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Lawal IO, Orunmuyi AT, Popoola GO, Mokoala KMG, Lengana T, Sathekge MM. Immune reconstitution inflammatory syndrome-associated Graves disease in HIV-infected patients: clinical characteristics and response to radioactive iodine therapy. HIV Med 2021; 22:907-916. [PMID: 34328251 DOI: 10.1111/hiv.13148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/08/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVES We aimed to describe the clinical characteristics and the response to radioactive iodine (RAI) treatment of immune reconstitution inflammatory syndrome-associated Graves disease (IRIS-GD) in comparison to Graves disease (GD) seen in HIV-uninfected patients. METHODS We retrospectively reviewed the medical records of patients treated with RAI for GD. We obtained clinical, biochemical and HIV-related information of patients from their medical records. We compared patient characteristics and response to RAI treatment between patients with IRIS-GD and GD seen in HIV-uninfected patients. RESULTS A total of 253 GD patients, including 51 patients with IRIS-GD, were included. Among IRIS-GD patients, CD4 cell nadir was 66 cells/µL (range: 37-103) with a peak HIV viral load of 60 900 copies/mL (range: 36 542-64 500). At the time of diagnosis of IRIS-GD, all patients had a completely suppressed HIV viraemia with a CD4 cell count of 729 cells/µL (range: 350-1279). The median interval between the commencement of HIV treatment and the onset of GD was 63 months. At 3 months follow-up, the proportion of patients with IRIS-GD achieving a successful RAI treatment outcome (euthyroid/hypothyroid state) was lower than that of HIV-uninfected patients (35.3% vs. 63.4%, respectively; p < 0.001). The response rate remained lower (60.8%) among patients with IRIS GD than among HIV-uninfected GD patients (80.2%, p = 0.004) at 6 months follow-up. After correcting for differences in age, gender and pre-treatment thyroid-stimulating hormone level, there was no significant difference in RAI treatment response between the two groups. CONCLUSIONS After correcting for possible confounders, the response to RAI treatment was not different between patients with IRIS-GD and GD in HIV-uninfected patients.
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Affiliation(s)
- Ismaheel O Lawal
- Department of Nuclear Medicine, University of Pretoria & Steve Biko Academic Hospital, Pretoria, South Africa.,Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
| | - Akintunde T Orunmuyi
- Department of Nuclear Medicine, University of Ibadan & University College Hospital, Ibadan, Nigeria
| | - Gbenga O Popoola
- Department of Epidemiology and Community Health, University of Ilorin, Ilorin, Nigeria
| | - Kgomotso M G Mokoala
- Department of Nuclear Medicine, University of Pretoria & Steve Biko Academic Hospital, Pretoria, South Africa.,Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
| | - Thabo Lengana
- Department of Nuclear Medicine, University of Pretoria & Steve Biko Academic Hospital, Pretoria, South Africa
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria & Steve Biko Academic Hospital, Pretoria, South Africa.,Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
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Ayad S, Gergis K, Mirza N, Rayad MN, Salamera J. Graves' Disease in a Patient With Human Immunodeficiency Virus Infection as an Immune Reconstitution Inflammatory Syndrome. Cureus 2021; 13:e15377. [PMID: 34249530 PMCID: PMC8249040 DOI: 10.7759/cureus.15377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/31/2021] [Indexed: 11/18/2022] Open
Abstract
The use of highly active antiretroviral therapy (HAART) in the management and treatment of human immunodeficiency virus type 1 (HIV-1) has dramatically changed the course of the disease and improved overall survival. HAART results in significant decrease in viral load and enhancement of CD4 cells and gradual restoration of the immune system. However, a subset of patients may experience a paradoxical worsening after the initiation of HAART due to a heightened and dysregulated immune response. This phenomenon is termed immune reconstitution inflammatory syndrome (IRIS). The manifestation of Graves’ disease (GD) after the introduction of HAART has been identified as IRIS manifestation in some patients. Thus, this occurrence should be suspected and further investigated in patients with HIV on antiretroviral therapy (ART) who present with symptoms consistent of hyperthyroidism to avoid overt hyperthyroidism. We report a case of IRIS associated Graves’ disease. Our case adds to the very limited literature about this phenomenon.
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Affiliation(s)
- Sarah Ayad
- Internal Medicine, Rutgers-New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
| | | | - Noreen Mirza
- Internal Medicine, Trinitas Regional Medical Center, Elizabeth, USA
| | | | - Julius Salamera
- Internal Medicine, Rutgers-New Jersey Medical School/Trinitas Regional Medical Center, Elizabeth, USA
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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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Tocut M, Brenner R, Zandman-Goddard G. Autoimmune phenomena and disease in cancer patients treated with immune checkpoint inhibitors. Autoimmun Rev 2018; 17:610-616. [PMID: 29631064 DOI: 10.1016/j.autrev.2018.01.010] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 01/11/2018] [Indexed: 12/16/2022]
Abstract
The discovery and approved treatment with immune checkpoint inhibitors (ICIs) for a variety of cancers has changed dramatically the morbidity and mortality rates for these patients. Despite the obvious benefits, their use is associated with unique immune-related adverse effects (irAEs), including autoimmune conditions such as: inflammatory arthritis, myositis, vasculitis and Sicca syndrome. The appearance of ICIs-induced autoimmune irAE requires from oncologists and rheumatologists a different approach to the identification and treatment of these conditions, which may differ from the classic and traditional approach to rheumatologic diseases. It should be taken into consideration that ICIs therapy in patients with preexisting autoimmunity could be possible, but with a cost of causing disease exacerbation. In this extensive review, we present the autoimmune irAEs, mostly as phenomena, but also as classic autoimmune diseases as well as therapeutic options for the side effects.
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Affiliation(s)
- Milena Tocut
- Dept. of Internal Medicine C, Wolfson Medical Center, Israel
| | - Ronen Brenner
- Dept. of Oncology, Wolfson Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Gisele Zandman-Goddard
- Dept. of Internal Medicine C, Wolfson Medical Center, Israel; Sackler Faculty of Medicine, Tel-Aviv University, Israel.
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Wang X, Zhang R, Tong Y, Ding X, Jin S, Zhao X, Zong J, Chen Z, Billiar TR, Li Q. High-mobility group box 1 protein is involved in the protective effect of Saquinavir on ventilation-induced lung injury in mice. Acta Biochim Biophys Sin (Shanghai) 2017; 49:907-915. [PMID: 28981603 DOI: 10.1093/abbs/gmx085] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Indexed: 01/07/2023] Open
Abstract
Saquinavir (SQV) is the first FDA approved HIV protease inhibitor. Previous studies showed that SQV can limit Toll-like receptor-4 (TLR4)-mediated inflammatory pathway and nuclear factor-κB (NF-κB) activation, thereby playing a protective role in many kinds of diseases. High-mobility group box 1 (HMGB1) has been identified as an inflammatory mediator and it might express its toxicity in a short period of time in ventilator-induced lung injury (VILI). In this study, C57BL/6 mice were randomly divided into four groups (n = 10): control group and control with SQV group (Con + SQV) were spontaneous breath. HTV group (HTV) received high tidal volume ventilation (HTV) for 4 h. HTV with SQV group (HTV + SQV) were pretreated with 5 mg/kg of SQV for 7 days before HTV. Mice were sacrificed after 4 h of HTV. Lung wet/dry weight (W/D) ratio, alveolar-capillary permeability to Evans blue albumin (EBA), cell counts, total proteins in bronchoalveolar lavage fluid (BALF), tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6) level in BALF and lung tissue, and lung histopathology were examined. Our results showed that HTV caused significant lung injury and NF-κB activation, which was correlated with the increase of TNF-α and IL-6 levels in BALF and plasma. SQV pretreatment significantly attenuated pulmonary inflammatory injury, as well as NF-κB activation. These findings indicate that the protective effect of SQV may be associated with the inhibition of NF-κB activation and HMGB1 expression in mice.
