Assays of TSH-receptor antibodies in 576 patients with various thyroid disorders: their incidence, significance and clinical usefulness

The incidence and the significance of TSH-receptor antibodies in Graves' disease and in various thyroid disorders have been evaluated. TSH-binding inhibiting antibodies (TBIAb) and thyroid stimulating antibodies (TSAb) were detected in a large proportion of Graves' disease patients (TBIAb in 68.8% and TSAb in 77.8%), in a small number of patients with idiopathic myxoedema or Hashimoto's thyroiditis, and were not detected in patients with endemic euthyroid goitre, differentiated thyroid carcinoma and toxic adenoma. Furthermore, TSH-receptor antibodies were present in some patients with toxic multinodular goitre (TBIAb in 12.7% and TSAb in 15.9%). When TSH-receptor and other thyroid autoantibodies were compared, it was found that 13 of the 15 Graves' patients with negative tests for thyroglobulin and thyroid microsomal antibodies were positive for TSH-receptor antibodies. On the other hand, 9 of the 11 patients with toxic multinodular goitre who had positive TSH-receptor antibody tests, also had serum thyroglobulin and/or thyroid microsomal antibodies. No significant differences in the prevalence of TSH-receptor antibodies were found in Graves' patients irrespective of the presence of ophthalmopathy or pretibial myxoedema. Elevated TBIAb activity at the end of anti-thyroid drug treatment was found in 52.9% of Graves' patients who subsequently relapsed, while in Graves' patients in remission TBIAb was always negative. TSH-receptor antibody results were not predictive of the outcome of radioiodine treatment in Graves' disease. Finally no correlation could be found between TBIAb and TSAb in Graves' disease and Hashimoto's thyroiditis. In conclusion: the high incidence of TSH-receptor antibodies in Graves' disease confirms their pathogenetic role in the development of hyperthyroidism; TSH-receptor antibodies in Graves' disease are not significantly associated with the presence of ophthalmopathy or pretibial myxoedema; TSH-receptor antibody assays may be useful for the diagnosis of Graves' disease in the absence of other signs of autoimmunity. TBIAb seems to be a good predictor of relapse in Graves' patients treated with anti-thyroid drugs; a fraction of toxic multinodular goitre could be a nodular variant of Graves' disease.     

Anti-CD38 autoimmunity in patients with chronic autoimmune thyroiditis or Graves' disease.

Autoantibodies directed against human CD38 (an enzyme catalysing the interconversion of NAD(+) and cyclic ADP-ribose) have been demonstrated recently in patients with type 2 diabetes. We tested 220 consecutive Caucasian patients with autoimmune chronic thyroiditis, 104 patients with Graves' disease, 220 subjects from the general population (control I) and 78 healthy control subjects not affected by thyroid autoimmune disorders (control II) for the presence of anti-CD38 autoimmunity. Using Western blot analysis and optical densitometry, a specific band corresponding to human recombinant CD38 was identified in the serum of several subjects. By defining anti-CD38 positivity as a standardized optical reading > 3 s.d. higher than the mean value of control I, 10.4% of patients with thyroiditis and 7.7% of Graves' patients were anti-CD38 positive (P = 0.0009 versus 1.8% of control I). Similarly, 13.1% of patients with thyroiditis and 10.5% of Graves' patients had a standardized optical reading > 3 s.d. higher than the mean value of the subjects not affected by thyroid autoimmune disorders (P = 0.002 versus 1.2% of control II). Anti-CD38 autoimmunity did not differ between euthyroid, hyperthyroid or hypothyroid patients or between patients with or without thyroid hypoechogenicity. Anti-CD38 autoantibodies were associated with higher levels of circulating antithyroid-peroxidase antibodies (P = 0.03) and they were more frequent in Graves' patients with ophthalmopathy (P < 0.05). Anti-CD38 autoantibodies are a new autoimmune marker in chronic autoimmune thyroiditis and Graves' disease. The specific role of CD38 and its autoantibodies in the modulation of thyroid cell function or growth remains to be investigated.     

