Introduction: Multiple autoimmune syndrome (MAS) type 3 is characterized by the coexistence of autoimmune thyroid disease with other organ-specific or systemic autoimmune disorders, excluding adrenal insufficiency. MAS represents a form of polyautoimmunity, in which shared immunological mechanisms contribute to clustering of multiple autoimmune diseases within a single individual. Recent studies suggest the clinical spectrum of MAS continues to expand, with increasing recognition of diverse autoimmune combinations across different organ systems. However, detailed clinical characterization of MAS type 3 involving overlapping endocrine and neuromuscular autoimmune diseases in young adults remains limited. Cases: We report four young adults (aged 21–37 years) with heterogeneous manifestations of MAS type 3 involving endocrine and systemic autoimmune diseases. Autoimmune thyroid disease was identified in three patients, all diagnosed with Graves’ disease with suppressed thyroidstimulating hormone, elevated free thyroxine, and positive thyrotropin receptor antibodies. Autoimmune diabetes was present in three patients, including latent autoimmune diabetes in adults (LADA) and type 1 diabetes mellitus, with variable glycemic control (hemoglobin A1c range 6.7–13.9%) and C-peptide levels ranging from preserved to markedly reduced. Myasthenia gravis was observed in three patients. Additional autoimmune conditions included systemic lupus erythematosus, systemic sclerosis, rheumatoid arthritis, and ulcerative colitis. Notably, rare combinations such as Graves’ disease with LADA and myasthenia gravis, as well as coexistence with systemic autoimmune diseases, were identified. All patients received individualized multidisciplinary management. Clinical and biochemical improvement was observed in all cases, with stabilization of both endocrine and systemic autoimmune manifestations. Conclusion This case series highlights the heterogeneous and expanding clinical spectrum of MAS type 3, including rare combinations of autoimmune endocrine and systemic diseases in young adults. Early recognition of autoimmune clustering and comprehensive screening are essential to optimize management and improve outcomes. These findings provide insights into autoimmune disease clustering and support the need for proactive multidisciplinary management strategies.
Young Adult ; Humans ; Autoimmune Diseases

Introduction: Thalassemia is a hemoglobin synthesis disorder associated with chronic anemia and transfusion-related iron overload, which predisposes patients to multiple endocrine complications. Iron deposition in the pituitary and gonads may result in growth hormone deficiency (GHD) and hypogonadism. Empty sella syndrome (ESS), characterized by herniation of the subarachnoid space into the sella turcica, may also contribute to hypopituitarism. The coexistence of thalassemia-related endocrinopathies, ESS, and autoimmune thyroid disease is rare and presents significant diagnostic complexity. Case: A 27-year-old female with transfusion-dependent thalassemia on deferiprone presented with secondary amenorrhea and short stature. Her height was 145 cm (below the target range of 140.5–157.5 cm), body mass index 17.3 kg/m², and Tanner stage M3P1. Laboratory evaluation revealed elevated thyroidstimulating hormone (10.92 mIU/L) with low-normal free thyroxine 4 (11.4 pmol/L), consistent with primary hypothyroidism. Thyroid ultrasound demonstrated features of chronic thyroiditis, and anti-thyroid peroxidase antibodies (8.18 IU/mL) supported a diagnosis of Hashimoto’s thyroiditis. Insulin-like growth factor-1 was markedly reduced (68 ng/mL), indicating GHD. Morning cortisol was within normal range (14.5 µg/dL). Gonadotropins were inappropriately low-normal (folliclestimulating hormone 7.42 mIU/mL, luteinizing hormone 11.41 mIU/mL) with low estradiol (26.49 pg/mL), suggesting hypogonadotropic hypogonadism. Skeletal survey showed thalassemia-related bone changes, including trabecular coarsening and metaphyseal widening, with a predicted adult height of 142.7 cm. Pituitary magnetic resonance imaging revealed an empty sella. Conclusion Thalassemia must be recognized not only as a primary hematologic condition but also as a complex multisystem disorder with profound endocrine implications. Furthermore, the co-occurrence of these conditions with rare manifestations such as ESS and Hashimoto’s thyroiditis underscores the diagnostic complexity faced by clinicians. Therefore, early detection and rigorous, regular endocrine screening are essential to optimize management strategies and improve the long-term quality of life for patients with thalassemia.
Empty Sella Syndrome ; Growth Hormone ; Thalassemia ; Thyroiditis

