Juvenile autoimmune thyroiditis

High frequency of autoimmune thyroiditis in euthyroid girls with premature adrenarche

Objective

The purpose of this study was to investigate the frequency of autoimmune thyroiditis (AT) among euthyroid prepubertal girls presenting with premature adrenarche (PA). We also aimed to identify the clinical, metabolic, and endocrine profile of girls with AT and concurrent PA and compare them to girls with AT without PA, PA alone and healthy controls.

Methods

Ninety-one prepubertal girls aged 5-10 years, who attended our department for AT, PA and normal variants of growth and puberty were recruited for the study: 73 girls had PA, 6 AT without PA and 12 were referred for investigation of growth. All girls underwent clinical examination, detailed biochemical and hormonal screen. Standard dose Synachten stimulation test (SDSST) and oral glucose tolerance test (OGTT) were performed in all girls with PA. The whole study population was divided in 4 groups: Group PA-/AT+ included 6 girls with AT without PA; Group PA+/AT- PA subjects without AT; Group PA+/AT+ girls with PA and concomitant AT; Group PA-/AT- twelve healthy girls without PA nor AT (controls).

Results

Among 73 girls presenting with PA 19 had AT (26%). BMI, systolic blood pressure (SBP) and the presence of goiter significantly differed between the four groups (p = 0.016, p = 0.022 and p < 0.001, respectively). When comparing hormonal parameters among the four groups significant differences were found in leptin (p = 0.007), TSH (p = 0.044), anti-TPO (p = 0.002), anti-TG (p = 0.044), IGF-BP1 (p = 0.006), Δ4-Α (p = 0.01), DHEA-S (p = <0.001), IGF-1 (p = 0.012) and IGF-BP3 (p = 0.049) levels. TSH levels were significantly higher in Group PA+/AT+ compared to PA+/AT- and PA-/AT- (p = 0.043 and p = 0.016, respectively). Moreover, girls with AT (Groups PA-/AT+ and PA+/AT+) had higher TSH levels than those in Group PA+/AT- (p = 0.025). Girls in Group PA+/AT + showed higher cortisol response at 60 min post-SDSST than girls in Group PA+/AT- (p = 0.035). During the OGTT, insulin concentrations at 60 min were significantly higher in Group PA+/AT + compared to Group PA+/AT- (p = 0.042).

Conclusion

A high frequency of AT among euthyroid prepubertal girls with PA was observed. The combination of PA with AT even in euthyroid state may be associated with a greater degree of insulin resistance, than PA alone.

[Clinical practice guidelines for acute and chronic thyroiditis (excluding autoimmune thyroiditis)]

Острые и хронические заболевания щитовидной железы занимают второе место по выявляемости после сахарного диабета. Всемирная организация здравоохранения отмечает ежегодную тенденцию к увеличению числа заболеваний щитовидной железы. В настоящих клинических рекомендациях будут рассмотрены вопросы этиологии, клинического течения, диагностики и лечения острых и хронических (за исключением аутоиммунного) воспалительных заболеваний щитовидной железы.Клинические рекомендации — это основной рабочий инструмент практикующего врача, как специалиста, так и врача узкой практики. Лаконичность, структурированность сведений об определенной нозологии, методов ее диагностики и лечения, базирующихся на принципах доказательной медицины, позволяют в короткий срок дать тот или иной ответ на интересующий вопрос специалисту, добиваться максимальной эффективности и персонализации лечения.Клинические рекомендации составлены профессиональным сообществом узких специалистов, одобрены экспертным советом Министерства здравоохранения РФ. Представленные рекомендации содержат максимально полную информацию, которая требуется на этапе диагностики острых и хронических тиреоидитов, этапе выбора тактики ведения пациентов с тиреоидитом, а также на этапе лечения пациента.Рабочая группа представляет этот проект в профессиональном журнале, посвященном актуальным проблемам эндокринологии, с целью повышения качества оказываемой медицинской помощи, повышения эффективности лечения острых и хронических тиреоидитов путем ознакомления с полным тестом клинических рекомендаций по острым и хроническим тиреоидитам (исключая аутоиммунный тиреоидит) максимально возможного количества специалистов в области не только эндокринологии, но и медицины общей (семейной) практики.

Evaluation of the Ovarian Reserve in Adolescents with Hashimoto’s Thyroiditis Using Serum Anti-Müllerian Hormone Levels

OBJECTIVE

This study aims to evaluate ovarian reserve in adolescent girls with Hashimoto’s thyroiditis (HT) by assessment of serum anti-Müllerian hormone (AMH) levels. It was hypothesized that HT decreases ovarian reserve and AMH levels are lower in the HT group.

METHODS

Thirty HT patients, aged between 10-18 years, and 30 healthy girls as the control group were enrolled in this cross-sectional study. The mean serum AMH levels of the groups were compared using the Mann-Whitney U test.

