Triiodothyronine-predominant Graves' disease in childhood: detection and therapeutic implications

OBJECTIVE

To assess in a pediatric population, the clinical characteristics and management of triiodothyronine-predominant Graves' disease (T3-P-GD), a rare condition well known in adults, but not previously described in children.

DESIGN

We conducted a university hospital-based observational study.

METHODS

All patients with GD followed for more than 1 year between 2003 and 2013 (n=60) were included. T3-P-GD (group I) was defined as high free T3 (fT3) concentration (>8.0 pmol/l) associated with a normal free thyroxine (fT4) concentration and undetectable TSH more than 1 month after the initiation of antithyroid drug (ATD) treatment. Group II contained patients with classical GD without T3-P-GD.

RESULTS

Eight (13%) of the patients were found to have T3-P-GD, a median of 6.3 (3.0-10.5) months after initial diagnosis (n=4) or 2.8 (2.0-11.9) months after the first relapse after treatment discontinuation (n=4). At GD diagnosis, group I patients were more likely to be younger (6.8 (4.3-11.0) vs 10.7 (7.2-13.7) years) and had more severe disease than group II patients, with higher serum TSH receptor autoantibodies (TRAb) levels: 40 (31-69) vs 17 (8-25) IU/l, P<0.04, and with slightly higher serum fT4 (92 (64-99) vs 63 (44-83) pmol/l) and fT3 (31 (30-46) vs 25 (17-31) pmol/l) concentrations. During the 3 years following T3-P-GD diagnosis, a double dose of ATD was required and median serum fT4:fT3 ratio remained lower in group I than in group II.

CONCLUSION

Severe hyperthyroidism, with particularly high TRAb concentrations at diagnosis, may facilitate the identification of patients requiring regular serum fT3 determinations and potentially needing higher doses of ATD dosage during follow-up.

Elevated serum immunoglobulin G4 levels in patients with Graves' disease and their clinical implications

BACKGROUND

Immunoglobulin G4-related disease (IgG4-RD) is a new clinical entity that affects various organs with increased IgG4 positive plasmacytes and progressive fibrosis. While IgG4-RDs in association with Hashimoto's thyroiditis or Riedel's thyroiditis have been reported, the relationship between IgG4-RD and Graves' disease (GD) is yet unknown. To elucidate the relation of GD to IgG4-RD, serum IgG4 levels and their clinical implications in patients with GD were investigated.

METHODS

In this prospective study, serum IgG4 levels were measured in 109 patients with GD and classified into two groups according to the comprehensive diagnostic criteria of IgG4-RD previously established: (i) GD with elevated-IgG4 levels (≥ 135 mg/dL), and (ii) GD with nonelevated IgG4 (<135 mg/dL).

RESULTS

Seven out of 109 patients with GD (6.4%) had elevated serum IgG4 levels [mean ± standard deviation (range): 175.0 ± 44.5 (136-266) mg/dL] and elevated ratios of IgG4/IgG [12.7 ± 4.5% (7.6%-21.2%)]. The remaining patients with GD had serum IgG4 levels and IgG4/IgG ratios of 39.6 ± 27.6 (3-132) mg/dL and 3.2 ± 2.2% (0.3%-11.5%), respectively. Ages in the elevated IgG4 group were significantly higher than those of the nonelevated IgG4 group: 54.7 ± 6.2 versus 43.4 ± 15.4 years, respectively. Ultrasound examinations revealed that the elevated IgG4 group had significantly increased hypoechogenic areas in the thyroid in comparison to the nonelevated IgG4 group (low echo scoring: 1.66 ± 0.81 vs. 0.61 ± 0.89, respectively). In the correlation analysis, TSAb (rs=0.385, n=42) titers were significantly correlated with se rum IgG4 levels, while they were not significantly different between the two groups. In the elevated IgG4 group, symptoms were controllable with a small dose of antithyroidal drug (ATD; n=4), a combination treatment with ATD and L-T4 (n=1), or L-T4 administration only one year after the first visit (n=2).

CONCLUSIONS

A small portion of GD patients harbored elevated serum IgG4 levels. They were older, had increased hypoechoic areas in the thyroid, and appeared to be responsive or prone to be hypothyroid after ATD treatment. Thus, the present study suggests the presence of a novel subtype of GD. Measuring serum IgG4 levels may help to distinguish this new entity and provide potential therapeutic options for GD.

Epidemiology of subtypes of hyperthyroidism in Denmark: a population-based study

OBJECTIVE

Few population-based studies have described the epidemiology of subtypes of hyperthyroidism.

DESIGN

A prospective population-based study, monitoring two well-defined Danish cohorts in Aalborg with moderate iodine deficiency (n=311 102) and Copenhagen with only mild iodine deficiency (n=227 632).

METHODS

A laboratory monitoring system identified subjects with thyroid function tests suggesting overt hyperthyroidism (low s-TSH combined with high s-thyroxine or s-triiodothyronine). For all subjects, we collected information on medical history, thyroid scintigraphy and thyroid hormone receptor antibody (TRAb) measurement. Information was used to disprove or verify primary overt hyperthyroidism and to subclassify hyperthyroidism into nosological disorders.

RESULTS

From 1997 to 2000 (2 027 208 person-years of observation), we verified 1682 new cases of overt hyperthyroidism. The overall standardized incidence rate (SIR) per 100 000 person-years was 81.6, and was higher in Aalborg compared with Copenhagen (96.7 vs 60.0, P<0.001), giving an SIR ratio (SIRR (95% confidence interval (CI))) between moderate versus mild iodine-deficient areas of 1.6 (1.4-1.8). Nosological types of hyperthyroidism (percentage/SIRR (95% CI)): multinodular toxic goitre (MNTG) 44.1%/1.9 (1.6-2.2), Graves' disease (GD) 37.6%/1.2 (0.99-1.4), solitary toxic adenoma (STA) 5.7%/2.4 (1.3-3.5), 'mixed type' hyperthyroidism (TRAb-positive, scintigraphicly multinodular) 5.4%/6.0 (3.0-12), subacute thyroiditis 2.3%/0.9 (0.4-1.4), postpartum thyroid dysfunction 2.2%/1.6 (0.8-3.0), amiodarone-associated hyperthyroidism 0.8%/7.1 (1.1-65), hyperthyroidism after thyroid radiation 0.7%/12.3 (0.8-50), lithium-associated hyperthyroidism 0.7%/0.97 (0.4-4.8) and hyperthyroidism caused by various other factors 0.7%. Lifetime risk for overt hyperthyroidism was 10.5%/6.5%/2.4% (females/all/males).

CONCLUSION

Hyperthyroidism was common in Denmark with MNTG and GD as dominating entities. The higher incidence of hyperthyroidism in the most iodine-deficient region was caused by higher frequency of MNTG, 'mixed-type', STA and amiodarone-associated hyperthyroidism.

