Lack of association of nonautoimmune hyperfunctioning thyroid disorders and a germline polymorphism of codon 727 of the human thyrotropin receptor in a European Caucasian population.

Constitutively activating mutations of the human TSH receptor (hTSHR) gene have been implicated as a major cause of hyperfunctioning nonautoimmune thyroid disease. However, significant geographic differences in the prevalence of these mutations have been observed. Recently, a high frequency of a germline polymorphism at codon 727 of the cytoplasmic tail of the hTSHR has been demonstrated in patients with toxic multinodular goiter. In the present study we assessed whether the codon 727 polymorphism is associated with hyperfunctioning thyroid adenomas. PCR followed by restriction enzyme digestion were used to genotype a total of 128 European Caucasian patients with toxic nonautoimmune thyroid disease (83 with toxic adenoma, 31 with toxic multinodular goiter, and 14 with disseminated autonomy) and to compare their codon 727 polymorphism frequencies with those of 99 healthy controls and 108 patients with Graves' disease. All individuals were drawn from an identical ethnic background. Sequencing of PCR products was used to confirm the mutation analysis. We found no significant differences in codon 727 polymorphism frequencies between patients with autonomously functioning thyroid disorders (13.3%) and the healthy control group (16.2%; P = 0.57). Moreover, the subtypes of toxic nonautoimmune thyroid disease (toxic adenoma, 13.2%; multinodular goiter, 9.6%; disseminated autonomy, 21.4%) were not related to significant differences in codon 727 polymorphism frequencies compared with the healthy control group (P = 0.67, P = 0.40, and P = 0.70, respectively). Additionally, there were no significant differences between patients with Graves' disease (21.3%) and healthy controls (P = 0.38). In conclusion, our data do not support an association between the codon 727 polymorphism of the hTSHR and toxic thyroid adenomas or toxic multinodular goiter in our study population. Thus, the codon 727 polymorphism of the hTSHR does not appear to be involved in the evolution of autoimmune or nonautoimmune hyperthyroidism in the European Caucasian population.

Interleukin-1 receptor antagonist ribonucleic acid and protein expression by cultured Graves' and normal orbital fibroblasts is differentially modulated by dexamethasone and irradiation.

Recent data have indicated that orbital fibroblasts (OF) can be stimulated to produce marked quantities of interleukin-1 receptor antagonist (IL-1RA), a powerful inhibitor of the proinflammatory activities of interleukin-1 in the orbital tissues in Graves' ophthalmopathy (GO). We examined whether the beneficial effects of dexamethasone or irradiation, the two main therapeutic modalities applied in patients with active GO, may be related to their capacity to alter IL-1RA ribonucleic acid (RNA) and protein expression in OF. Early passages of cultured OF were obtained from orbital connective tissue and extraocular muscle of patients with severe active GO and five control subjects. Modulation of the two variants of IL-1RA, intracellular IL-1RA (icIL-1RA) and soluble IL-1RA (sIL-1RA), was studied after exposure of OF to increasing concentrations of dexamethasone (10(-10)-(10(-6) mol/L)), the glucocorticoid receptor antagonist RU 38486 (10(-3) mol/L), or combinations thereof. Alternatively, cell monolayers were exposed to increasing doses of UV irradiation (0.1-1 J/cm2) or ionizing irradiation (0.2-2 Gy). The IL-1RA gene and protein variants were analyzed by RT-PCR, immunocytochemistry, immunoblotting, and enzyme-linked immunosorbent assay. Dexamethasone inhibited IL-1RA RNA steady state levels in GO OF and control OF in a dose-dependent manner. Combined exposure of OF to dexamethasone and RU 38486 completely restored baseline levels of IL-1RA RNA. By contrast, low doses of UV and ionizing irradiation dose dependently up-regulated IL-1RA-specific transcripts in GO OF and control OF, whereas higher doses were less effective. Immunoblotting and enzyme-linked immunosorbent assay revealed suppression of IL-1RA immunoreactivity after treatment with dexamethasone and enhanced expression of IL-1RA by GO OF and normal OF after low doses of UV and ionizing irradiation. Our results indicate that, in contrast to dexamethasone, low doses of irradiation stimulate expression of the IL-1RA gene and protein variants in OF. Induction by irradiation of IL-1RA expression in target cells of the orbital immune process represents an as yet unrecognized mechanism by which orbital radiotherapy may exert some of its beneficial therapeutic effects in patients with active GO.

