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Kazakou P, Tzanetakos D, Vakrakou AG, Tzartos JS, Evangelopoulos ΜE, Anagnostouli M, Stathopoulos P, Kassi GN, Stefanis L, Kilidireas C, Zapanti E. Thyroid autoimmunity following alemtuzumab treatment in multiple sclerosis patients: a prospective study. Clin Exp Med 2023; 23:2885-2894. [PMID: 36641771 PMCID: PMC10543528 DOI: 10.1007/s10238-022-00981-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 12/20/2022] [Indexed: 01/16/2023]
Abstract
Autoimmune thyroid disease (AITD) is the most common adverse effect in alemtuzumab (ALZ) treated relapsing-remitting (RR) multiple sclerosis (MS) patients. The objective of this prospective study was to analyze the occurrence, timing of onset, clinical course, and laboratory characteristics of AITD post-ALZ. We evaluated 35 RRMS patients treated with ALZ at a single academic MS center; clinical and laboratory data were collected before ALZ initiation and thereafter quarterly on follow-up with a median of 43.5 months. Seventeen out of 31 patients (54.8%) with no prior history of thyroid dysfunction developed AITD with a mean onset of 19.4 months ± 10.2 (SD) after the first ALZ cycle; Graves' disease (GD) (n = 9); hypothyroidism with positive stimulating thyrotropin receptor antibodies (TRAb) (n = 1); Hashimoto thyroiditis (HT) (n = 6); HT with hypothyroidism (n = 1). Interestingly, seven of nine (77.7%) GD patients showed a fluctuating course. Three out of four patients with preexisting thyroid disease remained stable, whereas one with prior HT and hypothyroidism developed fluctuating GD. All patients with GD commenced antithyroid drugs (ATDs); five continued on "block and replace" treatment; one required radioactive iodine, and one total thyroidectomy. Our analysis showed earlier onset of ALZ-induced AITD in comparison to most other ALZ cohorts; overall, these patients required complex therapeutic approaches of the AITD. We observed a higher rate of fluctuating GD, with earlier onset and lower remission rate than previously reported, which in the majority of patients required prolonged "block and replace" therapy in the minimum dose of each therapeutic agent or more definitive interventions.
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Affiliation(s)
- Paraskevi Kazakou
- Endocrine Unit and Diabetes Centre, Department of Clinical Therapeutics, Alexandra Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
| | - Dimitrios Tzanetakos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece.
| | - Aigli G Vakrakou
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - John S Tzartos
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Μaria-Eleptheria Evangelopoulos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Maria Anagnostouli
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Panos Stathopoulos
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Georgia N Kassi
- Department of Endocrinology, Alexandra Hospital, Athens, Greece
| | - Leonidas Stefanis
- 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Constantinos Kilidireas
- Multiple Sclerosis & Demyelinating Diseases Unit, 1st Department of Neurology, Eginition Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
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Wiersinga WM, Poppe KG, Effraimidis G. Hyperthyroidism: aetiology, pathogenesis, diagnosis, management, complications, and prognosis. Lancet Diabetes Endocrinol 2023; 11:282-298. [PMID: 36848916 DOI: 10.1016/s2213-8587(23)00005-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 12/28/2022] [Accepted: 01/03/2023] [Indexed: 02/26/2023]
Abstract
Hyperthyroidism is a common condition with a global prevalence of 0·2-1·3%. When clinical suspicion of hyperthyroidism arises, it should be confirmed by biochemical tests (eg, low TSH, high free thyroxine [FT4], or high free tri-iodothyonine [FT3]). If hyperthyroidism is confirmed by biochemical tests, a nosological diagnosis should be done to find out which disease is causing the hyperthyroidism. Helpful tools are TSH-receptor antibodies, thyroid peroxidase antibodies, thyroid ultrasonography, and scintigraphy. Hyperthyroidism is mostly caused by Graves' hyperthyroidism (70%) or toxic nodular goitre (16%). Hyperthyroidism can also be caused by subacute granulomatous thyroiditis (3%) and drugs (9%) such as amiodarone, tyrosine kinase inhibitors, and immune checkpoint inhibitors. Disease-specific recommendations are given. Currently, Graves' hyperthyroidism is preferably treated with antithyroid drugs. However, recurrence of hyperthyroidism after a 12-18 month course of antithyroid drugs occurs in approximately 50% of patients. Being younger than 40 years, having FT4 concentrations that are 40 pmol/L or higher, having TSH-binding inhibitory immunoglobulins that are higher than 6 U/L, and having a goitre size that is equivalent to or larger than WHO grade 2 before the start of treatment with antithyroid drugs increase risk of recurrence. Long-term treatment with antithyroid drugs (ie, 5-10 years of treatment) is feasible and associated with fewer recurrences (15%) than short-term treatment (ie, 12-18 months of treatment). Toxic nodular goitre is mostly treated with radioiodine (131I) or thyroidectomy and is rarely treated with radiofrequency ablation. Destructive thyrotoxicosis is usually mild and transient, requiring steroids only in severe cases. Specific attention is given to patients with hyperthyroidism who are pregnant, have COVID-19, or have other complications (eg, atrial fibrillation, thyrotoxic periodic paralysis, and thyroid storm). Hyperthyroidism is associated with increased mortality. Prognosis might be improved by rapid and sustained control of hyperthyroidism. Innovative new treatments are expected for Graves' disease, by targeting B cells or TSH receptors.
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Affiliation(s)
- Wilmar M Wiersinga
- Department of Endocrinology and Metabolism, Academic Medical Center, University of Amsterdam, Netherlands
| | - Kris G Poppe
- Endocrine Unit, CHU Saint-Pierre, Université Libre de Bruxelles, Brussels, Belgium
| | - Grigoris Effraimidis
- Department of Endocrinology and Metabolic Diseases, Larissa University Hospital, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
- Department of Endocrinology and Metabolism, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
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Sandgren S, Novakova L, Axelsson M, Amirbeagi F, Kockum I, Olsson T, Malmestrom C, Lycke J. The role of autoimmune antibodies to predict secondary autoimmunity in patients with relapsing-remitting multiple sclerosis treated with alemtuzumab: A nationwide prospective survey. Front Neurol 2023; 14:1137665. [PMID: 37006489 PMCID: PMC10061078 DOI: 10.3389/fneur.2023.1137665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/17/2023] [Indexed: 03/18/2023] Open
Abstract
BackgroundAlemtuzumab (ALZ) is an immune reconstitution therapy for treating relapsing-remitting multiple sclerosis (RRMS). However, ALZ increases the risk of secondary autoimmune diseases (SADs).ObjectiveWe explored whether the detection of autoimmune antibodies (auto-Abs) could predict the development of SADs.MethodsWe included all patients with RRMS in Sweden who initiated ALZ treatment (n = 124, 74 female subjects) from 2009 to 2019. The presence of auto-Abs was determined in plasma samples obtained at the baseline and at 6, 12, and 24 months of follow-up, as well as in a subgroup of patients (n = 51), it was determined in plasma samples obtained at the remaining 3-month intervals up to 24 months. Monthly blood tests, urine tests, and the assessment of clinical symptoms were performed for monitoring safety including that of SADs.ResultsAutoimmune thyroid disease (AITD) developed in 40% of patients, within a median follow-up of 4.5 years. Thyroid auto-Abs were detected in 62% of patients with AITD. The presence of thyrotropin receptor antibodies (TRAbs) at the baseline increased the risk of AITD by 50%. At 24 months, thyroid auto-Abs were detected in 27 patients, and 93% (25/27) developed AITD. Among patients without thyroid auto-Abs, only 30% (15/51) developed AITD (p < 0.0001). In the subgroup of patients (n = 51) with more frequent sampling for auto-Abs, 27 patients developed ALZ-induced AITD, and 19 of them had detectable thyroid auto-Abs prior to the AITD onset, with a median interval of 216 days. Eight patients (6.5%) developed non-thyroid SAD, and none had detectable non-thyroid auto-Abs.ConclusionWe conclude that monitoring thyroid auto-Abs, essentially TRAbs, may improve the surveillance of AITD associated with ALZ treatment. The risk for non-thyroid SADs was low, and monitoring non-thyroid auto-Abs did not seem to provide any additional information for predicting non-thyroid SADs.
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Affiliation(s)
- Sofia Sandgren
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- *Correspondence: Sofia Sandgren
| | - Lenka Novakova
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Markus Axelsson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Firoozeh Amirbeagi
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Laboratory for Clinical Immunology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ingrid Kockum
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Tomas Olsson
- Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
- Center for Molecular Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Clas Malmestrom
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Laboratory for Clinical Immunology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Jan Lycke
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Manso J, Zhu YH, Margoni M, Rinaldi F, Censi S, Carducci S, Cosma C, Plebani M, Gallo P, Mian C. Alemtuzumab-induced autoimmune thyroid events in patients with relapsing-remitting multiple sclerosis: A real-life and monocentric experience at a tertiary-level centre. Clin Endocrinol (Oxf) 2022; 97:331-338. [PMID: 34724236 DOI: 10.1111/cen.14616] [Citation(s) in RCA: 4] [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: 07/08/2021] [Revised: 09/01/2021] [Accepted: 10/01/2021] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Alemtuzumab-induced autoimmune thyroid events (AIATEs) are the most common adverse effects observed in relapsing-remitting multiple sclerosis (RRMS) patients. This study aims to explore the clinical and biochemical characteristics of such AIATEs, and to examine the risk factors for their occurrence, particularly for the worst clinical phenotype of fluctuating Graves' disease (GD). DESIGN, PATIENTS, MEASUREMENTS We retrospectively analysed a real-life single-centre consecutive series of 57 RRMS patients treated with alemtuzumab whose clinical and biochemical parameters were collected before starting the treatment and then monthly during their follow-up. RESULTS AIATEs developed in 39% of patients a mean 17 months ± 11 after the first cycle of alemtuzumab. The most common AIATEs were GD (64%), followed by Hashimoto's thyroiditis with hypothyroidism (23%), TSH-receptor-antibody (TRAb)-positive hypothyroidism (9%), and silent thyroiditis (4%). GD showed a fluctuating course in 57% of cases. Baseline positivity for anti-thyroperoxidase antibodies, and higher absolute titers of anti-thyroglobulin and anti-thyroperoxidase antibodies correlated significantly with the risk of developing AIATEs, but TRAb positivity did not. Higher TRAb titers at the time of GD being diagnosed correlated strongly with a greater risk of the fluctuating GD phenotype. On ROC curve analysis, we found that a cut-off of 7.3 IU/L could be used to predict the risk of developing a fluctuating GD, with a positive predictive value of 100%. CONCLUSIONS TRAb levels measured with commercial automatic methods at the time of a patient being diagnosed with alemtuzumab-induced GD emerged as a novel biomarker for predicting a fluctuating disease phenotype, with an influence on subsequent therapeutic decisions and patients' follow-up.
