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Aims: It has been suggested that the non-classic HLA class I molecule HLA-G plays a role in autoimmune disease by protecting tissues from damage by infiltrating cytotoxic T cells. Such infiltration occurs in the thyroid of patients with Graves’ disease (GD) and Hashimoto’s thyroiditis (HT) and can eventually result in tissue destruction. The aim of the current study was to analyse thyroid tissue and thyrocytes obtained from individuals with autoimmune thyroid disease for the expression of HLA-G. Methods: HLA-G expression was analysed in thyroid tissue taken from six patients with GD and one with HT by reverse transcriptase polymerase chain reaction. Thyroid tissue samples isolated from six patients with multinodular goitre (MNG) were used as non-autoimmune controls. HLA-G expression was also examined in cultured thyroid follicular cells (TFCs). Results: The expression of HLA-G was not detected in the thyroid gland of patients with either GD, HT, or MNG. Furthermore, HLA-G expression could not be detected in cultured patient TFCs under basal conditions or after stimulation with the proinflammatory cytokines—interleukin 1α, interferon γ, and tumour necrosis factor α. Conclusions: HLA-G expression does not occur in the thyroid of patients with GD, indicating that HLA-G does not play a pathophysiological role in this autoimmune disorder. Although the expression of HLA-G was not detected in the thyroid sample of the patient with HT, a greater sample size would be required to conclude that HLA-G does not have a part to play in this autoimmune thyroid disease.

Autoimmune thyroid disease is the archetype for organ-specific autoimmune disorders. Progress in treating these disorders lies in improvements of our understanding of the predisposing factors responsible, the mechanisms responsible for progression of disease, and the interaction between thyroid antigens and the immune system at the level of the T cell and antibody. In common with other autoimmune diseases, genetic, environmental and endogenous factors are required in an appropriate combination to initiate thyroid autoimmunity. At present the only genetic factors which have been confirmed lie in the HLA complex and CTLA-4 or a closely linked gene. Identifying other predisposing genes will require large-scale family studies, or further insights into likely candidate genes. A number of environmental factors are known to predispose to autoimmune thyroid disease, including smoking, stress and iodine intake, while immunomodulatory treatments are revealing new pathways for disease emergence.The thyroid cell itself appears to play a major role in disease progression, interacting with the immune system through expression of a number of immunologically active molecules including HLA class I and II, adhesion molecules, cytokines, CD40 and complement regulatory proteins. New techniques, in particular phage display libraries, are providing the methods with which to identify autoantibody diversity in autoimmune thyroid disease and to provide tools for mapping autoantigenic epitopes. Application of these techniques is likely to lead to an understanding of how TSH receptor antibodies interact with the receptor to cause Graves' disease and also to the identification of novel orbital autoantigens in thyroid-associated ophthalmopathy.

Although propylthiouracil inhibits type 1 deiodinase, leading to a more rapid fall in triiodothyronine (T(3)) than thyroxine (T(4)) levels in patients treated for hyperthyroidism, we report a patient with Graves' disease whose free T(3) paradoxically rose during such treatment, despite low free T(4) levels and increasing doses of propylthiouracil. A similar response has previously been associated with high levels of thyroid stimulating antibodies, but it has been unclear why there should be a dichotomy in the circulating thyroid hormone profile. Thyroid tIssue from our patient contained very high levels of type 1 and, especially, type 2 deiodinase, in contrast to other patients treated with Graves' disease, which were most likely secondary to high levels of thyroid stimulating antibodies. This unusual response to propylthiouracil is important to recognise therapeutically, and represents a further situation in which abnormal expression of deiodinase enzymes has clinical significance.

The major histocompatibility complex (MHC) class-II alleles at the DRB1, DQB1 and DPB1 loci were investigated in 40 patients with primary biliary cirrhosis (PBC) and 43 local healthy controls. Restriction fragment length polymorphism (RFLP) was used for DRB1 typing. DQB1 and DPB1 regions were amplified using the polymerase chain reaction (PCR) and then probed with 32P-labelled allele-specific oligonucleotide probes. There was an increased frequency of DR8 (10% compared to 4% in controls), and a decreased frequency of DR2 (18% compared with 28% in controls) in patients with PBC, but the differences were not significant. There were no significant differences for the other DR alleles, the seven DQ alleles, or the eight DP alleles. In conclusion, no significant MHC class-II associations with primary biliary cirrhosis have been demonstrated.

The development of experimental models of autoimmune hyperthyroid Graves' disease has proved a difficult challenge, but recently two novel methods have led to their successful development in mice. We describe our studies on replicating the adjuvant modified, human TSH receptor (TSHR) and major histocompatibility complex class II transfected fibroblast injection system, and the plasmid DNA vaccination method as models resembling the human disorder. The fibroblast injection model in female AKR/N (H-2k) mice led to 70% of the animals developing thyroid-stimulating antibodies and their thyroid glands showed large goiters with histological features of thyroid cell activation characteristic of Graves' glands. Consistent with the clinical homolog, there was no inflammatory cell infiltrate of the thyroid gland. Detailed studies on the anti-TSHR antibodies such as thyroid-stimulating blocking antibody, antibodies to the native TSHR by flow cytometry, and TSH-binding inhibiting Ig showed that they were heterogeneous and did not correlate with disease activity, thus resembling those present in patients with Graves' disease. In contrast, the plasmid DNA vaccination model in female BALB/c (H-2d) mice led to the generation of low levels of anti-TSHR antibodies by flow cytometry, which were undetectable for thyroid-stimulating antibodies, TSH-stimulating blocking antibodies, and TSH-binding inhibiting Ig activity. Moreover, this model too was not accompanied by lymphocytic cell infiltration. The data demonstrate the high incidence of hyperthyroid disease induced in the adjuvant modified, transfected fibroblast model in AKR/N mice to allow pathological mechanisms of disease to be studied.

