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Dwivedi SN, Kalaria T, Buch H. Thyroid autoantibodies. J Clin Pathol 2023; 76:19-28. [PMID: 36270794 DOI: 10.1136/jcp-2022-208290] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 09/24/2022] [Indexed: 12/26/2022]
Abstract
Thyroid-stimulating hormone (TSH) receptor antibody (TSH-R-Ab or TRAb) testing plays a pivotal role in arriving at the aetiological diagnosis in patients with thyrotoxicosis. A positive test establishes the diagnosis of Graves' disease (GD) while a negative result in conjunction with imaging studies supports other possible aetiologies. In patients with GD, TRAb levels at diagnosis and at the time of withdrawal of antithyroid drugs can identify patients who are unlikely to achieve remission and guide clinical management decisions. We provide an algorithm that incorporates TRAb in the decision-making process for the management of thyrotoxicosis. The utility of TRAb in predicting the risk of fetal and neonatal thyroid dysfunction is established and widely accepted in guidelines. TRAb may also help in the diagnosis of Graves' orbitopathy, especially in euthyroid or hypothyroid patients and its role in guiding its management is evolving as a useful adjunct to the clinical parameters used in making therapeutic decisions.Anti-thyroid peroxidase antibodies (TPOAb) and anti-thyroglobulin antibodies (TgAb) indicate thyroid autoimmunity. The most common use of TPOAb is to identify patients at a higher risk of progression to treatment-requiring hypothyroidism. They also aid the diagnosis of immune thyroiditis and Hashimoto's encephalopathy. Thyroglobulin measurement is used to help guide differentiated thyroid cancer treatment. TgAb is used as an accompanying test with thyroglobulin measurement as its presence can interfere with the thyroglobulin assay. A negative TgAb result reduces the likelihood of, but does not exclude, interference with thyroglobulin assay.
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Affiliation(s)
| | - Tejas Kalaria
- Clinical Biochemistry, New Cross Hospital, Black Country Pathology Services, Wolverhampton, UK
| | - Harit Buch
- Endocrinology and Diabetes, Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
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Stan MN, Algeciras-Schimnich A, Murthy V, Thapa P, Araki N. Diagnostic Utility of a New Assay for Thyroid Stimulating Immunoglobulins in Graves' Disease and Thyroid Eye Disease. Thyroid 2022; 32:170-176. [PMID: 34714163 DOI: 10.1089/thy.2021.0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Background: The syndrome of thyrotoxicosis typically relies on radioactive iodine scans for establishing its etiology. Alternatively, the determination of thyrotropin (TSH) receptor antibodies (TRAbs) helps to distinguish Graves' disease (GD) from thyrotoxic thyroiditis. Current assays are impacted by limitations in sensitivity and/or turnaround time. Therefore, we decided to test a new assay for the detection of TSH receptor stimulating antibodies (TSAbs) and compare it with the clinically available assays. Methods: We enrolled 110 individuals in 5 cohorts: patients with incident or recurrent GD (cohort 1); patients with thyroiditis, painless or subacute (cohort 2); patients with Graves' orbitopathy/thyroid eye disease (TED) in cohort 3; patients with Hashimoto's thyroiditis (cohort 4), and a control group of normal volunteers (cohort 5). The patients were tested with the two clinically available assays: Roche Elecsys anti-TSHR assay (ROC-TBII) from Roche Diagnostics and Thyretain™ TSI Reporter BioAssay Kit (QUI-TSI) from Quidel. In addition, the samples were tested with the aequorin TSAb assay (OTS-TSI) provided by Otsuka Pharmaceutical Co., Ltd. (Tokyo, Japan). The data were collected in a cross-sectional manner before initiation of therapy. Results: We had 36 cases of GD, 17 cases of thyroiditis, 27 cases of TED, 10 cases of Hashimoto's thyroiditis, and 20 normal volunteers. OTS-TSI had 100% sensitivity and specificity in distinguishing GD from thyroiditis, identical with QUI-TSI but superior to ROC-TBII (sensitivity 86% and specificity 94.1%). OTS-TSI had 93% sensitivity and 100% specificity for the diagnosis of TED, compared with normal controls. QUI-TSI and ROC-TBII performed similarly in this analysis, demonstrating 82% sensitivity and 100% specificity. The range of detectable values for OTS-TSI was 20-29,000 mIU/L and the turnaround time was ≤6 hours, without the need for cell culture equipment. Conclusions: OTS-TSI performed excellently, though similarly to QUI-TSI, for the differential diagnosis of GD vs. thyroiditis, while being superior in that respect to ROC-TBII. Furthermore, OTS-TSI has superior sensitivity to QUI-TSI and ROC-TBII for TED diagnosis, while retaining high specificity. It has a short turnaround time and avoids the need for cell culture and sterility. Larger studies in U.S. populations are needed for its validation.
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Affiliation(s)
| | | | - Vishakantha Murthy
- Division of Endocrinology, Department of Molecular Pharmacology and Experimental Therapeutics, Mayo Clinic, Rochester, Minnesota, USA
| | - Prabin Thapa
- Divisions of Clinical Trials and Biostatistics, Mayo Clinic, Rochester, Minnesota, USA
| | - Naohiro Araki
- Diagnostic Division, Otsuka Pharmaceutical Co. Ltd., Tokyo, Japan
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Iwata S, Tsumura K, Ashida K, Tokubuchi I, Demiya M, Kitamura M, Ohshima H, Yano M, Nagayama A, Yasuda J, Tsuruta M, Motomura S, Yoshida S, Nomura M. Thyroid-related ophthalmopathy development in concurrence with growth hormone administration. BMC Endocr Disord 2021; 21:168. [PMID: 34412613 PMCID: PMC8375170 DOI: 10.1186/s12902-021-00834-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 08/04/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Thyroid stimulating hormone (TSH) receptor and local infiltrate lymphocytes have been considered as major pathological factors for developing thyroid-related ophthalmopathy. Overexpression of insulin-like growth factor-I (IGF-I) receptor has emerged as a promising therapeutic target for refractory patients. However, the relationship between activation of growth hormone (GH)/IGF-I receptor signaling and development or exacerbation of thyroid ophthalmopathy has not been elucidated. Herein we describe a case that provides further clarification into the association between thyroid-related ophthalmopathy and GH/IGF-I receptor signaling. CASE PRESENTATION A 62-year-old Japanese female diagnosed with thyroid-related ophthalmopathy was admitted to Kurume University Hospital. She had received daily administration of GH subcutaneously for severe GH deficiency; however, serum IGF-I levels were greater than + 2 standard deviation based on her age and sex. She exhibited mild thyrotoxicosis and elevation in levels of TSH-stimulating antibody. Discontinuation of GH administration attenuated the clinical activity scores of her thyroid-related ophthalmopathy. Additionally, concomitant use of glucocorticoid and radiation therapies resulted in further improvement of thyroid-related ophthalmopathy. The glucocorticoid administration was reduced sequentially, followed by successful termination. Thereafter, the patient did not undergo recurrence of thyroid-related ophthalmopathy and maintained serum IGF-I levels within normal physiological levels. CONCLUSIONS We describe here a case in which development of thyroid-related ophthalmopathy occurred upon initiation of GH administration. GH/IGF-I signaling was highlighted as a risk factor of developing thyroid-related ophthalmopathy. Additionally, aberrant TSH receptor expression was suggested to be a primary pathophysiological mechanism within the development of thyroid-related ophthalmopathy. Physicians should be aware of the risks incurred via GH administration, especially for patients of advanced age, for induction of thyroid-related ophthalmopathy.
