Association between paroxysmal or persistent atrial fibrillation and hyperuricemia in patients who underwent coronary computed tomography angiography: from the FU-CCTA-AF Registry

BACKGROUND

Hyperuricemia (HU) and hypertension (HTN) contribute to atherosclerotic cardiovascular disease, and both are also involved in the onset and development of atrial fibrillation (AF).

OBJECTIVE

In the present study, we investigated the association between risk factors for atherosclerosis [including HU, HTN, blood pressure and serum uric acid (UA) levels] and paroxysmal atrial fibrillation (Paro-AF) or persistent atrial fibrillation (Pers-AF) in patients who underwent coronary computed tomography angiography (CCTA).

METHODS

We enrolled 263 patients from the Fukuoka University-CCTA-AF (FU-CCTA-AF Registry) who underwent CCTA prior to AF ablation therapy. AF was classified as either Paro-AF (≤ 7 days) or Pers-AF (> 7 days). HU was diagnosed by a serum UA level > 7.0 mg/dl, and coronary artery disease (CAD) was diagnosed when CCTA results showed ≥ 50% significant coronary artery stenosis. The number of significantly diseased coronary artery vessels (VD), the Gensini score and the coronary artery calcification score (CACS) were measured. Left atrial morphology was also evaluated.

RESULTS

Diastolic blood pressure and HbA1c in the Pers-AF group were significantly higher than those in the Paro-AF group. The Pers-AF group showed a significantly higher prevalence of HU and higher UA levels than the Paro-AF group. In a multivariate logistic regression analysis, HU was an independent associated factor to Pers-AF (odds ratio: 2.023, 95% confidence interval: 1.055-3.881, p = 0.034), while HTN was not.

CONCLUSION

In patients with AF, HU is associated with Pers-AF.

A Rare Case of Submassive Pulmonary Embolism with a Right Aberrant Subclavian Artery and Thrombosed Kommerell Diverticulum

An 81-year-old man presented with shortness of breath and was referred to our hospital with suspected acute pulmonary embolism. Enhanced computed tomography revealed a right aberrant subclavian artery with a thrombosed Kommerell diverticulum (KD), as well as deep vein thrombosis in the left leg and bilateral pulmonary artery thrombosis. Thrombosis in the KD disappeared after one month of anticoagulation treatment with rivaroxaban. Thrombosis of a KD is a rare condition that may cause distal emboli and subclavian steal syndrome, although this syndrome was not present in this case. Rivaroxaban is an effective anticoagulant for treating thrombosis of a KD.

Gap-related Pulmonary Vein and Left Atrial Flutter Mimicking Cavotricuspid Isthmus-dependent Atrial Flutter

We herein report a 79-year-old man with recurrent atrial flutter (AFL) following catheter ablation for pulmonary vein (PV) isolation and block line of the cavotricuspid isthmus. An electrophysiological study and three-dimensional mapping results revealed left atrium (LA)-PV macroreentrant flutter caused by a conduction gap, possibly correlated to prior application, which mimicked cavotricuspid isthmus-dependent AFL. This LA-PV flutter was terminated after applying radiofrequency to the gap at the antrum near the bottom left inferior PV in the posterior LA wall. During follow-up, the patient did not present with atrial tachyarrhythmias; antiarrhythmic drugs were therefore not administered.

Postural Conversion Computed Tomography for the Diagnosis of Pneumopericardium due to Perforation by the Active Atrial Lead

A 71-year-old woman with cardiac sarcoidosis underwent an implantable cardioverter-defibrillator implantation in the left precordium to prevent fatal arrhythmias. Two weeks later, she presented with dyspnea. Chest X-ray revealed right pneumothorax due to the active atrial lead perforation. Subsequently, air was detected surrounding the heart. Although it was difficult to differentiate pneumopericardium from pneumomediastinum, postural conversion computed tomography (CT) in the supine and prone positions documented air migration in the pericardial cavity and diagnosed pneumopericardium. This rare case of pneumopericardium combined with pneumothorax contralateral to the venous access site highlights the utility of postural conversion CT for diagnosis of pneumopericardium.

Hereditary Antithrombin Deficiency Presenting with Deep Venous Thrombosis During the Second Pregnancy

A 37-year-old woman developed deep venous thrombosis (DVT) of the left lower extremity at 8 weeks of gestation during her second pregnancy. There was no personal or family history of thrombosis. She received intravenous heparin, but heparin resistance was noted. The plasma antithrombin activity decreased to 45% in the acute phase, and it remained low postpartum. Her mother also had low plasma antithrombin activity (46%), and genetic testing revealed a heterozygous SERPINC1 mutation. Even without a family history of thrombosis, we should suspect hereditary antithrombin deficiency in patients with initial DVT and perform thorough investigation.

Pregnancy May Affect the Attenuation of an ST Segment Elevation in the Right Precordial Leads: A Female Patient with Brugada Syndrome

A 30-year-old woman was referred to our hospital to undergo an evaluation for suspected Brugada syndrome. She showed no symptoms, but had a strong family history of sudden cardiac death. During observation, Holter electrocardiography (ECG), which had been performed to investigate her symptoms of occasional dizziness, showed a sinus node dysfunction with an occasional long sinus pause. An implantable cardioverter defibrillator (ICD) was therefore put in place, and bradycardia pacing from the ICD relieved those symptoms during the subsequent 18-month follow-up. The patient completed two pregnancies during the follow-up period. No symptomatic changes occurred during the pregnancies, but ECG indicated that an ST segment elevation in the right precordial leads was attenuated during the second and third trimesters of both pregnancies.

