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Thyroid antigen associated immune complex glomerulonephritis in Graves' disease
Thyroid Antigen Associated Immune Complex Glomerulonephritis in Graves’ Disease
FREDERICK HORVATH, Jr., M.D.* P. TEAGUE, Ph.D. EOIN F. GAFFNEY, M.B.. B. Ch. DONALD R. MARS, M.D. THOMAS J. FULLER, M.D. Guinesville, Florida
A 60 year old hyperthyroid black woman with long-standing Graves’ disease treated with methimazole presented with anasarca and congestive heart failure. She was found to have the nephrotic syndrome with a urinary protein excretion of 32 g/day. Light and electron microscopy revealed a stage II membranous glomerulopathy. Direct and indirect immunofluorescence demonstrated immunoglobulin G (IgG), immunoglobulin M (IgM), third component of complement and thyroglobulin in a granular diffuse pattern consistent with an immune complex glomerulonephritis. Total thyroidectomy led to a decrease in proteinuria with little change in glomerular filtration rate during an 11 month follow-up period.,We believe this to be the first report of immune complex glomerulonephritis associated with thyroid antigen in Graves’ disease. Endogenous antigens, for example, deoxyribonucleic acid [l] and renal tubular epithelial antigen [z], have now been strongly implicated as mediators of immune complex glomerulonephritis in human subjects. Thyroglobulin, another endogenous antigen, was demonstrated several years ago in animal studies to mediate immune complex glomerulonephritis [3,4]. More recently, thyroglobulin-antithyroglobulin immune complex glomerulonephritis in association with chronic thyroiditis [5,6] has been reported in human subjects. Similar findings have also been noted in one additional patient with hyperthyroidism [7] and in another with hypothyroidism [S] of undetermined etiology. We present a patient with Graves’ disease in whom the nephrotic syndrome developed secondary to membranous glomerulonephritis. Direct and indirect immunofluorescent staining showed deposition of thyroglobulin, immunoglobulin and complement in all glomeruli. We believe this to be the first report of immune complex glomerulonephritis associated with thyroid antigen in Graves disease. CASE REPORT
From the Departments of Medicine and Pathology. University of Florida Medical School in Gainesville, and the Veterans Administration Hospital, Gainesville, Florida. Requests for reprints should be addressed to Dr. Thomas J. Fuller, Division of Renal Medicine, Box J-224, JHMHC. University of Florida, Gainesville, Flm-ida 32610. Manuscript accepted April 19. 1979. * Present address: 515 N.E. Glen Oak Avenue, Peoria, Illinois 61637.
A 60 year old black woman was referred to the Shands Teaching Hospital of the University of Florida for the first time in February, 1978 for severe congestive heart failure. She had a nine year history of hyperthyroidism for which she had been treated intermittently with methimazole. and a four year history of atria1 fibrillation and chronic congestive heart failure. Four months prior to her referral to the University of Florida she had been evaluated elsewhere for hyperthyroidism and congestive heart failure. Thyroid function studies revealed a thyroxine (T4) by radioimmunoassay of 16 &dl (normal 5 to 12pg/dlJ, triiodothyronine (Ts) resin uptake of 50.2 per cent (normal 35 to 45 per cent], a free T4 of 5.4 pg/dl (normal 1.8to 2.3pg/dl) and a free thyroxine index of 7.42[normal 1.57to 5.17). Thyroid sonography demonstrated a diffusely enlarged gland without cysts. Intravenous pyelography was es-
November
1979
The American
Journal of Medicine
Volume
67
901
IMMUNE COMPLEX GLOMERULONEPHRITIS IN GRAVES’ DISEASEPHORVA’TH ET AL.
