Long term follow-up and HLA association in patients with postpartum hypothyroidism.

The long term clinical outcome of postpartum hypothyroidism was investigated by follow-up studies of 44 patients (59 postpartum episodes; mean age of mothers at delivery, 28.2 yr) 5 or more yr later (mean interval after delivery, 8.7 yr; range, 5-16 yr). Forty-nine episodes (83%) in 34 women were followed by recovery within 1 yr postpartum, and those women remained euthyroid thereafter (group A); 10 women [10 episodes (17%)] developed permanent hypothyroidism during the follow-up period (group B). Five women in group B recovered during the first year, but became hypothyroid again later, the other 5 women in Group B remained persistently hypothyroid. HLA typing revealed significantly higher frequencies of HLA-DR3, -DRW8, -DRW9, -A26, -BW46, and -BW67, and significantly lower frequencies of HLA-DR2, -BW52, -BW62, and -CW7 in women with postpartum hypothyroidism than in normal women. Of 9 women with postpartum hypothyroidism who had HLA-DRW9 and/or -B51 associated with antithyroglobulin-antibody titers of 2(3) X 10 or higher, 6 developed permanent hypothyroidism. We conclude that long term follow-up is essential for women of postpartum hypothyroidism because of the risk of permanent hypothyroidism. The results suggest that some immunogenetic factors may be related to the etiology of postpartum hypothyroidism and that women with HLA-DRW9 and/or -B51 and higher titers of antithyroglobulin antibody are likely to develop permanent hypothyroidism.

Increase in antideoxyribonucleic acid antibody titer in postpartum aggravation of autoimmune thyroid disease.

Serum antidouble stranded DNA antibody levels were measured during pregnancy and after delivery in women who had postpartum exacerbations of Graves' and Hashimoto's diseases. The changes in serum anti-DNA antibody levels closely paralleled those in the serum free T4 index, significantly increasing in the thyrotoxic phase 3-8 months postpartum in women with postpartum exacerbations of thyrotoxicosis due to Graves' disease and 1-3 months postpartum in women with postpartum destructive thyrotoxicosis of Graves' and Hashimoto's diseases. No change in anti-DNA antibody level was found in women with no postpartum exacerbations of thyroid diseases, nor could we demonstrate significant increases in serum anti-DNA antibody titers in patients with thyrotoxicosis due to subacute thyroiditis or in normal pregnant and postpartum women. The changes in serum anti-DNA antibody titers may reflect some generalized immunological abnormality in women who have postpartum exacerbations of Graves' or Hashimoto's diseases.

Changes of lymphocyte subsets in normal pregnant and postpartum women: postpartum increase in NK/K (Leu 7) cells.

Changes in lymphocyte subsets in whole blood of normal pregnant and postpartum women were examined by flow cytometry with an automated leukocyte differential system. From the first trimester and throughout pregnancy, the absolute counts of T(CD3) and B(CD20) and T-cell subsets (CD4, CD8) decreased with a decrease in the absolute lymphocyte count, although the proportions of these cells remained unchanged except for a decrease in the percentage of T helper-inducer (CD4) cells in the first trimester. On the contrary, the percentage of NK/K (Leu 7) cells, but not of NK/K (CD16) cells, increased in the first trimester and then both gradually decreased in the second and third trimesters. In the postpartum period, the percentages and absolute counts of T(CD3) and NK/K (Leu 7) cells, but not of other cells, increased transiently. These changes of lymphocyte subsets may indicate suppression of immunological activity during pregnancy and its "increase" in the postpartum period.

Massage therapy on neck: a contributing factor for destructive thyrotoxicosis?

A 57-year-old woman with Hashimoto's disease is described who developed transient destructive thyrotoxicosis subsequently after she underwent physical massage therapy over her shoulder to neck, together with the goiter, for muscle stiffness in that part. This case supports the concept that physical vigorous manipulation might be a contributing factor for thyrotoxicosis in cases predisposed with autoimmune thyroiditis.