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Affiliation(s)
- Shimpei Iwata
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Kenji Tsumura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
- Clinical training center, Kurume University Hospital, Kurume, Fukuoka, Japan
| | - Kenji Ashida
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan.
| | - Ichiro Tokubuchi
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
- Division of Endocrinology and Metabolism, Omuta City Hospital, Omuta, Fukuoka, Japan
| | - Mutsuyuki Demiya
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
- Division of Endocrinology and Metabolism, Omuta City Hospital, Omuta, Fukuoka, Japan
| | - Miyuki Kitamura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
- Department of Pediatrics and Child Health, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Hiroyuki Ohshima
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Mamiko Yano
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Ayako Nagayama
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Junichi Yasuda
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Munehisa Tsuruta
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Seiichi Motomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
| | - Shigeo Yoshida
- Department of Ophthalmology, Kurume University School of Medicine, Kurume, Fukuoka, Japan
| | - Masatoshi Nomura
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Kurume University School of Medicine, 67 Asahi-machi, Kurume, Fukuoka, 830-0011, Japan
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Kahaly GJ, Diana T, Kanitz M, Frommer L, Olivo PD. Prospective Trial of Functional Thyrotropin Receptor Antibodies in Graves Disease. J Clin Endocrinol Metab 2020; 105:5684882. [PMID: 31865369 PMCID: PMC7067543 DOI: 10.1210/clinem/dgz292] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/17/2019] [Indexed: 11/19/2022]
Abstract
CONTEXT Scarce data exist regarding the relevance of stimulatory (TSAb) and blocking (TBAb) thyrotropin receptor antibodies in the management of Graves disease (GD). OBJECTIVE To evaluate the clinical utility and predictive value of TSAb/TBAb. DESIGN Prospective 2-year trial. SETTING Academic tertiary referral center. PATIENTS One hundred consecutive, untreated, hyperthyroid GD patients. METHODS TSAb was reported as percentage of specimen-to-reference ratio (SRR) (cutoff SRR < 140%). Blocking activity was defined as percent inhibition of luciferase expression relative to induction with bovine thyrotropin (TSH, thyroid stimulating hormone) alone (cutoff > 40% inhibition). MAIN OUTCOME MEASURES Response versus nonresponse to a 24-week methimazole (MMI) treatment defined as biochemical euthyroidism versus persistent hyperthyroidism at week 24 and/or relapse at weeks 36, 48, and 96. RESULTS Forty-four patients responded to MMI, of whom 43% had Graves orbitopathy (GO), while 56 were nonresponders (66% with GO; P < 0.01). At baseline, undiluted serum TSAb but not thyroid binding inhibitory immunoglobulins (TBII) differentiated between thyroidal GD-only versus GD + GO (P < 0.001). Furthermore, at baseline, responders demonstrated marked differences in diluted TSAb titers compared with nonresponders (P < 0.001). During treatment, serum TSAb levels decreased markedly in responders (P < 0.001) but increased in nonresponders (P < 0.01). In contrast, TBII strongly decreased in nonresponders (P = 0.002). All nonresponders and/or those who relapsed during 72-week follow-up period were TSAb-positive at week 24. A shift from TSAb to TBAb was noted in 8 patients during treatment and/or follow-up and led to remission. CONCLUSIONS Serum TSAb levels mirror severity of GD. Their increase during MMI treatment is a marker for ongoing disease activity. TSAb dilution analysis had additional predictive value.
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Affiliation(s)
- George J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
- Correspondence and Reprint Requests: Prof. George J Kahaly, MD, PhD, JGU Medical Center, Mainz 55101, Germany. E-mail:
| | - Tanja Diana
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Michael Kanitz
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Lara Frommer
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - Paul D Olivo
- Department of Molecular Microbiology, Washington University Medical School, St. Louis, Missouri
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Struja T, Jutzi R, Imahorn N, Kaeslin M, Boesiger F, Kutz A, Mundwiler E, Huber A, Kraenzlin M, Mueller B, Meier C, Bernasconi L, Schuetz P. Comparison of Five TSH-Receptor Antibody Assays in Graves' disease: results from an observational pilot study. BMC Endocr Disord 2019; 19:38. [PMID: 31023276 PMCID: PMC6482584 DOI: 10.1186/s12902-019-0363-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Early diagnosis and relapse prediction in Graves' disease influences treatment. We assessed the abilities of four TSH-receptor antibody tests [TRAb] and one cyclic adenosine monophosphate bioassay to predict relapse of Graves' disease. METHODS Observational study investigating patients presenting with Graves' disease at a Swiss hospital endocrine referral center or an endocrine outpatient clinic. Main outcomes were diagnosis and relapse of Graves' disease after stop of anti-thyroid drugs. We used Cox regression to study associations of TRAb levels with relapse risk and calculated c-statistics [AUC] to assess discrimination. Blood draws took place as close as possible to treatment initiation. RESULTS AUCs ranged from 0.90 (TSAb Biossay by RSR) to 0.97 (IMMULITE TSI by Siemens). Highest sensitivity (94.0%) was observed for IMMULITE TSI and RSR TRAb Fast, while the greatest specificity (97.9%) was found with the EliA anti-TSH-R (by Thermo Fisher). In Cox regression analysis comparing the highest versus the lower quartiles, the highest hazard ratio [HR] for relapse was found for BRAHMS TRAK (by Thermo Fisher) (2.98, 95% CI 1.13-7.84), IMMULITE TSI (2.40, 95% CI 0.91-6.35), EliA anti-TSH-R (2.05, 95% CI 0.82-5.10), RSR Fast TRAb (1.80, 95% CI 0.73-4.43), followed by RSR STIMULATION (1.18, 95% CI 0.46-2.99). Discrimination analyses showed respective AUCs of 0.68, 0.65, 0.64, 0.64, and 0.59. CONCLUSION The assays tested had good diagnostic power and relapse risk prediction with few differences among the new assays. Due to the small sample size and retrospective design with possible selection bias, our data need prospective validation.