sentially within normal limits. Blood urea nitrogen was 20 mg/dl. Urinalysis revealed 3+ proteinura. The patient was discharged on a regimen of methimazolc, digoxin, furosemide and potassium supplementation. On admission to Shands Teaching Hospital, physical examination revealed an undistressed patient with anasarca. Clinically, she appeared euthyroid. Her blood pressure was 180/96 mm Hg. The thyroid was slightly enlarged bilaterally and nontender. There was a ventricular gallop, a soft systolic flow murmur and an irregularly irregular rhythm. The liver span was 11 cm. Marked peripheral edema and ascites were present. Laboratory examination included a creatinine clearance (C,,.) of 52 cc/min. blood urea nitrogen 20 mg/dl, serum albumin 2.6 g/d1 and cholesterol 298 mg/dl. Urinalysis revealed a pH 6.0, 3+ protein, trace glucose, 2 to 5 fatty casts, 5 to 10 hyaline casts, 5 to 10 white. blood cells, 5 to 10 red blood cells/high power field (hpf) and several oval fat bodies. A 24 hour urine for protein yielded 32 g of protein. Antideoxyribonucleic acid, hepatitis B surface antigen, rheumatoid factor and a serologic test for syphilis (VDRL] were negative. C3 was 170 Fg/dl [normal 123 to 167 pg/dl). Thyroid function studies included a T4 by radioimmunoassay of 10.0 Fg/dl [normal 5.5 to 14 &dl), TB by radioimmunoassay of 130 pg/dl [normal 79 to 178 Mg/dl), a free T4 of 3.9 pg/dl (normal 1 to 2.3 pg/dl) and a thyroid-stimulating hormone (TSH] level of 3.9pU/ml (normal 1.5 to 10 pU/ml). Serum antithyroglobulin antibody was positive in low titer 1:20 (normal < l:lO]. Serum antimicrosomal antibody titer was 1:lOO [normal < l:lOO] (See “Methods”). Renal venogram was normal. Percutaneous renal biopsy was performed (See “Results”]. Following diuresis the patient was discharged: she was readmitted for total thyroidectomy in March 1978. Pathologic examination of the thyroid revealed early nodular hyperplasia consistent with involution of diffuse hyperplasia. The postoperative course was uneventful, and she was discharged on il regimen of Aldome@‘, furosemide, digoxin, potassium chloride and thyroid extract (later changed to Synthroid”]. During an 11 month outpatient follow-up the patient remained asymptomatic, without peripheral edema. On monthly determinations the glomerular filtration rate remained esscntially unchanged (C,,50 to 59 cc/min]; however, there was a moderate decrease in the degree of her proteinuria from 32 g to an average of 10 g/24 hours. Repeat tests for the detection of serum antithyroglobulin antibodies and antimicrosomal antibodies were negative one month and four months after thyroidectomy. The patient refused repeat biopsy.
cent gelvatol [Monsanto, New York, New York] solution buffered with 0.01M phosphate buffered saline solution, pH 7.2
1111. Indirect immunofluorcscent staining was performed with sheep antithyroglobulin and rabbit antimicrosomal antiserums given by B.A.L. Hum, M.D., Wellcome Reagents LTD., Beckcnham, Kent, England. Fluorescent goat antirabbit immunoglobulin and fluorescent burro antisheep immunoglobulin wcrc donated by Kallestad Labs., Chaska, Mn. Each was used at a final dilution of 1:20. The antithyroglobulin antiserum had ;I titer of 1:40 million, determined by passive hemagglutination ant1 was used at a dilution of 1:80in indirect immunofluoresccnce. It gave excellent staining of thyroglobulin in frozen sections of human thyroid. and staining was completely inhibited following solid-phase absorption with purified thyloglobulin. The antimicrosomal antiserum had a passive hemagglutination titer of 1:640,000 and was used for indirect immunofluorescence at a final dilution of 1:80 whichgave an cxpccted staining pattern with human thyroid. Conditions for indirect staining were as previously described 151. Prior to indirect staining, kidney sections from the patient and controls (two with systemic lupus erythematosus, two with membranous, and two 1 hour post-renal transplant biopsy specimens] were fixed in ethanol for 10 minutes prior to staining with the antithyroglobulin antiserum. Sections were used unfixed for staining with the antiserum to the microsomal antigen. Strum antimicrosomal and antithyroglobulin determinations were performed by Patterson-Coleman Laboratory, ‘T;lmpa, Florida, using indirect hemagglutination methods. RESULTS
Light Microscopy. Twelve glomeruli were identified. The glomerular capillary walls were diffusely thickened. Special stains demonstrated numerous “spikes” on the outer aspect of the capillary basement memcellularity was normal, branes [Figure 1). Glomerular and the mesangium was not expanded. There was focal tubular atrophy and interstitial fibrosis. There was
METHODS Light and electron microscopic methods were performed as previously described [9]. Immunofluorescence Microscopy. Direct immunofluorescent staining with antiserums to IgG, IgM, IgA, C3, C4 and fibrinogen was performed using reagents and methods previously described [lo] except when noted. Stained sections were counterstained for 5 seconds with a freshly prepared 1:lOO clihltion of Eriochrome black (Difco] (diluted in phosphate buffered saline solution, 0.01 M, pH 7.2), and then briefly washed with the diluent and covered with 0.05 ml of 20 per
902
November
1979 The American Journal of Medicine
gyrophilic capillary basement membrane spikes. Periodic acid-methenamine silver with Masson’s trichrome counterstain; magnification X 7,650, reduced by 53 per cent.