Ischemic or Nonischemic Functional Mitral Regurgitation and Outcomes in Patients With Acute Decompensated Heart Failure With Preserved or Reduced Ejection Fraction

The aim of this study was to evaluate the association of functional mitral regurgitation (FMR), preserved or reduced ejection fraction (EF), and ischemic or nonischemic origin with outcomes in patients discharged alive after hospitalization for acute decompensated heart failure (HF). Of the 4,842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 3,357 patients were evaluated to assess the association of FMR, preserved or reduced EF, and ischemic or nonischemic origin with the primary end point (all-cause death and readmission for HF after discharge). At the time of discharge, FMR was assessed semiquantitatively (classified as none, mild, or moderate to severe) by color Doppler analysis of the regurgitant jet area. According to multivariable analysis, in the ischemic group, either mild or moderate to severe FMR in patients with a preserved EF had a significantly higher risk of the primary end point than patients without FMR (hazard ratio [HR] 1.60; 95% confidence interval [CI] 1.12 to 2.29; p = 0.010 and HR 1.98; 95% CI 1.30 to 3.01; p = 0.001, respectively). In patients with reduced EF with an ischemic origin, only moderate to severe FMR was associated with a significantly higher risk of the primary end point (HR 1.67; 95% CI 1.11 to 2.50; p = 0.014). In the nonischemic group, there was no significant association between FMR and the primary end point in patients with either a preserved or reduced EF. In conclusion, among patients with acute decompensated HF with a preserved or reduced EF, the association of FMR with adverse outcomes may differ between patients who had an ischemic or nonischemic origin of HF.

The Change in Body Weight During Hospitalization Predicts Mortality in Patients With Acute Decompensated Heart Failure

Background

In our experience, the change in body weight (BW) during hospitalization varies greatly in patients with acute decompensated heart failure (HF). Since the clinical significance of a change in BW is not clear, we investigated whether a change in BW could predict mortality.

Methods

We retrospectively enrolled 130 patients (72 males; aged 68 ± 10 years) who were hospitalized due to acute decompensated HF and followed for 2 years after discharge. The change in the BW index during hospitalization (ΔBWI) was calculated as (BW at hospital admission minus BW at hospital discharge)/body surface area at hospital discharge.

Results

The patients were divided into quartiles according to ΔBWI, and the 2-year mortality rates in the quartiles with the lowest, second, third and highest ΔBWI were 18.8%, 12.1%, 3.1% and 9.1%, respectively. In a multivariate Cox proportional hazards analysis after adjusting for variables with a P value less than 0.05, ΔBWI was independently associated with 2-year mortality (P = 0.0002), and the quartile with the lowest ΔBWI had a higher relative risk (RR) for 2-year mortality than the quartile with the highest ΔBWI (RR: 7.46, 95% confidence interval: 1.03 - 53.99, P = 0.04).

Conclusion

In conclusion, ΔBWI was significantly associated with 2-year mortality after discharge, which indicates that ΔBWI might be a simple predictor of prognosis in acute decompensated HF.

A Rare Case of Biphasic Malignant Peritoneal Mesothelioma with Refractory Ascites

An 81-year-old man was admitted to our hospital with abdominal distension due to refractory ascites of unknown origin. He subsequently died of aspiration pneumonia. Autopsy revealed a diagnosis of biphasic malignant peritoneal mesothelioma (MPM) containing both epithelioid and sarcomatous components. The diagnosis of MPM is often difficult because serum tumor markers, imaging studies, and the cytology of ascites may not provide enough information. Accordingly, peritoneal biopsy is necessary in order to diagnose MPM based on the histological and immunohistochemical findings.

Acute Myocardial Infarction in a 26-Year-Old Patient With Familial Hypercholesteremia

A 26-year-old male suffered sustained chest pain. Electrocardiogram showed ST-segment elevation in the anteroseptal wall and reciprocal ST-segment change in the inferior wall. The troponin-I level and the white blood cell count were elevated. We gave a diagnosis of acute myocardial infarction. He underwent urgent coronary angiography, which revealed 90% diffuse stenosis in the middle right coronary artery and total occlusion in the proximal left anterior descending coronary artery (LAD). Since the electrocardiogram indicated that the culprit lesion was in the proximal LAD, we performed percutaneous coronary intervention. The coronary flow in the LAD was classified as thrombolysis in myocardial infarction trial 3. His coronary risk factors were obesity, smoking, family history, hypertension and diabetes, in addition to heterozygous familial hypercholesteremia (FH). Herein, we describe the case of a young patient with acute anteroseptal myocardial infarction and discuss the potential importance of controlling cholesterol levels in FH.

A case of cell-free and concentrated ascites reinfusion therapy effective for refractory ascites in spontaneous bacterial peritonitis in a renal transplant patient

A 58-year-old Japanese male with chronic hepatitis C underwent kidney transplantation from an unrelated donor in October 1998. In December 2004, the patient was admitted for spontaneous bacterial peritonitis (SBP). Abdominal paracentesis and albumin transfusion were performed, but control of ascites was poor. A randomized, controlled study of patients with SBP showed that patients receiving cefotaxime with a high-volume albumin transfusion (50–75 g/50 kg) were significantly less likely to have irreversible renal failure and had lower mortality. Japan, however, relies on imports for 70% of its albumin formulations, which complicates high-volume albumin transfusion. Consequently, albumin transfusion is often limited to single treatments in the range of only 25 g (25%, 100 ml). A single cell-free and concentrated ascites reinfusion therapy (CART) treatment can reinfuse approximately 60 g of albumin, corresponding to a high-volume albumin transfusion capable of reducing the associated risk of infection or allergic reaction. Though this case was an SBP patient, after the ascites were found to be negative for endotoxins, CART was performed, and control of ascites was achieved without observation of fever, hypotension, or other adverse effects. CART provides greater supplementation of albumin than albumin transfusion and can be an effective modality of treatment for hypoalbuminemia in SBP patients if ascites are negative for endotoxins.

