Autoimmune hypothyroidism and hyperthyroidism in patients with Turner's syndrome

A high prevalence of autoimmune thyroid disease (AITD) has been described in Turner's syndrome (TS) but the extent of this association is controversial for the prevalence of thyroid autoantibody and the clinical impact of thyroid dysfunction. In this study we searched for thyroid disease and thyroid autoantibodies in patients with TS. Seventy-five unselected TS patients (age range 3-30 years) were studied. Sera were tested for thyroid hormones, thyrotropin (TSH), thyroglobulin (TG-ab) and thyroperoxidase (TPO-ab) antibodies. The TSH-receptor antibodies with thyroid-stimulating (TS-ab) or TSH-blocking activity (TSHB-ab) were measured in the IgG fraction using a bioassay. Ten out of 75 (13.3%) TS patients had AITD: eight had autoimmune thyroiditis (AT) (six with subclinical and two with overt hypothyroidism and one with euthyroidism) and one had Graves' disease. The prevalence of AITD increased significantly (p < 0.05) from the first (15%) to the third (30%) decade of life. The prevalence of TPO-ab and/or TG-ab (20%) was higher (p < 0.05) in TS than in age-matched female controls and increased from the first (15%) to the third (30%) decade of life. Clinical AITD was diagnosed in 46% of TS patients with TPO-ab and/or TG-ab. Thyroid-stimulating antibody was detected in the hyperthyroid patient, and TSHB-ab was found in one of eight patients with hypothyroid AT. It was concluded that: TS patients are at higher than average risk of developing AITD not only in adolescence and adult age but also in childhood; hypothyroidism, mainly subclinical, is the most frequent thyroid dysfunction; elevated TPO-ab and/or TG-ab alone do not imply thyroid dysfunction; TS-ab or TSHB-ab are always associated with thyroid dysfunction although most cases of autoimmune hypothyroidism are not due to the latter antibody.

An increased incidence of thyroid antibodies in patients with Turner's syndrome and their first degree relatives

Previous studies have suggested that there may be a link between Turner's syndrome and autoimmunity. The numbers involved in these studies have tended to be small and few studies have included family members. This study has compared the incidence of thyroid antibodies in the serum of 60 patients with Turner' syndrome and 50 of their mothers with 127 controls. Total T4 and TSH levels were also measured. Of the 60 patients with Turner's syndrome 18 (30%) were positive for either thyroid peroxidase (TPO) and/or thyroglobulin antibodies. The peak incidence of thyroid antibodies occurred at 13 years of age. 11 (22%) of the mothers were also antibody positive. The incidence of thyroid antibodies was significantly higher in both the patients with Turner's Syndrome (30 vs 1.7% p < 0.001) and their mothers (22 vs 6.6% p < 0.05) than in the control groups. The increased incidence of thyroid antibodies found in these patients and their mothers confirms that there is an association between Turner's Syndrome and autoimmunity. However unlike previous studies we found more patients were positive for thyroglobulin than TPO antibodies.

Frequency, clinical and laboratory features of thyroiditis in girls with Turner's syndrome. The Italian Study Group for Turner's Syndrome

A total of 478 patients, mean age 15.5 (3.6-25.3) years, suffering from Turner's syndrome, were studied in order to determine the frequency of autoimmune thyroiditis, which is defined as the presence of antithyroid antibodies (AT-Ab) and typical ultrasound findings. We found 106 (22.2%) patients positive for AT-Ab and of those 49 (10%) also had positive ultrasound findings, and were therefore considered to be affected by thyroiditis. This frequency is significantly higher (p < 0.001) than that seen in the normal population. Goitre was detected on clinical examination in only 16 (33%) and by ultrasound in 19 (39%) patients. Hormonal evaluation showed that 17 patients were euthyroid, 27 had compensated hypothyroidism, 2 were hypothyroid and 3 were in a hyperthyroid phase. Clinical signs or symptoms of hypothyroidism were absent in all hypothyroid patients. In patients with thyroiditis, neither a higher frequency of malformations and autoimmune diseases nor a correlation with karyotype, oestrogens or growth hormone therapy was found.

