Clinical validity of a new commercial method for detection of TSH-receptor binding antibodies in sera from patients with Graves' disease treated with antithyroid drugs

In this work, we compared the activities of TSH binding inhibitory immunoglobulin (TBII) results obtained with a new human TBII assay (h-TBII) using the human recombinant TSH receptor with thyroid stimulating antibodies (TSAbs). Sera were obtained from 90 patients with Graves' disease before and after therapy with carbimazole (1-methyl-2-thio-3-carbethoxyimidazole). Before treatment, h-TBII were detected in 89/90 patients (98.9%) whereas TSAb activity was positive in 88/90 patients (97.7%). The two parameters fell during therapy. At the end of treatment, only h-TBII levels were significantly different between patients in remission and those in relapse (Z=-2.212; P=0.0270). The relapse rate in the patients with positive antibodies at drug withdrawal was significantly increased (chi(2)=6.057; P=0.0139 for h-TBII and chi(2)=8.988; P=0.0021 for TSAb). Most of patients (76%) relapsed during the 2 years following drug withdrawal. h-TBII or TSAb values were positive in 84.6% or in 80.8% of patients at the time of relapse. There was a significant correlation between the two antibody measurement methods before treatment, at drug withdrawal and at the time of relapse. These results indicate that the new TBII assay using human TSH receptor is as sensitive as the TSAb assay. Because of its much easier performance, it may advantageously replace TSAb measurement especially for the Graves' disease diagnosis and in the prediction of short-term relapse at the end of treatment.     

Clinical applications of the 2nd generation assay for anti-TSH receptor antibodies in Graves' disease. Evaluation in patients with negative 1st generation test.

Detection of autoantibodies to the thyrotropin receptor by radioreceptor assays is largely requested in clinical practice for the diagnosis of Graves' disease and its differentiation from diffuse thyroid autonomy. Additionally, thyrotropin receptor antibodies (TRAb) measurement during antithyroid drug treatment can be useful to evaluate the risk of relapse after discontinuation of the therapy. Nevertheless, some patients affected by Graves' disease are TRAb-negative when a 1st generation assay is used. In this study we evaluated the diagnostic performance of a newly developed 2nd generation TRAb assay in 46 patients with Graves' disease with negative 1st generation TRAb assay results. A control group of 50 Graves' disease patients with positive 1st generation TRAb assay results, 50 patients with Hashimoto's thyroiditis and 50 patients with nodular goiter were also examined. Forty one of 46 patients with Graves' disease with negative 1st generation TRAb assay results showed a positive 2nd generation test. No differences were seen in control groups. In conclusion, the 2nd generation TRAb assay is more sensitive than the 1st generation test and should be used in clinical practice. Long-term prospective studies are needed to evaluate the prognostic role of the 2nd generation TRAb assay in Graves' disease.     

在不同促甲状腺素(TSH)水平加用甲状腺素对Graves病患者病情反复的影响

G raves病是一种器官特异性自身免疫性疾病,抗甲状腺药物(ATD)是治疗G raves病的主要方法,安全可靠,但具有较高的复发率。目前有学者研究认为加用甲状腺素治疗可以降低G raves病的复发率、预防药物性甲状腺功能减退症的发生,防止甲状腺肿大和突眼的加重。但目前未见在G raves病     

Relapse of Graves' disease 23 years after treatment with radioactive iodine (131I)

The use of radioactive iodine (131I) in the treatment of Graves' disease results frequently in hypothyroidism requiring thyroid hormone supplementation. Relapse of Graves' disease months after inadequate treatment with 131I is well-recognized. However, late relapse of Graves' disease in a patient rendered hypothyroid by 131I years after therapy has not been reported. The authors discuss a patient who had a relapse of his Graves' disease 23 yr after treatment with 131I. Over the interval the patient had been on 1-thyroxine replacement for hypothyroidism and had persistently high levels of long acting thyroid stimulator or thyroid stimulating antibody. The authors speculate that the immune nature of Graves' disease may play a role in the observed clinical response to 131I.     