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Affiliation(s)
- Tristan Struja
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Rebecca Jutzi
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Noemi Imahorn
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Marina Kaeslin
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Fabienne Boesiger
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Alexander Kutz
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
| | - Esther Mundwiler
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Andreas Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | | | - Beat Mueller
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Medical Faculty of the University of Basel, Basel, Switzerland
| | - Christian Meier
- Medical Faculty of the University of Basel, Basel, Switzerland
- Endonet, Basel, Switzerland
| | - Luca Bernasconi
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - Philipp Schuetz
- Medical University Department, Clinic for Endocrinology, Diabetes & Metabolism, Kantonsspital Aarau, Tellstrasse, CH-5001 Aarau, Switzerland
- Medical Faculty of the University of Basel, Basel, Switzerland
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Abstract
PURPOSE Thyroid autoimmunity affects approximately 5% of the population, and its investigation relies heavily on the use of autoantibodies. Thyroid stimulating hormone receptor (TSHR) autoantibodies (TRAb) play a central role in the evaluation of Graves disease (GD), Graves ophthalmopathy (GO) and pretibial myxedema (PTM). However, there is still controversy regarding overall TRAb assay diagnostic accuracy and their prognostic utility. METHODS We reviewed and analyzed the literature reporting TRAb assays and their clinical utility. RESULTS Current assays measure the overall TRAb titer in a competitive manner (TSH binding inhibiting immunoglobulin assay) or biologic activity of the stimulating TSHR autoantibodies (thyroid stimulating immunoglobulin assay). Both types of assays have improved over time with advances in sensitivity and specificity. TRAb are particularly relevant in hyperthyroidism cases where use of iodinated contrast is not an option (e.g., pregnancy or recent use of iodinated contrast) or in cases of euthyroid eye disease, suspicious for GO. Third generation TRAb assays are useful for therapy selection in GD, prognostic predictions in GO and risk prediction for fetal and neonatal thyrotoxicosis. DISCUSSION Given the pathogenic role of TRAb, we expect that the future will bring useful evidence regarding their predictive role with respect to efficacy of therapeutic modalities for GO and PTM. We also hope to better understand the role of blocking and neutral antibodies against TSHR, and harness that ability for modulation of thyroid function or therapy of differentiated thyroid carcinoma managed with TSH suppression. CONCLUSIONS Thyroid autoimmune diseases have seen tremendous gains in understanding their pathophysiology, largely antibody mediated. Better TRAb testing is becoming a springboard for providing individualized patient care.
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Thyroid Stimulating Hormone Receptor Antibodies in Thyroid Eye Disease-Methodology and Clinical Applications. Ophthalmic Plast Reconstr Surg 2018; 34:S13-S19. [PMID: 29771755 DOI: 10.1097/iop.0000000000001053] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Thyroid stimulating hormone receptor antibodies (TSHR-Ab) cause autoimmune hyperthyroidism and are prevalent in patients with related thyroid eye disease (TED). PURPOSE To provide a historical perspective on TSHR-Ab and to present evidence-based recommendations for clinical contemporary use. METHODS The authors review the recent literature pertaining to TSHR-Ab in patients with TED and describe the various immunoassays currently used for detecting TSHR-Ab and their clinical applications. RESULTS We provide a historical summary and description of the various methods used to detect TSHR-Ab, foremost, the functional TSHR-Ab. Increasing experimental and clinical data demonstrate the clinical usefulness of cell-based bioassays for measurements of functional TSHR-Ab in the diagnosis and management of patients with autoimmune TED and in the characterization of patients with autoimmune-induced hyperthyroidism and hypothyroidism. Thyroid stimulating hormone receptor antibodies, especially the functional stimulating antibodies, are sensitive, specific, and reproducible biomarkers for patients with autoimmune TED and correlate well with clinical disease activity and clinical severity. Unlike competitive-binding assays, bioassays have the advantage of indicating not only the presence of antibodies but also their functional activity and potency. CONCLUSIONS Measurement of TSHR-Ab (especially stimulating antibodies) is a clinically useful tool for the management of patients with TED.
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Chhetri M, Miaskiewicz S, Lawrence TA, Kapetanos A. Unexpected cause of fever in a patient with untreated HIV. BMJ Case Rep 2018; 2018:bcr-2018-225087. [PMID: 29970608 DOI: 10.1136/bcr-2018-225087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a case of a 27-year-old man with a history of untreated HIV who presented with fever, rash and leg cramps. Initial suspicion was high for an infectious process; however, after an exhaustive evaluation, thyrotoxicosis was revealed as the aetiology of his symptoms. Recent intravenous contrast administration complicated his workup to determine the exact cause of hyperthyroidism. Differentiation between spontaneously resolving thyroiditis and autonomous hyperfunction was paramount in the setting of existing neutropenia and the need for judicious use of antithyroid therapy. The inability to enlist a nuclear scan in the setting of recent iodinated contrast administration prompted alternative testing, including thyroid antibodies and thyroid ultrasound. In this case, we will discuss the diagnostic challenges of thyrotoxicosis in a complex patient, the sequelae of iodine contrast administration, effects of iodine on the thyroid and the predictive value of other available tests.