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Affiliation(s)
- Jacopo Manso
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Yi Hang Zhu
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Monica Margoni
- Veneto Regional Multiple Sclerosis Center (CeSMuV), Padua University Hospital, Padua, Italy
| | - Francesca Rinaldi
- Veneto Regional Multiple Sclerosis Center (CeSMuV), Padua University Hospital, Padua, Italy
| | - Simona Censi
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Sofia Carducci
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
| | - Chiara Cosma
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Mario Plebani
- Department of Laboratory Medicine, University Hospital of Padova, Padova, Italy
| | - Paolo Gallo
- Veneto Regional Multiple Sclerosis Center (CeSMuV), Padua University Hospital, Padua, Italy
- Department of Neurosciences, Padua University, Padua, Italy
| | - Caterina Mian
- Department of Medicine (DIMED), Endocrinology Unit, Padua University, Padua, Italy
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Graves' disease following commencement of alemtuzumab therapy: Case report discussing clinical considerations and possible pathophysiology. JOURNAL OF CLINICAL AND TRANSLATIONAL ENDOCRINOLOGY CASE REPORTS 2022. [DOI: 10.1016/j.jecr.2022.100120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Lymphocyte Counts and Multiple Sclerosis Therapeutics: Between Mechanisms of Action and Treatment-Limiting Side Effects. Cells 2021; 10:cells10113177. [PMID: 34831400 PMCID: PMC8625745 DOI: 10.3390/cells10113177] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/04/2021] [Accepted: 11/09/2021] [Indexed: 01/18/2023] Open
Abstract
Although the detailed pathogenesis of multiple sclerosis (MS) is not completely understood, a broad range of disease-modifying therapies (DMTs) are available. A common side effect of nearly every MS therapeutic agent is lymphopenia, which can be both beneficial and, in some cases, treatment-limiting. A sound knowledge of the underlying mechanism of action of the selected agent is required in order to understand treatment-associated changes in white blood cell counts, as well as monitoring consequences. This review is a comprehensive summary of the currently available DMTs with regard to their effects on lymphocyte count. In the first part, we describe important general information about the role of lymphocytes in the course of MS and the essentials of lymphopenic states. In the second part, we introduce the different DMTs according to their underlying mechanism of action, summarizing recommendations for lymphocyte monitoring and definitions of lymphocyte thresholds for different therapeutic regimens.
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Graves' disease with spontaneous resolution following ocrelizumab in primary progressive multiple sclerosis. Endocr Regul 2021; 55:169-173. [PMID: 34523298 DOI: 10.2478/enr-2021-0018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Objectives. Immune reconstitution therapies (IRT), which include antibody-based cell-depleting therapies targeting CD52+ (alemtuzumab) or CD20+ (rituximab, ocrelizumab) leukocytes, are approved for the treatment of multiple sclerosis. Thyroid autoimmunity is a common adverse effect of alemtuzumab treatment, Graves' disease (GD) being the most prevalent manifestation. To date, thyroid autoimmunity events have not been reported with CD20-targeting monoclonal antibodies. Case Report. A 59-year-old woman with primary progressive multiple sclerosis with no prior personal history of thyroid disease or autoimmunity, was diagnosed with GD 6 months following the first ocrelizumab infusion. She was asymptomatic and had no signs of ophthalmopathy. Due to the temporal association of GD diagnosis with ocrelizumab infusion, absence of symptoms and our experience with alemtuzumab-induced GD, we decided for an active surveillance strategy and antithyroid drugs were not started. She underwent spontaneous resolution of hyperthyroidism with thyroid-stimulating hormone (TSH) receptor antibodies (TRAb) negativity and a mild and transitory period of subclinical hypothyroidism, while she continued the biannually ocrelizumab administration schedule. To present date, she has maintained close clinical and biochemical surveillance with normal TSH, free thyroxine (fT4) and free triiodothyronine (fT3) levels and undetectable TRAb. Conclusions. This is the first case of GD reported after ocrelizumab administration. The timing, onset and course of this case is similar to alemtuzumab-induced GD, usually interpreted as an "immune reconstitution syndrome"; however, ocrelizumab cell count depletion is inferior in severity, cell population affected and duration of depletion. This case highlights the importance of pre-screening and follow-up with thyroid function tests in patients treated with ocrelizumab. As a novel therapeutic antibody, further investigation is required to unravel the causes of thyroid autoimmunity.
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Sovetkina A, Nadir R, Scalfari A, Tona F, Murphy K, Rigoni E, Dorsey R, Malik O, Nandoskar A, Singh-Curry V, Nicholas R, Martin N. Development of Autoimmune Thyroid Disease in Multiple Sclerosis Patients Post-Alemtuzumab Improves Treatment Response. J Clin Endocrinol Metab 2020; 105:5872006. [PMID: 32667988 DOI: 10.1210/clinem/dgaa453] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 07/12/2020] [Indexed: 01/16/2023]
Abstract
CONTEXT Alemtuzumab is an anti-CD52 monoclonal antibody used in the treatment of relapsing-remitting multiple sclerosis (MS). Between 20% and 40% of alemtuzumab-treated MS patients develop autoimmune thyroid disease (AITD) as a side effect. OBJECTIVE The objective of this work is to determine whether MS disease progression following alemtuzumab treatment differs in patients who develop AITD compared to those who do not. DESIGN, SETTING, AND PATIENTS A retrospective analysis of 126 patients with relapsing-remitting MS receiving alemtuzumab from 2012 to 2017 was conducted at a tertiary referral center. MAIN OUTCOME MEASURES Thyroid status, new relapses, Expanded Disability Status Scale (EDSS) score change, and disability progression following alemtuzumab were evaluated. RESULTS Twenty-six percent (33 out of 126, 25 female, 8 male) of alemtuzumab-treated patients developed AITD, 55% of which was Graves disease. EDSS score following alemtuzumab was reduced in patients who developed AITD compared to those who did not (median [interquartile range]; AITD: -0.25 [-1 to 0.5] vs non-AITD: 0 [1-0]. P = .007]. Multivariable regression analysis confirmed that the development of AITD was independently associated with EDSS score improvement (P = .011). Moreover, AITD patients had higher relapse-free survival following alemtuzumab (P = .023). There was no difference in the number of new focal T2 lesions and contrast-enhancing magnetic resonance imaging lesions developed following alemtuzumab between the 2 groups. CONCLUSION Graves disease was the most common form of AITD developed by MS patients following alemtuzumab. This study suggests that MS patients who develop AITD may have an improved response to alemtuzumab, as measured by reduced disability and lower relapse rate.
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Affiliation(s)
- Alina Sovetkina
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
| | - Rans Nadir
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
| | - Antonio Scalfari
- Department of Neurology, Imperial Healthcare NHS Trust, London, UK
| | - Francesca Tona
- Department of Radiology, Imperial College Healthcare NHS Trust, London, UK
| | - Kevin Murphy
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
| | - Eleonora Rigoni
- Department of Neurology, Imperial Healthcare NHS Trust, London, UK
| | - Rachel Dorsey
- Department of Pharmacy, Imperial Healthcare NHS Trust, London, UK
| | - Omar Malik
- Department of Neurology, Imperial Healthcare NHS Trust, London, UK
| | | | | | - Richard Nicholas
- Department of Neurology, Imperial Healthcare NHS Trust, London, UK
| | - Niamh Martin
- Section of Endocrinology and Investigative Medicine, Imperial College London, London, UK
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Ataca Atilla P, Akkus E, Atilla E, Gokmen N, Civriz Bozdag S, Kurt Yuksel M, Toprak SK, Baskal N, Akan H, Demirer T, Topcuoglu P, Arslan O, Ilhan O, Ozcan M, Beksac M, Gurman G. Thyroid dysfunctions in adult patients after allogeneic hematopoietic stem cell transplantation. Clin Transplant 2020; 34:e14049. [PMID: 32713042 DOI: 10.1111/ctr.14049] [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: 06/27/2020] [Accepted: 07/20/2020] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Thyroid dysfunction (TD) is one of the major endocrinopathies shown after allogeneic hematopoietic stem cell transplantation over the long term. The incidence and the risk factors for TD have varied widely. PATIENTS AND METHODS Two hundred and fifty-nine patients with pre-transplant normal thyroid function tests who survived at least 1 year after allo-HSCT between 2006-2016 were included in the study. RESULTS Sixty-four patients (25%) developed TD at median of 34 months (range, 1-112 months). Hypothyroidism was detected in 32 patients (12%): 5 patients had primary hypothyroidism, and subclinical hypothyroidism occurred in 27 patients. 18 patients (7%) were diagnosed with hyperthyroidism: 2 patients (0.07%) were treated for primary hyperthyroidism, and 16 patients (6%) were followed for subclinical hyperthyroidism. Euthyroid sick syndrome occurred in 14 cases. None of the patients with thyroid dysfunction developed secondary thyroid malignancy. Receiving high-dose TBI (P = .001) was found to be significant risk for hypothyroidism; older age than median (P = .01) and pre-transplant active disease (P < .0001) were related to hyperthyroidism. CONCLUSIONS Thyroid dysfunction, mostly hypothyroidism, is a long-term complication after allo-HSCT in 25% of patients. Older age, pre-transplant active disease, and receiving TBI are among the risk factors. Sustained long-term monitoring of thyroid function test should be considered post allo-HSCT.
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Affiliation(s)
- Pinar Ataca Atilla
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Erman Akkus
- Department of Internal Medicine, Ankara University School of Medicine, Ankara, Turkey
| | - Erden Atilla
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Neslihan Gokmen
- Department of Basic Sciences, Istanbul Technical University, Istanbul, Turkey
| | - Sinem Civriz Bozdag
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Meltem Kurt Yuksel
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Selami Kocak Toprak
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Nilgun Baskal
- Department of Endocrinology, Ankara University School of Medicine, Ankara, Turkey
| | - Hamdi Akan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Taner Demirer
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Pervin Topcuoglu
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Onder Arslan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Osman Ilhan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Muhit Ozcan
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Meral Beksac
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Gunhan Gurman
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
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Yap SM, Dillon M, Crowley RK, McGuigan C. Alemtuzumab-related thyroid disease in people with multiple sclerosis is associated with age and brainstem phenotype at disease onset. Mult Scler J Exp Transl Clin 2020; 6:2055217320933928. [PMID: 32612846 PMCID: PMC7307483 DOI: 10.1177/2055217320933928] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/22/2020] [Indexed: 11/24/2022] Open
Abstract
Background Autoimmune thyroid disease (AITD) occurs in 40%–50% of alemtuzumab-treated persons with
multiple sclerosis (pwMS), most of whom will develop Graves’ Disease (GD). Objective To explore contributory factors for alemtuzumab-related AITD in pwMS. Methods A retrospective patient chart review was performed. Results Sixteen out of 52 (30.8%) pwMS developed AITD. GD occurred in 56.3%
(n = 9), the majority (n = 7, 77.8%) symptomatic. All
but one (85.7%) pwMS with symptomatic GD developed atypical, large and rapid
fluctuations in thyroid hormone levels unexplained by effect of anti-thyroid medication
alone. All symptomatic GD cases were age ≤32 years when starting alemtuzumab (ɸ = 0.60,
p = 0.03). PwMS who started alemtuzumab at a younger age developed
thyroid disease earlier (r = 0.51, p = 0.04). PwMS
with clinical and radiological evidence of brainstem involvement at onset of multiple
sclerosis were 11 times more likely to develop symptomatic GD compared with those with
other phenotypes (p < 0.01). Conclusion Alemtuzumab-induced reconstitution GD may result from early and increased
cross-reactivity between antigens common to the brainstem and thyroid, or presence of
shared Human Leukocyte Antigen (HLA) alleles that determine brainstem and thyroid
involvement. We suggest cautious use of alemtuzumab in younger (≤32 years) pwMS with
early brainstem involvement, especially those actively planning pregnancy, where
alternative therapies are readily available.
