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Thyroxine interactions with transthyretin: a comparison of 10 different naturally occurring human transthyretin variants.

Transthyretin (TTR) is a tetrameric protein that transports 15-20% of circulating T4. Alterations in TTR structure can manifest clinically as familial amyloidotic polyneuropathy or euthyroid hyperthyroxinemia. We have measured the relative affinity for T4 of several variant TTR molecules in human plasma. We have compared control plasma to plasma from a patient heterozygous for a [Thr109]TTR mutation associated with a 3-fold increased affinity for T4 and to plasma from patients with familial amyloidotic polyneuropathy with different point mutations in TTR. Relative affinity was measured in an assay in which [125I]T4 bound by TTR was isolated by immunoprecipitation with an antibody specific for TTR. [Thr109]TTR displayed the highest affinity for T4, whereas homozygous [Met30]TTR did not bind appreciable amounts of [125I]T4. The rank order of affinity of the various TTR mutations for T4 was: Thr109 heterozygous > wild type = Ala60 heterozygous = Ile122 heterozygous > His58 heterozygous approximately Tyr77 heterozygous approximately Ser84 heterozygous approximately Ile122 homozygous approximately Met30 heterozygous >> Met30 homozygous TTR. Thus, different point mutations in TTR increase, decrease, or do not affect TTR's affinity for T4. The ability of TTR to form amyloid fibrils does not appear to be related to its affinity for T4. Further study is required to define the molecular basis of alterations in T4 binding induced by point mutations located along the TTR tetramer.

Amyloidosis↗

[Changes in serum thyroid hormones in acute cerebrovascular apoplexy and their clinical significance].

Serum thyroid hormones were measured in 62 cases of acute cerebrovascular apoplexy. Compared with the control group, T3, FT3 were markedly lowered and rT3, T4 and TSH were significantly increased with lowered T3/rT3 ratio. The patients were divided into two groups, according to whether there was hemorrhage in their CSF. Changes of serum thyroid hormones in cerebral haemorrhage were more remarkable than those observed in cerebral thrombosis. 16 cases with increased T4, FT4 were diagnosed as euthyroid hyperthyroxinemia. It was found that the amount of thyroid hormone changes appeared to be in proportion to the severity of acute cerebrovascular apoplexy. The determination of serum thyroid hormones would be useful in evaluating the severity of the strokes and in studying the thyroid function in acute cerebrovascular apoplexy.

Adult↗

Familial partial peripheral and pituitary resistance to thyroid hormone: a frequently missed diagnosis?

The diagnosis of partial peripheral and pituitary resistance to thyroid hormone was ultimately made in two boys, 7 and 9 years of age, and a 10-year-old girl who had goiters and hyperthyroxinemia. The boys were treated with propythiouracil and/or thyroidectomy or iodine 131 for suspected thyrotoxicosis but had poorly suppressible serum thyroid-stimulating hormone (TSH) post treatment in spite of the usual L-thyroxine replacement. The girl had increasing goiter size while receiving propylthiouracil, 100 mg every eight hours. These findings led to reevaluation of thyroid hormone dynamics in these children and their families. Twelve additional family members, 3 to 38 years of age, compatible with an autosomal dominant inheritance, were also found to have peripheral and pituitary resistance to thyroid hormone. All affected individuals had elevated serum thyroxine and triiodothyronine levels, normal to slightly elevated triiodothyronine resin uptakes, and a nonsuppressed serum TSH. The five individuals who were given thyrotropin-releasing hormone showed exaggerated TSH responses, which normalized on L-thyroxine therapy. Misdiagnosis in six of 15 family members led to significant morbidity (hypothyroidism, delayed growth, and therapy risk). A nonsuppressed serum TSH in a patient with suspected thyrotoxicosis should lead to suspicion of this disorder. Appropriate management for this condition includes L-thyroxine therapy to decrease goiter size and normalize TSH responses to thyrotropin-releasing hormone.

Child↗

Resistance to thyroid hormone--an uncommon cause of thyroxine excess and inappropriate TSH secretion.