Pendred syndrome (PDS) is an autosomal recessive disorder characterized by deafness and goiter. Phenotypic heterogeneity is observed in affected individuals, and thyroid dysfunction is particularly variable. The syndrome is caused by mutations in the PDS (SLC26A4) gene, encoding an anion transporter pendrin, which localizes to the apical membrane of thyroid follicular cells. PDS is thought to enable efflux iodide into the follicle lumen. More than 50 diseases causing mutations of PDS have been reported. Here we have investigated the effect of nine PDS missense mutations on pendrin localization and iodide transport with the view to understanding their functional impact. As demonstrated by transient expression of green fluorescent protein-tagged pendrin mutant constructs in mammalian cell lines, appropriate trafficking to the plasma membrane was observed for only two mutants. The remaining PDS mutants appear to be retained within the endoplasmic reticulum following transfection. Iodide efflux assays were performed using human embryonic kidney 293 cells transfected with mutant pendrin and cotransfected with sodium iodide transporter to provide a mechanism of iodide uptake. The results indicated loss of pendrin iodide transport for all mislocalizing mutations. However, PDS mutants are associated with variable thyroid dysfunction in affected subjects. We concluded that additional genetic and/or environmental factors influence the thyroid activity in Pendred syndrome.

The complex relationship between pregnancy and thyroid function, and its clinical effect on mother and baby, continued to stimulate research in 2011. Key advances were made on three important issues: how long maternal thyroid function affects fetal thyroid hormone levels; whether thyroid autoimmunity affects pregnancy outcome; and the prevalence of permanent hypothyroidism after postpartum thyroiditis.

Background: Gestational thyrotoxicosis may be more prevalent in Asian women. Methods: We have measured thyroid function, ferritin and bone specific alkaline phosphatase (BALP) as peripheral markers of thyroid function and hCG in Asian and western Caucasian women in non-pregnant and early pregnancy. Results: TSH was lower in Asian women in non-pregnancy but not during normal pregnancy and this may reflect increased sensitivity of the thyroid gland to thyroid stimulation in the Asian population. No ethnic difference was found in FT3, FT4 or hCG but ferritin was lower and BALP higher in Asian women whether pregnant or not and this may be a reflection of iron balance and vitamin D status. Conclusions: We found during normal pregnancy that dynamic patterns of change for thyroid hormones and hCG are not different in Asian and western Caucasian women. We have developed gestation related reference intervals, which are a pre-requisite to the study of ethnic differences in gestation thyrotoxicosis in pregnancy.

SUMMARYPreviously, we reported the identification of Pmel17 autoantibodies in some patients with vitiligo. Here, we have determined the B cell epitopes on Pmel17 which are recognized by these autoantibodies. Deletion derivatives of Pmel17 cDNA were constructed using either subcloning of specific cDNA fragments or polymerase chain reaction amplification. Full-length Pmel17 cDNA and its truncated derivatives were then translated in vitro to produce [35S]-labelled proteins. The radiolabelled ligands were used subsequently in radiobinding assays to investigate the reactivity of sera from vitiligo patients. Two epitope regions were identified: one located at the C-terminal end of Pmel17 between amino acids 634–644 and one in a central region of the protein between amino acids 326–341. Computer analysis of the potential B cell epitopes on Pmel17 revealed that the epitope domain encompassing amino acids 326–341 was located in an area of the protein which was predicted to be highly antigenic. In contrast, the epitope identified at the C-terminal of Pmel17 (amino acids 634–644) was located in a region of the protein predicted to have low antigenicity. The amino acid sequences of the identified Pmel17 epitopes were compared to the amino acid sequences of the related melanogenic enzymes tyrosinase, tyrosinase-related protein-1 and tyrosinase-related protein-2. However, no sequence homology was found between either of the Pmel17 epitopes and the aforementioned proteins. This finding is consistent with our previous study in which we were unable to show the presence of Pmel17 antibodies which were cross-reactive with either tyrosinase, tyrosinase-related protein-1 or tyrosinase-related protein-2. It also suggests that the IgG response to Pmel17 is distinct from the antibody response to the other melanocyte-specific antigens.

Type V hypersensitivity is the final type of hypersensitivity in which antibodies are produced with the property of stimulating specific cell targets. The clearest example is Graves disease caused by antibodies that stimulate the thyroid-stimulating hormone receptor, leading to overactivity of the thyroid gland. Keywords: stimulatory hyper sensitivity; type V hypersensitivity; graves disease; stimulatory antibodies

OBJECTIVE Genetic factors have been proposed to account for the development of ophthalmopathy in a proportion of patients with Graves' disease. The aim of this study was to confirm the previously reported association between blood group P1 and thyroid-associated ophthalmopathy. DESIGN A prospective study of sequential Caucasian patients. PATIENTS We studied 169 patients with Graves' disease, 84 of whom had grade 3,4 or 6 ophthalmopathy and 85 had no eye signs. MEASUREMENTS Blood group P1 was measured by a standard serologlcal technique. RESULTS The frequency of the P1 blood group was 74.1% in the patients without eye signs and 77.4% in those with ophthalmopathy (X2= 025, P>0.1). By Woolf's method there was no significant difference in the test for heterogeneity of estimates between the present and the previously reported series of Graves' patients. Combining the results (n= 279), the pooled relative risk for ophthalmopathy with blood group P1 did not differ significantly from 10(X2= 233, P>0.1). CONCLUSIONS The presence of blood group P1 In patients with Graves' disease does not appear to be associated with an increased risk of developing thyroid-associated ophthalmopathy.