Graves' disease following subacute thyroiditis

Subacute thyroiditis is a painful, inflammatory disease frequently accompanied with fever. It is suspected to be a viral infectious disease, while Graves' disease is an autoimmune disease. Thus, there appears to be no etiological relationship between the two diseases. A total of 25,267 thyroid disease patients made their first visits to our thyroid clinic during a period of 24 years between 1985 and 2008. Among them, subacute thyroiditis and Graves' disease accounted for 918 patients (3.6%) and 4,617 patients (18.2%), respectively. We have encountered 7 patients (one male and six female) with subacute thyroiditis followed by Graves' disease in this period (0.15% of the 4,617 patients with Graves' disease and 0.76% of the 918 patients with subacute thyroiditis). The age ranges were 40~66 years (mean 48.7 years) at the onset of subacute thyroiditis. The intervals between the onsets of subacute thyroiditis and Graves' disease were 1~8 months (mean 4.7 months). Because Graves' disease was preceded by subacute thyroiditis, the signs and symptoms of both diseases were evident together in the intervening period. The diagnosis of Graves' disease in those patients is always difficult because of atypical signs and symptoms and an unclear onset time. The causes of the Graves'disease that followed subacute thyroiditis are still unknown. However, the inflammatory nature of subacute thyroiditis may lead to the activation of the autoimmune response in susceptible subjects, resulting in the onset of Graves' disease. Graves' disease should be suspected when a high blood level of thyroid hormone persists after subacute thyroiditis.     

Clinical utility of thyrotropin-receptor antibody assays: comparison of radioreceptor and bioassay methods

Thyrotropin (thyroid-stimulating hormone or TSH)-receptor antibodies, important in the pathogenesis of Graves' disease, can be assayed by one of two methods: (1) bioassays that measure stimulation of thyroid cellular activity by patient immunoglobulins or (2) radioreceptor assays that measure inhibition of binding of labeled TSH to TSH receptors by the same substances. In this study, we report our experience with bioassay of thyroid-stimulating immunoglobulins (TSI) based on measurement of generation of cyclic adenosine monophosphate in a clone of the Fisher rat thyroid cell line (FRTL-5) in 279 patients, and we compare, in 163 consecutive samples, the results obtained by a radioreceptor assay for thyrotropin-binding inhibiting immunoglobulins (TBII). Among the untreated, hyperthyroid patients with Graves' disease, TSI were present in 95% (38 of 40), and TBII were present in 85% (17 of 20). In patients with euthyroid Graves' disease, TSI were found in 57% (16 of 28), and TBII were present in 41% (7 of 17). Of 49 nongoitrous and euthyroid controls, only 4% had TSI and 3% had TBII. Extremely high TSI indices were found in all patients who had pretibial dermopathy (N = 10) or severe Graves' ophthalmopathy (N = 19) requiring orbital decompression. We conclude that both assays are highly sensitive and specific in diagnosing Graves' disease. The TSI bioassay was more sensitive (P less than 0.001) than the TBII radioreceptor assay in detection of Graves' disease. In our experience, both assays have proved useful in the diagnosis of euthyroid Graves' disease with ophthalmopathy and atypical manifestations of hyperthyroid Graves' disease.     

Prediction of remission after antithyroid drug treatment in Graves' disease

A prospective study was carried out to determine the factors which influence response to antithyroid drug treatment in Graves' disease and to assess their predictive value. Eleven variables were included in the assessment and were subjected to discriminant analysis, log rank test and "survival" analysis. The patients were observed for a considerable period (mean duration 51 months). Carbimazole (mean total dose 8 g) was given in combination with thyroxine for an average of eight months to 72 patients. Thirty-five patients relapsed and 37 remain in remission. Thyrotrophin binding inhibiting immunoglobulins (TBII) were detectable in 74 per cent of patients at diagnosis and thyroid stimulating antibodies detectable in 70 per cent. At the end of treatment thyrotrophin binding inhibiting immunoglobulins and thyroid stimulating antibodies were present in 36 and 27 per cent of patients respectively. Levels of thyrotrophin binding inhibiting immunoglobulins were significantly higher both before and after treatment in the group who relapsed, but were not of prognostic significance in an individual patient unless the value was extremely high (TBII index greater than 70). The presence of thyroid stimulating antibodies was of no value in predicting outcome. HLA typing confirmed the known association of Graves' disease with HLA B8 and HLA DR3 but neither of these antigens conferred and increased likelihood of relapse. The likelihood of relapse is shown to be directly related to the severity of the disease at the time of diagnosis, as measured by the serum total T3, and to the size of the thyroid gland; it is not affected by age, family history of thyroid disease or ophthalmopathy. The data indicate that antithyroid drug treatment can be expected to induce long-term remission in patients with mild disease (T3 less than 5 nmol/l) and small thyroids; carbimazole at this dose level is inappropriate for patients with severe disease (T3 greater than 9 nmol/) and large goitres.     

