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Hsu JC, Fan KC, Wang TC, Chuang SL, Chao YT, Lin TT, Huang KC, Lin LY, Lin LC. Long-term Effect of Thyrotropin-binding Inhibitor Immunoglobulin on Atrial Fibrillation in Euthyroid Patients. Endocr Pract 2024; 30:537-545. [PMID: 38574890 DOI: 10.1016/j.eprac.2024.03.391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/29/2024] [Accepted: 03/27/2024] [Indexed: 04/06/2024]
Abstract
OBJECTIVE Individuals with hyperthyroidism are at an increased risk of atrial fibrillation (AF), but the association between autoantibodies and AF or cardiovascular mortality in individuals who have returned to normal thyroid function remains unclear. METHODS The study utilized electronic medical records from National Taiwan University Hospital between 2000 and 2022. Each hyperthyroidism patient had at least 1 thyrotropin-binding inhibiting immunoglobulin (TBII) measurement. The relationship between TBII levels and the risk of AF and cardiovascular mortality was assessed using multivariable Cox regression models and Kaplan-Meier survival analysis. RESULTS Among the 14 618 enrolled patients over a 20-year timeframe, 173 individuals developed AF, while 46 experienced cardiovascular mortality. TBII values exceeding 35% were significantly associated with an elevated risk of AF for both the first TBII (hazard ratio {HR} 1.48 [1.05-2.08], P = .027) and mean TBII (HR 1.91 [1.37-2.65], P < .001). Furthermore, after free T4 levels had normalized, a borderline association between first TBII and AF (HR 1.59 [0.99-2.56], P = .056) was observed, while higher mean TBII increased AF (HR 1.78 [1.11-2.85], P = .017). Higher first and mean TBII burden continued to significantly impact the incidence of cardiovascular mortality (HR 6.73 [1.42-31.82], P = .016; 7.87 [1.66-37.20], P = .009). Kaplan-Meier analysis demonstrated that elevated TBII levels increased the risk of AF and cardiac mortality (log-rank P = .035 and .027, respectively). CONCLUSION In euthyroid individuals following antithyroid treatment, elevated circulating TBII levels and burden are associated with an elevated risk of long-term incident AF and cardiovascular mortality. Further reduction of TBII level below 35% will benefit to clinical outcomes.
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Affiliation(s)
- Jung-Chi Hsu
- Division of Cardiology, Department of Internal Medicine, National Taiwan University Hopistal Jinshan Branch, New Taipei City, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan
| | - Kang-Chih Fan
- Division of Endocrinology and Metabolism, Department of Internal Medicine, National Taiwan University Hospital Hsinchu Branch, Hsinchu City, Taiwan
| | - Ting-Chuan Wang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Lin Chuang
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Ting Chao
- Department of Medical Research, National Taiwan University Hospital, Taipei, Taiwan
| | - Ting-Tse Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Kuan-Chih Huang
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Division of Cardiology, Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsinchu, Taiwan.
| | - Lian-Yu Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan; Master's Program in Smart Medicine and Health Informatics, NTU, Taipei, Taiwan
| | - Lung-Chun Lin
- Division of Cardiology, Department of Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; Cardiovascular Center, National Taiwan University Hospital, Taipei, Taiwan; Department of Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
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Gao Y, Qiu L, Yu S, Cheng X. Thyroid stimulating receptor autoantibodies. Clin Chim Acta 2024; 559:119700. [PMID: 38697458 DOI: 10.1016/j.cca.2024.119700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 04/25/2024] [Accepted: 04/28/2024] [Indexed: 05/05/2024]
Abstract
Thyroid-stimulating hormone receptor autoantibodies (TRAbs) play a crucial role as pathogenic antibodies in both the diagnosis and management of Graves' disease (GD). GD, an autoimmune disease resulting from a combination of genetic and environmental factors, is the most common cause of hyperthyroidism. With advancements in technology for TRAb detection and the availability of automated commercial kits, TRAb has become an essential clinical laboratory marker for the diagnosis of GD, as well as extra-thyroidal manifestations like Graves' ophthalmopathy (GO). This article provides a comprehensive review of TRAb, encompassing its clinical assays along with its significance in the clinical setting.
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Affiliation(s)
- Yumeng Gao
- Department of Laboratory Medicine, Peking Union Medical College & Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing 100730, PR China
| | - Ling Qiu
- Department of Laboratory Medicine, Peking Union Medical College & Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing 100730, PR China; State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College & Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing 100730, PR China.
| | - Songlin Yu
- Department of Laboratory Medicine, Peking Union Medical College & Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing 100730, PR China
| | - Xinqi Cheng
- Department of Laboratory Medicine, Peking Union Medical College & Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing 100730, PR China.
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3
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Parsons SR, Wilson-Pogmore A, Sullivan TJ. Percutaneous triamcinolone injection for upper eyelid retraction in thyroid eye disease. FRONTIERS IN OPHTHALMOLOGY 2024; 4:1388197. [PMID: 38984143 PMCID: PMC11182225 DOI: 10.3389/fopht.2024.1388197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/15/2024] [Indexed: 07/11/2024]
Abstract
Purpose To evaluate percutaneous triamcinolone (TA) injection efficacy in treating upper eyelid retraction (UER) for Australian thyroid eye disease (TED) patients. Methods We conducted a retrospective analysis across 8 years and multiple diverse Australian centres identified UER patients who received TA injections. A single operator administered 40mg/1ml TA through upper eyelid skin. Assessments at 4-6 weeks and subsequent eyelid measurements gauged treatment response and complications. Results 24 patients and 25 eyelids were included in the study. 91.6% were female, mean age 40.8 ± 10.3 years with mean follow-up of 17.5 months (± 18.5). Pre-treatment MRD1 was 6.2mm ± 1.4, and we observed a mean improvement of 2.2mm from pre-treatment to post-treatment (p<0.001). The mean UER measurement before treatment (defined as MRD1 - 4.0mm) was 3.0mm ± 1.3 (range, 0-6mm). After treatment, the mean UER measurement was -0.1mm. Quality of life (QOL) assessment improved significantly, from pre-treatment score of 4.13 ± 2.4 to post-treatment 8.0 ±1.7 (p<0.001). Conclusions Percutaneous injection of TA is an effective and safe treatment option for UER in patients with TED. This technique can be performed without upper eyelid eversion, which makes it more tolerable for patients and less complex for the operator compared to the transconjunctival injection approach. Our results show a significant improvement in MRD1 and UER, as well as patient QOL. Moreover, we found a low rate of complications (4.2% induced ptosis) and no cases of raised intraocular pressure. Percutaneous TA injection can greatly reduce the need for eyelid lowering surgery in this patient population.
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Affiliation(s)
- Shaun R. Parsons
- Division of Oculoplastic and Orbital Surgery, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Department of Ophthalmology, Queensland Children’s Hospital, Brisbane, QLD, Australia
| | - Ario Wilson-Pogmore
- Division of Oculoplastic and Orbital Surgery, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Faculty of Medicine, Griffith University, Gold Coast, QLD, Australia
| | - Timothy J. Sullivan
- Division of Oculoplastic and Orbital Surgery, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
- Department of Ophthalmology, Queensland Children’s Hospital, Brisbane, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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4
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Fotso Simo SC, Lin KS, Bukharovich I. Thyrotoxic Cardiomyopathy: A Rare Case of Thyroid Storm Presenting as De Novo Heart Failure. Cureus 2024; 16:e57924. [PMID: 38725773 PMCID: PMC11079851 DOI: 10.7759/cureus.57924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Thyroid storm and heart failure represent formidable challenges in clinical practice. Their coexistence, however, poses an even greater threat to the patient's well-being. To facilitate early recognition and appropriate management, an understanding of the complex interplay between these two conditions is crucial. Through comprehensive assessment, vigilant monitoring, and prompt intervention, outcomes can be improved and the morbidity and mortality mitigated. We present a rare case of a 40-year-old male who presented with severe de novo heart failure and a concurrent thyroid storm. Despite an initial left ventricular systolic ejection fraction of 20% and evidence of global dilatation and hypokinesis on echocardiography, appropriate management resulted in improved clinical status and ultimately recovery of cardiac function.
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Affiliation(s)
| | - Kai Shiang Lin
- Internal Medicine, State University of New York Downstate Medical Center, Brooklyn, USA
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Naga Nitin LT, Lakkundi S, S L SR, Shanthaiah DM, Datta SG, Annavarapu U, Sarathi V. High Diagnostic Accuracy of Thyroid-Stimulating Hormone (TSH) Receptor Antibodies in Distinguishing Graves' Disease and Subacute Thyrotoxicosis in the Indian Population. Cureus 2024; 16:e54303. [PMID: 38496158 PMCID: PMC10944639 DOI: 10.7759/cureus.54303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Thyrotoxicosis is a common clinical condition encountered in endocrine practice. Graves' disease and subacute thyroiditis are the two common causes of thyrotoxicosis and often have overlapping clinical and biochemical features. 99mTc thyroid scintigraphy is the most commonly used confirmatory test to differentiate the two conditions but is not available in the majority of the second-tier cities of India. However, obtaining thyroid stimulating hormone (TSH) receptor antibodies (TSHrAb), another accurate test to differentiate the two conditions, in second-tier cities by outsourcing to labs in major cities is a feasible option nowadays. However, the data on the performance of TSHrAb to differentiate the two conditions in Indian patients is limited. Hence, we have evaluated the diagnostic accuracy of TSHrAb in the Indian population to differentiate Graves' disease and subacute thyroiditis. MATERIALS AND METHODS This prospective study was conducted on 115 consecutive newly diagnosed thyrotoxicosis patients presenting to the Department of Endocrinology at a tertiary health care centre in India. Clinical parameters like throat pain, duration of symptoms, and grade of goitre were noted. Measurement of total tri-iodothyronine (TT3), total thyroxine (TT4), TSH, TSHrAb, and 99mTc thyroid scintigraphy were performed in all participants. All participants were followed up at least for six months after the recruitment. Increased tracer uptake (>4%) and/or increased thyroid to parotid trace uptake ratio (>2.5) were used to diagnose Graves' disease. RESULTS Eighty-one and 34 patients were diagnosed with Graves' disease and subacute thyroiditis, respectively. TT3/TT4 ratio had low diagnostic accuracy (area under the curve (AUC): 0.6, best cut-off: 15.6, sensitivity: 53.1%, specificity: 79.4%). TSHrAb had the best AUC (0.9) to distinguish Graves' disease from subacute thyroiditis (cut-off: 2.0 IU/L, sensitivity: 97.5%, specificity: 100%). In contrast, the kit manufacturer's reference range (1.75 IU/L) was slightly more sensitive (98.8%), but less specific (94%). CONCLUSION The TT3/TT4 ratio is not a good test to differentiate Graves' disease and subacute thyroiditis. TSHrAb is accurate in distinguishing Graves' disease from subacute thyroiditis and a level of 2.0 may be a more accurate cut-off to differentiate the two conditions in the Indian population.
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Affiliation(s)
- Lakshmi T Naga Nitin
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, IND
| | - Shilpa Lakkundi
- Department of Pathology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, IND
| | - Sagar Reddy S L
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, IND
| | - Dhananjaya M Shanthaiah
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, IND
| | - Sumanas G Datta
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, IND
| | - Umalakhmi Annavarapu
- Department of Biochemistry, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, IND
| | - Vijaya Sarathi
- Department of Endocrinology, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, IND
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Jansen HI, Gohy HG, Boelen A, Bisschop PH, Hillebrand JJ, Heijboer AC. Stability of TSH receptor antibody concentrations and comparability of its immunoassays. Clin Chim Acta 2023; 548:117505. [PMID: 37543354 DOI: 10.1016/j.cca.2023.117505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 08/07/2023]
Abstract
BACKGROUND AND AIMS Graves' Disease (GD) is an autoimmune form of hyperthyroidism where autoantibodies are directed against the TSH-receptor (TSH-receptor antibodies; TRAb). GD is suspected if TRAb concentrations are above a pre-specified cut-off value. TRAb concentrations are measured using immunoassays. This study aimed to compare the performance of the recently implemented Alinity immunoassay to the KRYPTOR and Cobas TRAb immunoassays. MATERIALS AND METHODS Left-over serum samples in which TRAb concentrations were measured (KRYPTOR) were used. First, TRAb stability at -20 °C for four to six years and up to five freeze-thaw cycles were assessed. Second, TRAb measurements (n = 436) were repeated using the Alinity and Cobas immunoassay and results (scored as positive/negative based on cut-off value) were compared. RESULTS TRAb results were stable over five years and up to five freeze-thaw cycles. When comparing immunoassays, 86.2% of the results were similar. Total discrepancy differed between the immunoassays (5.4% Cobas vs Alinity, 8.8% Alinity vs KRYPTOR, 13.3 % Cobas vs KRYPTOR). The KRYPTOR immunoassay showed more negative TRAb results than Cobas and Alinity. CONCLUSION The Alinity immunoassay showed comparable TRAb results, even though slightly more positive results compared to the KRYPTORand slightly more negative results compared to the Cobas immunoassay were seen.
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Affiliation(s)
- Heleen I Jansen
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Laboratory Medicine, Endocrine Laboratory, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Department of Laboratory Medicine, Endocrine Laboratory, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Gastroenterology, Endocrinology & Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Héloïse G Gohy
- Amsterdam UMC Location University of Amsterdam, Department of Laboratory Medicine, Endocrine Laboratory, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Anita Boelen
- Amsterdam UMC Location University of Amsterdam, Department of Laboratory Medicine, Endocrine Laboratory, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Gastroenterology, Endocrinology & Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Peter H Bisschop
- Amsterdam Gastroenterology, Endocrinology & Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Department of Endocrinology and Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Jacquelien J Hillebrand
- Amsterdam UMC Location University of Amsterdam, Department of Laboratory Medicine, Endocrine Laboratory, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Gastroenterology, Endocrinology & Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands
| | - Annemieke C Heijboer
- Amsterdam UMC Location Vrije Universiteit Amsterdam, Department of Laboratory Medicine, Endocrine Laboratory, De Boelelaan 1117, 1081 HV Amsterdam, the Netherlands; Amsterdam UMC Location University of Amsterdam, Department of Laboratory Medicine, Endocrine Laboratory, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Gastroenterology, Endocrinology & Metabolism, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands; Amsterdam Reproduction & Development Research Institute, Meibergdreef 9, 1105 AZ Amsterdam, the Netherlands.