Resistance to thyroid hormone (RTH) is an uncommon inherited cause of hyperthyroxinemia with inappropriate TSH secretion. The syndromes are characterized by reduced target tissue responsiveness to circulating free thyroid hormones. The differential diagnosis to other diseases with similar laboratory results (high T4 with normal TSH) like familial dysalbuminemia or antibodies against iodothyronines or TSH is now possible with the appropriate use of new assays for free thyroid hormones. In the presence of thyrotoxic symptoms it may be difficult to differentiate the syndrome from a TSH-secreting pituitary tumour. Familial occurrence and a normal TSH-response to TRH that can not be suppressed by T3 are characteristic features of RTH, that may be helpful in that respect. The majority of RTH cases are dominantly inherited and have highly variable clinical signs and symptoms. There are, however, mainly two forms of the syndrome that have been shown to overlap clinically and biochemically, namely a generalised resistance (GRTH) and a more "selective" pituitary resistance to thyroid hormones (PRTH). The absence of thyrotoxic symptoms rather suggests GRTH, whereas thyrotoxic signs seem to be characteristic for PRTH. Following the cloning of thyroid hormone receptors, familial GRTH was shown to be tightly linked to the TR-(Thyroid hormone receptor)-beta gene locus. Molecular genetic studies have shown that even within a single kindred the same receptor mutation was associated with both, GRTH or PRTH, and therefore suggest that these two forms represent part of a variable clinical spectrum of a single genetic disorder.(ABSTRACT TRUNCATED AT 250 WORDS)

Diagnosis, Differential↗

Transthyretin mutations in health and disease.

To date, over 40 different mutations in transthyretin (TTR) have been associated with amyloid deposition. The major unresolved problem is the correlation between the clinical heterogeneity and the genetic heterogeneity. For instance, whereas some mutations produce neuropathy and some give rise to cardiomyopathy, others produce vitreous opacities, the vast majority being neuropathic. Moreover, some mutations are not amyloidogenic but are responsible to hyperthyroxinemias (by virtue of the protein function in thyroid transport), whereas others are apparently nonpathogenic. The study of TTR variants is very important to the understanding of the amyloid formation process and to establish a relationship between the structure and function of the molecule. The results of current TTR mutation screening programs and their characterization are summarized.

Alleles↗

Role of thyroid stimulating hormone suppression in the management of thyroid cancer.

Well-differentiated thyroid cancers (papillary, follicular, and some Hurthle cell tumors) contain membrane receptors for TSH. Responsiveness of these tumors to TSH stimuli is documented by increased radioactive iodine uptake, secretion of thyroglobulin, increase in thyroid size, and potential progression to an anaplastic type. Although TSH suppression has a variable effect on the growth of existing tumors and the incidence of recurrent disease, there is a sound rationale for long-term TSH suppression in all patients with differentiated tumors of the thyroid. The ultrasensitive TSH test permits ready monitoring of the adequacy of thyroxine dosage. The cost is minimal (approximately $.10/day) and the risks are negligible if one assumes the avoidance of hyperthyroxinemia.

Carcinoma↗

Expression of a human serum albumin variant with high affinity for thyroxine.

In this study a protein expression system was used to synthesize recombinant human serum albumin containing a mutation that has been shown to result in familial dysalbuminemic hyperthyroxinemia. Equilibrium dialysis was used to measure the binding of this recombinant human serum albumin with thyroxine. The association constant determined for the binding of this human serum albumin variant with thyroxine was shown to be 65-fold greater than that of recombinant normal human serum albumin.

Amino Acid Sequence↗

Thyroid function and immune profile in rheumatoid arthritis. A controlled study.

