1
|
Essouabni A, Melki FZ, Essafi MA, Aynaou H, Salhi H. A Rare and Unusual Evolution of Hypothyroidism in Hashimoto's Thyroiditis to Graves' Disease: A Case Report and Literature Review. Cureus 2024; 16:e59059. [PMID: 38800272 PMCID: PMC11128183 DOI: 10.7759/cureus.59059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/25/2024] [Indexed: 05/29/2024] Open
Abstract
Our article examines a rare case where hypothyroidism due to Hashimoto's thyroiditis progressed, after a long period (three years) of L-thyroxine substitution, into confirmed hyperthyroidism due to Graves' disease in a 69-year-old man. The article explores possible mechanisms of this unusual transition based on our case and others reported in the literature. Findings suggest that the coexistence of Hashimoto's thyroiditis and Graves' disease can lead to transitions between hypothyroidism and hyperthyroidism, influenced by the predominance of involved antibodies and residual capacity of thyroid tissue. The authors emphasize the importance of further studies to better understand these transitions and identify at-risk patients. In conclusion, the article highlights the necessity of considering the rare possibility of transition to Graves' disease in patients presenting with persistent hyperthyroidism despite cessation of L-thyroxine.
Collapse
Affiliation(s)
- Amal Essouabni
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fez, MAR
| | - Fatima Zahrae Melki
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fez, MAR
| | - Mohammed Amine Essafi
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fez, MAR
| | - Hayat Aynaou
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fez, MAR
| | - Houda Salhi
- Department of Endocrinology, Diabetology, Metabolic Diseases and Nutrition, Hassan II University Hospital, Fez, MAR
| |
Collapse
|
2
|
Stancu AM, Alexandrescu D, Badiu C. Effects of block-replace regimen in patients with autoimmune hypothyroidism converted to Graves' disease. Hormones (Athens) 2024; 23:107-111. [PMID: 37831339 DOI: 10.1007/s42000-023-00496-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/04/2023] [Indexed: 10/14/2023]
Abstract
PURPOSE We present two cases of autoimmune hypothyroidism converted to Graves' disease (GD) and their medical management. METHODS We tested thyroid function and thyroid antibodies and performed an ophthalmologic examination and neck ultrasound in two patients with autoimmune hypothyroidism converted to GD during a follow-up of several years. CASE REPORTS The first case is a 33 year-old woman with hypothyroidism due to Hashimoto's thyroiditis (HT). She developed signs and symptoms of hyperthyroidism after 7 years of treatment with the same dose of levothyroxine (LT4). Even when LT4 therapy was discontinued, she remained thyrotoxic, with mild Graves' ophthalmopathy (GO) and very high thyroid-stimulating hormone receptor antibodies (TRAb > 40 IU/L, reference range: <1.75 IU/L). Antithyroid medication was started on a titration regimen, without achievement of euthyroidism. She was switched to a block and replace regimen, using 20 mg of methimazole (MMI) and 75 mcg of LT4 daily, with normalization of thyroid hormones and improvement of GO without steroids. The second case is a 57 year-old man with a 2-year positive medical history of HT and 6 months of LT4 treatment. He developed hyperthyroidism and moderate-severe GO. Despite stopping LT4 and initiating antithyroid medication in a titration regimen, he did not achieve euthyroidism and had active GO. Pulse glucocorticoid therapy and switching to a block-replace regimen was required to achieve euthyroidism and reduce ocular proptosis and diplopia. CONCLUSION Spontaneous autoimmune conversion of hypothyroidism to hyperthyroidism can occur at any time: it is important to promptly identify these cases so as to manage them effectively.
Collapse
Affiliation(s)
- Ana-Maria Stancu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
- "C.I.Parhon" National Institute of Endocrinology, Bd. Aviatorilor, no. 34-36, sector 1, 011863, Bucharest, Romania.
| | - Daniela Alexandrescu
- "C.I.Parhon" National Institute of Endocrinology, Bd. Aviatorilor, no. 34-36, sector 1, 011863, Bucharest, Romania
| | - Corin Badiu
- "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
- "C.I.Parhon" National Institute of Endocrinology, Bd. Aviatorilor, no. 34-36, sector 1, 011863, Bucharest, Romania
| |
Collapse
|
3
|
Alnahdi H. The Thyroid Swing: A Patient's Journey From Hypothyroidism to Hyperthyroidism. Cureus 2024; 16:e52598. [PMID: 38374853 PMCID: PMC10875210 DOI: 10.7759/cureus.52598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2024] [Indexed: 02/21/2024] Open
Abstract
The flip from hyperthyroidism (HT), as observed in Graves' disease (GD) cases, to hypothyroidism associated with Hashimoto's disease (HD) has been widely recognized and documented. However, the converse is infrequently observed. The observed phenomenon is likely attributed to the major role played by thyroid-stimulating hormone receptor antibodies (TRAbs) in this alternating disease pattern and a substantial reduction in thyroid tissue mass that could be stimulated by these antibodies. Therefore, here we present a case of one middle-aged individual experiencing this transitional switch from hypothyroidism to GD. A 42-year-old male patient diagnosed with HD-related hypothyroidism for two years has remained stable with levothyroxine medication since diagnosis. However, his symptoms of thyrotoxicosis, such as anxiety, weight loss, and palpitations, had appeared during his follow-up time at the clinic. Physical examination revealed mild exophthalmos, which confirmed HT by thyroid function test results. The possibility of levothyroxine-induced HT was initially considered, although the observed symptoms failed to ameliorate despite the reduction and discontinuation of levothyroxine. The diagnosis of GD was confirmed after subsequent examination, and a follow-up was carried out. This particular case study underscores a distinctive correlation that carries substantial implications for the diagnosis and treatment of GD. The consideration of this shift is warranted in cases where HT continues to exist despite the reduction or cessation of levothyroxine treatment. The diagnosis is established through antibody titers and a radioiodine uptake scan. Treatment choice is based on the illness's stage and the patient's and care provider's preferences. In the initial phase, anti-thyroid medications may be employed. It is imperative to conduct regular follow-ups on these patients due to the potential transient nature of this clinical condition.
Collapse
Affiliation(s)
- Haifa Alnahdi
- Department of Internal Medicine, Endocrinology and Metabolism, Faculty of Medicine, King Abdulaziz University, Jeddah, SAU
| |
Collapse
|
4
|
Liu Y, Liu X, Wu N. A Review of Testing for Distinguishing Hashimoto's Thyroiditis in the Hyperthyroid Stage and Grave's Disease. Int J Gen Med 2023; 16:2355-2363. [PMID: 37313042 PMCID: PMC10259585 DOI: 10.2147/ijgm.s410640] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Accepted: 06/01/2023] [Indexed: 06/15/2023] Open
Abstract
Hashimoto's thyroiditis (HT) and Graves' disease (GD) are two very common autoimmune thyroid diseases (AITD). In this review, we use "HT in the hyperthyroidism stage" to refer to early HT with clinical manifestations of hyperthyroidism. In clinical practice, it is not easy to distinguish between HT in the hyperthyroidism stage and GD as they exhibit very similar clinical symptoms. The current literature lacks so far studies that systematically compare and summarize hyperthyroidism due to HT and GD from varied aspects. It is necessary to focus on all the clinical indices of HT in the hyperthyroidism stage and GD, for accurate diagnosis. Multiple databases such as PubMed, CNKI, WF Data, and CQVIP Data were used to search the literature concerning HT in the hyperthyroidism stage and GD. The information extracted from the relevant literature was summarized and further analyzed. To differentially diagnose hyperthyroidism as HT or GD, it is recommended to first focus on serological tests, followed by imaging tests, as well as the thyroid I131 uptake index. In pathology, fine needle aspiration cytology (FNAC) is the gold standard for the differential diagnosis of HT and GD. Test results from cellular immunology and genetics could also be used to accurately diagnose between the two diseases, which may be further developed and studied in the future. In this paper, we reviewed and summarized the difference between HT in the hyperthyroidism stage and GD from the following six aspects: blood tests, imaging, thyroid I131 uptake, pathology, cellular immunology, and genetics.