Production of beta-mannanase and beta-mannosidase from Aspergillus awamori K4 and their properties

beta-Mannanase and beta-mannosidase from Aspergillus awamori K4 was produced by solid culture with coffee waste and wheat bran. The optimum composition for enzyme production was 40% coffee waste-60% wheat bran. Two enzymes were partially purified. Optimum pH was about 5 for both enzymes, and optimum temperature was around 80 degrees C for beta-mannanase and 60-70 degrees C for beta-mannosidase. These enzymes produced some oligosaccharides from glucomannan and galactomannan by their hydrolyzing and transferring activities. beta-Mannanase hydrolyzed konjak and locust bean gum 39.1% and 15.8%, respectively. Oligosaccharides of various molecular size were released from glucomannan of konjak, but on the addition of cellulase, mannobiose was released selectively. In locust bean gum, tetra-, tri-, and disaccharides (mannobiose) were mainly released by K4 beta-mannanase. Tetra- and trisaccharides were heterooligosaccharides consisting of galactose and mannose residues. K4 beta-mannosidase had a transglycosylation action, transferring mannose residue to alcohols and sugars like fructose.

Usefulness of thyrotropin (TSH)-releasing hormone test and nocturnal surge of TSH for diagnosis of isolated deficit of TSH secretion

Six patients with idiopathic isolated deficit of TSH secretion were examined and reported on. Their clinical symptoms and routine biochemical data were unclear and were not specific for hypothyroidism. Serum triiodothyronine, free thyroxine and TSH levels were slightly low or low-normal. Basal metabolic rate and thyroidal (123)I-uptake were also slightly low or low-normal. The response of serum TSH to TRH stimulation was blunted in all patients. No nocturnal surge of serum TSH level could be seen in any of the patients. Empty sella was revealed in three patients, and pituitary microadenoma in one patient via magnetic resolution imaging. Antihuman pituitary cytosol antibody was seen in five patients. Autoimmunity may have played a role in the pathogenesis of idiopathic isolated TSH deficiency. Routine examination of thyroid function cannot easily detect this disease. TSH response to TRH stimulation and nocturnal surge of TSH should be examined when this disease is suspected.

Pretreatment with ammonia water for enzymatic hydrolysis of corn husk, bagasse, and switchgrass

Bagasse, corn husk, and switchgrass were pretreated with ammonia water to enhance enzymatic hydrolysis. The sample (2 g) was mixed with 1-6 mL ammonia water (25-28% ammonia) and autoclaved at 120 degreesC for 20 min. After treatment, the product was vacuum-dried to remove ammonia gas. The dried solid could be used immediately in the enzymatic hydrolysis without washing. The enzymatic hydrolysis was effectively improved with more than 0.5 and 1 mL ammonia water/g for corn husk and bagasse, respectively. In bagasse, glucose, xylose, and xylobiose were the main products. The adsorption of CMCase and xylanase was related to the initial rate of enzymatic hydrolysis. In corn husks, arabinoxylan extracted by pretreatment was substantially unhydrolyzed because of the high ratio of arabinose to xylose (0.6). The carbohydrate yields from cellulose and hemicellulose were 72.9% and 82.4% in bagasse, and 86.2% and 91.9% in corn husk, respectively. The ammonia/water pretreatment also benefited from switchgrass (Miscanthus sinensis and Solidago altissima L.) hydrolysis.

Hypervascular liver metastasis from hypovascular ductal cell carcinoma of the pancreas

In a case of hypervascular metastatic liver tumor, the vascularity of primary focus, pancreatic carcinoma was hypovascular. Based on the imaging findings, we thought before the operation that the two lesions were double cancers. Histological examination showed that the stromal volume of metastatic tumorous tissue was richer than that of the primary focus. It was suggested that the difference in the stromal volume was related to the difference of the vascularity. Some foctors originating in stromal cells might be involved in angiogenesis.

Undefined complications of parathyroid adenoma, parathyroid hyperplasia (primary hyperparathyroidism), thyroid follicular adenoma, thyroid papillary carcinoma, temporal astrocytoma, cerebellar meningioma, and hemangioma of external auditory meatus and oral papilloma

A 59-year-old woman who had parathyroid adenoma, parathyroid hyperplasia, thyroid follicular adenoma, thyroid papillary carcinoma, astrocytoma of the right temporal lobe, cerebellar meningioma, capillary hemangioma of the left external auditory meatus and papilloma of the left upper gingiva is reported. Dynamic magnetic resonance imaging, computed tomography with contrast-enhancement and gastrofiberscopy revealed no remarkable findings in the pituitary, pancreas, adrenals, stomach or duodenum. Similar lesions were not found in any family members. Defect of the causative genes of multiple endocrine neoplasia types I and IIa, MENIN and RET was not detected. Further follow-up of this patient and family members is needed.