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Affiliation(s)
- Siew Mei Yap
- Department of Neurology, St. Vincent's University Hospital, Dublin, Ireland
| | - Mary Dillon
- Department of Neurology, St. Vincent's University Hospital, Dublin, Ireland
| | - Rachel K Crowley
- Department of Endocrinology, St. Vincent's University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Dublin, Ireland
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Thyroid Eye Disease due to Immune Reconstitution Inflammatory Syndrome as a Consequence of Antiretroviral Therapy in the Setting of AIDS. Case Rep Endocrinol 2020; 2020:1728423. [PMID: 32099691 PMCID: PMC7037486 DOI: 10.1155/2020/1728423] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 01/02/2020] [Accepted: 01/24/2020] [Indexed: 11/17/2022] Open
Abstract
We describe a case of worsening Graves' orbitopathy due to immune reconstitution inflammatory syndrome (IRIS) in a 38-year-old HIV-infected male after beginning ART (antiretroviral therapy). Two years after initiation of ART, the patient developed symptoms of hyperthyroidism and thyroid eye disease (TED) or Graves' orbitopathy (GO). Thyroid iodine uptake scan was consistent with Graves' disease. The CT scan of the orbits revealed minimal right-sided proptosis, consistent with GO. He was treated with methimazole and a short course of high-dose prednisone for GO. Thyroid function tests normalized, and eye symptoms eventually stabilized. This case demonstrates the importance of awareness and early recognition of IRIS in its many forms, as it has significant therapeutic implications.
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Muller I, Moran C, Lecumberri B, Decallonne B, Robertson N, Jones J, Dayan CM. 2019 European Thyroid Association Guidelines on the Management of Thyroid Dysfunction following Immune Reconstitution Therapy. Eur Thyroid J 2019; 8:173-185. [PMID: 31602359 PMCID: PMC6738237 DOI: 10.1159/000500881] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/29/2019] [Indexed: 12/11/2022] Open
Abstract
Thyroid dysfunction (TD) frequently occurs as an autoimmune complication of immune reconstitution therapy (IRT), especially in individuals with multiple sclerosis treated with alemtuzumab, a pan-lymphocyte depleting drug with subsequent recovery of immune cell numbers. Less frequently, TD is triggered by highly active antiretroviral therapy (HAART) in patients infected with human immunodeficiency virus (HIV), or patients undergoing bone-marrow/hematopoietic-stem-cell transplantation (BMT/HSCT). In both alemtuzumab-induced TD and HIV/HAART patients, the commonest disorder is Graves' disease (GD), followed by hypothyroidism and thyroiditis; Graves' orbitopathy is observed in some GD patients. On the contrary, GD is rare post-BMT/HSCT, where hypothyroidism predominates probably as a consequence of the associated radiation damage. In alemtuzumab-induced TD, the autoantibodies against the thyrotropin receptor (TRAb) play a major role, and 2 main aspects distinguish this condition from the spontaneous form: (1) up to 20% of GD cases exhibit a fluctuating course, with alternating phases of hyper- and hypothyroidism, due to the coexistence of TRAb with stimulating and blocking function; (2) TRAb are also positive in about 70% of hypothyroid patients, with blocking TRAb responsible for nearly half of the cases. The present guidelines will provide up-to-date recommendations and suggestions dedicated to all phases of IRT-induced TD: (1) screening before IRT (recommendations 1-3); (2) monitoring during/after IRT (recommendations 4-7); (3) management of TD post-IRT (recommendations 8-17). The clinical management of IRT-induced TD, and in particular GD, can be challenging. In these guidelines, we propose a summary algorithm which has particular utility for nonspecialist physicians and which is tailored toward management of alemtuzumab-induced TD. However, we recommend prompt referral to specialist endocrinology services following diagnosis of any IRT-induced TD diagnosis, and in particular for pregnant women and those considering pregnancy.
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Affiliation(s)
- Ilaria Muller
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
- *Dr. Ilaria Muller, MD, PhD, Thyroid Research Group, Division of Infection and Immunity, School of Medicine, Cardiff University, University Hospital of Wales, Heath Park, Main building Room 256 C2 Link Corridor, Cardiff CF14 4XN (UK), E-Mail
| | - Carla Moran
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Beatriz Lecumberri
- Department of Endocrinology and Nutrition, La Paz University Hospital, IdiPAZ, Autonomous University of Madrid, Madrid, Spain
| | | | - Neil Robertson
- Division of Psychological Medicine and Clinical Neurosciences, Cardiff University, Cardiff, United Kingdom
| | - Joanne Jones
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Colin M. Dayan
- Thyroid Research Group, Division of Infection and Immunity, Cardiff University, Cardiff, United Kingdom
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Muller I, Barrett-Lee PJ. The antigenic link between thyroid autoimmunity and breast cancer. Semin Cancer Biol 2019; 64:122-134. [PMID: 31128301 DOI: 10.1016/j.semcancer.2019.05.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 05/17/2019] [Accepted: 05/21/2019] [Indexed: 02/06/2023]
Abstract
The association between breast cancer and benign thyroid disorders, in particular thyroid autoimmunity, has been debated for decades. Autoantibodies to thyroid peroxidase, the hallmark of thyroid autoimmunity, have a higher prevalence among patients with breast cancer compared with the general population. Furthermore a correlation between their positivity and a better prognosis of breast cancer was found in several independent small-scale studies, even if such observation was not confirmed in a subsequent retrospective study conducted on the largest patient cohort to date. The thyroid and mammary glands present several biological similarities, therefore the hypothesis of an immune response to shared thyroid/breast antigens could in part explain the association between thyroid autoimmunity and breast cancer. The sodium iodide symporter is expressed in both glands, however it seems unlikely to be the key common antigen, considering that autoantibodies targeting it are rare. Instead thyroid peroxidase, one of the major thyroid autoantigens, is also expressed in breast tissue and therefore represents the main antigenic link between thyroid autoimmunity and breast cancer. Furthermore lactoperoxidase, an enzyme of the same family that shares structural similarities with thyroid peroxidase, is expressed in neoplastic breast cells and is responsible for the cross-reactivity with some autoantibodies to thyroid peroxidase. Novel strategies for the diagnosis and treatment of breast cancer might take advantage of the antigenic link between thyroid and breast tissues.
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Affiliation(s)
- Ilaria Muller
- Thyroid Research Group, Division of Infection & Immunity, School of Medicine, Cardiff University, Cardiff, United Kingdom.
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14
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Muller I, Willis M, Healy S, Nasser T, Loveless S, Butterworth S, Zhang L, Draman MS, Taylor PN, Robertson N, Dayan CM, Ludgate ME. Longitudinal Characterization of Autoantibodies to the Thyrotropin Receptor (TRAb) During Alemtuzumab Therapy: Evidence that TRAb May Precede Thyroid Dysfunction by Many Years. Thyroid 2018; 28:1682-1693. [PMID: 30351224 DOI: 10.1089/thy.2018.0232] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Thyroid autoimmunity, especially Graves' disease or hypothyroidism with positive autoantibodies (TRAb) to the thyrotropin receptor (TSHR), occurs in 30-40% of patients with relapsing multiple sclerosis following treatment with alemtuzumab (ALTZ). ALTZ therapy therefore provides a unique opportunity to study the evolution of TRAb prior to clinical presentation. TRAb can stimulate (TSAb), block (TBAb), or not affect ("neutral") the TSHR function, causing hyperthyroidism, hypothyroidism, or euthyroidism, respectively. METHODS A longitudinal retrospective analysis was conducted of TRAb bioactivity over a period of nine years in 45 multiple sclerosis patients receiving ALTZ using available stored serum. Of these 45 patients, 31 developed thyroid dysfunction (TD) and 14 remained euthyroid despite being followed for a minimum of five years (NO-TD). The presence of TRAb was evaluated at standardized time points: (i) before ALTZ, (ii) latest time available following ALTZ and before TD onset, and (iii) following ALTZ during/after TD onset. Serum TRAb were detected by published in-house assays (ihTRAb): flow cytometry detecting any TSHR-binding TRAb, and luciferase bioassays detecting TSAb/TBAb bioactivity. Purified immunoglobulin G was used to verify TSAb/TBAb in selected hypothyroid cases. Standard clinical automated measurements of TRAb, antithyroid peroxidase autoantibodies (TPOAb), thyrotropin, free thyroxine, and free triiodothyronine were also collected. RESULTS Before ALTZ, combined ihTRAb (positive with flow cytometry and/or luciferase bioassay) but not automated TRAb were present in 5/16 (31.2%) TD versus 0/14 (0%) NO-TD (p = 0.017). Detectable ihTRAb preceded TD development in 9/28 (32.1%) and by a median of 1.2 years (range 28 days-7.3 years). Combination testing of ihTRAb and TPOAb at baseline predicted 20% of subsequent cases of hyperthyroidism and 83% of hypothyroidism. CONCLUSIONS Evidence is presented that TRAb measured with custom-made assays can be detected prior to any change in thyroid function in up to a third of cases of ALTZ-related TD. Furthermore, the presence of ihTRAb prior to ALTZ treatment was strongly predictive of subsequent TD. The findings suggest that a period of affinity maturation of TRAb may precede clinical disease onset in some cases. Combined testing of TPOAb and ihTRAb may increase the ability to predict those who will develop TD following ALTZ.
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Affiliation(s)
- Ilaria Muller
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Mark Willis
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Sarah Healy
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Taha Nasser
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Samantha Loveless
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Sara Butterworth
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Lei Zhang
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Mohd S Draman
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Peter N Taylor
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Neil Robertson
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Colin M Dayan
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Marian E Ludgate
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
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Cima LN, Martin SC, Lambrescu IM, Stejereanu L, Zaharia C, Colita A, Fica S. Long-term thyroid disorders in pediatric survivors of hematopoietic stem cell transplantation after chemotherapy-only conditioning. J Pediatr Endocrinol Metab 2018; 31:869-878. [PMID: 29935114 DOI: 10.1515/jpem-2018-0020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Accepted: 05/14/2018] [Indexed: 01/21/2023]
Abstract
BACKGROUND Thyroid dysfunction (TD) was usually described in hematopoietic stem cell transplantation (HSCT) recipients who were given total body irradiation (TBI) in the conditioning regimen. Because previous studies have reported discrepant results regarding the presence of long-term thyroid complications in HSCT survivors following chemotherapy-only conditioning, we investigated the frequency of thyroid abnormalities in a series of children treated with HSCT for different disorders without TBI as part of the conditioning protocol. METHODS We compared thyroid-stimulating hormone, free thyroxine, total triiodothyronine (TT3), anti-peroxidase (TPO Ab) and anti-thyroglobulin antibodies and thyroid volume z-score in 28 HSCT survivors and 16 healthy subjects matched for age and sex. RESULTS HSCT recipients had a higher frequency of TD and thyroid complications in total, including TD and euthyroid Hashimoto thyroiditis, compared to the control group. Patients transplanted for Hodgkin lymphoma (HL) were more likely to develop a thyroid complication compared to patients with non-malignant hematologic diseases and leukemia patients. BEAM (carmustine, etoposide, citarabin and melphalan) conditioning compared to busulfan (Bu) and fludarabine (Flu)-based regimens and autologous compared to allogenic grafting were associated with a higher prevalence of TD in our study. HSCT survivors had higher mean serum TT3 levels. A multivariate analysis revealed that autologous (auto)-HSCT recipients had higher mean serum titers of TPO Ab compared to allogenic (allo)-HSCT recipients and controls and the mean thyroid volume z-score was significantly higher in controls compared to auto-/allo-HSCT survivors. CONCLUSIONS We identified a 35.7% prevalence of thyroid abnormalities, emphasizing the need for a long-term surveillance of thyroid function and morphology even in this group of patients who were not exposed to TBI.
