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Muller I, Willis M, Healy S, Nasser T, Loveless S, Butterworth S, Zhang L, Draman MS, Taylor PN, Robertson N, Dayan CM, Ludgate ME. Longitudinal Characterization of Autoantibodies to the Thyrotropin Receptor (TRAb) During Alemtuzumab Therapy: Evidence that TRAb May Precede Thyroid Dysfunction by Many Years. Thyroid 2018; 28:1682-1693. [PMID: 30351224 DOI: 10.1089/thy.2018.0232] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Thyroid autoimmunity, especially Graves' disease or hypothyroidism with positive autoantibodies (TRAb) to the thyrotropin receptor (TSHR), occurs in 30-40% of patients with relapsing multiple sclerosis following treatment with alemtuzumab (ALTZ). ALTZ therapy therefore provides a unique opportunity to study the evolution of TRAb prior to clinical presentation. TRAb can stimulate (TSAb), block (TBAb), or not affect ("neutral") the TSHR function, causing hyperthyroidism, hypothyroidism, or euthyroidism, respectively. METHODS A longitudinal retrospective analysis was conducted of TRAb bioactivity over a period of nine years in 45 multiple sclerosis patients receiving ALTZ using available stored serum. Of these 45 patients, 31 developed thyroid dysfunction (TD) and 14 remained euthyroid despite being followed for a minimum of five years (NO-TD). The presence of TRAb was evaluated at standardized time points: (i) before ALTZ, (ii) latest time available following ALTZ and before TD onset, and (iii) following ALTZ during/after TD onset. Serum TRAb were detected by published in-house assays (ihTRAb): flow cytometry detecting any TSHR-binding TRAb, and luciferase bioassays detecting TSAb/TBAb bioactivity. Purified immunoglobulin G was used to verify TSAb/TBAb in selected hypothyroid cases. Standard clinical automated measurements of TRAb, antithyroid peroxidase autoantibodies (TPOAb), thyrotropin, free thyroxine, and free triiodothyronine were also collected. RESULTS Before ALTZ, combined ihTRAb (positive with flow cytometry and/or luciferase bioassay) but not automated TRAb were present in 5/16 (31.2%) TD versus 0/14 (0%) NO-TD (p = 0.017). Detectable ihTRAb preceded TD development in 9/28 (32.1%) and by a median of 1.2 years (range 28 days-7.3 years). Combination testing of ihTRAb and TPOAb at baseline predicted 20% of subsequent cases of hyperthyroidism and 83% of hypothyroidism. CONCLUSIONS Evidence is presented that TRAb measured with custom-made assays can be detected prior to any change in thyroid function in up to a third of cases of ALTZ-related TD. Furthermore, the presence of ihTRAb prior to ALTZ treatment was strongly predictive of subsequent TD. The findings suggest that a period of affinity maturation of TRAb may precede clinical disease onset in some cases. Combined testing of TPOAb and ihTRAb may increase the ability to predict those who will develop TD following ALTZ.
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Affiliation(s)
- Ilaria Muller
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Mark Willis
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Sarah Healy
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Taha Nasser
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Samantha Loveless
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Sara Butterworth
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Lei Zhang
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Mohd S Draman
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Peter N Taylor
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Neil Robertson
- 2 Division of Psychological Medicine and Clinical Neurosciences, School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Colin M Dayan
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
| | - Marian E Ludgate
- 1 Thyroid Research Group, Division of Infection and Immunity, School of Medicine; School of Medicine; Cardiff University, University Hospital of Wales, Cardiff, United Kingdom
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Hargreaves CE, Grasso M, Hampe CS, Stenkova A, Atkinson S, Joshua GWP, Wren BW, Buckle AM, Dunn-Walters D, Banga JP. Yersinia enterocolitica provides the link between thyroid-stimulating antibodies and their germline counterparts in Graves' disease. THE JOURNAL OF IMMUNOLOGY 2013; 190:5373-81. [PMID: 23630351 DOI: 10.4049/jimmunol.1203412] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Graves' disease results from thyroid-stimulating Abs (TSAbs) activating the thyrotropin receptor (TSHR). How TSAbs arise from early precursor B cells has not been established. Genetic and environmental factors may contribute to pathogenesis, including the bacterium Yersinia enterocolitica. We developed two pathogenic monoclonal TSAbs from a single experimental mouse undergoing Graves' disease, which shared the same H and L chain germline gene rearrangements and then diversified by numerous somatic hypermutations. To address the Ag specificity of the shared germline precursor of the monoclonal TSAbs, we prepared rFab germline, which showed negligible binding to TSHR, indicating importance of somatic hypermutation in acquiring TSAb activity. Using rFab chimeras, we demonstrate the dominant role of the H chain V region in TSHR recognition. The role of microbial Ags was tested with Y. enterocolitica proteins. The monoclonal TSAbs recognize 37-kDa envelope proteins, also recognized by rFab germline. MALDI-TOF identified the proteins as outer membrane porin (Omp) A and OmpC. Using recombinant OmpA, OmpC, and related OmpF, we demonstrate cross-reactivity of monoclonal TSAbs with the heterogeneous porins. Importantly, rFab germline binds recombinant OmpA, OmpC, and OmpF confirming reactivity with Y. enterocolitica. A human monoclonal TSAb, M22 with similar properties to murine TSAbs, also binds recombinant porins, showing cross-reactivity of a spontaneously arising pathogenic Ab with Y. enterocolitica. The data provide a mechanistic framework for molecular mimicry in Graves' disease, where early precursor B cells are expanded by Y. enterocolitica porins to undergo somatic hypermutation to acquire a cross-reactive pathogenic response to TSHR.
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Affiliation(s)
- Chantal E Hargreaves
- Division of Diabetes and Nutritional Sciences, King's College London School of Medicine, London SE5 9NU, United Kingdom
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