Serological overlap between lupus erythematosus, rheumatoid arthritis, and thyroid auto-immune disease

Thyroid function and immune profile in rheumatoid arthritis. A controlled study

The aim of our study was to determine the prevalence of thyroid dysfunction and autoimmune abnormalities in rheumatoid arthritis (RA) and to further investigate the possible association between D-penicillamine and autoimmune thyroiditis. For this purpose, one hundred and one unselected consecutive patients with RA and 70 age and sex matched controls were studied prospectively. Evaluation included a complete history and physical examination with special attention to symptoms suggestive of thyroid pathology, routine laboratory and serologic immune profile, plus determination of serum levels of thyroxine (T4), triiodothyronine (T3), thyroid stimulating hormone (TSH), antibodies to thyroid peroxidase (AbTPO) and TSH receptor antibodies (TRAB). Serum thyroxine binding globulin (TBG) was measured in all subjects with high thyroid hormone levels, whereas free T3 and T4 concentrations were determined in all individuals with abnormal T3, T4, TSH or TBG. Six patients with hyperhyroidism, 3 with hypothyroidism and 1 with the euthyroid hyperthyroxinemia (EH) syndrome were found, whereas four of the controls had hyperthyroidism. Thirteen patients and 6 controls had high AbTPO levels whereas no one had high TRAB. No association was detected between thyroid abnormalities and any serologic RA finding. Furthermore, no correlation between thyroid dysfunction and elevated AbTPO's was found. A relatively high prevalence of thyroid dysfunction (9,9%) and subclinical autoimmune thyroiditis (12,9%), the latter indicated by elevated AbTPO's, was found in our RA patients. These figures were higher than those in the control group (5,7% and 8,6% respectively), but the difference did not reach statistical significance. Of further interest may be our finding that, despite anecdotal reports blaming D-penicillamine for cases of autoimmune thyroiditis, the incidence of the latter was similar among recipients and nonrecipients of the drug. Similarly, TRAB were not detected in any patient treated with D-penicillamine.

Thyroid disorders in Korean patients with systemic lupus erythematosus

Although autoimmune thyroid diseases have been associated with systemic lupus erythematosus (SLE), the prevalence of thyroid disorder is controversial. To clarify the prevalence of thyroid disorder in Korean patients with SLE, thyroid functions and diseases were evaluated in 63 SLE patients. Of these patients, Hashimoto's thyroiditis (9.5%) as well as euthyroid sick syndrome (14.3%) were more common than Graves' disease (4.8%). The prevalence of antithyroid autoantibodies (antimicrosomal and/or antithyroglobulin autoantibodies) in SLE was 27.0%. High titers of these autoantibodies were mainly detected in Hashimoto's thyroiditis. These results suggested that thyroid diseases are not uncommon in SLE and autoimmune thyroid diseases are possible manifestations in some patients with SLE. Antithyroid autoantibodies may be good predictors for the detection of Hashimoto's thyroiditis developing in SLE.

A case of rheumatoid arthritis associated with silent thyroiditis

A 41-year-old female with rheumatoid arthritis had nontender enlarged thyroid gland. Thyroid function tests revealed increased concentrations of serum free T3 (FT3, 10.8 pmol/L) and free T4 (FT4, 31.1 pmol/L) with suppressed concentration of thyrotropin (TSH, lower than 0.1 mU/L) and low 24-hour thyroidal radioactive iodine uptake (1.6%). Serum thyrotropin receptor antibody (TRAb) was negative (0%) and she had positive anti-thyroglobulin and anti-microsomal antibodies. A diagnosis of silent thyroiditis was made based on laboratory findings. Serum concentrations of FT3 and FT4 normalized one month later without treatment. The causal relationship between the two diseases is discussed.