The association between chronic lymphocytic thyroiditis and thyroid tumors

An association between lymphocytic thyroiditis and thyroid papillary carcinoma is still controversial. To assess the relationship, a histopathologic analysis of surgically resected thyroid tumors together with the frequency and severity of chronic lymphocytic infiltration of the thyroid among patients with follicular adenoma, follicular carcinoma, and papillary carcinoma was performed. The prevalence of lymphocytic infiltrate, which is indicative of autoimmune thyroiditis, was significantly higher in patients with papillary carcinoma (58%) than in patients with follicular carcinoma (20%) or follicular adenoma (14%). The lymphocytic infiltration within the tumor compared with the severity of thyroiditis in the nontumorous tissue. Therefore, the association between chronic lymphocytic thyroiditis and papillary carcinoma was confirmed. The possibility that an immunologic mechanism involved in the pathogenesis of papillary carcinoma stimulates lymphocytic infiltration in the thyroid tissue through an autoimmune mechanism is suggested.     

CA 19-9 expression in subacute (de Quervain's) thyroiditis: an immunohistochemical study.

Carcinoma antigen 19-9 (CA 19-9) and carcinoembryonic antigen (CEA) expression was immunohistochemically investigated in 48 cases of subacute granulomatous (de Quervain's) thyroiditis, two of focal lymphocytic thyroiditis, three of Hashimoto's thyroiditis, two of Graves' disease, and seven follicular adenomas, 27 follicular carcinomas, and eight papillary carcinomas of the thyroid. CA 19-9 expression was found in all cases of subacute thyroiditis, lymphocytic thyroiditis, and papillary carcinomas examined and in approximately 50% of follicular adenomas and carcinomas. The strongest CA 19-9 staining was demonstrated in late stage subacute thyroiditis and in papillary carcinomas with marked sclerosis. Occasionally CA 19-9 expression was present in seemingly normal thyroid parenchyma adjacent to the thyroid lesions investigated. CEA was found in the center of the granulomatous lesions in acute stage subacute thyroiditis. All neoplasms were CEA negative. CA 19-9 and CEA could be demonstrated occasionally in multinucleated giant cells of subacute thyroiditis, which may suggest that these giant cells are of either histiocytic or follicular cell origin. Immunohistochemical investigation with antibodies against CA 19-9 and CEA may help to histomorphologically define subacute granulomatous thyroiditis.     

A differential association of interferon-gamma high-producing allele T and low-producing allele A (+874 A/T) with Hashimoto's thyroiditis and Graves' disease

Cytokines play a crucial role in the pathogenesis of autoimmune thyroid disease. The aim of this study was to investigate the relationship of the single base change polymorphic variants identified in the first intron of interferon-gamma (IFN-gamma) (+874 T/A) with susceptibility to thyroid dysfunctions. A total of 340 subjects were included in the study comprising of 190 patients (104 patients with Hashimoto's thyroiditis, 26 with non-Hashimoto's hypothyroidism and 60 Graves' disease) and 150 controls. Genotyping was done by amplification refractory mutation system-polymerase chain reaction using a set of sequence-specific primers. Statistical analysis revealed a significant association between high IFN-gamma-producing genotype TT and Hashimoto's thyroiditis compared to controls (P value < 0.001). On the other hand, the frequency of genotype TT was decreased in patients with Graves' hyperthyroidism with a significant increase in low IFN-gamma-producing genotype AA among this group (P = 0.03). To conclude the results of the study suggest a differential association of high- and low-producing alleles of IFN-gamma gene with Hashimoto's thyroiditis and Graves' disease. The high IFN-gamma-producing allele T was observed to be associated with Hashimoto's thyroiditis in the present study where as in Graves' hyperthyroidism the association was observed to be stronger with the low producing allele A.     