[In patients with Graves' disease signal-averaged P wave duration positively correlates with the degree of thyrotoxicosis]

Coexistence of the goitre, proptosis and palpitations was observed in XIX century for the first time. Sinus tachyarytmias and atrial fibrillation are typical cardiac symptoms of hyperthyroidism. Atrial fibrillation occurs more often in patients with toxic goiter than in young patients with Grave's disease. These findings suggest that causes of atrial fibrillation might be multifactorial in the elderly. The aims of our study were to evaluate correlations between the parameters of atrial signal averaged ECG (SAECG) and the serum concentration of thyroid free hormones. 25 patient with untreated Grave's disease (G-B) (age 29,6 +/- 9,0 y.o.) and 26 control patients (age 29,3 +/- 6,9 y.o.) were enrolled to our study. None of them had history of atrial fibrillation what was confirmed by 24-hour ECG Holter monitoring. The serum fT3, fT4, TSH were determined in the venous blood by the immunoenzymatic method. Atrial SAECG recording with filtration by zero phase Butterworth filter (45-150 Hz) was done in all subjects. The duration of atrial vector magnitude (hfP) and root meat square of terminal 20ms of atrial vector magnitude (RMS20) were analysed. There were no significant differences in values of SAECG parameters (hfP, RMS20) between investigated groups. The positive correlation between hfP and serum fT3 concentration in group G-B was observed (Spearman's correlation coefficient R = 0.462, p < 0.02). No significant correlations were found between RMS20 and serum fT3 in G-B group and between hfP or RMS 20 and serum fT3 in group K. These findings suggest that occurrence of atrial fibrillation in patients with Grave's disease depends not only on hyperthyroidism but on serum concentration of fT3 also.

[The clinical and laboratory findings in Graves' multinodular type disease]

Graves' disease (GD) is an autoimmune thyroid disease characterized among other findings by diffuse goiter. It is possible in GD to find a multinodular goiter (mGD). Are they two different diseases that coexist, or do we have a multinodular type of GD. Questions arise as for the time that this mGD appears in the process of GD and also, as for the clinical and laboratory characteristics of mGD. To answer these questions, we have studied retrospectively and randomly from the archives of the Department of Nuclear Medicine of AHEPA University Hospital, from 2000-2004, 20 female patients with multinodular type of GD (Group A) as first diagnosed by us and 50 female patients with diffuse type of GD (Group B) of about the same age. Patients with mGD had been examined before by us and their GD was documented. No other cause for exophthalmus except GD was found. Patients with any other additional disease were excluded from the study. All patients had 7-10 signs of hyperthyroidism (thyroid index). Many of the patients, after the present study, were given (131)I therapeutically. These groups were divided in subgroups of pre- and menopausal women (A1, B1 and A2, B2 respectively). The mean age of our patients in Groups A and B were 46 and 50 years with a range of 25-65 and 38-69 years respectively. Serum free triodothyronine (FT3), free thyroxine (FT4), thyroid stimulating hormone (TSH), thyroid peroxidase antibodies (AbTPO), antithyroglobulin antibodies (AbTG) and anti receptors of thyroid stimulating hormone antibodies (AbTSHR) were tested in all subjects studied by radioimmunoassays (RIA) or radioimmunometric assays (IRMA). All patients were under antithyroid treatment interrupted for about 10 days before the thyroid scan. Thyroid scintiscan was performed 24 h after oral intake of 1.8 MBq of (131)I. Clinical findings were evaluated by a clinical index of hyperthyroidism as modified by us. The time that the mGD appeared since the beginning of GD and the time the GD started were also studied. Our findings were as follows: A mean time of 10.35+/-6.7 years had elapsed from the start of GD till mGD was first diagnosed by us. A mean time of 3.1+/-1.6 years had elapsed after the start of the GD till patients of Group B were examined in this study. No difference in the values of FT3, FT4 and TSH between the two Groups or the Subgroups was found as expected because the clinical status of the patients varied. AbTG, AbTPO and AbTSHR were found in a much higher incidence and in higher values in Group A versus Group B (P=0.007 and 0.001 respectively) and in Subgroups A1, A2 versus B1 and B2 respectively. This increase was significant for AbTG and AbTPO in A2 versus B2 Subgroups and for AbTPO in A1 versus B1 Subgroups (P=0.007, 0.001 and 0.014 respectively). We were unable to find a similar work in the literature. In conclusion, we suggest that mGD as compared to GD: a)develops late in GD and thus patients had more relapses, b) has a higher incidence of abnormal values of AbTPO, AbTG and AbTSHR, c) has significantly higher values of AbTPO and less of AbTG than GD and d) thyroid hormones, clinical index of hyperthyroidism and the incidence of exophthalmos do not differ. Based on the above, we suggest that mGD is a late evolutionary type of GD. The study of patients of both sexes having GD of the same duration as mGD, the study of iodine metabolism and of thyroid gland pathology in these patients, is needed.

Peripheral parameters of oxidative stress in patients with infiltrative Graves' ophthalmopathy treated with corticosteroids

Infiltrative ophthalmopathy, which may develop in patients with Graves' disease, is considered an inflammatory disorder of autoimmune background. There is growing evidence that changed reactive oxygen species (ROS) metabolism plays an important role in pathogenesis of autoimmune diseases. Corticotherapy is a principal method of ophthalmopathy treatment, and its therapeutic effect is partially connected with influence on ROS generation systems. This study was undertaken to investigate corticosteroids treatment influence on blood extracellular indices of ROS metabolism in Graves' ophthalmopathy patients. Plasma indices of free radical generation and scavenging were determined in 22 euthyroid patients with active infiltrative Graves' ophthalmopathy initially, after intensive corticotherapy and after completing of steroid treatment. Age- and sex-matched 24 healthy volunteers and 25 euthyroid Graves' patients without overt ophthalmopathy served as controls. In the ophthalmopathy patients hydrogen peroxide (H(2)O(2)), lipid hydroperoxides (ROOH), thiobarbituric acid-reacting substances (TBARS) and ceruloplasmin (CP) levels and superoxide dismutase (SOD) and catalase (CAT) activities were increased, whereas glutathione peroxidase (GPx) and glutathione reductase (GR) activities were reduced. Intensive corticotherapy resulted in normalization (partial for ROOH) of ROS metabolism peripheral markers. After the withdrawal of corticosteroids a reduction of ophthalmopathy clinical activity was present, yet a marked restoration of increased oxidative stress indices was observed, along with activation of antioxidant defence systems (not significant for CAT activity). These data demonstrate that corticosteroids are effective in reduction of peripheral oxidative stress present in infiltrative Graves' ophthalmopathy, but this effect tends to be transient.

Signes cliniques de l’orbitopathie dysthyroïdienne

Dysthyroid ophthalmopathy is an inflammatory disease of the orbit, combined or not with thyroid disorders. However, pure ophthalmologic forms exist, and the diagnosis can be made by the ophthalmologist. The diagnosis is made by examining eyelid malposition, oculomotor disorders, inflammatory signs, proptosis measurement, and by the search for optic nerve pain. We discuss the NOSPECS classification, which can evaluate the severity and progression of the disease.

Thyroid-associated ophthalmopathy: a practical guide to classification, natural history and management

Thyroid-associated ophthalmopathy (TAO) is an autoimmune disorder that can be divided into three clinical subtypes: congestive, myopathic and mixed ophthalmopathy. It is probably caused by immune cross-reactivity between orbital and thyroid antigens. The best candidate antigens are the thyrotropin receptor and the novel protein, G2s, which is now identified as a fragment of the winged helix transcription factor, FOXP1. The relationship between radioiodine therapy and TAO is controversial, with two randomised controlled trials showing a transient worsening of the eye disease after treatment. The diagnosis of TAO is a clinical one, based on the presence of specific symptoms and signs. Orbital imaging, preferably magnetic resonance imaging, is useful when the diagnosis is in doubt and in patients with suspected optic neuropathy who may benefit from early intervention. Despite their lack of specificity, orbital antibodies may add weight to the diagnosis and may potentially be a useful tool in classifying the different subtypes of TAO and in monitoring disease activity. While antibodies against G2s and the thyrotropin receptor are seen in all subtypes, those against Fp and collagen XIII may be associated with the myopathic and congestive subtypes, respectively, where Fp is the flavoprotein subunit of the mitochondrial enzyme, succinate dehydrogenase. In most patients, TAO is self-limiting and no specific treatment is required. When treatment is indicated, glucocorticoids are the mainstay of therapy. Orbital radiotherapy improves the efficacy of glucocorticoids, but is probably less beneficial as monotherapy. Orbital surgery is best reserved for patients with 'burnt out' inactive disease, but urgent orbital decompression may be required for optic neuropathy. The severity and clinical activity of TAO are important in determining the need for specific treatment and the likelihood of success with medical therapy, respectively.