Properties of chitosanase from Bacillus cereus S1

Chitosanase from Bacillus cereus S1 was purified, and the enzymatic properties were investigated. The molecular weight was estimated to 45,000 on SDS-PAGE. Optimum pH was about 6, and stable pH in the incubation at 40 degrees C for 60 min was 6-11. This chitosanase was stable in alkaline side. Optimum temperature was around 60 degrees C, and enzyme activity was relatively stable below 60 degrees C. The degradations of colloidal chitosan and carboxymethyl cellulose (CMC) were about 30 and 20% relative to the value of soluble chitosan, respectively, but colloidal chitin and crystalline cellulose were not almost hydrolyzed. On the other hand, S1 chitosanase adsorbed on colloidal chitin completely and by about 50% also on crystalline cellulose, in contrast to colloidal chitosan, which it did not adsorb. S1 chitosanase finally hydrolyzed 100% N-deacetylated chitosan (soluble state) to chitobiose (27.2%), chitotriose (40.6%), and chitotetraose (32.2%). In the hydrolysis of various chitooligosaccharides, chitobiose and chitotriose were not hydrolyzed, and chitotetraose was hydrolyzed to chitobiose. Chitobiose and chitotriose were released from chitopentaose and chitohexaose. From this specificity, it was hypothesized that the active site of S1 chitosanase recognized more than two glucosamine residues posited in both sides against splitting point for glucosamine polymer.

Reduction of plasma gonadotropin levels and pituitary tumor size by treatment with bromocriptine in a patient with gonadotropinoma

A pituitary tumor with suprasellar extension was found by magnetic resonance imaging (MRI) in a male with diabetes mellitus. Endocrine examination revealed high plasma follicle-stimulating hormone (FSH) and alpha-subunit levels, which increased with administration of thyrotropin (TSH)-releasing hormone (TRH). Plasma luteinizing hormone (LH) and testosterone levels were low. Pituitary gonadotropin producing tumor was diagnosed. Because the patient refused surgery, bromocriptine was administered and plasma FSH and alpha-subunit rapidly decreased; on MRI the tumor size was gradually reduced. When pituitary operation is not feasible, bromocriptine is one choice of treatment.

Extrahepatic biliary cystadenocarcinoma arising from the left hepatic duct

A 54-year-old man, who had no clinical symptoms, underwent a routine health checkup at our hospital. Abdominal ultrasonography disclosed a well demarcated tumor containing a solid portion occupying the dilated left hepatic duct and a cystic portion expanding into the parenchyma of the left hepatic lobe, with mild dilatation of the intrahepatic bile ducts. These findings were later confirmed by computed tomography (CT) and magnetic resonance imaging. Endoscopic retrograde cholangiography revealed a complete defect at the level of the left hepatic duct, while drip infusion cholangiographic-CT (DIC-CT) disclosed a defect of the left hepatic duct only, with the distal portions of the left intrahepatic ducts being visualized on the image. Hepatic angiography revealed light stains in the solid portion in the parenchymal phase. At left lobectomy, a multiloculated polyp-like tumor was found arising from the left hepatic duct and expanding into the parenchyma of the left hepatic lobe. Microscopically, all the lining cells in the cysts and the tumor cells in the solid portion showed the features of papillary adenocarcinoma. In this patient with extrahepatic biliary cystadenocarcinoma, DIC-CT was useful in identifying the site of origin of the tumor, and hepatic angiography was also useful in differentiating this rare malignant tumor from benign cystadenoma.

Panhypopituitarism due to Rathke's cleft cyst associated with pituitary oncocytoma

A 38-year-old male with panhypopituitarism due to Rathke's cleft cyst associated with a pituitary oncocytoma is reported. The presenting signs were general myalgia and slight fatigue. Endocrine examinations revealed panhypopituitarism. Magnetic resonance imaging disclosed a suprasellar cystic lesion of the pituitary gland. Cytological examination demonstrated ciliated cells in the mucinous fluid flowing from the cyst during the pituitary operation. A pituitary oncocytoma with randomly scattered S-100 immunoreactive cells was found upon histologic examination of the nodular tissue curettaged from the internal wall of the cyst. These results suggest that the pituitary adenoma was derived from folliculostellate cells included in the Rathke's cleft wall.

Idiopathic and spontaneously regressing thrombus in right renal vein and inferior vena cava

We present the case of a 57-year-old woman with a thrombus in the right renal vein and the inferior vena cava that disappeared spontaneously during 6 months of observation. She had no thrombus-related disease such as kidney cancer, dehydration, multiple myeloma, nephrotic syndrome, or abnormal coagulability. While various examinations were being performed over a 2 month period the thrombus regressed spontaneously. After 6 months of follow-up the thrombus could not be seen on abdominal computerized tomography scan. Twenty months after disappearance of the thrombus the patient is doing well and has no recurrence of thrombus.

Thyrotropin-producing pituitary adenoma discovered as a pituitary incidentaloma

A 46-year-old woman with incidentally discovered thyrotropin (TSH)-producing pituitary adenoma showed endocrine data which was consistent with TSH-producing pituitary tumor. However, she showed only slight hyperthyroidism and the oversecretion and autonomous secretion of TSH from the tumor seemed to be limited from the results of several endocrine examinations. Immunohistochemical examination revealed that not only TSH-beta and TSH-alpha but also prolactin and growth hormone synthesizing cells were present in the tumor tissue. Pituitary-transcription activator 1 (Pit-1) immunoreactivity was also detected in the adenoma cell nuclei. It was conceivable that the presented TSH-producing adenoma clinically located close to the non-functioning adenoma and Pit-1 may have played an important role in the multidirectional differentiation or development of this tumor.