Volume 67
microsomal antigen in the renal biopsy specimen of the patient. However, indirect staining with the antithyroglobulin reagent revealed a 3+ diffuse granular pattern on the glomerular basement membranes of all glomeruli in a pattern indistinguishable from that observed in direct staining for anti-IgG (Figure 3). COMMENTS
Figure 2. Electron micro! showing multiple subepitheiial electron dense deposits separated by basement membrane projections. Overlying foot processes are fused. Original magnification X 12,600, reduced by 53 per cent.
moderate arteriosclerosis of the small and mediumsized arteries. Electron Microscopy. In thin sections of glomeruli, numerous subepithelial electron dense deposits were separated by basement membrane spikes. The biopsy specimen was interpreted as membranous nephropathy, stage II [12] (Figure 2). Immunofluorescence Microscopy. Direct staining for the patients renal biopsy specimen revealed a diffuse granular pattern on the glomerular basement membranes of all glomeruli. Positive staining was observed only for IgG (3+], IgM (1+) and C3 (1-k). Indirect staining for thyroglobulin and thyroid microsomal antigen was negative for all controls and for
staining on the glomerular basement membrane produced by indirect immunofluorescence with anti-thyroglobulin antiserum. Original magnification X 275, reduced by 43 per cent.
The association in this patient of long-standing thyroid disease and the nephrotic syndrome secondary to membranous glomerulonephritis suggested to us that these two entities may be linked by some pathophysiologic mechanism such as thyroid antigen-antibody immune complex mediated renal injury. Indirect hemagglutination techniques revealed circulating antithyroglobulin antibodies. Using appropriate controls, indirect immunofluorescence with antiserums specific for human thyroglobulin demonstrated this antigen to be present in a diffuse pattern on the glomerular basement membranes of all glomeruli. The predominant staining with IgG and slight staining with C3 and IgM is consistent with evidence that most antibody to human thyroglobulin is of the IgG class and that it does not avidly fix complement [13]. Because we did not test for circulating immune complexes, we are unable to determine if this deposition is secondary to circulating complexes or a result of “in situ” complex formation 1141. Experimental models of immune complex disease suggest that both a continuous or at least a persistently intermittent supply of antigen and a low grade immune response to this antigen favor the formation of immune complexes and the maintenance of a chronic disease state. Chronic autoimmune thyroiditis in which tissue destruction is a major event theoretically would serve as an excellent source for continuous antigen supply to the circulation and subsequent circulating immune complex formation. Suggestive evidence for circulating immune complexes in human thyroid disease has been provided by Calder et al. [15] with the demonstration of anticomplementary activity in the serum of 59 per cent of 39 patients with Hashimoto’s thyroiditis, 29 per cent of 34 patients with primary hypothyroidism ant1 17 per cent of 36 patients with thyrotoxicosis. If a diseased thyroid were to be further damaged, an increased release of antigen might enhance an immune complex process as suggested by Ploth et al. [5] in a hyperthyroid patient treated with I’“‘. Mori and Kriss [7], by competitive binding radioimmunoassay methods, found that 89 per cent of 55 untreated patients with Graves’ disease had antithyroglobulin antibodies, 98 per cent had antimicrosomal antibodies and 38 per cent had positive longacting thyroid stimulator (LATS), compared with control values of 20 per cent for antimicrosomal and 23 per cent for antithyroglobulin. Treatment of this group with 113’ produced a lo-fold increase in antithyroglobulin and a 15-fold increase in antimicrosomal antibodies compared with pretreatment values. These investigators
November 1979
The American Journal of Medicine
Vohne
67
903
IMMUNE
COMPLEX
GLOMERULONEPHRITIS
IN GRAVES’
DISEASE-HORVATH
believed that the rise in serum antibody levels represented an anamnestic response to release of specific antigen induced by radiation damage to the thyroid gland. Given the possibility that IJ3’ therapy could have worsened this patient’s renal lesion and that the thyroid was demonstrated to be an antigen source by indirect immunofluorescent techniques, thyroidectomy was chosen as the prefered therapy. Elimination of the antigenic source resulted in an expected disappearance of circulating antimicrosomal and antithyroglobulin antibodies. Although thyroidectomy did not lead to a marked improvement in renal function or proteinuria, it did nevertheless lead to a stabilization of the glomerular filtration rate and a
ET AL.