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7
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Sun Y, Su M, Wang M, Zhang R, Wang S, Tan J, Jia Q, Li H, Meng Z. Establishment and analytical performance of light-initiated chemiluminescence assay method for detecting thyrotropin receptor antibody. Biomark Med 2023; 17:349-357. [PMID: 37338244 DOI: 10.2217/bmm-2022-0666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
Aim: To evaluate double-antibody competitive light-initiated chemiluminescence assay method for detecting the thyrotropin receptor antibody. Materials & methods: The optimal working concentrations of competitive antibody and rTSHR were confirmed by checkerboard titration. Assay performance was assessed by precision, linearity, accuracy, limit of blank and clinical evaluation. Results: The coefficient of variation for repeatability and intermediate precision was 3.9-5.9 and 0.9-1.3%, respectively. The correlation coefficient was 0.999 by least squares linear fitting in linearity evaluation. The relative deviation ranged from -5.9 to 4.1%, and the limit of blank of the method was 0.13 IU/l. Compared with the Roche cobas system (Roche Diagnostics, Mannheim, Germany), the relationship between the two assays was shown to be significantly correlative. Conclusion: The light-initiated chemiluminescence assay method for detecting thyrotropin receptor antibody is a rapid, novel and accurate method for thyrotropin receptor antibody measurement.
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Affiliation(s)
- Ying Sun
- Department of Clinical Laboratory, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
| | - Mengxue Su
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
| | - Miao Wang
- Department of Nuclear Medicine, Tianjin Medical University Second Hospital, Pingjiang Road, No. 23, Hexi District, Tianjin, 300211, People's Republic of China
| | - Ruyi Zhang
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
| | - Shen Wang
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
| | - Jian Tan
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
| | - Qiang Jia
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
| | - Huiqiang Li
- School of Medical Laboratory, Tianjin Medical University, Tianjin, 300203, People's Republic of China
| | - Zhaowei Meng
- Department of Nuclear Medicine, Tianjin Medical University General Hospital, Tianjin, 300052, People's Republic of China
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Abstract
Thyroid-associated orbitopathy, the most common extrathyroidal manifestation of Graves' disease, is characterized by orbital inflammatory infiltration and activation of orbital fibroblasts, which mediates de novo adipogenesis, excessive production of hyaluronan, myofibroblast differentiation and ultimately tissue fibrosis. Interactions among T cells, B cells, and orbital fibroblasts result in their activation and perpetuation of orbital inflammation as well as tissue remodelling. T helper 17 cells belong to a newly identified pathogenic CD4+ T cell subset which possesses prominent pro-inflammatory and profibrotic capabilities. Thyroid stimulating hormone receptor/insulin-like growth factor-1 receptor crosstalk and the downstream signalling pathways of both receptors represent the major mechanisms leading to activation of orbital fibroblasts. Thyroid stimulating hormone receptor autoantibody is the disease specific biomarker of great clinical relevance and utility. There is growing evidence that oxidative stress, gut microbiome and epigenetics also play a role in the pathogenesis and their manipulation may represent novel therapeutic strategies.
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Affiliation(s)
- Alan Chun Hong Lee
- Division of Endocrinology and Metabolism, Department of Medicine, LKS Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China; Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz 55101, Germany.
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz 55101, Germany.
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9
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Brancatella A, Torregrossa L, Viola N, Sgrò D, Casula M, Basolo F, Materazzi G, Marinò M, Marcocci C, Santini F, Latrofa F. In Graves' disease, thyroid autoantibodies and ultrasound features correlate with distinctive histological features. J Endocrinol Invest 2023:10.1007/s40618-023-02044-0. [PMID: 36840841 DOI: 10.1007/s40618-023-02044-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/15/2023] [Indexed: 02/26/2023]
Abstract
PURPOSE Laboratory, imaging, and pathological features of Graves' disease (GD), although well characterized, have been barely correlated each other. Aim of the study was to link laboratory and ultrasound characteristics of GD with its pathological features. METHODS We correlated laboratory and ultrasound data at the time of diagnosis in 28 consecutive GD patients who underwent thyroidectomy with their pathological features, i.e., lymphocytic infiltration and follicular hyperplasia (both classified as mild or severe). RESULTS Thyroid volume correlated positively with the levels of FT4 (P = 0.002, r2 = 0.42), FT3 (P = 0.011, r2 = 0.22), autoantibodies to thyroglobulin (TgAbs) (P = 0.016, r2 = 0.32), autoantibodies to thyroid peroxidase (TPOAbs) (P = 0.011, r2 = 0.34) and the extent of lymphocytic infiltration (P = 0.006 comparing mild to severe lymphocytic infiltration) but not with the levels of autoantibodies to the thyrotropin receptor (TRAbs) and to follicular hyperplasia. Compared to subjects with mild lymphocytic infiltration, those with severe lymphocytic infiltration showed higher levels of TgAbs (316 vs 0.0 IU/mL, P < 0.0001) and TPOAbs (295 IU/mL vs 14 IU/mL, P < 0.0001) and similar levels of TRAbs (7.5 vs 13 IU/mL, P = 0.68). Compared to patients with mild, those with severe follicular hyperplasia had similar levels of TgAbs (76 vs 30 IU/mL, P = 0.31) and TPOAbs (251 IU/mL vs 45 IU/mL, P = 0.26) but higher levels of TRAbs (39 vs 7.2 IU/mL, P < 0.001). CONCLUSION In GD, TgAbs and TPOAbs levels correlate with the extent of lymphocytic infiltration, TRAbs levels with the degree of follicular hyperplasia. Thyroid volume, the main factor influencing the severity of hyperthyroidism, is related to lymphocytic infiltration and not to follicular hyperplasia.
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Affiliation(s)
- A Brancatella
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - L Torregrossa
- Pathology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, 56126, Pisa, Italy
| | - N Viola
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - D Sgrò
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - M Casula
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - F Basolo
- Pathology Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, 56126, Pisa, Italy
| | - G Materazzi
- Surgery Unit, Department of Surgical, Medical, Molecular Pathology and Critical Area, University of Pisa, 56126, Pisa, Italy
| | - M Marinò
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - C Marcocci
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - F Santini
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy
| | - F Latrofa
- Endocrinology Unit, Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa, Italy.
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10
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Boyle DC, Mullally JA. Thyrotoxicosis after COVID-19 Infection with a Delay in Graves' Disease Antibody Positivity. Case Rep Endocrinol 2023; 2023:8402725. [PMID: 37089262 PMCID: PMC10118873 DOI: 10.1155/2023/8402725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/03/2023] [Accepted: 02/23/2023] [Indexed: 04/25/2023] Open
Abstract
Background and Objective. Mounting evidence implicates COVID-19 as a cause of thyroid dysfunction, including thyrotoxicosis due to both thyroiditis and Graves' disease (GD). In this report, we present a case of thyrotoxicosis following COVID-19 infection that was ultimately found to represent GD with significantly delayed diagnostic serum antibody positivity. Case Report. A 65-year-old woman with a history of uncomplicated COVID-19 infection one month prior, presented to the Emergency Department with exertional dyspnea and palpitations, and was found to be in atrial fibrillation with rapid ventricular response (AF with RVR). Labs showed subclinical hyperthyroidism and the patient was started on a beta-blocker and methimazole. One month later, thyroid-stimulating immunoglobulin (TSI) resulted negative and thyroid function tests had normalized. The clinical picture suggested thyroiditis, and methimazole was stopped. One month later, the patient again presented in AF with RVR, with labs showing overt biochemical thyrotoxicosis. Antibodies were re-tested, and the thyrotropin receptor antibody (TRAb) and TSI resulted positive, confirming GD. Discussion. Most notable in this case is the feature of delayed GD antibody positivity: the diagnostic immunoassay for GD resulted negative one and two months after infection, but was ultimately positive three months after infection. To the authors' knowledge, this represents the longest delayed antibody positivity reported to date, amongst cases of new-onset GD following COVID. Conclusion. The clinical course of GD following COVID-19 infection is highly variable. This case underscores the need for vigilance in monitoring for delayed GD antibody positivity due to the important therapeutic implications of distinguishing thyroiditis from GD.
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Affiliation(s)
- Dennis C. Boyle
- Westchester Medical Center, Department of Medicine, Section of Internal Medicine, Valhalla, USA
| | - Jamie A. Mullally
- Westchester Medical Center, Department of Medicine, Division of Endocrinology and Metabolism, Valhalla, USA
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11
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Quantitation of Free Thyroxine by Equilibrium Dialysis and Liquid Chromatography-Tandem Mass Spectrometry. Methods Mol Biol 2022; 2546:485-492. [PMID: 36127615 DOI: 10.1007/978-1-0716-2565-1_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
A method for free thyroxine measurement in human serum using equilibrium dialysis followed by liquid chromatography tandem mass spectrometry (LC-MS/MS) is described. Free thyroxine in serum is first separated from protein-bound thyroxine by equilibrium dialysis and then measured by LC-MS/MS.
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12
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Liu T, Zhang X, Long L, Zhou L, Chen J, Li M, Gao Y, Zhou X, Han X, Ji L. Clinical evaluation of an automated TSI bridge immunoassay in the diagnosis of Graves' disease and its relationship to the degree of hyperthyroidism. BMC Endocr Disord 2022; 22:218. [PMID: 36045442 PMCID: PMC9429690 DOI: 10.1186/s12902-022-01114-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 07/27/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The rapid and accurate detection of thyroid-stimulating hormone (TSH) receptor antibodies has always been an urgent need for the clinical diagnosis and management of Graves' disease (GD). We aimed to evaluate the use of an automated thyroid-stimulating immunoglobulin (TSI) bridge immunoassay in the diagnosis of GD and to analyze the relationship between TSI and the degree of hyperthyroidism. METHODS A total of 227 new-onset GD patients, 29 Hashimoto thyroiditis, 43 non-autoimmune thyroid diseases and 37 euthyroid controls were consecutively recruited. All participants accepted the measurement of their serum thyroid function and thyroid-associated antibodies, including TSI being measured by an Immulite 2000 bridge immunoassay and TSH receptor autoantibodies (TRAb) being measured by a third-generation Roche electrochemiluminescence immunoassay. The quantitative consistency between the TSI and TRAb detection methods was analyzed by using Passing-Bablok regression and Bland-Altman plots. The diagnostic performance for GD was assessed by receiver operating characteristic (ROC) curve analysis. RESULTS Among 227 GD patients (174 females and 53 males, with a mean age of 39 years), the quantitative TSI was positively correlated with TRAb (r = 0.8099). According to the cut-off values proposed by the manufacturers (TSI: 0.55 IU/L, TRAb: 1.75 IU/L), the positive rates of TSI and TRAb in new-onset GD patients were 96.92% and 95.15%, respectively. Both TSI and TRAb levels positively correlated with FT4 levels (TSI: r = 0.243, TRAb: r = 0.317; all P < 0.001) and FT3 levels (TSI: r = 0.288, TRAb: r = 0.360; all P < 0.001) in new-onset GD patients. The ROC analysis showed that the optimal TSI cut-off value was 0.577 IU/L for GD diagnosis in this Chinese population, with a sensitivity of 96.92% and a specificity of 97.25%, respectively. The optimal TRAb cut-off value of was 1.38 IU/L, with a sensitivity of 96.92% and a specificity of 99.08%. There were no significant differences between the cut-off values obtained through the ROC analysis and those provided by the manufacturer for both TSI and TRAb when calculating their sensitivity and specificity in diagnosing GD. Among the 8 newly diagnosed GD cases with discordant qualitative antibody results, TSI was more likely than TRAb to match the clinical diagnosis of GD (6 TSI-positive vs. 2 TRAb-positive patients). CONCLUSION The automated TSI bridge immunoassay was positively correlated with thyroxine levels in new-onset GD patients and was more likely to be consistent with the clinical diagnosis of GD than with that of TRAb. The positive Immulite 2000 TSI cut-off value of 0.577 IU/L for GD diagnosis in the Chinese population were close to the value recommended by the manufacturer.
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Affiliation(s)
- Tianqi Liu
- Department of Endocrinology and Metabolism, Peking University People's Hospital, N0.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, 100044, China
| | - Xiuying Zhang
- Department of Endocrinology and Metabolism, Peking University People's Hospital, N0.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, 100044, China.
| | - Li Long
- Department of Endocrinology and Metabolism, the Second People's Hospital, Guiyang, 550000, China
| | - Lingli Zhou
- Department of Endocrinology and Metabolism, Peking University People's Hospital, N0.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, 100044, China
| | - Jing Chen
- Department of Endocrinology and Metabolism, Peking University People's Hospital, N0.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, 100044, China
| | - Meng Li
- Department of Endocrinology and Metabolism, Peking University People's Hospital, N0.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, 100044, China
| | - Ying Gao
- Department of Endocrinology and Metabolism, Peking University People's Hospital, N0.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, 100044, China
| | - Xianghai Zhou
- Department of Endocrinology and Metabolism, Peking University People's Hospital, N0.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, 100044, China
| | - Xueyao Han
- Department of Endocrinology and Metabolism, Peking University People's Hospital, N0.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, 100044, China
| | - Linong Ji
- Department of Endocrinology and Metabolism, Peking University People's Hospital, N0.11, Xi Zhi Men Nan Da Jie, Xicheng District, Beijing, 100044, China.
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López Ortega JM, Martínez PS, Acevedo-León D, Capell NE. Anti-TSH receptor antibodies (TRAb): Comparison of two third generation automated immunoassays broadly used in clinical laboratories and results interpretation. PLoS One 2022; 17:e0270890. [PMID: 35877662 PMCID: PMC9312426 DOI: 10.1371/journal.pone.0270890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/21/2022] [Indexed: 11/18/2022] Open
Abstract
Graves’ disease (GD) is the most common cause of hyperthyroidism in iodine-replete populations. It is an autoimmune disease caused by autoantibodies to the TSHR (TRAb). Although the diagnostic is mainly clinical, measuring TRAb improves accuracy and provides valuable prognostic information. The aim of this study was to compare the performance of two of the most widely used immunoassays i.e., EliA™ anti-TSH-R and Elecsys® anti-TSH-R. We have carried out a comparative study measuring TRAb by the two immunoassays in consecutive sera samples referred to the laboratory for TRAb measurement. Autoantibodies were measured in all samples in parallel by the two techniques. The two techniques were highly concordant as demonstrated by a Cohen’s kappa of 0.82. At the manufacturer recommended cut-off, sensitivity of Elecsys® TRAb test was higher (100% vs. 96.6%), while specificity of the EliA™ TRAb test was higher (99.4% vs. 95.3%). In most patients TRAb are detected by any of two tests which are both well suited for Clinical Laboratories use. However, a higher specificity may constitute an advantage for measurement used not for screening but for diagnostic purposes, as anti-TSH-R is.