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Affiliation(s)
- Mamta Chhetri
- Department of Endocrinology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Stasia Miaskiewicz
- Department of Endocrinology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Taylor Abegg Lawrence
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Anastasios Kapetanos
- Department of Internal Medicine, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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Stożek K, Bossowski A, Ziora K, Bossowska A, Mrugacz M, Noczyńska A, Walczak M, Petriczko E, Pyrżak B, Kucharska A, Szalecki M, Diana T, Kahaly GJ. Functional TSH receptor antibodies in children with autoimmune thyroid diseases. Autoimmunity 2018; 51:62-68. [DOI: 10.1080/08916934.2018.1431776] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Karolina Stożek
- Department of Pediatric Endocrinology, Diabetology with Cardiology Division, Medical University of Bialystok, Bialystok, Poland
| | - Artur Bossowski
- Department of Pediatric Endocrinology, Diabetology with Cardiology Division, Medical University of Bialystok, Bialystok, Poland
| | - Katarzyna Ziora
- Department of Pediatric Nephrology and Endocrinology, Silesian Medical University, Zabrze, Poland
| | - Anna Bossowska
- Division of Cardiology, Internal Affairs Ministry Hospital in Bialystok, Białystok, Poland
| | - Małgorzata Mrugacz
- Department of Ophthalmology and Visual Rehabilitation, Medical University of Bialystok, Białystok, Poland
| | - Anna Noczyńska
- Department of Endocrinology and Diabetology for Children and Adolescents, Wroclaw Medical University, Wrocław, Poland
| | - Mieczysław Walczak
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - Elżbieta Petriczko
- Department of Pediatrics, Endocrinology, Diabetology, Metabolic Diseases and Cardiology of the Developmental Age, Pomeranian Medical University, Szczecin, Poland
| | - Beata Pyrżak
- Department of Pediatrics and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Anna Kucharska
- Department of Pediatrics and Endocrinology, Medical University of Warsaw, Warsaw, Poland
| | - Mieczysław Szalecki
- Department of Endocrinology and Diabetology, Children's Memorial Health Institute, Warsaw, Poland
- Faculty of Health Sciences, Jan Kochanowski University, Kielce, Poland
| | - Tanja Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - George J. Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
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Diana T, Krause J, Olivo PD, König J, Kanitz M, Decallonne B, Kahaly GJ. Prevalence and clinical relevance of thyroid stimulating hormone receptor-blocking antibodies in autoimmune thyroid disease. Clin Exp Immunol 2017; 189:304-309. [PMID: 28439882 DOI: 10.1111/cei.12980] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 01/07/2023] Open
Abstract
The prevalence and clinical relevance of thyroid stimulating hormone (TSH) receptor (TSHR) blocking antibodies (TBAb) in patients with autoimmune thyroid disease (AITD) was investigated. Serum TBAb were measured with a reporter gene bioassay using Chinese hamster ovary cells. Blocking activity was defined as percentage inhibition of luciferase expression relative to induction with bovine TSH alone (cut-off 40% inhibition). All samples were measured for TSHR stimulatory antibody (TSAb) and TSHR binding inhibiting immunoglobulins (TBII). A total of 1079 unselected, consecutive patients with AITD and 302 healthy controls were included. All unselected controls were negative for TBAb and TSAb. In contrast, the prevalence of TBAb-positive patients with Hashimoto's thyroiditis and Graves' disease was 67 of 722 (9·3%) and 15 of 357 (4·2%). Of the 82 TBAb-positive patients, thirty-nine (48%), 33 (40%) and 10 (12%) were hypothyroid, euthyroid and hyperthyroid, respectively. Ten patients were both TBAb- and TSAb-positive (four hypothyroid, two euthyroid and four hyperthyroid). Thyroid-associated orbitopathy was present in four of 82 (4·9%) TBAb-positive patients, with dual TSHR antibody positivity being observed in three. TBAb correlated positively with TBII (r = 0·67, P < 0·001) and negatively with TSAb (r = -0·86, P < 0·05). The percentage of TBII-positive patients was higher the higher the level of inhibition in the TBAb assay. Of the TBAb-positive samples with > 70% inhibition, 87% were TBII-positive. Functional TSHR antibodies impact thyroid status. TBAb determination is helpful in the evaluation and management of patients with AITD. The TBAb assay is a relevant and important tool to identify potentially reversible hypothyroidism.
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Affiliation(s)
- T Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - J Krause
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - P D Olivo
- Department of Microbiology, Washington University, St Louis, MO, USA
| | - J König
- Institute of Medical Biostatistics, Epidemiology and Informatics, JGU Medical Center, Mainz, Germany
| | - M Kanitz
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
| | - B Decallonne
- Clinical and Experimental Endocrinology, UZ Leuven, Belgium
| | - G J Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany
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Tozzoli R, D'Aurizio F, Villalta D, Giovanella L. Evaluation of the first fully automated immunoassay method for the measurement of stimulating TSH receptor autoantibodies in Graves' disease. Clin Chem Lab Med 2017; 55:58-64. [PMID: 27331310 DOI: 10.1515/cclm-2016-0197] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 05/12/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Thyroid stimulating hormone (TSH) receptor autoantibodies (TRAb) are pathogenetic and diagnostic hallmarks of Graves' disease (GD). Three varieties of TRAb have been described: stimulating (S-TRAb), blocking (B-TRAb), and apoptotic (A-TRAb) autoantibodies. Very recently, the first immunoassay method (Immulite TSI assay, Siemens Healthcare Diagnostics) declared to measure serum S-TRAb concentration, has been made available in an automated commercial platform. The aim of the study was to evaluate the ability of this new test to identify patients suffering from GD, in comparison with two current IMA methods for total TSH receptor autoantibodies (T-TRAb) measurement. METHODS Sera of 383 subjects [72 patients with untreated GD, 55 patients with autoimmune thyroiditis (AIT), 36 patients with multinodular non-toxic goiter, 100 patients with other non-thyroid autoimmune diseases (NTAD) and 120 healthy subjects (HS)] were evaluated. RESULTS The threshold obtained by receiver operating characteristic (ROC) analysis was 0.54 IU/L, very similar to that proposed by the manufacturer (0.55 IU/L). Thyroid-stimulating immunoglobulins (TSI) were positive in all GD patients and negative in all but three controls (clinical sensitivity and specificity of 100% and 98.7%, respectively). Passing and Bablok regression analysis and Bland-Altman plot showed an acceptable agreement between TSI Immulite assay and other two immunoassay methods (Cobas/Elecsys, Roche and TRAK RIA, BRAHMS Thermo Scientific). CONCLUSIONS The diagnostic performance of fully automated Immulite TSI assay in GD patients is at least comparable to that of current TRAb immunoassays (IMAs) suggesting the possibility of including such assay in rapid and cost-saving diagnostic and monitoring algorithms. However, our results do not provide full evidence that this assay is specific for S-TRAb only, and future studies comparing Immulite TSI assay to stimulating activity are required.
