- Email: [email protected]
RENAL DEPOSITION OF CYTOMEGALOVIRUS ANTIGEN IN IMMUNOGLOBULIN-A NEPHROPATHY
11
well as FIS and VAS, (2) using a midphase interval of 4 weeks without medication, measurements of plasma concentration of mexiletine, and subjective and objective assessments before the mexiletine and placebo phases; and (3) escalating the dose of tablets during both treatment with mexiletine and on placebo and using low doses of mexiletine. Mexiletine is a promising treatment for chronic painful diabetic neuropathy. REFERENCES
6
Kastrup J, Petersen P, Dejgard A, Hilsted J, Angelo HR Treatment of chronic painful diabetic neuropathy with intravenous lidocaine infusion Br Med J 1986, 292: 173
7. Editorial. Tocainide and mexilitine—orally effective lidocaine analogues Arch Intern Med 1985, 145: 417-18. 8 Petersen P, Kastrup J. Dercum’s disease (adipositas dolorosa) Treatment of the severe pain with intravenous lidocaine. Pain 1987; 28: 77-80 9. Lindstrøm P, Lindblom U The analgesic effect of tocainide in trigeminal neuralgia. Pain 1987; 28: 45-50. 10 Scott J, Huskisson EC Graphic representation of pain Pain 1976, 2: 175-85 11 Jersild M, Lauritzen E. Sensibilite vibratoire chez les diabetiques. Diabète 1957; 6: 237-41. 12 Hilsted J, Jensen SB. A simple test for autonomic neuropathy in juvenile diabetics
Acta Med Scand 1979; 205: 385-87 Quantative determination of hemoglobin A1c by thin-layer isoelectric focusing J Chromatogr 1980; 182: 325-33 14 Kelly R, Christmore D, Smith R, Doshir L, Jacobs SL Mexiletin in plasma by high pressure liquid chromatography Ther Drug Monit 1981; 3: 279-86. 15. Editorial. Pain perception in diabetic neuropathy Lancet 1985; i 83-84. 16. Strichantz G. Molecular mechanisms of nerve block by local anasthetics Anaesthestology 1976; 45: 421-41. 17 Prescott LF, Clements JA, Pottage A. Absorption, distribution and elementation of Mexilitine. Postgrad Med J 1977; 53: 50-55 18. Bak FW, Jensen TS, Sugsby B, Kastrup J, Dejgaard A The effect of systemic lidocaine on nociceptive processing in diabetics. Pain 1987; suppl 4: 388. 19. Wiesenfeld-Hallin Z, Lindblom U. The effect of systemic tocainide, lidocaine and bupivicane on nociception in the rat. Pain 1985, 23: 357-60.
I Kvinesdal B, Molin J, Freland A, Gram LF Imipramine treatment of painful diabetic neuropathy. JAMA 1984; 251: 1727-30. 2 Jaspan J, Maselli R, Herold K, Bartkus C Treatment of severely painful diabetic neuropathy with an aldose reductase inhibitor: relief of pain and improved somatic and autonomic nerve function. Lancet 1983; ii: 758-62. 3. Rull JA, Quibrera R, Gonzalez-Milan H, Castaneda OL. Symptomatic treatment of penpheral diabetic neuropathy with Carbarnarepine (Tegretol) Double-blind, cross-over trial. Diabetologia 1969, 5: 215-18. 4 Boulton AJM, Drury FJ, Clarke B, Ward JD Continuous subcutaneous insulin infusion in the management of painful diabetic neuropathy. Diabetes Care 1982, 5: 386-90 5. Morley GK, Mooradian AD, Levine AS, Morley JE. Mechanism of pain in diabetic peripheral neuropathy. Am J Med 1984; 77: 79-82.
13 Mortensen HB.
RENAL DEPOSITION OF CYTOMEGALOVIRUS ANTIGEN IN IMMUNOGLOBULIN-A NEPHROPATHY
were
MARTIN C. GREGORY M. ELIZABETH HAMMOND EILEEN D. BREWER
Department of Medicine, Pathology, and Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA Renal biopsy specimens from patients with various glomerular disorders were examined by indirect immunofluorescence microscopy with three different heterologous antibodies directed against cytomegalovirus and two heterologous antibodies against herpes simplex virus (HSV) type 1. All 31 samples from patients with immunoglobulin-A (IgA) nephropathy, 1 of 12 with systemic lupus erythematosus (SLE), and 1 of 5 with Henoch-Schönlein purpura (HSP) showed mesangial staining with cytomegalovirus antiserum, whereas no sample from 37 patients with other forms of
Summary
glomerulonephritis was positive. Antigens of herpes simplex virus I were demonstrated in samples from 4 of 31 patients with IgA nephropathy, 1 of 12 patients with SLE, 1 of 5 patients with HSP, and 1 of 37 patients with other glomerular diseases. The consistent finding of glomerular cytomegalovirus antigen in IgA nephropathy suggests but does not prove that the virus has a role in the aetiology of this disorder. Introduction
(IgA) nephropathy is a focal proliferative mesangial glomerulonephritis of unknown aetiology. Its prevalence differs in different geographical regions, but since its recognition in 1968,1 it has proved common.2.3 Nevertheless no convincing cause for the disorder has come to light. We have investigated glomerular deposition of antigens reacting with three different heterologous antisera against cytomegalovirus in renal biopsy samples from patients with IgA nephropathy. IMMUNOGLOBULIN-A
Methods All
non-transplant renal biopsy samples received at our medical between February, 1985, and March, 1987, from patients with IgA nephropathy, systemic lupus erythematosus (SLE), Henoch-Schonlein purpura (HSP), or hepatic glomerulosclerosis centre
examined for evidence of cytomegalovirus or herpes simplex antigen in the glomeruli. 37 control biopsy samples from patients with other glomerular disorders taken during the same period were similarly examined. Because all adult and paediatric nephrologists in Utah send their renal biopsy samples to a central pathology laboratory, it is likely that all samples from patients in Utah and a small but uncertain proportion from patients in adjacent States have been examined. virus
Biopsy samples were examined in detail by light microscopy, immunofluorescence microscopy, and electron microscopy by standard methods. The diagnosis of IgA nephropathy was made when samples showed mesangial cellular proliferation and expansion of matrix by light microscopy, IgA and C3 deposited in an exclusively mesangial distribution by immunofluorescence, and mesangial electron-dense deposits by electron microcopy. In all cases, the diagnosis was reached in consultation with the nephrologist. SLE was excluded by the absence of clinical or pathological criteria for that disorder. All biopsy samples in the study were subjected to staining with antiserum to cytomegalovirus. 4 µm frozen sections were cut from each block, and sections from each patient were stained with one or two of three different heterologous antibodies against cytomegalovirus (Polysciences, Lee Biomolecular, and Biogenex Laboratories) and one of two different heterologous antibodies against herpes simplex virus type I (Biogenex Laboratories or Flow Laboratories). The tissue was washed in phosphate-buffered saline for 1 h, incubated with primary antibody for 30 min, washed for 15 min in phosphate-buffered saline, and incubated with fluoresceinisothiocyanate-labelled IgG fractions of anti-goat or anti-rabbit antibody for 30 min. After a final 15 min wash, the slides were mounted in ’Elvanol’ and viewed in a Zeiss immunofluorescent microscope equipped with epifluorescence.. Positive controls included a case of fatal cytomegalovirus-induced hepatitis and a case of fatal encephalitis induced by herpes simplex virus I. Negative controls, simultaneously run, included frozen sections from patients with other renal disorders as well as test sections with the primary antibody omitted. Blocking studies with aggregated’ and unaggregated IgG were carried out on freshly frozen tissue from two patients with IgA nephropathy; both samples initially reacted with cytomegalovirus antiserum but not with anti-human IgG. Samples of human IgG (Capell Laboratories) were diluted to 0-5 mg/ml and aggregated by heating to 63°C for 20 min. The product was allowed to cool and refrigerated overnight. Frozen sections of renal biopsy samples from the two patients were incubated for 30 min at room temperature with either aggregated or native IgG, washed, reincubated with cytomegalovirus antiserum, and treated with fluoresceinated secondary reagent before microscopy. Control sections were incubated with fluoresceinated anti-human IgG after pretreatment with aggregated or unaggregated IgG.