Discordant changes in serum anti-TSH receptor antibody and antithyroid microsomal antibody during pregnancy in autoimmune thyroid diseases.

Immunological effect of pregnancy on the level of anti-TSH receptor antibody (TRAb) and antithyroid microsomal antibody (MCAb) was examined serially in twelve patients; ten with active Graves' disease treated with antithyroid drugs for some time during pregnancy, one with previous Graves' disease with stimulating type TRAb, and one with primary atrophic hypothyroidism with blocking type TRAb. TRAb was measured by radioreceptor assay (TSH-binding inhibitor immunoglobulin, TBII) and MCAb was determined by radioimmunoassay. Among the ten patients with active Graves' disease, TBII level decreased as pregnancy progressed in seven but increased during pregnancy in three, whereas MCAb level decreased uniformly during pregnancy in all ten patients. However, possible immunosuppressive effect of antithyroid drugs on these antibody levels could not be completely excluded in these patients. On the other hand, in the two consecutive pregnancies of the patient with previous Graves' disease, TBII level increased "spontaneously" to 10-fold the initial value at 30 weeks during the first pregnancy, while it did not show consistent increase or decrease during the second one. Another patient with primary hypothyroidism showed increase in TBII level during pregnancy to 5-fold the initial value at week 28. In contrast to these TBII changes, MCAb levels and immunoglobulin concentrations decreased consistently during pregnancy in these two patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Radioreceptor assay of anti-TSH receptor antibody activity: comparison of assays using unextracted serum and immunoglobulin fractions, and standardization of expression of activities.

A radioreceptor assay for TSH receptor antibodies developed by Shewring and Smith is described in which unextracted serum is used. The assay is simple and reproducible. TSH-binding inhibitor immunoglobulin (TBII) activity determined using unextracted serum correlated well with that determined using the immunoglobulin fraction purified with polyethylene glycol. The assay detected TSH receptor antibodies in 81 of 85 patients (95%) with untreated Graves' disease, no patients with Graves' disease in remission, and 7 of 57 patients (12%) with Hashimoto's disease. TSH-binding inhibitor activity of a human TSH preparation (Kabi Diagnostica) was not detectable at 100 mU/L, but detectable at 1,000 mU/L. Consistent with this, TBII activity was not detectable in hypothyroid patients with goitrous Hashimoto's disease, whose serum TSH concentrations were 11-520 mU/L. Of 57 patients with Hashimoto's disease positive TBII activity was detected in only 7 of 15 patients (46%) with primary atrophic hypothyroidism. Five of these had very high TBII activities (greater than 90% inhibition of labelled TSH binding), and no linear dose-response relationship was observed in dilution experiments. For exact determination of TBII activity in specimens with high activities, serum samples were diluted with normal pooled serum and activities were expressed in U/ml by comparison with values for standard serum, prepared from bovine TSH diluted with normal pooled serum. In this way, samples with TBII activities of 1-50 U/ml (20-90% inhibition of binding of labelled TSH) showed linear dose-response relations in dilution experiments, and the dilution curves of all samples examined were parallel to the standard curve. This standardization procedure was used in determining the half life of TBII.

Highly sensitive immunoenzymometric assay for human thyrotropin.

A sensitive assay procedure for immunoenzymometric assay of serum thyrotropin (TSH) was developed by making several modifications of the Enzymun-Test TSH kit (Boehringer, Mannheim GmbH). Serum samples were first incubated in plastic tubes precoated with monoclonal antibodies specific to the beta subunit of human TSH. After the tubes were washed, the TSH bound to the tubes was detected with peroxidase-conjugated polyclonal antibodies to TSH. The sensitivity of the assay was 0.2 milli-int. unit/L, and the intra-and interassay CVs were less than 10%. Analytical recovery was 96 to 106%. The normal basal range of TSH was 0.5 to 4.8 milli-int. units/L. The basal levels of TSH in all but one of 48 thyrotoxic patients with Graves' disease were less than 0.2 milli-int. unit/L, clearly different from those of normal subjects. Thyrotoxic patients in early normal pregnancy showed TSH concentrations of 1.7 to 2.9 milli-int. units/L by conventional double-antibody radioimmunoassay, possibly from cross reactivity with human choriogonadotropin, but undetectable TSH by this method. Measurement of basal TSH by this sensitive assay can be used as an initial screening test for thyroid dysfunction.