Lack of association of Graves' disease with the A2 allele of the interleukin-1 receptor antagonist gene in a white European population.

OBJECTIVE: To assess whether the A2-type IL-1RA polymorphism is associated with Graves' disease and Graves' ophthalmopathy. Several reports have described a genetic association between the A2 allele of the interleukin-1 receptor antagonist (IL-1RA) gene and certain inflammatory and autoimmune diseases, suggesting that certain loci within the IL-1-related genes may modulate the autoimmune inflammatory response. Recently, we demonstrated marked differences in the expression and regulation of IL-1RA gene and protein between orbital fibroblasts derived from patients with active Graves' ophthalmopathy and healthy individuals. DESIGN: A total of 144 white European patients with Graves' disease were genotyped to compare their IL-1RA A2 allele frequency with that of 174 healthy controls. METHODS: The polymerase chain reaction was used to amplify the pentallelic variable-number tandem-repeat locus in intron 2 of the IL-1RA gene. RESULTS: We found no significant differences in IL-1RA A2 allele frequencies (0.20 and 0.26 respectively) and IL-1RA A2 carriage rates (31% and 40% respectively) between patients with Graves' disease and the control group. Moreover, presence or absence of Graves' ophthalmopathy in patients with Graves' disease was not related to significant differences in IL-1RA A2 allele frequencies and IL-1RA A2 carriage rates. CONCLUSIONS: Our data do not support an association between the IL-1RA A2 allele and Graves' disease or Graves' ophthalmopathy in our study population. Thus the A2-type IL-1RA gene polymorphism does not appear to indicate an increased susceptibility to develop Graves' disease and Graves' ophthalmopathy. Mechanisms unrelated to the IL-1RA A2 allele may be responsible for altered IL-1RA production within the orbital tissues in Graves' ophthalmopathy.

[Interferon therapy and autoimmunity]. / Interferontherapie und Autoimmunität.

The treatment of viral hepatitis or malignomas with interferon (IFN) can increase the incidence of autoimmune disease. This paper reviews published case and study reports. The incidence of overt autoimmune diseases under IFN treatment is about 3%. Autoantibodies can be detected in 23% of the patients. Autoimmune thyroid diseases are the most frequent ones, but nearly all autoimmune diseases can occur. Beside benign and reversible courses chronic developments and lethal outcomes are possible. Actual concepts concerning the pathogenesis of IFN-associated autoimmunity include induction of MHC and other molecules as well as the modulation of lymphocyte functions. Clinical and paraclinical controls are necessary under treatment with IFN and during follow-up.

Detection and modulation of interleukin-1 receptor antagonist messenger ribonucleic acid and immunoreactivity in Graves' orbital fibroblasts.

PURPOSE: To analyze the expression and regulation of intracellular and soluble interleukin-1 (IL-1) receptor antagonist (IL-1RA) in orbital fibroblasts and to determine whether a disbalance between IL-1 receptor agonist and antagonist may promote IL-1 mediated proinflammatory actions in Graves' ophthalmopathy (GO). METHODS: Early passages of cultured orbital fibroblasts (OFs) derived from four patients with active GO and six control subjects were examined for their baseline expression of the two variants of IL-1RA, intracellular IL-1RA (icIL-1RA) and soluble IL-1ra (sIL-1RA. In addition, modulation of icIL-1RA and sIL-1RA was studied after exposure of OF to a broad range of cytokines as well as to nonspecific stimulating agents such as lipopolysaccharide and phorbol-12-myristate 13-acetate. The IL-1RA gene and protein variants were analyzed by reverse transcriptase-polymerase chain reaction, immunocytochemical staining, immunoblotting, and enzyme-linked immunosorbent assay. RESULTS: At baseline, both GO- and control OF showed low levels of constitutive icIL-1RA ribonucleic acid and absence of sIL-1RA ribonucleic acid expression. Exposure to various cytokines stimulated icIL-1RA and sIL-1RA gene expression in both groups, but generally to markedly lower levels in GO-OF compared to that of control OF (P < 0.01). Analysis of IL-1RA protein expression showed low levels of constitutive IL-1RA immunoreactivity (22 kDa) in cell lysates and absence of sIL-1RA immunoreactivity in culture supernatants derived from both GO-OF and control OF. Interleukin-1-alpha was capable of inducing expression of two variants (23 and 26 kDa) of IL-1RA immunoreactivity in supernatants, derived from control OF, and to a lesser degree, GO-OF (P < 0.01). Quantitative analysis showed markedly lower abundance of IL-1RA immunoreactivity in cell lysates and supernatants derived from GO-OF monolayers compared to that detected in control OF (P < 0.001). CONCLUSIONS: Our results demonstrate differences in regulation of icIL-1RA and sIL-1RA and markedly lower levels of expression in cultured GO-OF compared to normal OF. Failure to generate, upon cytokine stimulation, sufficient quantities of icIL-1RA and sIL-1RA to balance agonist stimulation of the IL-1 receptor may facilitate IL-1-dependent proinflammatory and fibrogenic actions within the orbital tissue in GO.