Susceptibility to the autoimmune thyroid diseases, Graves’ disease (GD) and autoimmune hypothyroidism (AIH), depends on a complex interaction between environmental and genetic factors. The human leukocyte antigen and cytotoxic T lymphocyte-associated-4 regions appear to influence susceptibility to disease, but the effect is not major, and the other genes remain unknown. Cytokines are crucial in the regulation of immune and inflammatory responses and therefore are potential candidate genes for autoimmune thyroid disease. In a case-control study, using a unified method of genotyping, we have examined 15 polymorphisms in 9 cytokine genes in 215 patients with autoimmune thyroid disease (GD, 138; AIH, 77) and 101 normal controls. Polymorphisms in the genes for interleukin-1α (IL-1α), IL-1β, IL-1 receptor antagonist, IL-1 receptor 1, IL-4, IL-4 receptor, IL-6, IL-10, and transforming growth factor-β were investigated. Genotyping was performed using the PCR and sequence-specific primers. Analysis showed a reduced frequency of the variant t allele in the IL-4 promoter polymorphism (position −590) in patients with GD and in the entire patient group (GD and AIH) compared with the control group [corrected P (Pc) = 0.00004 and Pc < 0.00001 for GD and all patients, respectively]. This was reflected in a reduction in the heterozygote genotype in the patient groups compared to the controls [c/t heterozygotes GD, 12%; Pc = 0.06, odds ratio, 0.4 (95% confidence interval, 0.2–0.7); all patients, 11%; Pc = 0.008; odds ratio, 0.4 (95% confidence interval, 0.2–0.7); control subjects, 23%]. There were no significant differences between the study groups for the other polymorphisms examined, and subgroup analysis revealed no association with clinical parameters of disease. These results suggest that an IL-4 variant or a closely linked gene has a modest protective effect against the development of autoimmune thyroid disease, particularly GD. This variation in the IL-4 gene may provide further clues to the pathogenesis of autoimmune thyroid disease and other organ-specific autoimmune diseases. Furthermore, these results suggest that subtle variation in immunoregulatory genes may be associated with autoimmune disease states.

There is a close temporal relationship between the occurrence of Graves’ thyroid disease (GTD) and the onset of Graves’ ophthalmopathy (Fig. 1).1 Both Gorman et al., and Wiersinga et al, found that in approximately 3/4 of the patients both manifestations occurred within 18 months of eachother.2,3 In the majority, the eye signs develop after the first signs of hyperthyroidism. Although clinically manifest ophthalmopathy is seen in only appr. 35% of the patients with Graves’ hyperthyroidism, subclinical evidence for orbital disease is present in almost all patients.1 This close association has always been the most pertinent reason to think that the ophthalmopathy and the thyroid disorder are actually two manifestations of the same condition: Graves’ disease.

Graves’ ophthalmopathy (GO) is a medically incurable, chronic autoimmune process that affects the orbital tissues and is tightly linked with autoimmune thyroid diseases, most notably Graves’ disease (GD). The close clinical association between immunogenic hyperthyroidism, ophthalmopathy, and pretibial dermopathy suggests that the antigen responsible for these diverse conditions is common to thyroid gland, orbital tissues and pretibial skin.1,2 Gross examination of orbital tissues in patients with severe, active GO reveals edematous, enlarged extraocular muscle bodies in conjunction with an increased volume of orbital connective and fatty tissue (Chapter 1). Microscopically, two characteristic abnormalities are apparent: the presence of excessive amounts of hydrophilic glycosaminoglycans (GAGs), predominantly hyaluronic acid and chondroitin sulfate, and marked infiltration of the orbital connective tissue and extraocular muscles by immunocompetent cells (macrophages and T lymphocytes, few B cells). The orbital inflammatory process is likely to be driven by T-cells which, in response to an uncertain antigen, access and infiltrate the orbital space via certain adhesion molecules.1,3 Once recruited, these T cells release numerous cytokines capable of stimulating cell proliferation, GAG synthesis, and generation of new fat cells from orbital adipose precursor cells responding to adipogenic stimuli. Moreover, many of these autocrine and paracrine factors act to alter the expression of an array of immunomodulatory molecules in orbital preadipocyte fibroblasts.

Graves’ eye disease is characterized by a chronic round cell infiltrate of the retrobulbar tissues (sometimes of focal character and organized in T cell zones and B cell follicles1) and a very strong association with Graves’ thyroid disease. The latter is an accepted autoimmune disease and caused by autoantibodies (Abs) against the TSH-receptor (TSH-R), which stimulate thyrocytes to grow and to produce excessive amounts of thyroid hormones. On the basis of its histology and the association with Graves’ thyroid disease it has for long been the idea that Graves’ eye disease is of autoimmune character too, and that the TSH-R is an important antigen also in the pathogenesis of the eye signs. This chapter tries to summarize recent developments in endocrine autoimmunity in general and Graves’ ophthalmopathy in particular.

Cytokines are a heterogeneous group of water-soluble glycoproteins that play a crucial role in triggering and co-ordinating inflammatory and immune responses. These molecules usually have pleiotropic actions and their effects can be synergistic or antagonistic. Many cytokines are produced by both immune and non-immune cells, often act in an autocrine or paracrine fashion, and thus they infrequently achieve detectable levels in the circulation. In addition to their action on inflammatory cells, cytokines have a wide array of effects on non-immunological cells, thereby potentially modulating organ function.