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Diana T, Li Y, Olivo PD, Lackner KJ, Kim H, Kanitz M, Kahaly GJ. Analytical Performance and Validation of a Bioassay for Thyroid-Blocking Antibodies. Thyroid 2016; 26:734-40. [PMID: 26956921 DOI: 10.1089/thy.2015.0447] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND OBJECTIVE A cell-based bioassay for the measurement of thyroid blocking autoantibodies (TBAb) has been recently reported. The analytical performance and validation of this bioassay is assessed and described. METHODS Chinese hamster ovary cells expressing a chimeric thyrotropin receptor were treated with bovine (b) TSH and different concentrations of an immunoglobulin G (IgG) monoclonal human TBAb (K1-70). TBAb was measured as a function of luciferase activity relative to bTSH alone and expressed as percent inhibition. Results obtained in the chimeric cell line were compared with those of a wild-type cell line. Analytical performance studies were subsequently performed with the chimeric cell line only. RESULTS Immunodepletion of K1-70 IgG by using a protein G-Sepharose column showed that positive percent inhibition in the TBAb bioassay was detectable from K1-70 IgG only. The limit of blank was determined to be 12.2%. The limit of detection was 14% inhibition, equivalent to 0.4 ng/mL K1-70, while the limit of quantitation was 22% (coefficient of variation [CV] 12%) equivalent to 0.625 ng/mL K1-70. The dynamic range was between 14 ± 3.7 (mean % inhibition ± standard deviation) and 101 ± 2.6, equivalent to 0.4-10 ng/mL K1-70. The linear range was between 22 ± 2.6 and 93 ± 0.6 inhibition, equivalent to 0.625-5 ng/mL K1-70. The upper limit of the 99th percent reference range was 34% inhibition. In two laboratories, CV values for the intra- and inter-assay precisions for K1-70 ranged from 2% to 12% and from 1.7% to 14.5%, respectively. For patient sera, the CV values for the intra- and inter-assay precisions ranged from 3% to 9% and from 3% to 11%, respectively. No interference was found when follicle-stimulating hormone, luteinizing hormone, and human chorionic gonadotrophin were tested in the TBAb bioassay. The median of % inhibition values in 40 TBAb positive sera from patients with autoimmune thyroid disease were 93.5 (range 25-103) and 92 (range 64-107) for the wild type and chimeric cell lines, respectively. Further, all 40 samples of patients with various non-thyroidal autoimmune diseases were TBAb negative. CONCLUSIONS This TBAb bioassay exhibits excellent analytical performance and high level of reproducibility.
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Affiliation(s)
- Tanja Diana
- 1 Molecular Thyroid Research Laboratory, Johannes Gutenberg University Medical Center , Mainz, Germany
| | - Yunsheng Li
- 2 Research & Development, Quidel Corporation, San Diego, California
| | - Paul D Olivo
- 2 Research & Development, Quidel Corporation, San Diego, California
| | - Karl J Lackner
- 3 Institute of Clinical Chemistry and Laboratory Medicine, Johannes Gutenberg University Medical Center , Mainz, Germany
| | - Hannah Kim
- 2 Research & Development, Quidel Corporation, San Diego, California
| | - Michael Kanitz
- 1 Molecular Thyroid Research Laboratory, Johannes Gutenberg University Medical Center , Mainz, Germany
| | - George J Kahaly
- 1 Molecular Thyroid Research Laboratory, Johannes Gutenberg University Medical Center , Mainz, Germany
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Ponto KA, Diana T, Binder H, Matheis N, Pitz S, Pfeiffer N, Kahaly GJ. Thyroid-stimulating immunoglobulins indicate the onset of dysthyroid optic neuropathy. J Endocrinol Invest 2015; 38:769-77. [PMID: 25736545 DOI: 10.1007/s40618-015-0254-2] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Accepted: 02/05/2015] [Indexed: 01/02/2023]
Abstract
PURPOSE Recognition of dysthyroid optic neuropathy (DON) requires sensitive diagnostic tools. Clinical assessment may fail to reliably evaluate the acuteness of DON especially if signs for inflammation are missing. Aim of this cross-sectional study was to assess the relationship between thyroid-stimulating immunoglobulins (TSI) and onset of DON. METHODS At a multidisciplinary orbital center, serum TSI levels were measured in 180 consecutive patients with thyroid eye disease (TED) and 302 healthy controls with a FDA-cleared cell-based bioassay using a chimeric TSH receptor and a CRE-dependent luciferase. RESULTS Thirty of 180 (16.7 %) patients with TED had DON of recent onset or a past history of DON (post-DON). Optic disk swelling was present and visual-evoked potentials were pathologic in all eyes with DON of recent onset, but in one of 13 (7.7 %) with post-DON, only (p = 0.005). 19/20 (96 %) patients with DON of recent onset were TSI-positive. TSI was associated with DON of recent onset (OR: 20.96; 95 % CI 1.064-412.85, p = 0.045). All controls were TSI negative. TSI correlated with the clinical activity score (R = 0.70, p < 0.001) and higher TSI-levels were noted in active vs. inactive TED (485.1 ± 132.3 vs. 277.7 ± 143.7 %, cut-off < 140 %; p < 0.001). Six of seven (85.7 %) patients with inactive TED with recent onset DON versus one of four (25 %) with active post-DON were TSI-positive (p = 0.006). A discriminatory cut-point of 377 SRR % for TSI was determined based on a ROC analysis (sensitivity: 0.95, specificity: 0.8). CONCLUSIONS Serum TSI levels identify patients with DON of recent onset requiring urgent therapy.
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Affiliation(s)
- K A Ponto
- Department of Ophthalmology, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
| | - T Diana
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
| | - H Binder
- Department of Biomedical Statistics, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
| | - N Matheis
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
| | - S Pitz
- Department of Ophthalmology, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
| | - N Pfeiffer
- Department of Ophthalmology, Johannes Gutenberg University (JGU) Medical Center, Mainz, Germany.
| | - G J Kahaly
- Department of Medicine I, Johannes Gutenberg University (JGU) Medical Center, Langenbeckstreet 1, 55131, Mainz, Germany.
