Case report: Multiple autoimmune syndrome

This is a case of multiple autoimmune syndrome with the co-occurrence of vitiligo, pernicious anemia, celiac disease and autoimmune hepatitis is extremely rare. We are presenting a case is a 40-year-old woman with autoimmune hepatitis who is suffering from poor appetite, weight loss and skin lesions. Laboratory investigation shows hypochromic microcytic anemia, B12, and iron deficiency. The testing for parietal cell antibody was positive so pernicious anemia was diagnosed with positive Tissue transglutaminase antibody IgA so the diagnosis of celiac disease was confirmed.


INTRODUCTION
Multiple autoimmune syndrome (MAS) is a status in which patients have at least three distinct autoimmune diseases.About 25% of patients with autoimmune diseases have a tendency to develop another autoimmune condition [1].
MAS is classified into three groups, that each depend to specific diseases that tend to occur with one another: Type 1 "MAS": includes myasthenia gravis, thymoma, polymyositis, and giant cell myocarditis.
The pathologic mechanism responsible for the MAS is still not understood because of the fact that many autoimmune diseases share susceptibility genes which suggests a genetic cause.The phenomenon of familial autoimmunity and the juxtaposition of chromosomic regions associated with MAS (for example, the 6p21.3region) support that hypothesis.Even so, it is necessary to consider that genetic susceptibility to MAS can occur not only from the presence of risk alleles, but may be from the absence of protective ones.Many studies and genetic mapping have suggested a relation between many of HLA alleles on classes I and II and "MAS" [2].
So according to history, physical examination and investigation patient had vitiligo, pernicious anemia, celiac disease and autoimmune hepatitis.
She started to take oral iron and vitamin B12 supplementation, so hemoglobin return to normal from FIGURE 1. Depigmented patch with leukotrichia foot of patient 7.9 g/dl before treatment to 13.5 g/dl (normal val-ue12-15 g/dl) after treatment.

DISCUSSION
Autoimmune disease is the result of the immune system incidentally attacking of the body in place of saving it.When more than one autoimmune condition occurs gathered, this is defined as "polyautoimmunity".When three or more autoimmune conditions occur to gather, this is known as multiple autoimmune syndrome (MAS).
Researchers suggested that environmental factors and genetic background are involved.The combination of multiple autoimmune disease comprising autoimmune hepatitis, pernicious anemia, celiac disease and vitiligo is rare.
The American Association for the Study of Liver Diseases (AASLD) advise that patients with a new diagnosis of autoimmune hepatitis undergo serologic testing to rule out thyroid disease and celiac disease [3].
Riaz A et al. case report study show resented a case of a 70-year-old woman with AIH who s suffering from anemia which was investigated and pernicious anemia was diagnosed [4].A retrospective study by Teufel et al. showed some of the common associations include autoimmune thyroiditis, vitiligo, rheumatoid arthritis, celiac disease, systemic lupus erythematosus, type 1 diabetes, multiple sclerosis, polymyalgia rheumatica, and urticarial [5].
Villalta et al. study showed a high incidence of celiac disease in patients with autoimmune hepatitis [6].
Autoimmune hepatitis is occurred with a wide variety of other disorders including of other systems that may be found at disease onset or may develop during the course of the active liver disease.Most of these disorders are immunologic in origin.Patients may present with symptoms of the following hematologic disorders: Hypersplenism (usually attributable to cirrhosis and portal hypertension), Autoimmune hemolytic anemia, Coombs-positive hemolytic anemia, Pernicious anemia and ITP and Gastrointestinal disorders associated with autoimmune hepatitis includes inflammatory bowel disease, which is seen in 6% of cases.The presence of ulcerative colitis in patients with autoimmune hepatitis should prompt performance of magnetic resonance cholangiopancreatography (MRCP) to exclude a diagnosis of primary sclerosing cholangitis (PSC).[7].

CONCLUSION
Our patient exemplifies a rare association of multiple autoimmune syndromes comprising autoimmune hepatitis, pernicious anemia, celiac disease and vitiligo.

TABLE 1 .
Show the laboratory values of the patient