The forces driving autoimmune disease

There are two classes of autoimmune disease, organ-specific and non-organ specific or systemic. That cells producing autoantibodies are selected by antigen is strongly suggested by the presence of mutations and high affinity antibody. T-cells are pivotal in all forms of autoimmunity as evidenced by the therapeutic benefit of anti-T-cell monoclonals such as anti-CD4, and the frequent development of high affinity IgG autoantibodies. The production of anergic T-cells by the use of non-depleting anti-CD4 in the presence of antigen is discussed with particular reference to its potential for immunological intervention in autoimmune disease. It is possible to identify T-cell epitopes in organ-specific autoimmunity using pathogenic T-cell clones or hybridomas to identify the peptide sequences which are reactive. Antigen-specific therapy may ultimately be based on such peptide epitopes. The specificity of the T-cells in systemic autoimmunity is still obscure, but there is some evidence that reactivity with certain germ-line idiotypes can lead to the development of systemic autoimmunity. The possibility of stimulating B-cells specific for auto-antigens such as DNA becomes feasible if a complex of antibody and DNA is taken up by these specific B-cells and processed idiotype is presented to T-helpers specific for those idiotype epitopes. Evidence is presented that there may be pre-existing defects in the target organ in certain organ-specific disorders, and the evidence for a glycosylation defect in the IgG in patients with rheumatoid arthritis is explored. It is noted that the spouses of probands with rheumatoid arthritis is explored. It is noted that the spouses of probands with rheumatoid arthritis also tend to have this glycosylation defect and this raises the possibility of an effect due to an environmental factor, such as a microbial infection. Molecular mimicry of autoantigens by microbes can stimulate autoreactive cells by their cross-reactivity. It is emphasized that cross-reaction which gives rise to the priming of autoreactive T-cells could give rise to the establishment of a chronic autoimmune state. In animals with normal regulatory immune systems, such induced autoimmunity is ultimately corrected and it is only in animals where there are defects in regulation, that autoimmunity persists. Thus, there are many factors giving rise to autoimmunity, and the diseases are rightly regarded as multifactorial in origin.

Systemic lupus erythematosus and thyrotoxicosis: a hitherto little recognised association

Six patients are reported in whom systemic lupus erythematosus (SLE) and thyrotoxicosis coexisted. All had four or more American Rheumatism Association criteria (1982) for the diagnosis of SLE and had clinical manifestations and function test results characteristic of hyperthyroidism (except for one who had been thyroidectomised previously). In three patients the diagnosis of hyperthyroidism preceded that of SLE, in two patients both diseases began simultaneously, and only in one was the diagnosis of thyrotoxicosis made after that of SLE. It is suggested that hyperthyroidism associated with SLE may be a form of presentation of thyroiditis. This association may pass unnoticed because of the similarity of some clinical manifestations.

Prevalence of thyroid disease and abnormal thyroid function test results in patients with systemic lupus erythematosus

Although thyroid disease has been associated with other autoimmune conditions, it is not well recognized in systemic lupus erythematosus (SLE) patients. We found that in 332 SLE patients hospitalized during a 5-year period, the overall prevalence of diagnosed thyroid disease (7.5%) was similar to that in other female populations, but the prevalence of diagnosed hypothyroidism (6.6%) was unexpectedly high. There was also a high frequency of abnormal thyroid function test results in 175 SLE patients without diagnosed thyroid disease who underwent laboratory screening. More than 45% of these patients had elevated levels of thyroid-stimulating hormone, 34% had low T3 determinations, and 18% had high antimicrosomal antibody titers. When patients were categorized into "functional groups," some showed evidence of the "euthyroid sick syndrome" (15%), but many more had laboratory test results suggestive of true (5%) or incipient (39%) primary hypothyroidism. We conclude that abnormal thyroid function test results are common in patients with SLE and that hypothyroidism, especially, should be considered when evaluating symptoms and signs in SLE patients.

Role of aberrant HLA-DR expression and antigen presentation in induction of endocrine autoimmunity

Immune responses are initiated by HLA-DR+ cells, which present antigen to T cells. Observations that HLA-DR may be experimentally induced on thyroid epithelium and that HLA-DR occurs on thyrocytes in autoimmune thyroid diseases suggest a mechanism of autoimmunity with special relevance to organ-specific diseases. This involves the local aberrant expression of HLA-DR antigens by epithelial cells and their subsequent capacity to present autoantigens occurring on their surfaces to T lymphocytes. For autoantigens which T cells recognise infrequently because of their restricted tissue location and low concentration in the circulation, T-cell tolerance is unlikely, and so induction of autoreactive T cells would occur. Because interferon is the best known inducer of DR antigen expression and viral infections may predate endocrine autoimmunity, the following sequence seems likely: local viral infection which causes interferon production, or other local environmental factors which would induce DR expression, presentation of autoantigens, and subsequent autoimmune T-cell induction. These T cells would activate effector B and T cells. Whether the initial induction of autoimmune T cells leads to autoimmune disease would depend on factors such as abnormalities of the suppressor T-cell pathway, reported to coexist with autoimmunity and necessary to induce autoimmune disease in mice. This mechanism of autoimmune disease induction explains vague associations with viral infections and long latency periods before disease becomes manifest and gives a simple explanation for the well-documented association between HLA-DR and autoimmune diseases in man.