Evaluation of thyroid function in patients with thyroid hormone autoantibodies

Serum free thyroxine (FT4) levels were measured in patients with Hashimoto's thyroiditis and Graves' disease who were seropositive for thyroid hormone autoantibodies. The methods used were equilibrium dialysis/radioimmunoassay (FT4 by equilibrium dialysis, Nichols Institute) and FT4 analog radioimmunoassay (Amerlex MFT4) before and after treatment of sera with 12.5% polyethylene glycol (PEG). Furthermore, FT4 measurement in the PEG-treated sera was done using two other analog radioimmunoassays (DPC FT4 Kit and N-FT4 Corning). Serum thyrotropin (TSH) concentration before and after i.v. infusion of thyrotropin releasing hormone (TRH) was measured in five cases of Hashimoto's thyroiditis and four cases of Graves' disease with thyroid hormone autoantibodies. Although FT4 determination by analog tracer radioimmunoassays showed unusually high values for the hormone, results obtained by an equilibrium dialysis/radioimmunoassay method showed compatible values with basal TSH. Furthermore, FT4 concentrations measured with Amerlex MFT4 after treatment of sera with 12.5% PEG, correlated well with the values obtained by equilibrium dialysis/radioimmunoassay (r = 0.98, P < 0.001). Similar results were obtained with two other analog FT4 radioimmunoassays after treatment of sera with PEG. These results indicate that real FT4 values in patients with thyroid hormone autoantibodies are compatible with basal TSH concentrations. The presence of thyroid hormone autoantibodies per se does not affect the control mechanism of the hypothalamo-pituitary-thyroid axis. It was concluded that measurement of basal TSH as well as FT4 values by either equilibrium dialysis/radioimmunoassay or analog radioimmunoassays after PEG treatment provides clinicians with valid information for assessment of the precise status of thyroid function in patients with thyroid hormone autoantibodies.

Biological activities of rat antisera raised against synthetic peptides of human thyrotropin receptor

Twenty three male Wistar rats were divided into five groups and were immunized with five overlapping synthetic peptides (Group I (n = 5), peptide 12-30; Group II (n = 5), 24-44; Group III (n = 4), 308-328; Group IV (n = 5), 324-344; and Group V (n = 4), 339-364) of human thyrotropin receptor (TSHR), which had been conjugated with rabbit serum albumin. Sera obtained 34 days after the first immunization were investigated for their ability to displace 125I-TSH binding to thyrotropin receptor (thyrotropin binding inhibitor immunoglobulins (TBII)). In addition, biological activity, namely thyroid stimulating (TSAb) or blocking (TSBAb) activities in them were tested with cultured porcine thyroid cells. TBII activities in Group I, II, III, IV, and V rats were 12.6 +/- 4.1% (range 9.2-17.2%), 16.3 +/- 4.0% (range 11.7-22.0%), 16.7 +/- 4.9% (range 13.2-20.1%), 14.5 +/- 5.7% (range 8.1-19.0%), and 13.8 +/- 6.3% (range 8.1-14.3%), respectively, which were not significantly different from control rat sera (12.3 +/- 6.7%, range 1.2-20.1%). TSAb activities in Group I, II, III, IV, and V rats were 608 +/- 675% (range 275-1813%), 234 +/- 26% (range 209-265%), 313 +/- 175% (range 187-568%), 190 +/- 63% (range 145-301%), and 134 +/- 24% (range 107-158%), respectively. TSAb activities in Group I, II, III, and IV rats were significantly higher than those from control rat sera (P < 0.01) while those of Group V were not significantly different from control rat sera. None of the rats in each group exhibited TSBAb activity.(ABSTRACT TRUNCATED AT 250 WORDS)

A case of hypothyroidism with simultaneous presence of stimulating type anti-thyrotropin (TSH) receptor antibodies and anti-thyroxine (T4) autoantibodies

We have examined a hypothyroid patient with stimulating type anti-thyrotropin (TSH) receptor antibodies and without blocking type anti-TSH receptor antibodies. Although she had high serum TSH (240 microU/ml) and low free triiodothyronine (FT3, 0.49 pg/ml) concentrations, which agree with physical findings of hypothyroidism, she had an unusually high free thyroxine (FT4) concentration (3.56 ng/dl). Incubation of her serum with 125I-T4, followed by precipitation with 12.5% polyethylene glycol (PEG) disclosed a higher binding of 125I-T4 (34.4%) than in normal controls, being 5-7%. In addition, binding of 125I-T4 to her serum gamma-globulin was completely displaced by the addition of unlabelled T4. From these results it was concluded that her serum contained anti-T4 autoantibodies. Treatment with synthetic T4 was begun and her thyroid function was monitored by sensitive TSH radioimmunoassay (RIA) and RIA of FT4 after PEG treatment. Since both sensitive TSH RIA and FT4 RIA results after PEG treatment give results concordant with the physical findings, it was concluded that both of the RIA results are useful for the evaluation of thyroid function in patients with thyroid hormone autoantibodies.

A case of papillary carcinoma of the thyroid associated with parathyroid adenoma without hyperparathyroidism

A rare occurrence of the association of parathyroid adenoma in a case of thyroid papillary carcinoma is described. The patient was incidentally found to have parathyroid adenoma which was preoperatively diagnosed to be a metastatic lymph node. Analysis of her serum obtained before operation showed an elevation of serum parathyroid hormone (PTH) concentration without hypercalcemia. Since the association of hyperparathyroidism is high in patients with thyroid diseases, examination of not only serum levels of calcium and PTH but also careful interpretation of computed tomography (CT) and/or nuclear magnetic imaging (MRI) is necessary in the diagnosis of co-existing asymptomatic hyperparathyroidism.