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Affiliation(s)
- Xin Wang
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China
- Department of Anesthesiology, The First Clinical Medical College of Nanjing Medical University, Nanjing 210029, China
| | - Renlingzi Zhang
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Yao Tong
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Xibing Ding
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Shuqing Jin
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Xiang Zhao
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Jiaying Zong
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China
- Department of Anesthesiology, The First Clinical Medical College of Nanjing Medical University, Nanjing 210029, China
| | - Zhixia Chen
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China
| | - Timothy R Billiar
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA 15260, USA
| | - Quan Li
- Department of Anesthesiology, East Hospital, Tongji University School of Medicine, Shanghai 200120, China
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Azizi F, Mehran L, Hosseinpanah F, Delshad H, Amouzegar A. Primordial and Primary Preventions of Thyroid Disease. Int J Endocrinol Metab 2017; 15:e57871. [PMID: 29344036 PMCID: PMC5750785 DOI: 10.5812/ijem.57871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 07/09/2017] [Accepted: 08/14/2017] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Primordial and primary preventions of thyroid diseases are concerned with avoiding the appearance of risk factors, delaying the progression to overt disease, and minimizing the impact of illness. SUMMARY Using related key words, 446 articles related to primordial and primary, preventions of thyroid diseases published between 2001-2015 were evaluated, categorized and analyzed. Prevention and elimination of iodine deficiency are major steps that have been successfully achieved and maintained in many countries of the world in last 2 decades. Recent investigations related to the effect of cigarette smoking, alcohol consumption, and autoimmunity in the prevention of thyroid disorders have been reviewed. CONCLUSIONS The cornerstone for successful prevention of thyroid disease entails timely implementation of its primordial and primary preventions, which must be highly prioritized in related health strategies by health authorities.
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Affiliation(s)
- Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Ladan Mehran
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Farhad Hosseinpanah
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Hossein Delshad
- Obesity Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
| | - Atieh Amouzegar
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran
- Corresponding author: Atieh Amouzegar, Assistant Professor of Internal Medicine and Endocrinology, Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran, P.O. Box: 19395-4763. Tel: +98-2122432503, Fax: +98-2122402463, E-mail:
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Affiliation(s)
- Terry J Smith
- University of Michigan Medical School, Ann Arbor, MI
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9
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Hsu E, Phadke VK, Nguyen MLT. Short Communication: Hyperthyroidism in Human Immunodeficiency Virus Patients on Combined Antiretroviral Therapy: Case Series and Literature Review. AIDS Res Hum Retroviruses 2016; 32:564-6. [PMID: 26887978 DOI: 10.1089/aid.2015.0374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
We describe an HIV-infected patient initiated on combined antiretroviral therapy (cART) who subsequently developed immune restoration disease (IRD) hyperthyroidism-this case represents one of five such patients seen at our center within the past year. Similar to previous reports of hyperthyroidism due to IRD, all of our patients experienced a rapid early recovery in total CD4 count, but developed symptoms of hyperthyroidism on average 3 years (38 months) after beginning cART, which represents a longer time frame than previously reported. Awareness and recognition of this potential complication of cART, which may occur years after treatment initiation, will allow patients with immune restorative hyperthyroidism to receive timely therapy and avoid the long-term complications associated with undiagnosed thyroid disease.
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Affiliation(s)
- Emory Hsu
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Varun K. Phadke
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Minh Ly T. Nguyen
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
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Hatzl M, Öllinger A, Geit M, Wiesinger K, Angerbauer K, Auböck J, Gabriel M. Thyroid screening in HIV-infected patients with antiretroviral therapy. Wien Klin Wochenschr 2015; 127:601-5. [PMID: 25739648 DOI: 10.1007/s00508-015-0733-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 01/19/2015] [Indexed: 11/26/2022]
Abstract
BACKGROUND The literature reports an increased incidence of thyroid disorders in human immunodeficiency virus (HIV)-positive persons. We therefore retrospectively analyzed the strategy of collecting thyroid parameters on a routine basis. METHODS Overall 410 patients (147 women, 263 men; age, 10-74 years; median age, 45 years) were included. For screening purposes, three parameters were determined; basal thyroid-stimulating hormone (TSH), free thyroxine (fT4), and free triiodothyronine (fT3). Descriptive and statistical analyses were performed in the patient groups with increased bTSH (> 4.0 µU/ml) and with decreased fT4 (< 8.9 pg/ml) to evaluate possible correlation with age, gender, duration of antiretroviral therapy (ART), substance classes of ART (nucleosidal reverse transcriptase inhibitors (NRTIs), nonnucleosidal reverse transcriptase inhibitors, and protease inhibitors (PIs)), Centers for Disease Control and Prevention (CDC) disease stage, lowest number of CD4 cells during course of disease, and coexistent hepatitis C. RESULTS Elevated bTSH was found in 27 patients (median, 5.26 µU/ml), who also showed a correlation with ART duration and NRTI use. Decreased fT4 was seen in 53 persons, and a correlation with PI intake was observed. Of these patients, 31 exhibited normalization in follow-up. Decreased fT3 was observed in eight cases related to nonthyroid illness, and fT3 was elevated in ten patients. No overt hyperthyroidism was noticed; three cases of subclinical hyperthyroidism were transient. CONCLUSIONS In the examined group of patients, the prevalence of abnormal thyroidal parameters was 23 %. Decreased fT4, which does not require therapy, was observed most frequently (12 %) and correlated with PI use. On the other hand, elevated bTSH (6 %) correlated with ART duration and NRTI use. In mild subclinical hypothyroidism as observed in this patient population, thyroxine medication is not indicated in principle. Annual TSH screening is probably sufficient in HIV-infected patients with no clinical symptoms suggestive for thyroid disease.
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Affiliation(s)
- Margit Hatzl
- Institute of Nuclear Medicine and Endocrinology, General Hospital of the City of Linz, Krankenhausstrasse 9, 4021, Linz, Austria,
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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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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: 146] [Impact Index Per Article: 14.6] [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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13
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Graves' disease as immune reconstitution disease in HIV-positive patients is associated with naive and primary thymic emigrant CD4(+) T-cell recovery. AIDS 2014; 28:31-9. [PMID: 23939238 DOI: 10.1097/qad.0000000000000006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Immune restoration disease (IRD) can develop in HIV-infected patients following antiretroviral therapy (ART) initiation as unmasking or paradoxical worsening of opportunistic infections and, rarely, autoimmune phenomena. Although IRD usually occurs in the first months of ART during memory CD4 T-cell recovery, Graves' disease occurs as a distinctive late-onset IRD and its pathogenesis is unclear. DESIGN Seven patients who developed Graves' disease following ART initiation from the primary HIV care clinic at the National Institutes of Health were retrospectively identified and each was matched with two HIV-infected controls based on age, sex, and baseline CD4 T-cell count. Laboratory evaluations on stored cryopreserved samples were performed. METHODS Immunophenotyping of peripheral blood mononuclear cells (PBMCs), T-cell receptor excision circle (TREC) analysis in PBMCs, measurement of serum cytokines, and luciferase immunoprecipitation systems (LIPS) analysis for autoimmune antibodies were performed on stored samples for cases and controls at baseline and longitudinally following ART initiation. TSH/thyrotropin receptor (TSH-R) antibody testing was performed on serum from cases. Data were analyzed using nonparametric testing. RESULTS In comparison with controls, the proportion of naive CD4 T cells increased significantly (P = 0.0027) in the Graves' disease-IRD patients. TREC/10 PBMCs also increased significantly following ART in Graves' disease-IRD patients compared with controls (P = 0.0071). Similarly, LIPS analysis demonstrated increases in nonthyroid-related autoantibody titers over time following ART in cases compared with controls. CONCLUSION Our data suggest that Graves' disease-IRD, in contrast to early-onset IRD, is associated with naive and primary thymic emigrant CD4 T-cell recovery and inappropriate autoantibody production.