The aim of our study was to determine the prevalence of thyroid dysfunction and autoimmune abnormalities in rheumatoid arthritis (RA) and to further investigate the possible association between D-penicillamine and autoimmune thyroiditis. For this purpose, one hundred and one unselected consecutive patients with RA and 70 age and sex matched controls were studied prospectively. Evaluation included a complete history and physical examination with special attention to symptoms suggestive of thyroid pathology, routine laboratory and serologic immune profile, plus determination of serum levels of thyroxine (T4), triiodothyronine (T3), thyroid stimulating hormone (TSH), antibodies to thyroid peroxidase (AbTPO) and TSH receptor antibodies (TRAB). Serum thyroxine binding globulin (TBG) was measured in all subjects with high thyroid hormone levels, whereas free T3 and T4 concentrations were determined in all individuals with abnormal T3, T4, TSH or TBG. Six patients with hyperhyroidism, 3 with hypothyroidism and 1 with the euthyroid hyperthyroxinemia (EH) syndrome were found, whereas four of the controls had hyperthyroidism. Thirteen patients and 6 controls had high AbTPO levels whereas no one had high TRAB. No association was detected between thyroid abnormalities and any serologic RA finding. Furthermore, no correlation between thyroid dysfunction and elevated AbTPO's was found. A relatively high prevalence of thyroid dysfunction (9,9%) and subclinical autoimmune thyroiditis (12,9%), the latter indicated by elevated AbTPO's, was found in our RA patients. These figures were higher than those in the control group (5,7% and 8,6% respectively), but the difference did not reach statistical significance. Of further interest may be our finding that, despite anecdotal reports blaming D-penicillamine for cases of autoimmune thyroiditis, the incidence of the latter was similar among recipients and nonrecipients of the drug. Similarly, TRAB were not detected in any patient treated with D-penicillamine.

Adult↗

A Plurihormonal TSH-Secreting Pituitary Microadenoma: Report of a Case with an Atypical Clinical Presentation and Transient Response to Bromocriptine Therapy.

Inappropriate secretion of thyrotropin (TSH) is a rare cause of hyperthyroidism, and it is caused by either a TSH-producing pituitary adenoma (usually a macroadenoma) or to selective pituitary resistance to thyroid hormone. The case of a 31-yr-old male who presented with clinical features of thyrotoxicosis, including episodes of thyrotoxic paralysis, and a thyroid profile characterized by free hyperthyroxinemia and hypertriiodothyronemia with a nonsuppressed, inadequately normal TSH is reported. Dynamic testing showed both, lack of TSH stimulation by thyroid-releasing hormone (TRH), and lack of suppression by T3, consistent with autonomous TSH secretion. Pituitary MRI revealed a microadenoma. Seventy five percent of the patients serum TSH immunoreactivity eluted as u-subunit in Sephadex G-100 chromatography. A diagnosis of TSH-secreting microadenoma was established, and the patient was treated successfully with bromocriptine, which resulted in both clinical and biochemical resolution of his hyperthyroidism. Two months later, he became hyperthyroid again during bromocriptine therapy. Octreotide was started with adequate control of his symptoms and normalization of his free T4 level. He eventually underwent transsphenoidal surgery with successful resection of a chromophobic microadenoma which immunostained for TSH, growth hormone (GH), luteinizing hormone (LN), and follicle-stimulating hormone (FSH). One month postoperatively he is clinically and biochemically euthyroid on no medications.

Journal Article↗

Thyroxine binding to transthyretin Met 119. Comparative studies of different heterozygotic carriers and structural analysis.

The majority of the known transthyretin (TTR) variants are associated with amyloidosis, but there are also variants associated with euthyroid hyperthyroxinemia and others are apparently nonpathogenic. TTR Met 119 is a nonpathogenic variant found to be frequent in the Portuguese population. Previous studies on thyroxine (T4) binding to semi-purified TTR from heterozygotic carriers of TTR Met 119, reported by us and other groups, revealed different results. Therefore, to further characterize T4 binding to TTR Met 119 we performed T4-TTR binding studies in homotetrameric-recombinant TTR Met 119 variant and normal TTR. We also studied T4 binding to TTR purified from serum of different heterozygotic carriers of TTR Met 119 including compound heterozygotic individuals carriers of a TTR mutation in the other allele. We observed an increased T4 binding affinity to TTR Met 119 from heterozygotic individuals and compound heterozygotes and this effect of increasing T4 binding affinity was consistent and independent from the mutation present in the other allele. Recombinant homotetrameric TTR Met 119 and heterotetrameric protein from heterozygotic carriers of TTR Met 119 presented similar T4 binding affinity demonstrating the increased T4 binding affinity of TTR Met 119. X-ray crystallography studies performed on the recombinant TTR Met 119 variant revealed structural alterations mainly at the level of residue Leu 110 allowing a closer contact between the hormone and the mutant protein. These results are consistent with the observed T4 binding results.