12
,
PREVALENCE OF GLOMERULAR ANTIGENS IN PATIENTS WI’I’H
patients whose renal biopsy samples showed glomerular deposition of IgA and, or cytomegalovirus as well as those with diagnoses of HSP, SLE, or hepatic glomerulosclerosis were examined in detail. Where possible, patients were recalled to verify demographic data and to confirm that the clinical presentation agreed with the pathological diagnosis. Proportions were compared by chi-square testing. The
notes
of
VARIOUS GLOMERULAR DISORDERS
Results In 31 of 86 samples studied the pathological diagnosis was IgA nephropathy. All these patients had clinical histories consistent with the diagnosis of IgA nephropathy.25 8 were female and 23 male. Their ages ranged from 3 to 74 years (median 18 years). Besides mesangial hypercellularity and a focal or diffuse increase in mesangial matrix, there were variable degrees of global glomerulosclerosis and interstitial fibrosis in the biopsy samples depending on the duration and severity of the patient’s disease. By immunofluorsecence microscopy, mesangial deposition of IgA was shown in all 31 samples; IgG was present in 29, C3 in 30, and Clq in 12. All 31 patients showed mesangial deposits of cytomegalovirus in a distribution identical to those of IgA. 1 of 12 patients with SLE and 1 of 5 with HSP showed glomerular cytomegalovirus antigens in a distribution similar to that of IgA. The sole patient with hepatic glomerulosclerosis and IgA deposits had no cytomegalovirus antigen (see table). 37 patients with other primary and secondary glomerular disorders (table) -were examined. None had cytomegalovirus antigen in the glomeruli. The difference in the occurrence of cytomegalovirus between patients with IgA nephropathy and those with other glomerular disorders was highly
significant (table). In the blocking studies of two biopsy samples, aggregated or unaggregated IgG did not bind to mesangium. There was no competitive inhibition of the staining with cytomegalovirus antiserum in either biopsy sample after pretreatment with aggregated or unaggregated unlabelled IgG. 4 of 31 patients with IgA nephropathy and 1 of 36 with other glomerular disorders showed staining with antiserum against herpes simplex virus (table). This difference was not significant. The patient with SLE and the patient with HSP who had cytomegalovirus antigen in their glomeruli also had herpes simplex virus antigen. No diagnostic inclusion bodies were found by light microscopy in any of the biopsy samples. All samples were examined by electron microscopy; diagnostic virions were never seen in either tubules or glomeruli. Discussion of IgA nephropathy is not known. It is since it has become the commonest primary important, in nephropathy many regions of the world.z j Speculations about its aetiology have suggested a subtle derangement of immune regulation that permits the formation of Defects of in-vivo nephritogenic antigen-IgA reduced IgAand function,’ Fc-receptor C3b-receptor and increased serum specific suppressor-T-cell activity,’ have all been and be related observed polymeric IgA 9,10 may to these putative defects of immunity. Over twenty diseases have been reported in association with IgA nephropathy.11,12 With the exception of liver disease and HSP, none of these associations occurs sufficiently frequently to have causal significance. The relation between IgA nephropathy and HSP has long been debated. In our study, the discrepancy in the prevalence of cytomegalovirus antigen in the glomeruli The
cause
complexes. 26
*Membranous
nephropathy (6), mesangial proliferative glomerulonephritis mesangiocapillary glomerulonephritis (5), rapidly progressive glomerulonephritis (5), minimal change nephropathy (5), chronic glomerulonephritis (4), focal glomerulosclerosis (3), and vasculitis (3). CMV=cytomegatovirus; HSV-1= herpes simplex virus 1. For comparison with IgA nephropathy group: tp < 0 0005; tp < 0001. (6),
between these two disorders is evidence supporting different aetiologies. There are at least four possible explanations for the presence of cytomegalovirus antigen in the glomeruli of patients with IgA nephropathy. First, the staining of these deposits could be related to non-specific binding of cytomegalovirus antiserum in the glomeruli. This possibility is unlikely, since the binding of cytomegalovirus antibody was not associated with all deposits of IgA of the patients examined; there was no staining in most patients with SLE and HSP. Furthermore, identical results were obtained with three different heterologous antisera, and positive and negative controls always gave appropriate results. Patients with known cytomegalovirus infections have shown positive staining with the same heterologous antibodies; these controls included 3 patients with cytomegalovirus infections of the lung, 2 with cytomegalovirus infections of the kidney, and 3 with herpes simplex virus 1 infections of the brain. Control patients with non-IgA-associated disorders had uniformly negative results. Maggiore et al4 showed antiglobulin activity in the glomeruli of patients with essential mixed cryoglobulinaemia. The possibility that antiglobulins able to react with cytomegalovirus antiserum or the fluoresceinated secondary antibody could be deposited in the mesangium of patients with IgA nephropathy was ruled out by the blocking studies. Secondly, the immunofluorescence findings may not be directly related to the cause; for example, patients with IgA nephropathy may have an immune deficit that both predisposes them to the nephropathy and renders them susceptible to cytomegalovirus infections or hinders clearance of the antigen. Thirdly, these patients may have a renal infection with cytomegalovirus that incites a response manifest as IgA nephropathy. The lack of other histological evidence of infection in our patients makes this explanation unlikely. Moreover, the histological features of IgA nephropathy are unlike those of cytomegalovirus infections of the kidney.13,14 Results of enzyme-linked immunosorbent assays for serum cytomegalovirus antibodies were available in only 4 of our patients; 3 were negative and 1 was moderately positive. However, cultures of urine and renal tissue or the use of in-situ hybridisation probes with cytomegalovirus messenger RNA will be needed to decide whether cytomegalovirus renal infection is present in patients with ,
