Biomedical subjects
Publications and source records attributed to L Wartofsky.
Two patients are described who manifested the sequential occurrence of Graves' disease and subacute thyroiditis. The literature on this very unusual event is reviewed and speculation is offered on a possible mechanism linking thyroiditis to activation of Graves' disease in susceptible persons.
Short-term fasting in humans is associated with diminished delta TSH to TRH. The purposes of the present study were to reassess basal TSH levels and TRH responsiveness during fasting utilizing a sensitive radioimmunoassay (RIA: sensitivity 0.3 microU/ml; normal range 0.66-2.98 microU/ml) and to determine if normal feedback regulation is maintained during the fasting state. Eight control subjects (C) and six iodide-treated (I) subjects (262 mg/d) were studied in the fed state and on day 10 of fasting. T3, T4, and TSH were measured by RIA, and free T4 and free T3 by equilibrium dialysis. Basal serum TSH levels in the control group were 2.0 +/- 0.3 microU/ml (mean +/- SEM) in the fed state and increased to 14.7 +/- 3.5 microU/ml 20 min after TRH administration. The fasting basal TSH level of 1.6 +/- 0.3 microU/ml was significantly decreased (P less than 0.01) compared to control, as was the level of 8.8 +/- 2.3 microU/ml (P less than 0.01) obtained 20 min after TRH. In the iodide-treated group the basal TSH level was 1.4 +/- 0.2 microU/ml during feeding which increased (P less than 0.025) to 2.9 +/- 0.7 microU/ml during fasting; the TSH value 20 min after TRH was 12.6 +/- 2.5 microU/ml while feeding and 17.3 +/- 2.9 microU/ml while fasting. Free and total T3 decreased during fasting in both groups. Total T4 was unchanged between the fed and fasted periods in the two groups.(ABSTRACT TRUNCATED AT 250 WORDS)
The immunological mechanisms involved in Graves' ophthalmopathy are not known. To explore the pathophysiology of this disorder, we used an enzyme-linked immunosorbent assay to detect antibodies that bound to the 100,000 X g sediment fraction of porcine eye muscle. Serum from patients with Graves' ophthalmopathy had enhanced immunoglobulin binding to porcine eye muscle compared to serum from control subjects (P less than 0.0001); however, several individual normal serum samples also had elevated binding activity. Incubation of serum from some Graves' patients with skeletal muscle or liver tissue resulted in reduction in immunoglobulin binding to porcine eye muscle. Thyroglobulin and TSH reduced binding only at high concentrations. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis revealed some obvious differences in protein bands between porcine eye muscle and skeletal muscle. Serum from many normal subjects and patients with autoimmune thyroid disease formed bands with skeletal muscle protein fractions on immunoblotting, and no specific bands were found using serum from Graves' ophthalmopathy patients. Immunoblots of Graves' patients' serum after reaction with either porcine skeletal or eye muscle showed no reactivity with thyroglobulin (200K and 320K) or thyroid microsomal antigen (105K). Instead, immunoblots of eye muscle and serum from Graves' patients, with or without eye disease, showed two bands at 64K and 73K, which were shared by serum from normal subjects. In addition, several unique eye muscle determinants were detected in serum from 6 of 13 Graves' disease patients analyzed. These unique bands usually had mol wt of less than 50K, and 5 of the 6 patients whose serum reacted with these determinants had significant ophthalmopathy. Our findings support the presence of potential antigenic differences between eye muscle and skeletal muscle accounting for the immunological specificity of eye muscle as a target in Graves' ophthalmopathy.
