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DIAGNOSTIC AND TREATMENT
HEMATOLOGICAL DISORDERS IN PATIENTS WITH AUTOIMMUNE THYROIDITIS
Saidova F.Kh.1, Akhmedova L.M.2, Aslanova J.B.1, Shahsuvarov O.M.1, Muradov N.F.1
1 Scientific Center of Surgery named after acad. M.A.Topchubashov, Baku, Azerbaijan
2 Azerbaijan State Advanced Training Institute for Doctors named after A. Aliyev, Baku, Azerbaijan
Abstract
Objective. Identify the frequency of occurrence of various morphological types and different degrees of severity of anemia in patients with autoimmune thyroiditis.
Material and methods.Were analyzed 97 case histories of patients operated for autoimmune thyroiditis (AIT)in 2012. When assessing hematological parameters, two groups were identified: group 1 - patients with AIT with mild anemia (n = 72), age 45.7 ± 1.6, men - 5 (6.9%), women - 67 (93, 1%); group 2 - patients with AIT with moderate anemia (n = 25), age 40.0 ± 2.3, men - 1 (4%), women - 24 (96%). In the clinical analysis of blood, hemoglobin, hematocrit, the number of erythrocytes and erythrocyte indexes of MCV, MCH, MCHC were determined.
Results. By morphological type in patients with AIT with mild anemia, the hypochromic type was observed in 56 (77.8%) patients, normochromic - in 16 (22.2%) patients. In moderate anemia, this tendency was more pronouned: hypochromic type of anemia was detected in 23 (92%) patients, normochromic type - in 1(4%) and hyperchromic in 1(4%). Thus, in patients with AIT, mild anemia was more often determined (in 72.4%), then moderate anemia (in 25.7%). With moderate severity of anemia, microcytic (84%) and hypochromic (92%) types of anemia were more often observed. With mild anemia, the same types of anemias were observed, but with a lower frequency (76.4% and 77.8%, respectively).
Conclusion. The hemogram in patients with AIT was characterized by a more frequent development of mild anemia (72.4%). With mild anemia, hematological disorders were characterized by microcytic (76.4%) and hypochromic (77.8%) types of anemia. Similar, but more pronounced disorders were observed in moderate anemia: microcytic 84% and hypochromic 92%, which is characteristic for iron deficiency anemia.
https://doi.org/10.35805/BSK2022II031
Saidova F.Kh.
orcid.org/0000-0002-9511-7927 Akhmedova L.M. orcid.org/0000-0002-6941-6042 Aslanova J.B.
orcid.org/0000-0002-3981-4883
Shahsuvarov O.M.
orcid.org/0000-0003-3734-5320 Muradov N.F.
orcid.org/0000-0002-4839-5764
Corresponding author. Saidova F.Kh. - Doctor of Medical Sciences, professor, chief of department of endocrine surgery of Scientific Center of Surgery named M.A.Topchubashov, Baku, Azerbaijan E-mail: [email protected]
Conflict of interest
The authors declare that they have no conflicts of interest
Keywords: autoimmune thyroiditis, anemia, severity of anemia, morphological types of anemia
Аутоиммунды тиреоидитпен ауыратын наукастардагы гематологиялык езгерютер
Саидова Ф.Х.1, Ахмедова Л.М.2, Асланова Ж.Б.1, Шахсуваров О.М.1, Мурадов Н.Ф.1
1 Акад. М.А. Топчубашов атындагы гылыми хирургия орталыгы., Баку Qзiрбайжан
2 А. Алиев атындагы Qзiрбайжан мемлекетш дэр^ерлердщ б^мш жет^ру институты, Баку Qзiрбайжан
Ацдатпа
Мацсаты. Аутоиммунды тиреоидитпен ауыратын нау;астарда анемиянын эртYрлi морфоло-гиялы; тYрлерiнiн жэне ауырлы; дэрежес'т'ц жиiлiгiн аны;тау.