moderate decrease in proteinuria. An additional factor which cannot be excluded as a cause for the diminished proteinuria is optimal control of the congestive heart failure during the follow-up period. Extrapolating from the literature dealing with idiopathic membranous glomerulonephritis, it would be reasonable to suggest that diminution in thyroid antigen-antibody related membranous glomerulonephritis would be optimal if treatment (i.e., thyroidectomy) were to be instituted prior to the development of a late stage II or stage III lesion. Specifically, remissions of idiopathic membranous glomerulonephritis have been confined almost exclusively to patients whose lesions were stage I or II on initial biopsy [l6-181.
REFERENCES 1.
2.
Koffler D, Agnello V, Thoburn R, et al.: Systemic lupus erythematosus. Prototype of immune complex nephritis in man. J Exp Med 134: 1695,197l. Naruse T, Miyakawa Y, Kitamura K, et al.: Membranous glomerulonephritis mediated by renal tubular epithelial antigen-antibody complex. J Allergy Clin Immuno154: 311,
4.
Wcigle WO: Experimental auloimmune thyroiditis. Pathol Annu 6: 329.1973. O’Reagan SO, Fang JSC, Kaplan BS, et al.: Thyroid antigenantibodv nephritis. Clin Immunol Immunooath 6: 341. 1976.
5.
G.
7.
8. 9.
904
Finlayson G. Alexander A glomerulonephritis. 32: 140. 1975.
I I.
Humason GL: Animal Tissue Techniques, San Francisco, W. H. Freeman, 1972. Ehrcnreich T, Churg J: Pathology of membranous nephropathy. Pathology Annual, ~013, New York, Appleton-Century-crofts, 1968. Hay FC, Torrigiani G: The distribution of anti-thyroglobulin antibodies in immunoglobulin G subclasses. Clin Exp
II.
1974. 3.
disease. Am J Med 62: 761,1977. IO.
”
_
Immunol
Ploth DW, Fitz A, Schnetzler
D, et al.: Thyroglobulin-ancomplex glomerulonephritis therapy. Clin Immunol Immu-
tithyroglobulin immune complicating radioiodine nopath 9: 327, 1978. lordan SC. lohnston WH. Berestein TM: Immune comolex glomeruldnephritis mediated by ihyroid antigen. Arch
Pathol Lab Med 102: 530.1978. Mori T, Kriss JP: Measurements by competitive binding radioassay of serum anti-microsomal and anti-thyroglobulin antibodies in Graves Disease and other thyroid disorders. J Clin Endocrinol Metab 33: 688,1971. Earle DP: Glomerulonephritis: clinical aspects. Bull NY Acad Med 46: 749,197O. Fuller TJ, Richman AV, Auerbach D, et al: Immune glomerulonephritis in a patient with mixed connective tissue
November 1979
13.
L
The American Journal of Medicine
R. Juncos L. et al.: Immunoglobulin a clinicopathologic study. Lab Invest
16: 517.1974.
Couscr WG, Stcinmuller DR, Stilmant MM, et al.: Experimental glomerulonephritis in the isolated oerfused rat kidney. J Clin Invest 62: 1275,1978. ’ 15. Calder EA, Penhale WJ, Barnes EW, et al.: Evidence for circulating immune complexes in thyroid disease. Br Med J 2: 30. 1974. 16. Ehrcnreich T, Porush JG, Churg J, et al.: Treatment of idiopathic membranous nephropathy. N Engl J Med 295: 741. 1976. 17. Beregi E, Varga I: Analysis of 260 cases of membranous glomerulonephritis in renal biopsy material. Clin Nephro12: 14.