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Affiliation(s)
- Luminita N Cima
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 030167 Bucharest, Romania, Phone: +4 021 318 0719,
| | - Sorina C Martin
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Endocrinology, Diabetes and Metabolic Disorders, Elias University Hospital, Bucharest, Romania
| | - Ioana M Lambrescu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Endocrinology, Diabetes and Metabolic Disorders, Elias University Hospital, Bucharest, Romania
| | - Lavinia Stejereanu
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Cristina Zaharia
- Department of Paediatric Bone Marrow Transplantation, Fundeni Hospital, Bucharest, Romania.,Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Anca Colita
- Department of Paediatric Bone Marrow Transplantation, Fundeni Hospital, Bucharest, Romania.,Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Simona Fica
- Department of Endocrinology, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.,Department of Endocrinology, Diabetes and Metabolic Disorders, Elias University Hospital, Bucharest, Romania
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Pariani N, Willis M, Muller I, Healy S, Nasser T, McGowan A, Lyons G, Jones J, Chatterjee K, Dayan C, Robertson N, Coles A, Moran C. Alemtuzumab-Induced Thyroid Dysfunction Exhibits Distinctive Clinical and Immunological Features. J Clin Endocrinol Metab 2018; 103:3010-3018. [PMID: 29878256 PMCID: PMC6097600 DOI: 10.1210/jc.2018-00359] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/01/2018] [Indexed: 11/19/2022]
Abstract
CONTEXT Alemtuzumab, a highly effective treatment for multiple sclerosis (MS), predisposes to Graves disease (GD), with a reportedly indolent course. OBJECTIVE To determine the type, frequency, and course of thyroid dysfunction (TD) in a cohort of alemtuzumab-treated patients with MS in the United Kingdom. DESIGN Case records of alemtuzumab-treated patients who developed TD were reviewed. RESULTS A total of 41.1% (102 out of 248; 80 female and 22 male) of patients developed TD, principally GD (71.6%). Median onset was 17 months (range 2 to 107) following the last dose, with the majority (89%) within 3 years. Follow-up data (range 6 to 251 months) were available in 71 case subjects, of whom 52 (73.2%) developed GD: 10 of these (19.2%) had fluctuating TD. All 52 patients with GD commenced antithyroid drugs (ATDs): 3 required radioiodine (RAI) due to ATD side effects, and drug therapy is ongoing in 2; of those who completed a course, 16 are in remission, 1 developed spontaneous hypothyroidism, and 30 (64%) required definitive or long-term treatment (RAI, n = 17; thyroidectomy, n = 5; and long-term ATDs, n = 8). Three cases of thyroiditis and 16 cases of hypothyroidism were documented: 5 with antithyroid peroxidase antibody positivity only, 10 with positive TSH receptor antibody (TRAb), and 1 of uncertain etiology. Bioassay confirmed both stimulating and blocking TRAb in a subset of fluctuating GD cases. CONCLUSIONS Contrary to published literature, we recorded frequent occurrence of GD that required definitive or prolonged ATD treatment. Furthermore, fluctuating thyroid status in GD and unexpectedly high frequency of TRAb-positive hypothyroidism suggested changing activity of TRAb in this clinical context; we have documented the existence of both blocking and stimulating TRAb in these patients.
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Affiliation(s)
- Nadia Pariani
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Mark Willis
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Ilaria Muller
- Thyroid Research Group, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Sarah Healy
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Taha Nasser
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Anne McGowan
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Greta Lyons
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Joanne Jones
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Krishna Chatterjee
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Colin Dayan
- Thyroid Research Group, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Neil Robertson
- Division of Psychological Medicine and Clinical Neuroscience, Department of Neurology, Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Alasdair Coles
- Department of Clinical Neurosciences, Addenbrooke’s Hospital, Cambridge, United Kingdom
| | - Carla Moran
- University of Cambridge Metabolic Research Laboratories, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke’s Hospital, Cambridge, United Kingdom
- Correspondence and Reprint Requests: Carla Moran, MB, PhD, University of Cambridge, Metabolic Research Laboratories, Institute of Metabolic Science, Level 4, Box 289, Addenbrooke’s Hospital, Cambridge, CB2 0QQ, United Kingdom. E-mail:
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Cima LN, Lambrescu IM, Stejereanu L, Colita A, Or R, Fica S. Graves' orbitopathy after allogeneic bone marrow transplantation in a patient with Fanconi anemia - side effect of alemtuzumab therapy? Clin Case Rep 2018; 6:867-870. [PMID: 29744075 PMCID: PMC5930230 DOI: 10.1002/ccr3.1486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/02/2018] [Accepted: 02/14/2018] [Indexed: 11/10/2022] Open
Abstract
A few cases of thyroid eye disease following alemtuzumab therapy have been described in patients with multiple sclerosis. Our patient is the first case of Graves' orbitopathy after alemtuzumab conditioning for hematopoietic stem cell transplantation.
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Affiliation(s)
| | - Ioana Maria Lambrescu
- Endocrinology Carol Davila University of Medicine and Pharmacy Bucharest Romania.,Carol Davila University of Medicine and Pharmacy Bucharest Romania
| | - Lavinia Stejereanu
- Endocrinology Carol Davila University of Medicine and Pharmacy Bucharest Romania.,Carol Davila University of Medicine and Pharmacy Bucharest Romania
| | - Anca Colita
- Department of Pediatric Bone Marrow Transplantation Fundeni Hospital Bucharest Romania.,Pediatrics Carol Davila University of Medicine and Pharmacy Bucharest Romania
| | - Reuven Or
- Department of Bone Marrow Transplantation Cancer Immunotherapy & Immunobiology Research Center Hadassah University Hospital Jerusalem Israel.,Hematology Hadassah Hebrew University Medical Center Jerusalem Israel
| | - Simona Fica
- Endocrinology Carol Davila University of Medicine and Pharmacy Bucharest Romania.,Department of Endocrinology, Diabetes and Metabolic Disorders Elias University Hospital Bucharest Romania
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Struja T, Kutz A, Fischli S, Meier C, Mueller B, Recher M, Schuetz P. Is Graves' disease a primary immunodeficiency? New immunological perspectives on an endocrine disease. BMC Med 2017; 15:174. [PMID: 28942732 PMCID: PMC5611589 DOI: 10.1186/s12916-017-0939-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 09/04/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Uncertainty about factors influencing the susceptibility and triggers for Graves' disease persists, along with a wide variation in the response to anti-thyroid drugs, currently at approximately 50% of non-responders. The aim of this narrative review is to summarize immunological concepts, with a combined endocrine and immunological perspective, to highlight potential new areas of research. MAIN TEXT Relevant studies were identified through a systematic literature search using the PubMed and EMBASE databases in March 2016. No cut-offs regarding dates were imposed. We used the terms "Graves' Disease" or "Basedow" or "thyrotoxicosis" together with the terms "etiology", "pathophysiology", "immunodeficiency", "causality", and "autoimmunity". The terms "orbitopathy", "ophthalmopathy", and "amiodarone" were excluded. Articles in English, French, German, Croatian, Spanish, and Italian were eligible for inclusion. CONCLUSIONS While concepts such as the impact of iodine, smoking, human leucocyte antigen, infections, and ethnicity are established, new ideas have emerged. Pertaining evidence suggests the involvement of autoimmunity and immunodeficiency in the pathophysiology of Graves' disease. Recent studies point to specific immunological mechanisms triggering the onset of disease, which may also serve as targets for more specific therapies.
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Affiliation(s)
- Tristan Struja
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland.
| | - Alexander Kutz
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland
| | - Stefan Fischli
- Medical Clinic, Department for Endocrinology, Diabetes & Metabolism, Kantonsspital Luzern, Luzern, Switzerland
| | - Christian Meier
- Medical Faculty of the University of Basel, Basel, Switzerland.,Division of Endocrinology, Diabetes & Metabolism, University Hospital and University Basel, Basel, Switzerland
| | - Beat Mueller
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
| | - Mike Recher
- Medical Faculty of the University of Basel, Basel, Switzerland.,Medical Outpatient Clinic and Immunodeficiency Laboratory, Department of Biomedicine, University Hospital and University Basel, Basel, Switzerland
| | - Philipp Schuetz
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Aarau, Switzerland.,Medical Faculty of the University of Basel, Basel, Switzerland
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Goncharova ZA, Sizyakina LP, Belovolova RA, Megeryan VA. [Comorbid autoimmune pathology in patients treated with disease modifying drugs]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 116:53-60. [PMID: 28139612 DOI: 10.17116/jnevro201611610253-60] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Because of intensive growth of the prevalence of multiple sclerosis (MS) and other autoimmune diseases (AID) during the last years, the comorbidity of MS and AID is not a rarity. In this literature review, the development of comorbid AID in patients with MS is considered to be the probable complication of disease modifying therapy with drugs of different groups. The authors present the own data on the prevalence of comorbid autoimmune pathology in patients with MS treated with disease modifying drugs.
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Affiliation(s)
| | - L P Sizyakina
- The Research Institute of Clinical Immunology of Rostov State Medical University, Rostov-on-Don, Russia
| | - R A Belovolova
- The Research Institute of Clinical Immunology of Rostov State Medical University, Rostov-on-Don, Russia
| | - V A Megeryan
- Rostov State Medical University, Rostov-on-Don, Russia
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20
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Rotondi M, Molteni M, Leporati P, Capelli V, Marinò M, Chiovato L. Autoimmune Thyroid Diseases in Patients Treated with Alemtuzumab for Multiple Sclerosis: An Example of Selective Anti-TSH-Receptor Immune Response. Front Endocrinol (Lausanne) 2017; 8:254. [PMID: 29033895 PMCID: PMC5626941 DOI: 10.3389/fendo.2017.00254] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 09/15/2017] [Indexed: 01/14/2023] Open
Abstract
Alemtuzumab, a humanized anti-CD52 monoclonal antibody, is approved for the treatment of active relapsing-remitting multiple sclerosis (MS). Alemtuzumab induces a rapid and prolonged depletion of lymphocytes from the circulation, which results in a profound immuno-suppression status followed by an immune reconstitution phase. Secondary to reconstitution autoimmune diseases represent the most common side effect of Alemtuzumab treatment. Among them, Graves' disease (GD) is the most frequent one with an estimated prevalence ranging from 16.7 to 41.0% of MS patients receiving Alemtuzumab. Thyrotropin (TSH) receptor (R)-reactive B cells are typically observed in GD and eventually present this autoantigen to T-cells, which, in turn, secrete several pro-inflammatory cytokines and chemokines. Given that reconstitution autoimmunity is more frequently characterized by autoantibody-mediated diseases rather than by destructive Th1-mediated disorders, it is not surprising that GD is the most commonly reported side effect of Alemtuzumab treatment in patients with MS. On the other hand, immune reconstitution GD was not observed in a large series of patients with rheumatoid arthritis treated with Alemtuzumab. This negative finding supports the view that patients with MS are intrinsically more at risk for developing Alemtuzumab-related thyroid dysfunctions and in particular of GD. From a clinical point of view, Alemtuzumab-induced GD is characterized by a surprisingly high rate of remission, both spontaneous and after antithyroid drugs, as well as by a spontaneous shift to hypothyroidism, which is supposed to result from a change from stimulating to blocking TSH-receptor antibodies. These immune and clinical peculiarities support the concept that antithyroid drugs should be the first-line treatment in Alemtuzumab-induced Graves' hyperthyroidism.