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Affiliation(s)
- José María López Ortega
- Autoimmunity and Allergy Division, Clinical Laboratories, Dr. Peset University Hospital, Valencia, Spain
- * E-mail:
| | - Pilar Salvador Martínez
- Autoimmunity and Allergy Division, Clinical Laboratories, Dr. Peset University Hospital, Valencia, Spain
| | - Delia Acevedo-León
- Hormones and Immunology Division, Clinical Laboratories, Dr. Peset University Hospital, Valencia, Spain
| | - Núria Estañ Capell
- Hormones and Immunology Division, Clinical Laboratories, Dr. Peset University Hospital, Valencia, Spain
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14
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Abdalaziz A, Vanka R, Bartholomew P, Vennart N, Vernazza J, Stewart K, Tsatlidis V, Narayanan K, Weaver JU, Razvi S. The prevalence and significance of nonuniform thyroid radio-isotope uptake in patients with Graves' disease. Clin Endocrinol (Oxf) 2022; 97:100-105. [PMID: 35244288 PMCID: PMC9313567 DOI: 10.1111/cen.14709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 02/16/2022] [Accepted: 02/18/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To evaluate the prevalence and clinical significance of nonuniform technetium (99m Tc) uptake among patients with Graves' disease (GD). DESIGN, PATIENTS AND MEASUREMENTS Patients with GD, referred between July 2005 and March 2018, had Tc99 - uptake scans and TSH-receptor antibody (TRAb) measured before antithyroid drug (ATD) therapy. Risk of relapse after ATD cessation was monitored until June 2021 and compared between GD patients based on uptake patterns. RESULTS Of the 276 GD patients (mean age, 49.8 years; 84% female), 25 (9.0%) had nonuniform Tc99 uptake. At diagnosis, individuals with nonuniform uptake were older (mean age of 61.8 vs. 48.5 years, p < .001), had lower mean thyroid hormone levels (free thyroxine: 36.3 vs. 45.4 pmol/L, p = .04 and free triiodothyronine: 10.0 vs. 17.8 pmol/L, p < .001) and median TRAb levels (4.2 vs. 6.6 U/L, p = .04) compared with those with a uniform uptake. Older age was a significant predictor for the presence of nonuniform uptake in GD patients; odds ratio (95% confidence intervals) of 1.07 (1.03 - 1.10). The risk of relapse was similar in both groups after a median (IQR) follow-up of 41 (13-74) months after ATD cessation (56.0% vs. 46.3%, respectively); hazard ratio (95% confidence intervals) of 1.74 (0.96-3.15). CONCLUSIONS Nonuniform radio-isotope uptake is seen in 1 in 11 patients with GD which could be misdiagnosed as toxic multinodular goitre if TRAb levels are not measured. Treatment of GD patients with nonuniform radio-isotope uptake with ATD therapy as first-line appears to be equally effective as compared with those with uniform uptake. TRAb testing should be the main diagnostic test for patients with suspected GD with radio-labelled uptake scans being reserved for those who are TRAb negative.
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Affiliation(s)
- Altayeb Abdalaziz
- Department of EndocrinologyGateshead Health NHS Foundation TrustGatesheadUK
| | - Ramesh Vanka
- Department of EndocrinologyGateshead Health NHS Foundation TrustGatesheadUK
| | - Peter Bartholomew
- Department of Medical PhysicsSunderland and South Tyneside Hospitals NHS Foundation TrustSunderlandUK
| | - Nicholas Vennart
- Department of Medical PhysicsSunderland and South Tyneside Hospitals NHS Foundation TrustSunderlandUK
| | - Jonathan Vernazza
- Department of EndocrinologyGateshead Health NHS Foundation TrustGatesheadUK
| | - Kathryn Stewart
- Department of EndocrinologyGateshead Health NHS Foundation TrustGatesheadUK
| | | | | | - Jolanta U Weaver
- Department of EndocrinologyGateshead Health NHS Foundation TrustGatesheadUK
- Centre for Life, Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Salman Razvi
- Department of EndocrinologyGateshead Health NHS Foundation TrustGatesheadUK
- Centre for Life, Translational and Clinical Research InstituteNewcastle UniversityNewcastle upon TyneUK
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15
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Meling Stokland AE, Ueland G, Lima K, Grønning K, Finnes TE, Svendsen M, Ewa Tomkowicz A, Emblem Holte S, Therese Sollid S, Debowska A, Singsås H, Landsverk Rensvik M, Lejon H, Sørmo DE, Svare A, Blika S, Milova P, Korsgaard E, Husby Ø, Breivik L, Jørgensen AP, Sverre Husebye E. Autoimmune Thyroid Disorders in Autoimmune Addison Disease. J Clin Endocrinol Metab 2022; 107:e2331-e2338. [PMID: 35226748 PMCID: PMC9113809 DOI: 10.1210/clinem/dgac089] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Indexed: 01/19/2023]
Abstract
CONTEXT Autoimmune thyroid disease is the most common endocrine comorbidity in autoimmune Addison disease (AAD), but detailed investigations of prevalence and clinical course are lacking. OBJECTIVE This work aimed to provide comprehensive epidemiological and clinical data on autoimmune thyroid disorders in AAD. METHODS A nationwide registry-based study including 442 patients with AAD and autoimmune thyroid disease were identified through the Norwegian National Registry of Autoimmune Diseases. RESULTS Of 912 registered AAD patients, 442 (48%) were diagnosed with autoimmune thyroid disease. A total of 380 (42%) had autoimmune hypothyroidism. Of the 203 with available thyroid function tests at time of diagnosis, 20% had overt hypothyroidism, 73% had subclinical hypothyroidism, and 7% had thyroid levels in the normal range. Negative thyroid peroxidase antibodies was found in 32%. Ninety-eight percent were treated with levothyroxine, 5% with combination therapy with liothyronine or thyroid extracts, and 1% were observed without treatment. Seventy-eight patients (9%) were diagnosed with Graves disease (GD), of whom 16 (21%) were diagnosed with autoimmune hypothyroidism either before onset or after remission of GD. At the end of follow-up, 33% had normal thyroid hormone levels without antithyroid-drugs or levothyroxine treatment. The remaining had either active disease (5%), had undergone ablative treatment (41%), or had developed autoimmune hypothyroidism (21%). CONCLUSION The true prevalence of hypothyroidism in AAD is lower than reported in the current literature. Careful consideration of the indication to start thyroxin therapy is warranted. Long-term remission rates in GD patients with AAD are comparable to recent reports on long-term follow-up of patients without AAD.
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Affiliation(s)
| | - Grethe Ueland
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
| | - Kari Lima
- Department of Medicine, Akershus University Hospital, 1474 Nordbyhagen, Norway
| | - Kaja Grønning
- Department of Medicine, Akershus University Hospital, 1474 Nordbyhagen, Norway
| | - Trine E Finnes
- Department of Endocrinology, Innlandet Hospital Trust, 2318 Hamar, Norway
- Department of Endocrinology, Oslo University Hospital, 0372 Oslo, Norway
| | | | | | | | - Stina Therese Sollid
- Department of Medicine, Drammen Hospital, Vestre Viken Health Trust, 3004 Drammen, Norway
| | | | - Hallvard Singsås
- Department of Endocrinology, St. Olavs Hospital, 7006 Trondheim, Norway
| | | | - Helle Lejon
- Division of Internal Medicine, University Hospital of North Norway, 9019 Tromsø, Norway
| | - Dag-Erik Sørmo
- Division of Medicine, Levanger Hospital, 7600 Levanger, Norway
| | - Anders Svare
- Division of Medicine, Nord-Trøndelag Hospital Trust, 7800 Namsos, Norway
| | - Sigrid Blika
- Division of Medicine, Telemark Hospital, 3719 Skien, Norway
| | - Petya Milova
- Division of Medicine, Telemark Hospital, 3719 Skien, Norway
| | - Elin Korsgaard
- Division of Medicine, Vestre Viken Hospital Trust, 3612 Kongsberg, Norway
| | - Øystein Husby
- Department of Medicine, Bærum Sykehus, 1346 Gjettum, Norway
| | - Lars Breivik
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
| | - Anders P Jørgensen
- Department of Endocrinology, Oslo University Hospital, 0372 Oslo, Norway
| | - Eystein Sverre Husebye
- Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway
- Department of Clinical Science, University of Bergen, 5021 Bergen, Norway
- K. G. Jebsen Center for Autoimmune Disorders, University of Bergen, 5021 Bergen, Norway
- Correspondence: Eystein Sverre Husebye, MD, PhD, Department of Clinical Science, University of Bergen, N-5021 Bergen, Norway.
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16
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Fukahori K, Sawano K, Yoshida H, Nagasaki K. Asymmetrical Graves' disease in children: potential usefulness of potassium iodide monotherapy. BMJ Case Rep 2022; 15:e249571. [PMID: 35459658 PMCID: PMC9036365 DOI: 10.1136/bcr-2022-249571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2022] [Indexed: 11/03/2022] Open
Abstract
A male junior high school student presented with failure to gain weight and acceleration of growth for 2 years. Free triiodothyronine and free thyroxine levels were elevated, and the thyroid-stimulating hormone (TSH) level was suppressed. TSH receptor antibody (TRAb) and thyroid-stimulating antibody were negative. On I-123 thyroid scintigraphy, iodine uptake was most pronounced in the upper pole of the right lobe. The patient was initially diagnosed with asymmetrical TRAb-negative Graves' disease (GD). His thyroid hormone level normalised with potassium iodide (KI) alone, and he became TRAb-positive 4 months after the initiation of KI therapy. This case demonstrates a rare presentation of GD that was initially TRAb-negative, which had asymmetrical iodine uptake on a thyroid scan and was confirmed to be TRAb positivity during the follow-up. KI monotherapy could be one of the effective treatment options for GD that is initially TRAb-negative.
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Affiliation(s)
- Kyoko Fukahori
- Department of Pediatrics, Tsuruoka Municipal Shonai Hospital, Tsuruoka, Yamagata, Japan
| | - Kentaro Sawano
- Department of Pediatrics, Tsuruoka Municipal Shonai Hospital, Tsuruoka, Yamagata, Japan
- Division of Pediatrics, Department of Homeostatic Regulation and Development, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
| | - Hiroshi Yoshida
- Department of Pediatrics, Tsuruoka Municipal Shonai Hospital, Tsuruoka, Yamagata, Japan
| | - Keisuke Nagasaki
- Division of Pediatrics, Department of Homeostatic Regulation and Development, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
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17
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Baek HS, Lee J, Jeong CH, Lee J, Ha J, Jo K, Kim MH, Cho JH, Kang MI, Lim DJ. The Prediction Model Using Thyroid Stimulating Immunoglobulin Bioassay For Relapse of Graves’ Disease. J Endocr Soc 2022; 6:bvac023. [PMID: 35441120 PMCID: PMC9012332 DOI: 10.1210/jendso/bvac023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Indexed: 11/30/2022] Open
Abstract
Objective Thyroid-stimulating immunoglobulin (TSI) bioassay has a better ability to predict the relapse rate of Graves’ disease (GD) than the thyroid-stimulating hormone (TSH)-binding inhibitory immunoglobulin method in terms of measuring the TSH receptor antibody. However, the optimal TSI bioassay cutoff for predicting relapse after antithyroid drug (ATD) withdrawal is not well evaluated. Methods This retrospective study enrolled GD patients who had been treated with ATD and obtained their TSI bioassay <140% from January 2010 to December 2019 in a referral hospital. Results Among 219 study subjects, 86 patients (39.3%) experienced relapse. The TSI bioassay value of 66.5% significantly predicted the relapse of GD (P = 0.049). The group with a TSI bioassay value > 66.5% were expected to show a 23.8% relapse rate at 2 from ATD withdrawal, and the group with a TSI < 66.5% had a 12.7% relapse rate based on Kaplan-Meier curves analysis. The TSI bioassay showed a good ability to predict relapse GD in the female group (P = 0.041) but did not in the male group (P = 0.573). The risk scoring based on the nomogram with risk factors for GD relapse, which was constructed to overcome the limitation, increased the predictive ability of GD relapse by 11.5% compared to the use of the TSI bioassay alone. Conclusions The cutoff value of the TSI bioassay to predict GD relapse should be lower than that for diagnosing GD. However, as the single use of the TSI bioassay has limitations, a nomogram with multiple risk factors including TSI bioassay could be helpful to predict GD relapse.
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Affiliation(s)
- Han-Sang Baek
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jaejun Lee
- Department of Internal Medicines, Armed Forces Goyang Hospital, Goyang, Republic of Korea
| | - Chai-Ho Jeong
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeongmin Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jeonghoon Ha
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Kwanhoon Jo
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Hee Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Jae Hyoung Cho
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Moo Il Kang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong-Jun Lim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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18
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Stan MN, Algeciras-Schimnich A, Murthy V, Thapa P, Araki N. Diagnostic Utility of a New Assay for Thyroid Stimulating Immunoglobulins in Graves' Disease and Thyroid Eye Disease. Thyroid 2022; 32:170-176. [PMID: 34714163 DOI: 10.1089/thy.2021.0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: The syndrome of thyrotoxicosis typically relies on radioactive iodine scans for establishing its etiology. Alternatively, the determination of thyrotropin (TSH) receptor antibodies (TRAbs) helps to distinguish Graves' disease (GD) from thyrotoxic thyroiditis. Current assays are impacted by limitations in sensitivity and/or turnaround time. Therefore, we decided to test a new assay for the detection of TSH receptor stimulating antibodies (TSAbs) and compare it with the clinically available assays. Methods: We enrolled 110 individuals in 5 cohorts: patients with incident or recurrent GD (cohort 1); patients with thyroiditis, painless or subacute (cohort 2); patients with Graves' orbitopathy/thyroid eye disease (TED) in cohort 3; patients with Hashimoto's thyroiditis (cohort 4), and a control group of normal volunteers (cohort 5). The patients were tested with the two clinically available assays: Roche Elecsys anti-TSHR assay (ROC-TBII) from Roche Diagnostics and Thyretain™ TSI Reporter BioAssay Kit (QUI-TSI) from Quidel. In addition, the samples were tested with the aequorin TSAb assay (OTS-TSI) provided by Otsuka Pharmaceutical Co., Ltd. (Tokyo, Japan). The data were collected in a cross-sectional manner before initiation of therapy. Results: We had 36 cases of GD, 17 cases of thyroiditis, 27 cases of TED, 10 cases of Hashimoto's thyroiditis, and 20 normal volunteers. OTS-TSI had 100% sensitivity and specificity in distinguishing GD from thyroiditis, identical with QUI-TSI but superior to ROC-TBII (sensitivity 86% and specificity 94.1%). OTS-TSI had 93% sensitivity and 100% specificity for the diagnosis of TED, compared with normal controls. QUI-TSI and ROC-TBII performed similarly in this analysis, demonstrating 82% sensitivity and 100% specificity. The range of detectable values for OTS-TSI was 20-29,000 mIU/L and the turnaround time was ≤6 hours, without the need for cell culture equipment. Conclusions: OTS-TSI performed excellently, though similarly to QUI-TSI, for the differential diagnosis of GD vs. thyroiditis, while being superior in that respect to ROC-TBII. Furthermore, OTS-TSI has superior sensitivity to QUI-TSI and ROC-TBII for TED diagnosis, while retaining high specificity. It has a short turnaround time and avoids the need for cell culture and sterility. Larger studies in U.S. populations are needed for its validation.