Binding, Competitive↗

Abnormal iodoprotein distribution and resistance to proteolysis in Gunn rat black thyroid. An ultrastructural and biochemical study.

Gunn rats have a marked deficiency in hepatic UDP-glucuronosyl transferase activity which results in hyperthyroxinemia and hyperbilirubinemia. Their thyroids show a brownish-black discoloration associated ultrastructurally with intracellular dense granules and intraluminal dense masses. In order to determine whether colloid composition and colloid proteolysis are altered in the thyroid of the Gunn rat compared with the Wistar rat, we studied the in situ resistance of thyroid proteins to in vitro proteolysis, the pattern of in vivo (125I) labeled thyroid iodoproteins and the proteolysis of isolated iodoprotein fractions in both strains of rats. For the cytochemical study, thin sections of aldehyde-fixed and plastic-embedded thyroid tissue were treated with 0.3 or 1% pronase in aqueous solution. With the low concentration of pronase, the secretory granules in C-cells and the apical vesicles in follicular cells were extensively digested in both strains of rats, whereas the colloid in the follicular lumen and the colloid droplets were only partially digested. With the high concentration of pronase, the colloid in the lumen and the colloid droplets were more markedly digested in both strains. In the presence of both concentrations of pronase, the dense granules and intraluminal dense masses were unchanged in the Gunn rats. The (125I) iodoprotein pattern was investigated 24 h after a single injection of (125I) iodide and by labeling at the isotopic equilibrium. It was found that the (125I) thyroglobulin fraction was reduced, whereas the (125I) 3-8 S fraction was increased in Gunn rats compared to Wistar rats. Pronase hydrolysis of the soluble (125I) iodine fraction showed similar pronase-resistant fractions in both strains with the single labeling procedure. At the isotopic equilibrium, the pronase resistant fraction was significantly increased in Gunn rats (Gunn 24.0 +/- 5.3%; Wistar: 13.7 +/- 3.1% of the soluble 125I) and a linear correlation was observed between the (125I) 3-8 S fraction of the soluble extract and the pronase-resistant fraction. These data suggest that iodocompounds of small molecular size and low turnover accumulate in the thyroid of the Gunn rat due to their strong resistance to in vivo hydrolysis. A local accumulation of 3-8 S iodocompounds may occur within the intracellular dense granules and intraluminal dense masses in the thyroid of Gunn rat.

Animals↗

Effects of amiodarone administration during pregnancy on neonatal thyroid function and subsequent neurodevelopment.

Amiodarone, a benzofuranic derivative, iodine-rich drug, has been used in pregnancy for either maternal or fetal tachyarrhythmias. Amiodarone, its main metabolite (desethylamiodarone) and iodine are transferred, albeit incompletely, through the placenta, resulting in a relevant fetal exposure to the drug and iodine overload. Since the fetus acquires the capacity to escape from the acute Wolff-Chaikoff effect only late in gestation, the iodine overload may cause fetal/neonatal hypothyroidism and goiter. Among the reported 64 pregnancies in which amiodarone was given to the mother, 11 cases (17%) of hypothyroidism in the progeny (10 detected at birth, 1 in utero) were reported, 9 non-goitrous (82%) and 2 (18%) associated with goiter. Hypothyroidism was transient in all cases, and only 5 infants were treated short-term with thyroid hormones. Only 2 newborns had transient hyperthyroxinemia, associated with low serum TSH concentrations in one. Neurodevelopment assessment of the hypothyroid infants, when carried out, showed in some instances mild abnormalities, most often reminiscent of the Non-verbal Learning Disability Syndrome; however, these features were also reported in some amiodarone-exposed euthyroid infants, suggesting that there might be a direct neurotoxic effect of amiodarone during fetal life. Breast-feeding was associated with a substantial ingestion of amiodarone by the infant, but in the few cases followed it did not cause changes in the newborn's thyroid function. In conclusion, amiodarone therapy during pregnancy may cause fetal/neonatal hypothyroidism and, less frequently, goiter. Thus, the use of amiodarone in pregnancy should be limited to maternal/fetal tachyarrhythmias which are resistant to other drugs or life-threatening. If amiodarone is used during gestation, a careful fetal/neonatal evaluation of thyroid function and morphology is warranted. It seems prudent to advise that fetal/neonatal hypothyroidism be treated, as soon as the diagnosis is made, even in utero, to avoid neurodevelopment abnormalities, although the latter may occur independently of hypothyroidism. If breast-feeding is allowed, careful evaluation of the infant's thyroid function and morphology is required because of the continuing exposure of the infant to the drug.