慢性淋巴细胞性甲状腺炎伴TRAb阴性的甲状腺相关性眼病1例

甲状腺相关性眼病是一种自身免疫系统紊乱引起的眼球后及眶周组织的浸润性病变,常与Graves病并存或先后发病,但慢性淋巴细胞性甲状腺炎中甲状腺相关性眼病较罕见。本文报告1例促甲状腺素受体抗体(TRAb)阴性,细针穿刺活检示弥漫性淋巴细胞浸润,符合慢性淋巴细胞性甲状腺炎相关性眼病的诊断病例。     

Interferon-alpha-induced destructive thyroiditis followed by Graves' disease in a patient with chronic hepatitis C: a case report

Interferon-induced thyroiditis (IIT) is a major clinical problem for patients receiving interferon-alpha (IFN-α) therapy. But, destructive thyroiditis followed by Graves' disease associated with IFN-α therapy is very rarely reported. Herein, we report a rare case of pegylated IFN-α (pegIFN-α) induced destructive thyroiditis followed by Graves' disease in a patient with HCV infection. A 31-yr-old woman suffered from chronic active hepatitis C and was treated with pegIFN-α and ribavirin for 12 months. Results of a thyroid function test and autoantibody levels were normal before IFN-α therapy was initiated. Destructive thyrotoxicosis appeared seven months after the initiation of IFN-α therapy, followed by Graves' thyrotoxicosis two months after the cessation of therapy. The diagnoses of destructive thyroiditis and Graves' disease were confirmed by the presence of TSH receptor antibodies in addition to Tc-99m scintigraphy findings. The patient's antithyroglobulin antibody titer increased gradually during IFN-α therapy and remained weakly positive after IFN-α therapy was discontinued.     

The Association of HLA-B8 with Atrophic Thyroiditis

One-hundred-and-forty-seven patients with autoimmune thyroiditis were studied with respect to HLA antigens as they related to various clinical features. HLA--B8 was found to be significantly increased among 59 patients with atrophic thyroiditis (57% vs. 26% for controls) but was identical to controls in 88 patients with goitrous thyroiditis (26%). No relation was found in either group between B8 and thyroid autoantibody titer or, in the case of goitrous thyroiditis, the rate of progression of the disease. Thus a link seems to be established between Graves' disease and atrophic thyroiditis in that both are significantly associated with HLA-B8. This study stresses the need to take clinical features into consideration when examining for HLA/disease associations.     

Increase in peripheral natural killer cell activity in patients with autoimmune thyroid disease.

Changes in the activity and number of natural killer (NK) cells in peripheral blood in patients with autoimmune thyroid disease were examined. NK activity was measured in a 4-hr 51Cr-release assay and the number of NK cells was analyzed with FITC-conjugated monoclonal antibodies by use of an automated flow cytometer. NK activity in patients with untreated Graves' disease (n = 25, 39.7 +/- 13.5%, P less than 0.05) and Hashimoto's thyroiditis (n = 18, 41.0 +/- 14.2%, P less than 0.05) was high compared to the activity in non-pregnant controls (n = 61, 32.6 +/- 15.0%). NK activity in patients with postpartum Graves' thyrotoxicosis (n = 11, 48.6 +/- 18.9%) was markedly increased compared to the activity in non-pregnant controls (P less than 0.01) and in postpartum controls (n = 29, 33.8 +/- 15.2%, P less than 0.05), although the mean ages of each group did not differ significantly. Moreover, NK activities in the thyrotoxic state were significantly higher than those in the euthyroid state in the same patients with postpartum Graves' thyrotoxicosis or with postpartum destructive thyrotoxicosis. The number of CD16 positive cells increased in patients with postpartum Graves' thyrotoxicosis. However the number of CD16 and CD57 positive cells were normal in all other groups of patients. These results indicate that an increase of NK activity is associated with exacerbation of autoimmune thyroid disease both in Hashimoto's thyroiditis and in Graves' disease and suggest that NK cells might have an important role for the control of disease activity in autoimmune thyroid disease.     

Expression and function of multiple regulators of complement activation in autoimmune thyroid disease.

Membrane attack complexes of complement occur around thyroid follicles in Graves' disease and Hashimoto's thyroiditis. The lytic potential of such complexes is controlled by membrane-bound and fluid phase regulators and we have investigated the role of these in autoimmune thyroid disease. By immunohistochemical staining, clusterin and S-protein were found in all nine thyroid specimens from patients with Graves' disease and S-protein was found in one of two Hashimoto glands. CD46, CD55 and CD59 were found on thyroid cells in all specimens. CD46 and CD55 expression occurred on thyroid cells cultured in vitro and was increased significantly by culture with interleukin-1 (IL-1) and interferon-gamma (IFN-gamma), which are known to be released by the lymphocytic infiltrate in these conditions. Blocking CD55 had a weak and inconsistent effect on complement-mediated thyroid cell killing in vitro but, in four of five experiments, blocking CD46 enhanced killing. However, the effect of blocking CD59 was greater in all cases than blocking CD46 or CD55. Expression of these fluid phase and membrane-bound proteins may be important in determining the severity of thyroid damage produced by complement fixation in Graves' disease and Hashimoto's thyroiditis.     