Serum ferritin concentration in subacute thyroiditis

Serum concentration of ferritin was measured in 20 patients (19 women, one man) with untreated (thyrotoxic phase) subacute thyroiditis, 32 patients (21 women, 11 men) with untreated Graves' disease, 17 patients (all women) with euthyroid Hashimoto's thyroiditis, 12 patients (all women) with hepatitis A (HAV), eight patients (all women) with pneumonia, and 59 normal controls (30 women, 29 men). In female patients with subacute thyroiditis, the serum concentration of ferritin was 163.6 +/- 116.3 micrograms/L (after log transformation, 2.12 +/- 0.31 micrograms/L, mean +/- SD), which was significantly higher than values in female Graves' disease (P less than .05), Hashimoto's thyroiditis (P less than .001), pneumonia (P less than .05), and healthy subjects (P less than .001), being 97.9 +/- 71.9 micrograms/L (after log transformation, 1.85 +/- 0.42 micrograms/L), 51.6 +/- 53.0 micrograms/L (after log transformation, 1.48 +/- 0.50 micrograms/L), 88.2 +/- 56.3 micrograms/L (after log transformation, 1.86 +/- 0.30 micrograms/L), and 25.2 +/- 7.4 micrograms/L (after log transformation; 1.16 +/- 0.10 micrograms/L), respectively, but was not significantly different with HAV, being 368.3 +/- 514.0 micrograms/L (after log transformation, 2.32 +/- 0.47 micrograms/L). In a male with subacute thyroiditis, the serum concentration of ferritin was 521.8 micrograms/L (after log transformation, 2.72 micrograms/L), which was higher than +/- 3 SD and +/- 1 SD of the levels in healthy males (93.0 +/- 55.9 micrograms/L; after log transformation, 1.89 +/- 0.27 micrograms/L) and male Graves' disease patients (257.0 +/- 195.5 micrograms/L; after log transformation, 2.28 +/- 0.38 micrograms/L), respectively. Elevated serum ferritin concentration significantly declined with treatment by either aspirin or prednisolone (paired t test, P less than .001).(ABSTRACT TRUNCATED AT 250 WORDS)

Thyroid hormone metabolism and nuclear binding in Gunn rats

We examined the serum concentrations of total, free thyroid hormones and TSH, activity of hepatic T4 5'-deiodinase, and T3 binding to hepatic nuclei in homozygous (j/j) and heterozygous (j/+) Gunn rats. Both total T3 and free T3 (FT3) concentrations in sera from j/j rats were significantly lower than those of j/+ rats on 5-10, 15-20, and 25-30 days after birth. Both total T4 and free T4 (FT4) concentrations in j/j and j/+ rat sera were not significantly different on 5-10 days. However, in j/j rats they were significantly higher than those of j/+ rats on days 15-20 and 25-30. Serum reverse T3 (rT3) concentrations were higher in j/j than in j/+ rats on days 5-10, 15-20, and 25-30. Serum TSH concentration in j/j and j/+ rats on 15 days post-natal were 1.42 +/- 1.28 and 1.65 +/- 1.24 micrograms/l (mean +/- SD), respectively, which were not significantly different from each other. T3 formation from T4 in hepatic microsomal fractions obtained 15 days after birth was significantly lower in homozygotes than in heterozygotes (4.89 +/- 1.18 vs 11.15 +/- 2.38 pmol/mg protein/min, p less than 0.005). Binding constants (Ka) as well as maximal binding capacities (MBC) for T3 of hepatic nuclei from 15 day-old j/j and j/+ rats were similar (ka; 3.58 x 10(9) vs 3.15 x 10(9) M-1, MBC; 0.316 vs 0.380 pmol/mg DNA). From these results we suggest that decreased conversion from T4 to T3 is one of the major reasons for high serum levels of T4 and rT3, and low levels of T3 in j/j rats, and that nuclear T3 binding and pituitary TSH secretion are unaltered in j/j rats.

Immunogenetic study of thyroid hormone autoantibodies in a family

Haplotypes of the human major histocompatibility complex (HLA) and immunoglobulin G heavy chain allotype (Gm) were determined in nine members of a family in which three sisters had thyroid hormone autoantibodies (THAA) in serum. Among three sisters with THAA, two of them were hypothyroid and treated with synthetic thyroid hormones (patients nos. 1 and 2). The other remaining sister (patient no. 3) was euthyroid. Light chain allotype (Km) in them was also examined. Three patients had the same two Gm haplotypes. Km (1) allotype was negative in these three patients. HLA haplotypes of patient no. 1 were the same as those of patient no. 2. However, HLA haplotypes of patient no. 3 were completely different from those of patients nos. 1 and 2. The same combination of Gm haplotypes and the absence of Km (1) allotype were not observed in the remaining members without THAA. These results suggest that genes linked to Gm and Km allotypes are associated with the production of THAA at least in our patients.