Thyroid autoantibodies, Turner's syndrome and growth hormone therapy

The prevalence of thyroid autoantibodies, i.e. thyroglobulin antibodies and antibodies to thyroid peroxidase, was analyzed in 89 girls, aged 3-16 years (mean age 10 years), with Turner's syndrome. The analyses were performed before the start of growth-promoting treatment and during a follow-up period of 1-5 years. The patients were divided into four groups according to karyotype as follows: group 1, 45, X (n = 63); group 2 with structural abnormalities of the X chromosome (n = 10); group 3 with mosaicism but no structural abnormalities of the X chromosome (n = 10); and group 4, with isochromosome X of the long arm (n = 12): 199 healthy girls aged 12 years, served as controls. Thyroid autoantibodies were demonstrated in 46 of 89 (52%) patients with Turner's syndrome compared with 34 of 199 (17%) age-matched control girls (p < 0.001), thus confirming the relationship between thyroid abnormalities and Turner's syndrome. There was also an increase in the prevalence of thyroid antibodies with age. Simultaneous presence of both autoantibodies was significantly more frequent in group 1 (45, X) and group 4 (isochromosome X of the long arm) than in group 3 (mosaicism) (p = 0.04 and p < 0.002, respectively) and significantly more frequent in group 4 than in group 1 (p < 0.05). During 12-60 months of growth-promoting treatment, no increase in the prevalence of thyroid antibodies was observed. The findings demonstrate the importance of continuous monitoring of thyroid function in girls with Turner's syndrome.

HLA-A, B and DR antigens in patients with gonadal dysgenesis

HLA (human leukocyte antigens) antigens A, B, and DR were determined in a series of 50 patients with gonadal dysgenesis (GD), separated into different groups according to karyotype. There were no significant differences in frequency of HLA antigen types between GD patients and the population control. When frequencies of the HLA antigens in the various GD patient groups by karyotype were compared, only one significant difference was found: HLA-A3 was more common among GD patients with isochromosome X than among GD patients with karyotype 45,X (p < 0.001, corr. p < 0.008). Although GD patients have a higher expectancy for development of autoimmune disorders, and in our 50 patients thyroglobulin and/or microsomal antibodies were detected in 20 (i.e., 40%), we failed to find any increased frequency of specific HLA antigen types known to be associated with juvenile autoimmune thyroiditis.

Serum CA 125 in a pregnancy generated by ovum donation

Serum CA 125 was measured by radioimmunoassay during the first trimester at intervals of 2 weeks in a woman with Turner's syndrome, who conceived following ovum donation from a healthy anonymous donor. Serum CA 125 concentrations were lower than or at the 10th percentile of the normal range. These findings imply that CA 125 may be secreted from the ovary in the first trimester, or produced at another site in response to stimuli from the ovary.

Increased frequency of HLA B17 antigen in girls with Turner syndrome and their fathers

HLA-A, -B and -DR antigen distribution was studied in 49 girls with Turner Syndrome (TS), in 43 of their parents, as well as in 433 controls. No increased frequency of DR3, DR4 was found in our group. However, an increased frequency of HLA B17 antigen was disclosed (18.3% in TS versus 6.4% in the controls, p < 0.001 and pc < 0.01). Furthermore, the HLA B17 antigen was of paternal origin in 77.7% of the cases. The interpretation of the present findings is quite difficult. Most likely, the findings are related to the chromosomal abnormality rather than to autoimmunity. It is quite possible that genes within the region of class I genes create unfavorable circumstances leading to the loss of the sex chromosome or, alternatively, genes in this region confer protection and prevent miscarriage of the affected fetus.

Long-term effect of human growth hormone therapy on the prevalence of autoantibodies in Turner syndrome. The Dutch Growth Hormone Working Group

Abnormalities of immune status, particularly a high prevalence (about 50%) of thyroid autoantibodies, have been reported before in Turner syndrome. Results are conflicting as regards other abnormalities of immune function. Growth hormone (GH) has immunomodulatory effects, but results of its effects on GH-deficient children are inconsistent. In this study, 42 girls with Turner syndrome, aged 7.3-19 years, are investigated before, during and after 4 years of human GH therapy. Girls over 12 years old also received ethinyl oestradiol. The prevalence of antithyroid antibodies was 16.7% initially, 35.3% after 24-45 months and 48% after 4 years of therapy though, as there was no control group, it was difficult to conclude that GH was enhancing their appearance. Hypothyroidism was extremely uncommon, and the growth response was no different in those who had the antibodies from those who had not. There were no dramatic increases in prevalence of any of the other antibodies investigated, though the prevalence of parietal cell antibodies was higher than expected.

