Autoimmune polyendocrinopathy | Medicina Clínica (English Edition)

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The first syndrome was named in 1926 by Schmidt who described the combination of adrenal insufficiency and hypothyroidism.<a class="elsevierStyleCrossRef" href="#bib0005">1</a> The clinical presentation varies according to the different series described. Individual components of the syndrome may take years to manifest, leading to a delay in diagnosis. Several autoimmune polyendocrine syndromes have been described over time and these are detailed below (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The objective of this paper is to review the epidemiology, aetiology, clinical presentation, diagnosis, and treatment of autoimmune polyendocrine syndromes. A literature review was carried out including articles published in the PubMed database between 2003 and 2019 using the keywords: Polyendocrine Syndrome, autoimmune polyendocrinopathy, polyglandular autoimmune syndrome, type 1 diabetes and autoimmune diseases, type 1 diabetes and celiac disease, autoimmune thyroid disease, and gastritis. Review articles, prospective series studies, studies associating diabetes with celiac disease and autoimmune thyroid disease with autoimmune gastritis have been included, case reports have been excluded.Autoimmune polyendocrine syndrome type 1Epidemiology and clinical featuresAutoimmune polyendocrine syndrome (APS) type 1 is an autosomal recessive disease whose aetiology is due to a mutation in the Autoimmune Regulator (AIRE) gene. The estimated prevalence is 1:80,000 in most countries, with Finland (1:25,000), Sardinia (1:14,000) and Israel (1:9,000) being the highest.<a class="elsevierStyleCrossRef" href="#bib0010">2</a>The age of presentation is usually in childhood (between the ages of two and 18 years) and is defined as the development of two or three of the following components: chronic mucocutaneous candidiasis, hypoparathyroidism, and Addison's disease. Typical associated disorders such as enamel hypoplasia, enteropathy (diarrhoea or chronic constipation) and premature ovarian failure (in 60% of women before the age of 30) have been described. Other far less common manifestations include bilateral keratitis, periodic fever with rash, hepatitis, pneumonitis and autoimmune nephritis, exocrine pancreatic insufficiency, type 1 diabetes mellitus (DM1), hypothyroidism, pernicious anaemia, vitiligo, coeliac disease and functional asplenia. The first component of the syndrome to express itself is often different from the triad, delaying diagnostic suspicion.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>Chronic mucocutaneous candidiasis is usually the onset component, with a prevalence of 50% at 5 years of age and 94% at 20 years of age. Oral presentation is the most common form at the time of diagnosis, with potential later onset in nails, genitalia, oesophagus, and intestine.There is great variability in the phenotype and in the age of presentation of the different manifestations, even within the same family. This reinforces the theory that its etiopathogenesis is complex. In this sense, apart from mutations in the AIRE gene, genes of the major histocompatibility complex (some haplotypes have been associated with an increased risk of having a particular component of the syndrome) and environmental factors also play a role. Together, all of these may contribute to this phenotypic variation.According to the Norwegian National Registry of Autoimmune Diseases, the triad has been described to be present in 40% of patients with a median age of 14 years. According to this registry, the second most common endocrinopathy (other than the triad) is hypothyroidism, followed by primary gonadal failure characterized by secondary amenorrhea before 40 years of age. Also noteworthy is the high prevalence of enamel hypoplasia (up to 70% among patients undergoing dental assessment). In general, the different components of the syndrome increase in prevalence with age, but diagnosis of the disease at an earlier age is associated with a more severe phenotype.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Pathophysiology and geneticsOne of the functions of the immune system is immunological self-tolerance defined as an acquired lack of response to a self-antigen. This requires mechanisms that are capable of eliminating autoreactive T cells (reacting against self-antigens); these mechanisms are regulated centrally (thymus and bone marrow) and peripherally (target tissues and organs). APS occurs as a consequence of loss of immune tolerance to autoantigens.The AIRE gene is the gene responsible for APS type 1. This is expressed in thymic cells and, to a lesser extent, in dendritic cells. It is involved in the translation of thousands of proteins related to T-cell development. When the AIRE gene is absent or non-functional, autoreactive T cells with specificity for certain antigens escape negative selection of autoreactive lymphocytes and trigger autoimmune disease.More specifically, recent findings indicate that the AIRE gene controls immune tolerance by an additional mechanism that consists of the induction of a single regulatory T cell population called FOXP3 + (Tregs) in the thymus, whose function is to suppress autoreactive cells. In APS type 1, this population is either undeveloped or dysfunctional.More than 100 different mutations of the AIRE gene located on chromosome 21 have been described. In addition, populations with more prevalent mutations have been identified. The most commonly described mutation is the Finnish major mutation (p.R357X) located in the SAND domain, named after the proteins of the family: Sp100, AIRE-1, NUCP41/75, DEAF-1. This mutation is especially prevalent in Finland, Russia, and Eastern Europe. Another common mutation is the 13 base pair deletion (pC322del13) in the PHD1 domain, prevalent in Norway, the British Isles, France, and North America.Although the inheritance pattern is autosomal recessive, some cases with an autosomal dominant inheritance have been reported due to changes in critical AIRE gene amino acids, which inhibit the Wild Type form of the gene causing a dominant negative mutation. These variants are associated with a milder presentation of the syndrome and are more often accompanied by DM1.Some authors group the genotypes into three distinct subtypes that can give rise to three phenotypes which differ from each other in terms of the age of presentation of the first component of the syndrome.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>ImmunophenotypeAnti-interferon omega antibodies (anti-IFN-ω) are the most common, reported in 93% of patients with the syndrome. They can remain positive for decades and show a high specificity for the diagnosis of APS type 1. The second most common are anti-21-hydroxylase and anti-interleukin-22 antibodies, both present in approximately 71% of patients.There is a significant correlation between immunophenotype and phenotype. Thus, the presence of anti-NALP5 antibodies (NACHTleucine-rich-repeatprotein5) has been reported in 49% of patients with hypoparathyroidism. 93% of patients with Addison's disease have anti-21-hydroxylase antibodies and 43% have anti-17-hydroxylase antibodies. Notably, 100% of individuals with anti-21-hydroxylase antibodies develop adrenal insufficiency within three years. Among individuals with mucocutaneous candidiasis, up to 81% have anti-interleukin-22 antibodies.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>DiagnosisIt is based on clinical suspicion; however, it should be noted that in many cases years pass between the onset of the first and second component of the syndrome, delaying diagnosis. Some authors propose the determination of anti-IFN-ω antibodies in case of clinical suspicion due to their high sensitivity and specificity. If positive, AIRE<a class="elsevierStyleCrossRef" href="#bib0020">4</a> gene sequencing is recommended.PrognosisAn increase in mortality has been described in patients with APS type 1. The main cause of the increase in mortality among these patients is cardiovascular disease, followed by neoplasms and respiratory disease.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>An increase in the incidence of neoplasms has been observed, specifically cancer of the oral cavity, of the skin (not melanoma) and of the male genital organs.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>As preventive activities, as these patients are at increased risk of developing asplenia, pneumococcal, meningococcal, Haemophilus influenzae type B and annual influenza vaccines are recommended.Autoimmune polyendocrine syndrome type 2Signs and symptomsClassically defined as the coexistence of Addison's disease or serological evidence of autoimmune adrenalitis with DM1 (Carpenter syndrome) or autoimmune thyroid disease (Schmidt's syndrome).