Reciprocal changes in serum levels of immunoglobulins (IgG, IgA, IgM) and complements (C3, C4) in normal pregnancy and after delivery.

Sequential changes in serum levels of IgG, IgA, and IgM, and C3 and C4 during and after pregnancy were studied in 8 healthy women. Serum IgG decreased gradually during pregnancy, but increased markedly during the six months following delivery. Serum IgA and IgM levels also showed patterns similar to IgG. In contrast, C3 and C4 levels increased significantly and reached maximum levels in the last trimester during pregnancy, but decreased gradually for six months after delivery. Reciprocal changes between immunoglobulins and complements were clarified for the first time, and were suggestive of a compensatory autoregulatory mechanism in the suppression of the humoral immune system during pregnancy.

Universal predictive criteria for neonatal overt thyrotoxicosis requiring treatment.

The universal predictive criteria for neonatal overt thyrotoxicosis requiring treatment were examined in 108 neonates (including a pair of twins) born to mothers with Graves' disease (36 patients under treatment with antithyroid drugs [group A] and 71 in remission [group B]). Anti-thyroid-stimulating hormone (TSH) receptor antibody activity was measured by both radioreceptor assay (TSH-binding inhibitor immunoglobulin [TBII]) and biologic stimulation assay (thyroid stimulating antibody [TSAb]). For generalization of the predictive criteria, the expression of TBII activity was standardized using standard serum made taking units of Medical Research Council long-acting thyroid stimulator, standard B as a reference, and expression of TSAb activity was standardized using bovine TSH as a standard. TBII activity was positive in 22 mothers at delivery, and TSAb activity was positive in 18. In 12 cases, both activities were positive. Both the TBII and the TSAb activity of maternal serum at delivery correlated well with that of the cord serum. Neonatal thyrotoxicosis occurred in 9 of 108 neonates (8%), of whom five (5%) had clinical overt symptoms requiring antithyroid drug treatment. In all nine cases the TBII and TSAb activities were both positive, but no neonate without TBII or TSAb activity developed thyrotoxicosis. The prediction rate (42%) of neonatal overt thyrotoxicosis was higher when both TBII and TSAb were measured than when only TBII (23%) or TSAb (28%) was measured. Clinical overt thyrotoxicosis could be predicted in five of six neonates (83%) of mothers when the cutoff levels of antibody activities were increased to a TBII activity of above 8 U/ml and TSAb activity of above 1.0 TSH microUEq.(ABSTRACT TRUNCATED AT 250 WORDS)

Evaluation of TSH receptor antibody by 'natural in vivo human assay' in neonates born to mothers with Graves' disease.