215,1974. 18.
Gluck MC, Gallo G, Lowenstein J, et al.: Membranous glomerulonephritis, evaluation of clinical and pathologic features. Ann Intern Med 78: 1,1973.
Volume 67
FREDERICK HORVATH, Jr., M.D.* P. TEAGUE, Ph.D. EOIN F. GAFFNEY, M.B.. B. Ch. DONALD R. MARS, M.D. THOMAS J. FULLER, M.D. Guinesville, Florida
A 60 year old hyperthyroid black woman with long-standing Graves’ disease treated with methimazole presented with anasarca and congestive heart failure. She was found to have the nephrotic syndrome with a urinary protein excretion of 32 g/day. Light and electron microscopy revealed a stage II membranous glomerulopathy. Direct and indirect immunofluorescence demonstrated immunoglobulin G (IgG), immunoglobulin M (IgM), third component of complement and thyroglobulin in a granular diffuse pattern consistent with an immune complex glomerulonephritis. Total thyroidectomy led to a decrease in proteinuria with little change in glomerular filtration rate during an 11 month follow-up period.,We believe this to be the first report of immune complex glomerulonephritis associated with thyroid antigen in Graves’ disease. Endogenous antigens, for example, deoxyribonucleic acid [l] and renal tubular epithelial antigen [z], have now been strongly implicated as mediators of immune complex glomerulonephritis in human subjects. Thyroglobulin, another endogenous antigen, was demonstrated several years ago in animal studies to mediate immune complex glomerulonephritis [3,4]. More recently, thyroglobulin-antithyroglobulin immune complex glomerulonephritis in association with chronic thyroiditis [5,6] has been reported in human subjects. Similar findings have also been noted in one additional patient with hyperthyroidism [7] and in another with hypothyroidism [S] of undetermined etiology. We present a patient with Graves’ disease in whom the nephrotic syndrome developed secondary to membranous glomerulonephritis. Direct and indirect immunofluorescent staining showed deposition of thyroglobulin, immunoglobulin and complement in all glomeruli. We believe this to be the first report of immune complex glomerulonephritis associated with thyroid antigen in Graves disease. CASE REPORT
From the Departments of Medicine and Pathology. University of Florida Medical School in Gainesville, and the Veterans Administration Hospital, Gainesville, Florida. Requests for reprints should be addressed to Dr. Thomas J. Fuller, Division of Renal Medicine, Box J-224, JHMHC. University of Florida, Gainesville, Flm-ida 32610. Manuscript accepted April 19. 1979. * Present address: 515 N.E. Glen Oak Avenue, Peoria, Illinois 61637.
A 60 year old black woman was referred to the Shands Teaching Hospital of the University of Florida for the first time in February, 1978 for severe congestive heart failure. She had a nine year history of hyperthyroidism for which she had been treated intermittently with methimazole. and a four year history of atria1 fibrillation and chronic congestive heart failure. Four months prior to her referral to the University of Florida she had been evaluated elsewhere for hyperthyroidism and congestive heart failure. Thyroid function studies revealed a thyroxine (T4) by radioimmunoassay of 16 &dl (normal 5 to 12pg/dlJ, triiodothyronine (Ts) resin uptake of 50.2 per cent (normal 35 to 45 per cent], a free T4 of 5.4 pg/dl (normal 1.8to 2.3pg/dl) and a free thyroxine index of 7.42[normal 1.57to 5.17). Thyroid sonography demonstrated a diffusely enlarged gland without cysts. Intravenous pyelography was es-
November
1979
The American
Journal of Medicine
Volume
67
901
IMMUNE COMPLEX GLOMERULONEPHRITIS IN GRAVES’ DISEASEPHORVA’TH ET AL.