Orbital scintigraphy with the somatostatin receptor tracer 99mTc-P829 in patients with Graves' disease

Receptors for somatostatin (SST) (SSTR) are expressed on various tumor cells as well as on activated lymphocytes. Previous data have shown that (99m)Tc-P829 binds with high affinity to many different types of tumor cells as well as to leukocytes via the human hSSTR2, hSSTR3, and hSSTR5 target receptors. Consequently, (99m)Tc-P829 was successfully introduced as a peptide tracer for tumor imaging. In this study, we evaluated the orbital uptake of (99m)Tc-P829 in patients with active and inactive thyroid-associated orbitopathy (TAO), accompanied by lymphocyte infiltration in the acute stage and by muscle fibrosis in the chronic stage of the disease.

METHODS

To evaluate its clinical usefulness in Graves' disease, (99m)Tc-P829 scintigraphy (approximately equal to 740 MBq) was performed in 44 patients with TAO (median duration, 19 mo; range, 1-360 mo). The clinical activity of the orbital disease was graded by the NOSPECS (no signs or symptoms; only signs, no symptoms; signs only; proptosis; eye muscle involvement; corneal involvement; sight visual acuity reduction) classification of the American Thyroid Association, the clinical activity score (CAS), and the superonasal index (SNI). SPECT (360 degrees ) and planar studies were completed within 3 h after injection. Orbital (O) regions of interest (ROIs) were compared with temporoparietal and occipital (OCC) ROIs. Orbital uptake ratios in Graves' disease were compared with data obtained from lung cancer patients with no eye disease (n = 22).

RESULTS

Overall, (99m)Tc-P829 biokinetics were the same in Graves' disease patients as in lung cancer patients, showing a rapid blood clearance and visualization of the facial bones within minutes of injection. In all control patients, the orbit appeared as a "cold area," whereas visual orbital accumulation of (99m)Tc-P829 was found in patients with active TAO (O/OCC ratios: 1.26 +/- 0.04 vs. 1.69 +/- 0.04; P < 0.01, respectively). Patients with active eye disease (n = 25) presented with an increased orbital uptake of (99m)Tc-P829 compared with patients with inactive disease (n = 19; O/OCC ratio: 1.12 +/- 0.05; P < 0.01). A statistically significant correlation was found between CAS and the orbital uptake (O/OCC ratio) values (r = 0.90), whereas no correlation could be documented regarding the NOSPECS classification as well as the SNI.

CONCLUSION

In TAO, (99m)Tc-P829 yields high orbital binding with good clinical correlation. The better image quality due to the high energy of technetium, the lower radiation dose for patients and personnel, and the short acquisition protocol favor SSTR scintigraphy with (99m)Tc-P829 over (111)In-labeled compounds. The in-house availability of the radiotracer and cost-effectiveness are further advantages.

The role of Tc-99m polyclonal human immunoglobulin G scintigraphy in Graves' ophthalmopathy

OBJECTIVE

The aim of this study was to clarify whether Tc-99m HIG (Polyclonal Human Immunoglobulin G) can image and determine the severity of orbital involvement in patients with Graves' ophthalmopathy.

MATERIALS AND METHODS

Twenty-six patients between 19 and 56 years old with Graves' ophthalmopathy were examined. All patients received approximately 370 MBq Tc-99m HIG by i.v. injection. Planar and SPECT examination were performed 4 hours after the injection. Visual and semiquantitative evaluations were performed for both orbits by two independent observers,

RESULTS

Clinically active ophthalmopathy patients had noticeably increased orbital accumulation of Tc-99m HIG. In patients with inactive disease, and 14 of 19 had no uptake, whereas 5 patients had orbital radioactivity accumulation. The duration of Graves' ophthalmopathy did not correlate with the presence of active ophthalmopathy and Tc-99m HIG grade. There was no correlation between clinical classification and clinical activity (r = 278). There was a good correlation between clinical activity and the radioactivity grade with r = 0.666 (p = 0.01). The clinical classification closely correlated with Tc-99m HIG grade (r = 0.423, p = 0.05).

CONCLUSION

Tc-99m HIG scan can clearly identified clinically active patients, and subclinicial inflammation can be shown by this scintigraphic evaluation. The current preliminary results suggested that Tc-99m HIG SPECT might be useful for the assessment of disease activity in Graves' ophthalmopathy.

Classification and prediction of the progression of thyroid-associated ophthalmopathy by an artificial neural network

OBJECTIVE

We have used an artificial neural network in an attempt to classify and predict the progression of thyroid-associated ophthalmopathy (TAO) at the first clinical examination.

DESIGN

This retrospective comparative case series included a group of patients examined by the ophthalmologist only once because of the absence of signs of progressive disease (GR1), as subsequently monitored by an endocrinologist, and a group of patients on follow-up because of progressive disease (GR2).

PARTICIPANTS AND METHODS

We examined 242 patients, of whom 207 were women and 35 were men. GR1 included 129 patients (257 eyes) who, on ophthalmologic assessment, were further classified as having no TAO (n = 53; GR1a) and only lid signs or inactive, stable TAO (n = 76; GR1b). GR2 included 113 patients (219 eyes). One hundred three normal subjects (205 eyes), 50 women and 53 men, were tested to provide normal ranges for proptosis values. We applied a model of back propagation neural network with 17 input variables, a training matrix of 414 observations, a randomly selected test group of 115 observations, and, as output, the progression of disease. The ophthalmologic assessment included (1) lid fissure measurement, (2) Hertel, (3) color vision, (4) cover test and Hess screen, (5) visual acuity, (6) tonometry, (7) fundus examination, (8) visual field, and (9) orbital computed tomography scan or ultrasonography. Other parameters included in the neural analysis were gender and age of the patients, their cigarette smoking, and the interval between follow-up visits.

RESULTS

The prevalence of smokers among patients without TAO was significantly lower than that among those with TAO (P < 0.03). Mean proptosis values (Hertel) were significantly different in GR1, in GR2, and in a group of normal eyes (P < 0.0001), and the changes of values in consecutive measurements were associated with progression of the disease (P < 0.01). Differences of the proptosis values in the two groups of patients were not related to smoking. The neural network correctly classified 78.3% of 115 eyes (87 patients) and predicted TAO progression in 69.2% of 39 eyes (28 patients).

CONCLUSIONS

In our opinion, neural network analysis can be successfully applied for classifying TAO and predicting progression at the first clinical examination.

Prediction of the progression of thyroid-associated ophthalmopathy at first ophthalmologic examination: use of a neural network

In the present work we analyzed patients with thyroid-associated ophthalmopathy (TAO) at various clinical stages of disease progression and implemented a model of neural analysis for disease classification and prediction of progression. We studied 246 patients (group 1), seen only once because they had absent, minimal, or inactive TAO and 152 patients (group 2), seen two or more times because of active and/or progressive TAO. The ophthalmologic assessment included: (1) lid fissure measurement; (2) Hertel; (3) color vision; (4) cover test and Hess screen; (5) visual acuity; (6) tonometry; (7) fundus examination; (8) visual field; (9) orbital computed tomography (CT) scan or ultrasound. A back propagation model of neural network was based on the relative variations of 13 clinical eye signs (input variables) for classification and prediction of disease progression (output variable). Approximately 300 eyes (20%) were randomly selected as a test group. Correlation between expected and calculated patients' classification was highly significant (p < 0.00001). Concordance between clinical assessment and the neural network prediction was obtained in 78 of 117 eyes (67%). We have developed a neural model that allows classification of TAO and preliminary prediction of disease progression at the first clinical examination. The results are validating the classification into the two groups on which our initial assumption was based.