Prediction of outcome in Graves' disease after carbimazole treatment

In a prospective study to determine which factors would predict remission or relapse, 65 patients with hyperthyroid Graves' disease were treated for six months with a blocking replacement regimen of carbimazole, 40 mg daily, and triiodothyronine (T3). They were followed for one year after stopping treatment, by which time 32 (49 per cent) had relapsed. Although the treatment protocol, relapse rate and frequency of the HLA-DR3 antigen in this population were similar to those of a regionally separate Graves' population investigated previously, the predictive value of HLA-DR3 status together with thyroid stimulating antibody (TSAB) levels was strikingly different. In the present study there was no significantly abnormal distribution of any HLA antigen in the relapse group compared with those patients who achieved remission. Thyroid stimulating antibodies were detected in 62 patients (95 per cent) and fell significantly (p less than 0.05) after carbimazole treatment, irrespective of DR3 status or outcome; TSAB levels only became undetectable in nine patients (28 per cent) who subsequently relapsed and in nine patients (30 per cent) who maintained remission. T3-suppressed 20 min 123I uptake fell equally after treatment in the relapse and remission groups but continued to fall thereafter in the group which maintained remission. In these patients, 123I uptake was significantly lower at the end of the study period than at the end of treatment (p less than 0.05). Serum free T4 levels were higher before treatment in the patients who later relapsed than in those whose disease remitted (p less than 0.02). This proved the only significant marker associated with outcome but was of little predictive value in any patient. This study highlights the problem in predicting the outcome of antithyroid drug treatment, since even within the same country under similar conditions, divergent results have been obtained. It appears that the loci controlling the immune response in Graves' disease are likely to include genes lying outside the HLA-DR region. The results also suggest that the immunological effects of antithyroid drugs are maintained after stopping treatment in those patients whose disease remits.     

Use of an artificial neural network to predict Graves' disease outcome within 2 years of drug withdrawal

BACKGROUND: Graves' disease (GD) is an autoimmune disorder characterized by hyperthyroidism, which can relapse in many patients after antithyroid drug treatment withdrawal. Several studies have been performed to predict the clinical course of GD in patients treated with antithyroid drugs, without conclusive results. The aim of this study was to define a set of easily achievable variables able to predict, as early as possible, the clinical outcome of GD after antithyroid therapy. METHODS: We studied 71 patients with GD treated with methimazole for 18 months: 27 of them achieved stable remission for at least 2 years after methimazole therapy withdrawal, whereas 44 patients relapsed. We used for the first time a perceptron-like artificial neural network (ANN) approach to predict remission or relapse after methimazole withdrawal. Twenty-seven variables obtained at diagnosis or during treatment were considered. RESULTS: Among different combinations, we identified an optimal set of seven variables available at the time of diagnosis, whose combination was useful to efficiently predict the outcome of the disease following therapy withdrawal in approximately 80% of cases. This set consists of the following variables: heart rate, presence of thyroid bruits, psycological symptoms requiring psychotropic drugs, serum TGAb and fT4 levels at presentation, thyroid-ultrasonography findings and cigarette smoking. CONCLUSIONS: This study reveals that perceptron-like ANN is potentially a useful approach for GD-management in choosing the most appropriate therapy schedule at the time of diagnosis.     

Clinical value of thyrotropin binding inhibiting immunoglobulins (TBII) assay in hyperthyroidism

More than 500 sera were assayed for TBII under routine conditions using "Trak" assay in order to evaluate the sensitivity, specificity and prognostic interest of this determination in hyperthyroidism. The sensitivity for the diagnosis of Graves' disease was 83.5%, better in ophthalmopathic patients (93%) than in non ophthalmopathic patients (75%). The specificity was 99.4% with only one false positive in a hypothyroid patient. TBII level significantly decreases with carbimazole treatment except in patients who remain hyperthyroid. Determination of TBII before stopping carbimazole treatment or after surgery has a prognostic significance as a positive value indicates a relapse in almost all cases. Conversely, a fall of TBII to normal levels with treatment is insufficient to assess recovery. High levels are frequently observed after radioiodine therapy but do not indicate a poor prognosis.     