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Affiliation(s)
| | | | - Vishakantha Murthy
- Division of Endocrinology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Prabin Thapa
- Divisions of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Naohiro Araki
- Diagnostic Division, Otsuka Pharmaceutical Co. Ltd., Tokyo, Japan
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19
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Ota Y, Avram AM. Graves’ disease. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00203-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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20
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Sarić-Matutinović M, Diana T, Nedeljković-Beleslin B, Ćirić J, Žarković M, Perović-Blagojević I, Kahaly GJ, Ignjatović S. SENSITIVITY OF THREE THYROTROPIN RECEPTOR ANTIBODY ASSAYS IN THYROID-ASSOCIATED ORBITOPATHY. J Med Biochem 2021; 41:211-220. [PMID: 35510209 PMCID: PMC9010037 DOI: 10.5937/jomb0-34718] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 11/21/2021] [Indexed: 11/17/2022] Open
Abstract
Background Thyrotropin receptor autoantibodies (TSH-RAb) are indispensable biomarkers in the laboratory assessment of thyroid-associated orbitopathy (TAO). Clinical sensitivity of three different assays for TSH-R-Ab determination was evaluated in patients with TAO. Methods 87 consecutive TAO patients were enrolled and their serum samples analyzed in parallel with three assays. An ECLIA competitive binding and a chemiluminescent bridge immunoassay were used to measure total and binding TSH-R-Ab concentration, while their functional activity was determined using a stimulatory TSH-R-Ab (TSAb) cellbased bioassay. Results Compared to the two binding assays (ECLIA p<0.001, bridge p=0.003), the TSAb bioassay was more sensitive pertaining to the positive detection of TSH-R-Ab in TAO patients. No difference (p=0.057) was noted between the ECLIA and bridge assays regarding sensitivity rate. All patients with active and/or moderate-to-severe TAO tested positive in the TSAb bioassay (100% and 100%, respectively), while the positivity rates for bridge and ECLIA binding assays were 89.7% and 82.1% for active TAO, and 90.2% and 86.3% for severe TAO, respectively. Negative predictive values of the bioassay, bridge, and ECLIA assays were 100%, 75%, and 71%, respectively for active TAO, and 100%, 86%, and 71%, respectively for moderate-to-severe TAO. The superiority of the bioassay was most prominent in euthyroid (ET) TAO. Positivity rates of the TSAb bioassay, bridge and ECLIA binding assays were 89.6%, 75%, and 64.6%, respectively for inactive TAO; 86.1%, 69.4%, and 52.8%, respectively for mild TAO; 87.5%, 62.5%, and 12.5%, respectively for euthyroid TAO. The bridge assay correlated better with the ECLIA binding assay (r=0.893, p<0.001), compared to the bioassay (r=0.669, p<0.001). Conclusions In patients with TAO of various activity and severity, the TSAb bioassay demonstrates a superior clinical performance compared to both ECLIA and bridge binding assays.
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Affiliation(s)
| | - Tanja Diana
- Johannes Gutenberg University (JGU) Medical Center, Department of Medicine I, Molecular Thyroid Research Laboratory, Mainz, Germany
| | | | - Jasmina Ćirić
- University Clinical Center of Serbia, Clinic for Endocrinology, Diabetes and Metabolic Disorders, Belgrade
| | - Miloš Žarković
- University Clinical Center of Serbia, Clinic for Endocrinology, Diabetes and Metabolic Disorders, Belgrade
| | - Iva Perović-Blagojević
- Clinical Hospital Center 'Dr Dragiša Mišović-Dedinje', Service for laboratory diagnostics, Belgrade
| | - George J. Kahaly
- Johannes Gutenberg University (JGU) Medical Center, Department of Medicine I, Molecular Thyroid Research Laboratory, Mainz, Germany
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21
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Hu Y, Ni J, Cen Y, Zhang B, Wu W, Cheng W, Huang M, Guan M. Evaluation of analytic and clinical performance of two immunoassays for detecting thyroid-stimulating receptor antibody in the diagnosis of Graves' disease. J Clin Lab Anal 2021; 35:e23950. [PMID: 34752648 PMCID: PMC8649345 DOI: 10.1002/jcla.23950] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 07/18/2021] [Accepted: 07/31/2021] [Indexed: 12/04/2022] Open
Abstract
Objective To evaluate the analytical and clinical performance of two immunoassays for diagnosis of Graves’ disease (GD), the Immulite thyroid‐stimulating immunoglobulin (TSI), and Elecsys Anti‐TSH receptor (TSHR) assay. Methods Precision and analytical measurement range were assessed using pooled samples of patients. The comparison between the two methods was evaluated using 579 clinical samples, and receiver operating characteristic (ROC) curves were drawn using the final diagnosis as reference. Clinical sensitivity and specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated for the two tests. Results The repeatability and intermediate imprecision coefficient of variation (CV%) of the TSI assay were 3.8% and 4.1% at 0.95 IU/L, and 3.5% and3.6% at 19.5 IU/L, respectively. The assays were linear over a range 0.27–38.5 IU/L. There was a high correlation between the quantitative results of the two methods (correlation coefficient r = 0.930). The cut‐off value obtained by ROC analysis for TSI assay was 0.7 IU/L with sensitivity of 93.7% and specificity of 85.1%. An overall qualitative agreement of 91.5% between two methods was observed. Among 44 patients with discordant qualitative results, the TSI assay provided more satisfactory results consistent with clinical diagnoses. Conclusion The TSI assay showed excellent analytical performance and provided a high PPV for GD.
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Affiliation(s)
- Yao Hu
- Department of Laboratory Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Jiajin Ni
- Department of Nursing, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Yi Cen
- Department of Laboratory Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Buyue Zhang
- Department of Laboratory Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wenqing Wu
- Department of Laboratory Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Wei Cheng
- Department of Laboratory Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Mingying Huang
- Department of Laboratory Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
| | - Ming Guan
- Department of Laboratory Medicine, Huashan Hospital, Shanghai Medical College, Fudan University, Shanghai, China
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22
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Deligiorgi MV, Sagredou S, Vakkas L, Trafalis DT. The Continuum of Thyroid Disorders Related to Immune Checkpoint Inhibitors: Still Many Pending Queries. Cancers (Basel) 2021; 13:5277. [PMID: 34771441 PMCID: PMC8582503 DOI: 10.3390/cancers13215277] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Until more data are available to shed light on the thyroid disorders related to immune checkpoint inhibitors (ICPi) implemented for the treatment of hematological malignancies, the decision-making is guided by pertinent data derived mostly from solid tumors. METHODS The present review provides a comprehensive and updated overview of the thyroid disorders related to ICPi, namely to inhibitors of cytotoxic T-lymphocyte antigen 4 (CTLA-4), programmed cell death (PD) 1 (PD-1), and the ligand of the latter (PD-L1). RESULTS With the increasing recognition of ir thyroid disorders, many outstanding issues have emerged. Ir thyroid disorders are reminiscent of, but not identical to, thyroid autoimmunity. Interclass and intraclass ICPi differences regarding thyroid immunotoxicity await interpretation. The available data concerning the predictive value of thyroid autoantibodies for the development of ir thyroid disorders are inconclusive. Mounting data indicate an association of ir thyroid disorders with ICPi efficacy, but a causative link is still lacking. The path forward is a tailored approach, entailing: (i) the validation of tumor-specific, patient-specific, and ICPi-specific predictive factors; (ii) appropriate patient selection; (iii) the uncoupling of antitumor immunity from immunotoxicity; (iv) a multidisciplinary initiative; and (v) global registry strategies. CONCLUSIONS Untangling and harnessing the interrelationship of immuno-oncology with endocrinology underlying the ir thyroid disorders will yield the optimal patient care.
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Affiliation(s)
- Maria V. Deligiorgi
- Department of Pharmacology—Clinical Pharmacology Unit, Faculty of Medicine, National and Kapodistrian University of Athens, Building 16, 1st Floor, 75 Mikras Asias Str., Goudi, 11527 Athens, Greece; (S.S.); (L.V.); (D.T.T.)
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23
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Thia B, McGuinness MB, Ebeling PR, Khong JJ. Diagnostic accuracy of Immulite® TSI immunoassay for thyroid-associated orbitopathy in patients with recently diagnosed Graves' hyperthyroidism. Int Ophthalmol 2021; 42:863-870. [PMID: 34613563 DOI: 10.1007/s10792-021-02052-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/22/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE The Immulite® thyroid stimulating immunoglobulin (TSI) immunoassay is a relatively new commercial assay that has shown good diagnostic accuracy in Graves' hyperthyroidism (GH). However, its clinical utility in thyroid-associated orbitopathy (TAO) is less clear. The purpose of this study was to assess the diagnostic accuracy of the Immulite® TSI immunoassay for TAO and investigate the associations between TSI and other clinical measures. METHODS One hundred and forty patients that had been diagnosed with GH within the previous 12 months were recruited. Identification and grading of TAO were performed at enrolment and serum samples were analysed using the Immulite® TSI immunoassay. RESULTS Of the 140 participants recruited, 75 (53.6%) had TAO. Age, sex and time since GH diagnosis were similar between those with and without TAO (p ≥ 0.300). TSI level tended to decrease with increasing time from GH diagnosis (Spearman's ρ - 0.28, 95% CI - 0.43, - 0.12). TSI levels were higher among those with than those without TAO (median 4.0 vs. 2.7 IU/L, respectively, p = 0.037). There was no correlation between TSI level and inflammatory index score (ρ = 0.14, 95% CI - 0.03, 0.30) or clinical severity (p = 0.527) among those with TAO. TSI level showed poor diagnostic accuracy for TAO (area under the receiver operating characteristic curve 0.60, 95% CI 0.51, 0.70). CONCLUSIONS Although Immulite® TSI level was higher in the presence of TAO, it showed poor diagnostic accuracy and no correlation with clinical markers of TAO severity or activity.
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Affiliation(s)
- Brandon Thia
- Department of Ophthalmology, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia.
| | - Myra B McGuinness
- Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, 3002, Australia.,Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3010, Australia
| | - Peter R Ebeling
- Department of Medicine, Monash Medical Centre, School of Clinical Sciences, Monash University, Clayton, VIC, 3168, Australia
| | - Jwu Jin Khong
- Department of Ophthalmology, Austin Health, 145 Studley Road, Heidelberg, VIC, 3084, Australia.,Centre for Eye Research Australia, Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, 3002, Australia.,Orbital, Plastic and Lacrimal Unit, The Royal Victorian Eye and Ear Hospital, East Melbourne, VIC, 3002, Australia.,Department of Surgery, University of Melbourne, Austin Health, Heidelberg, VIC, 3084, Australia
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24
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Sarangi PK, Parida S, Mangaraj S, Mohanty BK, Mohanty J, Swain BM. Diagnostic Utility of Mean Peak Systolic Velocity of Superior Thyroid Artery in Differentiating Graves' Disease from Thyroiditis. Indian J Radiol Imaging 2021; 31:311-317. [PMID: 34556913 PMCID: PMC8448216 DOI: 10.1055/s-0041-1734360] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background
Differentiating Graves’ disease from thyroiditis can be at times clinically challenging. The gold standard test (thyroid nuclear imaging scan) is expensive, not routinely available, and has radiation exposure. Color Doppler ultrasonography of thyroid represents a suitable alternate which can be used for differentiating these conditions by studying thyroid blood flow parameters.
Aim
We aimed to investigate the use of thyroid blood flow parameters’ assessment of the superior thyroid artery (STA) and common carotid artery (CCA) with color Doppler ultrasonography for differentiating Graves’ disease from thyroiditis.
Materials and Methods
This is a cross-sectional study on 111 patients with newly diagnosed thyrotoxicosis (82 with Graves’ disease and 29 with thyroiditis) and 45 years of age and sex-matched healthy controls. All patients underwent detailed clinical and necessary investigations. Color Doppler ultrasonography of the thyroid gland and spectral flow analysis of both superior thyroid arteries was done using standard protocol. Sensitivity and specificity for mean peak systolic velocity of STA (STA-PSV) cut-offs were calculated using receiver operating characteristic curves.
Results
Patients with Graves’ disease have significantly higher free tri-iodothyronine (FT3) levels, free thyroxine (FT4) levels, antithyroid stimulating hormone receptor antibody (TRAb) levels, and thyroid volume as compared with those with thyroiditis. The mean STA-PSV of patients with Graves’ disease was significantly higher than thyroiditis and control group. Mean STA-PSV greater than 54.3 cm/s had 82.9% sensitivity and 86.2% specificity in diagnosing Graves’ disease. Mean PSV-STA/PSV-CCA ratio of 0.40 was 80.5% sensitive and 86.2% specific for Graves’ disease.
Conclusion
Mean STA-PSV has high sensitivity and specificity in differentiating Graves’ disease from thyroiditis and can be used routinely in clinical practice as a cheap and invaluable diagnostic tool.
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Affiliation(s)
- Pradosh K Sarangi
- Department of Radiodiagnosis, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
| | - Sasmita Parida
- Department of Radiodiagnosis, Pandit Raghunath Murmu Medical College and Hospital, Baripada, Odisha, India
| | - Swayamsidha Mangaraj
- Department of Endocrinology, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, Odisha, India
| | - Binoy K Mohanty
- Department of Endocrinology, Maharaja Krishna Chandra Gajapati Medical College and Hospital, Berhampur, Odisha, India
| | - Jayashree Mohanty
- Department of Radiodiagnosis, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
| | - Basanta M Swain
- Department of Radiodiagnosis, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, Odisha, India
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25
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Kim J, Choi MS, Park J, Park H, Jang HW, Choe JH, Kim JH, Kim JS, Cho YS, Choi JY, Kim TH, Chung JH, Kim SW. Changes in Thyrotropin Receptor Antibody Levels Following Total Thyroidectomy or Radioiodine Therapy in Patients with Refractory Graves' Disease. Thyroid 2021; 31:1264-1271. [PMID: 33947272 PMCID: PMC8377510 DOI: 10.1089/thy.2020.0756] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: The actions of thyrotropin-binding inhibitory immunoglobulins (TBIIs) against thyrotropin receptors in thyroid follicular cells have been studied as important etiological factors in Graves' disease (GD). The purpose of this study was to investigate changes in the TBII levels of patients undergoing total thyroidectomy (TTx) or radioactive iodine (RAI) therapy for GD refractory to antithyroid drugs (ATDs). Methods: We enrolled patients who underwent TTx or RAI for GD with previous ATD use between January 2011 and December 2017 at the Samsung Medical Center in Seoul, Korea. Thorough retrospective reviews of medical records were performed in 130 patients. Results: Patients with goiter, ophthalmopathy, high levels of TBIIs, and high doses of ATDs received TTx. Elderly patients with arrhythmia received RAI. We observed that TBII levels continued to decrease after TTx. On the contrary, TBIIs initially increased for 138 days (estimated median time) and then decreased slowly after RAI. A faster decline in TBII levels was observed in the TTx group than in the RAI group (p < 0.001). The estimated median time for TBIIs to decrease below 4.5 IU (3 × upper normal limit, which is known to be a risk factor for fetal hyperthyroidism) was 318 days in the TTx group and 659 days in the RAI group, respectively. In the RAI group, high levels of TBII (>4.5 IU/L) were present in 70 (82%) at 6 months, 57 (67%) at 1 year, and 3 (3%) at 2 years. In the TTx group, rapid decreases in TBII levels were observed in younger patients and those with lower baseline TBII levels. In the RAI group, smaller thyroid volume was correlated with more rapid decrease in TBII levels. Conclusions: The changes in TBII levels following TTx or RAI were different in patients with refractory GD. When deciding on TTx or RAI, this difference should be considered with patient age, severity of hyperthyroidism, goiter, ophthalmopathy, and future pregnancy plans (for young female patients).