Different immunophenotype and autoantibody production by peripheral blood and thyroid-derived lymphocytes in patients with Graves' disease.

Direct multi-colour flow cytometric analysis was employed in patients with Graves' disease (n = 10) to determine the immunophenotype in peripheral blood lymphocytes (PBL) at the time of diagnosis without treatment (PBLw) and prior to operation (PBLp) and in thyroid-derived lymphocytes (TL). Additionally, the secretion of anti-thyroperoxidase antibodies (anti-TPO) was measured during culture of isolated peripheral or thyroid-derived B cells. Among TL from patients with high serum levels of anti-TPO (6/10) a significantly (p < 0.01) higher percentage of B cells were detected compared to PBLp (TL: 21.7 +/- 7.2%; PBLp: 13.2 +/- 4.5%). Enriched thyroid-derived B cells only from these patients also showed high spontaneous anti-TPO secretion during culture. The difference between peripheral and thyroid-derived natural killer (NK) cells was highly significant (p < 0.001; TL: 5.6 +/- 6.3%; PBLp: 13.6 +/- 5.5%). Two patients were found with a higher number of NK cells within TL. These patients were among those who had a low number of B cells infiltrating the thyroid gland. Regarding the expression of several other differentiation antigens, i.e. CD4 and CD8, gamma/delta TCR bearing T cells and CD45R0 on CD4+ T cells as a marker for memory cells, on TL no differences could be detected between patients with or without anti-TPO. In TL 31.5 +/- 7.7% of CD3- cells expressed the HLA-DR antigen (vs. 6.1 +/- 2.4% in PBLp; p < 0.001). Half of these cells simultaneously expressed the activation antigen CD69. Surprisingly, the number of CD3+ TL bearing the IL-2 receptor (CD25) and transferrin receptor (CD71) was not increased. Taken together, the proportional distribution of B and NK cells within the thyroid correlates with the anti-TPO secretion in vivo and in vitro, suggesting different immune response regulation processes of TL.

[Clinical symptoms and duration of anamnesis in patients with hypophyseal tumors]. / Klinische Symptomatik und Anamnesezeiten bei Patienten mit Hypophysentumoren.

In 88 patients with operated pituitary tumours a retrospective statement of the duration of the disease up to the beginning of the therapy was carried out. In the case of the prolactin secreting tumours the times of anamnesis are approximately only half as long as in the comparable data of literature. The cause of this may by the large proportion of macroprolactinomas among our patients. In acromegaly the duration of the disease is from 3/4 to 25 years. By their insiduous clinical progression hormone-inactive tumours render an exact dating of the beginning of the disease impossible. Issuing from the still too long times of anamnesis the clinical symptoms of the endocrine-active and endocrine-inactive pituitary tumours relevant to practice are demonstrated. Including these symptoms into differential-diagnostic consideration an early diagnosing should be possible at least in endocrine-active tumours.

Clinical experience with a radioreceptor assay for TSH-binding inhibiting immunoglobulins (TBII).

The aim of the present study was to evaluate the clinical value of a commercial kit for determination of TBII. Forty-seven of 50 patients with untreated hyperthyroid Graves' disease were TBII positive (sensitivity 94%). TBII was in the normal range in all normal volunteers and in patients with simple goiter, thyroid cancer and in most cases of nonimmunogenic hyperthyroidism (19 of 22). After 12 months antithyroid drug therapy with methimazole of 21 patients the prevalence of positive TBII findings was 28%. In contrast to this, 50 percent of the patients had increased microsomal antibodies at the end of therapy. The determination of TBII by TRAK-assay proved to be a sensitive, specific and practical method. The assay can be used to differentiate between hyperthyroidism of autoimmune or nonimmunogenic origin. Even so this method seems to be helpful for the follow-up during medical treatment of patients with Graves' disease. The results indicate that persistence of increased TBII levels are markers of active Graves' disease and suggest that in this situation ablative measures should be performed. Normalization of TBII on the end of a longstanding antithyroid therapy does not exclude the possibility of relapse in the further course.