The thyroid stimulating hormone receptor in human disease.

The initial step in the action of thyrotropin (TSH) is its binding to the TSH receptor. TSH receptor antibodies are detected in up to 90% of patients with Graves' disease. Serial measurements of TSH receptor antibodies in patients with Graves' hyperthyroidism are helpful in predicting relapse. The TSH receptor was purified using affinity chromatography on wheat germ lectin agarose and TSH-agarose. Using an immunoblotting technique to characterize the TSH receptor, it was found to be an oligomeric glycoprotein consisting of three noncovalently bound subunits of Mr approximately 70,000, approximately 50,000 and approximately 35,000 which on reduction yield a single subunit of Mr approximately 25,000.     

A Study of Human Leukocyte D Locus Related Antigens in Graves'' Disease

An association between Graves' disease and the human leukocyte antigen (HLA) system has previously been reported. The disease was more strongly associated with the HLA D locus antigen Dw3 than with HLA B8. Products of the HLA D locus are determined by the interaction of test cells with standard typing lymphocytes, a technically difficult procedure. Recently, it has been possible to type serologically for D locus related (DRw) specificities on peripheral bone marrow-derived (B) lymphocytes. Blood B lymphocytes from 50 unrelated controls and 41 patients with Graves' disease were typed for seven HLA DRw specificities. 28 patients with Graves' disease (68%) were positive for DRw3, in contrast to 14 controls (28%); whereas only 21 patients (50%) were HLA B8 positive, compared with 13 (26%) controls. Thus, positivity for DRw3 afforded a relative risk for Graves' disease of 5.5, whereas that for HLA B8 amounted to 3.0. Additionally, a family with multiple cases of Graves' disease in which the disease was previously shown to be inherited with the haplotype, was linked to DRw2, which suggests that the susceptibility to the disease was inherited in association with that antigen. Two HLA B/glyoxalase recombination events were observed in this family; in both instances HLA DRw followed HLA B. This study thus demonstrates that the disease susceptibility gene for Graves' disease is in strong linkage disequilibrium with DRw3; however, it may be associated with other DRw specificities and inherited within family units in association with them.     

Thyrotoxic periodic paralysis: sonographic appearances of the thyroid

PURPOSE: The aim of the study was to describe the sonographic appearances of the thyroid in patients with thyrotoxic periodic paralysis (TPP). METHODS: Of the 25 patients diagnosed with TPP between January 1, 1998, and December 31, 2001, as identified by a search of our patient database, 13 had undergone sonography of the thyroid. We retrospectively reviewed the clinical records and thyroid sonograms of these 13 patients. The sonograms were assessed subjectively for thyroid size, echogenicity, vascularity, and the presence of solid nodules and cysts. RESULTS: Sonography showed abnormality of the thyroid in all 13 patients. In 11 patients (85%), sonography showed widespread hypoechogenicity (compared with the muscle) whose distribution was diffuse (6 patients) or patchy (5 patients) and diffusely distributed areas of hypervascularity (type 1 pattern). All 11 of these patients had a clinical diagnosis of Graves' disease. One patient (8%) had multinodular goiter and enlargement of the thyroid with multiple heterogeneous solid nodules and cysts (type 2 pattern); the clinical diagnosis was toxic multinodal goiter. One patient (8%) had a combination of type 1 and type 2 patterns and a clinical diagnosis of Graves' disease. CONCLUSIONS: The sonographic abnormalities of the thyroid in patients with TPP reflect the common underlying causes of thyrotoxicosis in the general population. The sonographic appearances associated with Graves' disease (type 1 pattern) were the most common abnormality detected. No sonographic features specific to TPP were identified.     

Autoantibody profiling of patients with autoimmune thyroid disease using a new multiplexed immunoassay method.

