TSH-R Ab Research Articles

7078 Diagnostic Obstacles in Thyroid-Stimulating Hormone-Secreting Pituitary Adenoma (TSH-oma): A Case Report

Abstract Disclosure: V.A. Mendpara: None. P.P. Rao: None. M.D. Lundholm: None. Background: Thyroid-stimulating hormone-secreting pituitary adenoma (TSH-oma) is a rare cause of hyperthyroidism, forming 0.5-3% of all functioning pituitary tumors and <1% of hyperthyroid cases. Here, TSH secretion is autonomous and unresponsive to the normal negative feedback of thyroid hormones, leading to inappropriate TSH, T4 and T3 elevation. In the absence of clinical symptoms it can be difficult to distinguish between thyroid hormone resistance (THR) and lab errors. Clinical Case: A 44-year-old Swahili-speaking female with a history of type 2 diabetes was admitted for hypoglycemia requiring insulin adjustment. In her workup, thyroid function tests were obtained, revealing normal or low TSH (0.28 mIU/L) and high free T4 levels (2.7 ng/dL). At outpatient follow-up, repeat labs showed elevated TSH, T3 and FT4 (5.22 mIU/L, 377 ng/dL and 4.7 ng/dL, respectively). She reported weight loss, occasional palpitations, and chronic insomnia but denied other symptoms. Graves' antibodies (TSI, TSHR Ab) were negative. On exam, she had a 30-40 gm, smooth, non-tender thyroid without adenopathy, and a BMI of 23 kg/m2. The initial differential diagnosis included TFT lab error, THR or TSH-oma. A FT4 by equilibrium dialysis was high at 7.8 ng/dL (1.1-2.4 ng/dL). N-telopeptide (NTX) and sex hormone-binding globulin (SHBG) were elevated, consistent with a true hyperthyroid state. Genetic testing for THR posed time and cost barriers. Elevated alpha-subunit levels (87 ng/mL, normal ≤1.8 ng/mL) with normal levels of other pituitary hormones prompted a pituitary MRI, unveiling a 4.7 cm suprasellar bilobed pituitary mass abutting the optic chiasm and invading the cavernous and sphenoidal sinuses. She denied peripheral vision loss or headaches. Hyperthyroidism was managed with methimazole until surgical intervention for the TSH-oma. A transsphenoidal resection was performed with histopathological confirmation of a TSH-staining pituitary adenoma. She was started on levothyroxine for central hypothyroidism thereafter. Discussion: It is challenging to find the cause of abnormal TFTs when patients are asymptomatic and the differential includes THR, lab errors or TSH-oma. Inaccurate diagnosis can lead to delays in care or unnecessary thyroid ablation or pituitary surgery. Conversely, early identification and appropriate treatment of TSH-omas can prevent neurological and endocrinological complications, such as optic chiasm compression, visual disturbances, headache and hypopituitarism. Despite a lack of convincing symptoms of hyperthyroidism, we used confirmatory labs (NTX, SHBG) to rule in biochemical hyperthyroidism along with alpha-subunit testing and pituitary MRI to solidify the TSH-oma diagnosis, leading to surgical intervention. This case highlights the vital steps in the diagnosis of a TSH-oma, emphasizing the need for logical evaluation and differentiation of this rare condition. Presentation: 6/1/2024

Clinical Changes and Autoantibody Level Changes in Thyroid Eye Disease Patients after Intravenous High-dose Steroid therapy

Purpose: To evaluate the effects of intravenous steroid therapy on the clinical activity score (CAS), exophthalmos, margin-reflex distance 1 (MRD1), and autoantibody levels in patients with thyroid eye disease.Methods: In this retrospective observational study, we enrolled 83 patients diagnosed with thyroid eye disease treated with intravenous steroid therapy. We assessed exophthalmos, MRD1, CAS, thyroid-stimulating antibody (TSAb), and thyroid-stimulating hormone receptor antibody (TSHR Ab) levels at baseline, 6 and 12 weeks after initiating therapy, and 2 months after therapy termination. Additionally, baseline serum selenium levels were examined to determine their impact on treatment efficacy.Results: TSAb, TSHRAb, and CAS levels showed a continuous decline from 443.22 to 341.03 specimen-to-reference control ratio (SRR%), 22.18 to 7.91 IU/L, and 3.37 to 1.88, respectively (<i>p</i> < 0.0001), up to 2 months following therapy termination. Exophthalmos did not show significant changes at any assessed time point up to 2 months after therapy termination. MRD1 decreased until 12 weeks after therapy initiation but showed no significant change 2 months later. No correlation was found between baseline serum selenium levels and changes in exophthalmos, MRD1, TSAb, TSHR Ab, or CAS.Conclusions: Intravenous steroid therapy was effective in reducing TSAb, TSHR Ab, and CAS levels up to 2 months after therapy termination. However, it had limited positive impact on exophthalmos or eyelid retraction. Baseline selenium levels did not correlate with the changes in any of the examined parameters.