<a class="elsevierStyleCrossRefs" href="#bib0030">6,7</a> However, some authors define it as the presence of two of the three autoimmune diseases without specifying whether a diagnosis of autoimmune adrenalitis is essential, probably because Addison's disease is present at onset in half of the patients and in others it may occur after autoimmune thyroid disease or DM1, although it is important to note that antibodies against the adrenal cortex and/or anti-21-OH antibodies are present in almost 90% of cases.<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The prevalence described is 1:100−1:20,000 people, with an annual incidence of 1–2 per 100,000 inhabitants. It is three times more common in females and the typical age of presentation is between 20 and 40 years.It is often associated with other autoimmune aetiologies such as celiac disease, alopecia, vitiligo, premature menopause, and pernicious anaemia. Other associated diseases have been described, although with a much lower frequency, such as Stiff-person syndrome, Parkinson's disease, selective immunoglobulin A deficiency, serositis, dermatitis herpetiformis, idiopathic thrombocytopenia and hypophysitis.Within the syndrome, the endocrinopathy most commonly associated with Addison's is autoimmune thyroid disease described in around 65% of cases, with a very similar prevalence of Graves-Basedow disease and Hashimoto's thyroiditis. The second most commonly associated with Addison is DM1, described in up to 53–60% of patients.<a class="elsevierStyleCrossRefs" href="#bib0035">7,8</a>DM1 has a peak of highest incidence between the ages of 20 and 30. Two peaks of incidence have been described in Addison's disease: between the ages of 20 and 30 and between the ages of 40 and 50. No such pronounced peak incidence has been reported in autoimmune thyroid disease, where it can occur throughout life, although with somewhat higher incidence in the 40s.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>The time interval between the first manifestation of the syndrome and the second can vary considerably. A longer period of time has been described between the diagnosis of DM1 and that of thyroid disease (with a mean interval of 16 years between the diagnosis of both). In contrast, shorter intervals between the diagnosis of Addison and thyroid disease have been described.<a class="elsevierStyleCrossRef" href="#bib0045">9</a>The association of DM1 with other autoimmune diseases is widely known. The most common is autoimmune thyroid disease with a reported prevalence of 10–30%, followed by celiac disease in 4–16% of cases and autoimmune gastritis in 4% of individuals with DM1. Less common is the association with vitiligo (2.4%), hyperthyroidism (1.3%) and Addison's disease (0.2%).<a class="elsevierStyleCrossRef" href="#bib0050">10</a>It is important to highlight two commonly associated diseases which, when co-existing, may require modifications in drug therapy. It involves the association of chronic autoimmune gastritis with autoimmune hypothyroidism. To understand the origin of this association, it must be borne in mind that the thyroid follicular cell and the gastric cell share a common embryological origin. Both cells have apical microvilli and concentrate and transport iodine across their cell membrane.<a class="elsevierStyleCrossRef" href="#bib0055">11</a> Iodine has also been involved in the proliferation of gastric mucosa cells. The pathophysiology of autoimmune gastritis usually includes an initial silent phase, in which gastric pH is altered. Ascorbic acid, under healthy physiological pH conditions in the stomach, allows the reduction of iron from its ferric to ferrous nutritional form, forming a complex that allows its absorption in the duodenum. In the initial stages, the altered pH can lead to microcytic iron deficiency anaemia and as gastric cell atrophy occurs, intrinsic factor is not produced in sufficient quantity and vitamin B12 absorption is impaired, leading to pernicious (macrocytic) anaemia. Thus, chronic autoimmune gastritis should be suspected in a patient with hypothyroidism who develops iron deficiency anaemia without response to oral iron therapy. Conversely, in patients with chronic atrophic gastritis and due to the modification of gastric pH, the T4 dosage form may be altered in its dissolution process leading to levothyroxine malabsorption. Therefore, gastric disease compromising absorption such as autoimmune gastritis should be ruled out in patients with hypothyroidism who have a significantly elevated levothyroxine requirement, although it can also occur in coeliac disease and lactose intolerance.Celiac disease is commonly associated with other autoimmune diseases. Up to one third of adults with the disease have been reported to have one or more autoimmune diseases.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Patients with DM1 and coeliac disease have been found to have an earlier onset of diabetes, may be more likely to have growth retardation and underweight, and lower glycosylated haemoglobin levels.<a class="elsevierStyleCrossRef" href="#bib0065">13</a> In addition, when celiac disease appears before DM1, there is a greater probability of developing a third autoimmune disorder.<a class="elsevierStyleCrossRef" href="#bib0070">14</a> Independent risk factors have also been described in patients with DM1 for the development of celiac disease, these are: earlier onset age (being four times more common when the onset takes place under the age of four), female sex and the presence of thyroid disease associated with DM1.<a class="elsevierStyleCrossRef" href="#bib0075">15</a>Genetics and pathophysiologyMajor histocompatibility complex class 2 genes located on chromosome 6 have been involved, so that the same genes and polymorphisms are associated with different autoimmune diseases. Moreover, some families have shown that susceptibility to endocrine autoimmune diseases has an autosomal dominant inheritance pattern with incomplete penetrance, associated with different specific HLA haplotypes. As in APS type 1, epigenetic and environmental factors can alter penetrance and phenotypic presentation.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>In addition to major histocompatibility complex class 2, genes encoding for cytotoxic T lymphocyte associated protein 4 (CTLA4) which is a regulator of T-lymphocyte activation, and which share the same mutations for different diseases have also been involved in the pathophysiology. However, the inheritance of SPA type 2 is further complicated by the fact that mutations have also been described in genes encoding for different proteins that affect regulatory T-cell signalling and can cause monogenic syndromes with the peculiarity that all of them can present enteropathy as a clinical manifestation. Finally, gene A related to major histocompatibility complex class I, located on chromosome 6 in the HLA region, may contribute to the genetic susceptibility of APS type 2.Diagnosis and screeningAutoantibody determination may be useful in the assessment of the risk of developing the disease, as many autoantibodies are present years before the clinical manifestation of the disease (preclinical period). For example, anti-thyroid peroxidase antibodies and anti-glutamic acid decarboxylase (anti-GAD) and anti-21-hydroxylase antibodies are predictive of disease development, although the time between detection of autoantibodies and clinical disease can be very long in some diseases, typically thyroid disease. Autoantibodies can bind to the cell surface without functional effects, or they can be blockers or stimulators, examples include autoimmune thyroid pathology, or blocking antibodies against the acetylcholine receptor in myasthenia gravis. The presence of autoantibodies is high in healthy relatives of APS type 2 patients.The American Diabetes Association recommends screening for other autoimmune diseases at the time of diagnosis of DM1 with a laboratory determination of anti-thyroid peroxidase antibodies and anti-thyroglobulin antibodies, thyrotropin (TSH) and anti-transglutaminase IgA and IgA antibodies. When IgA is low, anti-transglutaminase IgG and anti-gliadin antibodies are recommended. A TSH test every 1–2 years is recommended in the follow-up of DM1; also, continued screening for coeliac disease, with antibody testing every five years or more often in cases of growth retardation, increased frequency of hypoglycaemia or a first-degree relative with coeliac disease.<a class="elsevierStyleCrossRef" href="#bib0085">17</a>Autoimmune polyendocrine syndrome type 3It is defined as the presence of autoimmune thyroid disease and other autoimmune disease, excluding Addison's disease and hypoparathyroidism. It is not associated with immunodeficiencies. Most of the time it is difficult to differentiate from APS type 2. Its prevalence is higher than the other syndromes, up to 3−4% of the population. It can occur during the paediatric age or in youth. The most commonly associated autoimmune diseases are DM1 (APS type 3-A), celiac disease, pernicious anaemia (APS type 3-B), vitiligo or alopecia (APS type 3-C) or rheumatic diseases such as collagen disorders and vasculitis (APS 3-D type). Autosomal dominant inheritance with incomplete penetrance, environmental factors such as infections and association with different HLA haplotypes have been suggested in its pathophysiology. Examples of these include HLA-DQB1* 0301 with autoimmune thyroiditis, HLA-DRB1* 13 with vitiligo and HLA-DQB1* 03 and DRB1* 1104 with alopecia areata. At least four genes have been have been shown to confer susceptibility. These are: human leukocyte antigen class II on chromosome 6, CTLA4 on chromosome 2 and protein tyrosine phosphatase non-receptor 22 (PTNP22) on chromosome 1 and FOXP3 on X chromosome, all of which alter T-cell function.