Fas ligand gene polymorphisms are not associated with Hashimoto's thyroiditis and Graves' disease

Hashimoto's thyroiditis and Graves' disease represent the two most common autoimmune thyroid disorders. Whereas in Hashimoto's thyroiditis FasL expression causes thyrocytes to undergo apoptosis, additional anti-apoptotic molecules appear to protect these cells in Graves' disease. Mutations of the FasL gene were observed in systemic lupus erythematosus. Given its functional relevance for the pathogenesis of thyroid autoimmunity we wondered whether variants of the FasL gene play a role in Hashimoto's thyroiditis and Graves' disease. We genotyped families with at least one offspring affected by Hashimoto's thyroiditis (n = 86) and Graves' disease (n = 90) for two FasL gene polymorphisms (C -843 T in the promoter, A IVS2nt-124 G in intron 2). Extended transmission disequilibrium (ETDT) and chi(2) testing were performed. Neither polymorphism alone nor the promoter/intron 2 haplotypes (p = 0.91) were associated with Hashimoto's thyroiditis. No association with Graves' disease was observed for the promoter polymorphism (p = 0.91) and the intron 2 "A" allele (57.1%; p = 0.36) or the promoter/intron 2 haplotypes (p = 0.31). Moreover, intron 2 genotyping revealed no difference between an additional 251 patients with Graves' disease and 197 healthy controls (p = 0.37). Italian and German families did not differ for the studied polymorphisms. In conclusion, our data do not suggest common genetic FasL variants to significantly contribute to the pathogenesis of either Hashimoto's thyroiditis or Graves' disease.     

CD4~+CD25~+调节性T细胞在自身免疫性甲状腺疾病中数量和功能变化

目的:探讨自身免疫性甲状腺疾病患者外周血中CD4+CD25+调节性T细胞(Tregs)的数量和功能变化。方法:采用化学发光法测定20例初发Graves’病人、20例初发桥本甲状腺炎(HT)患者及20例健康体检者血清中促甲状腺素(TSH)、总三碘甲状腺原氨酸(TT3)、总甲状腺素(TT4)、甲状腺球蛋白抗体(TgAb)和甲状腺过氧化酶抗体(TPOAb)的水平;用流式细胞仪分析外周血单个核细胞(PBMC)中CD4+T细胞及CD4+CD25+Tregs的数量;采用磁珠分选技术分选5例HT病人和5例健康体检者PBMC中CD4+CD25+Tregs和CD4+CD25-T细胞,采用MTT法检测CD4+CD25+Tregs对自身CD4+CD25-T细胞增殖的抑制作用;提取各组PBMC的总RNA,经Real time-PCR检测TGFβ-1、Foxp3 mRNA的表达水平。结果:流式细胞检测结果显示,初发Graves’病人、初发HT患者外周血PBMC中CD4+T细胞数量与正常人比较无差异(P<0.05);初发HT患者外周血PBMC中CD4+CD25+Tregs占CD4+T细胞的比率为(1.55%±0.49%),明显低于正常对照组(2.86%±1.04%)(P<0.05);初发Graves’病人外周血PBMC中CD4+CD25+Tregs占CD4+T细胞的比率为(3.25%±0.97%),与正常对照组(2.86%±1.04%)相比无显著性差异(P<0.05)。MTT结果显示,初发HT患者CD4+CD25+Tregs对自身CD4+CD25-T细胞增殖的抑制百分率为15.7%±5.36%,与正常组(41.7%±9.87%)相比显著降低(P<0.05)。Real time-PCR结果显示,初发Graves’病人、初发HT患者PBMC的TGFβ-1 mRNA表达水平分别为(0.37±0.10)和(0.43±0.09),均明显低于正常对照组(1.02±0.04)(P<0.05);初发Graves’病人、初发HT患者PBMC的Foxp3 mRNA表达水平分别为0.62±0.09和0.42±0.29,均明显低于正常对照组(0.99±0.17)(P<0.05)。结论:本研究结果提示,HT患者外周血中CD4+CD25+Tregs的数量和功能明显降低。Graves’病和HT患者外周血PBMC中TGFβ-1、Foxp3 mRNA表达水平明显降低。     

Expression of tenascin in lymphocytic autoimmune thyroiditis.