Summary Background Multiple sclerosis results from T-cell-dependent inflammatory demyelination of the central nervous system. Our objective was long-term suppression of inflammation with short-term monoclonal antibody treatment. Methods We depleted 95% of circulating lymphocytes in 27 patients with multiple sclerosis by means of a 5-day pulse of the humanised anti-CD52 monoclonal antibody, Campath-1H. Clinical and haematological consequences of T-cell depletion, and in-vitro responses of patients' peripheral-blood mononuclear cells were analysed serially for 18 months after treatment. Findings Radiological and clinical markers of disease activity were significantly decreased for at least 18 months after treatment. However, a third of patients developed antibodies against the thyrotropin receptor and carbimazole-responsive autoimmune hyperthyroidism. The depleted peripheral lymphocyte pool was reconstituted with cells that had decreased mitogen-induced proliferation and interferon gamma secretion in vitro. Interpretation Campath-1H causes the immune response to change from the Th1 phenotype, suppressing multiple sclerosis disease activity, but permitting the generation of antibody-mediated thyroid autoimmunity.

The cyclic AMP pathway is a major regulator of thyrocyte function and proliferation and, predictably, its inappropriate activation is associated with a sub-set of human thyroid tumours. Activating mutations are, however, more common in the thyrotropin receptor (TSHR) than in its downstream transducer, Galphas. To investigate whether this reflects an inherent difference in their oncogenic potency, we compared the effects of retrovirally-transduced mutant (A623I) TSHR or (Q227L) Galphas (GSP), using the rat thyroid cell line FRTL5 and primary human thyrocytes. In FRTL5, expression of GSP or mutant (m) TSHR induced a 2 - 3-fold increase in basal levels of cAMP. This was associated with TSH-independent proliferation (assessed by both cell number and DNA synthesis) and function (as shown by increased expression of thyroglobulin (Tg) and the sodium/iodide symporter). In primary cultures, expression of mTSHR, but not GSP, consistently induced formation of colonies with epithelial morphology and thyroglobulin expression, capable of 10 - 15 population doublings (PD) compared to less than three in controls. Thus, while mTSHR and GSP exert similar effects in FRTL5, use of primary cultures reveals a major difference in their ability to induce sustained proliferation in normal human thyrocytes, and provides the first direct evidence that mTSHR is sufficient to initiate thyroid tumorigenesis.

Pregnancy is an immunological balancing act in which the mother's immune system has to remain tolerant of paternal major histocompatibility (MHC) antigens and yet maintain normal immune competence for defense against microorganisms. The placenta separates fetal and maternal blood and lymphatic systems and it is fetal trophoblast that plays the major role in evading recognition by the maternal immune system. Trophoblast cells fail to express MHC class I or class II molecules and the extravillous cytotrophoblast cells strongly express the nonclassic MHC gene encoding HLA-G, which may downregulate natural killer (NK) cell function. In addition, the trophoblast expresses Fas ligand, thereby conferring immune privilege: maternal immune cells expressing Fas will undergo apoptosis at the placenta/decidua interface. A third protective mechanism exploited by the trophoblast is the expression of the complement regulatory proteins CD46, CD55, and CD59. Uterine decidual and placental cells produce a huge array of cytokines which, in part, contribute to the deviation of the immune response from Th1 to Th2. This may leave the mother more open to infection whose control is Th1-dependent, but increased production of Th1 cytokines has been linked to spontaneous abortion and small-for-dates babies. This bias in cytokines and hormonally mediated effects on the thymus and on B cells may also contribute to the suppression of autoimmune responses and changes in circulating and local T-cell subsets in pregnancy.

The prevalence of thyroid nodules is increased in patients with Cushing's disease, but the possibility of an association between thyroid and adrenal nodules in other patient groups has not been formally tested. We have evaluated the co-existence of thyroid and adrenal nodules in retrospective and prospective autopsy studies. Retrospective (83 autopsies) and prospective (29 autopsies) blinded studies of thyroid and adrenal gland histopathology were performed by two experienced histopathologists in unselected autopsies. The presence of nodules, defined as areas of tissue having discrete edges within the gland parenchyma seen as a step difference between the cells or architecture adjacent to the nodule, was determined for each gland. No association was found between the presence of adrenal and thyroid nodules in either the retrospective or prospective studies (p>0.2 for both). In the retrospective study, 23% of specimens had thyroid nodules and 28% adrenal nodules. In the prospective study, 24% of specimens had thyroid nodules and 7% adrenal nodules. The proportion of patients with adrenal nodules in the prospective study was significantly less than that in the retrospective study. In conclusion, thyroid and adrenal nodules are frequent autopsy findings in the general population but we have found no evidence of a relationship between the occurrence of nodules in these glands.

In the present study, we describe the in vitro transcription-translation of human tyrosinase-related protein-1 (TRP-1) cDNA and subsequent use of the resulting 35S-labelled TRP-1 in a radioimmunoassay to analyse vitiligo sera for the presence of TRP-1 antibodies. Of 53 vitiligo sera examined in the assay, three (5.7%) were found to be positive for TRP-1 antibodies. In contrast, sera from 20 controls, 10 patients with Hashimoto's thyroiditis and 10 patients with Graves' disease were all negative for TRP-1 antibodies. Although glycosylation of the labelled protein was necessary for its immunoprecipitation by TRP-1-specific monoclonal antibody TA99, this post-translational processing did not affect the binding of any of the sera tested. All three patients positive for TRP-1 antibodies (aged 50-63 years) had had vitiligo of the symmetrical type for more than 1 year, and all of them also had an associated autoimmune disorder: Graves' disease in one and autoimmune hypothyroidism in two. In addition, antibodies to the melanogenic enzymes tyrosinase and tyrosinase-related protein-2 (TRP-2) were present in their serum. Absorption studies indicated that preincubation with COS-7 cell extract containing either expressed TRP-1, tyrosinase or TRP-2 absorbed out the immunoreactivity of the three sera positive in the radioimmunoassay (RIA) with [35S]TRP-1. The results indicate that autoantibodies to TRP-1 cross-react with tyrosinase and TRP-2, suggesting one or more common epitopes between the three proteins.