STAT3 single-nucleotide variants in autoimmune thyroid disease in the Pakhtun population of Khyber Pakhtunkhwa, Pakistan

The current study was conducted to assess the relationship between the STAT3 gene variants rs744166 and rs2293152 and autoimmune thyroid disorder in the Pakhtun population of the province, of Khyber Pakhtunkhwa, Pakistan. Blood was collected from 100 healthy individuals and 400 thyroid-disordered patients. Of these, one hundred were diagnosed with Hashimoto's thyroiditis (HT), while 32 were confirmed as Grave's disease (GD) patients. T3, T4, and TSH serum levels were checked to diagnose thyroid disorders. The blood was analyzed for anti-thyroid peroxidase antibodies (Anti-TPOAb) (AESKULISA- ATPO - elisa kit), (Germany), and thyroid stimulating hormone receptor antibodies (TSHRAb), TSHR Ab elisa kit (Diametra Italy), respectively. PCR was used to amplify the targeted STAT3 gene polymorphisms from rs744166 (301 bp) and rs2293152 (365 bp) sequences and then digested by specific restriction endonucleases (AluI) and AciI respectively. The disease displayed a female predominance. The genotype TC and CC of rs744166 showed a significant relationship with Grave's disease (p = 0.002, OR = 0.28, 95 % CI = 0.11–0.77) in patients. The C allele contributed significantly to the disease in GD patients. The SNP rs2293152 significantly differed between GD patients and control (p = 0.032, OR = 0.29, 95 % CI = 0.09–0.86). Similarly, the G and C alleles showed a significant (p = 0.02) difference between GD patients and the control. No significant association was found for both SNPs in Hashimoto's thyroiditis disease. It is concluded that the STAT3 gene (rs744166 and rs2293152) was found to have a potential role in autoimmunity in GD patients. Still, it needs further studies with larger sample sizes in the Pakhtun population to understand this relationship.

Effect of autoantibodies and cytokines on thyroid disorders in Thi-Qar

Introduction: The thyroid gland is one of the important endocrine gland that have many functional activates in the body. It is usually located in the front of the neck and is shaped like a butterfly. It goes all the way down to the platysma, stern thyroid, and Stern hyoid muscles. In all vertebrates, the thyroid gland and its hormones perform several important activities. Methodology: Fifty patients diagnosed with hyperthyroidism disease (25 males and 25 females). 50 subjects in good health as controls (25 males and 25 females). Results and dissuasion: When compared to controls, the findings of our investigation (17.04 ± 5.10 vs. 1.15 ±0.25 U /l) demonstrate a substantial rise (P≥0.00) of TSH-receptor Ab levels in the subjects (17.04 ± 5.10 vs. 1.15 ±0.25 U/l). The findings revealed a substantial rise (P≥0.00) in FT4 level in subjects (6.16 ±0.62 vs. 1.40±0.24 ng/dl) compared to controls. In our investigation, the T3 level demonstrates a considerable rise (P≥0.00) of patients (2.81±0.20 vs. 0.32±0.07 ng/dl) vs. control. The findings of our investigation, which were presented in table 3.2, clearly demonstrated a substantial drop (P≥0.00) of TSH level in subjects was (0.19± 00.6 vs. 3.19± 0.53 IU/L) compared to controls. Conclusions: TSH-R Ab is the better hyperthyroidism marker, especially in individuals having elevated TNF plus IL-6, in both males as well as females. The close relationship among TSH-R Ab elevation, FT-4 as well as FT-3 concentration in patients having hyperthyroidisms, which is associated with increased immune response activity manifested in TNF and IL-6 accompanied by a decrease in the concentration of TSH in general comparisons and between males and females as a control group.

FRI533 A Novel Cre-loxP Based Mouse Model For Graves' Disease

Abstract Disclosure: D. Kim: None. Y. Bao: None. M. Kang: None. Y. Cho: None. Y. Kim: None. Y. Hwang: None. C. Ku: None. E. Lee: None. Objectives: Over years, various approaches have been used to model human Graves’ disease in mice, including transfected fibroblasts, and plasmid or adenoviral immunizations with the extracellular A subunit of the human thyrotropin receptor (hTSHRa). However, these models require a lot of effort for multiple dosing over several months and the results are very heterogeneous, limiting their use as a platform for the development of new therapeutics. Thus, we developed a novel Cre-loxP based mouse model for Graves' disease. Methods: To overcome the limitation of existing animal models, we made ESC-derived KI mouse expressing hTSHRa that will act as an antigen in a conditional manner by inserting the CAG-loxP-STOP-loxP-hTSHRa cassette into the mouse Rosa26 locus. TAT-Cre, a recombinant cell-permeant fusion cre-recombinase protein, was used for site-specific recombination to avoid leaky expression which may induce immune tolerance. Various concentrations of TAT-Cre were tested to avoid neutralization and produce adequate hyperthyroidism. Serum TSHR Ab and T4 levels were measured. Immunohistochemical examinations of the thyroid gland and orbits were performed. Results: Treatment with TAT-Cre within the range of 250-750U produced the most efficient TSHR Ab and significantly increased T4. Four weeks after TAT-Cre 500U administration, TSHR Ab levels were already significantly produced in all mice and T4 levels started to increase. At 8 and 12 weeks, TSHR Ab levels were produced at a very high levels in all mice and T4 levels were increased to a very high levels in over 80% of mice. After 3 months, MRI images did not show any significant protrusion. However, there was an enlargement in the volume of the orbital muscles. We also found thyroid enlargement and hypertrophy, orbital macrophage infiltration and fibrosis in Immunohistochemical examinations. Conclusions: A new mouse model for Graves' disease was successfully established by using the Cre-loxP system. After being optimized for orbitopathy induction, this model can be used as a platform for the development of novel therapeutics. Presentation: Friday, June 16, 2023