AIMS: To study the distribution of tenascin by immunocytochemistry in autoimmune diseases of the thyroid. METHODS: Thyroids from patients with inflammatory lesions of the thyroid (lymphocytic thyroiditis Hashimoto, Grave's disease, thyroiditis DeQuervain) were studied by immunocytochemistry using antibodies against tenascin, collagen III, and collagen IV. RESULTS: In autoimmune lymphocytic thyroiditis Hashimoto there was a characteristic corona-like staining pattern of tenascin around all activated lymph follicles with germinal centres. This staining pattern contrasted with the immunoreactions for collagen III and IV, which were not enhanced in the perilymphofollicular interstitium. In cases of thyroiditis DeQuervain the areas of early and ongoing fibrosis showed some diffuse staining for tenascin and for collagen III. Enhanced diffuse immunostaining for collagen IV in the perivascular and interfollicular interstitium was present in cases of Grave's disease. In Grave's disease no characteristic immunoreaction was detectable for tenascin. CONCLUSIONS: The corona-like expression of tenascin around lymphofollicular infiltrates is distinctive of cases of lymphocytic thyroiditis. A similar staining pattern for tenascin has been reported in lymphoid hyperplasia of the thymus associated with myasthenia gravis, another autoimmunological disorder. There are good arguments that the activation and infiltration of lymph follicles in the thyroid during the course of autoimmune diseases lead to stimulation and activation of the surrounding mesenchyme producing tenascin as part of the extracellular matrix.     

TSH受体抗体测定的临床意义

目的:探讨血清TRAb的测定变化对G raves甲亢的临床意义。方法:应用放射免疫受体分析法(RRA)对302例甲状腺疾病患者及52例正常健康人的血清TRAb的值进行比较。结果:甲亢组TRAb的测定值阳性率为86.3%;甲亢缓解组TRAb的测定值阳性率为74.5%;甲亢治愈组TRAb的测定值阳性率为32.1%;甲亢复发组TRAb的测定值阳性率为90.3%;单纯性甲状腺肿组TRAb的测定值阳性率为0;甲瘤组TRAb的测定值阳性率为0;甲亢组、甲亢缓解组、甲亢治愈组、甲亢复发组与正常对照组相比有显著性差异(P<0.01);单纯性甲状腺肿组、甲瘤组与正常对照组相比无显著性差异(P>0.05)。结论:TRAb的测定对G raves甲亢的治疗具有重要的参考价值。     

Gm phenotypes in autoimmune thyroid disease

The Gm phenotype Gm f,b or Gm f,n,b was found in all forty patients with Graves' disease studied, contrasted with thirty-five out of forty controls and twenty out of thirty-one patients with thyroiditis. The difference between the two groups with autoimmune thyroid disease was significant. These results suggest that thyroid stimulating antibodies may be allotypically restricted.     

Thyroglobulin synthesis of oxyphilic cells in various types of neoplastic and autoimmune thyroid diseases.

To determine the content of thyroglobulin in oxyphilic cells of the thyroid, which have been considered as non-thyroglobulin producing cells, the degree of stainability of the various oxyphilic cells for thyroglobulin was compared with that of non-oxyphilic follicular cells in either same or different lesion. A total of 13 oxyphilic lesions, including three follicular adenomas containing oxyphilic cell nodules, four pure oxyphilic cell adenomas, and six Hashimoto's thyroiditis were compared with 16 of non-oxyphilic lesions such as, seven follicular adenomas, four chronic lymphocytic thyroiditis, and five Graves' disease. Many oxyphilic cells stained positively for thyroglobulin regardless of their morphologic variation, but less intensely than the usual follicular cells in follicular adenomas, chronic lymphocytic thyroiditis, and Graves' disease. The stainability of oxyphilic cells for thyroglogulin did not show any significant correlation with morphologic features, whereas in follicular adenomas, the non-oxyphilic follicular cells forming microfollicles stained less strongly for thyroglobulin than the same cells lining large mature follicles in a reproducible way. With above findings, we concluded that oxyphilic cells maintain the functional activity in terms of thyroglobulin synthesis, although the content of the thyroglobulin is less than that of non-oxyphilic colloid forming follicular cells.     