Collapse
Affiliation(s)
- Yutong Liu
- Student Affairs Department, Shengjing Hospital of China Medical University, Shenyang, 110004, People’s Republic of China
| | - Xiuyan Liu
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang, 110004, People’s Republic of China
| | - Na Wu
- Department of Endocrinology, Shengjing Hospital of China Medical University, Shenyang, 110004, People’s Republic of China
- Medical Department, Shengjing Hospital of China Medical University, Shenyang, 110004, People’s Republic of China
| |
Collapse
|
5
|
Chen M, Ge S, Driscoll M. Pretibial myxedema in a patient with HIV and hypothyroid to hyperthyroid transformation. JAAD Case Rep 2023; 36:75-77. [PMID: 37255864 PMCID: PMC10225818 DOI: 10.1016/j.jdcr.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Affiliation(s)
| | - Shealinna Ge
- Correspondence to: Shealinna Ge, MD, University of Maryland School of Medicine, Department of Dermatology, 419 W Redwood Street, Suite 235, Baltimore, MD 21201.
| | | |
Collapse
|
6
|
Daramjav N, Takagi J, Iwayama H, Uchino K, Inukai D, Otake K, Ogawa T, Takami A. Autoimmune Thyroiditis Shifting from Hashimoto's Thyroiditis to Graves' Disease. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59040757. [PMID: 37109715 PMCID: PMC10141468 DOI: 10.3390/medicina59040757] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/04/2023] [Accepted: 04/11/2023] [Indexed: 04/29/2023]
Abstract
In 15-20% of cases, Graves' disease (GD) shifts to Hashimoto's thyroiditis (HT), while the shift from HT to GD is rare. We present a case of a patient in whom HT shifted to GD, along with a literature review. A 50-year-old woman with myxedema was diagnosed with Hashimoto's disease due to hypothyroidism and the presence of antibodies against thyroid peroxidase (TPOAb) and thyroglobulin (TgAb); she also had thyroid stimulating antibodies (TSAb) without any signs of GD. Although thyroid hormone replacement therapy improved her thyroid function, 2 months later, hyperthyroidism appeared and did not improve after discontinuation of the replacement therapy. The patient was diagnosed with GD, which improved with antithyroid agent administration. To date, only 50 cases regarding conversion from HT to GD have been reported. The median age is 44 years (range, 23-82 years), and the median time of conversion is 7 years (range, 0.1-27 years). The male-to-female ratio of HT conversion to GD is 1:9, closer to that of regular GD (1:10) than that of general HT (1:18). All patients received thyroid hormone replacement therapy for hypothyroidism due to HT. Continuous evaluation of TSAb levels is recommended in HT, particularly in cases of TSAb-positive and those under replacement, since it may help predict conversion to GD. Evaluating the clinical characteristics of patients with HT preceding GD is crucial to ensure appropriate treatment and reduce the risk of adverse events.
Collapse
Affiliation(s)
- Narantsatsral Daramjav
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Aichi Medical University School of Medicine, Nagakute 480-1195, Aichi, Japan
| | - Junko Takagi
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Aichi Medical University School of Medicine, Nagakute 480-1195, Aichi, Japan
| | - Hideyuki Iwayama
- Department of Pediatrics, Aichi Medical University School of Medicine, Nagakute 480-1195, Aichi, Japan
| | - Kaori Uchino
- Department of Internal Medicine, Division of Hematology, Aichi Medical University School of Medicine, Nagakute 480-1195, Aichi, Japan
| | - Daisuke Inukai
- Department of Otorhinolaryngology Head and Neck Surgery, Aichi Medical University School of Medicine, Nagakute 480-1195, Aichi, Japan
| | - Kazuo Otake
- Department of Internal Medicine, Division of Endocrinology and Metabolism, Aichi Medical University School of Medicine, Nagakute 480-1195, Aichi, Japan
| | - Tetsuya Ogawa
- Department of Otorhinolaryngology Head and Neck Surgery, Aichi Medical University School of Medicine, Nagakute 480-1195, Aichi, Japan
| | - Akiyoshi Takami
- Department of Internal Medicine, Division of Hematology, Aichi Medical University School of Medicine, Nagakute 480-1195, Aichi, Japan
| |
Collapse
|
7
|
Nozue T, Tada H, Murakami M, Michishita I. A case of hyperchylomicronemia associated with GPIHBP1 autoantibodies and fluctuating thyroid autoimmune disease. J Clin Lipidol 2023; 17:68-72. [PMID: 36402671 DOI: 10.1016/j.jacl.2022.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/24/2022] [Accepted: 10/24/2022] [Indexed: 11/06/2022]
Abstract
Recent studies have reported that patients with autoimmune hyperchylomicronemia caused by glycosylphosphatidylinositol-anchored high-density lipoprotein binding protein 1 (GPIHBP1) autoantibodies are associated with rheumatoid arthritis, systemic lupus erythematosus, Sjogren's syndrome, Hashimoto's thyroiditis, Basedow's disease, and immune thrombocytopenia. We report a rare case of hyperchylomicronemia due to GPIHBP1 autoantibodies and fluctuating thyroid autoimmune disease. A 28-year-old woman, diagnosed with Hashimoto's thyroiditis at 26 years of age, started taking 50 µg/day of levothyroxine sodium. She had an episode of acute pancreatitis at 27 years of age; her serum triglyceride (TG) level was 1291 mg/dL at that time. The patient was referred to our hospital because her hyperchylomicronemia (hypertriglyceridemia) did not improve on treatment with pemafibrate and eicosapentaenoic acid (EPA). Serum total cholesterol and TG levels were 237 mg/dL and 2535 mg/dL, respectively, while plasma pre-heparin lipoprotein lipase (LPL) mass was 15 ng/mL (26.5-105.5 ng/mL). We diagnosed her as Basedow's disease based on autoimmune antibodies and ultrasound examination. Targeted exome sequencing revealed no pathogenic variants in the LPL or GPIHBP1 genes. The serum GPIHBP1 autoantibody level was 686.0 U/mL (<58.4 U/mL) and GPIHBP1 mass was 301.9 pg/mL (570.6-1625.6 pg/mL). The patient showed hyperchylomicronemia during periods of hypothyroidism and hyperthyroidism, whereas GPIHBP1 autoantibodies were positive during episode of hyperchylomicronemia but negative during periods of normal TG levels. Based on these findings, the patient was diagnosed with hyperchylomicronemia due to GPIHBP1 autoantibodies and treated with rituximab. GPIHBP1 autoantibodies remained undetectable and TG levels were controlled at approximately 200 mg/dL.
Collapse
Affiliation(s)
- Tsuyoshi Nozue
- Division of Cardiology, Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, Yokohama, Japan.
| | - Hayato Tada
- Department of Cardiovascular Medicine, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Japan
| | - Masami Murakami
- Department of Clinical Laboratory Medicine, Gunma University, Graduate School of Medicine, Maebashi, Japan
| | - Ichiro Michishita
- Division of Cardiology, Department of Internal Medicine, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| |
Collapse
|
8
|
Giannone M, Dalla Costa M, Sabbadin C, Garelli S, Salvà M, Masiero S, Plebani M, Faggian D, Gallo N, Presotto F, Bertazza L, Nacamulli D, Censi S, Mian C, Betterle C. TSH-receptor autoantibodies in patients with chronic thyroiditis and hypothyroidism. Clin Chem Lab Med 2022; 60:1020-1030. [PMID: 35511904 DOI: 10.1515/cclm-2022-0162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 04/15/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The reported prevalence of TSH-receptor (TSHR) autoantibodies (TRAb) in patients with chronic thyroiditis (CT) range from 0 to 48%. The objective was to study the prevalence of TRAb in patients with CT and hypothyroidism and to correlate it with gender, age, thyroid dimensions, TSH levels, and autoimmune diseases. METHODS The study comprised 245 patients with CT and hypothyroidism (median age 42 years, 193 females, 52 males) and 123 Italian healthy subjects matched for sex and age as controls. TRAb were tested with ELISA using a >2.5 IU/L cut off for positivity. TSHR blocking (TBAb) and TSHR stimulating autoantibodies (TSAb) were measured in 12 TRAb-positive patients using bioassays with Chinese hamster ovary (CHO) cells expressing wild-type or R255D-mutated TSHR. RESULTS TRAb positivity was found in 32/245 (13.1%) patients and significantly correlated (p<0.05) with TSH levels. TRAb positivity was significantly higher in males vs. females (p=0.034), in females 16-45 years of age vs. >45 years of age (p<0.05) and in patients with reduced vs. normal/increased thyroid dimensions (p<0.05). Linear regression analysis showed a correlation between TRAb concentrations with age (p<0.05) and TRAb concentrations with TSH (p<0.01). In bioassay with TSHR-R255D all 12 patients tested were TBAb-positive while 33% were also TSAb-positive suggesting the presence of a mixture of TRAbs with different biological activities in some patients. CONCLUSIONS TRAb have been found in patients with CT and hypothyroidism. A mixture of TBAb and TSAb was found in some patients and this may contribute to the pathogenesis of thyroid dysfunction during the course of the disease.