Autoimmune thyroid disease (ATD), the archetypal example of organ-specific autoimmune disease, comprises several disorders which as a group constitute the commonest clinically relevant autoimmune disease, affecting up to one percent of the population (1). Both hypothyroidism and hyperthyroidism are consequences of thyroid autoimmunity.

A 39-year-old Danish woman was treated with an oral dose of 400 MBq 131I for a non-toxic goiter with compression symptoms. Serum anti-TPO and TSH receptor antibodies were negative before radioiodine therapy. The patient developed hyperthyroidism four months after treatment and ophthalmopathy after another three months. TSH receptor stimulating and blocking antibodies, eye muscle IgA and IgG were measured and an increase in stimulating TSH receptor antibodies were found concomitant with development of hyperthyroidism. IgG class antibodies against porcine eye muscle antigens and eye muscle fibroblasts were elevated and unchanged during the follow-up. A significant increase in IgA class antibodies against porcine eye muscle antigens was seen concomitant with development of ophthalmopathy. It is speculated that 131I has led to an exacerbation of eye muscle as well as TSH receptor stimulating antibodies and possibly leading to the development of ophthalmopathy, or at least is associated with it.

Various names have been given to the eye signs associated with autoimmune thyroid disease—Graves’ ophthalmopathy, endocrine exophthalmos, ophthalmic Graves’ disease, and so on—but the term thyroid-associated ophthalmopathy (TAO) is now generally accepted as the best, providing recognition that the condition is not always associated with Graves’ disease. The major clinical signs are shown in Table 1 and Fig. 1. Fortunately TAO does not cause problems of diplopia or loss of visual fields in the majority of patients, but the impact of having bulging eyes and periorbital swelling on the patient’s sense of well-being is often underestimated, and even the grittiness and discomfort that are common and among the early features of TAO prove irksome to many patients with Graves’ disease.

Iodide concentration by the thyroid gland, an essential step for thyroid hormone synthesis, is mediated by the Na+/I- symporter (NIS). To identify factors that may regulate this process, we have studied NIS gene expression in the Fisher rat thyroid cell line (FRTL-5) by a semi-quantitative reverse transcription-polymerase chain reaction (RT-PCR) technique. Increasing concentrations of bovine TSH (0.1, 1, 10, 50 and 100 mU/l), with or without tumour necrosis factor-alpha (TNF alpha), interferon-gamma (IFN gamma) or interleukin-1 alpha (IL-1 alpha) were added to FRTL-5 cells previously deprived of TSH for a minimum of 5 days. RNA was extracted and samples were studied for NIS expression. TSH enhanced NIS mRNA expression in a dose-dependent manner, with induction evident at 0.1 mU/l, reaching a peak at 50 mU/l, an effect detected after 6 h of stimulation, but not in the first 2 h. Both TNF alpha and, to a lesser extent, IL-1 alpha inhibited basal and TSH-induced NIS expression. High concentrations of IFN gamma also downregulated TSH-stimulated NIS mRNA expression. Using the same technique, we also investigated NIS mRNA tissue distribution in two male and one female Wistar rats. High levels of NIS expression were detected in the thyroid, stomach, and mammary gland, lower levels were found in the intestine, adipose tissue and liver, borderline levels were expressed in the salivary gland, and no expression was detected in the kidneys. In summary, we have shown that TSH upregulates rat NIS gene expression in vitro, and this induction can be modulated by cytokines. Analysis of the distribution of rat NIS mRNA ex vivo demonstrated variable levels of NIS transcription in different tissue samples.

SUMMARY In the present study we describe the in vitro transcription-translation of human melanocyte-specific protein Pmel17 cDNA and subsequent use of the resulting 35S-labelled Pmel17 in an RIA to analyse vitiligo sera for the presence of Pmel17 antibodies. Of 53 vitiligo sera examined in the assay, three (5.9%) were found to be positive for Pmel17 antibodies. In contrast, sera from 20 healthy controls, 10 patients with Hashimoto's thyroiditis and 10 patients with Graves' disease (GD) were all negative for Pmel17 antibodies. All three patients positive for Pmel17 antibodies (aged 50–63 years) had had vitiligo of the symmetrical type for > 1 year and all of them also had an associated autoimmune disorder: GD in one and autoimmune hypothyroidism in two. In addition, all three patients had antibodies to the melanogenic enzymes tyrosinase, tyrosinase-related protein-1 (TRP-1) and tyrosinase-related protein-2 (TRP-2) in their serum. Absorption studies indicated that preincubation with COS-7 cell extract containing expressed Pmel17 absorbed out the immunoreactivity of the three sera positive in the RIA, confirming the anti-Pmel17 reactivity of the sera from these patients. In contrast, COS-7 cell extracts containing either expressed tyrosinase, TRP-1 or TRP-2 did not remove the anti-Pmel17 reactivity of the three sera in the RIA. This lack of cross-reactivity suggests that the humoral response to Pmel17 in these patients is specific and independent of the antibody reactivity to tyrosinase, TRP-1 and TRP-2.

