Rheumatologisch-osteologische Aspekte bei Schilddrüsenerkrankungen

Zusammenfassung

Erkrankungen der Schilddrüse führen nicht selten zu Symptomen vonseiten des Bewegungsapparats und sind andererseits häufig mit verschiedenen entzündlich-rheumatischen Erkrankungen assoziiert. Eine erhöhte Prävalenz von autoimmunen Schilddrüsenerkrankungen wird vor allem bei Patienten mit primärem Sjögren-Syndrom, rheumatoider Arthritis, juveniler chronischer Arthritis, systemischer Sklerose, systemischem Lupus erythematodes und Fibromyalgie beobachtet. Dabei besteht offenbar kein Zusammenhang zwischen der Schilddrüsenfunktion und der Koinzidenz mit entzündlich-rheumatischen Erkrankungen. Andererseits werden verschiedene unspezifische rheumatische Symptome bei Schilddrüsenfunktionsstörungen unabhängig vom Vorliegen einer entzündlich-rheumatischen Erkrankung beobachtet. Dazu zählen eine milde, nicht erosive Arthritis, Polyarthralgien und Myalgien bei autoimmuner Thyreoiditis. Bei Hyperthyreose tritt gehäuft eine Periarthritis humeroscapularis auf. Wesentlich seltener kommt es, insbesondere bei lange bestehender endokriner Orbitopathie, zu einer Akropachie. Insbesondere bei Asiaten wird die thyreotoxische periodische Paralyse, welche mit Hypokaliämie einhergeht, beobachtet. Typische Manifestationen der Hypothyreose sind das Karpaltunnelsyndrom und die Myopathie, welche häufig mit CK-Erhöhung einhergeht und differenzialdiagnostisch gegenüber der Polymyositis abzugrenzen ist. Eine außerordentlich wichtige Manifestation von Schilddrüsenfunktionsstörungen am Bewegungsapparat ist die Hyperthyreose-assoziierte Osteoporose. Pathogenetisch führt sowohl ein Überschuss an Schilddrüsenhormonen (T3) als auch ein Mangel an TSH zu einem verstärkten Knochenumbau mit negativer Bilanz. Bei manifester Hyperthyreose kann der Knochenmasseverlust 12 – 15 % betragen. Risikofaktoren für die Entwicklung einer Osteoporose bei latenter Hyperthyreose sind höheres Alter, Menopause, eine TSH-Suppression über lange Zeiträume sowie die Kombination mit weiteren Osteoporose-Risikofaktoren. Im Rahmen der Differenzialdiagnose der Osteoporose sollte daher eine latente oder manifeste Hyperthyreose immer ausgeschlossen werden. Die frühzeitige Therapie der Hyperthyreose stellt eine effektive Prophylaxe des Knochenmasseverlusts dar. Unter T 4-Therapie sollte eine TSH-Suppression aus Sicht des Knochenstoffwechsels vermieden werden. Falls eine TSH-Suppression erforderlich ist, wie bei Zustand nach Schilddrüsenkarzinom, ist eine prophylaktische Gabe von Bisphosphonaten zu bedenken.

Abstract

Thyroid diseases are often associated with symptoms of the locomotive system on one hand and with various rheumatic diseases on the other. An increased prevalence of autoimmune thyroid diseases is observed in primary Sjögrens syndrome, rheumatoid arthritis, juvenile chronic arthritis, systemic sclerosis, systemic lupus erythematosus and fibromyalgia. A strong pathogenetic relationship between thyroid function and the co-existing rheumatic disease is lacking. On the other hand, various unspecific rheumatic symptoms are observed frequently in hyperthyroidism and hypothyroidism. These include mild non-erosive arthritis, polyarthralgia and myalgia in autoimmune thyroiditis and adhesive capsulitis of the shoulder in hyperthyroidism. Especially in patients with long-lasting Graves disease with orbitopathy, thyroid acropachy can occur. About 2 % of Asian people with thyrotoxicosis may suffer from thyrotoxic periodic paralysis. Typical manifestations of hypothyroidism are carpal tunnel syndrome and hypothyroid myopathy which is associated with elevated creatine kinase and should be considered in differential diagnosis of polymyositis. A very important manifestation of thyroid disease is osteoporosis in hyperthyroidism. Both an excess of thyroid hormone and a deficiency of thyroid-stimulating hormone are involved in high bone turnover and bone loss. In hyperthyroid subjects, a reduction of 12 – 15 % in bone mineral density has been shown. Risk factors for bone loss in subclinical hyperthyroidism are older age, menopausal state, a long-lasting TSH suppression and the combination with other risk factors for osteoporosis. Overt and subclinical hyperthyroidism should be considered in the differential diagnosis of osteoporosis in general. An early treatment of hyperthyroidism is effective in the prevention of bone loss. With regard to bone metabolism, a TSH-suppression during T 4-therapy should be avoided if possible. If TSH suppression is indicated, the prophylactic use of bisphophonates should be considered.

Schilddrüsenerkrankungen - rheumatische Manifestationen - Osteoporose

thyroid diseases - rheumatoid manifestations - osteoporosis

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