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Affiliation(s)
- George J. Kahaly
- *Prof. George J. Kahaly, Johannes Gutenberg University Medical Center, Langenbeckstrasse 1, DE-55101 Mainz (Germany), E-Mail
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Diana T, Kanitz M, Lehmann M, Li Y, Olivo PD, Kahaly GJ. Standardization of a bioassay for thyrotropin receptor stimulating autoantibodies. Thyroid 2015; 25:169-75. [PMID: 25317659 DOI: 10.1089/thy.2014.0346] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Cell-based bioassays for functional thyroid stimulating autoantibodies (TSAb) are sensitive diagnostic tools. However, there is no bioassay available that is standardized with international reference material. We aimed to promote the standardization of the test results among laboratories that perform TSAb bioassays and calibrate TSAb levels against the second international standard (IS) 08/204 from the National Institute for Biological Standards and Control (NIBSC). METHODS Serum TSAb activity was measured with a FDA-cleared bioassay that utilizes CHO cells expressing a chimeric thyrotropin receptor (TSHR) and a c-AMP response-element-dependent luciferase. The IS was applied for calibration. TSAb results were reported as percentage of specimen-to-reference ratio (SRR%) and converted into mIU/L. RESULTS The IS dose-response curve was obtained using concentrations from 0.3125 to 200 mIU/L. Mean TSAb SRR%±standard deviation (SD) values for the IS concentrations 0.3125, 0.625, 1.25, 2.5, 5, 10, 20, 40, 60, 80, 100, 120, 160, and 200 mIU/L were 63±4 (CV 6.3%), 63±4 (6.3), 67±2 (3.0), 76±6 (7.9), 91±8 (8), 134±8 (5.9), 201±13 (6.5), 294±12 (4.1), 336±10 (3.0), 348±8 (2.3), 360±14 (3.8), 371±15 (4.0), 381±9 (2.4), and 389±10 (2.6), respectively. A total of 127 dilution experiments were performed using 12 high TSAb-positive sera from patients with Graves' disease. When diluting TSAb-positive sera, IS concentrations within the linear range 5, 10, 20, 40, and 80 mIU/L were used for the calibration curve. All standard curves had R(2) values >0.95. Low coefficient of variation (CV %) values for the IS calibration curve (4-6%) were obtained. Compared to bovine TSH, no significant differences were noted using either a pool of healthy donors or a normal serum as reference controls. The average IU measured value for the assay cutoff (SRR 140%) corresponded to 9.54±1.68 mIU/L, and clinical application was shown in 60 Graves' patients. CONCLUSIONS The TSAb bioassay demonstrated excellent performance in terms of linear range, limit of quantitation, and imprecision. The dilution experiments showed a high correlation coefficient and excellent reproducibility. Thus, TSAb levels can be reliably converted from SRR% to IU/L. These results offer the perspective of standardizing TSAb levels among laboratories and enable more accurate comparison of TSAb studies.
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Affiliation(s)
- Tanja Diana
- 1 Molecular Thyroid Research Laboratory, Johannes Gutenberg University Medical Center , Mainz, Germany
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Kampmann E, Diana T, Kanitz M, Hoppe D, Kahaly GJ. Thyroid Stimulating but Not Blocking Autoantibodies Are Highly Prevalent in Severe and Active Thyroid-Associated Orbitopathy: A Prospective Study. Int J Endocrinol 2015; 2015:678194. [PMID: 26221139 PMCID: PMC4499387 DOI: 10.1155/2015/678194] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
The clinical utility of the functional TSH receptor autoantibodies was prospectively evaluated in patients with thyroid-associated orbitopathy (TAO). Ophthalmic, endocrine, and serological investigations were performed in 101 consecutive patients with severe and active TAO. Serum thyroid stimulating (TSAb) and blocking (TBAb) antibody levels were measured with two bioassays using cells that express a chimeric TSH receptor and CRE-dependent luciferase. TSAb results are expressed as percentage of specimen-to-reference ratio (SRR %). Blocking activity is defined as percent inhibition of luciferase expression relative to induction with bovine TSH alone. All 101 consecutively followed-up patients with severe and active TAO were TBAb negative. In contrast, 91 (90%) were TSAb positive of whom 90 had Graves' disease. Serum TSAb levels correlated with the diplopia score (P = 0.016), total severity eye score (P = 0.009), proptosis (P = 0.007), lid aperture (P = 0.003), upper lid retraction (P = 0.006), keratopathy (P = 0.04), and thyroid binding inhibiting immunoglobulins (TBII, P < 0.001) and negatively with the duration of TAO (P = 0.002). Median serum values of TSAb were SRR% 418 (range 28% to 795%). TSAb, not TBAb, are highly prevalent in severe/active TAO and serum TSAb levels correlate with clinical disease severity.
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Affiliation(s)
- E. Kampmann
- Molecular Thyroid Research Laboratory, Johannes Gutenberg University (JGU) Medical Center, 55131 Mainz, Germany
- Department of Pediatrics, Johannes Gutenberg University (JGU) Medical Center, 55131 Mainz, Germany
| | - T. Diana
- Molecular Thyroid Research Laboratory, Johannes Gutenberg University (JGU) Medical Center, 55131 Mainz, Germany
| | - M. Kanitz
- Molecular Thyroid Research Laboratory, Johannes Gutenberg University (JGU) Medical Center, 55131 Mainz, Germany
| | - D. Hoppe
- Department of Psychology, Technical University of Darmstadt, 64283 Darmstadt, Germany
| | - G. J. Kahaly
- Molecular Thyroid Research Laboratory, Johannes Gutenberg University (JGU) Medical Center, 55131 Mainz, Germany
- *G. J. Kahaly:
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Diana T, Brown RS, Bossowski A, Segni M, Niedziela M, König J, Bossowska A, Ziora K, Hale A, Smith J, Pitz S, Kanitz M, Kahaly GJ. Clinical relevance of thyroid-stimulating autoantibodies in pediatric graves' disease-a multicenter study. J Clin Endocrinol Metab 2014; 99:1648-55. [PMID: 24517152 DOI: 10.1210/jc.2013-4026] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
CONTEXT AND OBJECTIVE The incidence of TSH receptor (TSHR) stimulating autoantibodies (TSAbs) in pediatric Graves' disease (GD) is controversial. This large, multicenter study evaluated the clinical relevance of TSAbs in children with GD both with Graves' orbitopathy (GO) and without orbital disease. DESIGN We conducted a cross-sectional retrospective study. SETTING Sera were collected in seven American and European academic referral centers and evaluated in a central laboratory. PATIENTS AND SAMPLES: A total of 422 serum samples from 157 children with GD, 101 control individuals with other thyroid and nonthyroid autoimmune diseases, and 50 healthy children were studied. MAIN OUTCOME MEASURES TSAbs were measured using a novel, chimeric TSHR bioassay and a cAMP response element-dependent luciferase. TSH binding-inhibitory Ig (TBII) and parameters of thyroid function were also determined. RESULTS In 82 untreated children with GD, sensitivity, specificity, and positive and negative predictive values for TSAb and TBII were: 100 and 92.68% (P = .031), 100 and 100%, 100 and 100%, and 100 and 96.15%, respectively. TSAb and TBII were present in 147 (94%) and 138 (87.9%) of the 157 children with GD (P < .039), respectively; and in 247 (94%) and 233 (89%) of the 263 samples from this group (P < .0075), respectively. In children with GD and GO, TSAb and TBII were noted in 100 and 96% (P < .001), respectively. Hyperthyroid children with GD and GO showed markedly higher TSAb levels compared to those with thyroidal GD only (P < .0001). No significant differences were noted for TBII between the two groups. After a 3-year (median) medical treatment, the decrease of TSAb levels was 69% in GD vs 20% in GD and GO (P < .001). All 31 samples of euthyroid children with GO were TSAb positive; in contrast, only 24 were TBII positive (P = .016). All children with Hashimoto's thyroiditis, nonautoimmune hyperthyroidism, type 1 diabetes, and juvenile arthritis and the healthy controls were TSAb and TBII negative. CONCLUSIONS Serum TSAb level is a sensitive, specific, and reproducible biomarker for pediatric GD and correlates well with disease severity and extrathyroidal manifestations.
