Medical Department of Endocrinology F, Herlev Hospital, Medical Department E, Frederiksberg Hospital,
Department
Tissue-Typing Laboratory, Rigshospitalet, Rheumatological Research, Gentofte Hospital, Denmark
of
HLA ANTIGENS IN GRAVES' DISEASE
By Karine Bech, Bo Lumholtz, J\l=o/\rnNerup, Mogens Thomsen, Per Platz, Lars P. Ryder, Arne Svejgaard, Kaj Siersb\l=ae\k-Nielsen,
Jens M\l=o/\lholmHansen and J\l=o/\rgenHannover
Larsen
ABSTRACT HLA
typing
of 86 patients with Graves' disease was performed for the series antigens. An increased frequency of HLA-B8 (47 per cent) and Dw3 (51 per cent) compared with controls (23.7 and 21 per cent, respectively) was observed. The increase of B8 and Dw3 was almost exclusively found in a group of 48 patients with relapse of disease, whereas the frequency of B8 and Dw3 in patients without relapse did not differ significantly from that of the control group. No association with the presence of exophthalmos, thyroid antibodies, or antibodies to Yersinia enterocolitica serotype 3 could be found.
A, B, C and D
Antigens of the major human histocompatibility system (HLA) have been reported to function as markers for heredity susceptibility in several diseases (Dausset et al. 1974; Svejgaard et al. 1975). There is no doubt that genetic factors are involved in the development of Graves' disease (Bartels 1941; Presented in part at the 7th Annual Meeting of European Thyroid Association, Helsinki, 1976, and at the First International Symposium on HLA and Disease, Paris, 1976. 510
Heimann
and an association with HLA has previously been reported al. 1974; Whittingham et al. 1975; Jaffiol et al. 1976). In Graves' (Grumet disease like some other endocrine autoimmune diseases the frequency of HLA-B8 is increased which points to the possibility that HLA-B8 or B8 as¬ sociated immune response gene(s) may be the common denominator for de¬ velopment of endocrine autoimmunity (Nerup et al. 1974). Most studies of Graves' disease only concern the antigens of the A, B and C segregant series. The immune response genes are assumed to be located in the neighbourhood of the D locus (Svejgaard et al. 1975). It is therefore of interest to investigate the frequency of some of the D antigens in Graves' disease. It has been proposed that the susceptibility to certain infections is genetically influenced and related to the HLA system (Dausset et al. 1974; Haverkorn et al. 1975). Earlier an increased frequency of antibodies to Yersinia enterocolitica serotype 3 (Y.ent.) in sera from patients with Graves' disease as well as other thyroid disorders has been found (Bech et al. 1974, 1977). The present series of patients was also tested for the occurrence of these antibodies in order to evaluate a possible association with the HLA system.
1966),
et
MATERIAL AND METHODS The material consisted of 86 unrelated, Caucasian Danes with Graves' disease, of which 20 had been treated with subtotal thyroidectomy (no relapses), 131-iodine (no relapses), or were still on antithyroid treatment at time of the investigation. The remaining 66 patients had all been treated with antithyroid drugs to an euthyroid state for at least 12 months (mean 24 months). Of these 48 had relapse of Graves' disease after cessation of the treatment (mean period of observation 21 months), and 18 patients were still euthyroid after an observation of at least 12 months (mean 20 months). The age of the patients ranged from 21 to 85 years (mean 52 years), and 22 patients were men.
The diagnosis was based on clinical and laboratory evidence of hyperthyroidism with or without diffuse goitre. Thyroid function was evaluated clinically and by means of the following parameters: Serum thyroxine, serum T;!-resin test, serum triiodothyronine and 131-iodine uptake by the thyroid gland. The gland was examined by pal¬ pation and TC" scintigraphy in order to characterize the goitre as diffuse or nodular. Anti-microsomal and anti-thyroglobulin thyroid antibodies were studies in 63 patients by immunofluorescence technique and haemagglutination reaction. Antibodies to Y.ent. serotype 3 were determined in 78 patients with an agglutination technique (Larsen
1975).