IgA nephropathy. Fourthly, cytomegalovirus antigen may be a component of an immune complex with IgA that deposits in or is transported to the mesangium and excites an inflammatory response. This process would explain the parallel deposition of IgA and cytomegalovirus in our cases. If this explanation
13
is correct, is
glomerular cytomegalovirus deposition a universal phenomenon or a peculiarity of this series? The finding of cytomegalovirus antigen in all our cases, who were of four races, makes genetic predisposition unlikely. The geographical distribution of the cases (from central and nothern Utah and southern Idaho and Wyoming) parallels the population distribution in our referral area and argues against a local infectious cause. Chronic occult viral infection could provide a continuing stimulus for IgA production. Long-term oral immunisation provokes the development of IgA nephropathy in mice.’S It is, of course, quite possible that cytomegalovirus is just one of several antigens that can form nephritogenic complexes with IgA, and that their frequency may differ in different areas. If this is true, it is not clear why cytomegalovirus should be the sole culprit in this region. The possibililty of a viral aetiology for IgA nephropathy has not been widely discussed. Najy et all’ sought serum antibodies to herpesviruses in patients with IgA nephropathy; the prevalence of antibodies to herpes simplex viruses 1 and 2, cytomegalovirus, and Epstein-Barr virus nuclear and capsid antigens was the same as in controls, although most titres were somewhat higher in the IgA nephropathy patients. In 1 of 54 renal biopsy samples, they found traces of herpes simplex virus 2 antigen in 2 glomeruli. No attempt was made to seek cytomegalovirus or Epstein-Barr-virus antigens in the biopsy samples. In Japan the prevalence of cytomegalovirus seropositivity and of IgA nephropathy are both high. Lymphocyte proliferation in response to cytomegalovirus antigen occurred significantly more often in Japanese patients with IgA nephropathy than in control subjects without renal disease." Patients with other types of glomerulonephritis were not studied. The patients with the highest stimulation indices tended to be those without renal insufficiency, and it was suggested that cytomegalovirus may have a role in the pathogenesis of IgA nephropathy. Simon et al18 described a patient in whom typical Epstein-Barr-virus infectious mononucleosis developed together with macroscopic haematuria and subendothelial IgA deposits. The patient recovered and 18 months later the kidney had returned to normal and IgA was no longer demonstrable (Prof P. Simon, unpublished). Despite the presence of IgA in the glomeruli, the optical, immunofluorescence, and electron microsopic features of this case were not typical of IgA nephropathy. Meadow and Scott!9 described identical twin boys; IgA nephropathy developed in one and HSP in the other a few days after an adenovirus respiratory infection. Although evidence for viral involvement in human IgA nephropathy has not been readily forthcoming, there are three putative animal models. Aleutian disease of mink is a persistent parvovirus infection.2O Proliferative glomerulonephritis with expansion of the mesangial matrix develops in the late stages of the infection, and the animals
! ’
!
die in uraemia."’ Ultrastructural examination shows various lesions; proliferation of mesangial cells and an increase in mesangial matrix are prominent, but mesangial electrondense deposits are less plentiful than are subendothelium deposits.21 Despite reports of IgG deposition,2O the predominant glomerular immunoglobulin is IgA, which is deposited along with complement in a granular pattern in capillary walls, and to a lesser extent, in mesangium.22 Antibody to Aleutian disease virus can be eluted from affected glomeruli. 23 The virus antigen has been demonstrated in the same distribution as the deposited immunoglobulins ’24 and crystalline arrays of virus-like
particles have been found in arterial and glomerular endothdium.2’i Aleutian disease is an imperfect analogue of human IgA nephropathy in that it occurs in a setting of overt viral infection with virus particles demonstrable in the kidney, and in that the brunt of the disease falls on the glomerular capillary walls, with lesser manifestations in the
mcsangium. Although mesangial IgA occurs in the mesangial proliferative glomerulonephritis of mice infected in utero with lymphocytic choriomeningitis virus,"’ IgG usually predominates and this disease appears to be an immune complex nephritis with complexes formed from virus antigen and maternal or filial immunoglobulin. Mice of the ddY strain carry a retrovirus and mammary, pulmonary, ovarian, and lymphatic tumours spontaneously develop. Renal disease manifest as proteinuria (but not haematuria) occurs regularly in female ddY mice. By light and electron microscopy, the murine disease closely resembles human IgA nephropathy.27 Early in the disease glomeruli show mainly the deposition of IgG and IgM ubiquitous in mice,2s but by 40 weeks of age there is a preponderance of granular mesangial IgA.27 Viral antigens have not been sought in the glomeruli of the ddY mouse and the effects of antiviral drugs on the evolution of the renal disease have not been investigated. Further studies will be necessary to see whether the association of cytomegalovirus antigen with IgA nephropathy can be confirmed in other populations and whether this association is important in the pathogenesis of IgA nephropathy. Nevertheless, the demonstration of simultaneous deposition of cytomegalovirus antigen and IgA in glomerular mesangium provides a potential new line of investigation in a disease whose aetiology has proved elusive. We thank Dr H. A. Bloomer, Dr R. E. Bond, Dr R. G. Lambert, Dr H. Seneklian, Dr R. L. Siegler, and Dr J. B. Sunson for allowing us to study their
patients. Correspondence should be addressed to M. C. G., Division of Nephrology, Department of Medicine, Universityof Utah School of Medicine, Salt Lake City, Utah 84132, USA REFERENCES 1
Berger J, Hinglais N. Les depôts intercapillaires d’IgA-IgG J Urol Nephrol 1968, 74:
694-95 2.Clarkson AR, Woodroffe AJ, Bannister KM, Lomax-Smith JD, Aarons I The syndrome of IgA nephropathy Clin Nephrol 1984, 21: 7-14 3 D’Amico G. Idiopathic IgA mesangial nephropathy Nephron 1985, 41: 1-13 4. Maggiore Q, Bartelemeo F, L’Abbete A, et al Glomerular localization of circulating antiglobulin activity in essential mixed cry oglobulinemia with glomerulonephritis Kidney Int 1982, 21: 387-94 5. Levy M, Gonzalez-Burchard G, Broyer M, et al Berger’s disease in children Medicine 1985; 64: 157-80 6 Egido J, Sancho J, Rivera F, Hernando L. The role of IgA and IgG immune complexes in IgA nephropathy Nephron 1984, 36: 52-59 7 Nicholls K, Kincaid-Smith P Defective in vivo Fc-and C3b-receptor function in IgA nephropathy. Am JKidnev Dis 1984, 4: 128-34. 8. Chatenoud L, Bach M-A. Abnormalities of T-cell subsets in glomerulonephritis and systemic lupus erythematosus Kidney Int 1981, 20: 267-74 9 Valentijn RM, Kauffmann RH, Brutel de la Riviere G, Daha MR, Van Es LA Presence of circulating macromolecular IgA in patients with hematuria due to primary IgA nephropathy Am J Med 1983, 74: 375-81 10 Lesavre P, Digeon M, Bach JF Analysis of circulating IgA and detection of immune complexes in primary IgA nephropathy Clin Exp Immunol 1982, 48: 61-69 11. Kincaid-Smith P, Nicholls K Mesangial IgA nephropathy Am J Kidney Dis 1983, 3: 90-102 12. Mustonen J, Pasternack A, Rantala I The nephrotic syndrome in IgA glomerulonephritis response to corticosteroid therapy Clinical Nephrol 1983; 20: 172-76 13 Platt JL, Sibley RK, Michael AF Interstitial nephritis associated with cytomegalovirus infection Kidney Int 1985, 28: 550-52 14 Richardson WP, Colvin RB, Cheeseman SH, et al Glomerulopathy associated with cytomegalovirus viremia in renal allografts. N Engl J Med 1981, 305: 57-63 15 Emancipator SN, Gallo GR, Lamm ME Experimental IgA-nephropathy induced by oral immuni/ation J Exp Med 1983, 157: 572-82 16 Najy J, Uj M, Szues G, Trinn C, Burger T Herpes virus antigens and antibodies in kidney biopsies and sera of IgA glomerulonephritic patients Clin Nephrol 1984;5: 259-62
14
TSH-RECEPTOR ANTIBODIES IN MOTHERS WITH GRAVES’ DISEASE AND OUTCOME IN THEIR OFFSPRING NOBUO MATSUURA
JUNJI KONISHI KANJI KASAGI
KENJI FUJIEDA
YASUHIRO IIDA MASAHIRO HAGISAWA SEIICHIRO FUJIMOTO MASARU FUKUSHI NOBUO TAKASUGI
Departments of Paediatrics and Obstetrics, Hokkaido University School of Medicine, Sapporo, Japan; Department of Nuclear Medicine, Kyoto University School of Medicine, Kyoto; and Sapporo City Institute of Public Health, Sapporo Blood was taken from 56 selected newborn babies whose mothers had Graves’ disease, to assess the relation between their thyroid function and the presence of thyrotropin (TSH) binding inhibitor immunoglobulins (TBII) and thyroid stimulating antibodies (TSAb) in maternal serum. All the mothers of the thyrotoxic babies had both these TSH receptor antibodies in their serum. However, most of the mothers whose thyroid function had been well controlled in pregnancy gave birth to normal babies. 15 babies had a transient syndrome of low serum thyroxine (T4) and free T4 with normal TSH and this tended to be associated with TSH receptor antibodies in maternal serum (TBII 9/15, TSAb 4/15). 2 infants had transient hyperthyroxinaemia without hyperthyroidism and both their mothers showed strong TSAb activity without TBII activity.
Summary
thyroxine (T4), and free thyroxine (FT,) was made by radioimmunoassay’" (normal values: TSH 4-6 [SD 2 9] µU/ml;T4 136.4 [28-3] nmol/l; FT4 33-8 [3-1] pmol/1) (TSH 0-03 pU/ml=1 ug/dl). Maternal blood samples were taken at or just before delivery. TBII was assayed by a radioreceptor assay of TSH"" (normal range = + 15% to - 15%, see fig 2) and TSAb was assayed by measurement of the increase in adenosine 3’,5’-monophosphate by the incubation of human adenoma cells or porcine thyroid cells with the patient’s IgG or bovine-TSH." 12 Potency of TSAb was expressed as an equivalent of bovine-TSH (normal range less than 1-2 yU/ml b-TSH). Group I consisted of 14 cases of neonatal thyrotoxicosis. Features in the infants were restlessness, sweating, exophthalmos, and irritability, and raised serum T4, triiodothyronine (T3), and FT,. Treatment was with Lugol’s solution and/or antithyroid drugs. Group II consisted of 16 infants with transient hypothyroxinaemia. These infants were identified in a neonatal T, screening programme or by routine follow-up tests of thyroid function in newborn infants whose mothers had Graves’ disease. Serum T, or filter paper blood FT, concentrations were below 64 4
Introduction THYROID
stimulating
immunoglobulins (TSI), against thyrotropin (TSH) important part in the production
be antibodies
presumed
to’
receptors,
may
play an hyperthyroidism in Graves’ disease.’ When these immunoglobulins cross the placenta they can cause neonatal thyrotoxicosis,’ 6 but the relation between the mother’s TSI and the status of the offspring has not been fully elucidated. We have measured TSIin two ways, as thyroid stimulating antibody (TSAb) and as TSH-binding inhibitor immunoglobulins (TBII), in mothers with Graves’ disease and have related the results to thyroid function in their of
.
babies.
Subjects
and Methods
56 selected mothers with Graves’ disease and their offspring (including a set of twins) were investigated. The 57 infants were divided retrospectively into four groups according to their clinical course and thyroid function. Umbilical cord blood was taken at delivery and filter paper spots of blood were taken every other day until the infants were discharged from the nursery at 5-7 days if they did not have symptoms. Analysis of the blood spots of TSH,
T, Kashiwabara H, Omori K, et al Prolifetative response against cytomegalovirus and prognosis of renal transplant and IgG nephropathy patients Transplant Proc 1987, 19: 2135-36 18 Simon P, Nouel O, Ang K-S, Deugnier Y, Ramée MP. Nephropathie à IgA au cours de la mononucléose infectieuse: une nouvelle observation Néphrologie 1981, 2: 44 19 Meadow SR, Scott DG Berger disease’ Henoch Schonlein syndrome without the rash J Pediatr 1985; 106: 27-32. 20. Porter DD, Larsen AE, Porter HG Aleutian disease of mink Adv Immunol 1980, 29: 17 Sakamaki
261-86. 21. Pan IC, Tsai KS, Grinyer I, Karstad L Glomerulonephritis in Aleutian disease of mink. ultrastructural studies. J Pathol 1970, 103: 33-40 22 Portis JL, Coe JE Deposition of IgA in renal glomeruli of mink affected with Aleutian Disease. Am J Pathol 1979, 96: 227-36 23 Cho HJ, Ingram DG. Pathogenesis of Aleutian disease of mink nature of the antiglobulin reaction and elution of antibody from erythrocytes and glomeruli of infected mink Infect Immunol 1973; 8: 264-71
Fig 1-Thyroid function hypothyroxinaemia. Shaded
area
in 8 group II infants with transient
shows the range of values (mean, 2
SD)
m
normal mfants."