<a class="elsevierStyleCrossRef" href="#bib0090">18</a>Polyendocrinopathy and X-linked enteropathyIt is a monogenic primary immunodeficiency that overlaps with APS type 1, but usually develops at a much younger age. It usually presents with neonatal DM1 and autoimmune enteropathy (diarrhoea with malabsorption). It usually has a very poor prognosis in the first years of life unless patients receive immunosuppressive treatment or bone marrow transplantation very early. The initial manifestation is usually diarrhoea, present in 100% of individuals throughout follow-up, followed by eczematous skin lesions in 78%. 35% have an allergy to cow's milk protein, 29% haematological disorders, 25% nephropathy and 14% hepatitis. DM1 is the onset manifestation in 26% of subjects. Some 150 mutations have been described in the FOXP3 gene on the X chromosome that encodes for a key transcription factor in the regulation of T<a class="elsevierStyleCrossRef" href="#bib0095">19</a> cells.Screening and monitoring of autoimmune polyendocrinopathyThe detection of a mutation of the AIRE gene requires lifelong follow-up of the patient, monitoring the relevant biochemical and hormonal laboratory levels. In these individuals, the detection of anti-21-hydroxylase antibodies requires annual monitoring of cortisol levels and even dynamic cortisol stimulation tests.When APS is suspected, it is important to carry out a complete family history, as well as a detailed history-taking aimed at the detection of autoimmune diseases.TSH monitoring is recommended annually in APS type 2 patients and their first-degree relatives when anti-thyroid antibodies are positive and every five years if they are negative and TSH is normal. There is no consensus on the need to request anti-21-hydroxylase antibodies in patients with DM1 and autoimmune thyroid disease. Some authors propose their determination as they correlate directly with the likelihood of developing adrenal insufficiency. There is a greater consensus on the recommendation to determine anti-transglutaminase antibodies for celiac disease screening in individuals with DM1. Autoantibody carriers without clinical manifestations should be monitored by laboratory tests. HLA typing is usually done only in the context of research projects.Monoclonal antibody treatment as a trigger for APSTreatment with immunotherapy (immune checkpoint inhibitors) in cancer patients has been associated with the development of autoimmune diseases. In a meta-analysis, monoclonal antibody treatment was associated with an increased risk of: hypophysitis: RR 22.03 (95% CI: 8.52–56.94; p < 0.00001); hypothyroidism: RR 8.26 (95% CI: 4.67–14.62; p < 0.00001); hyperthyroidism: RR 5.48 (95% CI: 1.33–22.53; 9 = 0.02); or adrenal insufficiency: RR 3.87 (95% CI: 1.12–13.41; p = 0.03).<a class="elsevierStyleCrossRef" href="#bib0100">20</a> In these patients it is recommended, prior to the initiation of immunotherapy treatment, the determination of fasting plasma glycaemia, plasma sodium, TSH, free thyroxine, cortisol at ±8:00 a.m. ACTH (provided the patient is not treated with glucocorticoids), LH, FSH and testosterone in males, FSH, LH and oestradiol in women with irregular menstrual cycles, FSH in menopausal women. Fasting plasma glucose, plasma sodium, TSH, cortisol at 8 a.m. and testosterone in males are recommended at each course of treatment for six months and every second course of treatment after six months.FutureThe combination of early diagnosis, together with personalised genomics, may allow early immunomodulatory therapy to halt the autoimmune process before the damage becomes irreversible. Research is currently underway to generate thymic epithelial tissue from stem cells that could be useful in correcting AIRE gene expression.ConclusionsAPS Type 1 occurs in childhood. Anti-IFN-ω antibodies are usually present, although their absence does not exclude the diagnosis. Therefore, AIRE gene sequencing is required if there is clinical suspicion of one or more manifestations of the syndrome. Once the diagnosis is made, all clinical manifestations should be examined as some are of later presentation, and patients show increased morbidity and mortality.Type 2 and type 3 APS can be difficult to differentiate because they have shared manifestations except for Addison's disease, although APS type 3 has an earlier age of presentation.In patients with an autoimmune glandular disease, it is important to carry out a detailed family and case history aimed at detecting other autoimmune manifestations so that the diagnosis of a possible APS does not go unnoticed and early treatment of each of its component diseases is established.FundingThis article has not received any type of funding.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1574019" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1418329" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1574018" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1418330" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Autoimmune polyendocrine syndrome type 1" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Epidemiology and clinical features" ] 1 => array:3 [ "identificador" => "sec0020" "titulo" => "Pathophysiology and genetics" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Immunophenotype" ] ] ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Diagnosis" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Prognosis" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Autoimmune polyendocrine syndrome type 2" "secciones" => array:7 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Signs and symptoms" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Genetics and pathophysiology" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Diagnosis and screening" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Autoimmune polyendocrine syndrome type 3" ] 4 => array:2 [ "identificador" => "sec0065" "titulo" => "Polyendocrinopathy and X-linked enteropathy" ] 5 => array:2 [ "identificador" => "sec0070" "titulo" => "Screening and monitoring of autoimmune polyendocrinopathy" ] 6 => array:2 [ "identificador" => "sec0075" "titulo" => "Monoclonal antibody treatment as a trigger for APS" ] ] ] 7 => array:2 [ "identificador" => "sec0080" "titulo" => "Future" ] 8 => array:2 [ "identificador" => "sec0085" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0090" "titulo" => "Funding" ] 10 => array:2 [ "identificador" => "sec0095" "titulo" => "Conflict of interests" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-12-14" "fechaAceptado" => "2021-02-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1418329" "palabras" => array:3 [ 0 => "Polyendocrine syndrome" 1 => "Autoimmune diseases" 2 => "Autoinmune polyendocrinopathy" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1418330" "palabras" => array:3 [ 0 => "Síndrome poliendocrino" 1 => "Enfermedades autoinmunes" 2 => "Poliendocrinopatía autoinmune" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Pluriglandular autoimmune syndrome (APS) can affect multiple endocrine glands and is associated with other autoimmune diseases. APS type 1 presents with hypoparathyroidism, mucocutaneous candidiasis and Addison's disease. It is caused by AutoImmune Regulator (AIRE) gene mutation. The diagnosis includes clinical manifestations in addition to AIRE gene sequencing. SPA type 2 presents with Addison's disease, type 1 diabetes, or autoimmune thyroid disease. Multiple genes have been implicated, including those of the class II major histocompatibility complex. SPA type 3 is characterized by autoimmune thyroid disease and other autoimmune disease, excluding Addison's disease and hypoparathyroidism, 4 genes have been implicated and confer susceptibility. The diagnosis of APS type 2 and type 3 includes clinical manifestations, nevertheless, the determination of autoantibodies can be useful to predict the risk of disease manifestation and to confirm the autoimmune disease in some cases." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Los síndromes pluriglandulares autoinmunes (SPA) afectan a múltiples glándulas endocrinas y asocian otras enfermedades autoinmunes. El SPA tipo 1 se presenta con hipoparatiroidismo, candidiasis mucocutánea y enfermedad de Addison, se debe a una mutación en el gen AIRE (AutoImmune Regulator). El diagnóstico es clínico además de la secuenciación del gen AIRE. El SPA tipo 2 se presenta con enfermedad de Addison, diabetes mellitus tipo1 o enfermedad tiroidea autoinmune, se han implicado múltiples genes, entre ellos los del complejo mayor de histocompatibilidad tipo 2. El SPA tipo 3 se caracteriza por la presencia de enfermedad tiroidea autoinmune y otra enfermedad autoinmune, excluyendo la enfermedad de Addison y el hipoparatiroidismo, se han implicado 4 genes que pueden conferir susceptibilidad. El diagnóstico del SPA tipo 2 y tipo 3 es clínico, aunque la determinación de autoanticuerpos puede ser útil para la evaluación del riesgo de presentar la enfermedad y para confirmar la enfermedad autoinmune en algunos casos." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Fernández Miró M, Colom Comí C, Godoy Lorenzo R. Síndromes pluriglandulares autoinmunes. Med Clin (Barc). 2021;157:241–246." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AI: autoimmune; DM1: type 1 diabetes mellitus; AR: autosomal recessive; AD: autosomal dominant; MHC: major histocompatibility complex; Ab: antibodies." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">APS type 1 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">APS type 2 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">APS type 3 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IPEX \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Clinical manifestations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Addison \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Addison \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Thyroid disease and other autoimmune disease other than Addison or hypoparathyroidism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AI enteropathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hypoparathyroidism \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AI thyroid disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Neonatal DM1 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Chronic mucocutaneous candidiasis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DM1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Eczema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Other manifestations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Enamel hypoplasia, AI oophoritis, enteropathy \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AI gastritis, vitiligo, celiac disease, alopecia, AI oophoritis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DM1, AI gastritis, vitiligo, celiac disease, alopecia, rheumatic disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AI thyroid disease AI, haemolytic anaemia, thrombocytopenia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age of onset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Childhood/adolescence \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adolescence/adult \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Childhood/youth \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Childhood \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Frequency \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1:100,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1:100−1:20,000 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3−4% general population \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1:1,000,000 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Treatment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hormone replacement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hormone replacement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hormone replacement \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hormone replacement \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Calcium and vitamin D, antifungals, immunosuppression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immunosuppression \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bone marrow transplant \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adrenal crisis and severe hypocalcaemia, oral and oesophageal cancer \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Adrenal crisis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DM complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Infections \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">DM complications \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Genetic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">AR, less common. AD. AIRE gene \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Polygenic, MHC and others \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Polygenic, HLA class II, CTLA-4, PTN22, FOXP3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">FOXP3, linked to the X chromosome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Immunophenotype \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-interferon omega Ab (>95%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-21-hydroxylase Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-GAD Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-GAD Ab, Lymphocytosis, eosinophilia, Hyper IgE \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-GAD Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-thyroid peroxidase and antithyroglobulin Ab, Anti-TSH receptor Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-thyroid peroxidase and antithyroglobulin Ab, Anti-TSH receptor Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Anti-transglutaminase, anti-gastric cell Ab \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2696995.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Characteristics of the different autoimmune polyendocrinopathies." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Eine biglandulare Erkrankung (Nebennieren und Schilddrüse) bei Morbus Adisonii" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.B. 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Autoimmune polyendocrinopathy

Síndromes pluriglandulares autoinmunes

Mercè Fernández Miró

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mfmiro79@gmail.com

Corresponding author.

, Cristina Colom Comí, Rita Godoy Lorenzo

Departamento de Medicina Interna y Especialidades Médicas, Centre d’Atenció Integral Dos de Maig, Consorci Sanitari Integral, Barcelona, Spain

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Autoimmune polyendocrinopathy comprises a series of functional disorders affecting multiple endocrine glands and may also be associated with other diseases of autoimmune aetiology&#46; The first syndrome was named in 1926 by Schmidt who described the combination of adrenal insufficiency and hypothyroidism&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The clinical presentation varies according to the different series described&#46; Individual components of the syndrome may take years to manifest&#44; leading to a delay in diagnosis&#46; Several autoimmune polyendocrine syndromes have been described over time and these are detailed below &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">The objective of this paper is to review the epidemiology&#44; aetiology&#44; clinical presentation&#44; diagnosis&#44; and treatment of autoimmune polyendocrine syndromes&#46; A literature review was carried out including articles published in the PubMed database between 2003 and 2019 using the keywords&#58; <span class="elsevierStyleItalic">Polyendocrine Syndrome&#44; autoimmune polyendocrinopathy&#44; polyglandular autoimmune syndrome&#44; type 1 diabetes and autoimmune diseases&#44; type 1 diabetes and celiac disease&#44; autoimmune thyroid disease&#44; and gastritis</span>&#46; Review articles&#44; prospective series studies&#44; studies associating diabetes with celiac disease and autoimmune thyroid disease with autoimmune gastritis have been included&#44; <span class="elsevierStyleItalic">case reports</span> have been excluded&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Autoimmune polyendocrine syndrome type 1</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Epidemiology and clinical features</span><p id="par0015" class="elsevierStylePara elsevierViewall">Autoimmune polyendocrine syndrome &#40;APS&#41; type 1 is an autosomal recessive disease whose aetiology is due to a mutation in the <span class="elsevierStyleItalic">Autoimmune Regulator</span> &#40;AIRE&#41; gene&#46; The estimated prevalence is 1&#58;80&#44;000 in most countries&#44; with Finland &#40;1&#58;25&#44;000&#41;&#44; Sardinia &#40;1&#58;14&#44;000&#41; and Israel &#40;1&#58;9&#44;000&#41; being the highest&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The age of presentation is usually in childhood &#40;between the ages of two and 18 years&#41; and is defined as the development of two or three of the following components&#58; chronic mucocutaneous candidiasis&#44; hypoparathyroidism&#44; and Addison&#39;s disease&#46; Typical associated disorders such as enamel hypoplasia&#44; enteropathy &#40;diarrhoea or chronic constipation&#41; and premature ovarian failure &#40;in 60&#37; of women before the age of 30&#41; have been described&#46; Other far less common manifestations include bilateral keratitis&#44; periodic fever with rash&#44; hepatitis&#44; pneumonitis and autoimmune nephritis&#44; exocrine pancreatic insufficiency&#44; type 