OR26-01 A Novel Small Molecule Thyrotropin Receptor Antagonist

Abstract Disclosure: G.J. Kahaly: None. A. George: None. L. Steiner: None. T. Weirauch: None. J. Henseling: None. L. Frommer: None. J. Wolf: None. Background & aims: Treatment of both Graves’ hyperthyroidism (GH) and Graves’ orbitopathy (GO) is still far from adequate, hence new therapeutic modalities, which specifically target the autoantigens in GH/GO, are warranted. This study determined the preclinical in vitro efficacy of SYD5115, a novel thyrotropin receptor (TSH-R) antagonist. Methods: SYD5115 is a nanomolar potent low molecular weight TSH-R antagonist with in vivo activity in rats after oral dosing. The compound consists of an N-acetylated dihydropyrrole pyrimidine core containing several substituents such as a difluorinated-spirocyclohexyl ring and a chiral carbamate group on the pyrimidine ring. The TSH-R inhibiting capability of SYD5115 was tested through stimulation of wild type and chimeric TSH-R expressed in Chinese hamster ovary (CHO) cells using-two functional (stimulatory and blocking) cell-based TSH-R-Ab bioassays. TSH-R expressing human orbital fibroblasts, collected from GH+GO patients (GOF), were stimulated with the monoclonal antibody M22 or with stimulatory TSH-R-Ab (TSAb)-positive sera with cyclic adenosine monophosphate (cAMP) or hyaluronic acid (HA) release as read-outs. The effect of SYD5115 on the viability of GOF was tested in both 4,5-dimethylthiazol-2-yl-2,5-diphenyltetrazolium bromide and the “scratch” cell growth assays. Results: The new small molecule SYD5115 significantly and dose-dependently inhibited the TSH-R activation through M22 or TSAb-positive sera in all performed bioassays. Inhibition showed similar levels in the TSAb reporter bioassay and in the cAMP assay with GOF. The % inhibition and compound concentration showed a sigmoidal relationship, with all seven TSAb positive sera markedly inhibited by SYD5115. A SYD5115 dose-dependent inhibition of M22 (10ng/ml, 6 hours)-stimulated HA and/or cAMP-release from GOF was observed. Strong SYD5115-induced inhibitions of M22-stimulated cAMP production in GOF were registered with SYD5115 concentrations of one (p=0.0029), 10 (p<0.0001), 100 (p<0.0001), 1,000 (p<0.0001), and 10,000 (p<0.0001) nM/L, respectively. SYD5115-induced inhibition of M22-stimulated HA production was noted with SYD5115 concentrations of 100 (p=0.0392), 1,000 (p=0.0431), and 10,000 (p=0.0245) nM/L, respectively. The inhibitory activity of SYD5115 was confirmed in a human osteosarcoma U2OS cell line stably expressing human TSH-R with cAMP as read-out. SYD5115 induced 100% inhibition of the M22-induced cAMP levels with a potency of 193 nM. Compared to control, SYD5115 affected neither the growth nor the migration of cultivated GOF. In addition, SYD5115 did not alter the viability of GOF. Conclusions: SYD5115 blocked M22- and TSAb-induced TSH-R activity with a nanomolar potency in TSH-R overexpressed CHO cells as well as primary GOF, which demonstrates the ability of this novel small molecule to inhibit TSH-R overactivity. Presentation: Saturday, June 17, 2023

SAT579 Newly Diagnosed Graves' Disease With Complete Heart Block In Elderly Patient. A Case Report

Abstract Disclosure: M.M. Eid: None. T. Zahra: None. J. Vargas-Jerez: None. Introduction: Hypothyroidism is the most common thyroid disorder in elderly. The prevalence of hyperthyroidism in elderly is 0.5-3% and mainly caused by toxic thyroid nodules. Graves’ disease is an autoimmune disorder mediated by TSH receptor antibody (TSHR AB), presents commonly with hyperthyroidism in middle age female(1). Complete heart block in elderly can be due to conduction system fibrosis, Ischemic/structural heart diseases, medications, electrolyte disturbance and hypothyroidism(2). Case 72yo, Female with history of DM and HTN. Denied smoking, alcohol, drug and allergy. Irrelevant family history. Medications include amlodipine, metformin and atorvastatin. She was referred to endocrinology clinic for low TSH (was normal last year). Review of system was negative, denied tremor, palpitation, anxiety, weight loss, bowel movement/mood/sleep change, vision/swallowing problem. Physical examination: ABP150/80, Heart Rate(HR) 75/min. Mild lid lag, no exophthalmos. No tremor. Thyroid gland: diffusely enlarged non tender, no bruit. Normal cardiopulmonary and abdomen examination. Laboratory work up TSH less than 0.01 normal 0.2 to 4.20 uIU/ml , FT4 3.5 normal 0.9 to1.8 ng/dl, FT3 6 normal 2 to 4.4 pg/ml. Repeat lab confirmed TSH suppression and high FT4 ,FT3. TSHR antibody 7.66 normal less than 1.75 IU/L, Thyroid stimulating immunoglobulin 5.05 normal less than 0.5 IU/L ,HBA1C 6.6, Normal liver and kidney function tests and Complete blood count. She was diagnosed with Graves’ disease, kept on Methimazole 10mg/day. 2 weeks later, she presented to the ED after syncope at home. Initial EKG showed complete heart block HR 35/min and right bundle branch block (RBBB), ABP 110/65. Hours later EKG showed transient first degree heart block HR 75/min, RBBB and left axis deviation, then complete heart block with HR 30/min. Normal Troponin, potassium 4.2 mmol/L, sodium 141 mmol/L, calcium 9.2mg/dl, TSH 0.015 uIU/ml,FT4 3 ng/dl. Negative Anti-Lyme IgG and IgM. Normal Echocardiogram. She underwent uneventful Dual chamber pacemaker implantation with close endocrinology follow up. Conclusion: Graves’ Disease has variable presentations in elderly. Hyperthyroidism causes tachyarrhythmia due to the positive chronotropic effect of thyroid hormones. Bradyarrhythmia in our case is most likely due to conduction system fibrosis and could be related to the inhibitory effect of TSHR AB in elderly in contrary to the simulating effect in young patients. It is still rare to diagnose symptomatic bradyarrhythmia with uncontrolled hyperthyroidism(1).

Automated evaluation of parapapillary choroidal microvasculature in thyroid eye disease.