The microlymphocytotoxicity test was used for typing the serologically defined anti¬ gens (Kissmeyer-Nielsen Se Kjerbye 1967). Twenty-five antigens in A and B series and 4 antigens in series C were typed for. The HLA factors of the D locus were typed for the one-way mixed lymphocyte culture test (Thomsen et al. 1975), and 8 antigens were typed for (Table 1). The control group consisted of healthy, unrelated, Caucasian
Danes. The statistical methods used was the Fisher's exact test, and the relative risk was estimated by the cross-ratio (Svejgaard et al. 1974).
511
HLA
Table 1. in Graves' disease.
antigens
Controls
Patients
Antigen Number
Frequency %>
Number
Frequency °/o
HLA-A28 HLA-Awl9
1967 1967 1967 1967 1967 1967 1967 1967
31.1 56.6 26.9 17.3 9.6 10.1 10.0 17.8
86 86 86 86 86 86 86 86
44 51 33 17 4 4 11
HLA B5 HLA B7 HLA B8 HLA B12 HLA B13 HLA B14 HLA- B18 HLA B27 HLA- Bwl5 HLA- Bwl6 HLA Bwl7 HLA Bw21 HLA- Bw22 HLA- Bw35 HLA- Bw37 HLA- Bw40 HLA- Bw41
1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1492 1967 1492
10.6 26.8 23.7 25.2 4.3 4.5 7.1 8.6 17.9
5 20 47 21
5.4 7.7 3.5 3.8 13.1 2.1 17.9 1.7
86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86
HLA-Cwl HLA-Cw2 HLA-Cw3 HLA-Cw4
426 426 426 426
8.4 11.0 37.0 17.1
86 86 86 86
4 7 27
HLA Dwl HLA Dw2 HLA Dw3 HLA- Dw4 HLA- Dw5 HLA- Dw6 HLA- Dw7 HLA- Dw8
91 157 157 157 34 89 157 157
18.9 23.6 21.0 17.2 8.8 18.0 9.6 8.9
29 86 86 86 9 29 86 45
21 26 51 15
HLA-A1 HLA-A2 HLA-A3 HLA-A9 HLA-A10 HLA-A11
512
20
4 1 5 6 15 1 6 7 4 15 1 21 1
12
11 21 15 4
Relative risk
1.8 0.9
1.3 1.0 0.4 0.4 1.1 1.2
0.0084 0.34 0.15 0.53 0.033 0.023 0.50 0.37
0.5 0.7 2.8 0.8 0.9 0.4 0.7 0.7 0.8 2.1 0.8 1.2 1.0 1.2 0.8 1.2 1.0
0.10 0.27 0.24 0.31 0.048 0.35 0.64 0.59 0.34 0.45 0.28 0.58
0.39 0.6 0.6 0.6
0.011 0.18 0.042 0.13
1.1 1.1 3.9
0.5 0.4 1.7 x 10-6 0.4 0.6 0.5 0.14 0.26
0.86 1.3 1.2 1.7 0.48
0.045 0.091 5.7 x 10-6 0.23 0.50
RESULTS
We found an increased frequency of HLA-B8 of 47 per cent (P 5.7 x 10-6, relative risk 2.8) and Dw3 of 51 per cent (P 1.7 x 10"6, relative risk 3.9) com¬ pared with 23.7 and 21 per cent in the controls (Table 1). The associations remained significant after multiplication of the P-value by the number of anti¬ gens tested. Thirty-five of the patients had lid retraction or eye profusion and the anti-microsomal or anti-thyroglobulin antibodies were detectable in 68 per cent (43 of 63 patients). Y. ent. serotype 3 antibodies (titre ^ 10) were found in 51 per cent (40 of 78 patients). No association between the HLA deter¬ minants and these features was found (Table 2), and there was no association with sex or age. On the other hand, in patients with relapse of Graves' disease the frequency of HLA-B8 and Dw3 increased even more to 54 and 65 per cent (P=7.4x lu6, and 3.9 x 10s), while in the patients without relapse the fre¬ quencies were only 33 per cent, and did not differ statistically significant from the controls (P 0.24 and 0.18). The risk to get relapse of the disease in pa=
=
=
Table 2. The association between HLA-Dw3 and some characteristical features of Graves' disease. HLA-Dw3 Total
Patients with relapse Patients without relapse Patients with eye involvement Patients without eye involvement Patients with thyroid antibodies (titre ;> 4) Patients without thyroid antibodies (titre < 4) Patients with yersinia antibodies (titre ¡> 10) Patients without yersinia antibodies (titre < 10)
Present
Absent
31(65%) 6 (33 %>)
17 12
48 18
18
(51 °/o)
17
35
26
(51 %>)
25
51
23
(53 %>)
20
43
12(60°/o)
8
20
(53 °/o)
19
40
20(53%)
18
38
21
Significance P-value*
0.01É
66
1.0
86
0.19
63
1.0
78
Fisher's exact test.