We retrospectively reviewed the therapeutic efficacy of antithyroid drugs for Graves disease. Sixty-nine patients were divided into three categories according to their response: 28 (40.6%) were unable to achieve a remission; 6 (8.7%) achieved a remission and subsequently had a relapse; and 35 (50.7%) were able to sustain a remission. The mean duration for sustained remissions was 33 months. Our earlier review of outcome of antithyroid therapy showed markedly reduced remission rates, which appeared to be related to increases in dietary iodine intake. Although the greater percentage of patients entering remission today is in marked contrast to the 1973 report, average dietary iodine content has been decreasing. A continuing role for antithyroid drugs should be maintained as an option in the management of Graves disease. Daily dietary iodine intake may influence the anticipated remission rate after antithyroid drug therapy.
Recent investigations have suggested that myc oncogene expression may be important in the development or progression of thyroid tumors. The purposes of the present study were to assess cellular (c)-myc expression in thyroid adenomas (n = 5), as well as in thyroid cancer (n = 4) and in normal thyrocytes (n = 7). Total RNA was prepared by extraction with guanididium thiocyanate and ultracentrifugation through a CsCl2 cushion. 30 micrograms total RNA was size fractionated on a 1% (w/v) agarose/formaldehyde gel and transferred to nylon membranes. These membranes were hybridized to a 32P-labelled third exon c-myc DNA. Following hybridization, blots were washed under high stringency and subjected to autoradiography; radioautographic bands were assessed visually or were quantitated by scanning densitometry. Nodular tissue had approximately the same degree of expression of the 2.4 Kb c-myc message as the surrounding normal tissue from the same gland (0.66 +/- 0.09 vs. 1.0 +/- 0.26, respectively); normal thyrocytes were capable in every instance of expressing the 2.4 Kb c-myc message. Thyroid cancer tissue expressed this message (0.91 +/- 0.17) but only at a level comparable to normal tissue. No other bands of hybridization were detected in any samples. We conclude that c-myc oncogene expression is comparable in normal thyrocytes and in thyroid nodules or thyroid cancer samples. These findings support a role for c-myc in both normal and neoplastic thyrocyte growth.
Enhanced oncogene expression observed in lymphocytes from patients with systemic lupus erythematosus has suggested the importance of studying oncogene expression and regulation in the cellular events of autoimmune thyroid diseases (AITD). The present study examines oncogene expression in peripheral and intrathyroidal lymphocytes from patients with Hashimoto's disease (HD) and Graves' disease (GD). Intrathyroidal lymphocytes from a patient with primary thyroid lymphoma were also examined. Lymphocytes were isolated by Ficoll-Hypaque gradients, and total RNA was prepared by extraction with guanididium thiocyanate and ultracentrifugation through a cesium chloride cushion. RNA concentrations were determined by O.D. readings at 260/280 nm and each sample subjected to gel electrophoresis with ethidium bromide staining to assure the integrity of the RNA. 30 micrograms total RNA was size fractionated on a 1% (w/v) agarose/formaldehyde gel and transferred to nylon membranes. These membranes were hybridized with nick-translated 32P labelled c-myc DNA (exon III), washed at high stringency and subjected to autoradiography. Specific bands were quantitated by scanning densitometry. Five RNA samples from GD thyroids had 2.4 Kb bands corresponding to c-myc with a mean O.D. (+/- SD) of 0.76 +/- 0.23, whereas 7 from normal thyroid glands had mean O.D. of 1.0 +/- 0.26. Peripheral lymphocytes from 7 GD patients had a mean O.D. of 1.41 +/- 0.25, 4 HD patients had a mean O.D. of 1.05 +/- 0.10 and 2 normal patients had a mean O.D. of 1.4 +/- 0.14. The readings for a sample obtained from intrathyroidal lymphocytes of a patient with HD and thyroid lymphoma were 1.0 and 1.4, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