[Endocrine orbitopathy--diagnosis]

Various modifications of classic Werner classification for endocrine orbitopathy are used. The application of this NOSPECS-scheme on the ocular and periocular changes in Graves' disease is discussed.

[Treatment results in 25 patients with Graves' ophthalmopathy between 1998 and 2001]

In our outpatient clinic 25 patients with Graves' ophthalmopathy were treated, 21 women, mean age 58.8 years (range 19-74 years) and 4 men, mean age 47.5 years (range 38-56 years). In the female group two showed euthyroid Graves' ophthalmopathy and one Hashimoto's disease; in the male group one showed euthyroid ophthalmopathy. Treatment was done depending on the findings of the NOSPECS-classification in identical way for each group. Final results were obtained three and six months after therapy, at that time all patients were euthyroid. In five patients (two men and three women) sicca-treatment was sufficient because the ophthalmopathy improved by therapy of the thyroid disease only. Three women were treated by oral steroids over three months and had a complete remission. Nine women were treated by oral steroids and external radiation, six of them showed major improvement but in one case orbital decompression had to be done. Somatostatin therapy was done over six months in six women who showed no change after oral steroids plus radiation. Out of them five showed major improvement but in spite of a positive octreoscan in one case orbital surgery had to be performed. Two men were treated by oral steroids and external radiation without change of disease, somatostatin therapy was not done because of a negative octreoscan. With the exception of one nonsmoking woman in whom orbital surgery had to be done, the treatment results were worse in smokers.

Graves' ophthalmopathy: natural history and treatment outcomes

BACKGROUND

The pathogenesis of Graves' ophthalmopathy has not been yet clarified, and from a therapeutic standpoint Graves' ophthalmopathy remains an enigma. The natural course and effects of different treatment regimens are poorly documented.

RESULTS

The mean observation period was 3.23 years (1-8.9 years) for all 196 patients, and 2.85 years (1-8.9 years) for the 81 patients with Graves' ophthalmopathy. The gender distribution was 77% female and 23% male in patients with Graves' disease and ophthalmopathy, and 81% female and 19% male in those patients without ophthalmopathy (p = 0.57). Seventy per cent of the patients developed Graves' ophthalmopathy within 12 months before or after the onset of the hyperthyroidism. Among the 81 patients with ophthalmopathy 53 (65%) received no therapy or only local protective agents. Twenty-five of these patients improved substantially, 26 did not change, and 2 deteriorated progressively. These results were independent of the severity of the EO (p = 0.42). Among the 11 patients initially treated with systemic corticosteroids 7 improved, 3 did not change, and 1 worsened. Five patients received initially orbital irradiation. Three improved and 2 did not change after radiotherapy. Orbital decompression was performed in 3 patients. Nine patients received a combination treatment.

CONCLUSION

In conclusion, our study of a relatively large patient sample revealed the known epidemiological facts regarding Graves' disease and endocrine ophthalmopathy. The majority of patients needed no therapy or only local protective agents, and 47% improved spontaneously. Systemic corticosteroids and orbital irradiation appear to be equally effective as initial treatment in patients with more severe forms of Graves' ophthalmopathy.

Clinical significance of classification of Graves' disease according to the characteristics of TSH receptor antibodies

BACKGROUND

It has been widely accepted that the epitope(s) and/or functional characteristics of thyrotropin receptor antibodies (TSHRAb) from Graves' patients are heterogenous among patients. However, the clinical significance of such heterogeneity has not been systematically evaluated yet. We were to elucidate and find the clinical significance of heterogeneity for TSH receptor antibodies in Graves' disease.

METHODS

We measured stimulating TSHRAb (TSAb) activities using CHO-hTSHR cells, FRTL-5 cells and chimeric receptor expressing cells (Mc1 + 2 and Mc2), specific blocking TSHRAb (TSBAb) activities using Mc2 cells and TBII activities using porcine thyroid membrane in 136 patients with untreated hyperthyroid Graves' disease.

RESULTS

Based on various TSHRAb activities from each patient, the patients could be categorized into 7 subgroups by cluster analysis; 1) Group 1 (n = 41) was characterized by moderate TSAb activities both in CHO-hTSHR cells and in FRTL-5 cells, typical TSAb epitope, rare blocking antibodies and high TBII activities. 2) Group 2 (n = 16) was characterized by the presence of blocking TSHRAb in most patients, albeit the other characteristics were the same as those in Group 1. 3) Group 3 (n = 19) patients had low TSAb activities both in CHO-hTSHR cells and in FRTL-5 cells, seldom had blocking TSHRAb, but they had high TBII activities. 4) Group 4 (n = 30) could be categorized as 'mild disease' group, as they had low activities in all kinds of TSHRAb assay and had low antimicrosomal antibody activities. 5) Group 5 (n = 14) was characterized by moderate TSAb activities with atypical epitope(s), rare blocking TSHRAb and moderate TBII activities. 6) Group 6 (n = 10) patients had very high TSAb activities with typical epitopes, seldom blocking TSHRAb and low TBII activities. 7) Group 7 (n = 6) was characterized by very high TSAb activities with atypical epitopes and high TBII activities. Pretreatment serum thyroid hormone level was low only in group 4 patients compared to the other 6 groups (p < 0.05). The size of goiter was significantly larger in those in group 1 and group 3 (p < 0.05) compared to the other 5 groups. The prevalence of clinically significant ophthalmopathy was higher in group 2 patients than the other 6 groups (50% vs. 27.5%, p = 0.06). Among 6 kinds of TSHRAb activities, only the blocking TSHRAb activity was significantly associated with the presence of ophthalmopathy in multivariate analysis.

CONCLUSION

These results suggest that the differences in epitopes for TSAb or the presence of blocking TSHRAb is not a major factor in determining the degree of thyrotoxicosis in Graves' disease. Although the pathogenic mechanism is not clear yet, we suggest that patients with ophthalmopathy have different TSHRAb repertoire from those without ophthalmopathy in Graves' disease.

Alterations of the internal reflectivity of extra-ocular muscles associated with several clinical stages of Graves' ophthalmopathy

In the period between February 1992 and June 1996, the authors performed extra-ocular muscle echobiometry on 163 patients with Graves' disease. The aim of this study is the evaluation of changes occurring in several clinical stages. The authors noted an increase in internal muscular reflectivity in the advanced phases and an irregular structure in the early stages. Controversial results in the literature warrant mastery of the method and further research.