[Lipoprotein metabolism in patients with disordered thyroid gland function before and following therapy]. / Lipoproteinstoffwechsel bei Patienten mit gestörter Schilddrüsenfunktion vor und nach Therapie.

Clinical manifest hypothyreosis leads to changes of plasma lipoproteins, which are characterized by elevated LDL levels, an increase of the relation LDL cholesterol/HDL cholesterol, an elevation of the quotient cholesterol/triglycerides within the VLDL and an increase of the relation HDL2/HDL3. Both these changes and the diminished activities of post-heparin lipase of hepatic and extrahepatic origin are reversible after substitution therapy. On the contrary, patients with hyperthyreosis M. Basedow show low lipoprotein levels, high activities of post-heparin lipase and an elevation of the relation of the apolipoproteins apo C II/apo C III within the VLDL fraction.

[Clinical relevance of the determination of TSH-binding inhibitory immunoglobulins (TBII) in patients with immunogenic hyperthyroidism in methimazole therapy]. / Klinische Relevanz der Bestimmung von TSH-Bindungs-inhibierenden Immunglobulinen (TBII) bei Patienten mit immunogener Hyperthyreose unter Methimazoltherapie.

In 38 patients with immunogenic hyperthyroidism a follow-up was performed to estimate the value of TBII before, during and after methimazole therapy. Before therapy increased TBII were detectable in 37 patients (94.4%). After 12 months methimazole therapy 25 patients had TSH-receptor antibodies (66%) within the normal range. In 13 patients positive antibody titres were found. In most cases persistence of increased TBII-values during drug treatment was an indicator of the persistence of active hyperthyroidism (10 of 13 patients). In the rule a disappearance of TBII-activity was combined with a functional remission (22 of 25 patients). Prolonged demonstration of TBII-activity in conjunction with persistence of hyperthyroidism should lead to ablative measures. In contrast to this medical therapy should be finished in patients with immunological and functional remission. Though in the further follow-up a recurrence of the immunological base of the disease with a functional and clinical relapse is possible.

[Clinical value of the determination of TSH-binding inhibitory immunoglobulins (TBII) by a radioreceptor assay]. / Klinische Wertigkeit der Bestimmung von TSH-Bindungs-inhibierenden Immunglobulinen (TBII) durch einen Radiorezeptorassay.

The aim of the present study was to evaluate the clinical value of a commercial kit for determination of TBII. The study consisted of 50 patients with untreated Graves' disease, 21 patients with Graves' disease before und during medical therapy, 18 patients after finishing medical therapy and 10 patients after surgical treatment. Besides these, 41 patients with other thyroid diseases and 36 patients without any thyroid disorder were included. In 47 (94%) of 50 patients with untreated Graves' disease TBII were detectable in serum using a TSH-standard-curve. Binding activities exceeding 10 U/l TSH equivalents were regarded as positive. In other thyroid diseases TBII were negative with the exception of 3 of 22 patient with autonomously functioning thyroid nodules. After 12 months of antithyroid drug treatment of 19 patients the incidence of positive antibody findings was 26%. During follow-up after medical therapy (1-9 years) 7 of 18 patients had increased TBII in correlation with clinical and functional findings. The determination of TBII by TRAK-Assay proved to be a sensitive and specific method. The assay can be used to differentiate between hyperthyroidism of autoimmune or non-immunogenic origin. Even so this method seems to be helpful for the follow-up under medical treatment of patients with Graves' disease.

[Bromocriptine treatment of hyperprolactinemia]. / Bromocriptin-Behandlung bei Hyperprolaktinämie.

In 36 female patients with microprolactinoma was carried out a primary therapy and in 19 patients (10 males, 9 females) with a postoperatively persisting hyperprolactinaemia a secondary therapy with bromocriptine. In close correlation between the PRL-levels and the bromocriptine dose we achieved a normalisation of the hormone levels in the microprolactinomas. A normalisation of the cycle was observed in 80%, a persisting of the galactorrhoea in about 90% and a conception in nearly two thirds of the women. Also in those patients who underwent a secondary therapy in nearly 80% a decrease of the PRL-levels into the normal region developed. In a longterm therapy with bromocriptine a reduction of the dose may become possible, so that controls of the hormone levels are necessary in larger intervals. Most side effects of a bromocriptine treatment are transitory.