RESULTS

There was no statistically significant difference between the patient and the control groups in terms of serum AMH levels. There was a negative correlation between serum AMH and thyroid stimulating hormone (TSH) levels and no correlation between serum AMH and anti-thyroid peroxidase (anti-TPO) or anti-thyroglobulin (anti-Tg) antibody levels.

CONCLUSION

Our results show that ovarian reserve of adolescent girls, as measured by serum AMH levels, is not affected by HT. Autoimmune damage to the ovaries may take time and the adolescent period may be too early to see these effects. Follow up of the patients for reproductive abnormalities and initiation of prospective studies is recommended.

Genomics and phenomics of Hashimoto's thyroiditis in children and adolescents: a prospective study from Southern India

BACKGROUND

Hashimoto's thyroiditis (HT) is the commonest cause of acquired hypothyroidism in children and adolescents in iodine non-endemic areas. The genetic analysis in HT shows two types of susceptibility genes-immune regulatory and thyroid specific genes. The exact genotype-phenotypic correlations and risk categorization of hypothyroid phenotypes resulting from these known mutations are largely speculative. The genetic studies in pediatric HT are very sparse from Indian sub-continent. In this context, we analysed the prevalence of TPO, NIS and DUOX2 gene mutations along with genotype-phenotype correlations in hypothyroid children with HT.

METHODS

This is inter-disciplinary study conducted by collaboration between a tertiary care endocrinology hospital, biochemistry department of a teaching medical institute and genetics lab. In this prospective study, we employed 8 sets of primers and screened for 142 known single nucleotide polymorphisms in TPO, NIS, DUOX2 genes. The subjects were children and adolescents with hypothyroidism due to HT. Congenital hypothyroidism, iodine deficiency and dyshormonogenetic hypothyroidism cases were excluded.

RESULTS

We detected 8 mutations in 7/20 (35%) children in the entire cohort (6 in NIS and 2 in TPO genes. No mutations were observed in DUOX2 gene. All our mutations were localized in introns and we found none in exons. Except for bi-allelic, synonymous polymorphism of TPO gene in child No. 18, all other mutations were heterozygous in nature. Genotype-phenotype correlations show that our mutations significantly expressed the presence of associated autoimmune manifestations and existence of family history. Clinical phenotypes of painful thyroiditis, severity of hypothyroidism and absence of goiter were statistically significant in the presence of these mutations. But, they could not reach significance on multivariate analysis.

CONCLUSIONS

NIS gene followed by TPO mutations appears to be most prevalent mutations in HT amongst South Indian children and these mutations significantly influenced phenotypic expressions such as severity of hypothyroidism, goiter, auto-immune manifestations and family history.

Lower CD28+ T cell proportions were associated with CMV-seropositivity in patients with Hashimoto's thyroiditis

BACKGROUND

Alterations in the naive T cell subpopulations have been demonstrated in patients with T cell mediated autoimmune disorders, reminiscent of immunological changes found in the elderly during immunosenescence, including the switch from CD45RA + to CD45RO + T cells and decreased thymic function with increased compensatory proliferative mechanisms, partly associated with latent Cytomegalovirus (CMV) infection. The present study was aimed to investigate proportions of lymphocytes, their relation to CMV-seropositivity and the replicative history of CD45RA + expressing T cells in Hashimoto's thyroiditis (HT, n = 18) and healthy controls (HC, n = 70).

METHODS

Proportions of peripheral T cells were investigated by flow cytometry. The replicative history was assessed by T cell receptor excision circles (TRECs) and relative telomere length (RTL). Expression of CD62L was analyzed by immunohistochemistry in thyroid sections. The role of CMV was assessed by serology, ELISPOT assay and in situ hybridization.

RESULTS

Our results demonstrated a significant increase of CD28-negative T cells, associated with CMV-seropositivity in HT patients. HT showed abundant CD45RO + T cells with peripheral loss of CD62L-expressing CD8 + CD45RA + T cells, the latter mainly depending on disease duration. CD62L was expressed in thyroid lymphocyte infiltrations. The diagnosis of HT and within the HT group CMV-seropositivity were the main determinants for the loss of CD28 expression. RTL was not different between HC and HT. HT showed significantly lower TRECs in CD4 + CD45RA + T cells compared to HC.

CONCLUSIONS

Patients with HT display a peripheral T cell phenotype reminiscent of findings in elderly persons or other autoimmune disorders. Whether these mechanisms are primary or secondary to the immunological alterations of autoimmune conditions should be investigated in longitudinal studies which may open research on new therapeutic regimes for treatment of HT and associated autoimmune diseases.

Iodine intake and prevalence of thyroid autoimmunity and autoimmune thyroiditis in children and adolescents aged between 1 and 16 years

OBJECTIVES

To determine the status of iodine nutrition in children and adolescents in Almería, Spain. To calculate prevalence of thyroid autoimmunity (TA) and autoimmune thyroiditis (AT) in pediatric ages and to research into associated factors.