The purpose of the study was to investigate the parapapillary choroidal microvasculature in thyroid eye disease (TED) using optical coherence tomography angiography (OCTA). Only one eye of each subject was included in the study. Patients with TED and controls were included in the study. Participants were divided into three groups: control, inactive TED (ITED) and active TED (ATED). OCTA scans of the optic discs were obtained in a 4.5 × 4.5-mm rectangular area. Radial peripapillary capillary (RPC) density and peripapillary retinal nerve fibre layer (pRNFL) thickness were automatically calculated by the device software. Parapapillary choroidal microvasculature (PPCMv) density was automatically calculated using MATLAB software. Forty-one patients with TED and 40 controls were included in the study. RPC density was significantly decreased in the ATED and dysthyroid optic neuropathy (DON) group compared to the controls and ITED group. There was significant increase in pRNFL in the ATED group. PPCMv density increased in the ATED group compared to the controls in whole ring area. The RPC density was significantly correlated with the TSHr Ab level (r < -0.396, p < 0.001). Clinical activity score correlated positively with PPCMv density (r = 0.349, p = 0.001) but negatively with RPC density (r = -0.321, p = 0.004). Changes in peripapillary microvascular perfusion may play a role in the development of DON. As the severity of TED increases with clinical activity, so do the changes observed in peripapillary parameters. The decrease in RPC density may be due to compression caused by optic disc oedema, which may result in reduced blood flow. The increase in PPCMv density may be related to factors such as orbital congestion.

Thyrotropin Receptor Antagonism by a Novel Small Molecule: Preclinical In Vitro Observations.

Background: Treatment of Graves' hyperthyroidism (GH) and Graves' orbitopathy (GO) is far from adequate, and hence, new substances that specifically target the autoantigens in GH/GO are warranted. This study determined the preclinical in vitro efficacy of SYD5115, a novel low-molecular-weight compound that inhibits the thyrotropin receptor (TSH-R). Methods: The TSH-R inhibiting capability of SYD5115 was tested through stimulation of wild-type and chimeric TSH-R expressed in Chinese hamster ovary (CHO) cells using two functional (stimulatory and blocking) cell-based TSH-R-Ab bioassays. TSH-R expressing human orbital fibroblasts, collected from GH+GO patients (GOF), were stimulated with the monoclonal antibody M22 or with stimulatory TSH-R-Ab (TSAb)-positive sera with cyclic adenosine monophosphate (cAMP) or hyaluronic acid (HA) release as readouts. The effect of SYD5115 on the viability of GOF was tested in 4,5-dimethylthiazol-2-yl-2,5-diphenyltetrazolium bromide and scratch cell growth assays. Results: SYD5115 significantly and dose dependently inhibited the TSH-R activation through M22 or TSAb-positive sera in all performed bioassays. Inhibition showed similar levels in the TSAb reporter bioassay and in the cAMP assay with GOF. The % inhibition and compound concentration showed a sigmoidal relationship, with all seven TSAb-positive sera markedly inhibited by SYD5115. An SYD5115 dose-dependent inhibition of M22 (10 ng/mL, 6 hours)-stimulated HA and/or cAMP-release from GOF was observed. Strong SYD5115-induced inhibitions of M22-stimulated cAMP production in GOF were registered with SYD5115 concentrations of 1 (p = 0.0029), 10 (p < 0.0001), 100 (p < 0.0001), 1,000 (p < 0.0001), and 10,000 (p < 0.0001) nM, respectively. SYD5115-induced inhibition of M22-stimulated HA production was noted with SYD5115 concentrations of 100 (p = 0.0392), 1000 (p = 0.0431), and 10,000 (p = 0.0245) nM, respectively. The inhibitory activity of SYD5115 was confirmed in a human osteosarcoma U2OS cell line stably expressing human TSH-R with cAMP as readout. SYD5115 induced 100% inhibition of the M22-induced cAMP levels with a potency of 193 nM. Compared with control, SYD5115 did neither impact the growth nor the migration of cultivated GOF. In addition, SYD5115 did not alter the viability of GOF. Conclusions: SYD5115 blocked M22- and TSAb-induced TSH-R activity with a nanomolar potency in TSH-R-overexpressed CHO cells as well as primary GOF, which demonstrates the ability of this small molecule to block TSH-R overactivity.

GRAVES DISEASE

Graves' disease is one of the most common autoimmune diseases. The disease is named after the scientist Robert James Graves, who first described it in the 19th century as a syndrome with an enlarged and overactive thyroid gland (hyperthyroidism due to circulating autoantibodies), rapid heart rate, and eye abnormalities. graves’ disease is the most common cause of hyperthyroidism and affects more women than men. Graves’ disease can appear at any age, but it most commonly appears for the first time between the ages of 20 and 40. Factor is a predisposition that is more dominant than environmental factors. There are circulating autoantibodies produced by B lymphocytes induced by autoreactive T lymphocytes that recognize thyrotropin-stimulating hormone (TSH) receptors in thyroid tissue as self-antigens. These autoantibodies are also known as TSH receptor antibodies (TSH-R Ab), thyrotropin stimulating antibodies (TSI), or thyrotropin receptor antibodies (TRAb). TRAb acts like TSH to cause thyroid hyperplasia (diffuse goitre), increased synthesis, and excessive and uncontrolled secretion of thyroid hormones (T4: tetraiodothyronine T4 and T3: triiodothyronine T3). Investigations to confirm Graves’ disease show elevated thyroid hormones (T4 and T3) with very low TSH and increased TRAb. On thyroid ultrasound, the majority of patients have a hypervascular and hypoechoic diffusely enlarged thyroid gland. The treatment for graves’ disease is to reduce the synthesis of thyroid hormones using anti-thyroid drugs, or to reduce the amount of thyroid tissue with radioactive iodine (RAI) or total thyroidectomy. Methimazole is the first-choice antithyroid drug with good effectiveness and safety. Although the recurrence rate after stopping the drug is still quite high