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Affiliation(s)
- Mario Rotondi
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, ICS-Maugeri IRCCS, University of Pavia, Pavia, Italy
| | - Martina Molteni
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, ICS-Maugeri IRCCS, University of Pavia, Pavia, Italy
| | - Paola Leporati
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, ICS-Maugeri IRCCS, University of Pavia, Pavia, Italy
| | - Valentina Capelli
- Department of Internal Medicine and Therapeutics, and Department of Medical and Surgical Sciences, University of Pavia, Pavia, Italy
| | - Michele Marinò
- Endocrinology Unit I, Department of Clinical and Experimental Medicine, University of Pisa, University Hospital of Pisa, Pisa, Italy
| | - Luca Chiovato
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, ICS-Maugeri IRCCS, University of Pavia, Pavia, Italy
- *Correspondence: Luca Chiovato,
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21
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Abstract
Hyperthyroidism is a form of thyrotoxicosis in which there is excess thyroid hormone synthesis and secretion. Multiple etiologies can lead to a common clinical state of "thyrotoxicosis," which is a consequence of the high thyroid hormone levels and their action on different tissues of the body. The most common cause of thyrotoxicosis is Graves' disease, an autoimmune disorder in which stimulating thyrotropin receptor antibodies bind to thyroid stimulating hormone (TSH) receptors on thyroid cells and cause overproduction of thyroid hormones. Other etiologies include: forms of thyroiditis in which inflammation causes release of preformed hormone, following thyroid gland insult that is autoimmune, infectious, mechanical or medication induced; secretion of human chorionic gonadotropin in the setting of transient gestational thyrotoxicosis and trophoblastic tumors; pituitary thyrotropin release, and exposure to extra-thyroidal sources of thyroid hormone that may be endogenous or exogenous. © 2017 American Physiological Society. Compr Physiol 7:67-79, 2017.
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Affiliation(s)
- Ishita Singh
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare Systems, Los Angeles, California, USA
| | - Jerome M Hershman
- Division of Endocrinology, Diabetes and Hypertension, Department of Medicine, David Geffen School of Medicine at UCLA and VA Greater Los Angeles Healthcare Systems, Los Angeles, California, USA
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22
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Kaleidoscope of autoimmune diseases in HIV infection. Rheumatol Int 2016; 36:1481-1491. [DOI: 10.1007/s00296-016-3555-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/13/2016] [Indexed: 12/23/2022]
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23
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Min HK, Kim IH, Kim JY, Ban TH, Kim KH, Ha J, Kim JH. Trastuzumab-associated autoimmune thyroid disease in a patient with metastatic breast cancer. Korean J Intern Med 2016; 31:608-11. [PMID: 26886211 PMCID: PMC4855083 DOI: 10.3904/kjim.2014.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Revised: 08/16/2014] [Accepted: 12/26/2014] [Indexed: 11/27/2022] Open
Affiliation(s)
| | | | | | | | | | | | - Jung-Hoon Kim
- Correspondence to Jung-Hoon Kim, M.D. Division of Oncology, Department of Internal Medicine, College of Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea, 56 Dongsu-ro, Bupyeong-gu, Incheon 21431, Korea Tel: +82-32-280-5969 Fax: +82-32-280-5987 E-mail:
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24
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Shahani L, Hamill RJ. Therapeutics targeting inflammation in the immune reconstitution inflammatory syndrome. Transl Res 2016; 167:88-103. [PMID: 26303886 DOI: 10.1016/j.trsl.2015.07.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Revised: 07/14/2015] [Accepted: 07/31/2015] [Indexed: 02/04/2023]
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is characterized by improvement in a previously incompetent human immune system manifesting as worsening of clinical symptoms secondary to the ability of the immune system to now mount a vigorous inflammatory response. IRIS was first recognized in the setting of human immunodeficiency virus, and this clinical setting continues to be where it is most frequently encountered. Hallmarks of the pathogenesis of IRIS, independent of the clinical presentation and the underlying pathogen, include excessive activation of the immune system, with increased circulating effector memory T cells, and elevated levels of serum cytokines and inflammatory markers. Patients with undiagnosed opportunistic infections remain at risk for unmasking IRIS at the time of active antiretroviral therapy (ART) initiation. Systematic screening for opportunistic infections before starting ART is a key element to prevent this phenomenon. Appropriate management of IRIS requires prompt recognition of the syndrome and exclusion of alternative diagnoses, particularly underlying infections and drug resistance. Controlled studies supporting the use of pharmacologic interventions in IRIS are scare, and recommendations are based on case series and expert opinions. The only controlled trial published to date, showed reduction in morbidity in patients with paradoxical tuberculosis-related IRIS with the use of oral corticosteroids. There are currently limited data to recommend other anti-inflammatory or immunomodulatory therapies that are discussed in this review, and further research is needed. Ongoing research regarding the immune pathogenesis of IRIS will likely direct future rational therapeutic approaches and clinical trials.
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Affiliation(s)
- Lokesh Shahani
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Tex
| | - Richard J Hamill
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Tex; Medical Care Line, Section of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Tex.
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25
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Sağ E, Gönç N, Alikaşifoğlu A, Kuşkonmaz B, Uçkan D, Özön A, Kandemir N. Hyperthyroidism After Allogeneic Hematopoietic Stem Cell Transplantation: A Report of Four Cases. J Clin Res Pediatr Endocrinol 2015; 7:349-54. [PMID: 26777050 PMCID: PMC4805214 DOI: 10.4274/jcrpe.2295] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Hematopoietic stem cell transplantation (HSCT) is the only curative treatment for many hematological disorders, primary immunodeficiencies, and metabolic disorders. Thyroid dysfunction is one of the frequently seen complications of HSCT. However, hyperthyroidism due to Graves' disease, autoimmune thyroiditis, and thyrotoxicosis are rare. Herein, we report a series of 4 patients who were euthyroid before HSCT but developed hyperthyroidism (3 of them developed autoimmune thyroid disease) after transplantation.
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Affiliation(s)
- Erdal Sağ
- Hacettepe University Faculty of Medicine, Department of Pediatrics, Ankara, Turkey Phone: +90 312 305 11 68 E-mail:
| | - Nazlı Gönç
- Hacettepe University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Ayfer Alikaşifoğlu
- Hacettepe University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Barış Kuşkonmaz
- Hacettepe University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Duygu Uçkan
- Hacettepe University Faculty of Medicine, Department of Pediatric Hematology, Ankara, Turkey
| | - Alev Özön
- Hacettepe University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
| | - Nurgün Kandemir
- Hacettepe University Faculty of Medicine, Department of Pediatric Endocrinology, Ankara, Turkey
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Abstract
Hashimoto's thyroiditis (HT) is part of a spectrum of thyroid autoimmune conditions and this review provides an update on the latest developments in the field. HT has a genetic predisposition with a number of immune-related and thyroid-specific genes conferring disease susceptibility. However, disentangling genes with protective and predisposing effect is a complex process that requires further work. The recent increase in the incidence of HT implicates environmental factors in disease pathogenesis including improved hygiene, increased dietary iodine intake, new treatment modalities and chemical agents. Additional unmodifiable predisposing factors include stress, climate, age and gender. Both cellular and humoral immunity play a role in HT pathogenesis. Defects in T regulatory cells and increased activation of follicular helper T cells may have a role in disease initiation/perpetuation. Infiltrating lymphocytes can be directly cytotoxic to thyroid follicular cells (TFC) or may affect cell viability/function indirectly through cytokine production, which alters TFC integrity and modulates their metabolic and immune function. Thyroid peroxidase and thyroglobulin antibodies are present in the majority of HT patients and help with management decisions. Antibodies against the sodium iodide symporter and pendrin are present in a minority with little known about their clinical relevance. In addition to immune cells, recent work has identified DNA fragments, generated following cell death, and micro RNA as potential factors in HT pathogenesis. Despite the large number of studies, the mechanistic pathways in HT are still not fully understood and further work is required to enhance our knowledge and identify novel preventative and therapeutic clinical targets.
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Affiliation(s)
- R A Ajjan
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - A P Weetman
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
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27
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Leporati P, Groppelli G, Zerbini F, Rotondi M, Chiovato L. Etiopathogenesis of Basedow's disease. Trends and current aspects. Nuklearmedizin 2015; 54:204-10. [PMID: 26293122 DOI: 10.3413/nukmed-0739-15-04] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 08/12/2015] [Indexed: 12/13/2022]
Abstract
Basedow's disease (BD) owes its name to the German physician Karl Adolph von Basedow, who described in 1840 the clinical picture of exophthalmic toxic goitre. More than one century after the seminal paper of Karl von Basedow, the ultimate cause of BD remains to be fully elucidated. In the last years, evidence was accumulated indicating that BD is a polygenic and multifactorial disease that develops as a result of a complex interplay between genetic susceptibility and environmental and endogenous factors, which leads to the loss of immune tolerance to thyroid antigens and in particular to the TSH receptor. Our aim is to review the current knowledge on the pathogenesis of BD. To this purpose, we will firstly focus our attention on the role of genetic factors (the HLA complex, the genes encoding for thyroglobulin, the TSH receptor, CD40, CTLA-4 and PTPN22), and of environmental factors (iodine, infections, psychological stress, gender, smoking, thyroid damage, vitamin D, selenium, immune modulating agents) as possible causes of BD. Taking advantage of the experimental animal models of BD, we will then focus on the immunological mechanisms leading to the loss of tolerance in BD. The pathogenic role played by the chemokine system will be also reviewed.
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Affiliation(s)
| | | | | | | | - L Chiovato
- Luca Chiovato, M.D., Ph.D., Unit of Internal Medicine and Endocrinology, Fondazione Salvatore Maugeri I.R.C.C.S., Chair of Endocrinology, University of Pavia, Via S. Maugeri 10, I-27100, Pavia, Italy, Fax +39/03 82/59 26 92,
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28
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Gupta M, Jafri K, Sharim R, Silverman S, Sindher SB, Shahane A, Kwan M. Immune reconstitution inflammatory syndrome associated with biologic therapy. Curr Allergy Asthma Rep 2015; 15:499. [PMID: 25504263 DOI: 10.1007/s11882-014-0499-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The use of biologics in the treatment of autoimmune disease, cancer, and other immune conditions has revolutionized medical care in these areas. However, there are drawbacks to the use of these medications including increased susceptibility to opportunistic infections. One unforeseen risk once opportunistic infection has occurred with biologic use is the onset of immune reconstitution inflammatory syndrome (IRIS) upon drug withdrawal. Although originally described in human immunodeficiency virus (HIV) patients receiving highly active antiretroviral therapy, it has become clear that IRIS may occur when recovery of immune function follows opportunistic infection in the setting of previous immune compromise/suppression. In this review, we draw attention to this potential pitfall on the use of biologic drugs.
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Affiliation(s)
- Malika Gupta
- Division of Allergy and Immunology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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29
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Marinò M, Latrofa F, Menconi F, Chiovato L, Vitti P. Role of genetic and non-genetic factors in the etiology of Graves' disease. J Endocrinol Invest 2015; 38:283-94. [PMID: 25421156 DOI: 10.1007/s40618-014-0214-2] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 11/12/2014] [Indexed: 12/21/2022]
Abstract
In spite of the advancements in understanding the pathogenic mechanisms of Graves' disease (GD), its ultimate cause remains elusive. The majority of investigators agree that GD is likely a multifactorial disease, due to a complex interplay of genetic and non-genetic factors that lead to the loss of immune tolerance to thyroid antigens and to the initiation of a sustained autoimmune reaction. Twin and family studies support a role of genetic factors, among which the HLA complex, CD40, CTLA-4, PTPN22, FCRL3, thyroglobulin, and the TSH receptor may be involved. Among non-genetic factors, iodine, infections, psychological stress, gender, smoking, thyroid damage, vitamin D, selenium, immune modulating agents, and periods of immune reconstitution may contribute the development of the diseases. Here we review in detail the respective role of genetic and non-genetic factors in the etiology of GD, taking advantage of the great bulk of data generated especially over the past 30 years.