Graves-Basedow disease goiter: a model of Bax-Bcl2 regulated apoptosis

This study demonstrates the involvement of a Bax-Bcl2-dependent apoptotic process in Graves-Basedow thyroid disease, a pathological condition known for its spontaneously oscillating evolution. A continuous series of 86 cases of surgically treated Graves' thyroid was evaluated for apoptotic cell content identified by histological criteria and confirmed by terminal desoxynucleotidyl transferase-mediated desoxyuridine triphosphate nick end-labeling (TUNEL). A significant correlation was found between tissue features of Graves' disease (epithelial hyperplasia, cellular hypertrophy, colloid content) and the amount of apoptotic cells. No correlation was found with lymphocytic infiltrates. Significantly, 11 cases (about 12% of the series) with high-level apoptosis displayed the typical features of active Graves' disease over all tissue sections. In contrast, cases with no detectable apoptosis exhibited regressive tissue features of Graves' disease. An intermediate group of cases was characterized by tissue heterogeneity with hyperactive foci, rich in apoptosis, alternating with regressive areas lacking apoptosis. In this group the participation of apoptosis to the remodeling of Graves' thyroid parenchyma, in a tight balance with cell proliferation, was best illustrated. Moreover, the thyroid follicle by accumulating apoptotic cells and bodies, allowed a tentative chronological ordering of apoptosis steps in correlation with Bax-Bcl2 tissue distribution and cellular pattern. Our observations suggest that the initiation of apoptosis corresponds to a loss of cellular cohesion, a drop in Bcl2 expression, and a delocalization of Bax from a putative Golgi storage location to a mitochondrial distribution.

[Graves' ophthalmopathy--a prospective clinical study]

Graves' disease is an autoimmune disorder, progressive and with a variable evolution. In 10-25% of cases, thyroid ophthalmopathy (or dysthyroid ophthalmopathy) occurs in the absence of both clinical and biochemical evidence of thyroid dysfunction. In patients with Graves' disease, ocular modification may precede, coincide with or follow of Graves' disease. Dysthyroid ophthalmopathy has in 85% of cases bilateral proptosis more than a half in unilateral proptosis.

[Endocrine orbitopathy: comparison of the long-term result and classification after radiotherapy]

BACKGROUND

This study compares 4 classifications in patients with progressive refractory Graves orbitopathy (GO) and examines their prognostic value in long-term follow-up.

PATIENTS AND METHODS

From 1984 to 1994, 60 consecutive patients (49 female, 11 male) received 20 Gy (10 x 2 Gy) radiotherapy with 6 MV Linac photons. Ocular symptoms and functional impairment was evaluated according to 4 GO-classification systems: Werner-, modified ATA- and Stanford-Score and Ophthalmopathy-Index (OI) according to Grussendorf. In addition, all patients noted their subjective response on a linear scale (0 to 100%).

RESULTS

Improvement was achieved within 1 year after radiotherapy according to the Werner-Score in 28 (47%) patients in > or = 1 symptom category, according to the modified ATA-score in 48 (80%), the Stanford-score in 47 (78%) and the OI-Score in 55 (92%) patients (reduction of > 2 points). The Werner-Score correlated less to the other scores (coefficient r < 0.5) than the other scores among themselves (r approximately 0.9). The ATA-Score improved in the different symptom categories between 47% (stage VI) and 87% (stage V). The OI-Score was reduced by a mean of 6 points. The patients reached a mean subjective improvement of +70 +/- 25%. Acute or chronic side effects were not observed. In multivariate analysis the "male gender" (p = 0.08), a "symptom duration prior to radiotherapy > 1 year" (p = 0.14) and a "high symptom category" (p = 0.11) indicated a negative prognostic trend.

CONCLUSIONS

External radiotherapy is effective for severe, progressive GO after pretreatment. A minimum follow-up of at least 12 months and standardized classification and success criteria are required.

Saccadic eye movements in Graves' disease

PURPOSE

To describe the saccades made by patients with Graves' disease (GD) and to attempt to distinguish these objectively and quantitatively from the saccades in control subjects.

METHODS

In 12 euthyroid patients with GD, the saccades of both eyes were recorded simultaneously with electromagnetic search coils. Subjects were asked to alternate their gazes between two fixed targets that were 10 degrees, 20 degrees, 30 degrees, or 40 degrees apart along each horizontal or vertical meridian. The data from the patients with GD and those from the similarly recorded group of 12 control subjects were examined in two ways. First, the difference in saccadic sizes between the two eyes was assessed. Second, the saccadic dynamics--that is, the maximum velocity and the saturation constant of the main sequence--were determined for each eye. Repeated measurement analysis of variance was used to test observed differences between the two groups. Finally, through exact logistic regression analysis, classification of the saccades as those of a patient with GD or of a control subject was carried out.

RESULTS

The saccades of patients with GD were generally less conjugate than those of control subjects (P < 0.05). On average, the maximum main sequence velocities in patients with GD were lower than in control subjects (P < 0.05). The saccades of patients with GD were well differentiated from those of control subjects.

CONCLUSIONS

The saccades in GD may differ markedly from normal saccades, and the two can be reliably distinguished.

[Radiotherapy only in severe, progressive endocrine orbitopathy: long-term results and comparison of various classification systems]

BACKGROUND

Therapeutic results after radiotherapy in thyroid associated orbitopathy (TAO) often are not comparable, because either different therapeutic methods at the same time or different scores were used in the evaluation. This study focuses on radiotherapy alone by means of different evaluation scores.

PATIENTS AND METHODS

60 patients (49 women, 11 men) received standard external beam radiotherapy (20 Gy: 10 fractions of each 2 Gy) as ultima ratio after failing different other therapies of thyroid associated orbitopathy. The mean interval from beginning of the symptoms to the radiotherapy was 17 +/- 36 months (between 6 and 240 months). The follow up was documented--classified by means of 4 different scores--before radiotherapy, 6-12 weeks, 1 year after radiotherapy and at last follow up. The changes of symptom categories or grades of the different scores were analysed.

RESULTS

Significant changes of the ophthalmic scores were observed when comparing the endpoints at 6-12 weeks, and at 1-year follow up after radiotherapy. The "classical" Werner score at 12 months follow up did not correlate well with the other TAO scores: American thyroid association (ATA) scoring system, Stanford scoring system, International ophthalmopathy index, while all other TAO scores revealed a high correlation among each other. According to the Orbitopathy Index (OI) of Grussendorf an improvement from 14.2 points to 6.0 points was achieved. Soft tissue involvement and corneal involvement demonstrated the highest response rate (83/87%), extraocular muscle involvement and proptosis a good response rate (69/70%). No long-term complications were observed.

CONCLUSION

According to this study there are indications that external beam radiotherapy is a suitable therapy even after pretreatment and a longer course of TAO. The OI, the ATA and the Stanford scoring systems lead to similar results in the assessment of thyroid orbitopathy.

Changes in epitopes for thyroid-stimulating antibodies in Graves' disease sera during treatment of hyperthyroidism: therapeutic implications

To determine whether there are changes in epitope recognition by stimulating TSH receptor antibodies (TSHRAbs) during treatment of hyperthyroidism and to evaluate the clinical relevance of such changes, we serially measured the activity of IgG preparations from 39 patients with Graves' disease over an 8-month period. To measure epitope changes of the stimulating TSHRAbs, we used Chinese hamster ovary (CHO) cells transfected with wild-type human TSHR (hTSHR) or TSHR chimeras with residues 90-165 (Mc2) substituted by equivalent residues of the rat LH/CG receptor. When initially examined, 37 of the 39 patients had significant stimulating TSHRAb activity measured with wild-type CHO-hTSHR cells. Serial measurements of stimulating TSHRAb activity in Mc2 chimera-transfected cells divided the 39 patients into three distinct groups. Thus, 10 patients (heterogeneous epitope group) exhibited low but significant activity in Mc2 chimera assays at the start of the study; 10 patients who were initially negative in Mc2 chimera assays remained negative (persistently homogeneous epitope group); and 19 patients who were initially negative in Mc2 chimera assays became transiently or persistently positive during treatment, despite a simultaneous decrease in TSHRAb activity measured with wild-type TSHR (changing epitope group). The functional stimulating TSHRAb epitope thus changed from residues 90-165 to residues outside this region in the last group, which comprises nearly two-thirds of the initially Mc2-negative patients (19 of 29) and one-half of all patients (19 of 39). Patients in the changing epitope group responded more quickly and to lower doses of methimazole than patients in the persistently homogeneous epitope group, behaving in this respect exactly as the patients in the heterogeneous epitope group. Additionally, although the decrease in stimulating TSHRAb activities during the 8-month treatment period was similar in the two groups, the thyrotropin binding inhibitor immunoglobulin (TBII) activities decreased more rapidly in patients in the persistently homogeneous epitope group than in patients in the changing epitope group (P < 0.05). There were no differences in initial stimulating TSHRAb or TBII activities, degree of hyperthyroidism, goiter size, or prior duration of symptoms between the persistently homogeneous epitope group and changing epitope group. In summation, we show that the epitopes of stimulating TSHRAbs in Graves' disease patients may change during their clinical course or treatment period, and that the change is from antibodies recognizing N-terminal TSHR residues 90-165 to antibodies recognizing other regions of the TSHR. We also show that the development of stimulating TSHRAbs with this heterogeneous epitope or their presence at the initial screening for disease activity seems to be associated with increased responsiveness to antithyroid drug therapy. We suggest, therefore, that Mc2 chimera assays may be useful to predict the response of patients to antithyroid drug therapy.