Influence of HLA genotype on birth weight of patients with Turner syndrome

Growth failure starting before birth is a common characteristic in Turner syndrome, and its pathogenesis is still not completely explained. Experiments performed in mice and rats to test whether a genetic disparity between mothers and offspring and maternal immunological status have any influence on litter size have demonstrated that allogenic litters are significantly larger in size than genetically compatible ones. Studies in humans have given contrasting results, but some authors have found that heterozygosity at enzyme loci and in blood groups is positively correlated with intrauterine growth. HLA class I and II polymorphisms were defined in 53 patients with Turner syndrome and in their parents, and lymphocytotoxic antibody detection was performed in 36 mothers. These data were related to the patients' birth weight. The frequency of the HLA-B16 allele in patients with a birth weight greater than 10th centile was significantly higher in comparison with those less than 10th centile. HLA antigen sharing was present in 43 couples (81.1%). Mean birth weight was 2934 +/- 472 g in patients without HLA antigen parental sharing and 2721 +/- 529 g in those whose parents shared HLA antigens. The mean birth weight of the 10 patients whose parents do not share HLA antigens was significantly higher than that of the patients with parental HLA-B+ DR sharing (P less than 0.05) and not significantly highe than in those patients with parental HLA sharing at other HLA loci. Patients whose parents shared B+DR antigens also had significantly smaller birth weights than those with B and A+B+DR sharing (P less than 0.025 and P less than 0.025). No significant difference in mean birth weight was found in relation to other parameters, such as mother-child histocompatibility, HLA homozygosity and lymphocytotoxic production in the mothers.

Prevalence of autoantibodies to endocrine organs in girls with Ullrich-Turner syndrome aged 5-14 years

Endocrine function tests and a broad panel of autoantibodies to endocrine organs were assessed in 77 patients aged 5-14 years with Ullrich-Turner syndrome (UTS), who were included in the German UTS Multicenter Study. None of these patients had abnormal pituitary, thyroid or adrenocortical function, as assessed by the adequate hormone tests. Antibodies to thyroid microsomes were found in 3 of the 77 (3.9%), antibodies to thyroglobulin in 0/77, antibodies to adrenocortical cells in 1/77 (1.3%), gastric parietal cell antibodies in 2/77 (2.6%), and anterior pituitary cell antibodies in 3/77 (3.9%) probands. These prevalences were not significantly higher than those obtained in 154 age- and sex-matched normal control children when 2 control subjects were assigned to each patient with UTS. Our data do not show an increase in serological signs of endocrine autoimmunity in young patients with UTS suggesting that a putative association of these syndromes does not exist from birth and is not usually present in childhood. However, we cannot exclude the possibility that UTS is associated with factors that render these patients more susceptible to endocrine autoimmunity later in life.

Islet cell cytoplasmic antibodies (ICA) in diabetes and disorders of glucose tolerance

Islet cell cytoplasmic antibodies were determined in 85 individuals 60 to 74 years old with fasting hyperglycaemia, in 65 patients with cystic fibrosis, in 113 patients with pancreatitis, in 21 patients with Turner's phenotype, and in 135 first-degree relatives of patients with Type 1 (insulin-dependent) diabetes. Islet cell antibodies were absent in all 60 to 74-year-old subjects with fasting hyperglycaemia detected by screening, and who did not require insulin treatment within 3 years. Islet cell antibodies were also absent in all patients with pancreatitis, cystic fibrosis, or Turner's phenotype. Islet cell antibodies were detected in 2 out of 135 (1.5%) first-degree relatives of new Type 1 diabetic patients, and in 1 out of 371 (0.3%) non-diabetic control subjects. During 12 years of follow-up 1 of the 2 first-degree relatives with islet cell antibodies and the only positive control developed Type 1 diabetes. It is suggested that islet cell antibodies are primarily associated with Type 1 diabetes and not with other disorders of glucose tolerance.