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Affiliation(s)
- M Marinò
- Department of Clinical and Experimental Medicine, University Of Pisa, Pisa, Italy.
- Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy.
| | - F Latrofa
- Department of Clinical and Experimental Medicine, University Of Pisa, Pisa, Italy
- Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - F Menconi
- Department of Clinical and Experimental Medicine, University Of Pisa, Pisa, Italy
- Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
| | - L Chiovato
- Unit of Endocrinology, Department of Internal Medicine and Medical Therapy, University of Pavia, Fondazione Salvatore Maugeri IRCCS, Pavia, Italy
| | - P Vitti
- Department of Clinical and Experimental Medicine, University Of Pisa, Pisa, Italy
- Endocrinology Unit, University Hospital of Pisa, Via Paradisa 2, 56124, Pisa, Italy
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Williams KM, Dietzen D, Hassoun AA, Fennoy I, Bhatia M. Autoimmune thyroid disease following alemtuzumab therapy and hematopoietic cell transplantation in pediatric patients with sickle cell disease. Pediatr Blood Cancer 2014; 61:2307-9. [PMID: 24938636 PMCID: PMC4440678 DOI: 10.1002/pbc.25102] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 04/25/2014] [Indexed: 11/06/2022]
Abstract
Allogenic hematopoietic cell transplantation (alloHCT) is currently the only curative treatment option for patients with sickle cell disease. Alemtuzumab is a monoclonal antibody directed against CD52 positive cells used in myeloablative conditioning regimens for alloHCT. Its use has been associated with development of autoimmune disease in adult patients with rheumatologic conditions. We report on three cases of new onset autoimmune thyroid disease after alloHCT treatment with alemtuzumab in pediatric patients with sickle cell disease.
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Affiliation(s)
| | - Danielle Dietzen
- Department of Pediatrics; Columbia University Medical Center; New York NY
| | - Abeer A. Hassoun
- Department of Pediatrics; Columbia University Medical Center; New York NY
| | - Ilene Fennoy
- Department of Pediatrics; Columbia University Medical Center; New York NY
| | - Monica Bhatia
- Department of Pediatrics; Columbia University Medical Center; New York NY
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31
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Strawa K, Markowska A, Miśkiewicz P, Kuś A, Ambroziak U, Szymański K, Zbiec R, Spólnicka M, Krajewski P, Bednarczuk T, Płoski R. Increased concentration of T-cell receptor rearrangement excision circles (TREC) in peripheral blood in Graves' disease. Clin Endocrinol (Oxf) 2014; 81:769-74. [PMID: 24815998 DOI: 10.1111/cen.12492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Revised: 01/06/2014] [Accepted: 05/01/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND T-cell receptor rearrangement excision circles (TREC) are circular DNA molecules generated during T-cell maturation in the thymus. Recent studies suggested that a decreased TREC concentration in peripheral blood may be a general feature of autoimmunity. Our purpose was to assess the TREC concentration in Graves' disease (GD). METHODS TREC concentration was assessed by real time PCR in DNA samples isolated from peripheral blood leucocytes among younger (n = 94, age range 6-29 years) and older patients with GD (n = 93, age range 57-80 years) and age-matched controls (n = 206). RESULTS TREC concentration decreased with age in all subjects, but it was significantly higher in GD compared with controls (P = 9·4 × 10(-10) ). TREC concentration was higher (P = 0·0038) in hyperthyroid (n = 78) than euthyroid (n = 82) patients with GD, but in both groups, it remained increased relative to controls (P = 2·2 × 10(-11) and P = 4·4 ×10(-7) , respectively). CONCLUSIONS Patients with GD, particularly those with hyperthyroidism, have increased concentration of TREC which may suggest increased rather than decreased thymic activity. Thus, GD does not follow the paradigm suggested for other autoimmune disorders which links autoimmunity with thymic senescence.
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Affiliation(s)
- Katarzyna Strawa
- Department of Medical Genetics, Centre for Biostructure, Medical University of Warsaw, Warsaw, Poland
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Antonelli A, Ferrari SM, Corrado A, Di Domenicantonio A, Fallahi P. Autoimmune thyroid disorders. Autoimmun Rev 2014; 14:174-80. [PMID: 25461470 DOI: 10.1016/j.autrev.2014.10.016] [Citation(s) in RCA: 491] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 10/09/2014] [Indexed: 12/18/2022]
Abstract
Autoimmune thyroid diseases (AITD) result from a dysregulation of the immune system leading to an immune attack on the thyroid. AITD are T cell-mediated organ-specific autoimmune disorders. The prevalence of AITD is estimated to be 5%; however, the prevalence of antithyroid antibodies may be even higher. The AITD comprise two main clinical presentations: Graves' disease (GD) and Hashimoto's thyroiditis (HT), both characterized by lymphocytic infiltration of the thyroid parenchyma. The clinical hallmarks of GD and HT are thyrotoxicosis and hypothyroidism, respectively. The mechanisms that trigger the autoimmune attack to the thyroid are still under investigation. Epidemiological data suggest an interaction among genetic susceptibility and environmental triggers as the key factor leading to the breakdown of tolerance and the development of disease. Recent studies have shown the importance of cytokines and chemokines in the pathogenesis of AT and GD. In thyroid tissue, recruited T helper 1 (Th1) lymphocytes may be responsible for enhanced IFN-γ and TNF-α production, which in turn stimulates CXCL10 (the prototype of the IFN-γ-inducible Th1 chemokines) secretion from the thyroid cells, therefore creating an amplification feedback loop, initiating and perpetuating the autoimmune process. Associations exist between AITD and other organ specific (polyglandular autoimmune syndromes), or systemic autoimmune disorders (Sjögren's syndrome, rheumatoid arthritis, systemic lupus erythematosus, systemic sclerosis, cryoglobulinemia, sarcoidosis, psoriatic arthritis). Moreover, several studies have shown an association of AITD and papillary thyroid cancer. These data suggest that AITD patients should be accurately monitored for thyroid dysfunctions, the appearance of thyroid nodules, and other autoimmune disorders.
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Affiliation(s)
- Alessandro Antonelli
- Department of Clinical and Experimental Medicine, Via Savi 10, I-56126 Pisa, University of Pisa, Italy.
| | - Silvia Martina Ferrari
- Department of Clinical and Experimental Medicine, Via Savi 10, I-56126 Pisa, University of Pisa, Italy
| | - Alda Corrado
- Department of Clinical and Experimental Medicine, Via Savi 10, I-56126 Pisa, University of Pisa, Italy
| | - Andrea Di Domenicantonio
- Department of Clinical and Experimental Medicine, Via Savi 10, I-56126 Pisa, University of Pisa, Italy
| | - Poupak Fallahi
- Department of Clinical and Experimental Medicine, Via Savi 10, I-56126 Pisa, University of Pisa, Italy
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Abstract
Thyroid abnormalities and nonthyroidal illness complicate human immunodeficiency virus (HIV) infection. Among the effects that result from HIV and other opportunistic infections, distinctive features of HIV infection include early lowering of reverse tri-iodothyromine (T3) levels, with normal free T3 levels. Later, some patients develop an isolated low free thyroxine level. After highly active antiretroviral therapy, the immune system reconstitutes in a way that leads to dysregulation of the autoimmune response and the appearance of Graves disease in 1% to 2% of patients. Opportunistic thyroid infections with unusual organisms are most commonly asymptomatic, but can lead to acute or subacute thyroiditis.
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Affiliation(s)
- Anthony P Weetman
- Department of Human Metabolism, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK.
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34
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Aranha AA, Amer S, Reda ES, Broadley SA, Davoren PM. Autoimmune thyroid disease in the use of alemtuzumab for multiple sclerosis: a review. Endocr Pract 2014; 19:821-8. [PMID: 23757618 DOI: 10.4158/ep13020.ra] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE The monoclonal antibody alemtuzumab has been demonstrated to reduce the risks of relapse and accumulation of sustained disability in multiple sclerosis (MS) patients when compared to β-interferon. The development of autoimmune diseases, including thyroid disease, has been reported in the literature with a frequency of 20 to 30%. In this article, we describe 4 cases of alemtuzumab-induced thyroid disease in patients with MS. We also performed a systematic review of the available literature. METHODS Four patients who had received alemtuzumab for MS and subsequently developed thyroid dysfunction are presented. We compared our patients' clinical courses and outcomes to established disease patterns. We also undertook a systematic review of the published literature. RESULTS All 4 patients presented with initial hyperthyroidism associated with elevated thyroid-stimulating hormone (TSH) receptor antibodies (TRAb). In 2 cases, hyperthyroidism did not remit after a total of 24 months of carbimazole therapy, and they subsequently underwent subtotal thyroidectomy. The third case subsequently developed biochemical hypothyroidism and required thyroxine replacement, despite having a markedly raised initial TRAb titer. Autoimmunity following alemtuzumab therapy in MS appears to occur as part of an immune reconstitution syndrome and is more likely in smokers who have a family history of autoimmune disease. CONCLUSION Management of alemtuzumab-induced thyroid disease is similar to the management of "wild-type" Graves' disease. The use of alemtuzumab in this setting will necessitate close monitoring of thyroid function and early intervention when abnormalities are developing.
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Effraimidis G, Wiersinga WM. Mechanisms in endocrinology: autoimmune thyroid disease: old and new players. Eur J Endocrinol 2014; 170:R241-52. [PMID: 24609834 DOI: 10.1530/eje-14-0047] [Citation(s) in RCA: 197] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The last 10 years have seen some progress in understanding the etiology of autoimmune thyroid disease (AITD). The female preponderance can now be explained - at least in part - by fetal microchimerism and X-chromosome inactivation. The number of identified susceptibility genes for AITD is increasing (among others now including TSHR, TG, HLA, CTLA4, PTPN22, CD40, FCRL3, IL2RA, and FOXP3), but these genes together probably do not explain more than about 10% of the heritability of AITD. As twin studies indicate that genes contribute for 70% of AITD, it follows that there must be many more loci, each of them contributing a little. While the genetic studies have clarified why various autoimmune diseases so often cluster in the same patient, the molecular mechanism of action of these genetic polymorphisms (frequently located in introns) has hardly been explained. Polymorphisms in AITD susceptibility genes may become helpful in clinical practice, e.g. in assessing risk of recurrent Graves' hyperthyroidism (GH) after a course of antithyroid drugs. Moderate alcohol intake decreases the risk on overt GH and overt Hashimoto's hypothyroidism. Current smokers - as well known - are at increased risk for Graves' disease, but - surprisingly - at diminished risk for Hashimoto's thyroiditis. Low selenium and low vitamin D levels might increase the risk of developing AITD, but data are still inconclusive. Current options for preventive interventions in subjects at risk to develop AITD are very limited.