Collapse
Affiliation(s)
- Mariella Giannone
- Gynecological Clinic, Dipartimento di Salute della Donna e del Bambino, Università Padova, Padova, Italy.,Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| | - Miriam Dalla Costa
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| | - Chiara Sabbadin
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| | - Silvia Garelli
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy.,Department of Medicine, Ospedale dell'Angelo, Mestre-Venezia, Italy
| | - Monica Salvà
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| | - Stefano Masiero
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| | - Mario Plebani
- Unit of Laboratory Medicine, Department of Medicine, Università di Padova, Padova, Italy
| | - Diego Faggian
- Unit of Laboratory Medicine, Department of Medicine, Università di Padova, Padova, Italy
| | - Nicoletta Gallo
- Unit of Laboratory Medicine, Department of Medicine, Università di Padova, Padova, Italy
| | - Fabio Presotto
- Department of Medicine, Ospedale dell'Angelo, Mestre-Venezia, Italy
| | - Loris Bertazza
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| | - Davide Nacamulli
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| | - Simona Censi
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| | - Caterina Mian
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| | - Corrado Betterle
- Endocrine Unit, Department of Medicine, Università di Padova, Padova, Italy
| |
Collapse
|
9
|
Jadhav R, Alberawi M, Gupta K. Graves' disease: A rare fate of Hashimoto's thyroiditis. World J Nucl Med 2021; 20:102-104. [PMID: 33850498 PMCID: PMC8034799 DOI: 10.4103/wjnm.wjnm_34_20] [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] [Received: 03/24/2020] [Revised: 07/07/2020] [Accepted: 05/26/2020] [Indexed: 12/02/2022] Open
Abstract
Hashimoto's thyroiditis is a known autoimmune disorder that leads to chronic inflammation of the thyroid gland, with a gradual decline in function and eventual hypothyroidism. Conversion of Hashimoto's thyroiditis to Graves' disease is unusual clinically and has been occasionally reported in the literature. Awareness of such a rare phenomenon is important for the physicians evaluating patients with autoimmune thyroid disorders. Close investigation of the patient's symptoms and biochemical status is crucial in the implementation of appropriate treatment.
Collapse
Affiliation(s)
- Rahul Jadhav
- Rush University Medical Center, Chicago, IL, USA
| | - Mohammad Alberawi
- Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, IL, USA
| | - Khushboo Gupta
- Department of Diagnostic Radiology and Nuclear Medicine, Rush University Medical Center, Chicago, IL, USA
| |
Collapse
|
10
|
Ambachew R, Yosef T, Gebremariam AM, Demere L, Aberra T, Tarekegn G, Reja A. Pretibial myxedema in a euthyroid patient: a case report. Thyroid Res 2021; 14:4. [PMID: 33648506 PMCID: PMC7919313 DOI: 10.1186/s13044-021-00096-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 02/14/2021] [Indexed: 11/26/2022] Open
Abstract
Background Pretibial myxedema also known as localized myxedema, thyroid dermopathy, or infiltrative dermopathy and rarely as localized mucinosis is an infrequent manifestation of Graves’ disease. It can appear before, during, or after the thyrotoxic state. Euthyroid pretibial myxedema is a rare presentation with few case reports in the literature. This case highlights the importance of considering pretibial myxedema when characteristic skin lesions are observed in a euthyroid patient. Case presentation A 72-year old male Ethiopian patient with a very rare presentation of biopsy-proven pretibial myxedema in a euthyroid state without history of thyroid disease and absence of thyroid autoimmune markers. Resolution of skin lesion was achieved after topical corticosteroid application. Conclusion Absence of history of thyroid disorder and normal thyroid function tests should not exclude the diagnosis of pretibial myxedema.
Collapse
Affiliation(s)
- Rediet Ambachew
- Department of Endocrinology, Addis Ababa University, College of health sciences, Addis Ababa, Ethiopia.
| | - Tizita Yosef
- Department of Dermatology and Venereology, Addis Ababa University, College of health sciences, Addis Ababa, Ethiopia
| | - Aklilu M Gebremariam
- Department of Dermatology and Venereology, Addis Ababa University, College of health sciences, Addis Ababa, Ethiopia.,Department of Pathology, Armauer Hansen Research Institute, Addis Ababa, Ethiopia
| | - Lishan Demere
- Department of Dermatology and Venereology, Addis Ababa University, College of health sciences, Addis Ababa, Ethiopia
| | - Theodros Aberra
- Department of Endocrinology, Addis Ababa University, College of health sciences, Addis Ababa, Ethiopia
| | - Getahun Tarekegn
- Department of Endocrinology, Addis Ababa University, College of health sciences, Addis Ababa, Ethiopia
| | - Ahmed Reja
- Department of Endocrinology, Addis Ababa University, College of health sciences, Addis Ababa, Ethiopia
| |
Collapse
|
11
|
Napolitano G, Bucci I, Di Dalmazi G, Giuliani C. Non-Conventional Clinical Uses of TSH Receptor Antibodies: The Case of Chronic Autoimmune Thyroiditis. Front Endocrinol (Lausanne) 2021; 12:769084. [PMID: 34803929 PMCID: PMC8602826 DOI: 10.3389/fendo.2021.769084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 10/11/2021] [Indexed: 01/21/2023] Open
Abstract
Anti TSH receptor antibodies (TSHrAb) are a family of antibodies with different activity, some of them stimulating thyroid function (TSAb), others with blocking properties (TBAb), it is a common finding that antibodies with different function might coexist in the same patient and can modulate the function of the thyroid. However, most of the labs routinely detect all antibodies binding to the TSH receptor (TRAb, i.e. TSH-receptor antibodies detected by binding assay without definition of functional property). Classical use of TSHr-Ab assay is in Graves' disease where they are tested for diagnostic and prognostic issues; however, they can be used in specific settings of chronic autoimmune thyroiditis (CAT) as well. Aim of the present paper is to highlight these conditions where detection of TSHr-Ab can be of clinical relevance. Prevalence of TSHrAb is different in in the 2 main form of CAT, i.e. classical Hashimoto's thyroiditis and in atrophic thyroiditis, where TBAb play a major role. Simultaneous presence of both TSAb and TBAb in the serum of the same patient might have clinical implication and cause the shift from hyperthyroidism to hypothyroidism and vice versa. Evaluation of TRAb is recommended in case of patients with Thyroid Associated Orbitopathy not associated with hyperthyroidism. At present, however, the most relevant recommendation for the use of TRAb assay is in patients with CAT secondary to a known agent; in particular, after treatment with alemtuzumab for multiple sclerosis. In conclusion, the routine use of anti-TSH receptor antibodies (either TRAb or TSAb/TBAb) assay cannot be suggested at the present for diagnosis/follow up of patients affected by CAT; there are, however, several conditions where their detection can be clinically relevant.
Collapse
Affiliation(s)
- Giorgio Napolitano
- Department of Medicine and Sciences of Aging, Unit of Endocrinology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti‐Pescara, Chieti, Italy
- *Correspondence: Giorgio Napolitano,
| | - Ines Bucci
- Department of Medicine and Sciences of Aging, Unit of Endocrinology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti‐Pescara, Chieti, Italy
| | - Giulia Di Dalmazi
- Department of Medicine and Sciences of Aging, Unit of Endocrinology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti‐Pescara, Chieti, Italy
| | - Cesidio Giuliani
- Department of Medicine and Sciences of Aging, Unit of Endocrinology, University “G. d’Annunzio” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti‐Pescara, Chieti, Italy
| |
Collapse
|
12
|
Sukik A, Mohamed S, Habib MB, Sardar S, Tanous B, Tahtouh R, Mohamed MFH. The Unusual Late-Onset Graves' Disease following Hashimoto's Related Hypothyroidism: A Case Report and Literature Review. Case Rep Endocrinol 2020; 2020:5647273. [PMID: 33489388 PMCID: PMC7787859 DOI: 10.1155/2020/5647273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 11/09/2020] [Accepted: 11/23/2020] [Indexed: 11/26/2022] Open
Abstract
Background. The shift of Graves' disease (GD) to Hashimoto's disease- (HD-) related hypothyroidism is well established. However, the opposite is rare. This is likely to the loss of critical thyroid mass available for stimulation by thyroid hormone receptor stimulating antibody, making this shift unusual. Herein, we report a young lady with a late shift from HD into GD and present a scoping literature review. Case presentation. We report a twenty-five-year-old lady with a sixteen-year-history of Hashimoto's-related hypothyroidism stable on levothyroxine. While following in the clinic, she started developing thyrotoxic symptoms in the form of anxiety, weight loss, and palpitation. Physical examination was remarkable for mild exophthalmos. The thyroid function test confirmed hyperthyroidism. Levothyroxine-induced hyperthyroidism was initially suspected; however, the symptoms did not improve despite reducing and stopping levothyroxine. Subsequent workup confirmed the diagnosis of GD. Discussion and Conclusion. This case highlights a unique association that has significant diagnostic and management implications. This shift should be considered when hyperthyroidism persists despite reducing or stopping levothyroxine. The diagnosis is made utilizing antibody titers and radioiodine update scan. While the management depends on the disease's stage and the treating physician preference, antithyroid agents can be used initially. Following up these patients is essential as the shift can be transient.