Introduction: Nonfunctioning pituitary adenomas (NFPA) may cause central hypothyroidism due to pituitary compression, often presenting with low thyroid-stimulating hormone (TSH). However, suppressed TSH in this setting should not automatically be attributed to pituitary dysfunction, as primary hyperthyroidism—such as Graves’ disease—may rarely coexist. Distinguishing between these disorders is essential to avoid misdiagnosis and inappropriate management. Case: A 42-year-old female presented with intermittent headache, visual field impairment, palpitations, fine tremors, and weight loss. Physical examination revealed visual field deficits and no goiter. Laboratory evaluation showed cortisol level of 1 µg/dL (normal: 3.7–19.4 µg/dL), luteinizing hormone 1.62 mU/L (normal: 2.4–12.6 mU/L), follicle-stimulating hormone 5.01 mU/L (normal: 3.5–12.5 mU/L), free thyroxine 4 28.32 pmol/L (normal: 12–22 pmol/L), TSH 0.02 µIU/mL (normal: 0.27–4.2 µIU/mL), and prolactin 70.84 ng/mL. Thyrotropin receptor antibody (TRAb) was 3.53 IU/L, confirming Graves’ disease. Contrast-enhanced brain magnetic resonance imaging demonstrated a pituitary macroadenoma (2.13 × 2.28 × 3.05 cm) with optic chiasm compression. The patient was diagnosed with NFPA, Graves’ disease, secondary adrenal insufficiency, possible hypogonadotropic hypogonadism, and hyperprolactinemia likely due to the stalk effect. Preoperative management included hydrocortisone replacement and antithyroid therapy. The patient subsequently underwent transsphenoidal surgery with appropriate perioperative care. Postoperatively, no new pituitary hormone deficiencies were observed. She was maintained on thiamazole 10 mg daily with clinical improvement and remains under regular follow-up. Conclusion This case highlights a rare but clinically important coexistence of NFPA and Graves’ disease. Suppressed TSH in patients with pituitary adenoma should not be assumed to reflect pituitary dysfunction without thorough evaluation. Comprehensive thyroid assessment is crucial to ensure accurate diagnosis and appropriate management.
Pituitary Neoplasms ; Graves Disease

Introduction: Neglected Club Foot deformity is not an uncommon limb anomaly encountered by orthopaedic surgeons. Many treatment methods have been proposed. Ilizarov apparatus is one of the techniques used to correct this deformity. Materials and methods: In this cross-sectional study 47 patients (56 feet) between the ages of 5 and 10 years with clubfoot deformity were treated using the Ilizarov external fixator. Age, sex, type of deformity, and radiographic parameters were measured on foot radiographs. Also, the American Orthopaedic Foot and Ankle Society (AOFAS) score and the Dimeglio classification were recorded for each patient before and after treatment. Results: The treatment was unilateral in 38 patients and bilateral in 9 patients. 39 patients (69.6%) were male, and 17 patients (30.4%) were female with a mean age of 7.86 ± 1.4 years. Plantar angles of ankle flexion and ankle flexion curve increased from 20.12±6.52 and -16.51±8.36 to 25.89±6.44 and 6.19±6.42, respectively. There was also an improvement in the talocalcaneal and tibiocalcaneal angles. Also, the angle between the first metatarsus and the talus in the front and side views improved (P<0.00). Additionally, the mean AOFAS score and Dimeglio classification significantly improved. Three cases were complicated with distal tibial physeal separation that were treated with additional open surgeries. Conclusion: Ilizarov technique without osteotomies and soft tissue release could be considered a less invasive and successful method of treatment for neglected clubfoot deformity in patient five to ten years old that are not good candidate for Ponseti method.

Introduction: C1 lateral mass and C2 pedicular screws insertion are used for C1-C2 posterior fusion. Fluoroscopy Guided technique is routinely used for screw placement but it is associated with risk of injury to spinal cord and vertebral artery. 3D printing has developed rapidly in the fields of medicine. It is helpful in improving precise treatment and used for instrumentation in spine. We want to evaluate the accuracy of C1 lateral mass screws and C2 pedicle screws insertion by Pre-Fabricated Template made by threedimensional (3D) printing. Materials and methods: Five cervical samples were obtained from cadavers. Based on fine-cut CT scan 3Dimages reconstructed and the path of the screws designed by special software. A template produced by 3D-printer from 3D images. After printing the templates, they were fixed on the relevant vertebra in the operation room and based on the template path, C1 lateral mass screw and C2 pedicular screws were inserted. Placement of the screws was evaluated using CT scans post-operatively. Results: A total of 14 screws were inserted by abovementioned method. After evaluation with CT scans none of the screws were entered in the spinal canal. Two screws had vertebral artery canal perforation with less than 50% breach. Violation was judged as noncritical and would probably not have resulted in injury to vertebral artery. Conclusions: The accuracy of C1 lateral mass screw and C2 pedicle screw insertion is acceptable with pre-fabricated template and can provide a useful aid for screw placement.