Материал жэне эдстер. 2012 жылы аутоиммунды тиреоидит (АИТ) бойынша ота жасалган 97 нау;астын сыр;ат тарихынын деректерi талданды. Гематологиялы; кeрсеткiштердi багалау кезнде ею топ белмдг. 1-топ - же^л дэрежел'1 анемия (п=72) жасы 45,7±1 АИТ бар нау;астар жас шамасы 40,7±1,6 ерлер-5(6,9%), эйелдер-67(93,1%)жэне2-топ-анемиянынорташаауырлыщагы(п=25) АИТ бар нау;астар, жасы 40,0±2,3, ерлер - 1 (4%), эйелдер - 24 (96%). Клиникалы; ;ан анализнде гемоглобин, гематокрит, эритроциттер саны жэне ММСН, МСНС эритроциттердщ индекстерi аны;талды.
Нэтижелер. Морфологиялы; тYрi бойынша же^л дэрежел'1 анемиямен ауыратын АИТ бар нау;астарда гипохромды тYрi 56 (77,8%) нау;аста, нормохромды - 16 (22,2%) нау;аста бай;алды. Орташа ауырлыщагы анемия кезнде бул тенденция са;талды жэне ай;ыныра; болды: анемиянын гипохромды; тYрi 23 (92%) нау;аста, нормохромды тYрi 1 (4%) жэне гиперхромды тYрi 1 (4%) нау;аста аны;талды. Сонымен, АИТ бар нау;астарда же^л дэрежел'1 анемия 72,4% жагдайда, ал орташа ауырлыщагы анемия 25,7% жагдайда жи аны;талды. Анемиянын орташа ауырлы; дэрежес'шде анемиянын микроцитарлы (84%) жэне гипохромды; (92%) тYрлерi жи бай;алды. Жеф анемия кез'шде анемиянын б'рдей тYрлерi бай;алды, б'ра;жилг темен (тиснше 76,4% жэне 77,8%).
Цорытынды. АИТ бар нау;астардагы гемограмма женл дэрежедегi анемиянын жиiрек дамуымен сипатталды (72,4%). Анемиянын же^л дэрежеснде гематологиялы; бузылулар анемиянын микроцитарлы (76,4%) жэне гипохромды (77,8%) тYрлерiмен сипатталды. ¥;сас, б'ра; ай;ыныра; бузылулар тем 'р тапшылыгы анемиясына тэн орташа ауырлыщагы (тиснше микроцитарлы (84%) жэне гипохромды (92%)) анемияда бай;алды.
Хат алысатын автор. Саидова Ф.Х. - Медицина гылымдарынын докторы, профессор, М.А. Топчубашов атындагы хирургия гылыми орталыгынын эндокриндiк хирургия бeлiмiнiн мецгерушЦ Баку Эзiрбайжан E-mail: [email protected]
Мудделер цацтыгысы
Аеторлар MYдделер %а%тыгысынын жо^тыгын молiмдейдi
Туйш сездер:
аутоиммунды тиреоидит, анемия, анемиянын ауырлы% дорежем, анемиянын морфологиялы% тYрлерi
Гематологические изменения у больных аутоиммунным тиреоидитом
Автор для корреспонденции. Саидова Ф.Х. - Доктор медицинских наук, профессор, заведующий отделением эндокринной хирургии Научного центра хирургии имени М.АТопчубашова, г.Баку, Азербайджан E-mail: [email protected]
Конфликт интересов
Авторы заявляют об отсутствии конфликта интересов
Ключевые слова:
аутоиммунный тиреоидит, анемия, степень тяжести анемии, морфологические типы анемии
Саидова Ф.Х.1, Ахмедова Л.М.2, Асланова Ж.Б.1, Шахсуваров О.М.1, Мурадов Н.Ф.1
1 Научный Центр хирургии им. акад. М.А.Топчубашова, г. Баку, Азербайджан
2 Азербайджанский Государственный институт усовершенствования врачей им. А. Алиева, г. Баку, Азербайджан
Аннотация
Цель. Выявить частоту встречаемости различных морфологических типов и различных степеней тяжести анемий у больных аутоиммунным тиреоидитом.