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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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Abstract
Alemtuzumab is a humanized anti-CD52 monoclonal antibody. Treatment in humans results in a rapid, profound, and prolonged B- and T-cell lymphopenia. Subsequently, lymphocyte reconstitution by homeostatic mechanisms alters the composition, phenotype, and function of T-cell subsets, thus allowing the immune system to be 'reset'. One phase II and two phase III randomized, multicenter, single-blinded (outcomes assessor) clinical trials of alemtuzumab in relapsing-remitting multiple sclerosis have now been completed. Against an active comparator and the current first-line therapy for relapsing-remitting multiple sclerosis (interferon-beta), alemtuzumab showed a significant reduction in annualized relapse rate as well as a significant reduction in the accumulation of disability. These outcomes are sustained over at least 5 years following treatment. The most common adverse effects are mild infusion reactions, an increased incidence of mild-to-moderate severity infections and secondary autoimmunity. The latter is observed in a third of treated patients, commonly thyroid disease but other target cells have been described including cytopenias. Marketing authorization applications have been submitted for the use of alemtuzumab in multiple sclerosis to the Food and Drug Administration and the European Medicines Agency, with licensing expected in 2013. Here, we discuss the outlook for alemtuzumab in multiple sclerosis in light of the currently available therapies, outcomes of and lessons learnt from clinical trials, and the overall position of monoclonal antibodies in modern treatment strategies.
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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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Kousin-Ezewu O, Coles A. Alemtuzumab in multiple sclerosis: latest evidence and clinical prospects. Ther Adv Chronic Dis 2013; 4:97-103. [PMID: 23634277 DOI: 10.1177/2040622313479137] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Alemtuzumab was first used in multiple sclerosis in 1991. It is a monoclonal antibody which is directed against CD52, a protein of unknown function on lymphocytes. Alemtuzumab causes a lymphopenia, following which homeostatic reconstitution leads to prolonged alteration of the immune repertoire. This reduces the risk of relapse and disability accumulation in multiple sclerosis; it is the only drug to show superiority over interferon β-1a in disability outcomes in a monotherapy phase III trial. It should be used with a parallel risk management programme to identify the principal adverse effects of alemtuzumab, especially secondary autoimmunity months or years later, mainly against the thyroid but also immune thrombocytopenia. This review charts the development of alemtuzumab as a drug for multiple sclerosis and summarizes the latest clinical trial data.
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Affiliation(s)
- Onajite Kousin-Ezewu
- Department of Clinical Neurosciences, University of Cambridge, Level 6, Block A, Box 165, Addenbrookes Hospital, Hills Road, Cambridge CB2 0QQ, UK
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Mingote E, Urrutia A, Viteri A, Faingold C, Musso C. Graves’ Disease as a Late Manifestation of Immune Reconstitution Syndrome after Highly Active Antiretroviral Therapy in an HIV-1 Infected Patient. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/wja.2013.33024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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19
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Abstract
Alemtuzumab is a humanized monoclonal antibody that is administered daily for 5 days, and then no further therapy is required for 12 months. It causes rapid and prolonged lymphocyte depletion; the consequent homeostatic reconstitution leads to a radically reformed lymphocyte pool with a relative increase in regulatory T cells and expansion of autoreactive T cells. Although previously licensed for the treatment of B-cell chronic lymphocytic leukemia, it is now been considered for licensing in the treatment of multiple sclerosis (MS). From a disappointing experience with alemtuzumab in progressive MS, Alastair Compston and I argued that immunotherapies should be given early in the course of the disease. In a unique program of drug development in MS, alemtuzumab has been compared in 1 phase 2 trial and 2 phase 3 trials with the active comparator interferon beta-1a. In all trials, alemtuzumab was more effective in suppressing relapses than interferon beta-1a. In one phase 2 and one phase 3 trial, alemtuzumab also reduced the risk of accumulating disability compared with interferon beta-1a. Indeed, alemtuzumab treatment led to an improvement in disability and a reduction in cerebral atrophy. The safety issues are infusion-associated reactions largely controlled by methylprednisolone, antihistamines, and antipyretics; mild-to-moderate infections (with 3 opportunistic infections from the open-label experience: 1 case each of spirochaetal gingivitis, pyogenic granuloma, and Listeria meningitis); and autoimmunity. Usually autoimmunity is directed against the thyroid gland, but causes (1 %) immune thrombocytopenia, and in a few cases antiglomerular basement membrane syndrome. Alemtuzumab is an effective therapy for early relapsing-remitting MS, offering disability improvement at least to 5 years after treatment. Its use requires careful monitoring so that potentially serious side effects can be treated early and effectively.
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Affiliation(s)
- Alasdair J Coles
- Department of Clinical Neurosciences, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.
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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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McLeod DSA, Woods ML, Kandiah DA. Immune reconstitution inflammatory syndrome manifesting as development of multiple autoimmune disorders and skin cancer progression. Intern Med J 2012; 41:699-703. [PMID: 21899684 DOI: 10.1111/j.1445-5994.2011.02546.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
We report the case of a 56-year-old man with the rare autoimmune pathologies of alternating hypothyroidism and hyperthyroidism due to thyroid-stimulating hormone receptor antibodies, and rheumatoid arthritis as manifestations of a human immunodeficiency virus-related immune reconstitution inflammatory syndrome. The patient also developed overt progression of a pre-existing skin malignancy that may also be related. This case highlights immune reconstitution syndrome as an important differential diagnosis following antiretroviral therapy commencement, and that a high index of suspicion should be maintained for this rare but important cluster of conditions. Furthermore, the patient's genetic predisposition to autoimmunity provides helpful insights into the pathogenesis of these disorders.
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Affiliation(s)
- D S A McLeod
- Department of Endocrinology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.