METHODS

Cross-sectional epidemiological study. By a multistage probability sampling 1387 children and adolescents aged between 1 and 16 were selected. Physical examination was carried out including neck palpation. Parents were asked about eating habits as well as about social and demographic aspects. Urinary iodine, free thyroxine, TSH, antiperoxidase and antithyroglobulin antibodies were measured. TA was diagnosed when any antibody was positive and AT when autoimmunity was associated with impaired thyroid function or goitre. Results are shown using percentages (and its 95% confidence interval). To study associated factors we used multiple logistic regression, quantifying the relation with odds ratio (OR), and multiple lineal regression.

RESULTS

Median urinary iodine concentration was 199.5 μg/l. The prevalences of TA and AT were 3.7% (2.4-5.0) and 1.4% (0.4-2.4). TA is associated with female sex (OR 2.78; P<0.001) and age (OR 1.30; P<0.001). Iodine status is associated with the intake of milk and dairy product (P<0.001) and vegetable (P=0.021) but not with use of iodized salt at home (P=0.1).

CONCLUSIONS

The iodine supply in children and adolescents in our city is optimal. Milk and dairy products are the most important iodine sources. TA and AT are prevalent in pediatric ages in our city mainly in females and older subjects.

The DIAGONALE study: a survey designed to analyze the diagnosis and management of goiter in France

OBJECTIVE

Euthyroid goiter is frequent for general practitioners (GPs) and endocrinologists (ENDOs). It may induce complications especially in elderly subjects when it becomes nodular and hyperfunctional whereas in young subjects prevention of iodine deficiency may prevent this evolution. The primary objective of the observational study diagnosis of iodine deficiency induced goiter and national medical practices (DIAGONALE) was to determine the circumstances of diagnosis of euthyroid goiter, its incidence, the patient characteristics and the management.

METHODS

A representative sample of GPs and ENDOs working in a private medical practice (exclusively or not) was randomly drawn from a national file without changing the physician-patient relationship.

RESULTS

Four hundred and sixty-nine GPs and 195 ENDOs participated in the study. Goiter was diagnosed in 0.86% of patients seen by GPs and 15.7% of patients seen by ENDOs. Pregnant women were mainly and teenagers exclusively seen by ENDOs. The interview and clinical examination were an important time in the management of euthyroid goiter. TSH level was systematically assayed as well as an ultrasonography; 22.6% of GPs did not perform a scintigraphy versus 63.1% of ENDOs. Levothyroxine treatment was frequently prescribed and the objective of TSH levels was 2mU/L for GPs and 1mU/L for ENDOs.

CONCLUSION

This observational study showed differences in the management of euthyroid goiter between GPs and ENDOs but also many common practices. It also highlighted a higher incidence rate of goiter in pregnant women and teenagers seen by ENDOs.

Autoimmune thyroid diseases in children

The two major autoimmune thyroid diseases (ATDs) include Graves' disease (GD) and autoimmune thyroiditis (AT); both of which are characterized by infiltration of the thyroid by T and B cells reactive to thyroid antigens, by the production of thyroid autoantibodies and by abnormal thyroid function (hyperthyroidism in GD and hypothyroidism in AT). While the exact etiology of thyroid autoimmunity is not known, it is believed to develop when a combination of genetic susceptibility and environmental encounters leads to breakdown of tolerance. It is important to recognize thyroid dysfunction at an early stage by maintaining an appropriate index of suspicion.

Goitrous autoimmune thyroiditis in a pediatric population: a longitudinal study

BACKGROUND

Patients with autoimmune thyroiditis can present with thyroid function that varies from euthyroidism to frank hypothyroidism or occasionally hyperthyroidism. Although there is a risk of progression from the euthyroid or subclinical hypothyroid state to frank hypothyroidism, the rate of progression is not known.

OBJECTIVES

Subjects with diffuse goiter and autoimmune thyroiditis were followed up to observe the rate of deterioration in thyroid function from euthyroid and subclinical hypothyroid states to hypothyroidism.

METHODS

Patients who presented with goiter and autoimmune thyroiditis were grouped as those with euthyroidism, subclinical hypothyroidism, and overt hypothyroidism on the basis of levels of thyroxine and thyrotropin at presentation. Patients were followed up for a minimum duration of 24 months with periodic monitoring of thyroid function.

RESULTS

Ninety-eight consecutive subjects (aged of 8-18 years) with a diagnosis of autoimmune thyroiditis and diffuse goiter were studied. At presentation, in 24 subjects (24.5%) thyroid function was normal (euthyroidism), 32 (32.6%) had subclinical hypothyroidism, and the remaining 42 subjects (42.9%) had hypothyroidism. All of the subjects with hypothyroid were maintained euthyroid on thyroxine during follow-up. Hypothyroidism developed in 3 of 24 patients with euthyroidism and in 4 of 32 patients with subclinical hypothyroidism.

CONCLUSIONS

Subjects with goitrous autoimmune thyroiditis need periodic monitoring of thyroid function. Development of thyroid dysfunction is insidious and may not be accompanied by symptoms and clinical signs. In pediatric and adolescent age groups it is imperative to correct thyroid dysfunction to achieve optimal growth and development.