Reverse transcriptase- polymerase chain reaction (RT-PCR) enhances the probability of detecting rare transcripts in complex mixtures of mRNA. Using thyroid autoantigens and the controversy about the role of the TSH-receptor (TSH-R) in thyroid-associated ophthalmopathy as an example, this study demonstrates the problems of interpreting RT-PCR results in typically non-expressing tissues resulting from the extremely high sensitivity of the method. Unexpected transcripts for thyroperoxidase, thyroglobulin, TSH-R (exon 1-4, 354 bp), FSH-receptor, or insulin fragments were demonstrated in a number of thyroid or orbit-derived as well as unrelated tissues or cell types. Unexpected transcripts were most prevalent in fibroblasts, irrespective of the tissue of origin and most likely caused by ectopic transcription. To establish a physiological significance of rare transcripts such as the TSH-R in orbital tissues, demonstration of the protein in addition to the positive RT-PCR results is needed.

The thyroid-stimulating hormone (TSH) binds to a receptor which activates adenylate cyclase and elevates cAMP concentration. In addition, effects of TSH on intracellular calcium and inositol phosphate accumulation have been reported. However, the mechanism of TSH-stimulated accumulation of inositol phosphates and elevation of calcium levels is unresolved. Previous work from this laboratory has shown TSH to cause acute transient increases in intracellular calcium in pig, human and FR TL-5 rat thyroid cells as well as in cell transfected with the human TSH receptor (JPO9 cells) in some (but not all) experiments. The aim of this study was to investigate the variability of the calcium response to TSH in JPO9 cells to learn more about the nature of this calcium signal induction. Calcium responses to TSH were determined using the fluorochrome fura-2 in both monolayers of adherent cells and adherent single cells. The responses to a single addition and to repetitive additions of TSH were compared. We also determined the cAMP response to TSH using these two protocols of TSH addition. Our data show that, whereas the cAMP response to TSH is highly predictable and consistent and does not require multiple exposures to TSH, cells were unlikely to respond to TSH with an increase in calcium unless they received multiple challenges with the hormone. A single addition of 10 mU/ml TSH failed to increase calcium in any of 40 single cells examined and in only 4 of 15 monolayers of cells (27%) examined; in contrast, 10 of 12 monolayers eventually responded with an increase in calcium after multiple exposure to TSH and 18 of 67 single cells. Similar data were obtained whether calcium was measured in single cells or in populations of cells. We also demonstrated cooperativity between an adenosine derivative, N6-(L-2-phenylisopropyl)adenosine, and TSH such that their co-administration resulted in a consistent and marked elevation in calcium levels not achieved with either agonist alone. In summary, we suggest that the coupling between the TSH receptor and the intracellular signalling system that leads to activation of intracellular calcium in JPO9 cells requires repetitive stimulation or the influence of other agonists, in contrast with the coupling between the TSH receptor and activation of the adenylate cyclase enzyme.

Thyroid eye disease (TED) has an autoimmune etiology, but the nature of the autoantigen that is the target of the initiating event remains unknown. A number of candidates have been proposed based on Western blotting, library screening, and deduction from sequence similarity. A strong favorite is the thyrotropin receptor (TSHR), which is the target of the thyroid stimulating antibodies (TSAB) of Graves' disease (GD). We have recently demonstrated TSHR transcripts in orbital adipose tissue from a patient with TED by Northern blot, transcripts in normal adipose tissue being at the limit of detection. We have shown that the transcripts are translated into protein by immunohistochemical analysis using two monoclonal antibodies to the TSHR generated by genetic immunization. TSHR immunoreactivity is associated with elongated cells with the appearance of a fibroblast, often adjacent to clusters of adipocytes, in orbital biopsies from patients with TED but not in strabismus or pseudotumor biopsies. In animal studies, we have transferred thyroiditis to naive BALBc and NOD mice, using T cells primed to the human TSHR, either using the receptor expressed as a bacterial fusion protein or by genetic immunization. The BALBc develop a Th2-type response to the receptor, but the NOD a Th1-type with thyrocyte destruction. Orbital pathology, edema, infiltration by mast cells and lymphocytes, and adipose accumulation was also induced in 68% of the BALBc but none of the NOD mice. Together these data indicate that the preadipocyte expresses the TSHR and that a Th2 autoimmune response to the receptor may be an initiating event in TED.

Summary: Autoimmune thyroid disease is one of the most common autoimmune diseases. There is typically patient antibody (Ab) reactivity to one or more of the antigens thyroglobulin (Tg), thyroid peroxidase (TPO) and the thyroid stimulating hormone receptor (TSFlr). With the advent of combinatorial library technology, there has been an enormous increase in the number of sequences from Ab to Tg and TPO, The repertoire of both Tg and TPO Ab is restricted and indicates the importance of somatic hypermutation in the development of the high affinity, Ab response. However, there are still too few sequences to determine patterns in which the mutation occurs, which residues are introduced during substitution and how individual substitutions affect the affinity of the Ab, Ab to the TSHr are of far greater pathological significance than those to Tg and TPO, but the current repertoire of Ab to the TSHr has yet to include the high affinity IgG Ab characteristic of patient serum Ab, Instructive analysis of the role of somatic hypermutation in the development of TSHr Ab therefore still awaits the isolation of the pathologically active repertoire. Despite this, the Ab response in thyroid autoimmunity remains one of the best characterised of human autoimmune diseases.

alpha-Melanocyte stimulating hormone (alpha-MSH) was found significantly to reduce tumour necrosis factor-alpha (TNF-alpha) stimulated upregulation of intercellular adhesion molecule-1 (ICAM-1) in normal adult cutaneous melanocytes. The maximum inhibitory response to alpha-MSH was obtained at around 10(-10) mol/L alpha-MSH when cells were coincubated with alpha-MSH and TNF-alpha for 24 h. alpha-MSH had little or no effect on basal ICAM-1 expression in melanocytes and the effects of alpha-MSH could be mimicked with 3-isobutyl-1-methylxanthine (IBMX). Preliminary data in three human melanoma cell lines also showed alpha-MSH and forskolin to be effective in significantly reducing TNF-alpha stimulated ICAM-1 expression over 24 h. The extent of the inhibition varied from cell line to cell line and was greatest in those cells with the highest number of alpha-MSH receptors. These data suggest that alpha-MSH has the ability to oppose the action of the pro-inflammatory cytokine TNF-alpha on melanocytes and melanoma cells.