Collapse
Affiliation(s)
- Aseel Sukik
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Sara Mohamed
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Mhd-Baraa Habib
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Sundus Sardar
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Bashar Tanous
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | - Raad Tahtouh
- Internal Medicine Department, Hamad Medical Corporation, Doha, Qatar
| | | |
Collapse
|
13
|
Horiya M, Anno T, Kawasaki F, Iwamoto Y, Irie S, Monobe Y, Tomoda K, Kaku K, Nakanishi S, Kaneto H. Basedow's disease with associated features of Hashimoto's thyroiditis based on histopathological findings. BMC Endocr Disord 2020; 20:120. [PMID: 32758269 PMCID: PMC7405338 DOI: 10.1186/s12902-020-00602-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/30/2020] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Basedow's disease and Hashimoto's thyroiditis are autoimmune thyroid disorders and usually diagnosed with elevation of serum autoimmune antibodies. Thyrotropin receptor antibodies (TRAb) and/or thyroid-stimulating antibody (TSAb) are usually used for diagnosis of Basedow's disease, and thyroid peroxidase antibodies (TPOAb) and/or thyroglobulin antibodies (TgAb) are for diagnosis of Hashimoto's thyroiditis. However, it is difficult to diagnose a subject as Basedow's disease with associated features of Hashimoto's thyroiditis only with elevation of such autoimmune antibodies. CASE PRESENTATION A 44-year-old woman with 5-year history of Basedow's disease underwent a total thyroidectomy. She did not have a goiter. TRAb, TSAb, TPOAg and TgAb were all positive before a total thyroidectomy. In histopathological macroscopic examination, diffuse hyperplasia of the thyroid gland was observed. Furthermore, in histopathological microscopic examination, both characteristics of Basedow's disease and Hashimoto's thyroiditis were observed. After a total thyroidectomy, titers of all thyroid-associated autoimmune antibodies were markedly reduced. CONCLUSION Herein, we report a subject with Basedow's disease without a goiter whose TPOAb and TgAb were relatively high at the onset of Basedow's disease. In addition, interestingly, the histopathological findings of this subject showed direct signs of Basedow's disease and Hashimoto's thyroiditis in the same thyroid gland. Considering from such findings, she seemed to have Basedow's disease with associated features of Hashimoto's thyroiditis. In conclusion, we should bear in mind the possibility of Basedow's disease with associated features of Hashimoto's thyroiditis in subjects with Basedow's disease, particularly when TPOAb and TgAb as well as TRAb and TSAb are positive.
Collapse
Affiliation(s)
- Megumi Horiya
- Department of General Internal Medicine 1, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama, 700-8505, Japan
| | - Takatoshi Anno
- Department of General Internal Medicine 1, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama, 700-8505, Japan.
| | - Fumiko Kawasaki
- Department of General Internal Medicine 1, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama, 700-8505, Japan
| | - Yuichiro Iwamoto
- Department of General Internal Medicine 1, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama, 700-8505, Japan
| | - Shintaro Irie
- Department of General Internal Medicine 1, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama, 700-8505, Japan
| | - Yasumasa Monobe
- Department of Pathology, Kawasaki Medical School, Okayama, 700-8505, Japan
| | - Koichi Tomoda
- Department of General Internal Medicine 1, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama, 700-8505, Japan
| | - Kohei Kaku
- Department of General Internal Medicine 1, Kawasaki Medical School, 2-6-1 Nakasange, Kita-ku, Okayama, 700-8505, Japan
| | - Shuhei Nakanishi
- Department of Diabetes, Metabolism and Endocrinology, Kawasaki Medical School, Kurashiki, 701-0192, Japan
| | - Hideaki Kaneto
- Department of Diabetes, Metabolism and Endocrinology, Kawasaki Medical School, Kurashiki, 701-0192, Japan
| |
Collapse
|
14
|
Rotondi M, Virili C, Pinto S, Coperchini F, Croce L, Brusca N, Centanni M, Chiovato L. The clinical phenotype of Graves' disease occurring as an isolated condition or in association with other autoimmune diseases. J Endocrinol Invest 2020; 43:157-162. [PMID: 31407208 DOI: 10.1007/s40618-019-01094-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 07/31/2019] [Indexed: 12/16/2022]
Abstract
PURPOSE Graves' disease (GD) can present as an isolated disease (iGD) or in association with other autoimmune diseases (aGD). The aim of this study, performed in two Endocrine referral centers settled in different geographical areas of Italy, was to compare the anthropometric, clinical, and biochemical phenotype of iGD patients with that of the aGD ones. METHODS Clinical history, physical examination data, serum levels of TSH, FT4, FT3, thyroglobulin (TgAb), thyroid-peroxidase (TPOAb) and TSH-receptor (TRAb) antibody, presence of Graves' orbitopathy (GO), and thyroid ultrasound examination at disease diagnosis were recorded. RESULTS 68 aGD and 136 iGD patients were consecutively recruited. At diagnosis, aGD and iGD patients did not differ for F/M ratio, age at presentation, thyroid function parameters, serum levels of TRAb, TgAb, TPOAb, presence of GO, and thyroid volume. The serum levels of TRAb were strongly correlated with the circulating concentrations of both FT3 (ρ = 0.667; p < 0.0001) and FT4 (ρ = 0.628; p < 0.001) in iGD patient, but not in the aGD ones (FT3: ρ = 0.231; p = 0.058; FT4: ρ = 0.096; p = 0.435). Compared with iGD patients, the aGD ones displayed a higher rate of transition from the previous hypothyroidism to hyperthyroidism (χ2 = 6.375; p = 0.012). CONCLUSION Despite similar anthropometric, clinical, and biochemical features at diagnosis, aGD patients display a higher rate of transition from a thyroid functional status to the other as compared with iGD patients.
Collapse
Affiliation(s)
- M Rotondi
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, Via S. Maugeri 4, 27100, Pavia, Italy
| | - C Virili
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - S Pinto
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, Via S. Maugeri 4, 27100, Pavia, Italy
| | - F Coperchini
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, Via S. Maugeri 4, 27100, Pavia, Italy
| | - L Croce
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, Via S. Maugeri 4, 27100, Pavia, Italy
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - N Brusca
- Department of Medical and Surgical Sciences and Biotechnology, Sapienza University of Rome, Rome, Italy
- Department of Experimental Medicine, "Sapienza" University of Rome, Rome, Italy
| | - M Centanni
- Endocrinology Unit, Department of Medico-Surgical Sciences and Biotechnologies, "Sapienza" University of Rome, Latina, Italy
| | - L Chiovato
- Unit of Internal Medicine and Endocrinology, Laboratory for Endocrine Disruptors, Istituti Clinici Scientifici Maugeri IRCCS, Via S. Maugeri 4, 27100, Pavia, Italy.
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy.
| |
Collapse
|
15
|
Ekpebegh C, Elmezughi K, Mtingi L. Graves' disease following hypothyroidism due to Hashimoto's thyroiditis in a black South African lady: a case report. Pan Afr Med J 2019; 32:186. [PMID: 31312298 PMCID: PMC6620106 DOI: 10.11604/pamj.2019.32.186.18713] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 04/10/2019] [Indexed: 11/11/2022] Open
Abstract
Graves' disease and Hashimoto's thyroiditis are autoimmune thyroid disorders with distinct pathological and histopathological features. The conversion from Hashimoto's thyroiditis to Graves' disease has been rarely reported throughout the world with no reports in the African race to our knowledge. We here report an African lady who was initially diagnosed with primary hypothyroidism following Hashimoto's disease but later became thyrotoxic due to Graves' disease.