[The thyrotropic function of the hypophysis and peripheral thyroid hormones after removal of bland and autonomous nodular goiters]. / Die thyreotrope Funktion der Hypophyse und die peripheren Schilddrüsenhormone nach Operation blander und autonomer Knotenstrumen.

Bilateral subtotal resection or enucleation or unilateral resection was performed in 60 patients (36 with bland nodular goitre, 24 with autonomic adenoma). The thyrotropic pituitary activity and the peripheral thyroid function were examined in all patients preoperatively and followed up for 12 months postoperatively. The results show that all patients with bilaterally resected bland nodular goitre require postoperative administration of thyroid hormone, since enhanced thyrotropic activity is seen not later than three months after surgery. Since thyrotropic function remains normal in unilaterally operated nodular goitre, thyroid hormone administration does not appear generally necessary. In patients with autonomic adenoma there is postoperatively variability of function, independent of the surgical method employed. In view of possible functional recompensation, final decision on the administration of thyroid hormones should not be made before the end of the sixth postoperative month. These results can be considered as guidelines for a differentiated postoperative management.

[Operative findings and therapeutic results in patients with primary hyperparathyroidism]. / Operationsbefunde und Therapieergebnisse bei Patienten mit primärem Hyperparathyreoidismus.

In the period from 1976 to September 1982 39 patients with the clinical diagnosis of primary hyperparathyroidism were operated on. Among then were 24 women and 14 men. The most frequent manifestation form is the renal one (n = 26). The proportion of patients with hypercalcaemic crisis was very large (n = 4). Topographically and anatomically the adenomas were most frequently found in the region of the right lower pole of the thyroid gland. 23 patients had a singular adenoma, 11 patients showed multiple adenomas and only 2 had a diffuse hyperplasia. In patients with persisting hyperparathyroidism before a repeated intervention an attempt of localization should be performed by a selective phlebography with taking of blood samples for the determination of PTH. The success of the operation is to be read off most clearly at the behaviour of the post-operative values of serum calcium. In 29 patients a normocalcaemia was achieved. 6 patients showed at first a hypocalcaemia, which however, was only temporary in 4 patients. 3 patients had a persisting hyperparathyroidism. In accordance with the literary data the formation of renal calculi clearly decreased after a successful operation.

[Results of lithium treatment in severe hyperthyroidism]. / Ergebnisse der Lithiumbehandlung bei schwerer Hyperthyreose.

Up to the present time lithium therapy is under discussion in patients with severe, particularly of contrast remedy induced hyperthyroidism. The aim of our presentation was to investigate if the short term combined methimazole-lithium therapy in the initial phase will be advantageous in contrast to the monotherapy of methimazole. The examination in our material showed a good effectiveness and tolerance of the combined therapy. At present the precise mechanism of action of lithium has not been elucidated. There is evidence that lithium inhibits the thyreoglobulin hydrolysis and the peripheral conversion of thyroxin to triiodothyronin. Other actions are under discussion. In our opinion only the combined methimazole-lithium therapy will be advantageous. Through this procedure an earlier drug effect could be expected and the increase of thyroid hormones after finishing lithium therapy will be suppressed. In the own material severe side effects are not demonstrable.

[Thyrostatic therapy of hyperthyroidism with special reference to drug side effects]. / Thyreostatikatherapie der Hyperthyreose unter besonderer Berücksichtigung von Arzneimittelnebenwirkungen.

In discussing undesirable therapy effects by thyrostatics one must issue from the fact that the possible side effects have a different genesis and appear in different frequency. While pharmacodynamically caused therapy effects are generally to be avoided, when considering the pathophysiology of the regulation of the thyroid gland, this is not the case as to allergic side effects and only to a limited extent with regard to toxic side effects. Allergic side effects abruptly and suddenly appear and do not show any dependence on dosage. But for the greater part these side effects are harmless. Severe side effects are nearly without exception of toxic genesis. The decrease of the initial dose and the early transition to a still effective maintenance dose reduce the possibility of toxic complications. In case that side effects lead to a discontinuation of the corresponding thyrostatic, a change to a thyrostatic of another chemical group is possible and necessary.