Hypothyroidism after treatment with interleukin-2 and lymphokine-activated killer cells

The development of a goiter and hypothyroidism in a 28-year-old man in whom metastatic melanoma had been treated with interleukin-2 and lymphokine-activated killer cells (LAK cells) prompted us to assess thyroid function in patients undergoing this therapy. Thirty-four patients with advanced neoplasms who had received interleukin-2 and LAK cells were followed for at least four weeks after treatment. Seven patients (21 percent) had laboratory evidence of hypothyroidism, with a decline in the serum thyroxine concentration to below normal (less than or equal to 35 nmol per liter; normal, 65 to 148), a decline in the serum free thyroxine index, and a rise in the serum thyrotropin concentration (peak values, 7.2 to 166 mU per liter; normal, 0.5 to 5.5) 6 to 11 weeks after treatment. Two patients had elevated serum thyrotropin levels before treatment, which increased further after treatment. In two patients, these abnormal values returned to normal within 10 months. All five symptomatic patients had borderline or elevated serum antimicrosomal antibody titers after treatment; two had serum antibodies to thyroglobulin. Five of the seven patients with hypothyroidism (71 percent) but only 5 of the 27 euthyroid patients (19 percent) had evidence of tumor regression (P less than 0.02). None of 11 patients treated with interleukin-2 but not LAK cells had hypothyroidism. We conclude that treatment with interleukin-2 and LAK cells can cause hypothyroidism, possibly by exacerbating preexisting autoimmune thyroiditis, and that it may be associated with a favorable tumor response.

Human epidermal keratinocytes in culture convert thyroxine to 3,5,3'-triiodothyronine by type II iodothyronine deiodination: a novel endocrine function of the skin

Cultured human keratinocytes converted T4 to T3 by type II iodothyronine deiodination. Homogenates of keratinocytes cultured from neonatal foreskin or adult arm skin had similar mean T4 5'-deiodinating activities. Conversion of T4 to T3 by intact cells was demonstrable in cultures from neonatal and adult donors. Only phenolic ring deiodination occurred in the cultured cells and their homogenates, the apparent Michaelis constant for T4 was 12 nmol/L, and T4 and rT3 each inhibited 5'-deiodination of the other. T4 5'-deiodination was unaffected by addition to the assay mixture of 1 mumol/L T3, but was inhibited less than 10% by 1 mmol/L 6-n-propyl-2-thiouracil, 50% by 270 nmol/L iopanoic acid, 50% by 9.4 mumol/L 3,5-diiodo- 3',5'-dimethyl-L-thyronine, and 33% by 42 mumol/L amiodarone. When keratinocytes were cultured for 3-4 days in medium containing iodothyronine-free fetal calf serum, the T4 5'-deiodination rates in homogenates doubled; this increase was prevented by restoring a physiological free T4 concentration, but not by a supraphysiological T3 concentration. Homogenates of fresh whole skin or fetal cadaveric epidermis did not convert T4 to T3 in measureable amounts, although one epidermal homogenate had low level T3 typrosyl-ring deiodinating activity. These results suggest that human epidermal type II iodothyronine deiodination in man might conceivably contribute to the intracellular T3 content of the skin and even to serum T3 concentrations, especially in hypothyroidism.

The clinical outcome of prospective screening for multiple endocrine neoplasia type 2a. An 18-year experience

An important question facing physicians who care for families with multiple endocrine neoplasia type 2a is whether prospective screening to detect early abnormalities of the thyroid, parathyroid, or adrenal glands favorably influences the ultimate course of the disease. An 18-year study of a large family has allowed us to examine the effect of early treatment on the clinical course of the disease. Of 22 patients who underwent thyroidectomy for early C-cell abnormalities, 19 remained free of detectable medullary thyroid carcinoma according to all criteria, at a mean of 11 years after thyroidectomy. None of the 22 patients had evidence of parathyroid disease either at the time of surgery or after a mean follow-up of 10 years. Prospective screening for adrenal medullary abnormalities by means of measurement of 24-hour urinary epinephrine excretion and the ratio of urinary epinephrine to norepinephrine was predictive of pheochromocytoma in 10 of 11 patients (with a false negative result in one patient) but was not useful in diagnosing adrenal medullary hyperplasia. We conclude that regular, prospective screening and early treatment of the manifestations of multiple endocrine neoplasia can prevent metastasis of medullary thyroid carcinoma and the morbidity and mortality caused by pheochromocytoma.