Antibody-dependent cell-mediated cytotoxicity (ADCC) is the process by which antibodies interact with killer cells to effect cell lysis, whereas natural killing (NK) refers to the ability of peripheral blood killer cells to lyse target cells in the absence of specific antibody. The purpose of the present study was to determine if either NK cells or ADCC might play a role in the development of Hashimoto's thyroiditis (HD) by testing the ability of killer cells to cause lysis of K562 erythroleukemia tumor cells and human thyrocytes in the presence and absence of serum from normal and HD patients. Using K562 target cells, NK activity was 70 +/- 4% (mean +/- SEM) for HD effector cells and 66 +/- 5% for normal effector cells at an effector to target ratio of 100:1. Similarly, with thyrocytes as targets, effector cells from HD patients (38 +/- 3%) and normal subjects (34 +/- 5%) caused comparable lysis (at an effector to target ratio of 100:1). Using K562 target cells, ADCC was 35% when effector cells from HD or normal subjects were coincubated with either normal or HD sera. Using thyrocyte target cells, lysis was about 25-30%, but, again, no differences were found between HD and normal effector cells or serum. There was a significant correlation between lysis for K562 and thyrocyte target cells, but there was no significant correlation between the titer of serum antithyroid microsomal antibodies and specific lysis. Intrathyroidal lymphocytes and peripheral lymphocytes from one patient with HD caused comparable lysis of labeled thyrocyte targets, as did normal peripheral lymphocytes. We conclude that ADCC and NK activities in peripheral lymphocytes were normal in HD patients and, therefore, may not have a primary role in mediating thyrocyte destruction in Hashimoto's thyroiditis.
Twenty-eight patients with destructive thyroiditis were followed to study the natural history of healing of thyroid gland injury. All had sequential measurements of thyroidal iodine [127I] content by fluorescent scanning (normal mean, 10.1 mg), 17 had serial serum thyroglobulin (Tg) measurements (normal, less than 21 ng/ml), and 13 had perchlorate discharge studies during the recovery phase. Seventeen patients had painful subacute thyroiditis (SAT), 9 had painless thyroiditis with thyrotoxicosis (PTT), and 2 had postpartum thyroiditis with thyrotoxicosis (PPT). Thyroidal iodine content decreased from a mean of 9.8 to a nadir of 3.8 mg in patients with SAT and from 8.5 to a nadir of 3.5 mg in patients with PTT. Mean serum Tg concentrations were highest (approximately 165 ng/ml) in both groups 1-3 months after the onset of symptoms. Abnormalities in both 127I content and Tg levels persisted for 2 or more yr in some individuals. No patient had detectable Tg antibodies by hemagglutination, but low titers were detected intermittently by sensitive RIA in 5 PTT patients. Microsomal antibodies were positive in only 1 of 16 SAT patients, but in 4 of 7 PTT patients and in both PPT patients. Three patients had positive perchlorate discharge tests (2 of 8 with SAT, 0 of 4 with PTT, and 1 of 1 with PPT). Permanent hypothyroidism occurred in 3 patients (2 with PTT; 1 with SAT and positive antibodies), but did not correlate with perchlorate results. HLA typing and serum immunoglobulin measurements were not useful for predicting the clinical course. These data indicate that several years may be necessary for complete resolution of destructive thyroiditis; many patients have evidence of thyroid injury persisting long after serum thyroid hormone and TSH levels become normal.
Traditional L-thyroxine dosing formulas may overestimate the thyroid hormone requirement in patients treated with contemporary L-thyroxine preparations. We did clinical and laboratory assessments of 41 patients treated in successive periods with Levothroid (Armour Pharmaceuticals, Kankakee, Illinois) and Synthroid (Flint Division, Travenol Laboratories, Morton Grove, Illinois), obtaining 87 sets of data. Clinical subgroups were defined on the basis of the thyrotrophin response to thyrotrophin-releasing hormone. Normal responses were seen in 9 of 14 (64%) patients taking 100 micrograms/d and were associated with an average replacement dosage of 127 micrograms/d (1.7 micrograms/kg body weight). Nine of twenty-eight (32%) serum thyroxine values in the "physiologically replaced" group were elevated. Forty-three of fifty-four (80%) patients ingesting 125 micrograms or more had blunted responses (thyroxine "overreplaced"), averaging a daily dosage of 154 micrograms (2.14 micrograms/kg X d). No significant difference was found between Levothroid and Synthroid in predicting clinical group assignment. Guidelines for currently available L-thyroxine preparations should be revised and the recommended dosage reduced.