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Affiliation(s)
- Jinyoung Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Min Sun Choi
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun Park
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hyunju Park
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Hye Won Jang
- Department of Medical Education, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jun-Ho Choe
- Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jung-Han Kim
- Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jee Soo Kim
- Division of Endocrine Surgery, Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young Seok Cho
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Joon Young Choi
- Department of Nuclear Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Tae Hyuk Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae Hoon Chung
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sun Wook Kim
- Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
- Address correspondence to: Sun Wook Kim, MD, PhD, Division of Endocrinology and Metabolism, Department of Medicine, Thyroid Center, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea
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Liu K, Fu Y, Li T, Liu S, Chen D, Zhao C, Shi Y, Cai Y, Yang T, Zheng X. Clinical efficacy of thyroid-stimulating immunoglobulin detection for diagnosing Graves' disease and predictors of responsiveness to methimazole. Clin Biochem 2021; 97:34-40. [PMID: 34331946 DOI: 10.1016/j.clinbiochem.2021.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 06/26/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND As thyroid-stimulating immunoglobulins (TSI) are a sign of Graves' disease (GD), measuring TSI titers is becoming increasingly important for GD diagnosis. This study evaluated the diagnostic accuracy of a new fully automated TSI immunoassay (Immulite™ TSI assay) in GD patients and compared it to the third generation thyroid-stimulating hormone receptor antibody (TRAb) electrochemiluminescence assay (Elecsys Anti-TSHR assay). Additionally, clinical characteristics associated with responsiveness to methimazole in patients with newly diagnosed GD were preliminarily explored. METHODS This study involved 324 subjects, comprising patients with untreated GD (GD-UT), Graves' ophthalmopathy (GO) patients, GD patients who had been treated for > 12 months (GD-T), autoimmune thyroiditis (AIT) patients, and healthy subjects (HS). The Immulite™ TSI and Elecsys Anti-TSHR assay were performed on all samples. According to their responsiveness to methimazole, the GD-UT patients were divided into rapid and slow responder groups, and their clinical characteristics were compared. RESULTS A receiver operating characteristic (ROC) curve analysis of GD-UT patients showed that the optimal TSI cut-off value was 0.57 IU/L. Logistic regression revealed that age and initial FT4 and TSI levels in the middle-dose methimazole group were related to a rapid response, while the initial FT4 level, but not TSI, in the high-dose group was also associated with a rapid response. CONCLUSIONS The clinical diagnostic performance of the Immulite™ TSI assay for diagnosing GD was comparable to that of the Elecsys Anti-TSHR assay. The initial FT4 and TSI levels can be used as predictors of the responsiveness to methimazole in patients with newly diagnosed GD.
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Affiliation(s)
- KunY Liu
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yu Fu
- Department of Nuclear Medicine, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - TianT Li
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China; Department of Critical Care Medicine, Nanjing Hospital Affiliated to Nanjing University of Chinese Medicine, Nanjing 210003, China
| | - SunQ Liu
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - DouD Chen
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - ChengC Zhao
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yun Shi
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Yun Cai
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - Tao Yang
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China
| | - XuQ Zheng
- Department of Endocrinology and Metabolism, the First Affiliated Hospital of Nanjing Medical University, Nanjing 210029, China.
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Tong M, Ding J, Huang B, Chen J, Wei X, Li Z, Shu J, Hu Z, Jiang X, Sheng H. Evaluation of the application of TSH receptor stimulating autoantibodies and the optimization of detection strategy in Graves' disease. Clin Chim Acta 2021; 521:34-39. [PMID: 34144042 DOI: 10.1016/j.cca.2021.06.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 05/17/2021] [Accepted: 06/09/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND We evaluated the use of thyroid stimulating immunoglobulin (TSI) assay to optimize the detection strategy for Graves' disease. METHODS Five hundred and forty-four well characterized serum samples from the Clinical Laboratory of Shanghai Tongren Hospital were collected from August 2019 to April 2020. The serum samples were obtained from 52 untreated GD patients, 155 treated GD patients, 83 patients with Hashimoto's thyroiditis, 70 patients with thyroid nodules, 83 patients with thyroid cancer, and 101 healthy subjects. All samples were evaluated by both TSI assay and TSH receptor autoantibodies (TRAb) assay. Moreover, 23 patients without a distinct thyroid disease diagnosis at the first visit were monitored for 6 months to make a final diagnosis. RESULTS The clinical sensitivity of the TSI and TRAb assays was 98.10% and 94.20% respectively, while the clinical specificity was 92.30% and 96.70% respectively. ROC plot analysis based on sera of UT-GD (newly diagnosed GD patients) revealed an area under the curve (AUC) of 0.974 for the TSI assay. The best cutoff value was 0.58 IU/l (98.0% of sensitivity, 92.8% of specificity). The AUC for the TRAb assay was 0.961. Furthermore, combining TSI and TRAb results, the area under the curve was 0.981. In a pilot study of 23 patients with an uncertain initial diagnosis, the follow-up results showed the clinical diagnosis of 22 out of 23 cases were resolved in agreement with the results obtained by the TSI assay, and one case matched the result obtained by TRAb assay. CONCLUSION The TSI assay presents very promising analytical characteristics and could be adopted in clinical practice to improve GD diagnosis. The TSI assay might be better than TRAb assay in initial differential diagnosis of GD from other thyroid diseases.
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Affiliation(s)
- Minghong Tong
- Department of Clinical Laboratory, Shanghai Tong Ren Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jun Ding
- Zhijiangxi Community Health Service Center, Shanghai, China
| | - Biao Huang
- College of Life Sciences and Medicine, Zhejiang Sci-Tech University, Hangzhou, China
| | | | - Xin Wei
- Department of Clinical Laboratory, Shanghai Tong Ren Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Zhiming Li
- Department of Clinical Laboratory, Shanghai Tong Ren Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Jie Shu
- Department of Clinical Laboratory, Shanghai Tong Ren Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Zhigang Hu
- Wuxi Children's Hospital Affiliated to Nanjing Medical University, Wuxi, China.
| | - Xiaohong Jiang
- Department of Endocrinology, Shanghai Tong Ren Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
| | - Huiming Sheng
- Department of Clinical Laboratory, Shanghai Tong Ren Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China.
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28
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Lui DTW, Lee CH, Chow WS, Lee ACH, Tam AR, Fong CHY, Law CY, Leung EKH, To KKW, Tan KCB, Woo YC, Lam CW, Hung IFN, Lam KSL. Insights from a Prospective Follow-up of Thyroid Function and Autoimmunity among COVID-19 Survivors. Endocrinol Metab (Seoul) 2021; 36:582-589. [PMID: 34107601 PMCID: PMC8258341 DOI: 10.3803/enm.2021.983] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The occurrence of Graves' disease and Hashimoto thyroiditis after coronavirus disease 2019 (COVID-19) raised concerns that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may trigger thyroid autoimmunity. We aimed to address the current uncertainties regarding incident thyroid dysfunction and autoimmunity among COVID-19 survivors. METHODS We included consecutive adult COVID-19 patients without known thyroid disorders, who were admitted to Queen Mary Hospital from July 21 to September 21, 2020 and had serum levels of thyroid-stimulating hormone, free thyroxine, free triiodothyronine (fT3), and anti-thyroid antibodies measured both on admission and at 3 months. RESULTS In total, 122 patients were included. Among 20 patients with abnormal thyroid function tests (TFTs) on admission (mostly low fT3), 15 recovered. Among 102 patients with initial normal TFTs, two had new-onset abnormalities that could represent different phases of thyroiditis. Among 104 patients whose anti-thyroid antibody titers were reassessed, we observed increases in anti-thyroid peroxidase (TPO) (P<0.001) and anti-thyroglobulin (P<0.001), but not anti-thyroid stimulating hormone receptor titers (P=0.486). Of 82 patients with negative anti-TPO findings at baseline, 16 had a significant interval increase in anti-TPO titer by >12 U, and four became anti-TPO-positive. Worse baseline clinical severity (P=0.018), elevated C-reactive protein during hospitalization (P=0.033), and higher baseline anti-TPO titer (P=0.005) were associated with a significant increase in anti-TPO titer. CONCLUSION Most patients with thyroid dysfunction on admission recovered during convalescence. Abnormal TFTs suggestive of thyroiditis occurred during convalescence, but infrequently. Importantly, our novel observation of an increase in anti-thyroid antibody titers post-COVID-19 warrants further follow-up for incident thyroid dysfunction among COVID-19 survivors.
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Affiliation(s)
- David Tak Wai Lui
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Chi Ho Lee
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Wing Sun Chow
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Alan Chun Hong Lee
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Anthony Raymond Tam
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Carol Ho Yi Fong
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Chun Yiu Law
- Division of Chemical Pathology, Queen Mary Hospital, Hong Kong,
China
| | - Eunice Ka Hong Leung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Kelvin Kai Wang To
- Department of Microbiology, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Kathryn Choon Beng Tan
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Yu Cho Woo
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Ching Wan Lam
- Department of Pathology, The University of Hong Kong, Hong Kong,
China
| | - Ivan Fan Ngai Hung
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
| | - Karen Siu Ling Lam
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong,
China
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29
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Brancatella A, Lupi I, Montanelli L, Ricci D, Viola N, Sgrò D, Antonangeli L, Sardella C, Brogioni S, Piaggi P, Molinaro E, Bianchi F, Aragona M, Antonuzzo A, Sbrana A, Lucchesi M, Chella A, Falcone A, Del Prato S, Elisei R, Marcocci C, Caturegli P, Santini F, Latrofa F. Management of Thyrotoxicosis Induced by PD1 or PD-L1 Blockade. J Endocr Soc 2021; 5:bvab093. [PMID: 34337277 PMCID: PMC8317632 DOI: 10.1210/jendso/bvab093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Indexed: 12/18/2022] Open
Abstract
Context Thyrotoxicosis is a common immune-related adverse event in patients treated with programmed cell death protein-1 (PD1) or programmed cell death protein ligand-1 (PD-L1) blockade. A detailed endocrinological assessment, including thyroid ultrasound and scintigraphy, is lacking, as are data on response to treatment and follow-up. Objective The aim of this study was to better characterize the thyrotoxicosis secondary to immune checkpoint inhibitors, gaining insights into pathogenesis and treatment. Methods We conducted a retrospective study of 20 consecutive patients who had normal thyroid function before starting immunotherapy and then experienced thyrotoxicosis on PD1 or PD-L1 blockade. Clinical assessment was combined with thyroid ultrasound, 99mtechnecium scintiscan, and longitudinal thyroid function tests. Results Five patients had normal or increased scintigraphic uptake (Sci+), no serum antibodies against the thyrotropin receptor, and remained hyperthyroid throughout follow-up. The other 15 patients had no scintigraphic uptake (Sci–) and experienced destructive thyrotoxicosis followed by hypothyroidism (N = 9) or euthyroidism (N = 6). Hypothyroidism was more readily seen in those with normal thyroid volume than in those with goiter (P = .04). Among Sci– individuals, a larger thyroid volume was associated with a longer time to remission (P < .05). Methimazole (MMI) was effective only in Sci+ individuals (P < .05). Conclusion Administration of PD1- or PD-L1–blocking antibodies may induce 2 different forms of thyrotoxicosis that appear similar in clinical severity at onset: a type 1 characterized by persistent hyperthyroidism that requires treatment with MMI, and a type 2, characterized by destructive and transient thyrotoxicosis that evolves to hypothyroidism or euthyroidism. Thyroid scintigraphy and ultrasound help in differentiating and managing these 2 forms of iatrogenic thyrotoxicosis.
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Affiliation(s)
| | - Isabella Lupi
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Lucia Montanelli
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Debora Ricci
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Nicola Viola
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Daniele Sgrò
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa 56126, Italy
| | - Lucia Antonangeli
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Chiara Sardella
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Sandra Brogioni
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Paolo Piaggi
- Department of Information Engineering, University of Pisa, Pisa 56126, Italy
| | - Eleonora Molinaro
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Francesca Bianchi
- Nuclear Medicine Unit, Azienda Ospedaliero-Unuversitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Michele Aragona
- Metabolic Diseases and Diabetes Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Andrea Antonuzzo
- Oncology Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56126, Italy
| | - Andrea Sbrana
- Oncology Unit, Azienda Ospedaliero-Universitaria Pisana and Department of Translational Research and New Technologies in Medicine and Surgery, University Hospital of Pisa, Pisa 56126, Italy
| | - Maurizio Lucchesi
- Pneumology Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Antonio Chella
- Pneumology Unit, Azienda Ospedaliero-Universitaria Pisana, University Hospital of Pisa, Pisa 56124, Italy
| | - Alfredo Falcone
- Oncology Unit, Azienda Ospedaliero-Univeritaria Pisana and Department of Translational Research and New Technologies in Medicine abd Surgery, University Hospital of Pisa, Pisa 56126, Italy
| | - Stefano Del Prato
- Metabolic Diseases and Diabetes Unit, Azienda Ospedaliero-Universitaria Pisana and Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa 56124, Italy
| | - Rossella Elisei
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana and Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa 56124, Italy
| | - Claudio Marcocci
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana and Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa 56124, Italy
| | - Patrizio Caturegli
- Department of Pathology, The Johns Hopkins University School of Medicine, Baltimore, Maryland 21205, USA
| | - Ferruccio Santini
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana and Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa 56124, Italy
| | - Francesco Latrofa
- Endocrinology Unit, Azienda Ospedaliero-Universitaria Pisana and Department of Clinical and Experimental Medicine, University Hospital of Pisa, Pisa 56124, Italy
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Silvestre RA, Almería Lafuente A, Jiménez-Mendiguchía L, García-Cano A, Romero López R, García-Izquierdo B, Pardo de Santayana C, Iglesias P, Diez JJ, Arribas Gómez I, Bernabeu-Andreu FA. Comparison of three methods for determining anti-thyrotropin receptor antibodies (TRAb) for diagnosis of Graves' disease: a clinical validation. ADVANCES IN LABORATORY MEDICINE 2021; 2:221-252. [PMID: 37363331 PMCID: PMC10197409 DOI: 10.1515/almed-2021-0015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/13/2020] [Indexed: 06/28/2023]
Abstract
Objectives Graves' disease is secondary to the presence of anti-thyrotropin receptor antibodies (TRAb), which stimulate thyroid hormones. TRab determination is crucial for etiological diagnosis. The objectives of this study were (i) to compare two methods for determining TRab by chemoluminiscence vs. standard TRACE-immunofluorescence; (ii) to determine the diagnostic validity of the three methods. Methods A retrospective study in 194 patients with a TRAb determination request. TRAb were determined by immunofluorescence (Kryptor, ThermoFisher) and chemiluminescence (Immulite, Siemens and Maglumi, Snibe). Clinical validation: medical records were reviewed and categorized according to thyroid function. Statistical analysis: Differences in quantitative variables were assessed by intraclass correlation coefficient, Bland-Altman plot, and mean differences (mD). Qualitative variables were dichotomized by cut-off points; Kappa coefficient was calculated. Correlations were evaluated by Pearson's coefficient and Passing-Bablok regression analysis. The diagnostic validity of the three methods was investigated. Results Kryptor-Immulite: mD: 1.2 (95%CI: -16 to >18). Passing-Bablok: Constant error (95%CI: -0.8349 to -0.5987). Proportional error (95%CI: 0.7862-1.0387). ICC: 0.86 (95%CI: 0.82-0.89). Kappa coefficient: 0.68 (95%CI 0.59-0.78). Kryptor-Maglumi: mD: -0.3 (95%CI: -12 to >12). Passing-Bablok: Constant error (95%CI: -0.7701 to >0.1621. Proportional error (95%CI: 0.8571 to 1.3179. ICC: 0.93 (95%CI: 0.89-0.97). Kappa coefficient: 0.53 (95%CI: 0.32-0.74). Diagnosis of Graves' disease was confirmed in 113 patients (Kryptorf showed better specificity and positive predictive value, whereas Immulite demonstrated better sensitivity and negative predictive value). Conclusions The three methods have a good diagnostic performance for Graves' disease, with superimposable results on Bland-Altman plot. Interchangeability was not confirmed on the regression and agreement analysis, with the presence of biases.