24. Porter DD, Larsen AE, Porter HG Reduced severity of lesions in mink infected J transplacentally with Aleutian disease virus. Immunol 1977; 119: 872-76 25 Tsai KS, Grinyer I, Pan IC, Karstad L Electron microscopic observation of cry stalline arrays of virus-like particules of tissues of mink with Aleutian disease Canad J Microbiol 1969, 15: 138-40. 26. Oldstone
MB, Dixon FJ. Disease accompanying
in
utero
viral infection The role of
antibody in tissue injury after transplacental infection with lymphocytic choriomengitis virus J Exp Med 1972, 135: 827-38 27 Imai H, Nakamota Y, Asakura K, Miki K, Yasuda T, Miura AB Spontaneous glomerular IgA deposition in ddY mice an animal model of IgA nephritis. Kidney maternal
Int 1985, 27: 756-61. 28. Markham RV, Sutherland JC, Mardiney MR. The ubiquitous occurrence of immune complex localization m the renal glomeruli of normal mice Lab Invest 1973, 29: 111-20.
well as FIS and VAS, (2) using a midphase interval of 4 weeks without medication, measurements of plasma concentration of mexiletine, and subjective and objective assessments before the mexiletine and placebo phases; and (3) escalating the dose of tablets during both treatment with mexiletine and on placebo and using low doses of mexiletine. Mexiletine is a promising treatment for chronic painful diabetic neuropathy. REFERENCES
6
Kastrup J, Petersen P, Dejgard A, Hilsted J, Angelo HR Treatment of chronic painful diabetic neuropathy with intravenous lidocaine infusion Br Med J 1986, 292: 173
7. Editorial. Tocainide and mexilitine—orally effective lidocaine analogues Arch Intern Med 1985, 145: 417-18. 8 Petersen P, Kastrup J. Dercum’s disease (adipositas dolorosa) Treatment of the severe pain with intravenous lidocaine. Pain 1987; 28: 77-80 9. Lindstrøm P, Lindblom U The analgesic effect of tocainide in trigeminal neuralgia. Pain 1987; 28: 45-50. 10 Scott J, Huskisson EC Graphic representation of pain Pain 1976, 2: 175-85 11 Jersild M, Lauritzen E. Sensibilite vibratoire chez les diabetiques. Diabète 1957; 6: 237-41. 12 Hilsted J, Jensen SB. A simple test for autonomic neuropathy in juvenile diabetics
Acta Med Scand 1979; 205: 385-87 Quantative determination of hemoglobin A1c by thin-layer isoelectric focusing J Chromatogr 1980; 182: 325-33 14 Kelly R, Christmore D, Smith R, Doshir L, Jacobs SL Mexiletin in plasma by high pressure liquid chromatography Ther Drug Monit 1981; 3: 279-86. 15. Editorial. Pain perception in diabetic neuropathy Lancet 1985; i 83-84. 16. Strichantz G. Molecular mechanisms of nerve block by local anasthetics Anaesthestology 1976; 45: 421-41. 17 Prescott LF, Clements JA, Pottage A. Absorption, distribution and elementation of Mexilitine. Postgrad Med J 1977; 53: 50-55 18. Bak FW, Jensen TS, Sugsby B, Kastrup J, Dejgaard A The effect of systemic lidocaine on nociceptive processing in diabetics. Pain 1987; suppl 4: 388. 19. Wiesenfeld-Hallin Z, Lindblom U. The effect of systemic tocainide, lidocaine and bupivicane on nociception in the rat. Pain 1985, 23: 357-60.
I Kvinesdal B, Molin J, Freland A, Gram LF Imipramine treatment of painful diabetic neuropathy. JAMA 1984; 251: 1727-30. 2 Jaspan J, Maselli R, Herold K, Bartkus C Treatment of severely painful diabetic neuropathy with an aldose reductase inhibitor: relief of pain and improved somatic and autonomic nerve function. Lancet 1983; ii: 758-62. 3. Rull JA, Quibrera R, Gonzalez-Milan H, Castaneda OL. Symptomatic treatment of penpheral diabetic neuropathy with Carbarnarepine (Tegretol) Double-blind, cross-over trial. Diabetologia 1969, 5: 215-18. 4 Boulton AJM, Drury FJ, Clarke B, Ward JD Continuous subcutaneous insulin infusion in the management of painful diabetic neuropathy. Diabetes Care 1982, 5: 386-90 5. Morley GK, Mooradian AD, Levine AS, Morley JE. Mechanism of pain in diabetic peripheral neuropathy. Am J Med 1984; 77: 79-82.
13 Mortensen HB.
RENAL DEPOSITION OF CYTOMEGALOVIRUS ANTIGEN IN IMMUNOGLOBULIN-A NEPHROPATHY
were
MARTIN C. GREGORY M. ELIZABETH HAMMOND EILEEN D. BREWER
Department of Medicine, Pathology, and Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, USA Renal biopsy specimens from patients with various glomerular disorders were examined by indirect immunofluorescence microscopy with three different heterologous antibodies directed against cytomegalovirus and two heterologous antibodies against herpes simplex virus (HSV) type 1. All 31 samples from patients with immunoglobulin-A (IgA) nephropathy, 1 of 12 with systemic lupus erythematosus (SLE), and 1 of 5 with Henoch-Schönlein purpura (HSP) showed mesangial staining with cytomegalovirus antiserum, whereas no sample from 37 patients with other forms of
Summary
glomerulonephritis was positive. Antigens of herpes simplex virus I were demonstrated in samples from 4 of 31 patients with IgA nephropathy, 1 of 12 patients with SLE, 1 of 5 patients with HSP, and 1 of 37 patients with other glomerular diseases. The consistent finding of glomerular cytomegalovirus antigen in IgA nephropathy suggests but does not prove that the virus has a role in the aetiology of this disorder. Introduction
(IgA) nephropathy is a focal proliferative mesangial glomerulonephritis of unknown aetiology. Its prevalence differs in different geographical regions, but since its recognition in 1968,1 it has proved common.2.3 Nevertheless no convincing cause for the disorder has come to light. We have investigated glomerular deposition of antigens reacting with three different heterologous antisera against cytomegalovirus in renal biopsy samples from patients with IgA nephropathy. IMMUNOGLOBULIN-A
Methods All
non-transplant renal biopsy samples received at our medical between February, 1985, and March, 1987, from patients with IgA nephropathy, systemic lupus erythematosus (SLE), Henoch-Schonlein purpura (HSP), or hepatic glomerulosclerosis centre
examined for evidence of cytomegalovirus or herpes simplex antigen in the glomeruli. 37 control biopsy samples from patients with other glomerular disorders taken during the same period were similarly examined. Because all adult and paediatric nephrologists in Utah send their renal biopsy samples to a central pathology laboratory, it is likely that all samples from patients in Utah and a small but uncertain proportion from patients in adjacent States have been examined. virus
Biopsy samples were examined in detail by light microscopy, immunofluorescence microscopy, and electron microscopy by standard methods. The diagnosis of IgA nephropathy was made when samples showed mesangial cellular proliferation and expansion of matrix by light microscopy, IgA and C3 deposited in an exclusively mesangial distribution by immunofluorescence, and mesangial electron-dense deposits by electron microcopy. In all cases, the diagnosis was reached in consultation with the nephrologist. SLE was excluded by the absence of clinical or pathological criteria for that disorder. All biopsy samples in the study were subjected to staining with antiserum to cytomegalovirus. 4 µm frozen sections were cut from each block, and sections from each patient were stained with one or two of three different heterologous antibodies against cytomegalovirus (Polysciences, Lee Biomolecular, and Biogenex Laboratories) and one of two different heterologous antibodies against herpes simplex virus type I (Biogenex Laboratories or Flow Laboratories). The tissue was washed in phosphate-buffered saline for 1 h, incubated with primary antibody for 30 min, washed for 15 min in phosphate-buffered saline, and incubated with fluoresceinisothiocyanate-labelled IgG fractions of anti-goat or anti-rabbit antibody for 30 min. After a final 15 min wash, the slides were mounted in ’Elvanol’ and viewed in a Zeiss immunofluorescent microscope equipped with epifluorescence.. Positive controls included a case of fatal cytomegalovirus-induced hepatitis and a case of fatal encephalitis induced by herpes simplex virus I. Negative controls, simultaneously run, included frozen sections from patients with other renal disorders as well as test sections with the primary antibody omitted. Blocking studies with aggregated’ and unaggregated IgG were carried out on freshly frozen tissue from two patients with IgA nephropathy; both samples initially reacted with cytomegalovirus antiserum but not with anti-human IgG. Samples of human IgG (Capell Laboratories) were diluted to 0-5 mg/ml and aggregated by heating to 63°C for 20 min. The product was allowed to cool and refrigerated overnight. Frozen sections of renal biopsy samples from the two patients were incubated for 30 min at room temperature with either aggregated or native IgG, washed, reincubated with cytomegalovirus antiserum, and treated with fluoresceinated secondary reagent before microscopy. Control sections were incubated with fluoresceinated anti-human IgG after pretreatment with aggregated or unaggregated IgG.