Neonatal thyrotoxicosis induced by transferred TSH receptor antibody (TRAb) is the ideal human in-vivo experimental system for the evaluation of TRAb. The clinical significance of circulating TRAb in Graves' disease was evaluated by this 'natural in-vivo human assay'. TRAb activity in vitro was measured by radioreceptor assay (thyrotrophin-binding inhibitor immunoglobulin, TBII) and sensitive cAMP accumulation assay using FRTL-5 cells (thyroid-stimulating antibody, TSAb). Further, the binding-stimulation index (B-S index) was newly introduced, which was the most useful indicator for prediction of neonatal thyrotoxicosis, calculated as the product of TBII and TSAb (Tamaki et al., 1988a). Maternal serum TRAb indices showed highly significant correlations with the serum free T4 index (FT4I) and free T3 index (FT3I) in neonates (5-10 days after birth) born to 20 mothers with Graves' disease who had positive TBII and/or TSAb (FT4I: r = 0.825 for TBII, r = 0.908 for TSAb, r = 0.944 for the B-S index, P less than 0.001; FT3I: r = 0.622 for TBII, P less than 0.01, r = 0.812 for TSAb, r = 0.791 for the B-S index, P less than 0.001; n = 20). In contrast, in 57 untreated adult patients with hyperthyroid Graves' disease, the FT4I and FT3I levels were not correlated with any of the TRAb indices. The linear regression relationship between the B-S index and FT4I found in neonates was applied to values in adult patients with Graves' disease, and the patients were divided into three groups on the basis of the 95% confidence limit: high, normal, and low responders of thyroid hormone (FT4I) secretion to the B-S index. FT4I and the ratio of FT4I to the B-S index were highest and the TRAb indices were lowest in the high responders, while FT4I and the FT4I/B-S index ratio were lowest and the TRAb indices were highest in the low responders. The FT4I/B-S index ratio was inversely correlated with the titres of antithyroid microsomal antibody in all the adult patients with untreated Graves' disease (r = -0.288, P less than 0.05). The results suggest that in-vitro assays using animal thyroid cells and cAMP as an index of response are suitable for detecting circulating thyroid stimulating activity in vivo. Secretion of thyroid hormones in Graves' disease may be regulated not only by circulating thyroid-stimulating antibodies but also by intrathyroidal stimulatory factors or by inhibitory or destructive factors.

Effective method for prediction of transient hypothyroidism in neonates born to mothers with chronic thyroiditis.

An effective method of prediction of neonatal transient hypothyroidism was examined in 105 neonates (including a pair of twins) born to mothers with chronic thyroiditis (92 mothers with goitrous Hashimoto's disease and 12 with primary atrophic hypothyroidism). Antithyroid microsomal antibody was measured by a hemagglutination technique (MCHA), and antithyroid-stimulating hormone (TSH) receptor antibody by both radioreceptor assay (TBII) and biologic thyroid-stimulation blocking assay (TSBAb). For generalization of predictive criteria, the expression of TBII activity was standardized using standard serum made taking units of MRC-LATS-standard B as a reference, and that of TSBAb activity was standardized as the degree of dilution with normal pooled serum to attain 50% inhibition of TSH (100 microU/ml)-induced cyclic adenosine monophosphate increase (TSBAb50). The MCHA titer in maternal serum at delivery correlated well with that of the corresponding cord serum, but not with the free thyroxine (T4) index or the TSH level in cord serum. TBII activity was positive in only 4 of 12 mothers with primary atrophic hypothyroidism, TSBAb activity was also positive only in these four mothers, and neonatal thyroid dysfunction was observed in three of their neonates. Two of these neonates developed transient hypothyroidism requiring T4 treatment, and the t third developed mild transient hyperthyrotropinemia with normal T4 and triidothyronine levels. The mothers whose neonates showed transient hypothyroidism had TBII activities of more than 300 U/ml and TSBAb50 activities of more than 300. Ninety-two mothers with goitrous Hashimoto's disease had neither TBII nor TSBAb activity, irrespective of their thyroid function, and delivered euthyroid babies.(ABSTRACT TRUNCATED AT 250 WORDS)

Cellular immunity as a valuable factor for prognostic prediction in patients with Graves' disease under antithyroid drug therapy.

Studies were performed on 42 unselected clinically euthyroid patients with Graves' disease under maintenance doses of antithyroid drugs for various clinical parameters to determine the remission rate and to investigate which parameters carry weight in determining the outcome of the disease and could be good predictive factors. T3 suppression test was performed in all patients, after which antithyroid drugs were discontinued and outcome of drug therapy was evaluated for 18-24 months. Patients were divided into two groups; group A, 12 patients, who stayed in remission and group B, 30, who had recurrence during the first year (0.5-9 months) after discontinuation of therapy. Duration of clinical history was not different between group A (mean 62.3 months) and group B (59.6 months), nor euthyroid periods before the test (15.5 months for group A and 17.6 months for group B). For thyroid specific parameters T4, T3, RT3U, TSH, thyroglobulin (Tg), thyroid suppressibility after T3 administration and goiter size; and anti-thyroglobulin antibody (TGHA), anti-thyroid microsomal antibody (MCHA), TSH-binding inhibitor immunoglobulins (TBII), thyroid-stimulating antibodies (TSAb), peripheral lymphocytes count and lymphocyte subsets [CD3, CD4, CD8, Leu7 and CD20 (B1)], as immunological parameters were analysed by linear discriminant analysis method to observe the significance in discriminating patients with or without remission and to evaluate the validity for predictive factors. (ABSTRACT TRUNCATED AT 250 WORDS)