Clinical Characteristics of Patients with Euthyroid Thyroid-associated Ophthalmopathy

Purpose: To compare clinical features between thyroid-associated ophthalmopathy (TAO) patients with hyperthyroidism and euthyroidism.Methods: Between September 2015 and January 2021, we enrolled 96 TAO patients with euthyroidism (n = 16) or hyperthyroidism (n = 80). We recorded the age, sex, smoking status, presence of hypertension and diabetes, total follow-up period, unilateral involvement, eyelid edema, lid lag and retraction, clinical activity score (CAS), modified NOSPECS score, exophthalmometry, Hess test, area of extraocular muscles on orbital computed tomography (CT), treatment with systemic and subconjunctival steroids and radiotherapy, and serum levels of free thyroxine, thyroid-stimulating hormone (TSH), anti-thyroglobulin antibody (anti-Tg Ab), anti-thyroid peroxidase antibody (anti-TPO Ab), TSH receptor antibody (TSHR Ab), and thyroid stimulating antibody.Results: Unilateral involvement was significantly more common in the euthyroid group, while conjunctival injection, CAS, extraocular muscle movement restriction within 10° on the Hess chart, maximum cross-sectional area of the inferior rectus on orbital CT, and treatment with intravenous high-dose steroid were significantly more common in the hyperthyroid group. Furthermore, the modified NOSPECS score and levels of free thyroxine, anti-Tg Ab, anti-TPO Ab, and TSHR Ab were significantly higher in the hyperthyroid than euthyroid group.Conclusions: Compared to hyperthyroid TAO patients, those with euthyroid TAO were more likely to have unilateral involvement. They also had lower clinical activity and severity, milder enlargement of extraocular muscles (EOMs), and lower rates of EOM movement restriction and treatment with intravenous high-dose steroid. Euthyroid TAO patients had lower levels of free thyroxine, anti-Tg Ab, anti-TPO Ab, and TSHR Ab compared to hyperthyroid TAO patients.

Predictors of autoimmune thyroid disease

This case-control study sought to investigate whether thyroid autoimmunity is significantly associated with identifiable and potentially modifiable environmental factors. A total of 324 individuals were recruited: 164 cases (with positive thyroid peroxidase antibodies [TPO-Ab] and/or thyroid-stimulating hormone receptor antibodies [TSH-R Ab]) and 160 controls (negative antibodies) who had been screened for thyroid autoimmunity within the previous 12 months. A questionnaire sought information on drug, social, and reproductive history, stress, and iodine intake, while blood specimens were collected to measure glycosylated hemoglobin, thyroid function, TPO-Ab/TSH-R Ab status, 25-hydroxyvitamin D level, and hepatitis C antibody status. Both TPO-Ab–positive and TSH-R Ab–positive individuals were exposed to a higher amount of smoking pack-years (P = 0.038 and 0.037, respectively). No significant predictors of TSH-R Ab positivity were identified on multivariate regression analysis. The odds for TPO-Ab positivity was increased by female gender (odds ratio [OR] 2.815, 95% confidence interval [CI], 1.387, 5.714; P = 0.004) and discontinuation of smoking (OR 2.367, 95% CI, 1.213, 4.621; P = 0.012), while birth in winter (OR 0.470, 95% CI, 0.253, 0.871; P = 0.017) and higher intake of iodine-rich foods (OR 0.864, 95% CI, 0.761, 0.981; P = 0.024) decreased the odds for TPO-Ab development. Therefore, avoidance of ever starting smoking and correction of iodine deficiency may help protect against TPO-Ab development.

Conducting Hormonal, Biochemical and Serological Tests in Autoimmune Thyroid Patients

Background: One of the most frequent autoimmune illnesses affecting the thyroid gland is immunological thyroid disease. Antibodies against the enzyme thyroglobulin and thyroid-stimulating hormone receptors are produced by the immune system. Hashimoto's disease and Graves' disease are the two primary forms of autoimmune diseases.&#x0D; Methods: 91 blood samples were taken, including 71 for thyroid disease patients and 20 for healthy persons as control samples, from both sexes and of various ages. The tests were performed using a variety of methodologies.&#x0D; Results: Some of autoantibodies were found in varying quantities in 44 individuals. While TPO antibodies were found in 75% of 33 individuals, Anti-TG Ab was found in 72.72% of the patients, 15.90% in seven patients, and anti-TSHR Ab and antinuclear antibodies were found in 22.72% of the patients compared to the control samples. Any type of autoantibody, as well as the results of hormonal testing, revealed disease in a variety of individuals at varying rates. Because the patients were on therapy, the highest rate was 59.09% for thyroid-stimulating hormones. Chemical analyses revealed a sugar and fat imbalance with no discernible link. Interleukin 4 was detected in 4 individuals (9.09%), including one patient with autoimmune hypothyroidism (2.27%) and three patients in C3 18 with immunological hyperthyroidism (6.82%). The findings revealed an increase in complement molecule concentration in 40.90% of patients, including 15 patients with autoimmune hypothyroidism (34.09%) and 3 patients with immune thyroid gland C3 hyperactivity (6.71%). The statistical study revealed a P &lt; 0.01 level of significance correlation between the presence of sugar and triglycerides and the complement molecule. Interleukin 4 and antibodies to receptors have a substantial correlation at the P &lt; 0.01TSHR Ab level TSH.&#x0D; Conclusions: The C3 gland patients for thyroid peroxidase had the largest amount of antibodies, lipids, and sugar, according to the study. Interleukin-4 occurred in certain individuals who had antibodies to thyroid-stimulating hormone receptors, according to the research.

Sensitivity of three thyrotropin receptor antibody assays in thyroid-associated orbitopathy.