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22
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Coppo R, Camilla R, Porcellini MG, Peruzzi L, Gianoglio B, Amore A, Daprà V, Loiacono E, Fonsato V, Dal Canton A, Esposito C, Esposito P, Tovo PA. Saquinavir in steroid-dependent and -resistant nephrotic syndrome: a pilot study. Nephrol Dial Transplant 2012; 27:1902-10. [PMID: 22431705 DOI: 10.1093/ndt/gfs035] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Some difficult cases of idiopathic nephrotic syndrome (NS) have been treated with a HIV protease inhibitor provided with proteasome-inhibiting activity. The objective of this study was to limit nuclear factor κB (NF-κB) activation which is up-regulated in these patients, aiming at decreasing proteinuria and prednisone need. METHODS Ten cases with long-lasting (up to 15 years) history of NS with steroid dependence (six cases, of which three with secondary steroid resistance) or resistance to steroids (four cases) unsuccessfully treated with multiple immunosuppressive drugs, accepted a treatment with the protease inhibitor saquinavir. p50/p65 NF-κB nuclear localization and immunoproteasome/proteasome messenger RNA (mRNA) were monitored in peripheral blood mononuclear cells (PBMCs). The effects of saquinavir on NF-κB nuclear localization in cultured PBMCs and in immortalized human podocytes were assessed. RESULTS After a median follow-up of 14.7 months (6-68.7), 1/4 primary steroid-resistant NS (SRNS) and 5/6 steroid-dependent NS or secondary SRNS became infrequent (5) or frequent (1) relapsers, with 63% prednisone reduction (from 25.3 to 8.4 mg/kg/month, P = 0.015). Saquinavir was effective in association with low doses of calcineurin inhibitors (cyclosporine 2 mg/kg/day or tacrolimus 0.01-0.06 mg/kg/day). No side effects were observed apart from transitory mild diarrhoea. In PBMCs, NF-κB was down-regulated, while MECL-1 immunoproteasome/beta2 proteasome mRNA ratio was reversed to normal values. In culture, saquinavir blunted NF-κB activation in human podocytes and in PBMCs. CONCLUSIONS In this pilot study, a HIV antiprotease drug reduced proteinuria and had a steroid-sparing effect in some multidrug-resistant/-dependent NS. This observation warrants further investigation.
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Affiliation(s)
- Rosanna Coppo
- Nephrology, Dialysis and Transplantation Unit, Regina Margherita University Hospital, Turin, Italy.
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Kawashima A, Tanigawa K, Akama T, Yoshihara A, Ishii N, Suzuki K. Innate immune activation and thyroid autoimmunity. J Clin Endocrinol Metab 2011; 96:3661-71. [PMID: 21956420 DOI: 10.1210/jc.2011-1568] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
CONTEXT Autoimmune thyroid disease (AITD) is the archetypal organ-specific autoimmune disorder and is characterized by the production of thyroid autoantibodies. However, the underlying mechanisms by which specific antibodies against thyroid proteins are produced are largely unknown. EVIDENCE ACQUISITION Published peer-reviewed basic and clinical literatures on immunology and autoimmune diseases were identified through searches of PubMed for articles published from January 1971 to May 2011. Articles resulting from these searches and relevant references cited in those articles were reviewed. All the relevant articles were written in English. EVIDENCE SYNTHESIS Recent studies have indicated that innate immune responses induced by both exogenous and endogenous factors affect the phenotype and severity of autoimmune reactions. One of the recent topics is the effect of self-genomic DNA fragments on immune activation. Expression of major histocompatibility complex class II on the autoimmune target cells seems to play an important role in the presentation of endogenous antigens. Accumulated evidence from animal models has generated new insights into the pathogenesis of AITD. CONCLUSION AITD develops by a combination of genetic susceptibility and environmental factors. Innate immune responses are associated with thyroid dysfunction, tissue destruction, and the likely development and perpetuation of AITD. In addition to the other factors, cell injury may contribute to the activation of innate immune response and the development of AITD.
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Affiliation(s)
- Akira Kawashima
- Laboratory of Molecular Diagnostics, Department of Mycobacteriology, Leprosy Research Center, National Institute of Infectious Diseases, 4-2-1 Aoba-cho, Higashimurayama, Tokyo 189-0002, Japan
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[Alemtuzumab: a further option for treatment of multiple sclerosis]. DER NERVENARZT 2011; 83:487-501. [PMID: 22038387 DOI: 10.1007/s00115-011-3393-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Alemtuzumab is a humanized monoclonal therapeutic antibody that targets the CD52 antigen which s expressed on most cells of the lymphoid lineage, exclusive of precursors. Alemtuzumab rapidly depletes CD52(+) cells from the peripheral blood. This depletion is long-lasting, and cells repopulate in a specific pattern with B cells and regulatory T cells peaking first. Alemtuzumab was examined for clinical utility in two open-labelled intervention trials in multiple sclerosis (MS). Because of very promising results its clinical efficacy was further explored in a clinical phase-II trial using s.c. interferon beta-1a as the active comparator. Severe or opportunistic infections were surprisingly rare given the long-term lymphopenia. However, up to 30% of patients developed some antibody-mediated autoimmunity. The thyroid gland was the most frequently affected organ. Immune-mediated thrombocytopenic purpura and Goodpasture's syndrome were additionally observed. This review summarizes the pre-clinical and clinical development of alemtuzumab and discusses potential modes of action as well as the pathogenetic link to the treatment emergent autoimmune phenomena.
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25
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Graves' Disease as a Manifestation of Immune Reconstitution in HIV-Infected Individuals after Initiation of Highly Active Antiretroviral Therapy. AIDS Res Treat 2011; 2011:743597. [PMID: 21804938 PMCID: PMC3144671 DOI: 10.1155/2011/743597] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 05/10/2011] [Indexed: 12/04/2022] Open
Abstract
Graves' disease after the initiation of highly active antiretroviral therapy (HAART) in certain HIV-1-infected individuals has been described as an immune reconstitution inflammatory syndrome (IRIS). This phenomenon should be suspected in individuals who present with clinical deterioration and a presentation suggestive of hyperthyroidism despite good virological and immunological response to HAART. Signs and symptoms of hyperthyroidism may be discrete or overt and typically develop 8–33 months after initiating therapy. One to two percent of HIV-infected patients can present with overt thyroid disease. Relatively few cases of Graves' IRIS have been reported in the literature to date. We describe four cases of Graves' IRIS in HIV-infected patients who were started on HAART therapy.
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26
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Immune reconstitution after a decade of combined antiretroviral therapies for human immunodeficiency virus. Trends Immunol 2011; 32:131-7. [PMID: 21317040 DOI: 10.1016/j.it.2010.12.002] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2010] [Revised: 12/04/2010] [Accepted: 12/09/2010] [Indexed: 01/26/2023]
Abstract
The introduction of combined antiretroviral therapies (HAART) has reversed the fatal course of human immunodeficiency virus (HIV) infection. HAART controls virus production and, in most cases, allows the quantitative and functional immune defects caused by HIV to be reversed. Here, we review T cell homeostatic mechanisms that drive immune recovery. These homeostatic mechanisms, as well as differences in T cell antigen exposure, explain the distinct patterns of recovery for HIV-specific T cells versus T cells specific for other pathogens. Immune restoration during HAART can, however, have adverse effects. Immune restoration syndrome occurs in some patients as a result of successful but unbalanced immunity.