Binding of thyroid hormones to human hemoglobin and localization of the binding site

Radiolabeled thyroid hormones were allowed to bind to erythrocyte cytosol and the complex was fractionated by Sephadex G-100 or by high-performance liquid chromatography (HPLC). On Sephadex G-100, four radioactive peaks (P1-P4) were obtained, whereas HPLC gave only three radioactive peaks (P1-P3). Chromatographic studies with human adult Hb and non-Hb cytosol protein fractions, which had been reacted with radiolabeled thyroid hormones, and immune precipitation with specific antisera for the hormones, confirmed that the first peak of Sephadex G-100 radioactivity was a mixture of Hb and non-Hb proteins, while the second peak was Hb. The third peak was free 125I and the fourth peak was unbound 125I-T3 or 125I-T4. The third peak of HPLC was confirmed to be a mixture of free 125I and unbound radiolabeled thyroid hormones. Scatchard analysis of the interaction between T4 and apo-Hb, and the alpha- and beta-chains of human Hb suggested the presence of the specific binding site(s) for the hormone. Interaction between T4 and synthesized peptides, which constitute the heme pocket of the beta-chain of Hb (beta 61-75, beta 71-85, beta 81-95), indicated that the T4 binding site of Hb resides within the heme-binding cavity. It is concluded that human erythrocyte cytosol does not contain "receptor" for thyroid hormones and cannot be a model for studying functions of cytosol "receptor" for the hormones; rather, it contains binding protein with large binding capacity, including Hb and non-Hb proteins, which possibly constitute a large reservoir for the hormone in blood.

Two cases of Graves' disease with antithyroid hormone antibodies: implication on the role of thyroglobulin as an antigen

We have experienced two cases of Graves' disease with antithyroid hormone autoantibodies (Case 1: anti-T4; Case 2: anti-T3) who finally underwent subtotal thyroidectomy after antithyroid drug treatment. Using serial sera obtained before and after operation, the correlation between titers of antithyroglobulin (anti-Tg) and anti-T4 or anti-T3 autoantibodies was examined in each case. There was a significant positive correlation between titers of anti-T4 (Case 1, r = 0.90, p less than 0.05), or anti-T3 (Case 2, r = 0.64, p less than 0.01) and anti-Tg antibodies. Using the homogenate of the thyroid tissue, it was found that the sole iodoprotein in the thyroid gland in each patient was 660 KDa Tg. In addition, Tg purified from the thyroid gland from Case 2 showed different immunological activity with normal Tg in two out of four murine monoclonal anti-Tg antibodies tested. On the other hand, Tg from Case 1 had identical immunological activity with normal Tg in every four monoclonal antibodies. These results are consistent with the view that the antigen responsible for the development of antithyroid hormone autoantibodies is Tg, at least in our two cases. The reason for the persistence of anti-T3 autoantibodies in Case 2, despite the subtotal thyroidectomy, could be due to some unidentified structural abnormalities of Tg which was detected only by the monoclonal anti-Tg antibodies.

Thyroxine binding to human serum albumin immobilized on sepharose and effects of nonprotein albumin-binding plasma constituents

125I-thyroxine (125I-T4) binding to human serum albumin (HSA) covalently attached onto CNBr-activated Sepharose (HSA-Sepharose) was studied. 125I-T4 binding to HSA-Sepharose was rapid and saturable. Nonlinear curve-fitting analysis of binding isotherms revealed two classes of binding sites. The values of dissociation constants of high and low affinity sites were 2.19 +/- 0.53 x 10(-6) M and 2.69 +/- 0.78 x 10(-5) M, respectively. The number of binding sites of the high and the low affinity sites were 1.28 +/- 0.46 mol/mol and 23.5 +/- 9.7 mol/mol of HSA, respectively. Fatty acids and bilirubin competitively inhibited the high-affinity binding of 125I-T4 to HSA-Sepharose without affecting the low-affinity binding. 8-anilino-1-naphthalene sulfonic acid (ANS) inhibited the high affinity T4 binding via reduction of the binding capacity. Unlabeled T4 showed little inhibition of ANS binding to HSA, as measured by fluorescence intensity. These results suggest that ANS allosterically inhibits the high-affinity T4 binding to HSA-Sepharose.

[Two cases of Graves' disease with anti-thyroid hormone autoantibodies: the effect of subtotal thyroidectomy on the titers of anti-thyroid hormone autoantibodies and anti-Tg antibodies]

We experienced two cases of Graves' disease associated with anti-thyroid hormone autoantibodies (Case 1: anti-T4, Case 2: anti-T3). Both cases underwent subtotal thyroidectomy, and titers of anti-thyroid hormone antibodies and anti-Tg antibodies were compared before and after operation. In case 1, titers of both anti-T4 and anti-Tg antibodies decreased after operation, whereas in Case 2, titers of both anti-T3 and anti-Tg were unchanged before and after operation. There was a significant positive correlation between titers of anti-T4 and anti-Tg antibodies in Case 1 (r = 0.90, P less than 0.01), and anti-T3 and anti-Tg antibodies in Case 2 (r = 0.64, P less than 0.01). These results strengthen the possibility that the antigen of anti-thyroid hormone autoantibodies in both cases is the Tg molecule.

Effect of 8-anilino-1-naphthalene sulfonic acid (ANS) on the interaction between thyroid hormone and anti-thyroid hormone antibodies

Effect of 8-anilino-1-naphthalene sulfonic acid (ANS) on the interaction between thyroid hormone and anti-thyroid hormone antibodies was examined. Addition of 5.1 x 10(6) or 6.3 x 10(6) molar excess of ANS, respectively, enhanced the binding of 125I-T3 or 125I-T4 to their respective autoantibodies. However, further increase in ANS concentration resulted in a decrease in binding. These results suggest that the optimum concentration of ANS for the detection of anti-thyroid hormone antibodies is 5 approximately 6 x 10(6) molar excess of ANS to 125I-T3 or 125I-T4. On the other hand, addition of 10(4) molar excess of ANS concentration decreased the binding of 125I-insulin to anti-insulin antibodies. It was therefore suggested that the effect of ANS could be a nonspecific one and likely due to its negative charge.