12
,
PREVALENCE OF GLOMERULAR ANTIGENS IN PATIENTS WI’I’H
patients whose renal biopsy samples showed glomerular deposition of IgA and, or cytomegalovirus as well as those with diagnoses of HSP, SLE, or hepatic glomerulosclerosis were examined in detail. Where possible, patients were recalled to verify demographic data and to confirm that the clinical presentation agreed with the pathological diagnosis. Proportions were compared by chi-square testing. The
notes
of
VARIOUS GLOMERULAR DISORDERS
Results In 31 of 86 samples studied the pathological diagnosis was IgA nephropathy. All these patients had clinical histories consistent with the diagnosis of IgA nephropathy.25 8 were female and 23 male. Their ages ranged from 3 to 74 years (median 18 years). Besides mesangial hypercellularity and a focal or diffuse increase in mesangial matrix, there were variable degrees of global glomerulosclerosis and interstitial fibrosis in the biopsy samples depending on the duration and severity of the patient’s disease. By immunofluorsecence microscopy, mesangial deposition of IgA was shown in all 31 samples; IgG was present in 29, C3 in 30, and Clq in 12. All 31 patients showed mesangial deposits of cytomegalovirus in a distribution identical to those of IgA. 1 of 12 patients with SLE and 1 of 5 with HSP showed glomerular cytomegalovirus antigens in a distribution similar to that of IgA. The sole patient with hepatic glomerulosclerosis and IgA deposits had no cytomegalovirus antigen (see table). 37 patients with other primary and secondary glomerular disorders (table) -were examined. None had cytomegalovirus antigen in the glomeruli. The difference in the occurrence of cytomegalovirus between patients with IgA nephropathy and those with other glomerular disorders was highly
significant (table). In the blocking studies of two biopsy samples, aggregated or unaggregated IgG did not bind to mesangium. There was no competitive inhibition of the staining with cytomegalovirus antiserum in either biopsy sample after pretreatment with aggregated or unaggregated unlabelled IgG. 4 of 31 patients with IgA nephropathy and 1 of 36 with other glomerular disorders showed staining with antiserum against herpes simplex virus (table). This difference was not significant. The patient with SLE and the patient with HSP who had cytomegalovirus antigen in their glomeruli also had herpes simplex virus antigen. No diagnostic inclusion bodies were found by light microscopy in any of the biopsy samples. All samples were examined by electron microscopy; diagnostic virions were never seen in either tubules or glomeruli. Discussion of IgA nephropathy is not known. It is since it has become the commonest primary important, in nephropathy many regions of the world.z j Speculations about its aetiology have suggested a subtle derangement of immune regulation that permits the formation of Defects of in-vivo nephritogenic antigen-IgA reduced IgAand function,’ Fc-receptor C3b-receptor and increased serum specific suppressor-T-cell activity,’ have all been and be related observed polymeric IgA 9,10 may to these putative defects of immunity. Over twenty diseases have been reported in association with IgA nephropathy.11,12 With the exception of liver disease and HSP, none of these associations occurs sufficiently frequently to have causal significance. The relation between IgA nephropathy and HSP has long been debated. In our study, the discrepancy in the prevalence of cytomegalovirus antigen in the glomeruli The
cause
complexes. 26
*Membranous
nephropathy (6), mesangial proliferative glomerulonephritis mesangiocapillary glomerulonephritis (5), rapidly progressive glomerulonephritis (5), minimal change nephropathy (5), chronic glomerulonephritis (4), focal glomerulosclerosis (3), and vasculitis (3). CMV=cytomegatovirus; HSV-1= herpes simplex virus 1. For comparison with IgA nephropathy group: tp < 0 0005; tp < 0001. (6),
between these two disorders is evidence supporting different aetiologies. There are at least four possible explanations for the presence of cytomegalovirus antigen in the glomeruli of patients with IgA nephropathy. First, the staining of these deposits could be related to non-specific binding of cytomegalovirus antiserum in the glomeruli. This possibility is unlikely, since the binding of cytomegalovirus antibody was not associated with all deposits of IgA of the patients examined; there was no staining in most patients with SLE and HSP. Furthermore, identical results were obtained with three different heterologous antisera, and positive and negative controls always gave appropriate results. Patients with known cytomegalovirus infections have shown positive staining with the same heterologous antibodies; these controls included 3 patients with cytomegalovirus infections of the lung, 2 with cytomegalovirus infections of the kidney, and 3 with herpes simplex virus 1 infections of the brain. Control patients with non-IgA-associated disorders had uniformly negative results. Maggiore et al4 showed antiglobulin activity in the glomeruli of patients with essential mixed cryoglobulinaemia. The possibility that antiglobulins able to react with cytomegalovirus antiserum or the fluoresceinated secondary antibody could be deposited in the mesangium of patients with IgA nephropathy was ruled out by the blocking studies. Secondly, the immunofluorescence findings may not be directly related to the cause; for example, patients with IgA nephropathy may have an immune deficit that both predisposes them to the nephropathy and renders them susceptible to cytomegalovirus infections or hinders clearance of the antigen. Thirdly, these patients may have a renal infection with cytomegalovirus that incites a response manifest as IgA nephropathy. The lack of other histological evidence of infection in our patients makes this explanation unlikely. Moreover, the histological features of IgA nephropathy are unlike those of cytomegalovirus infections of the kidney.13,14 Results of enzyme-linked immunosorbent assays for serum cytomegalovirus antibodies were available in only 4 of our patients; 3 were negative and 1 was moderately positive. However, cultures of urine and renal tissue or the use of in-situ hybridisation probes with cytomegalovirus messenger RNA will be needed to decide whether cytomegalovirus renal infection is present in patients with ,
IgA nephropathy. Fourthly, cytomegalovirus antigen may be a component of an immune complex with IgA that deposits in or is transported to the mesangium and excites an inflammatory response. This process would explain the parallel deposition of IgA and cytomegalovirus in our cases. If this explanation
13
is correct, is