Thyroid, parathyroid, and salivary gland evaluations in patients exposed to multiple fluoroscopic examinations during tuberculosis therapy: a pilot study

The prevalence of thyroid, parathyroid, and salivary abnormalities was determined in 91 women who received an average of 112 fluoroscopic chest examinations during pneumothorax treatment for tuberculosis more than 40 yr previously and in 72 women treated for tuberculosis by other modalities. Thyroid abnormalities were determined by physical examination, scintiscans, and measurements of serum free T4 index, TSH, and thyroid microsomal antibodies. Thyroid nodules were diagnosed in 7.7% of the exposed and 4.2% of the comparison group (prevalence ratio, 1.8; 90% confidence interval 0.6-5.7). Autoimmune thyroid disease was diagnosed in 15.2% of the exposed and 6.9% of the comparison group (prevalence ratio, 2.2; 95% confidence interval, 0.8-6.2). No salivary tumors were detected. Two exposed women and 1 comparison woman had primary hyperparathyroidism. Although absorbed dose to the thyroid could not be precisely determined, approximately 60 rads would be expected to yield the observed excess of thyroid nodules. While the prevalence ratios were not significantly increased in the exposed group, the results suggest that susceptibility of the thyroid to nodules from cumulative radiation doses of this magnitude could be increased even when the doses are accumulated over years and that such x-ray exposure of the thyroid gland may predispose the patient to the development of autoimmune disease.

Histocompatibility antigens in primary biliary cirrhosis

HLA-A, -B, and -DR antigens were examined in 71 patients with primary biliary cirrhosis (PBC) enrolled in a randomized, double-blind trial of colchicine versus placebo. All patients had typical laboratory and histological features of PBC, except that six had a negative test for antimitochondrial antibody. Frequencies of these antigens were compared with the international Caucasian panel of the Eighth International Workshop and with a local Caucasian panel. Antigen frequencies were compared using the chi 2 test, with a correction for the number of antigens tested. The PBC patients had a significant excess of DR4 (29 of 70 typed, or 41.1%) compared to the international (804 of 3811, or 21.1%, corrected p value less than 0.05) but not the local panel (47 or 129, or 36.4%). Of PBC patients, 52.9% had only one DR antigen identified, compared to 67.5% for the international panel and 49.6% for the local panel. In past studies, the HLA antigen most strongly correlated with PBC was DR8, but this was not included in our panel of antisera. However, no significant relationship between HLA and PBC was found among the antigens screened.

Abnormal thyroid hormone deiodination in tissues of ob/ob and db/db obese mice

To explore the relationships between thyroid hormone economy and defective thermogenesis in two genetically obese mouse strains, ob/ob and db/db, we measured iodothyronine deiodination in tissue homogenates and the T4 and T3 content of selected tissues. In lean mice acclimated at room temperature, type II 5'-deiodination in brown adipose tissue (BAT) homogenates rose 14.5-fold between 30 and 180 min of cold exposure at 4 C. In ob/ob mice kept at room temperature, type II 5'-deiodination rates in BAT homogenates were 2.29 times those in lean controls, but acute exposure to 4 C for 3 h caused a much smaller rise in 5'-deiodination in the ob/ob mice than in lean controls. Administration of 1 microgram/g norepinephrine caused similar elevations in BAT 5'-deiodination in ob/ob and lean mice. db/db mice had a defect in cold-stimulated BAT 5'-deiodination similar to that in the ob/ob mice in two of three experiments. In the obese animals of both strains, but not the lean mice, the magnitude of the rise in BAT type II deiodination after cold exposure was much greater in December than in warm months. Cerebrocortical homogenates from ob/ob mice had about 33% higher type II 5'-deiodination rates than those from lean controls, but showed normal type III T3 5'-deiodination. ob/ob liver homogenates had about 33% lower type I 5'-deiodination rates than controls. db/db, but not ob/ob, mice had lower serum T4 concentrations than controls. Both ob/ob and db/db mice had lower hepatic T4 concentrations than lean controls. The ob/ob animals had no alteration in brain T4 concentrations. Neither ob/ob or db/db mice had altered serum T3 concentrations, ob/ob mice had subnormal hepatic, but not brain, mean T3 concentrations. db/db mice also had reduced mean heptic T3 concentration. These results suggest that the subnormal cold-induced rise in ob/ob and db/db BAT type II 5'-deiodination is unrelated to thyroid status, perhaps being partly caused by defective sympathetic stimulation. This impaired deiodination response might result in subnormal intracellular T3 in BAT, thereby contributing to impaired thermogenesis. In contrast, the elevated cerebrocortical and unstimulated BAT type II deiodination and the decreased hepatic type I deiodination in the ob/ob mice are probably due to intracellular thyroid hormone deficiency.