BackgroundThyrotropin receptor autoantibodies (TSH-RAb) are indispensable biomarkers in the laboratory assessment of thyroid-associated orbitopathy (TAO). Clinical sensitivity of three different assays for TSH-R-Ab determination was evaluated in patients with TAO.Methods87 consecutive TAO patients were enrolled and their serum samples analyzed in parallel with three assays. An ECLIA competitive binding and a chemiluminescent bridge immunoassay were used to measure total and binding TSH-R-Ab concentration, while their functional activity was determined using a stimulatory TSH-R-Ab (TSAb) cellbased bioassay.ResultsCompared to the two binding assays (ECLIA p<0.001, bridge p=0.003), the TSAb bioassay was more sensitive pertaining to the positive detection of TSH-R-Ab in TAO patients. No difference (p=0.057) was noted between the ECLIA and bridge assays regarding sensitivity rate. All patients with active and/or moderate-to-severe TAO tested positive in the TSAb bioassay (100% and 100%, respectively), while the positivity rates for bridge and ECLIA binding assays were 89.7% and 82.1% for active TAO, and 90.2% and 86.3% for severe TAO, respectively. Negative predictive values of the bioassay, bridge, and ECLIA assays were 100%, 75%, and 71%, respectively for active TAO, and 100%, 86%, and 71%, respectively for moderate-to-severe TAO. The superiority of the bioassay was most prominent in euthyroid (ET) TAO. Positivity rates of the TSAb bioassay, bridge and ECLIA binding assays were 89.6%, 75%, and 64.6%, respectively for inactive TAO; 86.1%, 69.4%, and 52.8%, respectively for mild TAO; 87.5%, 62.5%, and 12.5%, respectively for euthyroid TAO. The bridge assay correlated better with the ECLIA binding assay (r=0.893, p<0.001), compared to the bioassay (r=0.669, p<0.001).ConclusionsIn patients with TAO of various activity and severity, the TSAb bioassay demonstrates a superior clinical performance compared to both ECLIA and bridge binding assays.

Title: Case of Hyperthyroidism in a Patient on Anti-PD-1 (Programmed Cell Death Receptor-1 Blocking Antibody) Therapy Caused by Destructive Thyroiditis Followed by Graves’ Disease

Introduction: Immune checkpoint inhibitor (ICI) related thyroid dysfunction such as destructive thyroiditis and hypothyroidism can occur with Anti-PD-1 therapy. Graves’ disease (GD) however is considered rare. We report a case of isolated hyperthyroidism in a patient on Pembrolizumab, Anti-PD-1 presenting initially as destructive thyroiditis and later transitioned to GD. Case: 57 y.o lady was diagnosed with squamous cell carcinoma of cervix, stage 4 in 2016. She was noted to have asymptomatic goiter in 1997. PET scan in 02/2017 showed hypermetabolic activity in the right lobe nodule of 5.6 cm with maximum SUV of 9.8. Baseline TSH was in normal range in 04/2017. US guided fine needle biopsy of the nodule resulted as follicular neoplasm with 15-30%, risk of malignancy. Molecular test showed 40% risk of malignancy. Lobectomy was deferred. Pembrolizumab was initiated for advanced cervical cancer in 07/2018. Repeat PET in 10/2018 showed resolution of metastasis and right thyroid mass was stable. TSH remained in euthyroid range for 4 months until 11/ 2018. In 01/2019, her TSH was low and became undetectable in 03/2019 with high free T4 and total T3. She developed symptoms of hyperthyroidism. TSI was positive and TSHR Ab was negative. RAIU was low. No iodinated contrast study done prior to I123 scan. In 05/2019 to 08/2019, free T4 and total T3 was normal range with detectable but low TSH consistent with transient resolving thyroiditis. In 10/2019, thyroid hormones significantly increased with recurrence of hyperthyroidism. Both TSI and TSHR Ab were elevated confirming diagnosis of GD. Due to overt thyrotoxicosis, Methimazole (MMI) was initiated in 10/2019. She was briefly lost to follow up and stopped MMI. RAIU scan in 12 /2019 showed increased uptake consistent with GD. MMI was resumed in 04/2020. 06/2020 - 09/2020, MMI dose was titrated to achieve euthyroid state. In 09/25/2020, hypothyroidism was noted which improved with MMI dose reduction. Anti- TPO and Anti-Tg were negative. Pembrolizumab was stopped in 07/2020 due to dilated cardiomyopathy. She completed 2-year course of Pembrolizumab with advanced cervical cancer showing excellent response. Discussion: Observed thyroid dysfunction with ICI, is transient destructive thyroiditis followed by hypothyroidism, which can be permanent. Our patient had an initial low RAIU indicating destructive thyroiditis along with, mildly elevated TSI suggestive of superimposed autoimmune process. The elevated TSI predisposed to later occurrence of GD likely precipitated by Pembrolizumab. MMI provided therapeutic benefit. Conclusion: Less than 10 cases of GD with ICI and 5 cases of GD with Anti-PD- 1 have been reported. Our patient is a second case of persistent hyperthyroidism due to GD induced by Pembrolizumab. GD should be considered if hyperthyroidism persists or recurs in patients on ICI with destructive thyroiditis, which is mostly transient.