513 Acta endocr. 86, 3
33
tients with HLA-B8 and Dw3 is 81 and 84 per cent (26 of 32, and 31 of 37 patients) compared to 65 and 59 per cent (22 of 34, and 17 of 29 patients) in HLA-B8 and Dw3 negative patients. This is statistically significant in case of HLA-Dw3 (P 0.02, Table 2). =
DISCUSSION
The finding of the increase of HLA-B8 in Caucasian patients with Graves' disease was first reported by Grumet et al. (1973), and was later confirmed (Grumet et al. 1974; Whittingham et al. 1975; Thomsen et al. 1975; Thorsby et al. 1975; Jaffiol et al. 1976). However, Nelson 8c Pollet (1975) could not verify this observation. In the present study the prevalence of HLA-B8 was found to be 47 per cent of the patients with Graves' disease in accordance with the previous studies. From combined analysis of all studies known by the HLA and Disease Registry in Copenhagen it appears that the increase of HLA-B8 is of prime importance. The increase of HLA-Al is probably due to linkage disequilibrium with B8. In a normal population there is also an asso¬ ciation between HLA-B8 and Dw3. An increase of HLA-Dw3 was reported by us (Thomsen et al. 1975) in a preliminary sample of 39 patients included in this report. This finding was confirmed by Thorsby et al. (1975) in a small series. In the present study HLA-Dw3 was found to be increased to 54 per cent in accordance with these investigators. In a Japanese population where the HLA-B8 antigen is absent, the HLA-Bw35 antigen is increased to the same extent as B8 in the Caucasian population (Konishi et al. 1976). Moreover, in the Japaneses the association with HLA-Bw35 seems to be secondary to an increase of a HLA-D determinant (HO) which is different from HLA-Dw3 (Sazazuki, personal communication), and HLA-Dwl, which is associated with HLA-Bw35 in Caucasians (Thomsen, unpublished). Attempt to correlate different characteristic features of the disease with the HLA system has given conflicting results. Thorsby et al. (1975) found an as¬ sociation between HLA-B8 and the presence of thyroid antibodies, and Ludwig et al. (1976) have reported an association between Cw3 and ophthalmopathy. Kotulla et al. (1976) tried to correlate the presence of thyroid stimulating immunoglobulins studied by human receptor assay with the HLA system but could not find any assocation. We could not find correlation between the HLA anti¬ gens studied and exophthalmos, thyroid antibodies, sex or age. In an earlier study increased frequency of Y. ent. serotype 3 antibodies in patients with Graves' disease as well as non-toxic goitre was found (Bech et al. 1974, 1977). Lidman et al. (1974, 1976) have shown a transient immunofluorescence of the thyroid cell membrane in patients with acute yersiniosis. In pa¬ tients with increased susceptibility to thyroid diseases the lipopolysaccharides 514
of the Y. ent. could have special affinity to the thyroid cell membrane and give rise to development of abnormal thyroid function. If this hypothesis is correct. an association with the HLA system might be demonstrable. We could not find any clear association between any of the studied antigens and the pre¬ sence of Y. ent. antibodies in the serum, but the serum samples were obtained at different times after disease onset which might have influenced the results. It was striking that the course of the disease seems to be genetically deter¬ mined as the frequency of HLA-B8 and Dw3 was higher in patients with relapse of Graves' disease in contrast to patients without relapse. The frequency of Dw3 was higher than B8, and furthermore, all B8 positive patients were also Dw3 positive. Thus, the disease association was more closely related to Dw3 than B8. The same characteristic has been shown in juvenile diabetes mellitus and idiopathic Addison's disease (Thomsen et il. 1975). In conclusion we have shown an increased frequency of HLA-B8 and Dw3 in patients with Graves' disease. Characteristics as eye involvement and thyroid antibodies could not be correlated to the investigated HLA markers, while the course of the disease seems to be genetically influenced. The HLA-Dw3 deter¬ minant was more firmly associated with the disease than B8 in patients with relapse of Graves' disease. The different prevalence of B8 and Dw3 in patients with and without relapse of Graves' disease after antithyroid treatment in¬ dicates a heterogeneity of the disease entity.
