target gland and their respective stimulatory pituitary hormone for proper interpretation. It would have been more appropriate to present the ACTH and cortisol levels, TSH with free T3 and T4, LH/FSH and oestrogen levels simultaneously as well as GH with provocation tests [4].
Although the history and the clinical picture leaves little doubt about the diagnosis of the case reported, more attention should have been given to the standards for work up of RP and panhypopituitarism which would have strengthened the validity of the case.
The author has declared no conflicts of interest.
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- Maria AL-Deiri, Jonathan JB, Chris MD. (2007) An unusual association with Raynaud's phenomenon. Rheumatology 46:92–93.
[Free Full Text] - Cutolo M, Grassi W, Matucci CM. (2003) Raynaud's phenomenon and the role of capillaroscopy. Arthritis Rheum 48:3023–30.[CrossRef][Web of Science][Medline]
- Lateiwish AM, Feher J, Baraczka K, Racz K, Kiss R, Glaz E. (1992) Remission of Raynaud's phenomenon after L-thyroxine therapy in a patient with hypothyroidism. J Endocrinol Invest 15:49–51.[Web of Science][Medline]
- Dexter RN. (1995) Hypopituitarism. In Becker KL (Ed.). Principles and practice of endocrinology and metabolism(Williams and Wilkins, Baltimore, MD) pp. 169–80.
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