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Porter BO, Ouedraogo GL, Hodge JN, Smith MA, Pau A, Roby G, Kwan R, Bishop RJ, Rehm C, Mican J, Sereti I. d-Dimer and CRP levels are elevated prior to antiretroviral treatment in patients who develop IRIS. Clin Immunol 2010; 136:42-50. [PMID: 20227921 DOI: 10.1016/j.clim.2010.02.010] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Revised: 02/12/2010] [Accepted: 02/15/2010] [Indexed: 11/24/2022]
Abstract
Biomarkers could be useful in evaluating immune reconstitution inflammatory syndrome (IRIS). A cohort of 45 HIV-1-infected, antiretroviral treatment (ART)-naive patients with baseline CD4 T cell counts <or=100 cells/microL who were started on ART, suppressed HIV-RNA to <50 copies/mL, and seen every 1-3 months for 1 year were retrospectively evaluated for suspected or confirmed IRIS. d-Dimer, C-reactive protein (CRP), and selected autoantibodies were analyzed at baseline, 1 and 3 months post-ART in cryopreserved plasma. Median differences between cases and controls were compared with Mann-Whitney and Fisher's exact tests. Sixteen patients (35.6%) developed IRIS (median of 35 days post-ART initiation): unmasking=8, paradoxical=7, autoimmune=1. Pre-ART d-dimer and CRP were higher in IRIS cases versus controls (d-dimer: 0.89 mg/L versus 0.66 mg /L, p=0.037; CRP: 0.74 mg/L versus 0.39 mg/L, p=0.022), while d-dimer was higher in unmasking cases at IRIS onset (2.04 mg/L versus 0.36 mg /L, p=0.05). These biomarkers may be useful in identifying patients at risk for IRIS.
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Affiliation(s)
- Brian O Porter
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD 20892, USA
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28
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Button T, Coles AJ. Alemtuzumab for the treatment of multiple sclerosis. FUTURE NEUROLOGY 2010. [DOI: 10.2217/fnl.09.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Alemtuzumab is a humanized monoclonal antibody against CD52, an antigen found on lymphocytes and monocytes. Pulsed administration causes prolonged T-cell depletion and has been shown to be effective in early relapsing–remitting multiple sclerosis, reducing relapse rate and risk of acquiring disability in comparison with the standard therapy IFN-β. Alemtuzumab is currently approved for the treatment of B-cell chronic lymphocytic leukemia but not for multiple sclerosis. The most significant complication of treatment is the late development of autoimmunity, which occurs in 30% of patients. Serious infections are rare. Phase III trials are ongoing and it is possible that alemtuzumab will have a place among the range of emerging disease-modifying therapies for multiple sclerosis.
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Affiliation(s)
- Tom Button
- University of Cambridge, Department of Clinical Neurosciences, Box 165, Addenbrooke’s Hospital, Cambridge, CB2 OQQ, UK
| | - Alasdair J Coles
- University of Cambridge, Department of Clinical Neurosciences, Box 165, Addenbrooke’s Hospital, Cambridge, CB2 OQQ, UK
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Abstract
Reconstitution Graves' disease occurs in three settings. First, bone marrow transplantation from a donor with Graves' disease may cause this disease to appear in the recipient, as a result of adoptive immunity, although disordered immunoregulation secondary to graft-versus-host disease may also play a role. Second, alemtuzumab treatment for multiple sclerosis leads to the development of Graves' disease in up to a third of patients during the phase of naive T-cell expansion, which follows therapeutic lymphocyte depletion. Other reconstitution autoimmune phenomena, including immune thrombocytopaenic purpura, are also recognised after alemtuzumab administration. Finally, reconstitution Graves' disease may occur during a similar phase of CD4(+) T-cell expansion, which follows highly active antiretroviral therapy for human immunodeficiency virus infection. Again, this complication is part of a broader spectrum of immunoregulatory disturbances, which can arise after immune reconstitution. The mechanisms responsible for reconstitution Graves' disease are at present unclear, but may include a relative bias towards a Th2-mediated immune response and reduced competition for autoreactive lymphocytes to expand during the time when recovery from lymphopenia commences.
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Affiliation(s)
- Anthony Weetman
- School of Medicine, Beech Hill Road, Sheffield, S10 2RX, UK.
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Gillard P, Huurman V, Van der Auwera B, Decallonne B, Poppe K, Roep BO, Gorus F, Mathieu C, Pipeleers D, Keymeulen B. Graves hyperthyroidism after stopping immunosuppressive therapy in type 1 diabetic Islet cell recipients with pretransplant TPO autoantibodies. Diabetes Care 2009; 32:1817-9. [PMID: 19549735 PMCID: PMC2752930 DOI: 10.2337/dc08-2339] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE After an initially successful islet cell transplantation, a number of patients return to C-peptide negativity, and therefore immunosuppressive therapy is discontinued. Some are then found to have developed Graves disease. We examined the risk of Graves disease after immunosuppression. RESEARCH DESIGN AND METHODS Immunosuppressive therapy was stopped in 13 type 1 diabetic islet cell recipients who had received one course of antithymocyte globulin and maintenance doses of mycophenolate mofetil and a calcineurin inhibitor. None had a history of thyroid disease. RESULTS In four patients, clinical Graves hyperthyroidism was observed within 21 months after discontinuation and 30-71 months after the start of immunosuppressive therapy. All four patients exhibited a pretransplant positivity for thyroid peroxidase (TPO) autoantibodies, while the nine others were TPO negative pre- and posttransplantation. CONCLUSIONS Type 1 diabetic recipients of islet cell grafts with pretransplant TPO autoantibody positivity exhibit a high risk for developing Graves hyperthyroidism after immunosuppressive therapy is discontinued for a failing graft.
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Affiliation(s)
- Pieter Gillard
- Department of Endocrinology, University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
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Reacciones cutáneas adversas a fármacos en los pacientes con infección por el VIH en la era TARGA. ACTAS DERMO-SIFILIOGRAFICAS 2009. [DOI: 10.1016/s0001-7310(09)70819-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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32
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Cutaneous Drug Reactions in HIV-Infected Patients in the HAART Era. ACTAS DERMO-SIFILIOGRAFICAS 2009. [DOI: 10.1016/s1578-2190(09)70062-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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[Possibilities and risks of the monoclonal antibody alemtuzumab as a new treatment option for multiple sclerosis]. DER NERVENARZT 2009; 80:468-74. [PMID: 19296065 DOI: 10.1007/s00115-009-2681-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Monoclonal antibodies are of growing interest as treatment options for immune-mediated diseases in neurology. As our knowledge of immunological principals increases, we learn to modulate specifically mechanisms of pathogenesis by the use of monoclonal antibodies. It is clearly desirable to improve efficacy in disease treatment without increasing toxicity by using drugs with more specific modes of action. Natalizumab was the first monoclonal antibody approved in the field of neurology for treatment of relapsing remitting multiple sclerosis (MS). Several other monoclonal antibodies are currently under investigation. Alemtuzumab, a monoclonal antibody targeting CD52, is a highly promising agent currently being studied in two phase III clinical trials. In this review, data from the recently published phase II clinical trial in the treatment of early relapsing remitting MS is summarized and analyzed in light of the development of alemtuzumab for MS and its potential role in treating this disease is discussed.