[Changes in anti-thyroid hormone and anti-thyroglobulin antibodies during thyroid hormone(s) or prednisolone treatments in 3 cases of Hashimoto's thyroiditis]

We have experienced 3 cases of Hashimoto's thyroiditis with anti-thyroid hormone antibodies. Changes in titers of anti-thyroglobulin(Tg) and anti-thyroid hormone antibodies during 6 year (Cases 1 and 2) and 7 year (Case 3) observation periods were examined in each case. Cases 1 (13-year-old) and 2 (10-year-old) are sisters with hypothyroidism whose chief complaint was short stature. They were diagnosed as having Hashimoto's thyroiditis by needle biopsy of the thyroid gland. Presence of anti-thyroid hormone antibodies were found in the sera of both cases (Case 1: anti-thyroxine(T4) antibodies, Case 2: anti-triiodothyronine(T3) antibodies). They were treated with synthetic T4 or combined therapy of T3 and T4, and serial sera obtained during the 6 year treatment period were tested for the titers of anti-Tg and anti-thyroid hormone antibodies. Case 3 (23-year-old female), who was diagnosed as having Hashimoto's thyroiditis associated with systemic lupus erythematosus (SLE) and Sjögren's syndrome had been treated with prednisolone(PSL) for 8 years. After one year of strating the treatment, she was found to have unusually low serum T3 measured by radioimmunoassay. Further examination revealed the presence of anti-T3 antibodies in her serum. Serial sera obtained during the 7 year observation period were tested for the titers of anti-Tg and anti-T3 antibodies. In cases 1 and 2, replacement therapy with thyroid hormone resulted in the decrease of titers of anti-thyroid hormone antibodies. In addition, increase in serum TSH concentrations was accompanied with increased titers of anti-Tg and anti-thyroid hormone antibodies in all 3 cases. The exact mechanism for it is not clear.(ABSTRACT TRUNCATED AT 250 WORDS)

[Fluctuations in the titers of anti-thyroid hormone and anti-thyroglobulin antibodies in 4 cases of Graves' disease during long-term treatment period]

We studied 4 cases of Graves' disease with anti-thyroid hormone antibodies. Changes in the serum levels of triiodothyronine(T3), thyroxine(T4), free T4, thyrotropin(TSH), and thyroglobulin(Tg), as well as titers of anti-Tg antibodies, anti-thyroid hormone antibodies, anti-TSH receptor antibodies(TRAb) and anti-microsomal antibodies(MCHA) during 2 10 years' treatment periods were examined in each case. Case 1; A woman, who was diagnosed as having Graves' disease when she was 10 years old, had been treated with methimazole(MMI) or propylthiouracil(PTU). Treatment with the antithyroid drug had been discontinued by herself when she was 19 years old until she was 24 years old, when she was pregnant and consulted our hospital. Since her serum levels of T3 were unusually high, examination of her serum for the presence of anti-T3 antibodies was done. The presence of anti-T3 antibodies in her serum was confirmed. Case 2; A woman, who was diagnosed as having Graves' disease at the age of 41, had been treated with MMI or PTU. Presence of serum anti-T3 antibodies was found in a screening test for the antibodies. Serial sera were obtained during the 5 year observation period when she was treated with MMI, PTU, and subtotal thyroidectomy. Titers of anti-Tg antibodies in her sera were in the normal range. Case 3; A woman, who was diagnosed as having Graves' disease at the age of 11, had been treated with MMI or PTU. Presence of anti-T3 and anti-T4 antibodies were found in her sera in a screening test. Serial sera obtained during the 4 year treatment period were tested. Case 4; A woman, who was diagnosed as having Graves' disease at the age of 14, had been treated with MMI. Presence of anti-T3 and anti-T4 antibodies was found in her sera in a screening test. Serial sera obtained during the 2 year treatment period were tested. Titers of anti-Tg were increased when the levels of TSH or titers of TRAb were increased. The results suggested that TSH and TRAb, which are thyroid stimulating substances, increased serum levels of Tg, which resulted in the increase of titers of anti-Tg. Because of the possibility that administration of PSL could modify B lymphocyte functions, periods during which PSL was administered were excluded from the examination of the correlation between Tg concentrations or titers of anti-Tg and titers of anti-thyroid hormone antibodies, as in Cases 2 and 4, respectively.(ABSTRACT TRUNCATED AT 400 WORDS)

Thyroid hormone autoantibodies (THAA) in three sisters: a four-year follow up

We have found three sisters who had thyroid hormone autoantibodies (THAA) in serum. Two of them were hypothyroid due to Hashimoto's thyroiditis. They were treated with synthetic thyroxine (T4) (Case 1) or T4 and triiodothyronine (T3) (Case 2). The other sister (Case 3) was euthyroid throughout the investigation period. Changes in the titers of THAA, antithyroglobulin (Tg) antibodies as well as in the concentrations of thyrotropin (TSH), and total and free thyroid hormones (T3, T4, FT3, and FT4) in sera from each patient were examined for four years. A significant positive correlation was observed between titers of THAA and anti-Tg antibodies in both Case 1 (anti-T3 and anti-T4) and 2 (anti-T4). On the other hand, a significant negative correlation between titers of anti-T3 and anti-Tg antibodies was observed in Case 3. These results suggest that antigen of THAA might be Tg in Case 1 and 2 and mechanism(s) of the production of THAA of Case 1 might be different from that of Case 1 and 2 in terms of their antigen or immune recognition of Tg.