Материал и методы. Проанализированы данные историй болезни 97пациентов, прооперированных по поводу аутоиммунного тиреоидита (АИТ) за 2012 г. При оценке гематологических показателей были выделены две группы: 1-ая группа - больные АИТ с анемией легкой степени (п=72) возраст 45,7±1,6, мужчин - 5(6,9%), женщин - 67(93,1%) и 2-ая группа - больные АИТ с анемией средней степени тяжести (п=25), возраст 40,0±2,3, мужчин - 1(4%), женщин -24(96%). В клиническом анализе крови определяли гемоглобин, гематокрит, количество эритроцитов и эритроцитарные индексы М МСН, МСНС.
Результаты. По морфологическому типу у больных АИТ с легкой степенью анемии гипохромный тип отмечался у 56 (77,8%) больных, нормохромный - у 16 (22,2%) больных. При анемии средней степени тяжести данная тенденция сохранялась и была более выраженной: гипохромный тип анемии определялся у 23(92%) больных,нормохромный тип - у 1(4%) и гиперхромный у 1 (4%).Итак, у больных АИТ чаще определялась анемия легкой степени в 72,4% случаев, а анемия средней степени тяжести в 25,7% случаев. При средней степени тяжести анемии чаще отмечались микроцитарный (84%) и гипохромный (92%) типы анемий. При анемии легкой степени наблюдались те же типы анемий, но с меньшей частотой (соответственно 76,4% и 77,8%).
Выводы. Гемограмма у больных АИТ характеризовалась более частым развитием анемии легкой степени тяжести (72,4%).При легкой степени анемии гематологические нарушения характеризовались микроцитарным (76,4%) и гипохромным (77,8%) типами анемий. Аналогичные, но более выраженные нарушения наблюдались и при анемии средней степени тяжести (соответственно микроцитарным (84%) и гипохромным (92%)), что характерно для железодефицитной анемии.
Existence of combined anemia and thyroid disease is an important problem which is tried to be solved by hematologists and thyroidologists for a long time. First of all this is due to the fact that thyroid pathology is the most widespread among endocrine diseases. Effect of thyroid hormones on hematopoiesis is widely described in literature. However, the exact mechanism of impact of thyroid hormones to blood system is not completely studied yet [1, 2]. Conducted in vitro experiments showed that the thyroid hormones have a direct effect on the proliferation of erythrocyte precursors and stimulate bone marrow erythropoiesis [1, 3, 4]. That is why we have to deal with a combination of anemic syndrome and thyroid disease in patients [1, 5, 6, 7, 8, 9, 10, 11]. Anemia development is observed both in persons with both hypothyroidism and hyperthyroidism [1, 2, 3, 5, 6, 11]. Data of several research works confirm the possibility of developing anemia already with an initial decrease in thyroid function [9, 12,13]. Hypothyroidism (subclinical and overt) is a risk factor of anemia, i.e. the frequency of anemia cases is higher among people with hypothyroidism than in other part of population [6, 9,14, 15]. Fatima Q. et. al. found out that the overall prevalence of anemia among patients with hypothyroidism was 56%, and this indicator is higher than WHO data on prevalence of anemia in the world [11]. According to the information given in the literature, anemia in hypothyroidism has
different pathogenesis, can occur as the result of bone marrow depression, decreased production of erythropoietin, concomitant deficiency of iron, vitamin B12, or folic acid [1, 12, 14,16].Low absorption of iron in the gastrointestinal tract and excessive blood loss, especially with menorrhagia can be reasons for development of anemia. It has been shown that iron absorption in hypothyroidism is reduced, however, this rate can be increased in response to thyroid hormone therapy [17]. If some author think that while compensating of functional activity of thyroid the blood picture is usually completely restored and it additional interventions are rarely required [3], but others found out that, only stimulation of erythropoiesis takes place against the background of replacement therapy, while hematological changes after achieving euthyroidism are not eliminated [14]. According to Omar S. et al. (2010) a combination of iron and levothyroxine preparations is necessary [18].