1 diabetes mellitus &#40;DM1&#41;&#44; hypothyroidism&#44; pernicious anaemia&#44; vitiligo&#44; coeliac disease and functional asplenia&#46; The first component of the syndrome to express itself is often different from the triad&#44; delaying diagnostic suspicion&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Chronic mucocutaneous candidiasis is usually the onset component&#44; with a prevalence of 50&#37; at 5 years of age and 94&#37; at 20 years of age&#46; Oral presentation is the most common form at the time of diagnosis&#44; with potential later onset in nails&#44; genitalia&#44; oesophagus&#44; and intestine&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">There is great variability in the phenotype and in the age of presentation of the different manifestations&#44; even within the same family&#46; This reinforces the theory that its etiopathogenesis is complex&#46; In this sense&#44; apart from mutations in the AIRE gene&#44; genes of the major histocompatibility complex &#40;some haplotypes have been associated with an increased risk of having a particular component of the syndrome&#41; and environmental factors also play a role&#46; Together&#44; all of these may contribute to this phenotypic variation&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">According to the Norwegian National Registry of Autoimmune Diseases&#44; the triad has been described to be present in 40&#37; of patients with a median age of 14 years&#46; According to this registry&#44; the second most common endocrinopathy &#40;other than the triad&#41; is hypothyroidism&#44; followed by primary gonadal failure characterized by secondary amenorrhea before 40 years of age&#46; Also noteworthy is the high prevalence of enamel hypoplasia &#40;up to 70&#37; among patients undergoing dental assessment&#41;&#46; In general&#44; the different components of the syndrome increase in prevalence with age&#44; but diagnosis of the disease at an earlier age is associated with a more severe phenotype&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pathophysiology and genetics</span><p id="par0040" class="elsevierStylePara elsevierViewall">One of the functions of the immune system is immunological self-tolerance defined as an acquired lack of response to a self-antigen&#46; This requires mechanisms that are capable of eliminating autoreactive T cells &#40;reacting against self-antigens&#41;&#59; these mechanisms are regulated centrally &#40;thymus and bone marrow&#41; and peripherally &#40;target tissues and organs&#41;&#46; APS occurs as a consequence of loss of immune tolerance to autoantigens&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The AIRE gene is the gene responsible for APS type 1&#46; This is expressed in thymic cells and&#44; to a lesser extent&#44; in dendritic cells&#46; It is involved in the translation of thousands of proteins related to T-cell development&#46; When the AIRE gene is absent or non-functional&#44; autoreactive T cells with specificity for certain antigens escape negative selection of autoreactive lymphocytes and trigger autoimmune disease&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">More specifically&#44; recent findings indicate that the AIRE gene controls immune tolerance by an additional mechanism that consists of the induction of a single regulatory T cell population called FOXP3 &#43; &#40;<span class="elsevierStyleItalic">Tregs</span>&#41; in the thymus&#44; whose function is to suppress autoreactive cells&#46; In APS type 1&#44; this population is either undeveloped or dysfunctional&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">More than 100 different mutations of the AIRE gene located on chromosome 21 have been described&#46; In addition&#44; populations with more prevalent mutations have been identified&#46; The most commonly described mutation is the <span class="elsevierStyleItalic">Finnish major mutation</span> &#40;p&#46;R357X&#41; located in the <span class="elsevierStyleItalic">SAND</span> domain&#44; named after the proteins of the family&#58; Sp100&#44; AIRE-1&#44; NUCP41&#47;75&#44; DEAF-1&#46; This mutation is especially prevalent in Finland&#44; Russia&#44; and Eastern Europe&#46; Another common mutation is the 13 base pair deletion &#40;pC322del13&#41; in the PHD1 domain&#44; prevalent in Norway&#44; the British Isles&#44; France&#44; and North America&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Although the inheritance pattern is autosomal recessive&#44; some cases with an autosomal dominant inheritance have been reported due to changes in critical AIRE gene amino acids&#44; which inhibit the <span class="elsevierStyleItalic">Wild Type</span> form of the gene causing a dominant negative mutation&#46; These variants are associated with a milder presentation of the syndrome and are more often accompanied by DM1&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">Some authors group the genotypes into three distinct subtypes that can give rise to three phenotypes which differ from each other in terms of the age of presentation of the first component of the syndrome&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Immunophenotype</span><p id="par0070" class="elsevierStylePara elsevierViewall">Anti-interferon omega antibodies &#40;anti-IFN-&#969;&#41; are the most common&#44; reported in 93&#37; of patients with the syndrome&#46; They can remain positive for decades and show a high specificity for the diagnosis of APS type 1&#46; The second most common are anti-21-hydroxylase and anti-interleukin-22 antibodies&#44; both present in approximately 71&#37; of patients&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">There is a significant correlation between immunophenotype and phenotype&#46; Thus&#44; the presence of anti-NALP5 antibodies &#40;<span class="elsevierStyleBold"><span class="elsevierStyleItalic">NA</span></span><span class="elsevierStyleItalic">CHT</span><span class="elsevierStyleBold"><span class="elsevierStyleItalic">l</span></span><span class="elsevierStyleItalic">eucine-rich-repeat</span><span class="elsevierStyleBold"><span class="elsevierStyleItalic">p</span></span><span class="elsevierStyleItalic">rotein</span><span class="elsevierStyleBold"><span class="elsevierStyleItalic">5</span></span>&#41; has been reported in 49&#37; of patients with hypoparathyroidism&#46; 93&#37; of patients with Addison&#39;s disease have anti-21-hydroxylase antibodies and 43&#37; have anti-17-hydroxylase antibodies&#46; Notably&#44; 100&#37; of individuals with anti-21-hydroxylase antibodies develop adrenal insufficiency within three years&#46; Among individuals with mucocutaneous candidiasis&#44; up to 81&#37; have anti-interleukin-22 antibodies&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Diagnosis</span><p id="par0080" class="elsevierStylePara elsevierViewall">It is based on clinical suspicion&#59; however&#44; it should be noted that in many cases years pass between the onset of the first and second component of the syndrome&#44; delaying diagnosis&#46; Some authors propose the determination of anti-IFN-&#969; antibodies in case of clinical suspicion due to their high sensitivity and specificity&#46; If positive&#44; AIRE<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> gene sequencing is recommended&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Prognosis</span><p id="par0085" class="elsevierStylePara elsevierViewall">An increase in mortality has been described in patients with APS type 1&#46; The main cause of the increase in mortality among these patients is cardiovascular disease&#44; followed by neoplasms and respiratory disease&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">An increase in the incidence of neoplasms has been observed&#44; specifically cancer of the oral cavity&#44; of the skin &#40;not melanoma&#41; and of the male genital organs&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">As preventive activities&#44; as these patients are at increased risk of developing asplenia&#44; pneumococcal&#44; meningococcal&#44; <span class="elsevierStyleItalic">Haemophilus influenzae</span> type B and annual influenza vaccines are recommended&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Autoimmune polyendocrine syndrome type 2</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Signs and symptoms</span><p id="par0100" class="elsevierStylePara elsevierViewall">Classically defined as the coexistence of Addison&#39;s disease or serological evidence of autoimmune adrenalitis with DM1 &#40;Carpenter syndrome&#41; or autoimmune thyroid disease &#40;Schmidt&#39;s syndrome&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#44;7</span></a> However&#44; some authors define it as the presence of two of the three autoimmune diseases without specifying whether a diagnosis of autoimmune adrenalitis is essential&#44; probably because Addison&#39;s disease is present at onset in half of the patients and in others it may occur after autoimmune thyroid disease or DM1&#44; although it is important to note that antibodies against the adrenal cortex and&#47;or