sentially within normal limits. Blood urea nitrogen was 20 mg/dl. Urinalysis revealed 3+ proteinura. The patient was discharged on a regimen of methimazolc, digoxin, furosemide and potassium supplementation. On admission to Shands Teaching Hospital, physical examination revealed an undistressed patient with anasarca. Clinically, she appeared euthyroid. Her blood pressure was 180/96 mm Hg. The thyroid was slightly enlarged bilaterally and nontender. There was a ventricular gallop, a soft systolic flow murmur and an irregularly irregular rhythm. The liver span was 11 cm. Marked peripheral edema and ascites were present. Laboratory examination included a creatinine clearance (C,,.) of 52 cc/min. blood urea nitrogen 20 mg/dl, serum albumin 2.6 g/d1 and cholesterol 298 mg/dl. Urinalysis revealed a pH 6.0, 3+ protein, trace glucose, 2 to 5 fatty casts, 5 to 10 hyaline casts, 5 to 10 white. blood cells, 5 to 10 red blood cells/high power field (hpf) and several oval fat bodies. A 24 hour urine for protein yielded 32 g of protein. Antideoxyribonucleic acid, hepatitis B surface antigen, rheumatoid factor and a serologic test for syphilis (VDRL] were negative. C3 was 170 Fg/dl [normal 123 to 167 pg/dl). Thyroid function studies included a T4 by radioimmunoassay of 10.0 Fg/dl [normal 5.5 to 14 &dl), TB by radioimmunoassay of 130 pg/dl [normal 79 to 178 Mg/dl), a free T4 of 3.9 pg/dl (normal 1 to 2.3 pg/dl) and a thyroid-stimulating hormone (TSH] level of 3.9pU/ml (normal 1.5 to 10 pU/ml). Serum antithyroglobulin antibody was positive in low titer 1:20 (normal < l:lO]. Serum antimicrosomal antibody titer was 1:lOO [normal < l:lOO] (See “Methods”). Renal venogram was normal. Percutaneous renal biopsy was performed (See “Results”]. Following diuresis the patient was discharged: she was readmitted for total thyroidectomy in March 1978. Pathologic examination of the thyroid revealed early nodular hyperplasia consistent with involution of diffuse hyperplasia. The postoperative course was uneventful, and she was discharged on il regimen of Aldome@‘, furosemide, digoxin, potassium chloride and thyroid extract (later changed to Synthroid”]. During an 11 month outpatient follow-up the patient remained asymptomatic, without peripheral edema. On monthly determinations the glomerular filtration rate remained esscntially unchanged (C,,50 to 59 cc/min]; however, there was a moderate decrease in the degree of her proteinuria from 32 g to an average of 10 g/24 hours. Repeat tests for the detection of serum antithyroglobulin antibodies and antimicrosomal antibodies were negative one month and four months after thyroidectomy. The patient refused repeat biopsy.
cent gelvatol [Monsanto, New York, New York] solution buffered with 0.01M phosphate buffered saline solution, pH 7.2
1111. Indirect immunofluorcscent staining was performed with sheep antithyroglobulin and rabbit antimicrosomal antiserums given by B.A.L. Hum, M.D., Wellcome Reagents LTD., Beckcnham, Kent, England. Fluorescent goat antirabbit immunoglobulin and fluorescent burro antisheep immunoglobulin wcrc donated by Kallestad Labs., Chaska, Mn. Each was used at a final dilution of 1:20. The antithyroglobulin antiserum had ;I titer of 1:40 million, determined by passive hemagglutination ant1 was used at a dilution of 1:80in indirect immunofluoresccnce. It gave excellent staining of thyroglobulin in frozen sections of human thyroid. and staining was completely inhibited following solid-phase absorption with purified thyloglobulin. The antimicrosomal antiserum had a passive hemagglutination titer of 1:640,000 and was used for indirect immunofluorescence at a final dilution of 1:80 whichgave an cxpccted staining pattern with human thyroid. Conditions for indirect staining were as previously described 151. Prior to indirect staining, kidney sections from the patient and controls (two with systemic lupus erythematosus, two with membranous, and two 1 hour post-renal transplant biopsy specimens] were fixed in ethanol for 10 minutes prior to staining with the antithyroglobulin antiserum. Sections were used unfixed for staining with the antiserum to the microsomal antigen. Strum antimicrosomal and antithyroglobulin determinations were performed by Patterson-Coleman Laboratory, ‘T;lmpa, Florida, using indirect hemagglutination methods. RESULTS
Light Microscopy. Twelve glomeruli were identified. The glomerular capillary walls were diffusely thickened. Special stains demonstrated numerous “spikes” on the outer aspect of the capillary basement memcellularity was normal, branes [Figure 1). Glomerular and the mesangium was not expanded. There was focal tubular atrophy and interstitial fibrosis. There was
METHODS Light and electron microscopic methods were performed as previously described [9]. Immunofluorescence Microscopy. Direct immunofluorescent staining with antiserums to IgG, IgM, IgA, C3, C4 and fibrinogen was performed using reagents and methods previously described [lo] except when noted. Stained sections were counterstained for 5 seconds with a freshly prepared 1:lOO clihltion of Eriochrome black (Difco] (diluted in phosphate buffered saline solution, 0.01 M, pH 7.2), and then briefly washed with the diluent and covered with 0.05 ml of 20 per
902
November
1979 The American Journal of Medicine
gyrophilic capillary basement membrane spikes. Periodic acid-methenamine silver with Masson’s trichrome counterstain; magnification X 7,650, reduced by 53 per cent.