Primary sclerosing cholangitis and low-dose oral pulse methotrexate therapy. Clinical and histologic response

Two patients with sclerosing cholangitis responded to low-dose methotrexate treatment. A 40-year-old man who had previously undergone total colectomy for ulcerative colitis presented with refractory erythroderma and sclerosing cholangitis. Both disorders were alleviated and have remained in remission on methotrexate, 5 mg every 12 hours three times each week (15 mg/wk). Liver function improved, bile duct scarring did not worsen, and repeat liver biopsy samples have shown striking improvement. A 60-year-old man with long-standing ulcerative colitis and repeated exacerbations of sclerosing cholangitis had a similar response to low-dose methotrexate, 2.5 mg every 12 hours three times each week (7.5 mg/wk), during a 6-year period. Recurrent episodes of cholangitis have disappeared, liver function has become normal, bile duct scarring has not worsened, and liver histologic findings have become normal. Because of the potential hepatotoxicity of methotrexate, we suggest that a prospective, randomized trial be done.

Anti-DNA antibody idiotypes in primary biliary cirrhosis

A significant increase in 16/6 Id--a major cross-reactive idiotype of anti-DNA antibodies (Ab) derived from a patient with systemic lupus erythematosus (SLE) and hitherto identified in SLE patients and their relatives, was found in 16/17 patients with primary biliary cirrhosis (PBC). The increased serum level of Ab with the 16/6 idiotype (16/6 Id) in PBC patients (median 50 ng/ml) was not found in 6/7 of the patients' spouses nor among 27/28 healthy controls or most patients with other types of cirrhosis. The quantity of 16/6 Id was not correlated to either the stage of disease or the presence of antimitochondrial, antinuclear, or anti-dsDNA antibodies. However, 16/6 Id could be shown to be associated with anti-ssDNA antibodies. The high frequency of the lupus-derived 16/6 Id in PBC may accompany the polyclonal B-cell activation seen in that disease. Of 14 healthy first-degree relatives of the PBC patients, 4 (29%) also had elevated serum 16/6 Id (20-25 ng/ml) and the cluster of 3 of them in a single family may indicate a genetic predisposition to develop PBC.

A randomized clinical trial comparing OKT3 and steroids for treatment of hepatic allograft rejection