ACKNOWLEDGMENTS The study was supported by grants from the Nordic Insulin Foundation and the Danish Medical Research Council.
REFERENCES Bartels E. D.: Heredity in Graves' Disease. Munksgaard, Copenhagen (1941). Bech K., Larsen J. H., Hansen J. E. M. & Nerup J.: Lancet 2 (1974) 951. Bech K., Nerup J. Se Larsen J. H.: Acta endocr. (Kbh.) 84 (1977) 87. Dausset J., Degos L. Se Hors J.: Clin, immunol. immunopath. 3 (1974) 127. Grumet F. C, Konishi J'., Payne R. O. Se Kriss J. P.: Clin. Res. 21 (1973) 493. Grumet F. C, Konishi J., Payne R. O. Se Kriss J. P.: J. clin. Endocr. 39 (1974) 1115. Haverkorn M. J., Hofman B., Masurel N. Se Rood J. J. van: Transplant. Rev. 22
(1975)
120.
Heimann P.: Acta med. scand. 179 (1966) 113. Jaffiol C, Seignalet J., Baldet L., Robin M., Lapinsky H. Se Mirouze
J.: Ann. Endocr. (Paris) 37 (1976) 111. Kissmeyer-Nielsen F. 8c Kjerbye K. E.: Histocompatibility Testing. Munksgaard, Copenhagen (1967). Konishi J., Grumet F. C, Payne R. O., Mori T. Se Kriss J. P.: Internat. Symp. on HLA and Disease. Inserm. Paris (1976) IV-9. 515 33*
Kotulla H. P., Schleusener H. Se Adlkofer F.: Acta endocr. (Kbh.) Suppl. 204 (1976) No. 16. Larsen J. H. In: Dumonde D. C, Ed. Infection and Immunology in Rheumatic Diseases. WHO/A.R.C. Internat. Symp. Blackwell, London (1975). Lidman K., Eriksson U., Fagraeus A. Se Norberg R.: Lancet 2 (1974) 1449. Lidman K., Eriksson U., Norberg R. Se Fagraeus A.: Clin. exp. Immunol. 23 (1976) 429. Ludwig H., Shernthauer G., Mayr W. R. Se Mehdi S. Q.: Clin. exp. Immunol. 23
(1976)
15.
Nelson S. P. 8c Pallet J. E.: Tissue Antigens 5 (1975) 38. Nerup J., Platz P., Andersen O. O., Christy M., Lyngsoe J., Poulsen J. E., Ryder L. P., Thomsen M., Nielsen L. S. 8c Svejgaard A.: Lancet 2 (1974) 864. Svejgaard A., Jersild C, Nielsen J. S. 8- Bodmer W. F.: Tissue Antigens 4 (1974) 95. Svejgaard A., Platz P., Ryder L. P., Nielsen L. S. 8c Thomsen M.: Transplant. Rev. 22
(1975)
3.
Thomsen M., Platz P., Andersen O. O., Christy M., Lyngsoe J., Nerup J., Rasmussen K., Ryder L. P., Nielsen J. S. Se Svejgaard A.: Transplant. Rev. 22 (1975) 125. Thorsby E., Segaard E., Solem J. H. Se Kornstad L.: Tissue Antigens. 6 (1975) 54. Whittingham S., Morris P. J. 8c Martin F. I. R.: Tissue Antigens 6 (1975) 23. Received
on
March 18th, 1977.