Volume 67
microsomal antigen in the renal biopsy specimen of the patient. However, indirect staining with the antithyroglobulin reagent revealed a 3+ diffuse granular pattern on the glomerular basement membranes of all glomeruli in a pattern indistinguishable from that observed in direct staining for anti-IgG (Figure 3). COMMENTS
Figure 2. Electron micro! showing multiple subepitheiial electron dense deposits separated by basement membrane projections. Overlying foot processes are fused. Original magnification X 12,600, reduced by 53 per cent.
moderate arteriosclerosis of the small and mediumsized arteries. Electron Microscopy. In thin sections of glomeruli, numerous subepithelial electron dense deposits were separated by basement membrane spikes. The biopsy specimen was interpreted as membranous nephropathy, stage II [12] (Figure 2). Immunofluorescence Microscopy. Direct staining for the patients renal biopsy specimen revealed a diffuse granular pattern on the glomerular basement membranes of all glomeruli. Positive staining was observed only for IgG (3+], IgM (1+) and C3 (1-k). Indirect staining for thyroglobulin and thyroid microsomal antigen was negative for all controls and for
staining on the glomerular basement membrane produced by indirect immunofluorescence with anti-thyroglobulin antiserum. Original magnification X 275, reduced by 43 per cent.
The association in this patient of long-standing thyroid disease and the nephrotic syndrome secondary to membranous glomerulonephritis suggested to us that these two entities may be linked by some pathophysiologic mechanism such as thyroid antigen-antibody immune complex mediated renal injury. Indirect hemagglutination techniques revealed circulating antithyroglobulin antibodies. Using appropriate controls, indirect immunofluorescence with antiserums specific for human thyroglobulin demonstrated this antigen to be present in a diffuse pattern on the glomerular basement membranes of all glomeruli. The predominant staining with IgG and slight staining with C3 and IgM is consistent with evidence that most antibody to human thyroglobulin is of the IgG class and that it does not avidly fix complement [13]. Because we did not test for circulating immune complexes, we are unable to determine if this deposition is secondary to circulating complexes or a result of “in situ” complex formation 1141. Experimental models of immune complex disease suggest that both a continuous or at least a persistently intermittent supply of antigen and a low grade immune response to this antigen favor the formation of immune complexes and the maintenance of a chronic disease state. Chronic autoimmune thyroiditis in which tissue destruction is a major event theoretically would serve as an excellent source for continuous antigen supply to the circulation and subsequent circulating immune complex formation. Suggestive evidence for circulating immune complexes in human thyroid disease has been provided by Calder et al. [15] with the demonstration of anticomplementary activity in the serum of 59 per cent of 39 patients with Hashimoto’s thyroiditis, 29 per cent of 34 patients with primary hypothyroidism ant1 17 per cent of 36 patients with thyrotoxicosis. If a diseased thyroid were to be further damaged, an increased release of antigen might enhance an immune complex process as suggested by Ploth et al. [5] in a hyperthyroid patient treated with I’“‘. Mori and Kriss [7], by competitive binding radioimmunoassay methods, found that 89 per cent of 55 untreated patients with Graves’ disease had antithyroglobulin antibodies, 98 per cent had antimicrosomal antibodies and 38 per cent had positive longacting thyroid stimulator (LATS), compared with control values of 20 per cent for antimicrosomal and 23 per cent for antithyroglobulin. Treatment of this group with 113’ produced a lo-fold increase in antithyroglobulin and a 15-fold increase in antimicrosomal antibodies compared with pretreatment values. These investigators