Collapse
Affiliation(s)
- Chukwuma Ekpebegh
- Department of Internal Medicine, Walter Sisulu University, Mthatha, South Africa
| | - Khaled Elmezughi
- Department of Internal Medicine, Walter Sisulu University, Mthatha, South Africa
| | - Lungiswa Mtingi
- Department of Internal Medicine, Walter Sisulu University, Mthatha, South Africa
| |
Collapse
|
16
|
Gonzalez-Aguilera B, Betea D, Lutteri L, Cavalier E, Geenen V, Beckers A, Valdes-Socin H. Conversion to Graves disease from Hashimoto thyroiditis: a study of 24 patients. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2019; 62:609-614. [PMID: 30624501 PMCID: PMC10118676 DOI: 10.20945/2359-3997000000086] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 10/19/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE The conversion of Hashimoto's thyroiditis (HT) to hyperthyroidism due to thyrotropin receptor antibodies is intriguing and considered rare. The contribution of TSH receptor blocking antibodies (TRAb), which may be stimulators (TSAb) or blockers (TBAb), is suspected. We describe clinical and biological variables in a series of patients switching from Hashimoto's thyroiditis to Grave's disease. SUBJECTS AND METHODS Retrospective case study of 24 patients with Hashimoto's thyroiditis followed during 48 ± 36 months that developed later Graves' disease (GD). These variables were analysed in the hypo and hyperthyroid phase: age, sex, initial TSH, free triiodothyronine (fT3), free thyroxine (fT4), anti-TPO, TBII antibodies, parietal cell autoantibodies, time between hypo and hyperthyroidism, thyroid volume and levothyroxine doses (LT). RESULTS In HT, mean TSH was 9.4 ± 26.1 UI/L and levothyroxine treatment was 66.2 ± 30.8 µg/day. The switch to GD was observed 38 ± 45 months after HT diagnosis. As expected, we found significant differences on TSH, FT3, FT4 and TBAb levels. Three out of 14 patients had parietal cell autoantibodies. In two of these three cases there was an Helicobacter pylori infection. There were no significant differences between HT and GD groups with respect to thyroid volume. CONCLUSIONS To our knowledge, large series documenting the conversion of HT to GD are scarce. Although rare, this phenomenon should not be misdiagnosed. Suspicion should be raised whenever thyroxine posology must be tapered down during the follow-up of HT patients. Further immunological and genetic studies are needed to explain this unusual autoimmune change.
Collapse
Affiliation(s)
- Beatriz Gonzalez-Aguilera
- Department of Endocrinology, University Hospital Juan Ramón Jiménez (Huelva), Quirónsalud Hospital Group, Sevilla, Spain
| | | | | | | | | | | | | |
Collapse
|
17
|
Nalla P, Young S, Sanders J, Carter J, Adlan MA, Kabelis K, Chen S, Furmaniak J, Rees Smith B, Premawardhana LDKE. Thyrotrophin receptor antibody concentration and activity, several years after treatment for Graves' disease. Clin Endocrinol (Oxf) 2019; 90:369-374. [PMID: 30485487 DOI: 10.1111/cen.13908] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 11/17/2018] [Accepted: 11/25/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE TSH receptor antibodies (TRAb) are responsible for autoimmune hyperthyroid disease (Graves' disease; GD) with TRAb levels tending to decrease following treatment. Measurement of TRAb activity during follow-up could prove valuable to better understand treatment effectiveness. STUDY DESIGN TRAb concentration and stimulating (TSAb) and blocking (TSBAb) activity of patient serum were assessed following different treatment modalities and follow-up length. METHODS Sixty-six subjects were recruited following treatment with carbimazole (n = 26), radioiodine (n = 27) or surgery (n = 13). TRAb, TPOAb, TgAb and GADAb were measured at a follow-up visit as well as bioassays of TSAb and TSBAb activity. RESULTS Forty-five per cent of all patients remained TRAb-positive for more than one year and 23% for more than 5 years after diagnosis, irrespective of treatment method. Overall, TRAb concentration fell from a median (IQR) of 6.25 (3.9-12.7) to 0.65 (0.38-3.2) U/L. Surgery conferred the largest fall in TRAb concentration from 11.4 (6.7-29) to 0.58 (0.4-1.4) U/L. Seventy per cent of TRAb-positive patients were positive for TSAb, and one patient (3%) was positive for TSBAb. TRAb and TSAb correlated well (r = 0.83). In addition, 38/66 patients were TgAb-positive, 47/66 were TPOAb-positive and 6/66 were GADAb-positive at follow-up. CONCLUSIONS TRAb levels generally decreased after treatment but persisted for over 5 years in some patients. TRAb activity was predominantly stimulatory, with only one patient demonstrating TSBAb. A large proportion of patients were TgAb/TPOAb-positive at follow-up. All treatment modalities reduced TRAb concentrations; however, surgery was most effective.
Collapse
Affiliation(s)
- Preethi Nalla
- Section of Endocrinology and Biochemistry, Aneurin Bevan University Health Board, Caerphilly, UK
| | | | | | - Joanne Carter
- Section of Endocrinology and Biochemistry, Aneurin Bevan University Health Board, Caerphilly, UK
| | - Mohamed A Adlan
- Section of Endocrinology and Biochemistry, Aneurin Bevan University Health Board, Caerphilly, UK
| | | | - Shu Chen
- FIRS Laboratories, RSR Ltd., Cardiff, UK
| | | | | | | |
Collapse
|
18
|
McLachlan SM, Rapoport B. Thyroid Autoantibodies Display both "Original Antigenic Sin" and Epitope Spreading. Front Immunol 2017; 8:1845. [PMID: 29326719 PMCID: PMC5742354 DOI: 10.3389/fimmu.2017.01845] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/06/2017] [Indexed: 11/13/2022] Open
Abstract
Evidence for original antigenic sin in spontaneous thyroid autoimmunity is revealed by autoantibody interactions with immunodominant regions on thyroid autoantigens, thyroglobulin (Tg), thyroid peroxidase (TPO), and the thyrotropin receptor (TSHR) A-subunit. In contrast, antibodies induced by immunization of rabbits or mice recognize diverse epitopes. Recognition of immunodominant regions persists despite fluctuations in autoantibody levels following treatment or over time. The enhancement of spontaneously arising pathogenic TSHR antibodies in transgenic human thyrotropin receptor/NOD.H2h4 mice by injecting a non-pathogenic form of TSHR A-subunit protein also provides evidence for original antigenic sin. From other studies, antigen presentation by B cells, not dendritic cells, is likely responsible for original antigenic sin. Recognition of restricted epitopes on the large glycosylated thyroid autoantigens (60-kDa A-subunit, 100-kDa TPO, and 600-kDa Tg) facilitates exploring the amino acid locations in the immunodominant regions. Epitope spreading has also been revealed by autoantibodies in thyroid autoimmunity. In humans, and in mice that spontaneously develop autoimmunity to all three thyroid autoantigens, autoantibodies develop first to Tg and later to TPO and the TSHR A-subunit. The pattern of intermolecular epitope spreading is related in part to the thyroidal content of Tg, TPO and TSHR A-subunit and to the molecular sizes of these proteins. Importantly, the epitope spreading pattern provides a rationale for future antigen-specific manipulation to block the development of all thyroid autoantibodies by inducing tolerance to Tg, first in the autoantigen cascade. Because of its abundance, Tg may be the autoantigen of choice to explore antigen-specific treatment, preventing the development of pathogenic TSHR antibodies.
Collapse
Affiliation(s)
- Sandra M McLachlan
- Thyroid Autoimmune Disease Unit, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles, CA, United States
| | - Basil Rapoport
- Thyroid Autoimmune Disease Unit, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles, CA, United States
| |
Collapse
|
19
|
Ren Z, He M, Deng F, Chen Y, Chai L, Chen B, Deng W. Treatment of pretibial myxedema with intralesional immunomodulating therapy. Ther Clin Risk Manag 2017; 13:1189-1194. [PMID: 28932121 PMCID: PMC5598751 DOI: 10.2147/tcrm.s143711] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Objective Local immune regulation therapy has been one of the therapeutic methods used for the treatment of autoimmune thyroid disease in patients with pretibial myxedema (PTM). However, the poor response rate and high recurrence rate are still major problems. Whether a premixed corticosteroid, compound betamethasone, could enhance remission rate and decrease recurrence rate in patients with PTM was investigated in the present study. Subjects and methods We have performed a clinical utility observation of compound betamethasone with intralesional injections based on basic thyroid disease treatment in 32 PTM patients between January 2008 and August 2016. The patients were followed up for 2 years, and the clinical outcomes and side effects were calculated and analyzed. Results All patients had a complete remission after different times of injection. A total of 21.7% patients had complete remission with one time of injection, 34.8% with two times of injection, 17.4% with three times of injection, 4.3% with four times of injection, and 4.3% with five times of injection. In all, 56.3% patients with a disease duration of <6 months had complete remission after a 1-month treatment, 37.5% patients with a disease duration between 6 months and 12 months had complete remission after a 2-month treatment, 3.1% patients with a disease duration of 2 years had complete remission after a 5-month treatment, and 3.1% with a disease duration of 5 years had complete remission after a 7-month treatment. Conclusion Compound betamethasone with multipoint intralesional injection is a feasible, effective, and secure novel strategy in the treatment of PTM.