Measurement of thyroid-stimulating hormone (TSH) levels in various timed blood samples after administration of thyrotropin-releasing hormone (TRH) has become a standard part of the diagnostic armamentarium for suspected thyroid disease. We reviewed the records of 165 patients who received TRH tests in an endocrinology outpatient clinic to assess the diagnostic utility of the test based upon other clinical parameters, and to assess concordance of the 30-minute TSH value after intravenous administration of TRH. Standard (control) values for TRH testing were obtained in 41 normal subjects. Patients were divided into groups of hyperresponders, hyporesponders, and normal responders. The overall concordance rate of the ultimate thyroid diagnosis and the 30-minute TSH value was 97%. With close adherence to clinical indications, the TRH test is of considerable benefit as an outpatient tool in the diagnostic assessment of thyroid disease. Basal and 30-minute TSH values are satisfactory for diagnosis in the majority of patients, thereby rendering unnecessary the discomfort and expense of multiple samples for TSH measurements.
To determine the presence and potential importance of antiidiotypic antibodies (anti-id) in the immune regulation of Graves' disease, sera from 57 patients with Graves' disease were screened before or during antithyroid therapy by enzyme-linked immunoabsorbent assay (ELISA) for presumptive anti-id, as defined by the presence of immunoglobulins (Igs) directed against TSH. The mean optical density, indicating the presence of TSH-binding antibodies, was 0.34 +/- 0.28 (+/- SD) in the sera of Graves' disease patients and 0.19 +/- 0.12 in the sera of 24 normal subjects (P less than 0.004). Control antigens (hCG and albumin) did not bind significant amounts of serum Igs. In 8 Graves' patients whose sera bound TSH, 40-80% inhibition was obtained with the addition of TSH receptor-purified IgG (approximately 1 microgram/ml) derived from a single Graves' patient's serum; no inhibition was found with normal IgG (approximately 10 micrograms/ml). Presumptive anti-id was isolated from sera of 6 Graves' patients by affinity purification with a TSH affinity column; the resultant IgG blocked immunoglobulin binding to the TSH receptor when added to the serum of the same patient from whom it had been isolated. The presence of anti-id correlated inversely with the presence of TSH receptor antibodies (r = -0.76; P less than 0.01). These studies demonstrate that 1) significant TSH binding is present in sera from Graves' disease patients, and 2) this TSH binding is specifically inhibitable by Graves' IgG, but not by normal IgG. These data support the hypothesis that TSH-binding immunoglobulins may represent anti-id that are present in Graves' disease as part of the immunological response to TSH receptor or TSH receptor antibodies. Such anti-id could modulate the expression of disease activity in Graves' disease by altering TSH receptor antibody action or production.
Five healthy adult well trained men (averaging 49 miles running per week) were exercised to exhaustion on a treadmill. Plasma epinephrine increased from 168 +/- 37 pg/ml prior to exercise to 633 +/- 155 pg/ml immediately after exercise (P less than 0.025) and plasma norepinephrine increased from 1608 +/- 345 to 8576 +/- 1662 pg/ml (P less than 0.025) in the two respective periods. Beta receptor density increased from 53 +/- 18 fmol/mg protein before exercise, to 223 +/- 63 fmol/mg (P less than 0.05) protein immediately after exercise, and then decreased to 83 +/- 27 fmol/mg protein 1 h later (P less than 0.05 compared to post-exercise). The mean Kd value prior to exercise of 1.5 +/- 0.2 X 10(-11) M was unchanged statistically throughout the study. Following correction for haemodilution, serum total and free T4 and T3 concentrations were also unchanged during exercise, although reverse T3 levels did increase from 39 +/- 4 to 45 +/- 0 ng/dl (P less than 0.05). These findings suggest that: 1) plasma epinephrine, norepinephrine and beta receptor density, but not Kd, increase acutely during exercise and 2) total and free T4 and T3, after correction for haemodilution, do not change during acute exercise. Our data indicate that acute exercise represents an unusual condition during which 'down regulation' is not observed, but, rather, there appear to be parallel alterations in beta receptor density and plasma catecholamine levels.