Soluble intercellular adhesion molecule-1 concentrations in patients with subacute thyroiditis and in patients with Graves' disease with or without ophthalmopathy

Increased circulating soluble ICAM-1 (sICAM-1) levels has been previously reported in Graves' disease (GD) patients with or without ophthalmopathy (GO) and in patients with toxic nodular goiter but not in patients with subacute thyroiditis. Conflicting results have also been reported about the usefulness of sICAM-1 levels as a marker for the activity of hyperthyroidism. We have therefore determined sICAM-1 levels by a sandwich enzyme linked immunosorbent assay (ELISA) method in 10 patients with subacute thyroiditis (Group 1), who are at the initial or acute phase of thyroiditis, in 10 hypothyroidic patients with Hashimoto's thyroiditis (Group 2), in 10 patients with euthyroid nodular goiter (Group 3), in 10 patients with untreated GD patients with active ophthalmopathy (Group 4), in 10 hyperthyroid GD patients without clinical ophthalmopathy (Group 5), in 10 patients with GO who are euthyroid and treated with glucocorticoids for 3 months (Group 6) and in 20 normal subjects (Control Group). Groups 1,2,4,5 and 6 (P < 0.00001 for Groups 1,4,5,6 and P < 0.05 for Group 2) but not Group 3 showed increased sICAM-1 levels compared with the control group. However Groups 4 and 6 (patient with GO) showed significantly higher sICAM-1 levels (P = 0.0003 for Group 4 and P = 0.00013 for Group 6) than Group 5. Furthermore Group 4 showed slightly but not significantly higher sICAM-1 levels than Group 6. Mean sICAM levels were significantly decreased 3 months after glucocorticoid treatment (Group 6), but had not returned to normal levels. Three patients did not respond to steroid therapy and their sICAM-1 levels were not decreased. We concluded that patients with GO with or without hyperthyroidism and patients with subacute thyroiditis have elevated sICAM-1 levels. Moreover, sICAM-1 levels reflect the degree of inflammatory activity in the thyroid gland or orbital tissue independent of the thyroidal status, since we found elevated levels in both hyperthyroidism and hypothyroidism.

[Morphology and clinical aspects of immune thyroid diseases]

The aetiopathogenesis of autoimmune thyroid disease is still a matter for discussion. Morphologically, these illnesses are associated with a broad spectrum of overlapping changes. Thus, pathology cannot serve as the logical basis for a new classification. Therefore this overview makes use of the conventional nomenclature of clinically established entities and includes recently defined lesions. Besides histological characteristics, details of differential diagnostic value are presented in the context of clinical and laboratory data relevant for pathological classification.

Evolution of classification systems for Graves' ophthalmopathy

Numerous classification schemes for Graves' ophthalmopathy have been proposed in the past 50 years. The evolution of these systems, culminating in the consensus document created by the major international thyroid societies, is reviewed.

Subgroups of Graves' patients identified on the basis of the biochemical activities of their immunoglobulins

Graves' patient immunoglobulins (IgG) are known to activate adenylyl cyclase. Recently, we have shown that they also stimulate phospholipase A2 (PLA2). Here we analyze the relationship of these biochemical activities of Graves' IgG to thyroid growth in vitro ([3H]thymidine incorporation) and in vivo (patient goiter size) as well as to clinical indicators of severity of the disease, such as ophthalmopathy, T3 levels, T3/T4 molar ratio, and TSH binding-inhibiting IgG activity. A cluster analysis of the biochemical parameters referring to the whole population (158 subjects) led to the identification of 4 subgroups of Graves' patients based on the different capabilities of IgG to stimulate adenylyl cyclase, PLA2, and [3H]thymidine incorporation. Importantly, a trend of increasing severity of the disease from group 1 to group 4 could be identified. In particular, patients in group 4 (characterized by elevated stimulation of adenylyl cyclase, PLA2, and [3H]thymidine incorporation) had the largest goiter, highest serum concentration of T3, highest T3/T4 molar ratio, and highest prevalence of ophthalmopathy. These results indicate that Graves' IgG induce thyroid growth by stimulating both adenylyl cyclase and PLA2, and suggest a method for the subclassification of Graves' patients that identifies four groups with different degrees of severity of the disease. Moreover, this classification might lead to the targeted use of a novel therapeutic approach based on the inhibition of PLA2 and arachidonic acid metabolism.

[The current role of radiotherapy in immunogenic exophthalmos]

In this study, the value of radiation therapy was investigated in 41 patients with Graves' ophthalmopathy treated with orbital irradiation at the Radiotherapy Department of Mauriziano Hospital in Turin, 1986 through 1993. Our series consisted of 41 patients (32 women and 9 men), whose mean age was 53.6 years (range: 26-72 years). All patients had a high index of endocrine ophthalmopathy, based on the American Thyroid Association classification-NOSPECS classes III and IV. Irradiation was administered with two opposed convergent beams tilted posteriorly 5-10 degrees with 20 Gy/12 fractions/2 weeks. The total dose delivered to the lens was than 5%. The follow-up consisted of endocrinologic and ophthalmologic tests and, if possible, of pre/post-irradiation orbital US. A positive result was obtained in 31 patients, which was very good in 22 of them. Severe complications, i.e., 1 corneal ulceration and 3 cataracts, were observed in the patients with associated ocular conditions and were treated simultaneously with high-dose corticosteroids so that no direct and unquestionable correlation can be made between irradiation and complications. To conclude, our data show that radiation therapy can improve the signs and symptoms of Graves' disease, as many authors report.

Age and gender influence the severity of thyroid-associated ophthalmopathy: a study of 101 patients attending a combined thyroid-eye clinic

BACKGROUND

The pathogenesis of thyroid-associated ophthalmopathy is thought to be autoimmune, although environmental and genetic factors are also considered to be important. As the morbidity of thyroid-associated ophthalmopathy is considerable and treatment often unsatisfactory, there a need to identify possible predisposing factors.

OBJECTIVE

The study was undertaken in order to ascertain the relationship between age, gender and severity of thyroid-associated ophthalmopathy.

PATIENTS

One hundred and one consecutive patients with thyroid-associated ophthalmopathy who presented over a period of 5 years to a combined thyroid-eye clinic.

METHODS

Patients were assessed by grading their inflammatory signs and degree of diplopia, and by measurement of exophthalmos, palpebral aperture, differential intraocular pressure, and visual acuity. On the basis of the above an ophthalmopathy index was devised to grade the overall severity of eye disease.