November 1979
The American Journal of Medicine
Vohne
67
903
IMMUNE
COMPLEX
GLOMERULONEPHRITIS
IN GRAVES’
DISEASE-HORVATH
believed that the rise in serum antibody levels represented an anamnestic response to release of specific antigen induced by radiation damage to the thyroid gland. Given the possibility that IJ3’ therapy could have worsened this patient’s renal lesion and that the thyroid was demonstrated to be an antigen source by indirect immunofluorescent techniques, thyroidectomy was chosen as the prefered therapy. Elimination of the antigenic source resulted in an expected disappearance of circulating antimicrosomal and antithyroglobulin antibodies. Although thyroidectomy did not lead to a marked improvement in renal function or proteinuria, it did nevertheless lead to a stabilization of the glomerular filtration rate and a
ET AL.
moderate decrease in proteinuria. An additional factor which cannot be excluded as a cause for the diminished proteinuria is optimal control of the congestive heart failure during the follow-up period. Extrapolating from the literature dealing with idiopathic membranous glomerulonephritis, it would be reasonable to suggest that diminution in thyroid antigen-antibody related membranous glomerulonephritis would be optimal if treatment (i.e., thyroidectomy) were to be instituted prior to the development of a late stage II or stage III lesion. Specifically, remissions of idiopathic membranous glomerulonephritis have been confined almost exclusively to patients whose lesions were stage I or II on initial biopsy [l6-181.
REFERENCES 1.
2.
Koffler D, Agnello V, Thoburn R, et al.: Systemic lupus erythematosus. Prototype of immune complex nephritis in man. J Exp Med 134: 1695,197l. Naruse T, Miyakawa Y, Kitamura K, et al.: Membranous glomerulonephritis mediated by renal tubular epithelial antigen-antibody complex. J Allergy Clin Immuno154: 311,
4.
Wcigle WO: Experimental auloimmune thyroiditis. Pathol Annu 6: 329.1973. O’Reagan SO, Fang JSC, Kaplan BS, et al.: Thyroid antigenantibodv nephritis. Clin Immunol Immunooath 6: 341. 1976.
5.
G.
7.
8. 9.
904
Finlayson G. Alexander A glomerulonephritis. 32: 140. 1975.
I I.
Humason GL: Animal Tissue Techniques, San Francisco, W. H. Freeman, 1972. Ehrcnreich T, Churg J: Pathology of membranous nephropathy. Pathology Annual, ~013, New York, Appleton-Century-crofts, 1968. Hay FC, Torrigiani G: The distribution of anti-thyroglobulin antibodies in immunoglobulin G subclasses. Clin Exp
II.
1974. 3.
disease. Am J Med 62: 761,1977. IO.
”
_
Immunol
Ploth DW, Fitz A, Schnetzler
D, et al.: Thyroglobulin-ancomplex glomerulonephritis therapy. Clin Immunol Immu-
tithyroglobulin immune complicating radioiodine nopath 9: 327, 1978. lordan SC. lohnston WH. Berestein TM: Immune comolex glomeruldnephritis mediated by ihyroid antigen. Arch
Pathol Lab Med 102: 530.1978. Mori T, Kriss JP: Measurements by competitive binding radioassay of serum anti-microsomal and anti-thyroglobulin antibodies in Graves Disease and other thyroid disorders. J Clin Endocrinol Metab 33: 688,1971. Earle DP: Glomerulonephritis: clinical aspects. Bull NY Acad Med 46: 749,197O. Fuller TJ, Richman AV, Auerbach D, et al: Immune glomerulonephritis in a patient with mixed connective tissue
November 1979
13.
L
The American Journal of Medicine
R. Juncos L. et al.: Immunoglobulin a clinicopathologic study. Lab Invest
16: 517.1974.
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