Bullous pemphigoid and Hashimoto's thyroiditis

Both bullous pemphigoid (BP) and Hashimoto's thyroiditis (HT) are suspected of being autoimmune disorders. Each disorder has been reported with other diseases associated with autoimmune phenomena. Thyroid disorders have been reported with BP, but never well documented HT with thyroid antibodies. We report a patient with hypothyroidism due to HT who subsequently developed BP. The importance of this association is discussed, particularly as it relates to autoimmunity.

Cutaneous lupus erythematosus and autoimmune thyroiditis

A 19-year-old girl presented with cutaneous lupus erythematosus and hypothyroidism, and developed a thyrotoxic crisis when chloroquine therapy was discontinued.

Multi-system immunologically mediated disease: T lymphocyte deficiency and thyroid immunologic disease--a report of four cases

Four cases are described of multi-system immunologically-mediated disease (systemic lupus erythematosus (two cases), polymyositis, and sarcoidosis) in association with thyroid autoimmunity. In all patients there was evidence of T lymphocyte deficiency, namely poor response of peripheral blood lymphocytes (PBL) to T cell mitogens (four cases) and failure or decreased ability to become sensitized to dinitrochlorobenzene (three cases), although two patients were ill and two were being treated with steroids. There was also evidence of B lymphocyte deficiency since PBL of no patient responded normally to pokeweed mitogen, a B and T lymphocyte mitogen. In two patients there was evidence of cell-mediated immunity to human thyroid antigens. Although thyroid stimulating antibody was not detected in the one patient with Graves' disease tested, significant titres of thyroid antibodies were detected in all cases. Possible relationships between T lymphocyte deficiency, organ-specific autoimmune disease and immunologically-mediated multi-system disorders are discussed.

Rheumatoid arthritis--a sequel to HBsAg hepatitis

Reported here is the first case of classic rheumatoid arthritis emerging in the setting of hepatitis B surface antigen (HBsAG)-positive viral hepatitis. Polyfocal arthritis and myalgia, lymphadenopathy and constitutional symptoms were the presenting manifestations of anicteric hepatitis in this 23 year old man. Smooth muscles antibodies, HBsAg and "rheumatoid" factor were demonstrated initially. The hepatocellular disease, biopsy-proved, resolved completely and without recurrence; clinically and serologically. Latex test positivity persisted, increasing in titer, and polyarthritis progressed to fulfull criteria for classic rheumatoid arthritis, with erosions on roentgenogram and characteristic synovial disease. After 60 months of follow-up, the rheumatoid synovitis has continued to progress despite appropriate therapy. The arthritis of viral hepatitis and the significance of rheumatoid factor in association with hepatocellular disease are discussed.

The clinical manifestations of systemic lupus erythematosus: a Cairo-Glasgow co-operative study

The clinical features of 78 patients with SLE seen in Cairo and Glasgow are reviewed. Raynaud's phenomenon was recorded more frequently here than in previous series. The value of serial measurements of anti-DNA antibodies, C3 and C4 in the management of SLE is discussed. Although antibodies to native DNA paralleled the disease course in only a minority of SLE patients anti-DNA antibodies were present during all major SLE exacerbations and could be diagnostically useful. Serious systemic infections complicating the management of SLE patients could occur and their diagnosis is discussed.

Tubuloreticular structures and antinuclear antibodies in autoimmune and non-autoimmune diseases

Tissues obtained at random from patients suffering from autoimmune and non-autoimmune diseases were studied for the presence of tubuloreticular structures (TRS). It could be demonstrated that the occurrence of TRS in renal tissue is not a specific characteristic of systemic lupus erythematosus whereas the presence of such structures in skin tissue might be suggestive for this disease. The serum of some of the patients could be studied for the presence of antinuclear antibodies (ANA). A statistically significant correlation was found between TRS and ANA in the group of patients with autoimmune diseases. The possibility is discussed that this correlation might favour the theory that viruses may be involved in the aetiology of autoimmune diseases, particularly of systemic lupus erythematosus.