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Affiliation(s)
- Ramona A. Silvestre
- Service of Biochemistry and Clinical Biochemistry, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Alejandro Almería Lafuente
- Service of Biochemistry and Clinical Biochemistry, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | | | - Ana García-Cano
- Service of Clinical Biochemistry, Ramón y Cajal University Hospital, Madrid, Spain
| | - Rubén Romero López
- Service of Biochemistry and Clinical Biochemistry, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Belén García-Izquierdo
- Service of Endocrinology and Nutrition, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | | | - Pedro Iglesias
- Service of Endocrinology and Nutrition, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | - Juan J. Diez
- Service of Endocrinology and Nutrition, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
| | | | - Francisco A. Bernabeu-Andreu
- Service of Biochemistry and Clinical Biochemistry, Puerta de Hierro Majadahonda University Hospital, Madrid, Spain
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Abstract
Adequate iodine intake is necessary for normal thyroid function. Iodine deficiency is associated with serious complications, but also iodine excess can lead to thyroid dysfunction, and iodine supplementation aimed to prevent iodine deficiency disorders has been associated with development of thyroid autoimmunity. The epidemiology of thyroid diseases has undergone profound changes since the implementation of iodoprophylaxis, notably by means of iodine-enriched salt, specifically resulting in decreased prevalence of goiter and neonatal hypothyroidism, improved cognitive function development in infancy, and reduced incidence of more aggressive forms of thyroid cancer. The main question we address with this review is the clinical relevance of the possible effect on autoimmunity exerted by the use of iodine-enriched salt to correct iodine deficiency. In animal models, exogenous iodine is able to trigger or exacerbate thyroid autoimmunity, but it is still not clear whether the observed immunological changes are due to a direct effect of iodine on immune response, or whether they represent a secondary response to a toxic effect of iodine on thyroid tissue. Previous iodine status of a population seems to influence the functional thyroid response to increased iodine intake and possibly the development of thyroid autoimmunity. Moreover, the prevalence of thyroid antibodies, regarded as hallmark of autoimmune thyroid disease, varies between populations under the influence of genetic and environmental factors, and the presence of thyroid antibodies does not always coincide with the presence of thyroid disease or its future development. In addition, the incidence of autoimmune diseases shows a general increasing trend in the last decades. For all these reasons, available data are quite heterogeneous and difficult to analyze and compare. In conclusion, available data from long-term population surveys show that a higher than adequate population iodine intake due to a poorly controlled program of iodine prophylaxis could induce thyroid dysfunction, including thyroid autoimmunity mostly represented by euthyroid or subclinical hypothyroid autoimmune thyroiditis. Close monitoring iodine prophylaxis is therefore advised to ensure that effects of both iodine deficiency and iodine excess are avoided.
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Le TN, Ganim I, Landa E, Patel H, Siraj T. Extreme Weight Loss and Psychosis as Presenting Signs of Thyrotoxicosis. Cureus 2021; 13:e14045. [PMID: 33898131 PMCID: PMC8059775 DOI: 10.7759/cureus.14045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Thyroid storm is an acute, life-threatening syndrome due to an exacerbation of thyrotoxicosis, which is when you have an excess of thyroid hormone in the body. Thyroid storm can be precipitated by infections, surgery, or untreated thyrotoxicosis. Multisystem involvement is often seen. Typical symptoms include fever and tachycardia, which are rather common, as well as more severe symptoms such as atrial fibrillation, congestive heart failure, hepatic failure, delirium and coma. The Burch-Wartofsky Point Scale is often used for the clinical diagnosis of thyroid storm. Prompt diagnosis and therapy are required to prevent complications and mortality in patients with thyroid storm. Here we present a case of thyroid storm in a patient that presented with psychosis and significant weight loss.
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Affiliation(s)
- Thu Nhi Le
- Internal Medicine, Arkansas College of Osteopathic Medicine, Fort Smith, USA
| | | | - Eric Landa
- Internal Medicine, Unity Health, Searcy, USA
| | - Hemal Patel
- Internal Medicine, Unity Health, Searcy, USA
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Lee SY, Pearce EN. Testing, Monitoring, and Treatment of Thyroid Dysfunction in Pregnancy. J Clin Endocrinol Metab 2021; 106:883-892. [PMID: 33349844 PMCID: PMC7947825 DOI: 10.1210/clinem/dgaa945] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Indexed: 11/19/2022]
Abstract
Both hyperthyroidism and hypothyroidism can have adverse effects in pregnancy. The most common causes of thyrotoxicosis in pregnancy are gestational transient thyrotoxicosis and Graves' disease. It is important to distinguish between these entities as treatment options differ. Women of reproductive age who are diagnosed with Graves' disease should be counseled regarding the impact of treatment options on a potential pregnancy. Although the absolute risk is small, antithyroid medications can have teratogenic effects. Propylthiouracil appears to have less severe teratogenicity compared to methimazole and is therefore favored during the first trimester if a medication is needed. Women should be advised to delay pregnancy for at least 6 months following radioactive iodine to minimize potential adverse effects from radiation and ensure normal thyroid hormone levels prior to conception. As thyroid hormone is critical for normal fetal development, hypothyroidism is associated with adverse obstetric and child neurodevelopmental outcomes. Women with overt hypothyroidism should be treated with levothyroxine (LT4) to a thyrotropin (thyroid-stimulating hormone; TSH) goal of <2.5 mIU/L. There is mounting evidence for associations of maternal hypothyroxinemia and subclinical hypothyroidism with pregnancy loss, preterm labor, and lower scores on child cognitive assessment. Although there is minimal risk of LT4 treatment to keep TSH within the pregnancy-specific reference range, treatment of mild maternal thyroid hypofunction remains controversial, given the lack of clinical trials showing improved outcomes with LT4 treatment.
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Affiliation(s)
- Sun Y Lee
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
- Correspondence: Sun Y. Lee, MD, MSc, Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, 720 Harrison Avenue, Suite 8100, Boston, MA 02118, USA.
| | - Elizabeth N Pearce
- Section of Endocrinology, Diabetes, and Nutrition, Boston University School of Medicine, Boston, MA, USA
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Perdomo CM, García-Goñi M, Sancho L, J Paricio J, Lozano MD, de la Higuera M, Currás M, Arbizu J, Galofré JC. Evaluation of the role of thyroid scintigraphy in the differential diagnosis of thyrotoxicosis. Clin Endocrinol (Oxf) 2021; 94:466-472. [PMID: 32767493 DOI: 10.1111/cen.14308] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 07/18/2020] [Accepted: 07/20/2020] [Indexed: 01/13/2023]
Abstract
OBJECTIVE A differential diagnosis of thyrotoxicosis is crucial as the treatment of the main causes of this condition can vary significantly. Recently published diagnostic guidelines on thyrotoxicosis embrace the presence of thyrotropin receptor (TSH-R) antibodies (TRAb) as the primary and most important diagnostic step. The application of diagnostic algorithms to aid in the treatment of hyperthyroidism supports using thyroid radionuclide scintigraphy (TRSt) in baffling clinical scenarios, when TRAb are absent or when third-generation TRAb are not available. First-generation TRAb measurement may have limitations. Consequently, patients with thyrotoxicosis and first-generation TRAb results may be misdiagnosed and consequently improperly treated. Our purpose was to compare first-generation TRAb values to TRSt in the differential diagnosis of hyperthyroidism. METHODS We conducted a retrospective study of 201 untreated outpatients with overt or subclinical hyperthyroidism on whom first-generation TRAb and TRSt had been performed at the time of diagnosis. Histological specimens were analysed in patients who had previously undergone thyroid surgery at our centre. SPSS 20.0 was used in statistical analysis. RESULTS Seventy-three out of 201 (36.3%) patients had positive TRAb. A diffuse uptake was present in 83.5% (61/73), whereas 13.7% (10/73) had a heterogeneous uptake and 2.7% (2/73) had an absent uptake. Thirty out of 91 (33%) patients with diffuse uptake were negative for positive TRAb and were diagnosed with Graves' disease. Analysis of 37 histological specimens indicated that TRSt had greater accuracy (81% vs 75.7%) and specificity (79.2% vs 57.1%) when compared to TRAb in the differential diagnosis of thyrotoxicosis. However, TRSt sensitivity was inferior to TRAb (84.6% vs 92.3%). CONCLUSIONS Our study endorses that initial differential diagnosis of thyrotoxicosis should not be based solely on first-generation TRAb as this approach may leave nearly 20% of the patients misdiagnosed and, consequently, improperly treated. Our results underscore that thyroid scintigraphy should also be performed when only first-generation TRAb assays are available during the initial differential diagnosis of thyrotoxicosis.
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Affiliation(s)
- Carolina M Perdomo
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Pamplona, Spain
| | - Marta García-Goñi
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Pamplona, Spain
| | - Lidia Sancho
- Department of Nuclear Medicine, Clínica Universidad de Navarra, Pamplona, Spain
| | - José J Paricio
- Department of Pathology, Clínica Universidad de Navarra, Pamplona, Spain
| | - María D Lozano
- Department of Pathology, Clínica Universidad de Navarra, Pamplona, Spain
| | | | - María Currás
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Pamplona, Spain
| | - Javier Arbizu
- Department of Nuclear Medicine, Clínica Universidad de Navarra, Pamplona, Spain
| | - Juan C Galofré
- Department of Endocrinology and Nutrition, Clínica Universidad de Navarra, Pamplona, Spain
- IdiSNA (Instituto de Investigación Sanitaria de Navarra), Pamplona, Spain
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D'Aurizio F. The role of laboratory medicine in the diagnosis of the hyperthyroidism. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2021; 65:91-101. [PMID: 33565846 DOI: 10.23736/s1824-4785.21.03344-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Hyperthyroidism is a clinical condition characterized by inappropriately high synthesis and secretion of thyroid hormones by the thyroid gland. It has multiple aetiologies, manifestations and potential therapies. Graves' disease is the most common form of hyperthyroidism, due to the production of autoantibodies against thyrotropin receptor, capable of over-stimulating thyroid function. A reliable diagnosis of hyperthyroidism can be established on clinical grounds, followed by the evaluation of serum thyroid function tests (thyrotropin first and then free thyroxine, adding the measurement of free triiodothyronine in selected specific situations). The recent guidelines of both the American and European Thyroid Associations have strongly recommended the measurement of thyrotropin receptor autoantibodies for the accurate diagnosis and management of Graves' disease. If autoantibody test is negative, a radioiodine uptake should be performed. Considering the most recent laboratory improvements, binding assays can be considered the best first solution for the measurement of thyrotropin receptor autoantibodies in diagnosis and management of overt cases of Graves' disease. In fact, they have a satisfactory clinical sensitivity and specificity (97.4% and 99.2%, respectively) being performed in clinical laboratories on automated platforms together with the other thyroid function tests. In this setting, the bioassays should be reserved for fine and complex diagnoses and for particular clinical conditions where it is essential to document the transition from stimulating to blocking activity or vice versa (e.g. pregnancy and post-partum, related thyroid eye disease, Hashimoto's thyroiditis with extrathyroidal manifestations, unusual cases after LT4 therapy for hypothyroidism or after antithyroid drug treatment for Graves' disease). Undoubtedly, technological advances will help improve laboratory diagnostics of hyperthyroidism. Nevertheless, despite future progress, the dialogue between clinicians and laboratory will continue to be crucial for an adequate knowledge and interpretation of the laboratory tests and, therefore, for an accurate diagnosis and correct management of the patient.
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Affiliation(s)
- Federica D'Aurizio
- Department of Laboratory Medicine, Institute of Clinical Pathology, Santa Maria della Misericordia University Hospital, Udine, Italy -
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Kahaly GJ. Management of Graves Thyroidal and Extrathyroidal Disease: An Update. J Clin Endocrinol Metab 2020; 105:5905591. [PMID: 32929476 PMCID: PMC7543578 DOI: 10.1210/clinem/dgaa646] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 09/11/2020] [Indexed: 12/14/2022]
Abstract
CONTEXT Invited update on the management of systemic autoimmune Graves disease (GD) and associated Graves orbitopathy (GO). EVIDENCE ACQUISITION Guidelines, pertinent original articles, systemic reviews, and meta-analyses. EVIDENCE SYNTHESIS Thyrotropin receptor antibodies (TSH-R-Abs), foremost the stimulatory TSH-R-Abs, are a specific biomarker for GD. Their measurement assists in the differential diagnosis of hyperthyroidism and offers accurate and rapid diagnosis of GD. Thyroid ultrasound is a sensitive imaging tool for GD. Worldwide, thionamides are the favored treatment (12-18 months) of newly diagnosed GD, with methimazole (MMI) as the preferred drug. Patients with persistently high TSH-R-Abs and/or persistent hyperthyroidism at 18 months, or with a relapse after completing a course of MMI, can opt for a definitive therapy with radioactive iodine (RAI) or total thyroidectomy (TX). Continued long-term, low-dose MMI administration is a valuable and safe alternative. Patient choice, both at initial presentation of GD and at recurrence, should be emphasized. Propylthiouracil is preferred to MMI during the first trimester of pregnancy. TX is best performed by a high-volume thyroid surgeon. RAI should be avoided in GD patients with active GO, especially in smokers. Recently, a promising therapy with an anti-insulin-like growth factor-1 monoclonal antibody for patients with active/severe GO was approved by the Food and Drug Administration. COVID-19 infection is a risk factor for poorly controlled hyperthyroidism, which contributes to the infection-related mortality risk. If GO is not severe, systemic steroid treatment should be postponed during COVID-19 while local treatment and preventive measures are offered. CONCLUSIONS A clear trend towards serological diagnosis and medical treatment of GD has emerged.