Digoxin-like immunoreactivity in Chinese medicine.

Immunoreactive digoxin-like activity was observed in Chinese medicine, KYUSHIN tablet, taken popularly in Japan without prescription. The antibodies used in the assays of digoxin reacted with Chan-su, the major effective component of KYUSHIN, which contained cardiotonic steroids with similar chemical structure as digoxin. One tablet of KYUSHIN had digoxin-like immunoreactivity equivalent to 1.9, 1.5, and 72 micrograms of digoxin measured by three different commercial kits. These different equivalences may be attributed to differences in cross-reactivity of the antibody used in the immunoassays. Two healthy volunteers took two KYUSHIN tablets three times a day, a typical dose, and digoxin-like immunoreactivity reached almost 0.4 micrograms/L in 0.5 day. Therapeutic drug monitoring should be interpreted carefully in patients taking Chinese medicines, many of which contain the Chan-su component.

Separation and analysis of mononuclear cells infiltrating the thyroid of patients with Graves' disease.

A simple method was established for separating lymphocytes infiltrating the thyroid from thyroid epithelial cells. Namely, suspensions of minced thyroid from patients with Graves' disease were layered on a Percoll two-step density gradient (p = 1.050 and 1.077 g/ml) and centrifuged (400g, 30 min, 4 degrees C). In this way 0.1-18 X 10(5) lymphocytes/g of thyroid tissue with a purity of 65-95% were obtained. Thyroid lymphocytes were analyzed quantitatively with monoclonal antibodies by laser flow cytometry and compared with peripheral lymphocytes. The proportion of OKT3+ cells was decreased with increase in OKIa+ cells. The percentage of OKIa+ cells was significantly correlated with that of Leu12+ cells. The percentages of OKT4+ cells and OKIa+ cells were higher when analyzed with an extended gate window, which was arranged for detection of activated, large-sized lymphocytes. The percentages of OKT8+ and Leu7+ cells were not significantly different from those in peripheral blood. From these results it was concluded that the proportion of B lymphocytes is increased and that of T lymphocytes is decreased, the proportion of activated B lymphocytes is increased, some helper/inducer T cells are activated in the thyroid gland in Graves' disease, and these activated lymphocytes may be important in local production of antithyroid autoantibodies.

Marked increase of CD5 + B cells in hyperthyroid Graves' disease.

We examined the proportions of B lymphocytes bearing CD5 cell surface antigen (CD5+ B cells), which are capable of making autoantibodies, in peripheral blood from patients with various thyroid diseases. The level of CD5+ B cells was markedly increased (>9.0%) above the normal range (0.5-7.7%) in untreated, hyperthyroid patients with Graves' disease, although about 10% of the patients had no detectable serum thyroid-stimulating hormone (TSH) receptor antibody (TRAb). However, the levels of CD5+ B cells were normal in untreated patients with destructive thyrotoxicosis due to aggravation of Hashimoto's thyroiditis or subacute thyroiditis. In patients with stimulated hyperthyroid Graves' disease the levels of CD5+ B cells were correlated with those of thyroid hormones and TRAb, all significantly increased. However, once hyperthyroidism was controlled by anti-thyroid drugs, CD5+ B cells were decreased, followed in turn by reduction of TRAb. We conclude that the proportion of CD5+ B cells is useful as a therapeutic index and for diagnosis of Graves' disease and its differentiation from destruction-induced thyrotoxicosis.