The relationship between the erythrocyte index and the level of thyroid hormones is observed in normal function of thyroid [12, 13]. M'Rabet-Bensalah K. et al (2016) found that only in 5% of cases of anemia is combined with a violation of the level of thyroid hormones [19]. Connections between autoimmune process in the thyroid gland and hematological diseases are being studied only during the last decade. There are separate informations about combination
ВЕСТНИК ХИРУРГИИ КАЗАХСТАНА №71 • 2022
32
of AIT and autoimmune processes in the system of hematopoiesis [20].
The correct interpretation of erythrocyte indices let us to obtain additional information about the morphological types of anemia while diagnosing the anemia. Erythrocyte index - is an average volume of erythrocytes (MCV- it is a qualitative indicator. Its value below 80 fl is assessed as microcytosis, which is observed in iron deficiency anemia (IDA), thalassemia, chronic diseases, hyperthyroidism. MCV over 95 fl is assessed as macrocytosis and mostly is observed in patients with anemia with vitamin B12 or folic acid deficiency. The normal volume of erythrocytes (normocytosis) is observed with anemia as the result chronic diseases, autoimmune hemolytic diseases [1].
Erythrocyte index - average concentration of HGB in erythrocyte (MCH)-quantitative indicator that almost always correlates with MCV. Changing of these indicators is closely interconnected and often happens in parallel. MCH corresponds to the color index (CI), therefore hypo-, hyper- and normochromic anemias are associated with MCH. Indicators of average concentration of HGB in erythrocytes (MCHC) more objectively determines the concentration of hemoglobin. This is a hard option, which has small spread of values. Decreasing of MCHC is observed in patients with moderate and severe IDA, and increases in hereditary hematological diseases.
The purpose of the study: is to identify the frequency of occurrence of various morphological types and different degrees of severity of anemia in patients with autoimmune thyroiditis. Material and methods
We determined hemoglobin (HGB), hematocrit (HCT), erythrocyte count and erythrocyte indices MCV, MCH, MCHC in a clinical blood test. Anemia was diagnosed in patients with hemoglobin level less than 120 g/l (WHO, 2001). In correspondence with existing recommendations mild anemia when HGB level was
more than 90g/l (but less than 120 g/l), moderate anemia when HGB level is within 70-90 g/l, severe when Hb level is less than 70 g/l was diagnosed. MCV less than 80 fl was considered as microcytic anemia, MCV within 80-95 fl - as normalcytic anemia, MCV more than 95 fl - as macrocytar anemia. Normochromic anemia was considered with MCH 27-31 pg, hypochromic anemia with MCH less than 27 pg, and hyperchromic anemia with MCH more than 31 pg. 97 case histories of patients, operated for AIT in 2012 in the department of endocrine surgery of the Scientific Center of Surgery named after acad. M.A. Topchubashov, were analyzed for studying the prevalence of anemia combined with AIT. Two groups have been detested while assessment of hematological parameters: the 1st group - patients with AIT with mild anemia (n=72) age - 45.7±1.6 years, male -5(6.9%), female -67 (93.1%) and the 2nd group
- patients with AIT with moderate anemia (n=25), age
- 40.0±2.3 years, male - 1(4%), female -24 (96%).