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Affiliation(s)
- T Diana
- Thyroid Laboratory (T.D., M.K., G.J.K.), Department of Medicine I, Johannes Gutenberg University Medical Center, 55101 Mainz, Germany; Division of Endocrinology (R.S.B., A.H., J.S.), Department of Medicine, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts 02115; Department of Pediatrics, Endocrinology, Diabetology, with the Cardiology Division (A. Bossowski), Medical University in Bialystok, 15-089 Bialystok, Poland; Department of Pediatrics (M.S.), University La Sapienza, 00185 Rome, Italy; Department of Pediatric Endocrinology and Rheumatology (M.N.), University of Medical Sciences, 61-701 Poznan, Poland; Institute of Medical Statistics, Biometry, and Epidemiology (J.K.), Johannes Gutenberg University Medical Center, 55101 Mainz, Germany; Department of Cardiology (A. Bossowska), Internal Affair and Administration, Ministry Hospital, 15-089 Bialystok, Poland; Department of Pediatrics (K.Z.), Silesia Medical University, 40-055 Katowice, Poland; and Department of Ophthalmology (S.P.), Johannes Gutenberg University Medical Center, 55101 Mainz, Germany
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Abstract
Changes in thyroid hormone concentrations that are characteristic of hyperthyroidism must be distinguished from physiological changes in thyroid hormone economy that occur in pregnancy, especially in the first trimester. Approximately one to two cases of gestational hyperthyroidism occur per 1000 pregnancies. Identification of hyperthyroidism in a pregnant woman is important because adverse outcomes can occur in both the mother and the offspring. Graves' disease, which is autoimmune in nature, is the usual cause; but hyperthyroidism in pregnancy can be caused by any type of hyperthyroidism--eg, toxic multinodular goitre or solitary autonomously functioning nodule. Gestational transient thyrotoxicosis is typically reported in women with hyperemesis gravidarum, and is mediated by high circulating concentrations of human chorionic gonadotropin. Post-partum thyroiditis occurs in 5-10% of women, and many of those affected ultimately develop permanent hypothyroidism. Antithyroid drug treatment of hyperthyroidism in pregnant women is controversial because the usual drugs--methimazole or carbimazole--are occasionally teratogenic; and the alternative--propylthiouracil--can be hepatotoxic. Fetal hyperthyroidism can be life-threatening, and needs to be recognised as soon as possible so that treatment of the fetus with antithyroid drugs via the mother can be initiated. In this Review, we discuss physiological and pathophysiological changes in thyroid hormone economy in pregnancy, the diagnosis and management of hyperthyroidism during pregnancy, severe life-threatening thyrotoxicosis in pregnancy, neonatal thyrotoxicosis, and post-partum hyperthyroidism.
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Affiliation(s)
- David S Cooper
- Division of Endocrinology and Metabolism, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Peter Laurberg
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark
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Li Y, Kim J, Diana T, Klasen R, Olivo PD, Kahaly GJ. A novel bioassay for anti-thyrotrophin receptor autoantibodies detects both thyroid-blocking and stimulating activity. Clin Exp Immunol 2013; 173:390-7. [PMID: 23647395 PMCID: PMC3949626 DOI: 10.1111/cei.12129] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2013] [Indexed: 12/23/2022] Open
Abstract
Autoantibodies to the thyrotrophin (TSH) receptor (anti-TSHR) are unique, in that they are involved directly in the pathophysiology of certain autoimmune thyroid diseases (AITD). Thyroid-stimulating antibodies (TSAb) act as agonists that activate the thyroid gland and cause Graves' disease. Other anti-TSHR antibodies block TSH and can cause hypothyroidism. Thyroid-blocking antibodies (TBAb) have not been studied as extensively as TSAb. We developed a TBAb bioassay based on a cell line that expresses a chimeric TSHR. The 50% inhibitory concentration of the chimeric Chinese hamster ovary (CHO)-Luc cells was more than five-fold lower compared with the wild-type CHO-Luc cells. We tested the performance of this bioassay using a thyroid-blocking monoclonal antibody K1-70, established an assay cut-off and detected TBAb in 15 of 50 (30%) patients with AITD. Interestingly, the assay detects both TSAb and TBAb and measures the net activity of a mixture of both types of antibodies. There was a high correlation (R(2) 0·9, P < 0·0001) between the results of the TSAb assay and the negative percentage inhibition of the TBAb assay. The TBAb bioassay was approximately 20-fold more sensitive than a commercially available TSHR binding assay (TRAb). In contrast to TRAb, sera with high levels of TBAb activity were able to be diluted several hundred-fold and still exhibit blocking activity above the cut-off level. Thus, this TBAb bioassay provides a useful tool for measuring the activity of anti-TSHR antibodies and may help clinicians to characterize the diverse clinical presentations of patients with AITD.