BACKGROUND: It has been proposed that only anti-thyroid-peroxidase (TPOAb) and not anti-thyroglobulin (TgAb) antibodies should be assayed in the diagnosis of autoimmune thyroid disease (AITD). METHODS: We analyzed the thyroid autoantibody profile with a multiplex bead array system, which allows simultaneous measurement of thyroid autoantibodies (FIDIS, BioMedical Diagnostics, Marne La Vallée, France). A total of 151 AITD patients (111 Hashimoto's thyroiditis and 40 Graves' disease) and 414 control patients were recruited to the study. RESULTS: The diagnostic sensitivity of TPOAb was greater than that of TgAb in both Hashimoto's thyroiditis (91.9% vs. 82.5%) and Graves' disease (82.5% and 52.5%, respectively), whereas the diagnostic specificity was similar (92.7% for TPOAb and 92.4% for TgAb). CONCLUSIONS: The presence of isolated positivity for TgAb in 6% of the Hashimoto's thyroiditis patients indicates that the use of only the TPOAb test does not guarantee sufficient diagnostic sensitivity. In the light of recent findings relating to the pathogenetic role of TgAb and TPOAb in Hashimoto's thyroiditis, knowledge of the autoantibody profile could allow the identification of sub-groups of patients with a different degree of activation of the thyroid autoimmune process.     

Anti-thyroid-stimulating hormone receptor antibodies determined by second-generation assay.

BACKGROUND: The aim of our study was to determine the frequency of anti-thyroid-stimulating hormone (TSH) receptor antibodies (TRAb) in Tunisian patients with Graves' disease (GD) and to compare the validity of TRAb to that of thyroperoxidase (TPO-Ab) and thyroglobulin antibodies (TG-Ab). METHODS: ELISA was used to determine the frequency of TRAb, TPO-Ab and TG-Ab in sera of 190 patients with GD. Patients were divided into four groups: those with untreated active GD (group A, n=71), those receiving treatment with anti-thyroid drugs (group B, n=85), those in relapse (group C, n=15) and those in remission (group D, n=19). Sera of 100 healthy blood donors served as controls. RESULTS: The sensitivity of TRAb for the diagnosis of GD (95.8%) was significantly higher than that of TPO-Ab (73.2%) and TG-Ab (42.2%) (p=0.0005 and p<10(-7), respectively). The positive rate for TRAb was lower in group B than in group A (70.6% and 95.8%, respectively; p=0.0001). The levels of TRAb were significantly higher in group A than in group B (mean 30.1 and 14.2 IU/L, respectively; p=0.006). CONCLUSIONS: TRAb, but neither TPO-Ab nor TG-Ab, is valuable in the diagnosis and management of patients with GD.     

Graves病眼型和眼型Graves病临床分析比较

目的比较分析Graves病眼型和眼型Graves病的不同临床特点,以供临床诊断。方法对69例Graves病眼型和38例眼型Graves病病例资料进行了临床分析。结果发现两者具有特征性眼症,眼睑退缩,上睑下落退缓,眼球前突症状。Graves病眼型患者自觉症状明显,且多双眼患病,双眼球突出,病程较长,而眼型Graves病患者多为青状年,约半数无任何自觉症状,且单眼患病多见,主要为单眼球突出。实验室检查眼型Graves病患者三碘甲状腺原氨酸(T3)、甲状腺素(T4)、促甲状腺素(TSH)一般均在正常范围内,Graves病眼型患者T3、T4、TSH常常有不同程度增高。结论Graves病眼型应根据临床表现,实验室检查T3、T4、131I进行确诊,眼型Graves病排除甲状腺功能亢进外,眼眶X线片、B超排除眶内占位性病变以确诊。临床医师应提高对Graves病眼型和眼型Graves病的认识,以减少误诊和漏诊。     

ANCA and predicting relapse in systemic vasculitis

We studied 60 patients with ANCA-positive systemic vasculitis(SV) to assess the prognostic significance of clinical and serologicalfeatures at presentation, and the value of sequential monitoringof ANCA, C-reactive protein (CRP) and ESR levels as predictorsof disease relapse. Patients were recruited at the time of diagnosis,treated with a standard protocol, and assessed monthly for oneyear. Clinical remission was achieved in 56/60 (93%), and ANCAbecame undetectable in 50/60 (83%) after treatment. During theone year follow-up period, disease relapses were seen in 23(38%) patients. No specific associations were observed betweeninitial disease presentation, initial ANCA level or ANCA antigenicspecificity and relapse. However, 13/23 (57%) of relapses werepreceded by a rise in ANCA a mean of 7.8 weeks earlier, whileat the time of relapse 19/23 (83%) were ANCA-positive. Risesin CRP and ESR occurred in 23/60 (38%) and 14/43 (33%), respectively,but were less closely associated with relapse than ANCA. A sustainedrise in ANCA was seen in six patients without relapse whileclinical relapse occurred with a negative ANCA in four. SequentialANCA monitoring at monthly intervals during disease remissionis of value, at least during the first year, in the predictionand diagnosis of relapse in SV, and is superior to measurementof CRP or ESR.     