A multiinstitutional randomized trial was undertaken comparing OKT3 with steroids for treatment of hepatic allograft rejection. All patients received baseline immunosuppression with Cyclosporine (CsA) and steroids. At the time of biopsy-confirmed rejection, up to 2 intravenous boluses (250-1000 mg) of methylprednisolone were initially administered. Twenty-eight patients who failed to respond were then randomly assigned to OKT3 or continued steroid therapy. Rescue therapy with the opposite treatment arm was added after 6 days if the primarily allocated protocol failed. Three of 13 patients assigned to the steroid group responded promptly, and continue with good function 7-12 months later. OKT3 rescue was required in 10 patients who failed to improve despite receiving up to 6 g of methylprednisolone (mean: 3.3 g/patient). One patient died of sepsis and hepatic failure. Rejection was reversed in 9 OKT3-rescue patients, 7 of whom are well 1-17 months later. In the OKT3 group, improved allograft function was observed within 72 hr in 11 of 15 patients. Two patients with inadequate response were successfully rescued with steroids; 1 patient underwent retransplantation; and 1 patient developed a biliary fistula that eventually resulted in sepsis and death. In summary, 23 of 28 hepatic recipients (82%) are alive with the original allograft 1-17 (mean 7.8) months after treatment for acute rejection. Another patient is alive 14 months following retransplantation. Eighteen (78%) of the survivors required OKT3 as initial (11) or rescue (7) therapy, whereas only 5 were successfully managed with steroids. OKT3 is superior to steroids for reversing liver allograft rejection and has greatly reduced the need for retransplantation even in recipients selected on the basis of having failed initial steroid therapy.

A prospective trial of colchicine for primary biliary cirrhosis

We entered 60 patients with primary biliary cirrhosis in a double-blind randomized controlled trial to determine whether colchicine is therapeutically effective. Thirty patients had early disease (Stages 1 and 2), and 30 had advanced disease (Stages 3 and 4). Fifteen patients with early disease and 15 with advanced disease received colchicine (0.6 mg twice daily), and the remainder received placebo. Patients were studied about every two months; those remaining in the blind phase at two years underwent repeat liver biopsy and were then placed on open-label colchicine (0.6 mg twice daily). With a few exceptions, the results in patients with early disease were similar to those in patients with advanced disease; hence, data on patients in all stages were combined in the main analysis. During the two-year study period the colchicine-treated patients, as compared with the placebo-treated patients, had improvement in levels of serum albumin, serum bilirubin, alkaline phosphatase, cholesterol, and aminotransferases. However, there was no such improvement in the severity of symptoms or physical findings; moreover, there was no significant difference in the histologic changes noted at liver biopsy in the two treatment groups. At four years after entry, the cumulative mortality from liver disease was 21 percent in patients given colchicine and 47 percent in those given placebo (P = 0.05). The only side effect of colchicine was diarrhea, noted in three patients. The consistent and significant improvement in a number of markers of liver disease and the apparent decreased mortality from liver disease suggest that colchicine may provide some long-term clinical benefit in patients with primary biliary cirrhosis. However, the failure of colchicine to reduce hepatic inflammation and fibrosis leaves uncertain the effect of the drug on the longterm outcome of this disease.

Sustained rises in serum thyrotropin, thyroxine, and triiodothyronine during long term, continuous thyrotropin-releasing hormone treatment in patients with amyotrophic lateral sclerosis

In a pilot therapeutic trial, four patients with amyotrophic lateral sclerosis (ALS) were treated with long term, continuous infusions of TRH, three intrathecally and one epidurally. They had prompt increases in serum TSH and thyroid hormone concentrations, averaging 120% for TSH, 49% for serum T4, 68% for the serum free T4 index, 49% for serum T3, and 67% for the serum free T3 index. These elevations were statistically significant for all but serum T3 and persisted for the duration of treatment (4-7 months). Mean values during treatment were near the upper limit of normal for each of these hormone measurements. After TRH withdrawal, serum TSH fell transiently below the normal range. A comparison group of four patients with ALS treated by twice weekly intrathecal bolus doses of TRH had no significant changes in serum TSH, T4, or T3. During continuous TRH treatment, the responsiveness of both TSH and PRL to a standard iv TRH stimulation test was blunted, but not abolished. Basal serum PRL was occasionally elevated in the two women during continuous TRH treatment, but was normal in the men, and serum GH was normal in all patients. In the patients receiving continuous TRH treatment, indexes of end-organ effects of thyroid hormone were inconclusive; none had a rise in serum ferritin, one of four had a rise in serum sex hormone-binding globulin, and three had increased creatinuria. These results provide direct evidence in man that chronic TRH administration can cause modest sustained increases in serum TSH and thyroid hormones, though the metabolic consequences of these changes are uncertain, and appears to raise the set-point of the pituitary-thyroid axis, i.e. the serum T4 and T3 concentrations needed for a given degree of suppression of basal TSH secretion.