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Affiliation(s)
- Y Li
- Diagnostic Hybrids Inc.Athens, Ohio, USA
| | - J Kim
- Diagnostic Hybrids Inc.Athens, Ohio, USA
| | - T Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I, Gutenberg University Medical CenterMainz, Germany
| | - R Klasen
- Diagnostic Hybrids Inc.Athens, Ohio, USA
| | - P D Olivo
- Diagnostic Hybrids Inc.Athens, Ohio, USA
| | - G J Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Gutenberg University Medical CenterMainz, Germany
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Abstract
CONTEXT TSH receptor antibodies (TRAb) cause Graves' disease (GD) hyperthyroidism. Widely available TRAb measurement methods have been significantly improved recently. However, the role of TRAb measurement in the differential diagnosis of hyperthyroidism, the prediction of remission of GD hyperthyroidism, the prediction of fetal/neonatal thyrotoxicosis, and the clinical assessment of Graves' ophthalmopathy (GO) are controversial. EVIDENCE ACQUISITION We reviewed and analyzed the literature reporting primary data on the clinical use of TRAb. We focused our analyses on clinical studies analyzing third-generation TRAb assays. EVIDENCE SYNTHESIS The performance of TRAb in the differential diagnosis of overt hyperthyroidism is excellent, with sensitivity and specificity in the upper 90%. TRAb can accurately predict short-term relapses of hyperthyroidism after a course of antithyroid drugs but are less effective in predicting long-term relapses or remissions. Pregnancies in women with GD with negative TRAb are highly unlikely to result in fetal hyperthyroidism, whereas high titers of TRAb in pregnancy require careful fetal monitoring. GD patients with GO frequently have high TRAb levels. However, there are insufficient data to use the test to predict the clinical course of GO and response to treatment. CONCLUSIONS Third-generation TRAb assays are suitable in the differential diagnosis of hyperthyroidism. In GD, TRAb should be tested before deciding whether methimazole can be stopped. TRAb should be used in pregnant women with GD to assess the risk of fetal thyrotoxicosis. The use of TRAb in GO requires further studies.
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Affiliation(s)
- Giuseppe Barbesino
- Thyroid Unit, Division of Endocrinology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
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Leschik JJ, Diana T, Olivo PD, König J, Krahn U, Li Y, Kanitz M, Kahaly GJ. Analytical performance and clinical utility of a bioassay for thyroid-stimulating immunoglobulins. Am J Clin Pathol 2013; 139:192-200. [PMID: 23355204 DOI: 10.1309/ajcpzut7cnueu7op] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
The analytical performance and the clinical utility of a thyrotropin receptor (TSHR)-stimulating immunoglobulin (TSI) bioassay were compared with those of a TSHR-binding inhibitory immunoglobulin (TBII) assay. Limits of detection (LoD) and quantitation (LoQ), assay cutoff, and the half-maximal effective concentration (EC(50)) were measured. Dilution analysis was performed in sera of hyperthyroid patients with Graves disease (GD) during antithyroid treatment (ATD). Titer was defined as the first dilution step at which measurement of TSI or TBII fell below the assay cutoff. The LoD, LoQ, cutoff, and EC(50) of the bioassay were 251-, 298-, 814-, and 827-fold lower than for the TBII assay. There were 22%, 42%, 23%, and 14% more positive samples in the TSI bioassay at dilutions of 1:3, 1:9, 1:27, and 1:81 (P < .0001), respectively. Responders to ATD demonstrated marked differences in titers compared with nonresponders. The bioassay detected lower levels of TSHR autoantibodies, and the dilution analysis provided similar predictive values of both assays in GD.
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Affiliation(s)
- Johannes J. Leschik
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Tanja Diana
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | | | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), Division Medical Biometry, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Ulrike Krahn
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), Division Medical Biometry, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - Yunsheng Li
- Diagnostic Hybrids, a Quidel Company, Athens, OH
| | - Michael Kanitz
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
| | - George J. Kahaly
- Molecular Thyroid Research Laboratory, Department of Medicine I, Johannes Gutenberg University Medical Center, Mainz, Germany
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Holthoff HP, Zeibig S, Jahns-Boivin V, Bauer J, Lohse MJ, Kääb S, Clauss S, Jahns R, Schlipp A, Münch G, Ungerer M. Detection of anti-β1-AR autoantibodies in heart failure by a cell-based competition ELISA. Circ Res 2012; 111:675-84. [PMID: 22811559 DOI: 10.1161/circresaha.112.272682] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
RATIONALE Autoantibodies directed against the second extracellular loop of the cardiac β1-adrenergic receptor (β1-AR) are thought to contribute to the pathogenesis of dilated cardiomyopathy (DCM) and Chagas heart disease. Various approaches have been used to detect such autoantibodies; however, the reported prevalence varies largely, depending on the detection method used. OBJECTIVE We analyzed sera from 167 DCM patients (ejection fraction<45%) and from 110 age-matched volunteers who did not report any heart disease themselves, with an often used simple peptide-ELISA approach, and compared it with a novel whole cell-based ELISA, using cells expressing the full transgene for the human β1-AR. Additionally, 35 patients with hypertensive heart disease with preserved ejection fraction were investigated. METHODS AND RESULTS The novel assay was designed according to the currently most reliable anti-TSH receptor antibody-ELISA used to diagnose Graves disease ("third-generation assay") and also detects the target antibodies by competition with a specific monoclonal anti-β1-AR antibody (β1-AR MAb) directed against the functionally relevant β1-AR epitope. Anti-β1-AR antibodies were detected in ≈60% of DCM patients and in ≈8% of healthy volunteers using the same cutoff values. The prevalence of these antibodies was 17% in patients with hypertensive heart disease. Anti-β1-AR antibody titers (defined as inhibition of β1-AR MAb-binding) were no longer detected after depleting sera from IgG antibodies by protein G adsorption. In contrast, a previously used ELISA conducted with a linear 26-meric peptide derived from the second extracellular β1-AR loop yielded a high number of false-positive results precluding any specific identification of DCM patients. CONCLUSIONS We established a simple and efficient screening assay detecting disease-relevant β1-AR autoantibodies in patient sera yielding a high reproducibility also in high throughput screening. The assay was validated according to "good laboratory practice" and can serve as a companion biodiagnostic assay for the development and evaluation of antibody-directed therapies in antibody-positive heart failure.
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