Study the association between IL-17 level and autoimmune antibodies in hypo and hyper thyroidisms patients

The current study included measuring the level of IL-17A and IL-17F and some autoimmune antibodies related to the thyroid gland in case of hypo and hyperthyroid in Iraqi patients to evaluate the correlation between all the measured parameters in this study.The study has been carried out in AL-Kindey Endocrine Gland and Diabetic Center in Baghdad during the period between February 2018 and May 2018, included: 88 patients were divided into three groups, The first group composed of 30 patients of Hypothyroidism that included (26) of them were females, (4) of them males. The second group composed of 30 of patients of Hyperthyroidism that included (20) of them were females, (10) of them were males . and second groups were conducted with hypo and hyperthyroidism respectively.While the third group composed of 28 of healthy individuals (Control) that composed of (25) of them were females, (3) of them were males was represented as control .The results revealed a significant (P &lt; 0.05) correlation between TSH concentration and age in patients groups. When the age is more than 40 years, the concentration of TSH was noticed to be higher than that in patients aged less than 40 years. The results show that the level of antibodies was significantly increased (P&lt;0.01) in hypo and hyperthyroid patients in comparison with the control group. At the same time the level of Anti-TG antibodies was higher significantly in the hypothyroid patients than its level in hyperthyroid patients group. No significant differences have been found between hypo and hyperthyroid patients in the level of Anti-TPO and Anti TSH-R antibodies. But its noticed that the higher level of Anti-TPO Ab. was found in the hypothyroid group where as higher level of Anti TSH-R Ab. was found in the hyperthyroid group and simultaneously both types were significantly higher than their levels in the control group As well as the results demonstrated a highly significant increase (P&lt; 0.01) in the levels of IL-17 Types (A and F) in hypo and hyperthyroid patients with bias toward the comparison with the control group. The statistical study showed a significant negative correlation between the level of TSH and Anti-TG levels (r= -0.33). While a significant positive correlation between the level of Anti-TG and level of IL-17F (r= 0.39) in hypothyroid patients. Also in hypothyroid patients, there is a significant positive correlation between the level of Anti-TPO and IL-17A (r= 0.33). In conclusion: The positive correlation between IL-17F and Anti-TG and between IL-17A and Anti- TPO in hypothyroid patients refer to increase in the concentration of IL-17 may lead to increase the thyroid autoantibodies, which affect thyroid tissue potency, decreasing thyroid hormone production, according to feedback inhibition loop.

Nanoparticles Bearing TSH Receptor Protein and a Tolerogenic Molecule Do Not Induce Immune Tolerance but Exacerbate Thyroid Autoimmunity in hTSHR/NOD.H2h4 Mice.

Transgenic NOD.H2h4 mice that express the human (h) TSHR A-subunit in the thyroid gland spontaneously develop pathogenic TSHR autoantibodies resembling those in patients with Graves disease. Nanoparticles coupled to recombinant hTSHR A-subunit protein and a tolerogenic molecule (ligand for the endogenous aryl-hydrocarbon receptor; ITE) were injected i.p. four times at weekly intervals into hTSHR/NOD.H2h4 mice with the goal of blocking TSHR Ab development. Unexpectedly, in transgenic mice, injecting TSHR A-subunit-ITE nanoparticles (not ITE-nanoparticles or buffer) accelerated and enhanced the development of pathogenic TSHR Abs measured by inhibition of TSH binding to the TSHR. Nonpathogenic TSHR Abs (ELISA) were enhanced in transgenics and induced in wild-type littermates. Serendipitously, these findings have important implications for disease pathogenesis: development of Graves TSHR Abs is limited by the availability of A-subunit protein, which is shed from membrane bound TSHR, expressed at low levels in the thyroid. The enhanced TSHR Ab response following injected TSHR A-subunit protein-nanoparticles is reminiscent of the transient increase in pathogenic TSHR Abs following the release of thyroid autoantigens after radio-iodine therapy in Graves patients. However, in the hTSHR/NOD.H2h4 model, enhancement is specific for TSHR Abs, with Abs to thyroglobulin and thyroid peroxidase remaining unchanged. In conclusion, despite the inclusion of a tolerogenic molecule, injected nanoparticles coated with TSHR A-subunit protein enhanced and accelerated development of pathogenic TSHR Abs in hTSHR/NOD. NOD.H2h4 These findings emphasize the need for sufficient TSHR A-subunit protein to activate the immune system and the generation of stimulatory TSHR Abs in genetically predisposed individuals.

Peripheral blood picture and aminotransferase activity in children with newly diagnosed Graves' disease at baseline and after the initiation of antithyroid drug therapy.

Aim of the studyAssessment of the peripheral blood picture and aminotransferase activity in children with newly diagnosed Graves’ disease (GD) at baseline and 4-6 weeks after the initiation of antithyroid drug (ATD) therapy.Material and methodsData of 59 children were assessed retrospectively. Baseline analysis included concentrations of thyroid-stimulating hormone (TSH), free triiodothyronine (fT3), free thyroxine (fT4), TSH receptor antibodies (TSH-R Ab), complete blood cell count (CBC), aspartate (AST) and alanine aminotransferase (ALT) activity. Reassessment of CBC and aminotransferase activity was performed 4-6 weeks after the initiation of ATD therapy.ResultsSignificant decreases in the neutrophil count, MCV, haemoglobin (Hgb), red blood cell (RBC) count, white blood cell (WBC) count and platelet (PLT) count were found in 37.3%, 32.2%, 22%, 13.6%, 8.5% and 5% of untreated patients, respectively. Increased baseline ALT and AST activity was observed in 44% and 32.2% of children, respectively. Initiation of ATD therapy led to significant changes in Hgb, RBC and PLT count, RDW and ALT activity. Negative associations between TSH-R Ab, TSH and MCV were found. ALT and AST activity were negatively related to baseline TSH levels. ALT activity was also associated with baseline fT4 and fT3.ConclusionsThe incidence of haematopoiesis and liver abnormalities in GD children seems to be similar to that reported in adult patients. The most common alterations are changes in neutrophil count, RBC parameters and ALT activity. The initiation of ATD therapy usually leads to significant improvement in those parameters.

