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Multiple Autoimmune Syndrome in Graves’ Disease and Hashimoto’s Patients

Multiple autoimmune syndrome involves someone having three or more autoimmune conditions.  I’ve mentioned in past blog posts how someone who has one autoimmune condition has a good chance of developing additional autoimmune conditions.  In fact, even though I primarily see people with Graves’ disease and Hashimoto’s thyroiditis, it’s common for people with these conditions to have other autoantibodies.

But why do some people develop multiple autoantibodies?  Is it because they are exposed to multiple triggers?  Or does a single environmental factor cause the development of multiple autoantibodies?  Either one of these scenarios is a possibility.  For example, certain infections such as Epstein-Barr [1] and Cytomegalovirus can lead to the development of different types of autoantibodies.  In other words, Epstein-Barr and Cytomegalovirus can trigger multiple autoimmune conditions in the same person.  However, it’s also possible for someone to have multiple triggers which are responsible for different autoantibodies.

The Triad of Autoimmunity

In the past I discussed the triad of autoimmunity [2].  According to this triad the following three components are necessary in order for someone to develop an autoimmune condition:

1. A genetic predisposition

2. An environmental trigger

3. A leaky gut [3]

So according to the triad of autoimmunity, in order for someone to develop multiple autoimmune conditions they need to have a genetic predisposition for each of these conditions.  As I mentioned earlier, some of these people will have multiple autoimmune triggers, while others will have one or two environmental triggers which caused the development of all of the person’s autoantibodies.  Either way the goal should be to detect and remove these triggers.

The third component of the triad of autoimmunity is a leaky gut, which is also known as an increase in intestinal permeability.  So even if someone has a genetic predisposition for one or more autoimmune conditions AND they’re exposed to one or more environmental triggers, according to the triad of autoimmunity, the person won’t develop an autoimmune condition if they don’t have a leaky gut.  This is one reason why it’s important to try to avoid anything that can cause a leaky gut while trying to restore your health.  An example of this is gluten, as even if you remove the environmental trigger but continue to eat gluten (or other foods which can increase gut permeability), then you most likely won’t reverse the autoimmune component.

3 Categories of Multiple Autoimmune Syndrome                

Multiple autoimmune syndrome (MAS) is classified into three groups:

Type 1: type 1 MAS includes myasthenia gravis, thymoma, polymyositis and giant cell myocarditis

Type 2: type 2 MAS includes Sjögren’s syndrome, rheumatoid arthritis, primary biliary cirrhosis, scleroderma, and autoimmune thyroid disease

Type 3: type 3 MAS groups together autoimmune thyroid disease, myasthenia gravis and/or thymoma, Sjögren’s syndrome, pernicious anemia, idiopathic thrombopenic purpura, Addison’s disease, type 1 diabetes mellitus, vitiligo, autoimmune hemolytic anemia, systemic lupus erythematosus, and dermatitis herpetiformis.

You’ll notice that autoimmune thyroid conditions are in the second and third categories of multiple autoimmune syndrome.  So if someone has Graves’disease or Hashimoto’s thyroiditis, depending on their genetic predisposition they might be more likely to develop one or more of the other autoimmune conditions listed under the second category (Sjögren’s syndrome, rheumatoid arthritis, primary biliary cirrhosis, scleroderma), or they might develop one or more of the autoimmune conditions listed in the third category.

Which Autoimmune Conditions Are Commonly Associated with Graves’ Disease and Hashimoto’s?

Sjögren’s syndrome.  This is a systemic autoimmune condition, and one study showed that Sjögren’s syndrome was 10 times more frequent in patients with autoimmune thyroid disease, and autoimmune thyroiditis was 9 times more frequent in Sjögren’s syndrome (1) [4].

Celiac disease.  I’ve written a separate article entitled “Celiac Disease and Thyroid Health [5]“, and how this condition is more common in those people with Graves’ disease and Hashimoto’s.  There is some evidence that the risk of thyroid disease is threefold higher in those with Celiac disease (2) [6].  I should mention that while Celiac disease is common in those with autoimmune thyroid conditions, Celiac disease is not included in the classification of multiple autoimmune syndrome.

Vitiligo.  In many people with multiple autoimmune syndrome vitiligo is the first autoimmune disease to be diagnosed.  This shouldn’t be too surprising since vitiligo represents the most common cause of acquired skin, hair, and oral depigmentation, affecting 0.5–1% of the population worldwide (3) [7].  A few different studies show that vitiligo is more common in Graves’ disease and Hashimoto’s thyroiditis (4) [8] (5) [9] (6) [10].

Systemic lupus erythematosus.  Many people with systemic lupus erythematosus (SLE) have thyroid autoantibodies.  One study I came across showed that the prevalence of Hashimoto’s thyroiditis in those with SLE was 12.6% (7) [11].  Another study showed that patients with SLE had a higher prevalence of hypothyroidism and than hyperthyrodism (8) [12]. I did come across a case study where a woman developed SLE one year after being diagnosed with Graves’ disease (9) [13].

Rheumatoid arthritis.  The prevalence of thyroid autoimmunity in those with rheumatoid arthritis has ranged from 0.5% in Morocco (10) [14] to 27% in Slovakia (11) [15].  Not only does the incidence vary between regions, but ethnicities as well.  One study involving 800 patients with rheumatoid arthritis showed that 37.8% had thyroid peroxidase antibodies and 20.8% had elevated thyroblogulin antibodies (12) [16].

Type 1 diabetes mellitus.  There are numerous journal articles that show a relationship between type 1 diabetes [17]and thyroid autoimmunity.  A few of these studies show an association between type 1 diabetes and Hashimoto’s (13) [18] (14) [19], while a couple of other studies show a link between type 1 diabetes and Graves’ disease (15) [20] (16) [21].

Conventional vs. Natural Treatment Options

Is there a different treatment approach when someone has multiple autoimmune conditions?  Not necessarily, as regardless of whether someone has a single autoimmune condition or multiple autoimmune conditions, the goal is to find and remove the triggers.  I commonly have patients who have the autoantibodies for both Graves’ disease and Hashimoto’s thyroiditis.  While the management of these two conditions differ, finding the triggers involve a similar process.  That being said, someone with autoantibodies for both Graves’ disease and Hashimoto’s very well might have multiple triggers.  This is one reason why you might see one type of autoantibody decrease while other antibodies don’t decrease.

For example, some people have thyroid peroxidase antibodies, thyroglobulin antibodies, and thyroid stimulating immunoglobulins.  While ideally you want to see all of these gradually decrease over time, this isn’t always the case.  While fluctuations in thyroid antibodies commonly occur, when you see one or two of these antibodies decrease consistently and yet another antibody not decrease, then this very well might be because one or two environmental triggers have been detected and removed, but another one remains.

In summary, if you have Graves’ disease or Hashimoto’s, then there is an increased risk of having additional autoimmune conditions.  If you have three or more autoimmune conditions then this is classified as multiple autoimmune syndrome.  In this blog post I discussed the 3 categories of multiple autoimmune syndrome, along with some autoimmune conditions that are commonly associated with Graves’ disease and Hashimoto’s.  I also discussed how some people have a single trigger responsible for all of their autoimmune conditions, although it’s more common to have multiple triggers, which can make it more challenging to restore one’s health.

Do you have more than one autoimmune condition? If so please feel free to share your experience in the comments below!