Disseminated intravascular coagulation complicating propylthiouracil therapy. A case description of a 16-year-old girl

A 16-year-old girl with thyrotoxicosis, treated successfully for two years with propylthiouracil, developed a purpuric rash, prolonged pro- thrombin time, increased split fibrin products, elevated antinuclear anti body titer and glomerular changes. The symptoms abated after ther apy with heparin and prednisone, although the ANA titer remained elevated. This is presented as the first reported instance of dissem inated intravascular clotting resulting from propylthiouracil therapy.

Discoid lupus erythematosus at the site of an intradermal injection of killed Staphylococcus aureus

A case of chronic discoid lupus erythematosus is described in which there were recurrent relapses following infections, and at the same time repeated `flare ups' at the site of a delayed hypersensitivity reaction to Staphylococcus aureus. The appearance of the injection site changed from that of a typical `tuberculin reaction' to a patch of discoid lypus erythematosus which was confirmed both histologically and by immunofluorescence.

Pathological changes of thymic epithelial cells and autoimmune disease in NZB, NZW and (NZB x NZW)F1 mice

An extensive histological study was carried out of NZB, NZW and (NZB × NZW)F₁, (BWF₁), mice of all ages between birth and 18 months. The thymuses of these mice were compared to those of three normal mouse strains. The study of the NZW mice showed that these mice, although they only occasionally have weakly positive Coombs' tests, may develop a renal disease probably of an autoimmune nature, similar to that of the NZB and the BWF₁ mice. Mice of all the three NZ strains developed lesions of the skin, liver, intestines, lymphatic tissues and kidneys much resembling those occurring in human systemic lupus erythematosus (SLE), neonatally thymectomized mice and, with the exception of the renal changes, the lesions of graft versus host disease.

The comparative study of the thymus in autoimmune and normal strains, revealed that important changes of the large medullary epithelial cells, involved in the formation of Hassall's corpuscles, occur very early in the three autoimmune strains. In the NZB mice the large epithelial cells are severely decreased in number in the first weeks following birth. The depletion of epithelial cells could be ascribed to a secondary degeneration of these cells soon after birth.

In contrast with the NZB mice, an extensive hyperplasia of the large epithelial cells and Hassall's corpuscles was observed in the NZW and BWF₁ mice, and was already apparent in the newborn animal. Many of the epithelial aggregates seemed to have been invaded by lymphoid cells. Both epithelial cells and the lymphoid cells engaged in this process showed a variety of degenerative changes. As in the NZB, a depletion of epithelial cells occurred in a later phase, at the age of 8 months in the BWF₁ and at 1 year in the NZW. In the majority of young mice of the normal strains invasion of islands of epithelial cells by lymphoid cells may also be observed, although this process is far less extensive than in the autoimmune strains and does not result in either epithelial hyperplasia or depletion of epithelial cells.

The described phenomenon of invasion of epithelial structures in the thymus by subsequently disintegrating lymphoid cells seems to support Burnet's concept, that so-called `forbidden clones' of lymphoid cells are eliminated in the thymus.

Ankylosing spondylitis: a late re-evaluation of 92 cases

Ninety-two patients who satisfied the criteria proposed by Kellgren for the diagnosis of ankylosing spondylitis were re-evaluated by clinical, radiological and laboratory parameters after an average length of illness of 18.7 years. The following associated clinical lesions were studied: aortic insufficiency 8%, heart block 3%, iritis 11%, and other associated lesions. Long-term effects of x-ray therapy were evaluated by comparing irradiated and non-irradiated patients; no significant difference was noted in the clinical course of these two treatment groups. On serum protein electrophoresis no characteristic dysproteinemia was demonstrated; in no instance was there a marked hypergammaglobulinemia. Test results for rheumatoid factor, antinuclear factor and antithyroglobulin were all within the range expected for a normal population. In addition to bilateral sacroiliitis, several other characteristic radiological lesions, such as anterior spondylitis, were present in a high percentage of cases. It is suggested that the diagnostic criteria proposed by Kellgren, although useful, should be enlarged and refined.

Idiopathic retroperitoneal fibrosis associated with an arteritis

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Auto-immune reactions in ulcerative colitis

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