RESULTS

The mean age was 49.2 years (SD 13.4), the female-to-male ratio was 4.05, and mean ophthalmopathy index 6.49 (SD 3.3). Optic nerve compression was present in 9.9% of patients. There was a positive relationship between age and ophthalmopathy index (P < 0.001); after correcting for age, males had an average ophthalmopathy index 41% greater than that of females.

CONCLUSION

There is an association between severity of thyroid-associated ophthalmopathy and (i) advancing age and (ii) female-to-male ratio, which has not been previously described. Patients over the age of 60 (particularly males) with Graves' disease appear to be at risk of developing severe eye disease.

Orbital decompression for preservation of vision in Graves' ophthalmopathy

Graves' ophthalmopathy (thyroid eye disease) can result in progressive visual loss. The University of Washington (Seattle) experience in orbital decompression was reviewed for the years 1983 through 1990 to determine overall safety and outcome. Twenty patients underwent transantral decompression of 36 orbits for either steroid therapy failure, steroid therapy intolerance, or recurrence of optic neuropathy with tapering of the steroid therapy. Decompression successfully improved visual function in 33 of the orbits (92%) and a second decompression procedure was successful in another two (5%) of the orbits (6%). There were no major complications or cases of decreased visual function. Diplopia, present preoperatively in 17 patients (85%), was improved in eight patients (47%) and unchanged in nine patients (53%). However, of the three patients without preoperative diplopia (15%), one had development of new-onset diplopia postoperatively. Transantral decompression of the orbit offers a safe and effective therapeutic modality for vision-threatening Graves' ophthalmopathy.

Smoking and risk of Graves' disease

OBJECTIVE

To assess if smoking is associated with Graves' disease and, if so, to ascertain whether this association persists when controlling for confounding factors.

DESIGN

Consecutive entry case-control study with two age- and sex-matched control subjects from two different populations per case patient.

SETTING

University hospital.

PATIENTS

Five groups were studied: (1) Graves' ophthalmopathy and Graves' hyperthyroidism (n = 100; divided in four subgroups according to the severity of the eye disease); (2) Graves' hyperthyroidism without clinical eye involvement (n = 100); (3) sporadic nontoxic goiter (n = 100); (4) autoimmune hypothyroidism (n = 75); and (5) toxic nodular goiter (n = 75). The study comprised 200 subjects from a hospital-based population, and 200 from a population-based group served as control subjects.

MAIN OUTCOME MEASURE

Smoking status was determined from a questionnaire at the time of onset of the disease to exclude any effect of the disease itself on smoking.

RESULTS

Smoking greatly increased the risk for Graves' ophthalmopathy (odds ratio, 7.7; 95% confidence interval, 4.3 to 13.7), but patients with Graves' hyperthyroidism alone were also more often smokers than control subjects (odds ratio, 1.9; 95% confidence interval, 1.1 to 3.2). Smoking was not associated with the other thyroid diseases studied. Essentially similar results were obtained after adjustment for differences in education between case patients and control subjects. Among the patients with Graves' ophthalmopathy, smokers had more severe eye disease than nonsmokers, but no association was found between the number of cigarettes smoked per day or the duration of smoking and the severity of the ophthalmopathy. However, there was a significant increase in the odds ratios in patients with more severe eye disease.

CONCLUSIONS

Smoking is associated with Graves' disease, and it especially increases the risk for the development of more severe ophthalmopathy. Thus, smoking appears to be one of the multiple factors inducing Graves' disease in genetically predisposed individuals.

A new classification for human autoimmune thyroid disease

We propose a new classification for the human autoimmune thyroid diseases including Graves' disease and Hashimoto's disease. The system proposed involves redefining the term "thyroiditis" and recognition that all clinicians need to speak the same language of medicine whatever their specialty and whatever their nationality. Major advances in our understanding of autoimmune mechanisms suggest that a new classification can add considerable clarity to clinical definitions.

[A clinical analysis of Graves' ophthalmopathy and ophthalmic Graves' disease]

Clinical analysis of 29 cases of Graves' ophthalmopathy and 71 cases of ophthalmic Graves' disease showed that both identities had common ocular features of lid retraction, upper lid lag and exophthalmos, while Graves' ophthalmopathy tended to occur in later life, with longer morbid course, marked systemic symptoms and binocular involvement in contrast to ophthalmic Graves' disease. The clinical and differential diagnoses and treatment of the maladies were discussed.

[Computerized tomography of the orbit in Graves' ophthalmopathy. New observations]

In order to evaluate Graves' ophthalmopathy new CT parameters have been introduced such as: the diameters of the five extraocular muscles, the value of their addition, the grade of apical crowding, the enlargement of optic nerve sheaths and of the superior ophthalmic vein, and the anterior displacement of the lacrimal gland. On this subject we report our further experience after reviewing 68 cases in which the new ocular parameters were correlated with altered ocular motility and optic neuropathy. The results confirmed our previous study, dealing with several groups of patients, which at the moment seem to be 2, instead of 3 groups: a) patients with increase in both muscular and fatty tissue (54/68 cases); b) patients with main or exclusive increase in fatty tissue (14/68 cases). Relevant clinical signs were present only in the first group of patients, where the medial, inferior and superior muscles were affected in 53/55, 53/55 and 50/55 cases respectively. A muscle increase by nearly 50% was more frequently found in cases with altered ocular motility, an increase by 90% was often associated with optic neuropathy. In case of optic neuropathy apical crowding was often observed, mainly in coronal scans, together with significant enlargement of the optic nerve sheath and of the superior ophthalmic vein. As to proptosis, preseptal area and anterior displacement of the lacrimal gland, they demonstrated lower correlation with the reference symptoms, even though their occurrence was high in symptomatic patients.

[Correlation between syndrome types of traditional Chinese medicine and peripheral T lymphocytes subsets in Graves' disease]

This paper reports the determined results of OKT3, OKT4, OKT8, ERFC, smIg and CIC, TMCA, TGA in 31 cases of Graves disease and in 20 normal controls. The results showed that the OKT3, OKT4, OKT8, ERFC were significantly lower than those in the normal controls, whereas the smIg was higher than that in normal controls. The difference between the two groups was very significant. Even though the ratio of OKT4/OKT8 showed no significance of both. Typology of Graves disease according to the theory of TCM, all 31 cases were divided into two types: (1) 14 cases of depression of Liver-energy and asthenia of Spleen; (2) 17 cases of deficiency of yin leads to hyperactivity of Fire. The OKT8 and the ratio of OKT4/OKT8 in the latter respectively were lower and higher than those of the former. The difference between the two types was significant (P less than 0.01, P less than 0.05) whereas the positive rates of the CIC, TMCA, TGA also were higher in the deficiency of Yin leads to hyperactivity of Fire than those in the depression of Liver-energy and asthenia of Spleen. After treatment with combined TCM-WM on 31 cases of Graves disease, it was found that the OKT4, OKT8, ERFC were significantly elevated, the smIg was markedly decreased than those without treatment. It was also found that smIg markedly decreased in two types, OKT8, ratio of OKT4/OKT8 in the latter and ERFC in both types all returned to normal. Remainder indexes had no obvious change before and after treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Why the NOSPECS classification of Graves' eye disease should be abandoned, with suggestions for the characterization of this disease

The NOSPECS classification of Graves' eye disease is inadequate for a number of reasons: (a) poor characterization of the condition with no indication of disease activity, marked underrepresentation of eyelid position, and overrepresentation of corneal problems, (b) it represents neither a continuous nor stepladder progression of disease as the numbered classification would suggest, (c) parts of it are subjective, and (d) the gradings of classes 3, 5, and 6 are poor. Graves' eye disease should be characterized rather than classified, using objective clinical assessments of optic nerve function, proptosis, ocular motility, and eyelid position. It is recommended that a multicenter clinical trial be done to determine the significance of different values and changes in values for each assessment. Disease activity is to be defined by the clinical trial in terms of changes of the four assessments as a function of time. This should produce a simple characterization that would create an image of the patient's eye problems for a knowledgeable physician and be sufficient to guide decisions on whether currently accepted surgical therapies are advisable. Data from the clinical trial would enable the characterization to predict the likelihood of success of various immunosuppressive therapies.