Differences in blood levels of thyroid hormones have been reported when patients taking synthetic L-thyroxine were shifted from one manufactured form of the hormone to another. Because recent formulation changes have rendered these earlier data obsolete, we did a crossover study to determine differences in bioavailability of the two principal brands of thyroxine, Synthroid and Levothroid. Twenty patients received Synthroid and then Levothroid, and 14 received Levothroid and then Synthroid. Patients received each drug for 6 weeks. Although no significant differences were seen in routine thyroid hormone measurements, combined data from both groups showed a significantly higher free thyroxine level in the patients treated with Synthroid, as well as lower thyrotrophin values at 15 and 30 minutes after administration of thyrotrophin-releasing hormone. Equal doses of the currently manufactured forms of these two products are similar but not bioequivalent.
In this enzyme-linked immunoassay for human thyrotropin (TSH) in unextracted serum we use 96-well immunoenzymometric assay plates, first coated with polyclonal antibody to TSH, then incubated with the serum samples and reacted with mouse monoclonal antibody to human TSH. After incubation with alkaline phosphatase-labeled antibody against mouse IgG, disodium p-nitrophenyl phosphate is added and the color change is measured spectrophotometrically. Assay sensitivity is 0.1 milli-int. unit/L. Cross reactivity with lutropin, follitropin, or choriogonadotropin was negligible. TSH concentrations ranged from 0.4 to 4.1 milli-int. units/L in 43 normal subjects (mean 2.0, SD 1.0), and were uniformly less than 0.3 milli-int. unit/L in 23 patients with hyperthyroidism. Features which make this assay advantageous to the clinical laboratory include ease of set-up, ability to assay many samples at a time, high sensitivity, rapid turnaround time (8 h), and absence of requirements for radioactive materials.
The American Institute of Nutrition purified ingredient diet (AIN-76) prevented occurrence of mature cataracts associated with hereditary retinal degeneration in pink-eyed, tan-hooded Royal College of Surgeons (RCS) rats. Rats fed a natural ingredient open formula NIH diet or a closed formula commercial diet had a cataract incidence of 27-29% by 3 to 12 months of age. In contrast, only 1 of 50 rats fed the AIN diet developed a mature cataract in one year. When the NIH diet and the commercial diet were pelleted with 25% of ground sunflower kernels, rats fed these diets had a delay in onset and a reduced incidence of mature cataracts to 18% and 5%, respectively. No mature cataracts occurred in rats fed the AIN diet supplemented with 25% sunflower kernels. All diets were fed to the parental generation as well as the progeny (experimental group). The rats were reared at a low level of illumination (1-3 footcandles inside the cage) to minimize effects of light. Prevention of mature cataracts by the AIN purified diet suggests that diets permitting cataracts to occur may have a constituent at a concentration innocuous for normal rats but beyond the homeostatic control of the RCS rat. Posterior subcapsular cataracts of RCS rats are a model for cataracts associated with human hereditary retinal degenerations, such as retinitis pigmentosa and gyrate atrophy. Manipulation of dietary ingredients allowed by the use of the AIN diet may permit identification of nutrients, nutrient interactions of toxic factors involved in cataractogenesis and its prevention.