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Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- Correspondence and Reprint Requests: George J. Kahaly, MD, PhD, JGU Medical Center, Mainz 55101, Germany. E-mail:
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Quinn M, Bashari W, Smith D, Gurnell M, Agha A. A remarkable case of thyrotoxicosis initially caused by graves' disease followed by a probable TSHoma - a case report. BMC Endocr Disord 2020; 20:133. [PMID: 32854689 PMCID: PMC7457301 DOI: 10.1186/s12902-020-00611-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 08/18/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Graves' disease is the commonest cause of thyrotoxicosis whilst thyrotropin (TSH)-producing pituitary adenomas (thyrotropinomas, TSHomas) are very rare and account for just 1-2% of all pituitary adenomas. Coexistence of a TSHoma and Graves' disease has been very rarely reported. Here, we report a case of a patient whose initial presentation with primary thyrotoxicosis due to Graves' disease, was subsequently followed by a relapse of thyrotoxicosis due to a probable TSHoma. CASE A sixty-eight year old woman was referred to our department with classical features of thyrotoxicosis. Initial biochemistry confirmed hyperthyroxinaemia [free thyroxine (fT4) 20.4 pmol/L (reference range 7.0-16.0)] and a suppressed TSH [< 0.02mIU/L (0.50-4.20)]. A technetium pertechnetate uptake scan was consistent with Graves' Disease. She was treated with carbimazole for 18 months and remained clinically and biochemically euthyroid. After stopping carbimazole her fT4 started to rise but TSH remained normal. Laboratory assay interference was excluded. A TRH stimulation test demonstrated a flat TSH response and pituitary MRI revealed a microadenoma. Remaining pituitary hormones were in the normal range other than a slightly raised IGF-1. An 11C-methionine PET/CT scan coregistered with volumetric MRI (Met-PET-MRICR) demonstrated high tracer uptake in the left lateral sella region suggestive of a functioning adenoma. The patient declined surgery and was unable to tolerate cabergoline or octreotide. Thereafter, she has elected to pursue a conservative approach with periodic surveillance. CONCLUSION This is a very unusual case of thyrotoxicosis caused by two different processes occurring in the same patient. It highlights the importance of considering dual pathology when previously concordant thyroid function tests become discordant. It also highlights a potential role of Met-PET-MRICR in the localisation of functioning pituitary tumours.
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Affiliation(s)
- Mark Quinn
- Department of Diabetes and Endocrinology, Beaumont Hospital and the RCSI, Dublin, Ireland.
| | - Waiel Bashari
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Diarmuid Smith
- Department of Diabetes and Endocrinology, Beaumont Hospital and the RCSI, Dublin, Ireland
| | - Mark Gurnell
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge and National Institute for Health Research Cambridge Biomedical Research Centre, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK
| | - Amar Agha
- Department of Diabetes and Endocrinology, Beaumont Hospital and the RCSI, Dublin, Ireland
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Analytical performance evaluation of thyroid-stimulating hormone receptor antibody (TRAb) immunoassays. Clin Biochem 2020; 86:56-60. [PMID: 32858059 DOI: 10.1016/j.clinbiochem.2020.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/04/2020] [Accepted: 08/18/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND Thyroid-stimulating hormone receptor (TSHR)-activating autoantibodies stimulate thyroid growth and hormone synthesis/secretion, causing hyperthyroidism of Graves' disease (GD). TRAb measurement helps diagnose GD and is an important first test in evaluating hyperthyroidism according to the recent American Thyroid Association guidelines. We compared the performance of the BRAHMS TRAK Kryptor (Thermo Scientific) and Roche cobas TRAb immunoassays for use in GD. METHOD Method comparison (n = 40) and clinical agreement were assessed between the Kryptor, cobas e411, and cobas e601. The analytical performance of Kryptor and cobas e411 were assessed for within- and between-day imprecision across 20 days, linearity, functional assay sensitivity (FAS), dilution recovery, and cut-off verification. RESULTS The Kryptor, e411, and e601 TRAb immunoassays correlated well (r > 0.95, overall percent agreement = 0.95, Cohen's kappa = 0.90). With a total allowable error of 20%, percent bias was within 13%, which was minimally negative at <20 IU/L, but highly positive (33%-34%) >20 IU/L. The Kryptor, but not e411, was linear across the claimed analytical measuring range (AMR). The claimed functional assay sensitivity (FAS), which was close to the clinical GD cut-off 1.8 IU/L, was verified for Kryptor and e411. CONCLUSION Overall, our evaluation demonstrates acceptable comparability between TRAb immunoassays with in-house imprecision up to 13% and 10% on Kryptor and e411, respectively. While Roche has preferable calibration frequency and on-board reagent stability, both platforms demonstrate acceptable imprecision using patient samples at their claimed FAS, which is important for GD diagnosis. Diluted results (using a negative patient pool as diluent) exhibits proportional positive bias on the Kryptor relative to the Roche methods.
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Davies TF, Andersen S, Latif R, Nagayama Y, Barbesino G, Brito M, Eckstein AK, Stagnaro-Green A, Kahaly GJ. Graves' disease. Nat Rev Dis Primers 2020; 6:52. [PMID: 32616746 DOI: 10.1038/s41572-020-0184-y] [Citation(s) in RCA: 168] [Impact Index Per Article: 42.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2020] [Indexed: 02/08/2023]
Abstract
Graves' disease (GD) is an autoimmune disease that primarily affects the thyroid gland. It is the most common cause of hyperthyroidism and occurs at all ages but especially in women of reproductive age. Graves' hyperthyroidism is caused by autoantibodies to the thyroid-stimulating hormone receptor (TSHR) that act as agonists and induce excessive thyroid hormone secretion, releasing the thyroid gland from pituitary control. TSHR autoantibodies also underlie Graves' orbitopathy (GO) and pretibial myxoedema. Additionally, the pathophysiology of GO (and likely pretibial myxoedema) involves the synergism of insulin-like growth factor 1 receptor (IGF1R) with TSHR autoantibodies, causing retro-orbital tissue expansion and inflammation. Although the aetiology of GD remains unknown, evidence indicates a strong genetic component combined with random potential environmental insults in an immunologically susceptible individual. The treatment of GD has not changed substantially for many years and remains a choice between antithyroid drugs, radioiodine or surgery. However, antithyroid drug use can cause drug-induced embryopathy in pregnancy, radioiodine therapy can exacerbate GO and surgery can result in hypoparathyroidism or laryngeal nerve damage. Therefore, future studies should focus on improved drug management, and a number of important advances are on the horizon.
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Affiliation(s)
- Terry F Davies
- Thyroid Research Laboratory, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,James J. Peters VA Medical Center, New York, NY, USA. .,Mount Sinai Thyroid Center, Mount Sinai Downtown at Union Sq, New York, NY, USA.
| | - Stig Andersen
- Department of Geriatric and Internal Medicine and Arctic Health Research Center, Aalborg University Hospital, Aalborg, Denmark
| | - Rauf Latif
- Thyroid Research Laboratory, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,James J. Peters VA Medical Center, New York, NY, USA
| | - Yuji Nagayama
- Department of Molecular Medicine, Atomic Bomb Disease Institute, Nagasaki University, Nagasaki, Japan
| | - Giuseppe Barbesino
- Thyroid Unit, Division of Endocrinology, Massachusetts General Hospital, Boston, MA, USA
| | - Maria Brito
- Mount Sinai Thyroid Center, Mount Sinai Downtown at Union Sq, New York, NY, USA
| | - Anja K Eckstein
- Department of Ophthalmology, University Duisburg Essen, Essen, Germany
| | - Alex Stagnaro-Green
- Departments of Medicine, Obstetrics and Gynecology and Medical Education, University of Illinois College of Medicine at Rockford, Rockford, IL, USA
| | - George J Kahaly
- Department of Medicine I, Johannes Gutenberg University Medical Centre, Mainz, Germany
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Francis N, Francis T, Lazarus JH, Okosieme OE. Current controversies in the management of Graves' hyperthyroidism. Expert Rev Endocrinol Metab 2020; 15:159-169. [PMID: 32315207 DOI: 10.1080/17446651.2020.1754192] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/07/2020] [Indexed: 12/12/2022]
Abstract
Introduction: The management of Graves' disease centers on the use of effective and well-established therapies, namely thionamide antithyroid drugs, radioactive iodine, and thyroidectomy. Optimal treatment strategies are however controversial and vary significantly across centers.Areas covered: This review addresses specific controversies in Graves' disease management including the choice of primary therapy, the approach to women planning pregnancy, and optimal strategies for antithyroid drug and radioiodine therapy.Expert opinion: Important considerations in choosing therapy include treatment efficacy, adverse effects, patient convenience, and resource settings. Recent data suggest that early and effective control of hyperthyroidism is key to improving cardiovascular morbidity and mortality. Studies addressing cancer risk in radioiodine-treated patients face methodological challenges and require clarification in appropriately designed studies. Remission rates with antithyroid drugs are comparable when thionamides are used alone (titration-regimen) or in combination with levothyroxine (block and replace) and can be optimized by extending treatment for at least 12-18 months. Fixed and calculated radioiodine activity regimens are both effective but entail a trade-off between convenience and precision in the administered activity. Optimal preconception strategies are still evolving but ablative treatment in advance of pregnancy offers the most pragmatic means of reducing adverse effects of hyperthyroidism in subsequent pregnancy.
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Affiliation(s)
- Niroshan Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - Thanuya Francis
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
| | - John H Lazarus
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
| | - Onyebuchi E Okosieme
- Endocrinology and Diabetes Department, Prince Charles Hospital, Cwm Taf University Health Board, Merthyr Tydfil, UK
- Thyroid Research Group, School of Medicine, Cardiff University, Cardiff, UK
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Scappaticcio L, Trimboli P, Keller F, Imperiali M, Piccardo A, Giovanella L. Diagnostic testing for Graves' or non-Graves' hyperthyroidism: A comparison of two thyrotropin receptor antibody immunoassays with thyroid scintigraphy and ultrasonography. Clin Endocrinol (Oxf) 2020; 92:169-178. [PMID: 31742747 DOI: 10.1111/cen.14130] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/14/2019] [Accepted: 11/15/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Graves' disease (GD) is the most common cause of hyperthyroidism. In many cases, when the aetiological diagnosis of GD is not evident based on the clinical evaluation and thyroid function testing, it may become challenging to distinguish Graves' hyperthyroidism from other forms of thyrotoxicosis. The current study was primarly carried out to compare the diagnostic effectiveness of two TSH receptor antibody immunoassays (IMAs), ultrasonography and thyroid scintigraphy in hyperthyroidism scenario. METHODS We retrospectively analysed consecutive patients with newly diagnosed and untreated thyrotoxicosis who underwent thyroid functional tests, both TRAb and TSI measurements, thyroid scintigraphy and ultrasonography. TRAb assessment was carried out by Kryptor® compact PLUS, while TSI by Immulite® . Echo pattern 3 corresponded to 'thyroid inferno', and the final diagnosis of GD vs non-Graves' hyperthyroidism was made according to the thyroid scan (qualitative scintigraphy). Receiver operating characteristic (ROC) curves were drawn using the final diagnosis as reference. Clinical sensitivity and specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) were calculated for all the tests. RESULTS A total of 124 untreated hyperthyroid patients were included in our study (GD, n = 86 vs non-Graves' hyperthyroidism, n = 38). ROC curves showed that the optimal cut-off values associated with the highest diagnostic sensitivity and specificity was 0.7 IU/L for TRAb Kryptor® (93 [85.4-97.4] and 86.8 [71.9-95.5]) and 0.1 IU/L for TSI Immulite® (94.2 [86.9-98.1] and 84.2 [68.7-93.9]), respectively. For the echo pattern 3, we found a good sensitivity (92.1%) and a high PPV (95.2%) but a quite low specificity value (69.8%) and a relative low NPV (57.5%). For thyroid scintigraphy, the TcTU cut-off value of 1.3% corresponded to the best limit for sensitivity and specificity in our patients (95.3 [88.5-98.7] and 96.4 [81.6-99.4]). The Passing-Bablok regression equation and the Bland-Altman test showed a great degree of correlation and agreement existed between TRAb Kryptor® and Immulite® TSI results. CONCLUSIONS Thyroid scintigraphy remains the most accurate method to differentiate causes of thyrotoxicosis. However, TRAb assays can be alternatively adopted in this setting, limiting the use of thyroid scintigraphy (TcTU evaluation) to TRAb-negative patients. Thyoid US is less accurate than both TRAb/TSI and thyroid scintigraphy, but the 'thyroid inferno' pattern provides a high PPV for GD.
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Affiliation(s)
- Lorenzo Scappaticcio
- Unit of Endocrinology and Metabolic Diseases, University of Campania "L. Vanvitelli", Naples, Italy
- Clinic for Nuclear Medicine and Competence Thyroid Centre, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Pierpaolo Trimboli
- Clinic for Nuclear Medicine and Competence Thyroid Centre, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
| | - Franco Keller
- Institute of Laboratory Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Mauro Imperiali
- Institute of Laboratory Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Arnoldo Piccardo
- Division of Nuclear Medicine, Ente Ospedaliero Galliera, Genova, Italy
| | - Luca Giovanella
- Clinic for Nuclear Medicine and Competence Thyroid Centre, Imaging Institute of Southern Switzerland, Bellinzona, Switzerland
- Institute of Laboratory Medicine, Ente Ospedaliero Cantonale, Bellinzona, Switzerland
- Clinic for Nuclear Medicine, University Hospital and University of Zurich, Zurich, Switzerland
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Schwiebert C, Kühnen P, Becker NP, Welsink T, Keller T, Minich WB, Wiegand S, Schomburg L. Antagonistic Autoantibodies to Insulin-Like Growth Factor-1 Receptor Associate with Poor Physical Strength. Int J Mol Sci 2020; 21:ijms21020463. [PMID: 31940750 PMCID: PMC7013472 DOI: 10.3390/ijms21020463] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 01/04/2023] Open
Abstract
Natural autoantibodies to the IGF1 receptor (IGF1R-aAb) have been described in relation to Graves' ophthalmopathy. Other physiological roles of natural IGF1R-aAb are not known. We hypothesized that IGF1R-aAb may be related to muscle development. Serum samples (n = 408) from young overweight subjects (n = 143) were collected during a lifestyle intervention study. Anthropometric parameters, along with leptin, IGF1 and IGF1R-aAb concentrations, were analyzed, and the subjects were categorized into positive or negative for IGF1R-aAb. Eleven out of 143 subjects (7.7%) were positive for IGF1R-aAb. Identified IGF1R-aAb were molecularly characterized and showed antagonistic activity in vitro impairing IGF1-mediated IGF1R activation. Mean body weight, height or age were similar between IGF1R-aAb-positive and -negative subjects, but IGF1 concentrations differed. Jumping ability, as well as right and left handgrip strengths, were lower in the IGF1R-aAb-positive as compared to the IGF1R-aAb-negative subjects. We conclude that natural IGF1R-aAb are detectable in apparently healthy subjects and are capable of antagonizing IGF1-dependent IGF1R activation. Moreover, the presence of IGF1R-aAb is associated with poor physical strength. Although the causality of this association is unclear, the data imply a potential influence of IGF1R autoimmunity on muscle development.