Collapse
Affiliation(s)
- Ziwei Ren
- Department of Endocrinology and Nephrology, Chongqing Emergency Medical Hospital (The Fourth People's Hospital of Chongqing)
| | - Min He
- Department of Endocrinology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China
| | - Fang Deng
- Department of Endocrinology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China
| | - Yan Chen
- Department of Endocrinology and Nephrology, Chongqing Emergency Medical Hospital (The Fourth People's Hospital of Chongqing)
| | - Liyin Chai
- Department of Endocrinology and Nephrology, Chongqing Emergency Medical Hospital (The Fourth People's Hospital of Chongqing)
| | - Bing Chen
- Department of Endocrinology, Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China
| | - Wuquan Deng
- Department of Endocrinology and Nephrology, Chongqing Emergency Medical Hospital (The Fourth People's Hospital of Chongqing)
| |
Collapse
|
20
|
Aversa T, Corrias A, Salerno M, Tessaris D, Di Mase R, Valenzise M, Corica D, De Luca F, Wasniewska M. Five-Year Prospective Evaluation of Thyroid Function Test Evolution in Children with Hashimoto's Thyroiditis Presenting with Either Euthyroidism or Subclinical Hypothyroidism. Thyroid 2016; 26:1450-1456. [PMID: 27541075 DOI: 10.1089/thy.2016.0080] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Whether the course of thyroid function in Hashimoto's thyroiditis (HT) differs in children who present with either euthyroidism or subclinical hypothyroidism (SH) has been incompletely investigated. AIM Using a five-year prospective evaluation of 234 children with HT and no prognostic risk factors, this study investigated whether the evolution of the thyroid status is influenced by the biochemical pattern at initial diagnosis. RESULTS In the entire series, thyrotropin values significantly increased during follow-up, while free thyroxine values decreased and the proportion of children with a thyroid dysfunction increased from 27.3% to 47.4% (p = 0.0001). An increasing proportion of cases with severe thyroid dysfunction was identified, especially among the 64 patients presenting with SH (group B), but also among the 170 children presenting with euthyroidism (group A) at initial diagnosis. At the end of follow-up, the prevalence of children with overt hypothyroidism was 12.3% in group A compared with 31.2% in group B (p = 0.0007). In the overall population, however, the majority of patients (52.6%) exhibited biochemical euthyroidism at the end of follow-up. CONCLUSIONS Children with HT may develop a deterioration of thyroid status during the first five years of disease. Such a trend may be observed, even in the patients who initially present with a mild biochemical picture (either SH or euthyroidism). A total of 57.1% of initially euthyroid children remain euthyroid, and 40.6% of patients with initial SH normalize thyroid function within five years after HT diagnosis. The patients presenting with SH are more prone to the risk of developing severe thyroid dysfunction over time.
Collapse
Affiliation(s)
- Tommaso Aversa
- 1 Department of Pediatrics, University of Messina , Messina, Italy
| | - Andrea Corrias
- 2 Department of Pediatrics, University of Turin , Regina Margherita Children's Hospital, Turin, Italy
| | | | - Daniele Tessaris
- 2 Department of Pediatrics, University of Turin , Regina Margherita Children's Hospital, Turin, Italy
| | - Raffaella Di Mase
- 3 Department of Pediatrics, University "Federico II ," Naples, Italy
| | | | - Domenico Corica
- 1 Department of Pediatrics, University of Messina , Messina, Italy
| | - Filippo De Luca
- 1 Department of Pediatrics, University of Messina , Messina, Italy
| | | |
Collapse
|
21
|
Wasniewska M, Aversa T, Salerno M, Corrias A, Messina MF, Mussa A, Capalbo D, De Luca F, Valenzise M. Five-year prospective evaluation of thyroid function in girls with subclinical mild hypothyroidism of different etiology. Eur J Endocrinol 2015; 173:801-8. [PMID: 26374873 DOI: 10.1530/eje-15-0484] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 09/15/2015] [Indexed: 11/08/2022]
Abstract
AIM To follow-up for 5 years thyroid status evolution in 127 girls with mild (TSH 5-10 mU/l) subclinical hypothyroidism (SH) of different etiologies. PATIENTS The population was divided into two age-matched groups of 42 and 85 girls with either idiopathic (group A) or Hashimoto's thyroiditis (HT)-related SH (group B). Group B was in turn divided into three subgroups, according to whether SH was either isolated or associated with Turner syndrome (TS) or Down syndrome (DS). RESULTS At the end of follow-up the rate of girls who became euthyroid was higher in group A (61.9% vs 10.6%), whereas the rates of patients who remained SH (55.3% vs 26.2%), became overtly hypothyroid (30.6% vs 11.9%) or required levothyroxine (l-T4) therapy (63.5% vs 23.8%) were higher in group B. Among the girls of group B, the risk of remaining SH or developing overt hypothyroidism was higher in the subgroups with TS or DS than in those with isolated HT. CONCLUSIONS Long-term prognosis of mild and idiopathic SH is frequently benign, even though a l-T4 treatment may be needed throughout follow-up in almost a quarter of cases; long-term prognosis is different in the girls with either idiopathic or HT-related SH; and the association with either TS or DS impairs the outcome of HT-related SH.
Collapse
Affiliation(s)
| | | | - Mariacarolina Salerno
- Department of PediatricGynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125 Messina, ItalyPediatric Endocrinology UnitDepartment of Translational Medical Sciences, University 'Federico II', Naples, ItalyDepartment of PediatricsUniversity of Turin, Turin, Italy
| | - Andrea Corrias
- Department of PediatricGynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125 Messina, ItalyPediatric Endocrinology UnitDepartment of Translational Medical Sciences, University 'Federico II', Naples, ItalyDepartment of PediatricsUniversity of Turin, Turin, Italy
| | | | - Alessandro Mussa
- Department of PediatricGynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125 Messina, ItalyPediatric Endocrinology UnitDepartment of Translational Medical Sciences, University 'Federico II', Naples, ItalyDepartment of PediatricsUniversity of Turin, Turin, Italy
| | - Donatella Capalbo
- Department of PediatricGynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125 Messina, ItalyPediatric Endocrinology UnitDepartment of Translational Medical Sciences, University 'Federico II', Naples, ItalyDepartment of PediatricsUniversity of Turin, Turin, Italy
| | | | | |
Collapse
|
22
|
Aversa T, Messina MF, Mazzanti L, Salerno M, Mussa A, Faienza MF, Scarano E, De Luca F, Wasniewska M. The association with Turner syndrome significantly affects the course of Hashimoto's thyroiditis in children, irrespective of karyotype. Endocrine 2015; 50:777-82. [PMID: 25542186 DOI: 10.1007/s12020-014-0513-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/15/2014] [Indexed: 10/24/2022]
Abstract
Only few studies have investigated to now whether the association with Turner syndrome (TS) may affect the course of Hashimoto's thyroiditis (HT) in children. Aim of this study was to ascertain whether the presentation and long-term course of HT in TS children may be characterized by a peculiar and atypical pattern. The clinical and biochemical findings at HT diagnosis in 90 TS children (group A) were compared with those recorded in 449 girls with HT but without TS (group B); in group A patients, thyroid function tests were re-evaluated after a median time interval of 4.9 years. At HT diagnosis median TSH levels and the rate of cases presenting with a thyroid dysfunction picture were significantly lower in group A, irrespective of karyotype abnormalities. In group A only 34.8 % of the girls who had initially presented with euthyroidism remained euthyroid even at re-evaluation, whilst 67.7 % of those who had presented with subclinical hypothyroidism became overtly hypothyroid over time; also such evolutive pattern was irrespective of karyotype abnormalities. (1) In TS girls, HT presents with a milder hormonal pattern, which often deteriorates over time; (2) these biochemical features are not necessarily linked with a specific karyotype.