anti-21-OH antibodies are present in almost 90&#37; of cases&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The prevalence described is 1&#58;100&#8722;1&#58;20&#44;000 people&#44; with an annual incidence of 1&#8211;2 per 100&#44;000 inhabitants&#46; It is three times more common in females and the typical age of presentation is between 20 and 40 years&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">It is often associated with other autoimmune aetiologies such as celiac disease&#44; alopecia&#44; vitiligo&#44; premature menopause&#44; and pernicious anaemia&#46; Other associated diseases have been described&#44; although with a much lower frequency&#44; such as <span class="elsevierStyleItalic">Stiff-person</span> syndrome&#44; Parkinson&#39;s disease&#44; selective immunoglobulin A deficiency&#44; serositis&#44; dermatitis herpetiformis&#44; idiopathic thrombocytopenia and hypophysitis&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">Within the syndrome&#44; the endocrinopathy most commonly associated with Addison&#39;s is autoimmune thyroid disease described in around 65&#37; of cases&#44; with a very similar prevalence of Graves-Basedow disease and Hashimoto&#39;s thyroiditis&#46; The second most commonly associated with Addison is DM1&#44; described in up to 53&#8211;60&#37; of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">DM1 has a peak of highest incidence between the ages of 20 and 30&#46; Two peaks of incidence have been described in Addison&#39;s disease&#58; between the ages of 20 and 30 and between the ages of 40 and 50&#46; No such pronounced peak incidence has been reported in autoimmune thyroid disease&#44; where it can occur throughout life&#44; although with somewhat higher incidence in the 40s&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">The time interval between the first manifestation of the syndrome and the second can vary considerably&#46; A longer period of time has been described between the diagnosis of DM1 and that of thyroid disease &#40;with a mean interval of 16 years between the diagnosis of both&#41;&#46; In contrast&#44; shorter intervals between the diagnosis of Addison and thyroid disease have been described&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">The association of DM1 with other autoimmune diseases is widely known&#46; The most common is autoimmune thyroid disease with a reported prevalence of 10&#8211;30&#37;&#44; followed by celiac disease in 4&#8211;16&#37; of cases and autoimmune gastritis in 4&#37; of individuals with DM1&#46; Less common is the association with vitiligo &#40;2&#46;4&#37;&#41;&#44; hyperthyroidism &#40;1&#46;3&#37;&#41; and Addison&#39;s disease &#40;0&#46;2&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">It is important to highlight two commonly associated diseases which&#44; when co-existing&#44; may require modifications in drug therapy&#46; It involves the association of chronic autoimmune gastritis with autoimmune hypothyroidism&#46; To understand the origin of this association&#44; it must be borne in mind that the thyroid follicular cell and the gastric cell share a common embryological origin&#46; Both cells have apical microvilli and concentrate and transport iodine across their cell membrane&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Iodine has also been involved in the proliferation of gastric mucosa cells&#46; The pathophysiology of autoimmune gastritis usually includes an initial silent phase&#44; in which gastric pH is altered&#46; Ascorbic acid&#44; under healthy physiological pH conditions in the stomach&#44; allows the reduction of iron from its ferric to ferrous nutritional form&#44; forming a complex that allows its absorption in the duodenum&#46; In the initial stages&#44; the altered pH can lead to microcytic iron deficiency anaemia and as gastric cell atrophy occurs&#44; intrinsic factor is not produced in sufficient quantity and vitamin B12 absorption is impaired&#44; leading to pernicious &#40;macrocytic&#41; anaemia&#46; Thus&#44; chronic autoimmune gastritis should be suspected in a patient with hypothyroidism who develops iron deficiency anaemia without response to oral iron therapy&#46; Conversely&#44; in patients with chronic atrophic gastritis and due to the modification of gastric pH&#44; the T4 dosage form may be altered in its dissolution process leading to levothyroxine malabsorption&#46; Therefore&#44; gastric disease compromising absorption such as autoimmune gastritis should be ruled out in patients with hypothyroidism who have a significantly elevated levothyroxine requirement&#44; although it can also occur in coeliac disease and lactose intolerance&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Celiac disease is commonly associated with other autoimmune diseases&#46; Up to one third of adults with the disease have been reported to have one or more autoimmune diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Patients with DM1 and coeliac disease have been found to have an earlier onset of diabetes&#44; may be more likely to have growth retardation and underweight&#44; and lower glycosylated haemoglobin levels&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> In addition&#44; when celiac disease appears before DM1&#44; there is a greater probability of developing a third autoimmune disorder&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Independent risk factors have also been described in patients with DM1 for the development of celiac disease&#44; these are&#58; earlier onset age &#40;being four times more common when the onset takes place under the age of four&#41;&#44; female sex and the presence of thyroid disease associated with DM1&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Genetics and pathophysiology</span><p id="par0150" class="elsevierStylePara elsevierViewall">Major histocompatibility complex class 2 genes located on chromosome 6 have been involved&#44; so that the same genes and polymorphisms are associated with different autoimmune diseases&#46; Moreover&#44; some families have shown that susceptibility to endocrine autoimmune diseases has an autosomal dominant inheritance pattern with incomplete penetrance&#44; associated with different specific HLA haplotypes&#46; As in APS type 1&#44; epigenetic and environmental factors can alter penetrance and phenotypic presentation&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">In addition to major histocompatibility complex class 2&#44; genes encoding for <span class="elsevierStyleItalic">cytotoxic T lymphocyte associated protein 4</span> &#40;CTLA4&#41; which is a regulator of T-lymphocyte activation&#44; and which share the same mutations for different diseases have also been involved in the pathophysiology&#46; However&#44; the inheritance of SPA type 2 is further complicated by the fact that mutations have also been described in genes encoding for different proteins that affect regulatory T-cell signalling and can cause monogenic syndromes with the peculiarity that all of them can present enteropathy as a clinical manifestation&#46; Finally&#44; gene A related to major histocompatibility complex class I&#44; located on chromosome 6 in the HLA region&#44; may contribute to the genetic susceptibility of APS type 2&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Diagnosis and screening</span><p id="par0160" class="elsevierStylePara elsevierViewall">Autoantibody determination may be useful in the assessment of the risk of developing the disease&#44; as many autoantibodies are present years before the clinical manifestation of the disease &#40;preclinical period&#41;&#46; For example&#44; anti-thyroid peroxidase antibodies and anti-glutamic acid decarboxylase &#40;anti-GAD&#41; and anti-21-hydroxylase antibodies are predictive of disease development&#44; although the time between detection of autoantibodies and clinical disease can be very long in some diseases&#44; typically thyroid disease&#46; Autoantibodies can bind to the cell surface without functional effects&#44; or they can be blockers or stimulators&#44; examples include autoimmune thyroid pathology&#44; or blocking antibodies against the acetylcholine receptor in myasthenia gravis&#46; The presence of autoantibodies is high in healthy relatives of APS type 2 patients&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The American Diabetes Association recommends screening for other autoimmune diseases at the time of diagnosis of DM1 with a laboratory determination of anti-thyroid peroxidase antibodies and anti-thyroglobulin antibodies&#44; thyrotropin &#40;TSH&#41; and anti-transglutaminase IgA and IgA antibodies&#46; When IgA is low&#44; anti-transglutaminase IgG and anti-gliadin antibodies are recommended&#46; A TSH test every 1&#8211;2 years is recommended in the follow-up of DM1&#59; also&#44; continued screening for coeliac disease&#44; with antibody testing every five years or more often in cases of growth retardation&#44; increased frequency of hypoglycaemia or a first-degree relative with coeliac disease&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Autoimmune