Chronic lymphocytic thyroiditis in a cynomolgus macaque (Macaca fascicularis)

Chronic lymphocytic thyroiditis characterized by multifocal follicular lymphoid cell infiltrates with germinal centers, thyroid acinar atrophy and pituitary cell hyperplasia/hypertrophy of the adenohypophysis was detected in a vehicle control, 4-year-old female Cynomolgus macaque in a routine toxicology study. Lymphoid cells of germinal centers were positive for the B-cell marker CD20 by immunohistochemistry (IHC), while remaining lymphocytes were positive for the T-cell marker CD3. Hypertrophied/hyperplastic pituitary cells were positive for thyroid stimulating hormone (TSH) by IHC, consistent with an adaptive response due to removal of hormonal negative feedback from the diseased thyroid gland. Features of this case are similar to chronic lymphocytic thyroiditis in humans, an autoimmune disorder also known as Hashimoto's disease. Chronic lymphocytic thyroiditis with compensatory pituitary changes may occur spontaneously in young, clinically normal cynomolgus macaques and its presence in drug treated animals should be interpreted with caution.     

The effects of plasma from patients with Graves' disease on foetal mouse hearts in organ culture

Plasma, obtained during plasma exchange therapy, from 3 euthyroid patients with Graves' disease and severe progressive exophthalmos induced an increase in heart rate and then early death when applied to foetal mouse hearts maintained in isolated organ culture. All plasma samples which induced an increase in foetal heart rate had high titres of thyroid stimulating immunoglobulins. Plasma samples obtained after exchange had a much diminished effect. These studies may indicate a previously unrecognized non-thyroidal action of the abnormal immunoglobulins associated with Graves' disease and suggest that chronic thyroid heart disease may be due, at least in part, to the effect of these immunoglobulins especially when not associated with elevated thyroid hormones concentrations.     

Lymphocyte transformation with thyroglobulin in thyroid diseases

The lymphocyte transformation test (LTT) with thyroglobulin was correlated with humoral thyroglobulin antibodies (TGA) in different thyroid diseases. All patients with significant TGA had a positive LTT, while two LTT positive patients either had no TGA or revealed them a few weeks later. Lymphocyte transformation was found in all investigated cases of chronic thyroiditis and Hashimoto's disease, half of the patients with multinodular goitres and Graves' disease, and some cases (five out of sixteen) of simple goitres.     

Review of thyroid disease and recent progress in thyroid research

Major thyroid diseases and recent progress in thyroid research are reviewed, including our clinical experiences and data on genetic analysis. Of the 19,944 patients receiving care in our endocrinology and metabolism department over the past 26 years(from 1974 to 2000), there were 4,471(22.4%) patients with thyroid diseases. Of these patients with thyroid disease, 37.3% had Graves' disease, 24.1% had Hashimoto's thyroiditis, and 22.2% had a benign thyroid tumor. Male-to-female ratio for Graves' disease was 1:3.2. The precise mechanism and genetic or environmental factors underlying the onset and progression of autoimmune thyroid disease need further investigation, although recent thyroid research, especially molecular level studies, has resulted in many new insights. Our genetic analysis of patients and experimental animals with thyroglobulin(Tg) abnormalities indicated the amino acids involved in the surface electric charge were important in maintaining the solid structure of Tg and thyroid hormone synthesis in addition to tyrosine and cysteine. In three patients with hyperthyroid Graves' disease, Hashimoto's thyroiditis or idiopathic hypothyroidism, followed by the author for 8 to 20 years, it was indicated that continued comprehensive care was needed for various episodes, even those arising from non-endocrine conditions, throughout the clinical course, although clinical and laboratory findings showed improvement of the thyroid disease itself.