Collapse
Affiliation(s)
- Tommaso Aversa
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy
| | - Maria Francesca Messina
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy
| | - Laura Mazzanti
- Department of Pediatrics, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Mariacarolina Salerno
- Pediatric Endocrinology Unit, Department of Translational Medical Sciences, University "Federico II" of Naples, Naples, Italy
| | | | - Maria Felicia Faienza
- Pediatrics Unit, Department of Biomedical Sciences and Human Oncology, University of Bari 'A. Moro', Bari, Italy
| | - Emanuela Scarano
- Department of Pediatrics, S.Orsola-Malpighi University Hospital, University of Bologna, Bologna, Italy
| | - Filippo De Luca
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Malgorzata Wasniewska
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy
| |
Collapse
|
23
|
Aversa T, Valenzise M, Salerno M, Corrias A, Iughetti L, Radetti G, De Luca F, Wasniewska M. Metamorphic thyroid autoimmunity in Down Syndrome: from Hashimoto's thyroiditis to Graves' disease and beyond. Ital J Pediatr 2015; 41:87. [PMID: 26558364 PMCID: PMC4642678 DOI: 10.1186/s13052-015-0197-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 11/04/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is known that Hashimoto's thyroiditis (HT) may progress to Graves' disease (GD) and that this phenomenon may be more frequent in the patients with Down syndrome (DS). AIMS To shed light on the relationships between Down syndrome (DS) and metamorphic thyroid autoimmunity. PATIENTS AND METHODS We reconstructed the conversion process from HT to GD in 12 DS children. All the data recorded at HT diagnosis and throughout the time interval from entry to GD presentation were retrospectively taken from patients' files, as well as those recorded at GD diagnosis and during the subsequent evolution. From GD diagnosis all patients underwent methimazole treatment, at a dose that was adjusted on the basis of clinical findings and thyroid tests. RESULTS Time interval between HT and GD was not different in the seven patients who received during that time a L-thyroxine (L-T4) treatment than in those who were not treated. After methimazole onset all patients exhibited a prolonged remission of hyperthyroidism. In 8/12 patients this treatment is still being continued 2-7 years after its initiation. The mean methimazole dosage needed to maintain euthyroidism in these eight patients was 0.12 ± 0.02 mg/kg/day. In the remaining four patients methimazole was withdrawn from 1.9 to 7 years after its initiation and no relapses were recorded 2.0-2.1 years after its withdrawal. These patients developed, 0.1-0.3 years after methimazole withdrawal, a picture of overt hypothyroidism and needed treatment with L-T4, that is now being continued. No patients needed non-pharmacological therapies. CONCLUSIONS 1) DS children might be incline to manifest over time a phenotypic metamorphosis from HT to GD and to subsequently fluctuate from hyperthyroidism to hypothyroidism; 2) in DS GD may have a mild biochemical and clinical course.
Collapse
Affiliation(s)
- Tommaso Aversa
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Mariella Valenzise
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Mariacarolina Salerno
- Pediatric Endocrinology Unit, Department of Translational Medical Sciences, University "Federico II" of Naples, Naples, Italy.
| | - Andrea Corrias
- Department of Pediatrics, University of Turin, Turin, Italy.
| | - Lorenzo Iughetti
- Department of Pediatrics, University of Modena and Reggio Emilia, Modena, Italy.
| | - Giorgio Radetti
- Department of Paediatrics, Regional Hospital, Bolzano, Italy.
| | - Filippo De Luca
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Malgorzata Wasniewska
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| |
Collapse
|
24
|
Abstract
The availability of human monoclonal antibodies (MAbs) to the TSHR has enabled major advances in our understanding of how TSHR autoantibodies interact with the receptor. These advances include determination of the crystal structures of the TSHR LRD in complex with a stimulating autoantibody (M22) and with a blocking type autoantibody (K1-70). The high affinity of MAbs for the TSHR makes them particularly suitable for use as ligands in assays for patient serum TSHR autoantibodies. Also, M22 and K1-70 are effective at low concentrations in vivo as TSHR agonists and antagonists respectively. K1-70 has important potential in the treatment of the hyperthyroidism of Graves' disease and Graves' ophthalmopathy. Small molecule TSHR antagonists described to date do not appear to have the potency and/or specificity shown by K1-70. New models of the TSHR ECD in complex with various ligands have been built. These models suggest that initial binding of TSH to the TSHR causes a conformational change in the hormone. This opens a positively charged pocket in receptor-bound TSH which attracts the negatively charged sulphated tyrosine 385 on the hinge region of the receptor. The ensuing movement of the receptor's hinge region may then cause activation. Similar activation mechanisms seem to take place in the case of FSH and the FSHR and LH and the LHR. However, stimulating TSHR autoantibodies do not appear to activate the TSHR in the same way as TSH.
Collapse
Affiliation(s)
- J Furmaniak
- FIRS Laboratories, RSR Ltd, Parc Ty Glas, Llanishen, Cardiff, UK
| | - J Sanders
- FIRS Laboratories, RSR Ltd, Parc Ty Glas, Llanishen, Cardiff, UK
| | - R Núñez Miguel
- FIRS Laboratories, RSR Ltd, Parc Ty Glas, Llanishen, Cardiff, UK
| | - B Rees Smith
- FIRS Laboratories, RSR Ltd, Parc Ty Glas, Llanishen, Cardiff, UK
| |
Collapse
|
25
|
Morshed SA, Davies TF. Graves' Disease Mechanisms: The Role of Stimulating, Blocking, and Cleavage Region TSH Receptor Antibodies. Horm Metab Res 2015; 47:727-34. [PMID: 26361259 PMCID: PMC5047290 DOI: 10.1055/s-0035-1559633] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The immunologic processes involved in Graves' disease (GD) have one unique characteristic--the autoantibodies to the TSH receptor (TSHR)--which have both linear and conformational epitopes. Three types of TSHR antibodies (stimulating, blocking, and cleavage) with different functional capabilities have been described in GD patients, which induce different signaling effects varying from thyroid cell proliferation to thyroid cell death. The establishment of animal models of GD by TSHR antibody transfer or by immunization with TSHR antigen has confirmed its pathogenic role and, therefore, GD is the result of a breakdown in TSHR tolerance. Here we review some of the characteristics of TSHR antibodies with a special emphasis on new developments in our understanding of what were previously called "neutral" antibodies and which we now characterize as autoantibodies to the "cleavage" region of the TSHR ectodomain.
Collapse
Affiliation(s)
- S A Morshed
- Thyroid Research Unit, Icahn School of Medicine at Mount Sinai, James J. Peters VA Medical Center, New York, USA
| | - T F Davies
- Thyroid Research Unit, Icahn School of Medicine at Mount Sinai, James J. Peters VA Medical Center, New York, USA
| |
Collapse
|
26
|
Abstract
Hashimoto's thyroiditis (HT) is part of a spectrum of thyroid autoimmune conditions and this review provides an update on the latest developments in the field. HT has a genetic predisposition with a number of immune-related and thyroid-specific genes conferring disease susceptibility. However, disentangling genes with protective and predisposing effect is a complex process that requires further work. The recent increase in the incidence of HT implicates environmental factors in disease pathogenesis including improved hygiene, increased dietary iodine intake, new treatment modalities and chemical agents. Additional unmodifiable predisposing factors include stress, climate, age and gender. Both cellular and humoral immunity play a role in HT pathogenesis. Defects in T regulatory cells and increased activation of follicular helper T cells may have a role in disease initiation/perpetuation. Infiltrating lymphocytes can be directly cytotoxic to thyroid follicular cells (TFC) or may affect cell viability/function indirectly through cytokine production, which alters TFC integrity and modulates their metabolic and immune function. Thyroid peroxidase and thyroglobulin antibodies are present in the majority of HT patients and help with management decisions. Antibodies against the sodium iodide symporter and pendrin are present in a minority with little known about their clinical relevance. In addition to immune cells, recent work has identified DNA fragments, generated following cell death, and micro RNA as potential factors in HT pathogenesis. Despite the large number of studies, the mechanistic pathways in HT are still not fully understood and further work is required to enhance our knowledge and identify novel preventative and therapeutic clinical targets.
Collapse
Affiliation(s)
- R A Ajjan
- Division of Cardiovascular and Diabetes Research, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - A P Weetman
- Department of Human Metabolism, University of Sheffield, Sheffield, UK
| |
Collapse
|
27
|
Aversa T, Lombardo F, Valenzise M, Messina MF, Sferlazzas C, Salzano G, De Luca F, Wasniewska M. Peculiarities of autoimmune thyroid diseases in children with Turner or Down syndrome: an overview. Ital J Pediatr 2015; 41:39. [PMID: 25971674 PMCID: PMC4440559 DOI: 10.1186/s13052-015-0146-2] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/01/2015] [Indexed: 11/10/2022] Open
Abstract
UNLABELLED Aim of this commentary is to summarize the salient literature news on the relationships between autoimmune thyroid diseases (ATDs) and either Down syndrome (DS) or Turner syndrome (TS).According to literature reports both Hashimoto's thyroiditis (HT) and Graves' disease (GD) are more frequent in children with DS or TS than in those without these chromosomopathies.An up-regulation of proinflammatory cytokines might be responsible for the enhanced susceptibility of TS children to ATDs, whereas a dysregulation of immune system may favor the development of ATDs in DS.In TS children biochemical presentation of HT is less severe than in peer controls. In both DS and TS GD picture at the time of diagnosis is not significantly different than in the pediatric general population.The evolution over time of GD in DS and TS does not differ from that observed in the pediatric general population, whereas the evolution of HT in both TS and DS is more severe than in girls without these chromosomopathies. CONCLUSIONS The association with TS or DS is able to affect both epidemiology and course of ATDs by conditioning: a) an increased susceptibility to these disorders; b) a less severe biochemical presentation and a more severe evolutive pattern of HT in TS girls; c) a more severe biochemical presentation and evolution of HT in DS patients.