polyendocrine syndrome type 3</span><p id="par0170" class="elsevierStylePara elsevierViewall">It is defined as the presence of autoimmune thyroid disease and other autoimmune disease&#44; excluding Addison&#39;s disease and hypoparathyroidism&#46; It is not associated with immunodeficiencies&#46; Most of the time it is difficult to differentiate from APS type 2&#46; Its prevalence is higher than the other syndromes&#44; up to 3&#8722;4&#37; of the population&#46; It can occur during the paediatric age or in youth&#46; The most commonly associated autoimmune diseases are DM1 &#40;APS type 3-A&#41;&#44; celiac disease&#44; pernicious anaemia &#40;APS type 3-B&#41;&#44; vitiligo or alopecia &#40;APS type 3-C&#41; or rheumatic diseases such as collagen disorders and vasculitis &#40;APS 3-D type&#41;&#46; Autosomal dominant inheritance with incomplete penetrance&#44; environmental factors such as infections and association with different HLA haplotypes have been suggested in its pathophysiology&#46; Examples of these include HLA-DQB1&#42; 0301 with autoimmune thyroiditis&#44; HLA-DRB1&#42; 13 with vitiligo and HLA-DQB1&#42; 03 and DRB1&#42; 1104 with alopecia areata&#46; At least four genes have been have been shown to confer susceptibility&#46; These are&#58; human leukocyte antigen class II on chromosome 6&#44; CTLA4 on chromosome 2 and <span class="elsevierStyleItalic">protein tyrosine phosphatase non-receptor 22</span> &#40;PTNP22&#41; on chromosome 1 and FOXP3 on X chromosome&#44; all of which alter T-cell function&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Polyendocrinopathy and X-linked enteropathy</span><p id="par0175" class="elsevierStylePara elsevierViewall">It is a monogenic primary immunodeficiency that overlaps with APS type 1&#44; but usually develops at a much younger age&#46; It usually presents with neonatal DM1 and autoimmune enteropathy &#40;diarrhoea with malabsorption&#41;&#46; It usually has a very poor prognosis in the first years of life unless patients receive immunosuppressive treatment or bone marrow transplantation very early&#46; The initial manifestation is usually diarrhoea&#44; present in 100&#37; of individuals throughout follow-up&#44; followed by eczematous skin lesions in 78&#37;&#46; 35&#37; have an allergy to cow&#39;s milk protein&#44; 29&#37; haematological disorders&#44; 25&#37; nephropathy and 14&#37; hepatitis&#46; DM1 is the onset manifestation in 26&#37; of subjects&#46; Some 150 mutations have been described in the FOXP3 gene on the X chromosome that encodes for a key transcription factor in the regulation of T<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> cells&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Screening and monitoring of autoimmune polyendocrinopathy</span><p id="par0180" class="elsevierStylePara elsevierViewall">The detection of a mutation of the AIRE gene requires lifelong follow-up of the patient&#44; monitoring the relevant biochemical and hormonal laboratory levels&#46; In these individuals&#44; the detection of anti-21-hydroxylase antibodies requires annual monitoring of cortisol levels and even dynamic cortisol stimulation tests&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">When APS is suspected&#44; it is important to carry out a complete family history&#44; as well as a detailed history-taking aimed at the detection of autoimmune diseases&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">TSH monitoring is recommended annually in APS type 2 patients and their first-degree relatives when anti-thyroid antibodies are positive and every five years if they are negative and TSH is normal&#46; There is no consensus on the need to request anti-21-hydroxylase antibodies in patients with DM1 and autoimmune thyroid disease&#46; Some authors propose their determination as they correlate directly with the likelihood of developing adrenal insufficiency&#46; There is a greater consensus on the recommendation to determine anti-transglutaminase antibodies for celiac disease screening in individuals with DM1&#46; Autoantibody carriers without clinical manifestations should be monitored by laboratory tests&#46; HLA typing is usually done only in the context of research projects&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Monoclonal antibody treatment as a trigger for APS</span><p id="par0195" class="elsevierStylePara elsevierViewall">Treatment with immunotherapy &#40;immune checkpoint inhibitors&#41; in cancer patients has been associated with the development of autoimmune diseases&#46; In a meta-analysis&#44; monoclonal antibody treatment was associated with an increased risk of&#58; hypophysitis&#58; RR 22&#46;03 &#40;95&#37; CI&#58; 8&#46;52&#8211;56&#46;94&#59; p&#160;&#60;&#160;0&#46;00001&#41;&#59; hypothyroidism&#58; RR 8&#46;26 &#40;95&#37; CI&#58; 4&#46;67&#8211;14&#46;62&#59; p&#160;&#60;&#160;0&#46;00001&#41;&#59; hyperthyroidism&#58; RR 5&#46;48 &#40;95&#37; CI&#58; 1&#46;33&#8211;22&#46;53&#59; 9&#160;&#61;&#160;0&#46;02&#41;&#59; or adrenal insufficiency&#58; RR 3&#46;87 &#40;95&#37; CI&#58; 1&#46;12&#8211;13&#46;41&#59; p&#160;&#61;&#160;0&#46;03&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> In these patients it is recommended&#44; prior to the initiation of immunotherapy treatment&#44; the determination of fasting plasma glycaemia&#44; plasma sodium&#44; TSH&#44; free thyroxine&#44; cortisol at &#177;8&#58;00 a&#46;m&#46; ACTH &#40;provided the patient is not treated with glucocorticoids&#41;&#44; LH&#44; FSH and testosterone in males&#44; FSH&#44; LH and oestradiol in women with irregular menstrual cycles&#44; FSH in menopausal women&#46; Fasting plasma glucose&#44; plasma sodium&#44; TSH&#44; cortisol at 8 a&#46;m&#46; and testosterone in males are recommended at each course of treatment for six months and every second course of treatment after six months&#46;</p></span></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Future</span><p id="par0200" class="elsevierStylePara elsevierViewall">The combination of early diagnosis&#44; together with personalised genomics&#44; may allow early immunomodulatory therapy to halt the autoimmune process before the damage becomes irreversible&#46; Research is currently underway to generate thymic epithelial tissue from stem cells that could be useful in correcting AIRE gene expression&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conclusions</span><p id="par0205" class="elsevierStylePara elsevierViewall">APS Type 1 occurs in childhood&#46; Anti-IFN-&#969; antibodies are usually present&#44; although their absence does not exclude the diagnosis&#46; Therefore&#44; AIRE gene sequencing is required if there is clinical suspicion of one or more manifestations of the syndrome&#46; Once the diagnosis is made&#44; all clinical manifestations should be examined as some are of later presentation&#44; and patients show increased morbidity and mortality&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">Type 2 and type 3 APS can be difficult to differentiate because they have shared manifestations except for Addison&#39;s disease&#44; although APS type 3 has an earlier age of presentation&#46;</p><p id="par0215" class="elsevierStylePara elsevierViewall">In patients with an autoimmune glandular disease&#44; it is important to carry out a detailed family and case history aimed at detecting other autoimmune manifestations so that the diagnosis of a possible APS does not go unnoticed and early treatment of each of its component diseases is established&#46;</p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Funding</span><p id="par0220" class="elsevierStylePara elsevierViewall">This article has not received any type of funding&#46;</p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Conflict of interests</span><p id="par0225" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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            1 => array:3 [
              "identificador" => "sec0020"
              "titulo" => "Pathophysiology and genetics"
              "secciones" => array:1 [
                0 => array:2 [
                  "identificador" => "sec0025"
                  "titulo" => "Immunophenotype"
                ]
              ]
            ]
            2 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Diagnosis"
            ]
            3 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Prognosis"
            ]
          ]
        ]
        6 => array:3 [
          "identificador" => "sec0040"
          "titulo" => "Autoimmune polyendocrine syndrome type 2"
          "secciones" => array:7 [
            0 => array:2 [
              "identificador" => "sec0045"
              "titulo" => "Signs and symptoms"
            ]
            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Genetics and pathophysiology"
            ]
            2 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Diagnosis and screening"
            ]
            3 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Autoimmune polyendocrine syndrome type 3"