Cytokines are an extraordinarily diverse group of molecules, with pleiotropic and often overlapping effects. They are crucial to the autoimmune response, and, in particular, regulation of CD4 + and CD8 + T-cell function depends on the balance of cytokines produced during an immune response. It is also now clear that cytokines are produced by a wide array of cells, including the thyroid follicular cells (TFCs). Intrathyroidal lymphocytes produce a heterogeneous pattern of cytokines and we have summarized the likely effects of these. In Graves' disease, TFCs can themselves express immunologically important molecules as the result of cytokine stimulation and these could contribute to the perpetuation of the autoimmune process. In addition, cytokines have a number of generally inhibitory effects on thyroid hormone production which would tend to counter the stimulatory effects of thyroid-stimulating hormone receptor antibodies in Graves' disease.

Normal human skin melanocytes do not pigment consistently to alpha-melanocyte stimulating hormone (alpha-MSH) in culture. The aim of this study was to establish media conditions in which to obtain a reproducible melanogenic response to alpha-MSH in these cells. Twenty-five media of varying mitogen composition were examined. As previously noted by other workers, melanocyte morphology and proliferation are greatly affected by media composition. However, under the majority of media conditions that supported melanocyte survival and proliferation, cells did not respond to alpha-MSH with any consistent increase in dopa oxidase activity or melanin content. In only one medium condition, where basic fibroblast growth factor (bFGF) was the sole mitogen present, alpha-MSH induced both an increase in dopa oxidase activity (at 48%) and in melanin content (of 283%).

SUMMARYAn immunodominant region recognized by serum autoantibodies has been defined on the autoantigen thyroid peroxidase (TPO) using recombinant human TPO-specific Fab or a panel of mouse MoAbs. We have now analysed the epitopic relationships between the four recombinant Fab that identify the A and B domains of the TPO immunodominant region and (i) the mouse TPO MoAb as well as (ii) nine new TPO-specific Fab isolated independently. Competition between mouse MoAbs and recombinant Fab for binding to 125I-TPO revealed three patterns. First, for MoAbs 15, 59, 64 and 18, TPO binding was virtually abolished (≈ 90%) by Fab which define the A domain of TPO, with less inhibition by B domain Fab. Second, for MoAbs 2, 9 and 47, the Fab competed much less for TPO binding, and, when detectable, inhibition was predominantly with B domain Fab (65–20%). Third, for MoAbs 53, 30, 1, 24 and 40, none of the Fab competed effectively for 125I-TPO binding. Thus, the epitopes for MoAbs 18, 59, 64 and 15 correspond to those of the A domain defined by the human Fab, and the epitopes for MoAbs 2, 9 and 47 correspond to those of the B domain. In the second part of the study, competition studies demonstrated that the epitopes of nine new Fab corresponded to those of the four Fab that define the immunodominant region. For four new Fab, TPO binding was inhibited to a greater extent by B- than by A- domain Fab (65–95% versus

Antibodies to autonomic nervous system structures have previously been detected using a complement fixation immunofluorescence test in the sera of patients with insulin-dependent diabetes mellitus (IDDM) and non-insulin dependent diabetes mellitus (NIDDM). These antibodies might play a role in the aetiology of autonomic neuropathy. Sera from 45 IDDM, 40 NIDDM and 52 control subjects were tested by immunofluorescence for antibodies to human sympathetic ganglia, human adrenal medulla and rabbit vagus nerve. The use of human sympathetic ganglia was compared with rabbit tissue for the detection of sympathetic ganglia antibodies; the results for these autonomic nervous system antibodies were also compared with results using an ELISA. There was no relationship between the presence of antibodies detected by ELISA and those detected by immunofluorescence, but of 14 IDDM patients with thyroid antibodies, 12 had autonomic nervous system antibodies detected by either immunofluorescence or ELISA (p < 0.005 compared to patients without thyroid antibodies). To further characterize the autoantigen(s), immunoblotting was performed. An adrenal antigen corresponding to 74 kDa was detected in sera from three patients, only one of whom had antibodies detectable by ELISA and immunofluorescence. One IDDM serum showed specific binding to a vagus nerve antigen corresponding to 33 kDa. No specific binding to sympathetic ganglia antigen was demonstrated. Antibodies against autonomic nervous system antigens are an inconsistent feature of diabetes, and appear more associated with coincidental autoimmunity against other organs such as the thyroid.

Animal models of autoimmune thyroiditis - recent advances, Y.M. Kong thyroid autoantigens, M. Ludgate autoimmune hypothyroidism, A.P. Weetman, et al Graves' disease - progress to date and future prospects, A.M. McGregor postpartum thyroiditis, J.H. Lazarus, et al thyroid-associated ophthalmopathy, R.M. Cidduhy, R.S. Bahn beta cell antigens, A. Plesner, A. Lernmark an aetiology and pathogenesis of insulin-dependent diabetes mellitus (IDDM), J.F. Bach Addison's disease and related polyendocrinopathies, P. Peterson, et al premature ovarian failure, J.N. Anasti pituitary autoimmunity, H.A. Sawers, J.S. Bevan autoimmune gastritis and pernicious anaemia, P. Burman, et al vitiligo, D.J. Gawkrodger.