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Affiliation(s)
- Grigoris Effraimidis
- Department of Endocrinology and MetabolismAcademic Medical Center, Room F5-169, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands
| | - Wilmar M Wiersinga
- Department of Endocrinology and MetabolismAcademic Medical Center, Room F5-169, University of Amsterdam, Meibergdreef 9, Amsterdam 1105AZ, The Netherlands
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36
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McAninch EA, Xu C, Lagari VS, Kim BW. Coccidiomycosis thyroiditis in an immunocompromised host post-transplant: case report and literature review. J Clin Endocrinol Metab 2014; 99:1537-42. [PMID: 24606101 DOI: 10.1210/jc.2013-4373] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
CONTEXT Acute infectious thyroiditis, particularly fungal thyroiditis, is rare and typically presents in immunocompromised individuals. Here we report the first case of coccidiomycosis thyroiditis occurring in an organ recipient as a consequence of likely allograft contamination and discuss the management strategies for thyroid masses in the setting of disseminated infection. EVIDENCE ACQUISITION AND SYNTHESIS In this clinical case seminar, we summarize the previously published cases of coccidiomycosis thyroiditis based on a MEDLINE search of all peer-reviewed publications (original articles and reviews) on this topic. We identified six other cases, five of which also occurred in immunocompromised hosts, although none occurred in organ recipients. CONCLUSION A case of coccidiomycosis thyroiditis occurring in a post-liver transplant immunocompromised host is reported. Analysis of donor serum revealed the liver allograft as the likely infectious source, resulting in hematological spread to the thyroid. Although our patient's thyroid gland was lacking gross structural abnormalities at presentation, new-onset thyroid masses developed after relative immune restoration and initiation of antifungal therapies. The differential diagnosis of new-onset thyroid masses in immunocompromised hosts is discussed, with a focus on immune reconstitution inflammatory syndrome. The role of thyroidectomy in the management of fungal thyroiditis is also discussed.
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Affiliation(s)
- Elizabeth A McAninch
- Division of Endocrinology, Diabetes, and Metabolism, University of Miami, Miami, Florida 33136
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37
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Weetman AP. Graves' disease following immune reconstitution or immunomodulatory treatment: should we manage it any differently? Clin Endocrinol (Oxf) 2014; 80:629-32. [PMID: 24528193 DOI: 10.1111/cen.12427] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Revised: 02/04/2014] [Accepted: 02/08/2014] [Indexed: 11/30/2022]
Abstract
Graves' disease and other disorders of thyroid function may occur following treatment with novel anticancer agents or during periods of lymphocyte recovery after lymphopenia. There are three main settings for such lymphocyte reconstitution: recovery after a bone marrow or haematopoietic stem cell transplant, alemtuzumab treatment and the use of highly active antiretroviral therapy (HAART) for human immunodeficiency virus infection. The available evidence suggests that Graves' disease behaves as normal in most of these cases and should be treated conventionally, but it may follow a more favourable course in those receiving alemtuzumab or HAART. As spontaneous or drug-induced remission may be more likely in these two settings, first-line treatment should usually consist of an antithyroid drug.
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Affiliation(s)
- Anthony P Weetman
- Department of Human Metabolism, Faculty of Medicine Dentistry and Health, The Medical School, University of Sheffield, Sheffield, UK
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38
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Rommer PS, Dudesek A, Stüve O, Zettl UK. Monoclonal antibodies in treatment of multiple sclerosis. Clin Exp Immunol 2014; 175:373-84. [PMID: 24001305 DOI: 10.1111/cei.12197] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2013] [Indexed: 01/14/2023] Open
Abstract
Monoclonal antibodies (mAbs) are used as therapeutics in a number of disciplines in medicine, such as oncology, rheumatology, gastroenterology, dermatology and transplant rejection prevention. Since the introduction and reintroduction of the anti-alpha4-integrin mAb natalizumab in 2004 and 2006, mAbs have gained relevance in the treatment of multiple sclerosis (MS). At present, numerous mAbs have been tested in clinical trials in relapsing-remitting MS, and in progressive forms of MS. One of the agents that might soon be approved for very active forms of relapsing-remitting MS is alemtuzumab, a humanized mAb against CD52. This review provides insights into clinical studies with the mAbs natalizumab, alemtuzumab, daclizumab, rituximab, ocrelizumab and ofatumumab.
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Affiliation(s)
- P S Rommer
- Clinic and Policlinic of Neurology, University of Rostock, Rostock, Germany; Department of Neurology, Medical University of Vienna, Vienna, Austria
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McLachlan SM, Rapoport B. Breaking tolerance to thyroid antigens: changing concepts in thyroid autoimmunity. Endocr Rev 2014; 35:59-105. [PMID: 24091783 PMCID: PMC3895862 DOI: 10.1210/er.2013-1055] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 09/24/2013] [Indexed: 02/06/2023]
Abstract
Thyroid autoimmunity involves loss of tolerance to thyroid proteins in genetically susceptible individuals in association with environmental factors. In central tolerance, intrathymic autoantigen presentation deletes immature T cells with high affinity for autoantigen-derived peptides. Regulatory T cells provide an alternative mechanism to silence autoimmune T cells in the periphery. The TSH receptor (TSHR), thyroid peroxidase (TPO), and thyroglobulin (Tg) have unusual properties ("immunogenicity") that contribute to breaking tolerance, including size, abundance, membrane association, glycosylation, and polymorphisms. Insight into loss of tolerance to thyroid proteins comes from spontaneous and induced animal models: 1) intrathymic expression controls self-tolerance to the TSHR, not TPO or Tg; 2) regulatory T cells are not involved in TSHR self-tolerance and instead control the balance between Graves' disease and thyroiditis; 3) breaking TSHR tolerance involves contributions from major histocompatibility complex molecules (humans and induced mouse models), TSHR polymorphism(s) (humans), and alternative splicing (mice); 4) loss of tolerance to Tg before TPO indicates that greater Tg immunogenicity vs TPO dominates central tolerance expectations; 5) tolerance is induced by thyroid autoantigen administration before autoimmunity is established; 6) interferon-α therapy for hepatitis C infection enhances thyroid autoimmunity in patients with intact immunity; Graves' disease developing after T-cell depletion reflects reconstitution autoimmunity; and 7) most environmental factors (including excess iodine) "reveal," but do not induce, thyroid autoimmunity. Micro-organisms likely exert their effects via bystander stimulation. Finally, no single mechanism explains the loss of tolerance to thyroid proteins. The goal of inducing self-tolerance to prevent autoimmune thyroid disease will require accurate prediction of at-risk individuals together with an antigen-specific, not blanket, therapeutic approach.
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Affiliation(s)
- Sandra M McLachlan
- Thyroid Autoimmune Disease Unit, Cedars-Sinai Research Institute, and University of California-Los Angeles School of Medicine, Los Angeles, California 90048
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Almeida Ferreira M, Carvalho AC, Silva SV, França M, Borges F. Two endocrine diseases in one case of immune reconstitution inflammatory syndrome. HIV & AIDS REVIEW 2014. [DOI: 10.1016/j.hivar.2014.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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41
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Frisch M, Nielsen NM, Pedersen BV. Same-sex marriage, autoimmune thyroid gland dysfunction and other autoimmune diseases in Denmark 1989-2008. Eur J Epidemiol 2013; 29:63-71. [PMID: 24306355 DOI: 10.1007/s10654-013-9869-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Accepted: 11/28/2013] [Indexed: 01/05/2023]
Abstract
Autoimmune diseases have been little studied in gay men and lesbians. We followed 4.4 million Danes, including 9,615 same-sex married (SSM) persons, for 47 autoimmune diseases in the National Patient Registry between 1989 and 2008. Poisson regression analyses provided first hospitalization rate ratios (RRs) comparing rates between SSM individuals and persons in other marital status categories. SSM individuals experienced no unusual overall risk of autoimmune diseases. However, the risk of autoimmune thyroid dysfunction was increased, notably Hashimoto's thyroiditis (women(SSM), RR = 2.92; 95% confidence interval (CI) 1.74-4.55) and Graves' disease (men(SSM), RR = 1.88; 95% CI 1.08-3.01). There was also an excess of primary biliary cirrhosis (women(SSM), RR = 4.09; 95% CI 1.01-10.7), and of psoriasis (men(SSM), RR = 2.48; 95% CI 1.77-3.36), rheumatic fever (men(SSM), RR = 7.55; 95% CI 1.87-19.8), myasthenia gravis (men(SSM), RR = 5.51; 95% CI 1.36-14.4), localized scleroderma (men(SSM), RR = 7.16; 95% CI 1.18-22.6) and pemphigoid (men(SSM), RR = 6.56; 95% CI 1.08-20.6), while Dupuytren's contracture was reduced (men(SSM), RR = 0.64; 95% CI 0.39-0.99). The excess of psoriasis was restricted to same-sex married men with HIV/AIDS (men(SSM), RR = 10.5; 95% CI 6.44-15.9), whereas Graves' disease occurred in excess only among same-sex married men without HIV/AIDS (men(SSM), RR = 1.99; 95% CI 1.12-3.22). Lesbians and immunologically competent gay men in same-sex marriage face no unusual overall risk of autoimmune diseases. However, the observed increased risk of thyroid dysfunction in these lesbians and gay men deserves further study.
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Affiliation(s)
- Morten Frisch
- Department of Epidemiology Research, Statens Serum Institut, 5 Artillerivej, DK-2300, Copenhagen S, Denmark,
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Sinha A, Abinun M, Gennery AR, Barge D, Slatter M, Cheetham T. Graves' immune reconstitution inflammatory syndrome in childhood. Thyroid 2013; 23:1010-4. [PMID: 23556479 DOI: 10.1089/thy.2012.0618] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The use of hematopoietic stem cell transplantations (HSCTs) as a curative therapy for life-threatening immunodeficiencies has had a profound impact on clinical outcomes. A subset of patients may experience immune reconstitution inflammatory syndrome (IRIS) post-transplant affecting the thyroid gland, but this has received little attention in the pediatric literature. We present the clinical, biochemical, and cytological course of patients with Graves' disease after HSCT in the pediatric population. PATIENTS AND METHODS Four children (median age 1.5 years, range 2 months-9 years) underwent HSCT. The conditioning regimen included chemotherapy but not radiotherapy. None of the children or their donors had evidence of thyroid disease pre-HSCT or during the follow-up period. Engraftment was uneventful in all, with stable donor T-cell chimerism, and none had evidence of graft-versus-host disease. RESULTS Patients developed Graves' disease soon after undergoing HSCT, with a median time interval between HSCT and Graves' disease of 22 months (range 16-28 months). Graves' disease was diagnosed on the basis of clinical and biochemical parameters, including a suppressed thyrotropin, raised free thyroxine, and raised thyrotropin receptor antibodies. Three patients were hypothyroid initially (suggestive of a Th1 profile) before Graves' disease (suggestive of a Th2 profile). In three patients, the clinical picture changed rapidly with hypothyroidism abruptly followed by profound thyroid hormone excess. The onset of Graves' IRIS coincided with a rapid expansion in naïve and total CD4. CONCLUSIONS Immunological dysregulation during T-cell engraftment is the most likely mechanism for developing Graves' IRIS after allogenic HSTC. Clinicians need to be aware that HSCT-engendered immune recovery may result in a particularly aggressive form of autoimmune thyroid disease in children with implications for the developing central nervous system. Careful surveillance of thyroid function post-HSCT is essential.
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Affiliation(s)
- Akash Sinha
- Department of Pediatric Endocrinology, Great North Children's Hospital, Newcastle upon Tyne, UK
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Kibirige D, Ssekitoleko R. Endocrine and metabolic abnormalities among HIV-infected patients: A current review. Int J STD AIDS 2013; 24:603-11. [DOI: 10.1177/0956462413479895] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Multiple endocrine and metabolic abnormalities have been reported among human immunodeficiency virus (HIV) patients since the pre-antiretroviral therapy era. These abnormalities present with either subclinical or overt clinical features. Endocrine and metabolic abnormalities primarily occur due to the direct destructive effects of HIV, malignancies and opportunistic infections on the varied endocrine glands and antiretroviral therapy-associated toxicities. This article offers a broad review on the commonly encountered endocrine and metabolic abnormalities among HIV-infected patients. Timely endocrine or metabolic evaluations should be performed among patients suspected with endocrine or metabolic dysfunction and appropriate treatment instituted since the majority of these conditions pose an increased risk of mortality if undiagnosed or untreated.