Amiodarone↗

Abnormal thyroid function test results in patients with Fisher-Evans syndrome.

Thyroid function was evaluated in patients affected by Fisher-Evans syndrome (FES) and compared to that of patients affected only by autoimmune hemolytic anemia (AIHA) and to that of patients affected only by idiopathic thrombocytopenic purpura (ITP). The study population consisted of 20 patients with FES, 44 with AIHA and 20 with ITP. All patients were examined for thyroid function abnormalities and thyroid autoantibodies. Abnormal thyroid function test results were observed in 40, 25 and 10% of the patients, respectively. The prevalence of antithyroid antibodies (ATA) in FES was 25%; this is higher than the sum of the prevalences of ATA in patients affected only by AIHA (11.4%) or only by ITP (none). Subclinical primary hypothyroidism and hyperthyroxinemia with or without hypertriiodothyroninemia, with TSH serum levels below normal, were present in 20% and 10% of patients affected by FES, respectively. Of the former, 75% were positive for ATA. These results: i) confirm the high prevalence of abnormal thyroid test results in patients affected by AIHA, ITP and FES; ii) demonstrate the higher prevalence of autoimmune hypothyroidism in FES; iii) lead to the possibility of including FES as one of the multiple autoimmune syndromes.

Adolescent↗

A new type of albumin with predominantly increased binding affinity for 3,3',5-triiodothyronine in a patient with Graves' disease.

A new type of serum albumin, that shows a markedly enhanced binding activity for 3,3', 5-triiodothyronine (T3), a somewhat increased activity for thyroxine (T4), and a normal activity for 3,3', 5-triiodothyronine (rT3) is described. This albumin was found in a patient with Graves' disease. After successful subtotal thyroidectomy, the existence of abnormal binding activity for T3 was suspected in this patient because of persistently increased total T3 concentrations in spite of elevated thyrotropin levels. Although free T3 and T4 concentrations measured by radioimmunoassay using commercial tracer analogue kits were markedly increased, those measured by equilibrium dialysis were within normal ranges. Electrophoretic studies revealed that these abnormalities were due to the markedly increased T3 binding activity by the serum albumin; that for T4 was also slightly increased. Scatchard plot analysis revealed that the association constant (Ka) for T3 of the patient's albumin was 5.1 X 10(6)/M (normal pooled albumin; 6.2 X 10(5)/M), and those for T4 and rT3 were 5.2 X 10(6)/M and 2.7 X 10(6)/M, respectively (normal pooled albumin; 2.1 X 10(6)/M for both T4 and rT3). The increased binding of albumin to T3 and T4 was markedly inhibited by barbitone, and 8-anilino-1-naphthalene-sulfonic acid. These characteristic features, and erroneously high values of free T3 and T4 concentrations measured by tracer analogue kits were similar to those seen in patients with familial dysalbuminemic hyperthyroxinemia, which have been previously reported. These findings strongly suggest that this albumin is a new variant in various dysalbuminemic syndromes, and the abnormal binding of iodothyronines moieties in these syndromes are not biochemically identical.

Adult↗

Effect of thyroidectomy and thyroxine on hexachlorobenzene induced porphyria.

The role of thyroid status in hexachlorobenzene (HBC) induced porphyria was studied in normal, thyroidectomized and thyroxine (T4) treated rats. Female Wistar rats were treated with HCB for different periods of time. Serum T4 levels were depressed after 8 days of HCB administration whereas levels of triiodothyronine (T3) were not altered. T4 administered simultaneously with HCB resulted in hyperthyroxinemia. The time course of porphyrinogen carboxy-lyase (PCL) activity in the three HBC treated groups was studied. A rapid and significant decrease of PCL activity was found after 8 days of HCB treatment in T4 treated rats with respect to untreated animals. In contrast, HCB treatment of normal and thyroidectomized rats elicited a significant decrease of PCL activity after 21 and 30 days, respectively. This study shows that thyroid hormone plays an important role in the early establishment of HCB induced porphyria.