Although medication for Graves' hyperthyroidism can be withdrawn without adverse effects for the patient, the data regarding the optimal duration of therapy are still unsatisfactory. This Viewpoint discusses how long treatment for Graves' disease should be continued and how withdrawal of antithyroid drugs might affect remission and relapse.

SUMMARY TAO is characterized by an autoimmune process affecting the orbital contents. T cells have been suggested to have a major role in pathogenesis, but so far only limited data are available to clarify the extraocular muscle (EOM)-infiltrating T cell phenotype, antigenic reactivity and cytokine profile in TAO patients. In the present study, biopsies of affected EOM were taken and the infiltrating T cells isolated and expanded in vitro with mitogen. Their phenotype was determined by flow cytometric (FACS) analysis and compared with peripheral blood-derived T cell lines, treated in the same way from the same patient. Cytokines present in the supernatant after mitogen stimulation of the T cell lines were assayed by ELISA. In addition, cytokine mRNA present at the time of biopsy was determined by rapid RNA extraction from EOM and reverse transcription-amplification with specific cytokine oligonucleotide probes (IL-1α, IL-1β, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13, IL-15, interferon-gamma (IFN-γ), tumour necrosis factor-alpha (TNF-α)). In the T cell lines from two patients, proliferation assays were carried out with antigens derived from thyroid gland, EOM and a thyrotropin (TSH) receptor preparation. Most T cell lines were CD4+, CD45RO+, and TCR α/β+, both from the EOM and the peripheral blood. A wide variety of cytokines was detected by analysis of supernatants or mRNA, but the profiles were not identical comparing the two approaches. However, IL-4 was detected by both. Dose-dependent proliferation was observed in response to thyroid extract in a biopsy-derived T cell line. In conclusion, EOM-infiltrating T cells from patients with TAO, expanded in vitro, were chiefly CD4+ and produced a mixture of cytokines, including IL-4. The proliferation data suggest that there are thyroid-reactive T cells in EOM.

Three steroidogenic P450 cytochromes, steroid 17alpha-hydroxylase (P450c17), steroid 21-hydroxylase (P450c21) and side-chain cleavage enzyme (P450scc), have been described as autoantigens in APS I. In this study we report an immunoprecipitation assay for the detection of autoantibodies to these three enzymes using in vitro 35S-labelled antigens. Overall, 33 out of 46 (72%) patients with APS I had autoantibodies to at least one of the three proteins and each protein was recognized by patient sera with equal frequency. A higher rate of autoantibody positivity was observed in APS I patients with Addison's disease compared with patients without Addison's disease (85% versus 39%). All 11 patients with ovarian failure had anti-P450c17 or anti-P450scc antibodies. The immunoprecipitation results with P450c17, P450c21 and P450scc correlated well with the results obtained by immunoblotting assays. In addition, the steroidogenic enzymes 11beta-hydroxylase (P450c11beta), aromatase (P450arom), 3beta-hydroxysteroid dehydrogenase (3betaHSD) and adrenodoxin were studied by immunoprecipitation assay, but no reaction was found either with 46 APS I or with 26 healthy control sera. To study the suggested immunological cross-reactivity between P450c17 and P450c21 enzymes, nine APS I patient sera were preabsorbed with bacterially expressed P450c17 or P450c21 and subsequently used in immunoprecipitation assay. The absorption experiments clearly indicated that the preincubation inhibited only the reactivity of corresponding antigen, suggesting independent autoantibody response to the two enzymes. Our results suggest that the immune response to some but not to all steroidogenic enzymes is a specific feature of APS I that may be pathogenically significant.

A polymorphism in codon 52 of the human thyrotropin receptor results in a proline to threonine substitution in the extracellular domain of the receptor, and it has been suggested that the rarer, 52Thr, allele is associated with susceptibility to Graves' disease in the female population. To investigate this association we analyzed the distribution of TSH-R alleles in male (n = 60) and female (n = 120) Graves' patients, and control subjects (male n = 160 and female n = 85), using a PCR amplification and mismatch oligonucleotide hybridization technique. The variant allele was present in 8.3% of patients and 7.3% of control subjects. The frequencies in male and female patients were 6.7 and 9.2% respectively, and the allele distribution did not differ significantly from that observed in controls. No association was found between this TSH-R polymorphism and the occurrence of Graves' disease in the male or female population.

There is no consensus on the role of antibody-dependent cell-mediated cytotoxicity (ADCC) in autoimmune thyroid disease; recent reports have suggested that antibodies mediating ADCC are found particularly in patients with primary myxoedema, occur less frequently in Hashimoto's thyroiditis and are absent in Graves' disease. Using an ADCC assay with a single source of effector and target cells, and expressing results as lytic units, we have found antibodies capable of mediating ADCC in 9 of 17 patients with primary myxoedema, 9 of 22 patients with Hashimoto's thyroiditis and 6 of 22 patients with Graves' disease. There was no significant difference between the groups in this distribution. Mean levels of ADCC activity were not significantly different comparing primary myxoedema and Hashimoto's thyroiditis patients, although levels were lower in Graves' disease patients compared to those with Hashimoto's thyroiditis (P < 0.05). There was no correlation between TPO antibodies (total IgG or IgG subclasses) measured by ELISA and ADCC activity. These results suggest that thyroid antigens besides TPO are involved in ADCC and that antibodies mediating ADCC are not restricted to subgroups of patients with autoimmune thyroid disease.