Prediction of Remission after Antithyroid Drug Treatment in Graves' Disease

SUMMARY A prospective study was carried out to determine the factorswhich influence response to antithyroid drug treatment in Graves'disease and to assess their predictive value. Eleven variableswere included in the assessment and were subjected to discriminantanalysis, log rank test and ‘survival’ analysis.The patients were observed for a considerable period (mean duration51 months). Carbimazole (mean total dose 8 g) was given in combination withthy roxine for an average of eight months to 72 patients. Thirty-fivepatients relapsed and 37 remain in remission. Thyro-trophinbinding inhibitingimmunoglobulins (TBII) were detectable in74 per cent of patients at diagnosis and thyroid stimulatingantibodies detectable in 70 per cent. At the end of treatmentthyrotrophin binding inhibiting immunoglobulins and thyroidstimulating antibodies were present in 36 and 27 per cent ofpatients respectively. Levels of thyrotrophin binding inhibitingimmunoglobulins were significantly higher both before and aftertreatment in the group who relapsed, but were not of prognosticsignificance in an individual patient unless the value was extremelyhigh (TBII index>70). The presence of thyroid stimulatingantibodies was of no value in predicting outcome. HLA typingconfirmed the known association of Graves' disease with HLAB8 and HLA DR3 but neither of these antigens conferred an increasedlikelihood of relapse. The likelihood of relapse is shown to be directly related tothe severity of the disease at the time of diagnosis, as measuredby the serum total T3, and to the size of the thyroid gland;it is not affected by age, family history of thyroid diseaseor ophthalmopathy. The data indicate that antithyroid drug treatmentcan be expected to induce long-term remission in patients withmild disease (T3<5nmol/1) and small thyroids; carbimazoleat this dose level is inappropriate for patients with severedisease (T3>9 nmol/) and large goitres.     

Use of Chinese hamster ovary cell lines transfected with cloned human thyrotropin receptor for the measurement of thyroid-stimulating antibodies: advantages and difficulties

We compared the activities of thyroid-stimulating antibodies (TSAb) as measured with two cell lines (JP26 and JP26/26) transfected with cloned human thyrotropin (TSH) receptor and the values for TSAb measured on human thyrocytes cultures. Sera were obtained from patients with Graves' disease, before, during and after therapy with carbimazole (1-methyl-2-thio-3-carbethoxyimidazole). The activities of TSAb performed with the three assays correlated significantly. The TSAb technique using JP26/26 cells was as sensitive as the method performed on human thyrocyte cultures since positive TSAb values were found in 45 out of 47 (95.7%) newly diagnosed patients, in 100% of patients who relapsed after drug withdrawal and in none in remission. When the JP26 cell line was used, sensitivity decreased as the detection rate was only 53.2 and 55.5% before treatment and in case of relapse, respectively. The TSH receptors analysis showed a receptor density two times higher for JP26/26 than for JP26. JP26/26 cells provide similar diagnostic information on human thyrocytes in patients with Graves' disease. Moreover with these cells, the procedure for cell culture is less cumbersome and precision is better. However, rigorous culture conditions are required to maintain TSH receptor expression in transfected cells.     

血清T_3、T_4水平及T_3/T_4比率对预测抗甲状腺药物治疗Graves病预后的价值

118例Graves病初发患者,用他巴唑治疗6月,停药后随访1年,51例缓解,67例复发。结果表明,治前的血清T_3、T_3/T_4比率及治疗结束时的T_3,在复发组与缓解组之间均有统计学差异(P<0.0005,0.005及0.025).而血清T_4,无论治前或治末,均无统计学差别(P>0.05).血清T_3/T_4比率是否与预后有关,其实质是取决于血清T_3,尤其是治前的血清T_3。