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Coles AJ, Compston DAS, Selmaj KW, Lake SL, Moran S, Margolin DH, Norris K, Tandon PK. Alemtuzumab vs. interferon beta-1a in early multiple sclerosis. N Engl J Med 2008; 359:1786-801. [PMID: 18946064 DOI: 10.1056/nejmoa0802670] [Citation(s) in RCA: 731] [Impact Index Per Article: 45.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Alemtuzumab, a humanized monoclonal antibody that targets CD52 on lymphocytes and monocytes, may be an effective treatment for early multiple sclerosis. METHODS In this phase 2, randomized, blinded trial involving previously untreated, early, relapsing-remitting multiple sclerosis, we assigned 334 patients with scores of 3.0 or less on the Expanded Disability Status Scale and a disease duration of 3 years or less to receive either subcutaneous interferon beta-1a (at a dose of 44 microg) three times per week or annual intravenous cycles of alemtuzumab (at a dose of either 12 mg or 24 mg per day) for 36 months. In September 2005, alemtuzumab therapy was suspended after immune thrombocytopenic purpura developed in three patients, one of whom died. Treatment with interferon beta-1a continued throughout the study. RESULTS Alemtuzumab significantly reduced the rate of sustained accumulation of disability, as compared with interferon beta-1a (9.0% vs. 26.2%; hazard ratio, 0.29; 95% confidence interval [CI], 0.16 to 0.54; P<0.001) and the annualized rate of relapse (0.10 vs. 0.36; hazard ratio, 0.26; 95% CI, 0.16 to 0.41; P<0.001). The mean disability score on a 10-point scale improved by 0.39 point in the alemtuzumab group and worsened by 0.38 point in the interferon beta-1a group (P<0.001). In the alemtuzumab group, the lesion burden (as seen on T(2)-weighted magnetic resonance imaging) was reduced, as compared with that in the interferon beta-1a group (P=0.005). From month 12 to month 36, brain volume (as seen on T(1)-weighted magnetic resonance imaging) increased in the alemtuzumab group but decreased in the interferon beta-1a group (P=0.02). Adverse events in the alemtuzumab group, as compared with the interferon beta-1a group, included autoimmunity (thyroid disorders [23% vs. 3%] and immune thrombocytopenic purpura [3% vs. 1%]) and infections (66% vs. 47%). There were no significant differences in outcomes between the 12-mg dose and the 24-mg dose of alemtuzumab. CONCLUSIONS In patients with early, relapsing-remitting multiple sclerosis, alemtuzumab was more effective than interferon beta-1a but was associated with autoimmunity, most seriously manifesting as immune thrombocytopenic purpura. The study was not powered to identify uncommon adverse events. (ClinicalTrials.gov number, NCT00050778.)
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MESH Headings
- Adjuvants, Immunologic/adverse effects
- Adjuvants, Immunologic/therapeutic use
- Adolescent
- Adult
- Alemtuzumab
- Antibodies, Monoclonal/adverse effects
- Antibodies, Monoclonal/therapeutic use
- Antibodies, Monoclonal, Humanized
- Antibodies, Neoplasm/adverse effects
- Antibodies, Neoplasm/therapeutic use
- Autoimmune Diseases/chemically induced
- Female
- Humans
- Infections/chemically induced
- Interferon beta-1a
- Interferon-beta/adverse effects
- Interferon-beta/therapeutic use
- Magnetic Resonance Imaging
- Male
- Middle Aged
- Multiple Sclerosis, Relapsing-Remitting/drug therapy
- Multiple Sclerosis, Relapsing-Remitting/pathology
- Purpura, Thrombocytopenic/chemically induced
- Purpura, Thrombocytopenic/immunology
- Thyroid Diseases/chemically induced
- Thyroid Diseases/immunology
- Treatment Outcome
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35
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Dhasmana DJ, Dheda K, Ravn P, Wilkinson RJ, Meintjes G. Immune reconstitution inflammatory syndrome in HIV-infected patients receiving antiretroviral therapy : pathogenesis, clinical manifestations and management. Drugs 2008; 68:191-208. [PMID: 18197725 DOI: 10.2165/00003495-200868020-00004] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
The use of antiretroviral therapy (ART) to treat HIV infection, by restoring CD4+ cell count and immune function, is associated with significant reductions in morbidity and mortality. Soon after ART initiation, there is a rapid phase of restoration of pathogen-specific immunity. In certain patients, this results in inflammatory responses that may result in clinical deterioration known as 'the immune reconstitution inflammatory syndrome' (IRIS). IRIS may be targeted at viable infective antigens, dead or dying infective antigens, host antigens, tumour antigens and other antigens, giving rise to a heterogeneous range of clinical manifestations. The commonest forms of IRIS are associated with mycobacterial infections, fungi and herpes viruses. In most patients, ART should be continued and treatment for the associated condition optimized, and there is anecdotal evidence for the use of corticosteroids in patients who are severely affected. In this review, we discuss research relating to pathogenesis, the range of clinical manifestations, treatment options and prevention issues.
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Affiliation(s)
- Devesh J Dhasmana
- Department of Respiratory Medicine, Harefield Hospital, Middlesex, UK
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36
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37
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Fernández-Casado A, Martin-Ezquerra G, Yébenes M, Plana F, Elvira-Betanzos JJ, Herrero-González JE, Mariñoso ML, Pujol RM. Progressive supravenous granulomatous nodular eruption in a human immunodeficiency virus-positive intravenous drug user treated with highly active antiretroviral therapy. Br J Dermatol 2007; 158:145-9. [PMID: 17941945 DOI: 10.1111/j.1365-2133.2007.08238.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We describe a 41-year-old human immunodeficiency virus-infected woman with a previous history of intravenous drug abuse, who developed multiple linear nodules following the superficial veins on both arms. Histopathological examination disclosed a dermal histiocytic inflammatory reaction with sarcoid-like granuloma formation occasionally showing an intracytoplasmic refractile material in the histiocytic cells. Nodular lesions developed progressively after starting on highly active antiretroviral therapy (HAART) which increased her CD4 cell count and suppressed her viral load. The appearance of latent inflammatory or autoimmune disease following HAART is a well-recognized phenomenon. We consider that this peculiar 'progressive supravenous granulomatous nodular eruption' should be included within the spectrum of the so-called immune reconstitution inflammatory syndrome.
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Affiliation(s)
- A Fernández-Casado
- Department of Dermatology, Hospital del Mar-IMAS, Passeig Marítim 25-29, 08003 Barcelona, Spain
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38
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Ingiliz P, Appenrodt B, Gruenhage F, Vogel M, Tschampa H, Tasci S, Rockstroh JK. Lymphoid pneumonitis as an immune reconstitution inflammatory syndrome in a patient with CD4 cell recovery after HAART initiation. HIV Med 2007; 7:411-4. [PMID: 16903987 DOI: 10.1111/j.1468-1293.2006.00389.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In the era of highly active antiretroviral therapy (HAART), immune reconstitution inflammatory syndrome (IRIS) has come to present a significant clinical challenge. Following the recovery of memory T cells, latent infections may lead to clinical and laboratory deterioration despite immunological and virological reconvalescence. However, many other forms of complications after induction of HAART, which are not entirely understood, must be included in the entity of IRIS. Here we report a case of a patient complaining of respiratory distress and fever 10 days after initiating HAART. Radiologically and clinically, his findings mimicked Pneumocystis jiroveci pneumonia. However, no infectious agent could be detected, and bronchoalveolary lavage showed a high cell count (90% lymphocytes and 4% eosinophils) consistent with interstitial pneumonitis. He improved dramatically after treatment with oral steroids.
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Affiliation(s)
- P Ingiliz
- Department of Medicine I, University of Bonn, Bonn, Germany.