            ]
            4 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Polyendocrinopathy and X-linked enteropathy"
            ]
            5 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Screening and monitoring of autoimmune polyendocrinopathy"
            ]
            6 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Monoclonal antibody treatment as a trigger for APS"
            ]
          ]
        ]
        7 => array:2 [
          "identificador" => "sec0080"
          "titulo" => "Future"
        ]
        8 => array:2 [
          "identificador" => "sec0085"
          "titulo" => "Conclusions"
        ]
        9 => array:2 [
          "identificador" => "sec0090"
          "titulo" => "Funding"
        ]
        10 => array:2 [
          "identificador" => "sec0095"
          "titulo" => "Conflict of interests"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2020-12-14"
    "fechaAceptado" => "2021-02-05"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1418329"
          "palabras" => array:3 [
            0 => "Polyendocrine syndrome"
            1 => "Autoimmune diseases"
            2 => "Autoinmune polyendocrinopathy"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec1418330"
          "palabras" => array:3 [
            0 => "S&#237;ndrome poliendocrino"
            1 => "Enfermedades autoinmunes"
            2 => "Poliendocrinopat&#237;a autoinmune"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pluriglandular autoimmune syndrome &#40;APS&#41; can affect multiple endocrine glands and is associated with other autoimmune diseases&#46; APS type 1 presents with hypoparathyroidism&#44; mucocutaneous candidiasis and Addison&#39;s disease&#46; It is caused by AutoImmune Regulator &#40;AIRE&#41; gene mutation&#46; The diagnosis includes clinical manifestations in addition to AIRE gene sequencing&#46; SPA type 2 presents with Addison&#39;s disease&#44; type 1 diabetes&#44; or autoimmune thyroid disease&#46; Multiple genes have been implicated&#44; including those of the class II major histocompatibility complex&#46; SPA type 3 is characterized by autoimmune thyroid disease and other autoimmune disease&#44; excluding Addison&#39;s disease and hypoparathyroidism&#44; 4 genes have been implicated and confer susceptibility&#46; The diagnosis of APS type 2 and type 3 includes clinical manifestations&#44; nevertheless&#44; the determination of autoantibodies can be useful to predict the risk of disease manifestation and to confirm the autoimmune disease in some cases&#46;</p></span>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Los s&#237;ndromes pluriglandulares autoinmunes &#40;SPA&#41; afectan a m&#250;ltiples gl&#225;ndulas endocrinas y asocian otras enfermedades autoinmunes&#46; El SPA tipo 1 se presenta con hipoparatiroidismo&#44; candidiasis mucocut&#225;nea y enfermedad de Addison&#44; se debe a una mutaci&#243;n en el gen AIRE &#40;<span class="elsevierStyleItalic">AutoImmune Regulator</span>&#41;&#46; El diagn&#243;stico es cl&#237;nico adem&#225;s de la secuenciaci&#243;n del gen AIRE&#46; El SPA tipo 2 se presenta con enfermedad de Addison&#44; diabetes mellitus tipo1 o enfermedad tiroidea autoinmune&#44; se han implicado m&#250;ltiples genes&#44; entre ellos los del complejo mayor de histocompatibilidad tipo 2&#46; El SPA tipo 3 se caracteriza por la presencia de enfermedad tiroidea autoinmune y otra enfermedad autoinmune&#44; excluyendo la enfermedad de Addison y el hipoparatiroidismo&#44; se han implicado 4 genes que pueden conferir susceptibilidad&#46; El diagn&#243;stico del SPA tipo 2 y tipo 3 es cl&#237;nico&#44; aunque la determinaci&#243;n de autoanticuerpos puede ser &#250;til para la evaluaci&#243;n del riesgo de presentar la enfermedad y para confirmar la enfermedad autoinmune en algunos casos&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Fern&#225;ndez Mir&#243; M&#44; Colom Com&#237; C&#44; Godoy Lorenzo R&#46; S&#237;ndromes pluriglandulares autoinmunes&#46; Med Clin &#40;Barc&#41;&#46; 2021&#59;157&#58;241&#8211;246&#46;</p>"
      ]
    ]
    "multimedia" => array:1 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at0005"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">AI&#58; autoimmune&#59; DM1&#58; type 1 diabetes mellitus&#59; AR&#58; autosomal recessive&#59; AD&#58; autosomal dominant&#59; MHC&#58; major histocompatibility complex&#59; Ab&#58; antibodies&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">APS type 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">APS type 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">APS type 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">IPEX&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Clinical manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Addison&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Addison&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Thyroid disease and other autoimmune disease other than Addison or hypoparathyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AI enteropathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hypoparathyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AI thyroid disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Neonatal DM1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic mucocutaneous candidiasis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Eczema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Other manifestations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Enamel hypoplasia&#44; AI oophoritis&#44; enteropathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AI gastritis&#44; vitiligo&#44; celiac disease&#44; alopecia&#44; AI oophoritis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM1&#44; AI gastritis&#44; vitiligo&#44; celiac disease&#44; alopecia&#44; rheumatic disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AI thyroid disease AI&#44; haemolytic anaemia&#44; thrombocytopenia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Age of onset&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Childhood&#47;adolescence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adolescence&#47;adult&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Childhood&#47;youth&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Childhood&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Frequency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#58;100&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#58;100&#8722;1&#58;20&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&#8722;4&#37; general population&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#58;1&#44;000&#44;000&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Treatment&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hormone replacement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hormone replacement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hormone replacement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hormone replacement&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Calcium and vitamin D&#44; antifungals&#44; immunosuppression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immunosuppression&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Bone marrow transplant&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adrenal crisis and severe hypocalcaemia&#44; oral and oesophageal cancer&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Adrenal crisis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Infections&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">DM complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Genetic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">AR&#44; less common&#46; AD&#46; AIRE gene&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Polygenic&#44; MHC and others&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Polygenic&#44; HLA class II&#44; CTLA-4&#44; PTN22&#44; FOXP3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">FOXP3&#44; linked to the X chromosome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Immunophenotype&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anti-interferon omega Ab &#40;&#62;95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anti-21-hydroxylase Ab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anti-GAD Ab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anti-GAD Ab&#44; Lymphocytosis&#44; eosinophilia&#44; Hyper IgE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anti-GAD Ab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anti-thyroid peroxidase and antithyroglobulin Ab&#44; Anti-TSH receptor Ab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anti-thyroid peroxidase and antithyroglobulin Ab&#44; Anti-TSH receptor Ab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anti-transglutaminase&#44; anti-gastric cell Ab&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2696995.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Characteristics of the different autoimmune polyendocrinopathies&#46;</p>"
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