Implications of extrapolative factors and their role in the development of breast cancer in females susceptible to Autoimmune Thyroid Disorders (AITDs)

Background: Apart from different cancer types in females, breast cancer falls among frequent cancers all over the world. The data from the current studies shows that females with advanced stages of breast cancer also prone to Autoimmune Thyroid Disorders (AITDs). Methodology: Hundred breast cancer patients (Stage-III) with palpable thyroid nodule in the age group of 30-75 y were eligible for inclusion in the study. Hundred age and sex-matched clinically apparently healthy individuals were included as controls. FT3, FT4, TSH, TPOAb, TgAb, TSHr Ab, prolactin and estradiol were estimated by using ELISA kit method. Serum Protein-Bound Iodine (PBI) and selenium were estimated by using a flow injection hydride generation Atomic Absorption Spectrometric (AAS) method. Results: The mean age and weight for diseased group were 58.36 ± 11.78 y and 74.96 ± 12.66 kg. The decreased levels (3.73 ± 0.189 pmol/L) of T3 were observed in newly diagnosed breast cancer patients as compared to controls (4.72 ± 0.24 pmol/L). Higher levels of T4 (17.86 ± 4.98 pmol/L) were recorded in patients as compared to controls (10.11 ± 1.64 pmol/L). The serum TSH levels in the breast cancer patients were raised (3.54 ± 0.26 mIU/L) in contrary to control group (1.9 ± 0.134 mIU/L). Significantly higher levels of Thyroglobulin Antibodies (TgAb), Thyro-Peroxidase Antibodies (TPOAb) and Thyrotropin Stimulating Hormone receptor Antibodies (TSHrAb) were recorded in breast cancer patients (62.07 ± 6.94 pmol/L, 24.1 ± 6.81 and 3.1 ± 0.43 IU/L pmol/L) as compared to controls respectively. The levels of iodine and selenium in patients were reduced (32.03 ± 4.76 ng/ml and 51.03 ± 2.13 mlU/L) as compared to the controls. Highly significant higher serum levels of prolactin (35.09 ± 4.76) were observed in diseases group as compared to controls (7.14 ± 1.57 pg/ml). Serum estrogen levels in patients were 10.47 ± 1.67 pg/ml, while in healthy individuals they were 6.55 ± 0.88 pg/ml, which shows statistically highly significant profile between the two groups. Conclusion: The present study show an association in between breast cancer and thyroid disorders, as thyroid hormone profile regulates breast cancer initiation. Therefore, these biomarkers can be used in prognosis i.e., in management and progression of breast cancer.

Etiopathogenesis of Graves-Basedow disease; where we are and where we are going

Graves-Basedow disease (GBd) since late fifties has been considered to be autoimmune thyroid disorder where the presence of thyroid stimulating antibodies (TSAb) may lead to hyperthyroidism, thyroid orbitopathy and thyroid dermopathy. During last years it was generally accepted that development of Graves-Basedow disease is dependent on the presence of two or three groups of factors - genetic and environmental or genetic, environmental and endogenous. Familial clustering of GBd, familial presence of thyroid autoantibodies and high concordance in the incidence and clinical course of the disease in monozygotic siblings all suggested that several genes decide about susceptibility to this disorder and likely its phenotypes. On the other hand environmental agents and endogenous factors served as triggers important to the development of the disease, its clinical course and response to given therapy. It was believed that finally, development of GBd (and other autoimmune disorders) is a consequence of lack of balance between the formation of self reactive T cells and central and peripheral tolerance. As a result thyroid was infiltrated by self reactive T cells that in turn affected B cells and led to the production of thyroid stimulating antibodies. Most recently etiopathogenesis of GBd became further complicated by both clinical and molecular findings. First, GBd can be clinically presented as a hypothyroidism depending on the switch of TSAb production to thyroid blocking antibody (TBAb) production as well as vice versa. Some findings suggest that in prone classically hyperthyroid patient the administration of methimazole can provoke switch off of TSAb generation and start of TBAb followed by block of thyroid hormones biosynthesis and quite rapid morphological damage of thyroid cells. It is a pity that in other hypothyroid patient administration of thyroxine can switch on the generation of TSAb and switch off the production of TBAb. Second, it is more and more obvious that autoimmune thyroid disorders and differentiated thyroid cancer (DTC) especially of papillary type (PTC) share some genetic factors (RET/PTC1) and environmental and epidemiological features. In addition presence of GBd disease in patients with DTC leads to increased mortality of cancer patients. Third, microarray DNA analysis of thyroids from GBd patients with severe course of the disease led to the identification of seven additional genes either overexpressed or underexpressed that may be responsible for high level of TSH-R Abs, large goiter size and high free T3/free T4 ratio, features characteristic for patients that poorly respond to anti-thyroid drug therapy. In addition to these clinical observations, the pathogenesis of GBd during the last two-three years was strongly affected by studies suggesting that non sufficient peripheral tolerance was a key to autoimmunity in general, including mechanisms leading to development of Graves-Basedow disease. In a way we returned to Volpe hypothesis developed in the 70-ies of the previous century that pointed out the role of T-suppressor cells. At present the name suppressor cells was postponed and we know that control of self reactive T cells is a function of T regulatory cells (Tregs). It has been proven that block of activation of Tregs both in experimental animals and humans led to the development of generalized fatal autoimmunity. The mechanism of appropriate Tregs activation concerning first signal (MHC-TCR) and especially second costimulatory signals (CD28-B7-1(CD80) or CD28-B7-2 (CD86)) will be presented and their role for the thyroid autoimmunity discussed. The progress in our knowledge concerning autoimmunity as a whole and GBd as a thyroid autoimmune disorder clearly shows that pathogenesis of this disorder is more complex than previously expected and that personalized approach to given patient based on clinical and molecular findings is more important than the hope that single finding (light in corridor) brings a positive solution for all patients with Graves-Basedow disease.