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39
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Calabrese LH, Kirchner E, Shrestha R. Rheumatic complications of human immunodeficiency virus infection in the era of highly active antiretroviral therapy: emergence of a new syndrome of immune reconstitution and changing patterns of disease. Semin Arthritis Rheum 2006; 35:166-74. [PMID: 16325657 DOI: 10.1016/j.semarthrit.2005.03.007] [Citation(s) in RCA: 137] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the impact of the introduction of highly active antiretroviral therapy (HAART) on the nature and frequency of rheumatic complications in human immunodeficiency virus (HIV)-infected patients. METHODS Case report and systematic review of a newly described syndrome of rheumatic immune reconstitution syndrome and prospective longitudinal cohort study analyzing the frequency and nature of rheumatic complications in the setting of HIV infection from 1989 through 2000. RESULTS A newly described syndrome of either the de novo appearance or the exacerbation of clinically occult autoimmunity following immune reconstitution from HAART is described. Including the present case report, 32 cases have been individually described with sarcoidosis and autoimmune thyroid disease being most common with arthritis and various forms of connective tissue disease making up the rest. The mean onset to their appearance following HAART was nearly 9 months and most resolved with little or no therapy. In addition, a longitudinal analysis of 395 HIV-infected patients from 1989 to 2000 designed to detect the appearance of rheumatic complications has revealed a dramatic decline in certain problems such as reactive arthritis, psoriatic arthritis, and various forms of connective tissue disease. New rheumatic complications possibly due to the effects of longer survival and metabolic derangements associated with this form of therapy are now being described and may become more formidable problems in this population in the future. CONCLUSIONS HAART has had a profound beneficial effect on survival in HIV-infected patients but has also contributed to both an altered frequency and a different nature of rheumatic complications now being observed in this population. Rheumatologists need to be aware of these changes to provide optimal diagnosis and treatment for this group.
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Affiliation(s)
- Leonard H Calabrese
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University and Department of Rheumatic and Immunologic Diseases, Cleveland Clinic Foundation, Cleveland, OH 44195, USA.
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40
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Knysz B, Bolanowski M, Klimczak M, Gladysz A, Zwolinska K. Graves' Disease as an Immune Reconstitution Syndrome in an HIV-1–Positive Patient Commencing Effective Antiretroviral Therapy: Case Report and Literature Review. Viral Immunol 2006; 19:102-7. [PMID: 16553555 DOI: 10.1089/vim.2006.19.102] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Combination antiretroviral therapy (cART) reduces morbidity and mortality in human immunodeficiency virus (HIV) infection, but it may also alter the clinical course of subclinical opportunistic infections and can even induce autoimmune disease. These atypical presentations are known as immune restoration disease (IRD), immune reconstitution syndrome/immune recovery syndrome (IRS), or immune restoration inflammatory syndrome (IRIS). We report the case of a 27-year-old, HIV-1-positive woman who developed hyperthyroidism attributable to Graves' disease (GD) after commencing potent cART. At the initiation of cART, her CD4 T cell count was 15 cells/microL and plasma HIV RNA 35 000 copies/mL. Her commencement of cART resulted in complete viral suppression and subsequent improvement of the CD4 T-cell count. Three years later, the diagnosis of GD was established based on a typical clinical picture and the results of hormonal and immunological analyses. It coincided with a 58-fold rise of the CD4 T cells. Retrospective analysis of serum samples revealed normal thyroid function and lack of anti-thyroid peroxidase (anti-TPO), anti- thyroid-stimulating hormone receptor (anti-TSHR), and anti-thyroglobulin (anti-TG) autoantibodies at the beginning of cART. HLA class II gene examination did not reveal susceptibility for the GD development in this patient. We suggest that GD in our patient was an IRD, and advise this as a possible differential diagnosis in patients presenting with hyperthyroidism on cART. To provide further details relevant to this case, we also review the literature concerning IRD-GD.
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Affiliation(s)
- Brygida Knysz
- Department of Infectious Diseases, Wroclaw Medical University, Wroclaw, Poland.
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41
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Crum NF, Ganesan A, Johns ST, Wallace MR. Graves disease: an increasingly recognized immune reconstitution syndrome. AIDS 2006; 20:466-9. [PMID: 16439886 DOI: 10.1097/01.aids.0000196173.42680.5f] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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42
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Chen F, Day SL, Metcalfe RA, Sethi G, Kapembwa MS, Brook MG, Churchill D, de Ruiter A, Robinson S, Lacey CJ, Weetman AP. Characteristics of autoimmune thyroid disease occurring as a late complication of immune reconstitution in patients with advanced human immunodeficiency virus (HIV) disease. Medicine (Baltimore) 2005; 84:98-106. [PMID: 15758839 DOI: 10.1097/01.md.0000159082.45703.90] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Experimental evidence from animal models has provided a framework for our current understanding of autoimmune disease pathogenesis and supports the importance of genetic predisposition, molecular mimicry, and immune dysregulation. However, only recently has evidence emerged to support the role of immune dysregulation in human organ-specific autoimmune disease. In the current study of the "late" manifestation of autoimmune thyroid disease (AITD) in a cohort of human immunodeficiency virus (HIV)-positive patients following highly active antiretroviral therapy (HAART), we discuss how immune dysregulation and factors associated with the immunopathology of HIV infection fit the current understanding of autoimmunity and provide a plausible basis for our clinical observations. De novo diagnoses of thyroid disease were identified between 1996 and 2002 in 7 HIV treatment centers (5/7 centers completed the study). Patients were diagnosed as clinical case entities and not discovered through thyroid function test screening. Paired plasma specimens were used to demonstrate sequential rise in thyroid antibodies. Seventeen patients were diagnosed with AITD (median age, 38 yr; 65% were of black African or black Caribbean ethnicity; and 82% were female). The median duration of immune reconstitution was 17 months. Graves disease (GD) was diagnosed in 15 of 17 patients. One patient developed hashithyrotoxicosis with atypically raised C-reactive protein, and another developed hypothyroidism. One GD patient had associated secondary hypoadrenalism. The estimated combined prevalence of GD for 4 treatment centers for female patients was 7/234 and for males was 2/1289. The denominator numbers were matched controls, from 4 centers able to provide data, who commenced HAART during the same time (January 1996 to July 2002) and who did not develop clinical AITD. The mean baseline pre-HAART CD4 count was 67 cells/mL, and the mean increase from nadir to AITD presentation was 355 cells/mL. AITD patients were more likely than controls (95% confidence interval, chi-square test) to be severely compromised at baseline (as defined by a CD4 count < 200 cells/mL or the presence of an acquired immunodeficiency syndrome [AIDS]-defining diagnosis), and to experience greater CD4 increments following HAART. AITD may be a late manifestation of immune reconstitution in HIV-positive patients taking HAART, and immune dysregulation may be an important factor.