Previous studies have demonstrated that serum TSH and GH decrease during fasting. Taking advantage of the fact that somatostatin antiserum administration is an effective, specific method of blocking endogenous somatostatin activity, we performed the present investigation to explore whether known fasting-induced increases in somatostatin might underlie the mechanism(s) of this decrement. After a 48 hour fast, two groups of male rats were anesthetized and an indwelling right atrial catheter inserted. The control rats (n = 11) were injected with normal sheep serum and the experimental rats (n = 9) were injected with a specific antiserum to cyclic somatostatin; one and one-half hours later, blood was collected in a basal state after which 200 ng TRH was injected. The basal mean (+/- SE) T3 and T4 concentrations were 23 +/- 3 ng/dl and 1.9 +/- 0.1 ug/dl, respectively, in the fasted control group and 30 +/- 2 ng/dl and 2.3 +/- 0.2 ug/dl in the fasted somatostatin antiserum injected rats. While serum T4 and T3 levels were statistically unchanged between these two groups, basal TSH increased from 537 +/- 81 ng/ml in the control rats to 2913 +/- 742 ng/ml in the somatostatin antiserum-treated rats (P less than 0.05). Basal growth hormone levels were also higher in the somatostatin antiserum-injected rats (196 +/- 19 ng/ml vs 72 +/- 7 ng/ml (P less than 0.0025). TSH peak values following TRH injection were not different in the two study groups. In summary, the present study indicates that: (1) somatostatin antiserum increases both basal GH and TSH values in fasting rats; and (2) somatostatin and TRH may act through different pathways to modulate TSH secretion. By implication, therefore, it is suggested that enhanced somatostatin-like activity may represent one mechanism mediating the fasting-induced decrement observed in serum TSH and GH.
Traditionally, it has been thought that the bioavailable fraction of circulating serum hormones, i.e. that which is available for cellular uptake and is physiologically active, is limited to the free (nonprotein bound) hormone. However, recent evidence, based on acute organ uptake of labeled hormone, suggests that the amount of hormone which is bioavailable in vivo may exceed that which is calculated to be free in vitro. To explore the bioavailability of circulating protein-bound thyroid hormones under steady state conditions in vivo, we altered serum thyroid hormone-binding proteins in rats by inducing nephrotic syndrome with puromycin aminonucleoside. Nephrotic rats (serum albumin, 1.1 g/dl) were found to have a marked reduction in serum T4 [2.1 +/- 0.2 (SEM) vs. 6.5 +/- 0.3 microgram/dl; P less than 0.01] and an elevation of serum T3 [141 +/- 8 vs. 51 +/- 2 ng/dl; P less than 0.01]. Estimated T4 production rate was normal in nephrotic rats, and the 3- to 4-fold increase in T4 MCR appeared to account for the marked reduction in serum T4. By contrast, increased serum T3 levels in nephrotic rats reflected both a reduction (55%) in T3 MCR and an increased rate of peripheral conversion of T4 to T3. A circulating inhibitor of T4 binding to serum proteins appeared to be present in nephrotic rats. The changes in the various serum components of thyroid hormone [T4-binding prealbumin (TBPA)-bound, albumin-bound, free] produced by nephrotic syndrome were compared with the corresponding changes in indices of thyroid hormone bioavailability (MCR, urinary excretion, hepatic content, TSH suppression, single pass extraction by liver). These comparisons suggested that nephrotic syndrome results in increased bioavailability of circulating T4 and decreased bioavailability of circulating T3. The bioavailable fraction of circulating T3 in vivo seemed to include both free T3 and that which is albumin bound in vitro. The bioavailable fraction of circulating T4 resembled free T4 more than non-TBPA-bound T4 (= albumin bound + free), although a nephrosis-induced increase in bioavailability of TBPA-bound T4 was also possible. We conclude that nephrotic rats have low serum T4, which is related to accelerated T4 clearance, and high serum T3, which is related both to decreased T3 clearance and increased peripheral conversion of T4 to T3. Under steady state conditions in vivo, bioavailable circulating T3 appears to include both free T3 and the T3 that is bound to albumin in vitro.
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