Cyclosporine blood concentrations determined by specific versus nonspecific assay methods

Cyclosporine blood concentrations were simultaneously determined by radioimmunoassay (RIA) and high-performance liquid chromatography (HPLC) at multiple points in time in two patients receiving cyclosporine for immunosuppression following liver transplantation. Radioimmunoassay levels always exceed those determined by HPLC; however, the divergence between the two methods increased as serum bilirubin concentration increased, with HPLC:RIA ratios generally less than 0.3 when serum bilirubin concentrations exceeded 10.0 mg/dL. These preliminary results suggest that retention of immunoactive cyclosporine metabolites due to imparied liver function may account for RIA-determined cyclosporine concentrations that greatly exceed those measured by HPLC.

In vitro anti-mitochondrial antibody synthesis in patients with primary biliary cirrhosis

Suppressor cell function was studied in 31 patients with primary biliary cirrhosis. Blood mononuclear cells were activated in vitro with suboptimal or optimal concentrations of concanavalin A and suppression of mitogen-induced proliferation or synthesis of anti-mitochondrial antibodies was measured. At suboptimal concentrations of concanavalin A, mean (+/- SE) suppression of proliferation by patients' cells was significantly less than 14 controls (18.7 +/- 5% vs 34.3 +/- 5%; P less than 0.005). The degree of suppressor activity correlated with the clinical disease, i.e., suppression was greater in patients with early than advanced disease. Spontaneous anti-mitochondrial antibody synthesis was not detected in cultures of mononuclear cells from normal subjects nor from patients with negative serum antibody, nor could it be induced by pokeweed mitogen in either group. In contrast, spontaneous anti-mitochondrial antibody synthesis was detected in cultures of 18/23 patients with positive serum antibody and was significantly augmented by pokeweed in 12/18. Anti-mitochondrial antibody synthesis was augmented by 48% (+/- 19) in response to pokeweed and concanavalin A-induced suppression higher (39.4 +/- 7%) in patients with low titer antibody compared to 1.6% (+/- 8) pokeweed augmentation and 5.5 +/- 3% concanavalin A-induced suppression in patients with high titer antibody. These results suggest that some patients with primary biliary cirrhosis have an immunoregulatory defect which expresses itself in part as an inability to regulate autoantibody synthesis.

Abnormal thyroid hormone binding to serum proteins in ob/ob and db/db genetically obese mice

Sera from ob/ob and db/db genetically obese mice exhibited abnormal nonspecific (no antibody present) binding measurements in T4 and T3 RIAs employing dextran-charcoal separations. They also showed decreased charcoal uptake compared to sera of lean controls in a conventional charcoal T4 uptake binding test. After correction for the abnormal nonspecific binding and after extraction of serum, mean serum T4 concentrations were similar in control and ob/ob mice. Mean serum T3 concentrations differed significantly (85 ng/dl in controls and 178 ng/dl in ob/ob) when a correction for altered binding in the T3 assay was made, but not when extracted serum was assayed (109 ng/dl in lean and 124 ng/dl in ob/ob). Dialyzable fractions of T4 and T3 were significantly reduced in both ob/ob and db/db mice. Free T4 concentrations were 0.82 +/- 0.05 (+/- SE) ng/dl in control and 0.61 +/- 0.05 ng/dl in ob/ob sera (P less than 0.01). Polyacrylamide gel electrophoresis showed increased binding of tracer T4 and T3 in ob/ob and db/db sera to a postalbumin with mobility similar to that of human T4-binding globulin. In ob/ob sera, this appeared to result from an increased binding capacity of the postalbumin. After in vivo iv injection of tracer T4 and T3 to ob/ob and lean control mice, analysis of tissue and plasma radioactivity showed that, except for T4 in cerebral cortex, tissue to plasma T4 and T3 ratios were lower in cerebral cortex, cerebellum, and liver of ob/ob mice. In summary, these data show increased binding of T4 and T3 to a postalbumin in two strains of genetically obese mice and, in the ob/ob strain, complex relationships between tissue and serum concentrations of thyroid hormones.