Mathematical analysis of the achieved results was carried out using the software package Excel 2017. Structural characteristics of the variation series were used (mean, mean error), for assessment of differences between samples we used nonparametric Wilcoxon-Mann-Whitney test. Differences at values p<0.05 were considered as statistically significant [21]. Results
97 patients with AIT aged between 17-78 years (average age was 43.9±1.3 years) have been examined. Mild anemia was observed in 72 (74.2%) patients, moderate anemis - in 25 (25.7%) patients. Average age of patients with mild anemia was 45.7±1.6 years, 5 (6.9%) of them were men, 67 (93.1%) were women. The average age of persons with anemia of moderate severity was 40.0±2.3 years, 1(4%) of them was men, 24 (96%) were women. As seen from the above mentioned information, then frequency of anemia among women is higher - 91(93,8%), than in men - 6 (6,2%).
Results of studying of anemia of different severity in patients with AIT are given in Table 1.
Parameters Almost healthy (n=15) All patients (n=97) Mild anemia (n=72) Moderate anemia (n=25)
HGB, g/l Hemoglobin concentration 133,2±1,8 100,611,1* 105,0±0,9* 87,8±0,9*A
RBC* 1012/l RBC count 4,3± 0,07 4,02±0,04* 4,14±0,05 3,64±0,07*A
HCT, % Hematocrit 39,8±0,5 30,4±0,3* 31,5±0,3* 27,2±0,7*A
CI Color index 0,92±0,006 0,76±0,006* 0,77±0,006* 0,74±0,01*A
MCV, fl Average volume of erythrocytes 91,9 ±0,6 76±0,6* 76,5±0,7* 74,6±01,3*
MCH, pg Average content of HGB in erythrocyte 30,8±0,2 25,4±0,2* 25,6±0,2* 24,9±04*
MCHC, g/dl Average concentration of HGB in erythrocyte 33,4±0,04 33,4±0,07 33,3±0,07 33,5±0,2
Table 1.
The hemogram in patients with AIT (M±m)
*- statistical significance of differences in data of practically healthy peopleA - statistical significance of differences between groups of patients
Table 2.
Matrix of correlation coefficients of patients with AIT with anemia of mild and moderate severity
The study of hemogram parameters in the group "all patients" let us to identify the decrease in HGB level to 100.6±1.1 g/l (133.2±1.8 g/l in healthy people). In patients with mild anemia HGB levels were reduced by 24.5%, in anemia of moderate severity - by 1,5 times (p<0,05). The average number of erythrocytes in the "all patients" group was 4.02±0.04 (4.3±0.07 in healthy people). In patients with a mild degree of anemia, the decrease in red blood cells was not statistically reliable and insignificant - by 3.7%, with an average degree of 15.3% (p<0.05). hematocrit values were significantly low. The average value of hematocrit in the "all patients" group was 30.4±0.3% (39.8±0.5% in group of healthy persons, p<0,001). In cases of mild anemia hematocrit was reduced by 20.9%, in cases of moderate anemia - by 31.7%.
The study of erythrocyte indexes showed that in the "all patients" group, the average volume of erythrocytes was 76.0±0.6 fl., which is statistically significantly different from the indicators of control group (91.9±0.6 fl.). In AIT patients with mild anemia
MCV was-76.5±0.7 fl, what is 16.8% lower than in control group, and in patients with moderate anemia this indicator was-74.6±1.3, what is lower by 18.9% than norm.
The average content of HGB in erythrocytes of the "all patients" group was statistically significantly lower than in the control group (30.8±0.2 pg) and was 25.4±0.2 pg. With a mild severity of anemia, a decrease in MCH by 16.9% relative to the control data was noted, and with moderate severity - by 19.2%. The average concentration of hemoglobin in erythrocytes (MCHC) changed in the groups statistically unreliably related to the control and among them. Discussion
The tendency of decreasing in hemogram parameters depending on the severity of anemia was observed in patients with AIT. Comparative analysis showed the statistically reliable difference between anemia of mild and moderate severity according the following indicators: hemoglobin, red blood cell count, hematocrit, color index (Table 1).
Correlation analysis between hemogram parameters of patients with AIT with anemia of mild and moderate severity is given in Table 2.