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Affiliation(s)
- Fabian Chen
- From Department of Genitourinary Medicine (FC, GS, CJL), St. Mary's Hospital, London; Department of Genitourinary Medicine (SLD, AdR), Guy's & St. Thomas' Hospital NHS Foundation Trust, London; University of Sheffield (RAM), Division of Clinical Sciences (North), Northern General Hospital, Sheffield; Department of Genitourinary Medicine (FC, MSK), Northwick Park Hospital, London; Department of Genitourinary Medicine (FC, MGB), Central Middlesex Hospital, London; The Lawson Unit, Department of Genitourinary Medicine (DC), Royal Sussex County Hospital, Brighton; Department of Endocrinology & Metabolic Medicine (SR), St. Mary's Hospital, London; Imperial College School of Medicine (SLD, CJL), London; Hull York Medical School (CJL), University of York; The Medical School (APW), University of Sheffield, Sheffield, United Kingdom
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43
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Jimenez C, Moran SA, Sereti I, Wynne S, Yen PM, Falloon J, Davey RT, Sarlis NJ. Graves' disease after interleukin-2 therapy in a patient with human immunodeficiency virus infection. Thyroid 2004; 14:1097-102. [PMID: 15650365 DOI: 10.1089/thy.2004.14.1097] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Interleukin-2 (IL-2) is a cytokine that regulates the proliferation and differentiation of lymphocytes, and is currently used clinically in the treatment of assorted malignancies. Additionally, IL-2 is being actively investigated in clinical trials for treatment of human immunodeficiency virus (HIV) infection. Patients treated with IL-2 are susceptible to autoimmune thyroid disease (AITD), presenting as thyroiditis, which leads to either thyrotoxicosis or hypothyroidism, if not correctly and promptly identified and treated. IL-2-induced hypothyroidism can also sometimes follow a thyrotoxic phase. However, the development of Graves' disease (GD) in this clinical setting has not been reported to date. Here, we report the case of a 39-year-old HIV-infected man in whom GD developed after IL-2 therapy. We correlated the immunologic parameters pertinent to the patient's HIV infection status with clinical, hormonal, and serologic evidence of GD during its emergence. This revealed an association between peripheral blood cell numbers of specific lymphocyte subpopulations (CD4(+), CD3(+)CD25(+), and naïve T-cells) and serum levels of markers for AITD (free thyroxine [T(4)] and thyroid-stimulating immunoglobulin). Interestingly, no association was found between natural killer (NK) cell numbers and AITD markers. The immunopathogenesis of GD in this patient may be similar to that hypothesized for the GD that occurs in immune-reconstituted patients after combination antiretroviral therapy. From a practical standpoint, we propose that patients who have received or are receiving treatment with IL-2 who show signs of hyperthyroidism need to be carefully evaluated for GD.
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Affiliation(s)
- Camilo Jimenez
- Joint Endocrinology, Diabetes & Metabolism Fellowship at Baylor College of Medicine/The University of Texas-M.D. Anderson Cancer Center, Houston 77030, USA
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44
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Chamberlain AJ, Hollowood K, Turner RJ, Byren I. Tumid lupus erythematosus occurring following highly active antiretroviral therapy for HIV infection: A manifestation of immune restoration. J Am Acad Dermatol 2004; 51:S161-5. [PMID: 15577760 DOI: 10.1016/j.jaad.2004.04.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Tumid lupus erythematosus (LE) is a relatively rare and only recently recognized subset of chronic cutaneous lupus. We report a case occurring in a male with HIV infection whereby his rash was only unmasked by immune restoration following highly active antiretroviral therapy (HAART). The phenomenon of latent inflammatory or autoimmune disease appearing following HAART is now recognized as the "immune restoration syndrome" and tumid LE has not been reported in this setting previously. Fortunately this variant of lupus does not result in scarring and is responsive to anti-malarials, allowing continuation of HAART in this patient.
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45
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Spencer-Green G. Clinical Hyperthyroidism in Chinese Patients with Stable HIV Disease. Clin Infect Dis 2004; 39:1257. [PMID: 15486862 DOI: 10.1086/424749] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
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46
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Abstract
Recent research in autoimmune thyroid disease (AITD) has largely focused on delineation of the autoantigens and their epitopes, but there is now renewed interest in the immunoregulatory properties of T cells, an understanding of which may explain the emergence of AITD in experimental settings. T cell recognition of autoantigens has shown considerable intra- and interindividual heterogeneity, and a mixed pattern of cytokine production indicates that both the Th1 and Th2 limbs of the helper T cell response are involved in all types of AITD. It is now clear that secretion of chemokines and cytokines within the thyroid accounts for the accumulation and expansion of the intrathyroidal lymphocyte pool, and that the thyroid cells themselves contribute to this secretion. The thyroid cells also produce a number of proinflammatory molecules which will tend to exacerbate the autoimmune process. Thyroid cell destruction in autoimmune hypothyroidism is dependent on T cell-mediated cytotoxicity with the likely additional effect of death receptor-mediated apoptosis.
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Affiliation(s)
- A P Weetman
- Clinical Sciences Centre, University of Sheffield, Northern General Hospital, UK.
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47
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Romero S, Barroso E, Gil J, Aranda I, Alonso S, Garcia-Pachon E. Follicular bronchiolitis: clinical and pathologic findings in six patients. Lung 2004; 181:309-19. [PMID: 14749935 DOI: 10.1007/s00408-003-1031-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/10/2003] [Indexed: 11/26/2022]
Abstract
The purpose of this study was to review our experience with patients who had a definitive diagnosis of follicular bronchiolitis (FB), and to describe in detail the clinical and pathological findings, looking for common clinical aspects that may help to identify this entity. Ours is a community 750 bed teaching hospital that acts as a tertiary referral center for several subspecialties, including thoracic surgery. Six patients with a morphological diagnosis of FB, defined by the presence of coalescent germinal centers adjacent to airways, were included. Lung biopsy was obtained by thoracotomy in all patients (2 women and 4 men, mean age 53 years). In one patient FB was associated with advanced AIDS, and in another with prolonged exposure to polyethylene-flock. In 4 patients no condition previously associated with FB was found. Five patients had a history of repeated respiratory infections, 3 patients complained of dyspnea and none had peripheral blood eosinophilia. After a mean follow-up of 25 months, 2 patients responded well to steroid therapy; 3 patients suffered symptomatic exacerbations that required an increase in the steroid dose and 1 patient was not treated with steroids. The most important contribution of this series is the description of a subset of patients with FB who were not associated with other processes. These patients present relatively homogeneous clinical and pathological pictures that do not differ greatly from secondary forms.
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Affiliation(s)
- S Romero
- Servicios de Neumologia, Hospital General Universitario de Alicante, Spain.
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48
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Abstract
Most work describing the histopathology of normal human thymus has focused on pediatric thymus because of tissue availability and high thymopoietic activity. However, pathologic examination of the thymus can provide information about immune status that is relevant to the clinical care of patients of all ages. Understanding age-related changes in the relative abundance and composition of anatomic compartments within the thymus is critical for evaluation of the thymus in normal adults and patients with diseases that affect the thymus. The purpose of this review is to acquaint diagnostic pathologists with some of the newer histologic, flow cytometric, and molecular techniques for assessment of non-neoplastic thymus. Diagnostic criteria are presented for assessment of thymic function and for determining the mechanisms underlying thymic hyperplasia. Accurate assessment of thymic function is critical for the diagnosis and treatment of patients with complete DiGeorge syndrome and can complement the clinical care of patients with a variety of disorders that affect the immune system.
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Affiliation(s)
- Laura P Hale
- Department of Pathology, Duke University Medical Center, Durham, NC 27710, USA
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49
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Werwitzke S, Tiede A, Stoll M, von Depka M. Immune reconstitution inflammatory syndrome (IRIS) as a cause for inhibitor development in hemophilia. J Thromb Haemost 2004; 2:193-4. [PMID: 14717985 DOI: 10.1111/j.1538-7836.2004.0562b.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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50
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Tiroiditis de Graves Basedow asociada a terapia de alta actividad antirretrovírica a propósito de un caso. Semergen 2004. [DOI: 10.1016/s1138-3593(04)74339-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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