glomerular cytomegalovirus deposition a universal phenomenon or a peculiarity of this series? The finding of cytomegalovirus antigen in all our cases, who were of four races, makes genetic predisposition unlikely. The geographical distribution of the cases (from central and nothern Utah and southern Idaho and Wyoming) parallels the population distribution in our referral area and argues against a local infectious cause. Chronic occult viral infection could provide a continuing stimulus for IgA production. Long-term oral immunisation provokes the development of IgA nephropathy in mice.’S It is, of course, quite possible that cytomegalovirus is just one of several antigens that can form nephritogenic complexes with IgA, and that their frequency may differ in different areas. If this is true, it is not clear why cytomegalovirus should be the sole culprit in this region. The possibililty of a viral aetiology for IgA nephropathy has not been widely discussed. Najy et all’ sought serum antibodies to herpesviruses in patients with IgA nephropathy; the prevalence of antibodies to herpes simplex viruses 1 and 2, cytomegalovirus, and Epstein-Barr virus nuclear and capsid antigens was the same as in controls, although most titres were somewhat higher in the IgA nephropathy patients. In 1 of 54 renal biopsy samples, they found traces of herpes simplex virus 2 antigen in 2 glomeruli. No attempt was made to seek cytomegalovirus or Epstein-Barr-virus antigens in the biopsy samples. In Japan the prevalence of cytomegalovirus seropositivity and of IgA nephropathy are both high. Lymphocyte proliferation in response to cytomegalovirus antigen occurred significantly more often in Japanese patients with IgA nephropathy than in control subjects without renal disease." Patients with other types of glomerulonephritis were not studied. The patients with the highest stimulation indices tended to be those without renal insufficiency, and it was suggested that cytomegalovirus may have a role in the pathogenesis of IgA nephropathy. Simon et al18 described a patient in whom typical Epstein-Barr-virus infectious mononucleosis developed together with macroscopic haematuria and subendothelial IgA deposits. The patient recovered and 18 months later the kidney had returned to normal and IgA was no longer demonstrable (Prof P. Simon, unpublished). Despite the presence of IgA in the glomeruli, the optical, immunofluorescence, and electron microsopic features of this case were not typical of IgA nephropathy. Meadow and Scott!9 described identical twin boys; IgA nephropathy developed in one and HSP in the other a few days after an adenovirus respiratory infection. Although evidence for viral involvement in human IgA nephropathy has not been readily forthcoming, there are three putative animal models. Aleutian disease of mink is a persistent parvovirus infection.2O Proliferative glomerulonephritis with expansion of the mesangial matrix develops in the late stages of the infection, and the animals
! ’
!
die in uraemia."’ Ultrastructural examination shows various lesions; proliferation of mesangial cells and an increase in mesangial matrix are prominent, but mesangial electrondense deposits are less plentiful than are subendothelium deposits.21 Despite reports of IgG deposition,2O the predominant glomerular immunoglobulin is IgA, which is deposited along with complement in a granular pattern in capillary walls, and to a lesser extent, in mesangium.22 Antibody to Aleutian disease virus can be eluted from affected glomeruli. 23 The virus antigen has been demonstrated in the same distribution as the deposited immunoglobulins ’24 and crystalline arrays of virus-like
particles have been found in arterial and glomerular endothdium.2’i Aleutian disease is an imperfect analogue of human IgA nephropathy in that it occurs in a setting of overt viral infection with virus particles demonstrable in the kidney, and in that the brunt of the disease falls on the glomerular capillary walls, with lesser manifestations in the
mcsangium. Although mesangial IgA occurs in the mesangial proliferative glomerulonephritis of mice infected in utero with lymphocytic choriomeningitis virus,"’ IgG usually predominates and this disease appears to be an immune complex nephritis with complexes formed from virus antigen and maternal or filial immunoglobulin. Mice of the ddY strain carry a retrovirus and mammary, pulmonary, ovarian, and lymphatic tumours spontaneously develop. Renal disease manifest as proteinuria (but not haematuria) occurs regularly in female ddY mice. By light and electron microscopy, the murine disease closely resembles human IgA nephropathy.27 Early in the disease glomeruli show mainly the deposition of IgG and IgM ubiquitous in mice,2s but by 40 weeks of age there is a preponderance of granular mesangial IgA.27 Viral antigens have not been sought in the glomeruli of the ddY mouse and the effects of antiviral drugs on the evolution of the renal disease have not been investigated. Further studies will be necessary to see whether the association of cytomegalovirus antigen with IgA nephropathy can be confirmed in other populations and whether this association is important in the pathogenesis of IgA nephropathy. Nevertheless, the demonstration of simultaneous deposition of cytomegalovirus antigen and IgA in glomerular mesangium provides a potential new line of investigation in a disease whose aetiology has proved elusive. We thank Dr H. A. Bloomer, Dr R. E. Bond, Dr R. G. Lambert, Dr H. Seneklian, Dr R. L. Siegler, and Dr J. B. Sunson for allowing us to study their
patients. Correspondence should be addressed to M. C. G., Division of Nephrology, Department of Medicine, Universityof Utah School of Medicine, Salt Lake City, Utah 84132, USA REFERENCES 1
Berger J, Hinglais N. Les depôts intercapillaires d’IgA-IgG J Urol Nephrol 1968, 74:
694-95 2.Clarkson AR, Woodroffe AJ, Bannister KM, Lomax-Smith JD, Aarons I The syndrome of IgA nephropathy Clin Nephrol 1984, 21: 7-14 3 D’Amico G. Idiopathic IgA mesangial nephropathy Nephron 1985, 41: 1-13 4. Maggiore Q, Bartelemeo F, L’Abbete A, et al Glomerular localization of circulating antiglobulin activity in essential mixed cry oglobulinemia with glomerulonephritis Kidney Int 1982, 21: 387-94 5. Levy M, Gonzalez-Burchard G, Broyer M, et al Berger’s disease in children Medicine 1985; 64: 157-80 6 Egido J, Sancho J, Rivera F, Hernando L. The role of IgA and IgG immune complexes in IgA nephropathy Nephron 1984, 36: 52-59 7 Nicholls K, Kincaid-Smith P Defective in vivo Fc-and C3b-receptor function in IgA nephropathy. Am JKidnev Dis 1984, 4: 128-34. 8. Chatenoud L, Bach M-A. Abnormalities of T-cell subsets in glomerulonephritis and systemic lupus erythematosus Kidney Int 1981, 20: 267-74 9 Valentijn RM, Kauffmann RH, Brutel de la Riviere G, Daha MR, Van Es LA Presence of circulating macromolecular IgA in patients with hematuria due to primary IgA nephropathy Am J Med 1983, 74: 375-81 10 Lesavre P, Digeon M, Bach JF Analysis of circulating IgA and detection of immune complexes in primary IgA nephropathy Clin Exp Immunol 1982, 48: 61-69 11. Kincaid-Smith P, Nicholls K Mesangial IgA nephropathy Am J Kidney Dis 1983, 3: 90-102 12. Mustonen J, Pasternack A, Rantala I The nephrotic syndrome in IgA glomerulonephritis response to corticosteroid therapy Clinical Nephrol 1983; 20: 172-76 13 Platt JL, Sibley RK, Michael AF Interstitial nephritis associated with cytomegalovirus infection Kidney Int 1985, 28: 550-52 14 Richardson WP, Colvin RB, Cheeseman SH, et al Glomerulopathy associated with cytomegalovirus viremia in renal allografts. N Engl J Med 1981, 305: 57-63 15 Emancipator SN, Gallo GR, Lamm ME Experimental IgA-nephropathy induced by oral immuni/ation J Exp Med 1983, 157: 572-82 16 Najy J, Uj M, Szues G, Trinn C, Burger T Herpes virus antigens and antibodies in kidney biopsies and sera of IgA glomerulonephritic patients Clin Nephrol 1984;5: 259-62
14
TSH-RECEPTOR ANTIBODIES IN MOTHERS WITH GRAVES’ DISEASE AND OUTCOME IN THEIR OFFSPRING NOBUO MATSUURA
JUNJI KONISHI KANJI KASAGI
KENJI FUJIEDA
YASUHIRO IIDA MASAHIRO HAGISAWA SEIICHIRO FUJIMOTO MASARU FUKUSHI NOBUO TAKASUGI
Departments of Paediatrics and Obstetrics, Hokkaido University School of Medicine, Sapporo, Japan; Department of Nuclear Medicine, Kyoto University School of Medicine, Kyoto; and Sapporo City Institute of Public Health, Sapporo Blood was taken from 56 selected newborn babies whose mothers had Graves’ disease, to assess the relation between their thyroid function and the presence of thyrotropin (TSH) binding inhibitor immunoglobulins (TBII) and thyroid stimulating antibodies (TSAb) in maternal serum. All the mothers of the thyrotoxic babies had both these TSH receptor antibodies in their serum. However, most of the mothers whose thyroid function had been well controlled in pregnancy gave birth to normal babies. 15 babies had a transient syndrome of low serum thyroxine (T4) and free T4 with normal TSH and this tended to be associated with TSH receptor antibodies in maternal serum (TBII 9/15, TSAb 4/15). 2 infants had transient hyperthyroxinaemia without hyperthyroidism and both their mothers showed strong TSAb activity without TBII activity.
Summary
thyroxine (T4), and free thyroxine (FT,) was made by radioimmunoassay’" (normal values: TSH 4-6 [SD 2 9] µU/ml;T4 136.4 [28-3] nmol/l; FT4 33-8 [3-1] pmol/1) (TSH 0-03 pU/ml=1 ug/dl). Maternal blood samples were taken at or just before delivery. TBII was assayed by a radioreceptor assay of TSH"" (normal range = + 15% to - 15%, see fig 2) and TSAb was assayed by measurement of the increase in adenosine 3’,5’-monophosphate by the incubation of human adenoma cells or porcine thyroid cells with the patient’s IgG or bovine-TSH." 12 Potency of TSAb was expressed as an equivalent of bovine-TSH (normal range less than 1-2 yU/ml b-TSH). Group I consisted of 14 cases of neonatal thyrotoxicosis. Features in the infants were restlessness, sweating, exophthalmos, and irritability, and raised serum T4, triiodothyronine (T3), and FT,. Treatment was with Lugol’s solution and/or antithyroid drugs. Group II consisted of 16 infants with transient hypothyroxinaemia. These infants were identified in a neonatal T, screening programme or by routine follow-up tests of thyroid function in newborn infants whose mothers had Graves’ disease. Serum T, or filter paper blood FT, concentrations were below 64 4
Introduction THYROID
stimulating
immunoglobulins (TSI), against thyrotropin (TSH) important part in the production
be antibodies
presumed
to’
receptors,
may
play an hyperthyroidism in Graves’ disease.’ When these immunoglobulins cross the placenta they can cause neonatal thyrotoxicosis,’ 6 but the relation between the mother’s TSI and the status of the offspring has not been fully elucidated. We have measured TSIin two ways, as thyroid stimulating antibody (TSAb) and as TSH-binding inhibitor immunoglobulins (TBII), in mothers with Graves’ disease and have related the results to thyroid function in their of
.
babies.
Subjects
and Methods
56 selected mothers with Graves’ disease and their offspring (including a set of twins) were investigated. The 57 infants were divided retrospectively into four groups according to their clinical course and thyroid function. Umbilical cord blood was taken at delivery and filter paper spots of blood were taken every other day until the infants were discharged from the nursery at 5-7 days if they did not have symptoms. Analysis of the blood spots of TSH,
T, Kashiwabara H, Omori K, et al Prolifetative response against cytomegalovirus and prognosis of renal transplant and IgG nephropathy patients Transplant Proc 1987, 19: 2135-36 18 Simon P, Nouel O, Ang K-S, Deugnier Y, Ramée MP. Nephropathie à IgA au cours de la mononucléose infectieuse: une nouvelle observation Néphrologie 1981, 2: 44 19 Meadow SR, Scott DG Berger disease’ Henoch Schonlein syndrome without the rash J Pediatr 1985; 106: 27-32. 20. Porter DD, Larsen AE, Porter HG Aleutian disease of mink Adv Immunol 1980, 29: 17 Sakamaki
261-86. 21. Pan IC, Tsai KS, Grinyer I, Karstad L Glomerulonephritis in Aleutian disease of mink. ultrastructural studies. J Pathol 1970, 103: 33-40 22 Portis JL, Coe JE Deposition of IgA in renal glomeruli of mink affected with Aleutian Disease. Am J Pathol 1979, 96: 227-36 23 Cho HJ, Ingram DG. Pathogenesis of Aleutian disease of mink nature of the antiglobulin reaction and elution of antibody from erythrocytes and glomeruli of infected mink Infect Immunol 1973; 8: 264-71
Fig 1-Thyroid function hypothyroxinaemia. Shaded
area
in 8 group II infants with transient
shows the range of values (mean, 2
SD)
m
normal mfants."
24. Porter DD, Larsen AE, Porter HG Reduced severity of lesions in mink infected J transplacentally with Aleutian disease virus. Immunol 1977; 119: 872-76 25 Tsai KS, Grinyer I, Pan IC, Karstad L Electron microscopic observation of cry stalline arrays of virus-like particules of tissues of mink with Aleutian disease Canad J Microbiol 1969, 15: 138-40. 26. Oldstone
MB, Dixon FJ. Disease accompanying
in
utero
viral infection The role of
antibody in tissue injury after transplacental infection with lymphocytic choriomengitis virus J Exp Med 1972, 135: 827-38 27 Imai H, Nakamota Y, Asakura K, Miki K, Yasuda T, Miura AB Spontaneous glomerular IgA deposition in ddY mice an animal model of IgA nephritis. Kidney maternal
Int 1985, 27: 756-61. 28. Markham RV, Sutherland JC, Mardiney MR. The ubiquitous occurrence of immune complex localization m the renal glomeruli of normal mice Lab Invest 1973, 29: 111-20.