Classification of the eye changes of Graves' disease

Classification of the eye changes of Graves' disease may have clinical use in the description of the present eye state, in the assessment of treatment results, and in the choice of therapy. Requirements for any classification system should include simplicity, clinical nature (i.e., easily carried out by any physician equipped with ordinary noninvasive techniques), reproducibility and meaningfulness (i.e., objective and of clinical relevance to the patient). The NOSPECS system (although it can be improved) is suitable for pure description. It is not very helpful in the assessment of treatment results. Therapeutic outcome probably is best described by measuring quantitatively changes in visual acuity, eye muscle motility, and proptosis. Such an approach, however, does not solve the problem of whether or not the overall outcome is a success in the patient with improvement in one aspect but worsening in another item. A recently developed clinical activity score may be helpful in the selection of therapy, especially for deciding whether or not immunosuppressive therapy should be instituted.

Clever is not enough: NOSPECS is form in search of function

The NOSPECS mnemonic helps students to examine systematically the eyes and orbits of patients with Graves' ophthalmopathy. NOSPECS and related numerical indices are unsuited to recording the results of treatment for Graves' ophthalmopathy because they do not distinguish between primary causes and secondary events. They do not discriminate between what is important and what is not. They do not reflect the effectiveness of treatment directed toward only one component of the index. An alternative is proposed in which investigators conducting clinical trials are asked to specify the potential benefits of therapy. Specific measurements are suggested that may be used in support of each claim. These data should be provided separately, not lumped in an overall index.

[CT of the orbit in Graves' ophthalmopathy]

Fifty patients suffering from Graves' disease underwent CT examination of the orbit. The medical rectus width was measured, together with the degree of proptosis and the value of the preseptal area, in order to evaluate the volumetric increase in both the muscle and the fatty tissue. The three parameters were correlated with disorders of ocular motility and with optic neuropathy. The results indicate the presence of 3 classes of patients; a) with main or exclusive increase of muscular tissue; b) with main or exclusive increase of fatty tissue; c) with increase of both muscular and fatty tissues. Only in patients from class c) disorders of ocular motility and optic neuropathy were seen to occur.

Secretory IgA and lysozyme in tears of patients with Graves' ophthalmopathy

Using an enzyme linked immuno-assay (ELISA) and spectrophotometry, we determined levels of secretory IgA and lysozyme in tears of 69 patients with Graves' ophthalmopathy and 28 controls. The quantitative determination of secretory IgA and lysozyme in tears provided an impression of the functioning of the lacrimal gland in the two groups. An IgA/lysozyme ratio was calculated in both patients and controls as a parameter for the activity of the secretory IgA-producing plasma cells in the lacrimal gland. An increase in the IgA/lysozyme ratio was observed in 23 patients (33%) and one control (3%). Half of the patients who had suffered from the disease for more than 5 years showed a raised IgA/lysozyme ratio. No correlation was found between the IgA/lysozyme ratio and the NOSPECS classification. Our findings suggest that the lacrimal gland is involved in the orbital condition produced by Graves' ophthalmopathy. In most cases the involvement occurs in patients with a long history of the disease.

Clinical criteria for the assessment of disease activity in Graves' ophthalmopathy: a novel approach

Patients with serious inflammatory Graves' ophthalmopathy should be treated with anti-inflammatory drugs or radiotherapy to prevent complications like fibrosis, while those with non-inflammatory ophthalmopathy may be treated by surgery immediately. It is often difficult, however, to distinguish inflammatory from non-inflammatory Graves' disease. We therefore present a simple clinical classification here to differentiate between these two conditions. This classification is based on the classical signs of inflammation--pain, redness, swelling, and impaired function. After two consecutive clinical examinations an 'activity score' can be determined, ranging from 0 to 10 points. In a retrospective study testing the efficacy of this classification we found that patients with an activity score of 3 or more at the beginning of therapy responded well to anti-inflammatory drugs, while those with a lower activity score mostly did not. Comparing the pretreatment activity score with the degree of enlargement of the extraocular muscles on the CT scan, we found a significant correlation between these two parameters: the higher the activity score, the more the enlargement of the muscles. We conclude that this classification facilitates the proper selection of patients for treatment.

[Results of treatment of endocrine orbitopathy]

We registered 101 patients from the ambulatory endocrinological dispensary with an endocrine orbitopathy stage II to VI. The peak of age at the time of the disease was in the fifth decennium of age. Females are four times more, frequently affected than males. Only one third of the patients could be registered and treated at the early stage of the endocrine orbitopathy within the first six months after appearance of the symptoms. The metabolic condition of the thyroid gland was hyperthyroid in 70.3% of the cases. 82.2% of all patients showed a struma. By a thyrostatic treatment of hyperthyroid persons in 14.1% a decrease of Hertel's values and in 31.0% a reduction of the subjective eye complaints was obtained. The parabulbar dexamethasone therapy in each case in circa half the patients resulted in an improvement of Hertel's values as well as of the subjective symptoms. A comparison of the oral dexamethasone and prednisolone showed a more favourable effect, when Hertel's values were measured. It is to be stated that there is not therapeutic remedy of choice of the endocrine orbitopathy, but the combination of several forms of treatment is necessary.

[Biological criteria of isolated Graves' ophthalmopathy]

The diagnostic value of biological tests, especially the thyroid stimulating immunoglobulin (TSI) assay, was studied in 29 patients with endocrine Graves' ophthalmopathy without hyperthyroidism. In 21 patients the presence of biological abnormalities (L-T3 suppression test, TRH test, presence of antithyroid antibodies) indicated that the ophthalmopathy was related to Graves' disease. The remaining 8 patients were free of any biological abnormality. The contribution of the TSI assay to the pathophysiological diagnosis of ophthalmopathy is poor. These immunoglobulins were detected in 12 out of 29 cases, but they were associated with the above-mentioned abnormalities in all but 3 of these 12 cases.

A prognostic score for Graves' disease

We have reanalysed the clinical and laboratory data on 196 individuals with Graves' disease. The consensus of two clustering techniques and a new method of allocating patients to a cluster resulted in two groups of patients, those with a severe and others with a mild disease. The severe disorder is characterized by a high frequency of HLA-B8 and -Al, a low complement level, high titres of circulating immune complex and anti-thyroglobulin antibody, a high lymphocyte transformation index and serum T3 level, a low level of active E-rosettes, large goitres and a high value for the Crooks test. The mild disorder shows a higher frequency of HLA-B12 and an abnormally low absolute lymphocyte number. A weight was calculated for each character according to the relative frequency in the two clusters. A total score could then be calculated for each patient based on their clinical and laboratory findings. There were two distinct distributions of scores corresponding to the two subgroups. This suggests different aetiological factors which may be more easily studied in these more homogeneous groups. Prognostic predictions can be made using the score. The risk of recurrence and the frequency and severity of ophthalmopathy increases dramatically as the score increases. The use of the score in making therapeutic decisions needs to be tested.