Parameters «All are sick» (n=97) HGB Mild anemia (n=72) HGB Moderate anemia (n=25) HGB
Erythrocytes 0,64 0,54 0,39
Hematocrit 0,87 0,97 0,5
MCV 0,28 0,26 0,35
MCH 0,3 0,28 0,37
MCHC - 0,03 - 0,22 - 0,22
Correlation analysis on the Chaddock scale with mild anemia showed a positive moderate relationship between HGB and erythrocytes (r=0.54), between HGB and hematocrit (r=0.97), weak HGB and MCV (r=0.26) and HGB and MCH (r=0.28) were observed. Correlations in patients with AIT with moderate severity of anemia were less pronounced. The positive
moderate relationship between HGB and hematocrit (r=0.39), between HGB and hematocrit (r=0.5), a positive moderate relationship between HGB & MCV (r=0.35) and HGB & MCH (r=0.37) were observed. A weak negative relationship was determined between MCHC and HGB in case of anemia of mild and moderate severity.
Table 3.
Morphological types of anemia in case of AIT
Morphological type of anemia All patients (n=97) Mild anemia (n=72) Moderate anemia (n=25)
Microcytic 76 (78.3%) 55(76.4%) 21(84%)
Normocytic 21(21.7%) 17(23.6%) 4(16%)
Macrocytic - - -
Normochromic 17(17.5%) 16(22.2%) 1(4%)
Hypochromic 79(81.4%) 56(77.8%) 23(92%)
Hyperchromic 1(1.0%) - 1(4%)
The achieved results indicate the presence of abnormalities in the hemogram of patients with AIT. According to the volume of erythrocytes (MCV), in the group "all patients" anemia was distributed as followings: microcytic anemia was diagnosed in 76.0 (78.3%) patients, normocytic anemia was detected in 21 (21.7%) patients, and macrocytic anemia was not detected. In patients with AIT with mild severity of anemia microcytic anemia was determined in
most cases - in 55 (76.4%) patients, normocytic - in 17 (23.6%). In patients with anemia of moderate severity, microcytic anemia was determined in 21 (84%) cases, normocytic anemia - in 4 (16%) cases (Table 3). Hypochromic type of anemia (according to the MSI index) in the "all patients" group was noted in 79 (81.4%) patients, normochromic type in 17 (17.5%) and hyperchromic type in 1 (1%) patient. Among patients with AIT with mild severity of anemia the
34
BECTHMK XMPyPrMM KA3AXCTAHA №71 • 2022
hypochromic type was observed in 56 (77.8%) patients, normochromic in 16 (22.2%) patients according to the morphological type. In patients with moderate anemia this trend remained and was more pronounced: hypochromic type of anemia was diagnosed in 23 (92%) patients, normochromic type in 1 (4%) and hyperchromic in 1 (4%) patient. An increased number of hypochromic red blood cells indicates an iron deficiency, what means that the erythrocyte works in conditions of its deficiency (Table 3).
Thus, in patients with AIT, anemia of mild severity was determined more often - in 72.4% of cases, and anemia of moderate severity in 25.7% of cases. With an moderate severity of anemia, microcytic (84%) and hypochromic (92%) types of anemia were more
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often observed. In mild anemia, the same types of anemia were observed, but with a lower frequency (respectively 76.4% and 77.8%). Conclusion
1. Hemogram of patients with AIT was characterized by more frequent development of mild anemia (72.4%).
2. Hematological disorders were characterized by microcytic (76.4%) and hypochromic (77.8%) types of anemia were observed in cases of anemia of mild severity. Similar, but more pronounced disorders were observed in moderate anemia (respectively microcytic (84%) and hypochromic (92%), what is characteristic for iron deficiency anemia.
Thyroid Studies Collaboration. The relation between thyroid function and anemia: a pooled analysis of individual participant data. J ClinEndocrinolMetab. 2018;103(10):3658-3667. Pubmed ID 30113667
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