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Affiliation(s)
- Christian Schwiebert
- Institute for Experimental Endocrinology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; (C.S.); (N.-P.B.); (T.W.); (W.B.M.)
| | - Peter Kühnen
- Department of Paediatric Endocrinology and Diabetology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; (P.K.); (S.W.)
| | - Niels-Peter Becker
- Institute for Experimental Endocrinology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; (C.S.); (N.-P.B.); (T.W.); (W.B.M.)
| | - Tim Welsink
- Institute for Experimental Endocrinology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; (C.S.); (N.-P.B.); (T.W.); (W.B.M.)
| | - Theresa Keller
- Institute of Biometry and Clinical Epidemiology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Charitéplatz 1, D-10117 Berlin, Germany;
| | - Waldemar B. Minich
- Institute for Experimental Endocrinology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; (C.S.); (N.-P.B.); (T.W.); (W.B.M.)
| | - Susanna Wiegand
- Department of Paediatric Endocrinology and Diabetology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; (P.K.); (S.W.)
| | - Lutz Schomburg
- Institute for Experimental Endocrinology, Charité–Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Augustenburger Platz 1, D-13353 Berlin, Germany; (C.S.); (N.-P.B.); (T.W.); (W.B.M.)
- Correspondence: ; Tel.: +49-30-450-524289
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Tozzoli R. Receptor autoimmunity: diagnostic and therapeutic implications. AUTO- IMMUNITY HIGHLIGHTS 2020; 11:1. [PMID: 32127047 PMCID: PMC7065331 DOI: 10.1186/s13317-019-0125-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 12/26/2019] [Indexed: 12/21/2022]
Abstract
Receptor autoimmunity is one of the ways in which autoimmune diseases appear in humans. Graves' disease, myasthenia gravis, idiopathic membranous nephropathy, and autoimmune acute encephalitis are the major autoimmune diseases belonging to this particular group. Receptor autoimmune disease are dependent on the presence of autoantibodies directed against cell-surface antigens, namely TSH receptor in thyrocytes, acetylcholine receptor in neuromuscular junction, phospholipase 2 receptor in podocytes, and NMDA receptor in cortical neurons. In this article we outline the distinctive features of receptor autoimmunity and the specific relationship between the autoimmunology laboratory and the presence/concentration of autoantibodies. Some immunological features distinguish receptor autoimmunity. Anti-receptor autoantibody pathologies are considered T cell-dependent, B-cell-mediated autoimmune disorders: the knowledge about the presence of circulating and/or localized autoantibodies to target organs and identification of autoantigens involved in the autoimmune reaction is of paramount importance. Due to the close correlation between the concentration of anti-receptor autoantibodies, the autoimmune target of some cell-surface receptors and the intensity of symptoms, the measurement of these immunoglobulins has become central to diagnose autoimmune diseases in all affected patients, not just in clinically dubious cases. The measurement of autoantibodies is also relevant for differential diagnosis of autoimmune and non-autoimmune forms with similar symptoms. From the methodological point of view, quantitative immunoassay methods of measurement should be preferred over semi-quantitative ones, for the capacity of the first class of methods to define precisely the reference ranges and decision levels overcoming the measurement uncertainty of semi-quantitative methods.
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Affiliation(s)
- Renato Tozzoli
- Laboratory of Clinical Pathology, S. Maria degli Angeli Hospital, and Consultant Endocrinologist, San Giorgio Clinics, Pordenone, Italy.
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Wu Z, Zhu Y, Zhang M, Wang C, Zhou L, Liu W, Yang W, Li M, Zhang S, Ren Q, Han X, Ji L. Serum Ratio of Free Triiodothyronine to Thyroid-Stimulating Hormone: A Novel Index for Distinguishing Graves' Disease From Autoimmune Thyroiditis. Front Endocrinol (Lausanne) 2020; 11:620407. [PMID: 33488527 PMCID: PMC7821852 DOI: 10.3389/fendo.2020.620407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Accepted: 12/07/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Graves' disease (GD) and autoimmune thyroiditis (AIT) are two major causes of thyrotoxicosis that require correct diagnosis to plan appropriate treatment. The objectives of this study were to evaluate the usefulness of thyroid-related parameters for distinguishing GD from AIT and identify a novel index for differential diagnosis of thyrotoxicosis. DESIGN This retrospective study was performed using electronic medical records in Peking University People's Hospital (Beijing, China). METHODS In total, 650 patients with GD and 155 patients with AIT from December 2015 to October 2019 were included in cohort 1. Furthermore, 133 patients with GD and 14 patients with AIT from December 2019 to August 2020 were included in cohort 2 for validation of the novel index identified in cohort 1. All patients were of Chinese ethnicity and were newly diagnosed with either GD or AIT. Thyroid-related clinical information was collected before intervention by reviewing the patients' electronic medical records. Receiver operating characteristic curve analysis was used to identify the optimal cutoff for distinguishing GD from AIT. RESULTS In cohort 1, thyroid-stimulating hormone (TSH) receptor antibody was identified as the best indicator for distinguishing GD from AIT. The area under the receiver operating characteristic curve was 0.99(95% confidence interval: 0.98-0.99, p<0.0001)and the optimal cutoff was 0.84 IU/l (98% sensitivity and 99% specificity). The free triiodothyronine (FT3)/TSH ratio (FT3/TSH) was the second -best for distinguishing GD from AIT, the area under the receiver operating characteristic curve of FT3/TSH was 0.86 (95% confidence interval: 0.84-0.88, p<0.0001); its optimal cutoff was 1.99 pmol/mIU (79% sensitivity and 80% specificity). Its effectiveness was confirmed in cohort 2 (81% sensitivity and 100% specificity). CONCLUSIONS The FT3/TSH ratio is a new useful index for differential diagnosis of thyrotoxicosis, especially when combined with TRAb.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Xueyao Han
- *Correspondence: Linong Ji, ; Xueyao Han,
| | - Linong Ji
- *Correspondence: Linong Ji, ; Xueyao Han,
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Abstract
PURPOSE OF REVIEW Graves' hyperthyroidism is associated with significant obstetric, maternal, fetal, and neonatal complications. Early diagnosis and an understanding of the management of Graves' hyperthyroidism in pregnancy can help to prevent these complications. Antithyroid drugs (ATD) should be avoided in early pregnancy, given their association with congenital malformations. RECENT FINDINGS TSH-receptor antibodies (TRAb) are integral in the management of Graves' hyperthyroidism in pregnancy and in the preconception period. TRAb are indicative of the current activity of Graves' hyperthyroidism and the likelihood of relapse. Furthermore, TRAb predicts the risk of fetal and neonatal hyperthyroidism.The incidence of congenital malformations is roughly the same for propylthiouracil (PTU) and methimazole (MMZ). Exposure to both ATDs in early pregnancy has been associated with increased incidence of congenital malformations compared with exposure to either ATD alone. SUMMARY The goal of the physician is maintaining euthyroidism throughout pregnancy and delivery of a healthy, euthyroid baby. An understanding of the natural progression of Graves' hyperthyroidism in pregnancy and the proper utilization of TRAb enables the physician to minimize the risks associated with Graves' hyperthyroidism and side effects of ATDs unique to pregnancy. The physician should prioritize preconception counseling in women with Graves' hyperthyroidism in order to avoid hyperthyroidism and having to use ATDs in pregnancy.
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Affiliation(s)
- Caroline T Nguyen
- Division of Endocrinology, Diabetes, & Metabolism, Department of Medicine and Obstetrics and Gynecology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
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Kim JJ, Jeong SH, Kim B, Kim D, Jeong SH. Analytical and clinical performance of newly developed immunoassay for detecting thyroid-stimulating immunoglobulin, the Immulite TSI assay. Scand J Clin Lab Invest 2019; 79:443-448. [DOI: 10.1080/00365513.2019.1658216] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Jin Ju Kim
- Department of Laboratory Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Soon-Ho Jeong
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byungkwang Kim
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dokyun Kim
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seok Hoon Jeong
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Brancatella A, Viola N, Brogioni S, Montanelli L, Sardella C, Vitti P, Marcocci C, Lupi I, Latrofa F. Graves' Disease Induced by Immune Checkpoint Inhibitors: A Case Report and Review of the Literature. Eur Thyroid J 2019; 8:192-195. [PMID: 31602361 PMCID: PMC6738242 DOI: 10.1159/000501824] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/29/2019] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION In the last few years, immune checkpoint inhibitors (ICPis) have become a common treatment of cancer. ICPis are associated with peculiar immune side effects, termed immune-related adverse events (irAEs). Thyroid disfunction is a common irAE, but clinical manifestation, severity, and pathogenesis can be variable. While destructive thyroiditis and hypothyroidism are the most common thyroid irAEs induced by ICPis, autoimmune hyperthyroidism (Graves' disease) is rare. We describe a case of a Graves' disease induced by anti-PD-1 therapy and we review the previous reports on this issue. CASE PRESENTATION A 51-year-old man developed an overt autoimmune hyperthyroidism 2 months after he had started nivolumab (anti-PD-1) therapy for a metastatic non-small cell lung cancer. Although TSH-receptor autoantibodies (TRAb) were negative, the persistence of hyperthyroidism, the hypervascular pattern at thyroid ultrasound, and the high uptake at thyroid scintigraphy were all features suggestive of Graves' disease. Methimazole was started with the prompt restoration of euthyroidism. TRAb remained undetectable during the entire follow-up. CONCLUSIONS Autoimmune hyperthyroidism can be induced by anti-PD-1 treatment. TRAb were negative in both cases of nivolumab-induced Graves' disease described to date. A correct differential diagnosis between destructive thyroiditis and autoimmune hyperthyroidism is crucial for the appropriate treatment.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Francesco Latrofa
- *Francesco Latrofa, MD, Department of Clinical and Experimental Medicine, Unit of Endocrinology, University of Pisa, Ospedale Cisanello, Via Paradisa 2, IT–56124 Pisa (Italy), E-Mail
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Sharma A, Stan MN. Thyrotoxicosis: Diagnosis and Management. Mayo Clin Proc 2019; 94:1048-1064. [PMID: 30922695 DOI: 10.1016/j.mayocp.2018.10.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 09/25/2018] [Accepted: 10/22/2018] [Indexed: 12/20/2022]
Abstract
Thyrotoxicosis is the clinical manifestation of excess thyroid hormone action at the tissue level due to inappropriately high circulating thyroid hormone concentrations. Hyperthyroidism, a subset of thyrotoxicosis, refers specifically to excess thyroid hormone synthesis and secretion by the thyroid gland. We performed a review of the literature on these topics utilizing published data in PubMed and MEDLINE. In this review, we discuss the more common etiologies of thyrotoxicosis, focusing on the current approach to diagnosis and management, new trends in those directions, and potential upcoming changes in the field.
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Affiliation(s)
- Anu Sharma
- Division of Endocrinology, Metabolism and Diabetes, University of Utah School of Medicine, Salt Lake City, UT
| | - Marius N Stan
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN.
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Struja T, Jutzi R, Imahorn N, Kaeslin M, Boesiger F, Kutz A, Mundwiler E, Huber A, Kraenzlin M, Mueller B, Meier C, Bernasconi L, Schuetz P. Comparison of Five TSH-Receptor Antibody Assays in Graves' disease: results from an observational pilot study. BMC Endocr Disord 2019; 19:38. [PMID: 31023276 PMCID: PMC6482584 DOI: 10.1186/s12902-019-0363-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early diagnosis and relapse prediction in Graves' disease influences treatment. We assessed the abilities of four TSH-receptor antibody tests [TRAb] and one cyclic adenosine monophosphate bioassay to predict relapse of Graves' disease. METHODS Observational study investigating patients presenting with Graves' disease at a Swiss hospital endocrine referral center or an endocrine outpatient clinic. Main outcomes were diagnosis and relapse of Graves' disease after stop of anti-thyroid drugs. We used Cox regression to study associations of TRAb levels with relapse risk and calculated c-statistics [AUC] to assess discrimination. Blood draws took place as close as possible to treatment initiation. RESULTS AUCs ranged from 0.90 (TSAb Biossay by RSR) to 0.97 (IMMULITE TSI by Siemens). Highest sensitivity (94.0%) was observed for IMMULITE TSI and RSR TRAb Fast, while the greatest specificity (97.9%) was found with the EliA anti-TSH-R (by Thermo Fisher). In Cox regression analysis comparing the highest versus the lower quartiles, the highest hazard ratio [HR] for relapse was found for BRAHMS TRAK (by Thermo Fisher) (2.98, 95% CI 1.13-7.84), IMMULITE TSI (2.40, 95% CI 0.91-6.35), EliA anti-TSH-R (2.05, 95% CI 0.82-5.10), RSR Fast TRAb (1.80, 95% CI 0.73-4.43), followed by RSR STIMULATION (1.18, 95% CI 0.46-2.99). Discrimination analyses showed respective AUCs of 0.68, 0.65, 0.64, 0.64, and 0.59. CONCLUSION The assays tested had good diagnostic power and relapse risk prediction with few differences among the new assays. Due to the small sample size and retrospective design with possible selection bias, our data need prospective validation.
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Affiliation(s)
- Tristan Struja
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Rebecca Jutzi
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Noemi Imahorn
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Marina Kaeslin
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Fabienne Boesiger
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Alexander Kutz
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Esther Mundwiler
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Beat Mueller
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Medical Faculty of the University of Basel, Basel, Switzerland
| | - Christian Meier
- Medical Faculty of the University of Basel, Basel, Switzerland
- Endonet, Basel, Switzerland
| | - Luca Bernasconi
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Medical Faculty of the University of Basel, Basel, Switzerland
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