Animals↗

Iodine contamination as a cause of hyperthyroidism or lack of TSH response to TRH stimulation (results based on a screening investigation).

The sera of all patients with completely suppressed TSH response to TRH obtained during one year (n = 668), and of those with diminished TSH response (n = 153) were screened for total serum iodine content. The ratio between serum iodine and thyroxine iodine below 1.5 indicates none or only a minor degree of iodine contamination, whereas a ratio above 1.5 is a clear index of exogenous iodine contamination. Eighty-four (21.3%) of 395 patients with overt hyperthyroidism were iodine contaminated. No prevalence of hyperthyroidism with hyperthyroxinemia could be detected as compared to T3-hyperthyroidism in the contaminated groups. Surprisingly, the iodine contamination rate was twice as high in 273 patients with suppressed TSH response to TRH but normal thyroid hormone levels and not fully explained thyroidal diseases. A high incidence of multifocal autonomous adenomas of the thyroid is the most probable explanation for the TSH suppression in iodine contaminated patients with normal thyroid hormone levels.

Angiocardiography↗

Plasma thyrotropin, thyroxine, triiodothyronine, free thyroxine, free triiodothyronine, and cortisol levels in blind prepubertal boys.

Findings on thyroid function in blind subjects are lacking. The aim of this study was to investigate the thyroid hormonal pattern in prepubertal blind subjects. Six healthy and 8 blind males, aged 7-10 yr, in Tanner stage one puberty, living at Institute "Martuscelli" for blind young subjects, Napoli, Italy, were studied. Each had a TRH (200 micrograms) test at 08:00 h after nocturnal rest. Plasma TSH, T4, T3, free T4(FT4), free T3(FT3) and cortisol (F) were measured by RIA. Our blind subjects show levels of TSH (basal values and absolute peak after TRH), T4, T3 and F normal but FT4 levels significantly higher than controls (39 pg/ml +/- 4.7 vs 12 +/- 0.6, p less than 0.001; 14 pg/ml +/- 1.3 vs 4.7 +/- 0.2, p less than 0.001, respectively). Our results, similar to those found in some patients with euthyroid hyperthyroxinemia, suggest that the prolonged inability to receive light signal could influence the metabolism of thyroid hormones and/or cause a tissue resistance to their action, even if this hypothesis must be verified by future more extensive investigations.

Blindness↗

Community outbreak of thyrotoxicosis: epidemiology, immunogenetic characteristics, and long-term outcome.

Between January and March 1984, the first community outbreak of transient thyrotoxicosis in the United States was documented in a seven-county area of southeastern Nebraska; 36 of the total 49 patients resided in York County (2.4 cases per 1,000 population). The median age of patients was 36 years, range six to 82 years; 51 percent were women. By definition, all patients were symptomatic, visited a physician, and had a newly identified elevated serum concentration of thyroxine or triiodothyronine of unknown cause. None had a goiter or a painful thyroid gland. Low 131I uptake measurements were found in all nine patients studied. Six patients were hospitalized; none died. Investigation of all 12 household contacts of eight selected patients revealed five additional persons with thyrotoxicosis and four with asymptomatic hyperthyroxinemia. A case-control study revealed that illness was associated with a significantly higher frequency of a reported recent respiratory viral-like condition. In another case-control study, the HLA-DR3 antigen was present in more case subjects (39 percent) than control subjects (14 percent). In addition, a significantly higher proportion of patients than control subjects purchased beef from one of the three supermarkets in York Country. Concomitant with the outbreak, the supermarket implicated in the outbreak purchased an unusually large quantity of beef (7,000 pounds) from a nonregular supplier in Nebraska, which had reportedly instituted the practice of trimming gullets (a procedure that removes the muscles from bovine larynx for beef) about three months earlier. Thus, it is concluded that the Nebraska outbreak, like one in Minnesota that occurred 18 months later, probably resulted from patients having eaten ground beef that was contaminated with bovine thyroid gland. This form of thyrotoxicosis, perhaps misdiagnosed as painless thyroiditis in the past, probably represents a previously under-recognized public health problem.

Adult↗