Clinical and laboratory assessment of thyroid abnormalities

Clinical assessment of the patient with suspected thyroid disease remains an important part of the workup. Available laboratory tests of thyroid function include measurements of serum thyroid hormones and thyroid-stimulating hormone, titers of autoantibodies involved with Graves' disease and thyroiditis, and thyroid imaging and uptake techniques. The usefulness and limitations of each of these tests are reviewed.

Characteristics of thyroxine 5'-deiodination in cultured human placental cells. Regulation by iodothyronines

Human and rat placental homogenates convert L-thyroxine (T4) to 3,5,3'-L-triiodothyronine (T3) via a pathway termed type II iodothyronine deiodination. To study regulation of this pathway, cell dispersions were prepared from human placental chorionic-decidual membrane. Dispersed cells deiodinated T4 and 3,3',5'-triiodothyronine (rT3), but not T3, at the 5' position. The reaction was only slightly inhibited by 1 mM 6-n-propylthiouracil, enhanced by dithiothreitol, and substantially inhibited by 50 nM iopanoic acid. Incubation of the cells in thyroid hormone-depleted medium induced a near doubling of T4 5'-deiodination in 36-48 h, with a significant rise seen as early as 12 h. Addition of T4, rT3, or T3 to hormone-depleted medium impaired the rise in type II deiodination in a dose-dependent fashion. T4 and rT3 were equipotent in this regard, and T3 was 2-3 times less potent. T4 was effective in physiological concentrations, 6.5-13 nM in medium containing 10% calf serum, and the effect of T4 was not due to its conversion to either T3 or rT3. In cells with deiodinase activity raised by 48 h incubation in thyroid hormone-depleted medium, addition of T4, T3, or rT3 reversed the increase in 8-24 h. Secretion of prolactin and beta hCG by the dispersed cells was not substantially affected by thyroid hormone deprivation. The increase in type II deiodination during thyroid hormone deprivation appears to depend on a signal from the thyroxine molecule, per se, and could potentially defend intracellular, and/or circulating, T3 pools in pathological states of mild-to-moderate hypothyroxinemia.

Isoenzyme studies in transient hyperphosphatasemia of infancy. Ten new cases and a review of the literature

A literature review and ten new cases of benign transient hyperphosphatasemia of infancy are presented, with special attention paid to isoenzyme studies. Polyacrylamide gel electrophoresis, heat denaturation, and binding of alkaline phosphatase to anti-human alkaline phosphatases showed that the sources of the elevated alkaline phosphatase levels are normal bone and liver and not the small intestine. The data also suggest that the following criteria be present for a diagnosis of transient hyperphosphatasemia: (1) an age of less than 5 years, (2) variable symptoms, (3) no bone or liver disease noted on physical examination or (4) from laboratory investigations, (5) isoenzyme analysis showing elevations in both bone and liver activity, and (6) a return to normal serum alkaline phosphatase activity values within four months.

Liver disease and the PI ElembergM phenotype of alpha 1-antitrypsin

The purpose of this article is to document clinical and pathologic observations concerning liver disease associated with the PI ElembergM phenotype of alpha 1-antitrypsin. Deposits of alpha 1-antitrypsin that were periodic acid-Schiff positive and stained with an antiserum to alpha 1-antitrypsin were found in the liver of a markedly jaundiced, terminally ill patient with Stage IV primary biliary cirrhosis. A biopsy performed three years earlier failed to reveal alpha 1-antitrypsin deposits. The phenotype PI ElembergM was verified by both acid starch gel electrophoresis and isoelectric focusing in agarose. The deposits of alpha 1-antitrypsin in the liver appear to be a consequence of the patient's disease and age and not due to an association with the PI*Elemberg allele. Accumulation of alpha 1-antitrypsin in the liver of this patient may be due to an accelerated synthesis of this protease inhibitor exceeding the liver's capacity for glycosylation or other steps in its secretion.