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Affiliation(s)
- Davis Kibirige
- Department of Medicine, St. Raphael of St. Francis hospital Nsambya, Kampala, Uganda
- Diabetes and Endocrine Clinic, St. Raphael of St. Francis hospital Nsambya, Kampala, Uganda
| | - Richard Ssekitoleko
- Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
- Infectious diseases unit, Mulago National Referral and Teaching Hospital, Kampala, Uganda
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Yao Y, Luo Y, He Y, Zheng Y, Zhang Q, Zhou H, Zeng S, Chen Z, He B, He M. The effect of a year of highly active antiretroviral therapy on immune reconstruction and cytokines in HIV/AIDS patients. AIDS Res Hum Retroviruses 2013; 29:691-7. [PMID: 23151174 DOI: 10.1089/aid.2012.0275] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
To investigate the effect of a year of highly active antiretroviral therapy (HAART) on immune reconstruction and cytokine production in HIV/AIDS patients, 35 AIDS patients were recruited for HAART treatment and 35 healthy volunteers were assigned as controls. The dynamic changes in HIV load, blood T cell subset counts, as well as interleukin (IL)-12, interferon (IFN)-γ, and interferon-inducible protein-10 (IP-10) levels in AIDS patients were evaluated before HAART and at 6 and 12 months after therapy. Our results revealed that HIV virus load in HIV/AIDS patients was reduced below the detectable limit after patients received 6 months of HAART. CD3(+)CD4(+), CD4(+)CD45RA(+)62L(+), and CD4(+)CD45RO(+) T cells were found to be significantly decreased in HIV/AIDS patients compared to the healthy controls, but increased after HAART. CD3(+)CD8(+) and CD8(+)CD38(+) cells were found to be increased in HIV/AIDS patients but decreased after HAART. Plasma IL-12 and IFN-γ levels were lower but IP-10 level was higher in AIDS patients compared to controls. HAART significantly improved IL-12 and IFN- γ levels but reduced IP-10 level in AIDS patients (p<0.01). CD4(+)CD45RA(+)62L(+) and CD4(+)CD45RO(+) T cells were positively correlated with plasma IL-12/IFN-γ levels (p<0.05), but negatively correlated with plasma IP-10 level. However, CD3(+)CD8(+) cells were negatively correlated with plasma IL-12 and IFN-γ levels, but positively correlated with IP-10 level (p<0.05). HAART benefits HIV/AIDS patients by not only inhibiting virus replication but also by contributing to immune reconstruction, such as restoring subsets of T cells and adjusting cytokine production in HIV/AIDS patients.
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Affiliation(s)
- Yunhai Yao
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Yan Luo
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Yan He
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Yuhuang Zheng
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Quan Zhang
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Huaying Zhou
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Si Zeng
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Zi Chen
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Bo He
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Mei He
- Department of Infectious Disease, Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
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Falgarone G, Heshmati HM, Cohen R, Reach G. Mechanisms in endocrinology. Role of emotional stress in the pathophysiology of Graves' disease. Eur J Endocrinol 2013; 168:R13-8. [PMID: 23027804 DOI: 10.1530/eje-12-0539] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The role of stress in the pathophysiology of Graves' disease is suggested by several clinical observations, by recent advances in immunology and by better understanding of autoimmune diseases which provides new insights into potential effects of stress hormones on T helper cell imbalance involved in the pathogenesis of autoimmune diseases. Stress management should therefore be an important part of the treatment of Graves' disease, as stress reduction may improve the effect of therapy. However, this field still requires interventional data to support stress management in the treatment of Graves' disease.
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Honda A, Kashiwazaki K, Tsunoda T, Gallant JE, Brown TT. Short communication: CD4 cell count increases during successful treatment of Graves' disease with methimazole in HIV-infected patients on antiretroviral therapy. AIDS Res Hum Retroviruses 2012; 28:1627-9. [PMID: 22632156 DOI: 10.1089/aid.2011.0309] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
With the increased survival of HIV-infected patients receiving antiretroviral therapy (ART), unexpected complications due to the untoward effect of antiretroviral agents or immunologic changes have been observed. Here, we report two cases of Graves' disease (GD) presenting with classic symptoms of hyperthyroidism occurring 44 and 47 months after ART initiation. Both patients had severe immune suppression prior to ART initiation (CD4 cell count≤50 cells/μL), with an increase on CD4 cell count to 354 and 329 cells/μL, respectively, at the time of GD diagnosis. Administration of methimazole (MMI) resulted in dramatic improvements in symptoms and thyroid function. In addition, CD4 cell count unexpectedly increased to >500 cells/μL within three months on MMI. Hyperthyroidism caused by GD has been increasingly reported following the initiation of ART and may be related to immune reconstitution. The mechanisms underlying the increases in CD4 cell count after successful treatment of GD with MMI require further investigation, but may be due to improved immune recovery with the correction of hyperthyroidism or a specific effect of MMI on immune function.
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Affiliation(s)
- Arata Honda
- Department of Clinical Laboratory, Tokyo Metropolitan Health and Medical Treatment Corporation, Ebara Hospital, Tokyo, Japan
| | - Koichi Kashiwazaki
- Department of Endocrinology and Metabolism, Tokyo Metropolitan Health and Medical Treatment Corporation, Ebara Hospital, Tokyo, Japan
| | - Takafumi Tsunoda
- Department of Infectious diseases, Tokyo Metropolitan Health and Medical Treatment Corporation, Ebara Hospital, Tokyo, Japan
| | - Joel E. Gallant
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd T. Brown
- Division of Endocrinology and Metabolism, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Dalan R, Leow MKS. Immune manipulation for Graves' disease: re-exploring an unfulfilled promise with modern translational research. Eur J Intern Med 2012; 23:682-91. [PMID: 22877994 DOI: 10.1016/j.ejim.2012.07.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Revised: 07/11/2012] [Accepted: 07/12/2012] [Indexed: 11/15/2022]
Abstract
Although Graves' disease is the commonest autoimmune thyroid disorder, current therapeutics typically center on the eradication of the antigenic stimulus (i.e. thyroid gland) rather than radically tackling the underlying autoimmune processes. Consequently, it is not a surprising fact that Graves' disease remains essentially a chronic drug-dependent ailment afflicting untold numbers worldwide for decades despite progress in deciphering its autoimmune nature. Addressing the latter is key to a future cure as underscored by appropriate, albeit crude, proof-of-concept scenarios of clinical remissions achieved with hematopoietic stem cell transplantation, immune down-regulation during pregnancy, use of corticosteroids or immunosuppressives, and cytokine biologics in animal models. Ongoing basic and translational research to further elucidate and refine our understanding of the pathogenesis of Graves' disease holds the promise of unraveling novel immune manipulative techniques that will bring the world a step closer to the elusive cure of the underlying autoimmunity amidst skepticisms on the value of the science from the present lack of paralleled advances at the bedside. We review the updated literature and describe the forms of immune manipulation hitherto explored that will offer a route to a future cure, from thionamides, hematopoietic stem cell transplantation to the latest immunomodulatory agents.
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Affiliation(s)
- Rinkoo Dalan
- Department of Endocrinology, Tan Tock Seng Hospital, Singapore.
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48
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Orgiazzi J. Thyroid autoimmunity. Presse Med 2012; 41:e611-25. [DOI: 10.1016/j.lpm.2012.10.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 10/08/2012] [Accepted: 10/08/2012] [Indexed: 01/11/2023] Open
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Kamath C, Young S, Kabelis K, Sanders J, Adlan MA, Furmaniak J, Rees Smith B, Premawardhana LD. Thyrotrophin receptor antibody characteristics in a woman with long-standing Hashimoto's who developed Graves' disease and pretibial myxoedema. Clin Endocrinol (Oxf) 2012; 77:465-70. [PMID: 22891608 DOI: 10.1111/j.1365-2265.2012.04397.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
CONTEXT Sequential conversion of Hashimoto's thyroiditis (HT) to Graves' disease (GD) is uncommon. Distinct immune paradigms, paucity of functioning tissue in long-standing HT, and infrequent conversion of blocking (TBAb) to stimulating (TSAb) thyrotrophin receptor antibody (TRAb) may account for this. Molecular and crystal structure analysis helps delineate TSH receptor (TSHR)/TRAb interactions in detail. Such 'fingerprinting' helps determine the behaviour and characteristics of TRAb in longitudinal studies. PATIENT An 80-year-old woman taking thyroxine for long-standing HT became hyperthyroid. This persisted despite thyroxine withdrawal - free T3 was 7·3 pmol/l (2·6-5·7) and TSH < 0·01 mU/l (0·2-4·5) and TRAb highly positive. She had a goitre (ultrasound - HT), pretibial myxoedema, with mild inactive Graves' orbitopathy. She had RAI treatment and is on thyroxine replacement. MEASUREMENTS AND RESULTS Blood samples at presentation (A) and 1 year (B) showed high TSAb and TPOAb activity but no TBAb. Experiments involving TSHR mutations confirmed that (i) TRAb had stable characteristics over 1 year; (ii) TSHR mutation R255D caused complete inhibition and (iii) R109A caused marked reduction of cAMP production by M22 (TSHR-stimulating human monoclonal antibody) and A and B; (iv) mutations R80A, E107A and K129A while affecting M22 had little effect on A and B. CONCLUSIONS The reasons for an immunological paradigm shift in this elderly woman remain speculative. We believe that de-novo TSAb synthesis occurred converting her long-standing HT to GD although the mechanisms responsible remain unexplained. TRAb analysis confirmed stable autoantibody characteristics over 1 year and variable effects of TSHR mutations on TRAb and M22 function.
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Affiliation(s)
- C Kamath
- Section of Diabetes and Endocrinology, Department of Medicine, Caerphilly Miners' Hospital, Caerphilly, UK
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50
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Visser R, de Mast Q, Netea-Maier RT, van der Ven AJAM. Hashimoto's thyroiditis presenting as acute painful thyroiditis and as a manifestation of an immune reconstitution inflammatory syndrome in a human immunodeficiency virus-seropositive patient. Thyroid 2012; 22:853-5. [PMID: 22784301 DOI: 10.1089/thy.2012.0055] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND An immune reconstitution inflammatory syndrome (IRIS) may complicate immune restoration following start of antiretroviral therapy (ART) in human immunodeficiency virus (HIV)-infected patients. The occurrence of Graves' disease in the setting of an IRIS is well recognized. We hereby report a case of Hashimoto's thyroiditis, presenting as an acute painful thyroiditis, and as a complication of IRIS. SUMMARY A painful acute thyroiditis with thyrotoxicosis occurred in a 37-year-old HIV-infected woman 10 months after initiation of ART. This thyroiditis was associated with the appearance of a high titer of anti-thyroid peroxidase (anti-TPO) antibodies and was followed by persistent hypothyroidism, requiring thyroxine replacement therapy. CONCLUSIONS Hashimoto's thyroiditis may present as an acute thyroiditis with thyrotoxicosis in HIV-infected patients after initiation of ART. Clinicians caring for HIV-infected patients should be aware of this possible association.
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Affiliation(s)
- Roos Visser
- Department of Internal Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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