Collapse
Affiliation(s)
- Tommaso Aversa
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Fortunato Lombardo
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Mariella Valenzise
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Maria Francesca Messina
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Concetta Sferlazzas
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Giuseppina Salzano
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Filippo De Luca
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| | - Malgorzata Wasniewska
- Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Via Consolare Valeria, 98125, Messina, Italy.
| |
Collapse
|
28
|
García-Arnés JA, García-Casares N, Soler J, Garín JM, Garriga MJ, León M. Ureteric myxoedema. A new location in Graves' disease. Clin Endocrinol (Oxf) 2014; 80:613-4. [PMID: 23692561 DOI: 10.1111/cen.12250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Revised: 05/13/2013] [Accepted: 05/14/2013] [Indexed: 12/22/2022]
Affiliation(s)
- Juan A García-Arnés
- Department of Endocrinology, Carlos Haya Regional University Hospital, Malaga, Spain.
| | | | | | | | | | | |
Collapse
|
29
|
Aversa T, Lombardo F, Corrias A, Salerno M, De Luca F, Wasniewska M. In young patients with Turner or Down syndrome, Graves' disease presentation is often preceded by Hashimoto's thyroiditis. Thyroid 2014; 24:744-7. [PMID: 24325626 DOI: 10.1089/thy.2013.0452] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND It is known that, in the general population, there exists a continuum between Hashimoto's thyroiditis (HT) and Graves' disease (GD) within the spectrum of autoimmune thyroid diseases, although the mechanisms involved in the metamorphosis from HT to GD or vice versa have not been elucidated as of yet. The aim of this study was to ascertain whether the association with Down or Turner syndromes (DS and TS) may affect the switching process from HT to GD. METHODS Thirty-five young GD patients with either DS or TS (group A) and 109 age-matched GD patients with neither DS nor TS were retrospectively investigated in order to either confirm or exclude antecedents of HT. The investigations were based on either clinical records or questionnaires addressed to family pediatricians. Retrospective investigations also aimed to ascertain how many patients in each group exhibited a biochemical picture of either subclinical or overt hypothyroidism at the time of HT diagnosis, and how many had received levothyroxine (L-T4) therapy prior to the onset of GD. In both groups, all the patients with documented antecedents of HT underwent an assessment of their iodine status after GD diagnosis. RESULTS Antecedents of HT were significantly more common in group A than in group B (25.7% vs. 3.7%, p=0.0004), with a time interval between HT and GD that was significantly higher in group A (p=0.003). Both thyroid function and autoimmunity tests at HT presentation and the prevalence of patients who underwent L-T4 therapy prior to GD diagnosis were not significantly different in the two groups, nor was the iodine status after GD diagnosis. CONCLUSIONS In young patients with TS or DS, GD presentation is often (25.7% of cases) preceded by HT. This evolution trend does not seem to be conditioned by either thyroid tests at HT diagnosis, or L-T4 treatment, or iodine status alterations. Patients with these chromosomopathies and coexisting HT may be at high risk of progressing to GD. The pathophysiological bases of these findings need to be clarified.
Collapse
Affiliation(s)
- Tommaso Aversa
- 1 Department of Pediatrics, University of Messina , Messina, Italy
| | | | | | | | | | | |
Collapse
|
30
|
McLachlan SM, Rapoport B. Breaking tolerance to thyroid antigens: changing concepts in thyroid autoimmunity. Endocr Rev 2014; 35:59-105. [PMID: 24091783 PMCID: PMC3895862 DOI: 10.1210/er.2013-1055] [Citation(s) in RCA: 138] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 09/24/2013] [Indexed: 02/06/2023]
Abstract
Thyroid autoimmunity involves loss of tolerance to thyroid proteins in genetically susceptible individuals in association with environmental factors. In central tolerance, intrathymic autoantigen presentation deletes immature T cells with high affinity for autoantigen-derived peptides. Regulatory T cells provide an alternative mechanism to silence autoimmune T cells in the periphery. The TSH receptor (TSHR), thyroid peroxidase (TPO), and thyroglobulin (Tg) have unusual properties ("immunogenicity") that contribute to breaking tolerance, including size, abundance, membrane association, glycosylation, and polymorphisms. Insight into loss of tolerance to thyroid proteins comes from spontaneous and induced animal models: 1) intrathymic expression controls self-tolerance to the TSHR, not TPO or Tg; 2) regulatory T cells are not involved in TSHR self-tolerance and instead control the balance between Graves' disease and thyroiditis; 3) breaking TSHR tolerance involves contributions from major histocompatibility complex molecules (humans and induced mouse models), TSHR polymorphism(s) (humans), and alternative splicing (mice); 4) loss of tolerance to Tg before TPO indicates that greater Tg immunogenicity vs TPO dominates central tolerance expectations; 5) tolerance is induced by thyroid autoantigen administration before autoimmunity is established; 6) interferon-α therapy for hepatitis C infection enhances thyroid autoimmunity in patients with intact immunity; Graves' disease developing after T-cell depletion reflects reconstitution autoimmunity; and 7) most environmental factors (including excess iodine) "reveal," but do not induce, thyroid autoimmunity. Micro-organisms likely exert their effects via bystander stimulation. Finally, no single mechanism explains the loss of tolerance to thyroid proteins. The goal of inducing self-tolerance to prevent autoimmune thyroid disease will require accurate prediction of at-risk individuals together with an antigen-specific, not blanket, therapeutic approach.
Collapse
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
| | | |
Collapse
|
31
|
McLachlan SM, Rapoport B. Thyrotropin-blocking autoantibodies and thyroid-stimulating autoantibodies: potential mechanisms involved in the pendulum swinging from hypothyroidism to hyperthyroidism or vice versa. Thyroid 2013; 23:14-24. [PMID: 23025526 PMCID: PMC3539254 DOI: 10.1089/thy.2012.0374] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Thyrotropin receptor (TSHR) antibodies that stimulate the thyroid (TSAb) cause Graves' hyperthyroidism and TSHR antibodies which block thyrotropin action (TBAb) are occasionally responsible for hypothyroidism. Unusual patients switch from TSAb to TBAb (or vice versa) with concomitant thyroid function changes. We have examined case reports to obtain insight into the basis for "switching." SUMMARY TBAb to TSAb switching occurs in patients treated with levothyroxine (LT4); the reverse switch (TBAb to TSAb) occurs after anti-thyroid drug therapy; TSAb/TBAb alterations may occur during pregnancy and are well recognized in transient neonatal thyroid dysfunction. Factors that may impact the shift include: (i) LT4 treatment, usually associated with decreased thyroid autoantibodies, in unusual patients induces or enhances thyroid autoantibody levels; (ii) antithyroid drug treatment decreases thyroid autoantibody levels; (iii) hyperthyroidism can polarize antigen-presenting cells, leading to impaired development of regulatory T cells, thereby compromising control of autoimmunity; (iv) immune-suppression/hemodilution reduces thyroid autoantibodies during pregnancy and rebounds postpartum; (v) maternally transferred IgG transiently impacts thyroid function in neonates until metabolized; (vi) a Graves' disease model involving immunizing TSHR-knockout mice with mouse TSHR-adenovirus and transfer of TSHR antibody-secreting splenocytes to athymic mice demonstrates the TSAb to TBAb shift, paralleling the outcome of maternally transferred "term limited" TSHR antibodies in neonates. Finally, perhaps most important, as illustrated by dilution analyses of patients' sera in vitro, TSHR antibody concentrations and affinities play a critical role in switching TSAb and TBAb functional activities in vivo. CONCLUSIONS Switching between TBAb and TSAb (or vice versa) occurs in unusual patients after LT4 therapy for hypothyroidism or anti-thyroid drug treatment for Graves' disease. These changes involve differences in TSAb versus TBAb concentrations, affinities and/or potencies in individual patients. Thus, anti-thyroid drugs or suppression/hemodilution in pregnancy reduce initially low TSAb levels even further, leading to TBAb dominance. In contrast, TSAb emergence after LT4 administration may be sufficient to counteract TBAb inhibition. The occurrence of "switching" emphasizes the need for careful patient monitoring and management. Finally, whole genome screening of relatively rare "switch" patients and appropriate Graves' and Hashimoto's controls could provide unexpected and valuable information regarding the basis for thyroid autoimmunity.
Collapse
Affiliation(s)
- Sandra M McLachlan
- Thyroid Autoimmune Disease Unit, Cedars-Sinai Medical Center and UCLA School of Medicine, Los Angeles, California 90048, USA.
| | | |
Collapse
|