Immunologic studies in Turner syndrome before and during treatment with growth hormone. The Dutch Growth Hormone Working Group

Immunologic studies of 14 girls with Turner syndrome were done before and during treatment with biosynthetic growth hormone (GH). Compared with control subjects, the patients before treatment had a decreased CD4/CD8 ratio and an increased number of cells bearing the natural killer cell marker CD16; serum immunoglobulin levels were within the normal range. During GH treatment some of the girls had a slight reduction in the percentage of CD20+ B cells, but we observed no impairment of B lymphocyte function as demonstrated by the normal in vivo antibody response to the primary antigen Helix Pomatia hemocyanin, administered 6 months after the start of GH treatment. The number of CD16+ natural killer cells returned to normal. Although the number of children with thyroid antibodies increased from two before treatment to five after 1 year, no conclusion about an adverse effect of GH is warranted, because the phenomenon might be part of the natural course of the disease. We conclude that girls with Turner syndrome have minor changes in some immunologic measurements and that GH treatment resulted in some alterations that have no effect on immune function.

Common variable immunodeficiency in association with Turner's syndrome

Common variable immunodeficiency is a heterogeneous syndrome which may occur at any age and may be associated with recurrent sinopulmonary and gastro-intestinal infections, atopic illness, autoimmune disorders and varying degrees of hypogammaglobulinaemia (1). The clinical syndrome is very similar to that described in X-linked agamma-globulinaemia but the mode of inheritance is unknown (2). In this communication, a patient with Turner's syndrome with X-isoX chromosomal pattern in conjunction with common variable immunodeficiency is reported.

[Turner's syndrome and autoimmune dysthyroidism]

The authors report a case of Turner's syndrome associated with Hashimoto's thyroiditis and present the various physiopathological hypotheses currently offered to explain the frequent association of an autoimmune pathology and a gonadal dysgenesis with an absence of X chromosome which is held responsible for autoimmunity. Is the chromosomal abnormality a factor predisposing to autoimmunity or does it result from a disturbance of the immune mechanism? Environmental factors, such as bacteria, viruses or some pollutants might be responsible for both the immune disorders and the chromosomal abnormality. The association of the two types of disease may also be accidental. In the present state of our knowledge, there is no answer to these questions.

Turner's syndrome: treatment of 203 patients with recombinant human growth hormone for one year. A multicentre study

A total of 203 patients with Turner's syndrome were treated with three different kinds of recombinant hGH preparations for one year. One hundred and seven patients were treated with hGH at a weekly dosage of 0.5 IU/kg, 71 with 1.0 IU.kg-1.week-1, and the remaining 25 patients with combined administration of 0.5 IU.kg-1.week-1 hGH and a small amount of anabolic steroid. All three treatment groups showed statistically significant growth increases during the treatment. Fifty percent of the patients treated with 0.5 IU.kg-1.week-1 and 80% of the patients treated with 1.0 IU.kg-1.week-1 showed growth rates more than 2 cm per year greater than pretreatment values or beyond the second SD of the untreated growth rate. Plasma somatomedin C levels were elevated and no remarkable advances in bone age were observed during the treatment. Antibody against hGH was observed in 71.4% and 10.8% of the methionyl-hGH and methionine-free-hGH treated patients, respectively. However, the antibodies did not suppress the growth promoting effect of methionyl-hGH. Otherwise, there were no significant changes in physical or laboratory examinations. No glucose intolerance was observed. These results indicate that hGH treatment is useful for the acceleration of growth velocity in patients with Turner's syndrome.

Autoimmunity, HLA, Gm and Km polymorphisms in Turner's syndrome

Considering the high frequency of autoimmune disorders in Turner's syndrome and the close relationship between autoimmunity, HLA and immunoglobulin constant region gene polymorphisms, we studied 46 patients with Turner's syndrome, by determination of autoantibodies, HLA histoglobulins and Gm and Km allotypes. OSA and in particular PCA resulted significantly more frequent in patients than in the controls. A higher frequency of HLA-A31, B38 antigens and of blanks at HLA-A locus was found in Turner's subjects than in the controls. A31 was significantly more frequent in autoantibody positive patients while B38 was more frequent in autoantibody negative Turner's subjects than in the controls. DR4 antigen was present only in autoantibody negative patients. Gm 3; 23; 5* phenotype was significantly less frequent, while Gm 3;..; 5* phenotype was more frequent in patients than in controls. Our data confirm the higher incidence of autoimmunity disorders in Turner's syndrome than in normal subjects. Particular HLA and immunoglobulin types seem to mark this condition. The increase in the blank frequency at A locus could be explained by the presence of a rare antigen at HLA-A locus or a particularly elevated homozygous condition in these subjects.

Defective polymorphonuclear chemotaxis in patients with Turner's syndrome (45,X)

Polymorphonuclear leucocytes from patients with full Turner's syndrome (45,X) revealed a significantly weaker chemotactic response towards zymosan-activated serum than normal female and male controls. Random mobility and chemokinetic responses of polymorphonuclear leucocytes were normal, and so were all locomotive responses of mononuclear phagocytes in patients with Turner's syndrome. A subclinical polymorphonuclear leucocyte chemotactic defect is suggested by these results, and a possible regulatory effect by a gene(s) in chromosome X (and Y) that must be present in a full double dose to preserve this function can be proposed. Control of polymorphonuclear leucocyte chemotaxis may represent yet another exception to the general rule of X-inactivation.

Age-related anti-thyroid antibodies and thyroid abnormalities in Turner syndrome

One hundred pediatric patients with Turner syndrome were studied to determine the correlation between the presence of anti-thyroid antibodies with age and karyotype, and the value of anti-thyroid antibody titers as predictors of subsequent thyroid abnormalities. (54 patients = 45,X; 46 = other karyotypes.) The frequency of positive titers of anti-thyroid antibodies increased linearly with cumulative age. Anti-parietal cell and anti-adrenocortical cell antibodies were not increased in these patients (1.3 and 2.6% respectively). The ability to use positive anti-thyroid antibody titers to predict the development of thyroid abnormalities increased from age 10 years and became statistically significant at ages 13-17 years for the whole group as well as 45,X patients. None of the patients had clinical symptoms of thyroid dysfunction although 22% developed thyroid abnormalities, which included elevated TSH, low T4, and/or goiter.

Growth hormone treatment in Turner's syndrome

A total of 21 patients with Turner's syndrome were treated with pituitary hGH and/or somatrem for 1-2 years. Plasma non-esterified fatty acid increased significantly from 0.52 +/- 0.06 to 1.30 +/- 0.09 mEq/litre at 4 hours after injection of hGH, 4 IU (mean +/- SEM, p less than 0.001). Basal plasma IGF-1 levels were within the normal range; however, they increased significantly at 24 hours after the first three daily injections of hGH, 4 IU (basal, 0.92 +/- 0.14 units/ml; 24 hours, 1.39 +/- 0.16 units/ml; 48 hours, 1.68 +/- 0.19 units/ml; 72 hours, 1.91 +/- 0.22 units/ml; p less than 0.001). For long-term treatment, patients were given hGH, 4-16 IU for 1-2 years. Their height velocity increased to 5.5 +/- 1.2 cm/year and 5.1 +/- 0.6 cm/year in the first and second year of the treatment, respectively. These values were greater than the pretreatment value of 3.6 +/- 0.8 cm/year (p less than 0.001). Antibody against hGH was observed in 60% of the patients at the end of 12 months of somatrem treatment. Otherwise there were no significant changes in physical, blood or urine examinations. These results indicate that hGH treatment is useful for the acceleration of growth velocity in patients with Turner's syndrome.

Serologically H-Y antigen-negative XO mice

In a series of six independent experiments organ homogenates of 35 mice of the XX, XO or XY sex chromosome constitutions were absorbed using three different anti-H-Y antisera raised in inbred female LEW rats. Residual activities of absorbed antisera were tested in the Raji cell, complement-dependent, cytotoxicity test. Homogenates of various tissues, including the gonads, of XX and XO females were equally unable to absorb H-Y antibodies, indicating that tissues of these mice do not carry the H-Y antigen. In contrast, XY male homogenates fully absorbed H-Y antibodies of antisera at concentrations of 1/2 to 1/4. We discuss our findings with special attention to the problem of the existence of one or more H-Y antigens and, to the genetic regulation of the expression of this antigen.