516
Department
Tissue-Typing Laboratory, Rigshospitalet, Rheumatological Research, Gentofte Hospital, Denmark
of
HLA ANTIGENS IN GRAVES' DISEASE
By Karine Bech, Bo Lumholtz, J\l=o/\rnNerup, Mogens Thomsen, Per Platz, Lars P. Ryder, Arne Svejgaard, Kaj Siersb\l=ae\k-Nielsen,
Jens M\l=o/\lholmHansen and J\l=o/\rgenHannover
Larsen
ABSTRACT HLA
typing
of 86 patients with Graves' disease was performed for the series antigens. An increased frequency of HLA-B8 (47 per cent) and Dw3 (51 per cent) compared with controls (23.7 and 21 per cent, respectively) was observed. The increase of B8 and Dw3 was almost exclusively found in a group of 48 patients with relapse of disease, whereas the frequency of B8 and Dw3 in patients without relapse did not differ significantly from that of the control group. No association with the presence of exophthalmos, thyroid antibodies, or antibodies to Yersinia enterocolitica serotype 3 could be found.
A, B, C and D
Antigens of the major human histocompatibility system (HLA) have been reported to function as markers for heredity susceptibility in several diseases (Dausset et al. 1974; Svejgaard et al. 1975). There is no doubt that genetic factors are involved in the development of Graves' disease (Bartels 1941; Presented in part at the 7th Annual Meeting of European Thyroid Association, Helsinki, 1976, and at the First International Symposium on HLA and Disease, Paris, 1976. 510
Heimann
and an association with HLA has previously been reported al. 1974; Whittingham et al. 1975; Jaffiol et al. 1976). In Graves' (Grumet disease like some other endocrine autoimmune diseases the frequency of HLA-B8 is increased which points to the possibility that HLA-B8 or B8 as¬ sociated immune response gene(s) may be the common denominator for de¬ velopment of endocrine autoimmunity (Nerup et al. 1974). Most studies of Graves' disease only concern the antigens of the A, B and C segregant series. The immune response genes are assumed to be located in the neighbourhood of the D locus (Svejgaard et al. 1975). It is therefore of interest to investigate the frequency of some of the D antigens in Graves' disease. It has been proposed that the susceptibility to certain infections is genetically influenced and related to the HLA system (Dausset et al. 1974; Haverkorn et al. 1975). Earlier an increased frequency of antibodies to Yersinia enterocolitica serotype 3 (Y.ent.) in sera from patients with Graves' disease as well as other thyroid disorders has been found (Bech et al. 1974, 1977). The present series of patients was also tested for the occurrence of these antibodies in order to evaluate a possible association with the HLA system.
1966),
et
MATERIAL AND METHODS The material consisted of 86 unrelated, Caucasian Danes with Graves' disease, of which 20 had been treated with subtotal thyroidectomy (no relapses), 131-iodine (no relapses), or were still on antithyroid treatment at time of the investigation. The remaining 66 patients had all been treated with antithyroid drugs to an euthyroid state for at least 12 months (mean 24 months). Of these 48 had relapse of Graves' disease after cessation of the treatment (mean period of observation 21 months), and 18 patients were still euthyroid after an observation of at least 12 months (mean 20 months). The age of the patients ranged from 21 to 85 years (mean 52 years), and 22 patients were men.
The diagnosis was based on clinical and laboratory evidence of hyperthyroidism with or without diffuse goitre. Thyroid function was evaluated clinically and by means of the following parameters: Serum thyroxine, serum T;!-resin test, serum triiodothyronine and 131-iodine uptake by the thyroid gland. The gland was examined by pal¬ pation and TC" scintigraphy in order to characterize the goitre as diffuse or nodular. Anti-microsomal and anti-thyroglobulin thyroid antibodies were studies in 63 patients by immunofluorescence technique and haemagglutination reaction. Antibodies to Y.ent. serotype 3 were determined in 78 patients with an agglutination technique (Larsen
1975).
The microlymphocytotoxicity test was used for typing the serologically defined anti¬ gens (Kissmeyer-Nielsen Se Kjerbye 1967). Twenty-five antigens in A and B series and 4 antigens in series C were typed for. The HLA factors of the D locus were typed for the one-way mixed lymphocyte culture test (Thomsen et al. 1975), and 8 antigens were typed for (Table 1). The control group consisted of healthy, unrelated, Caucasian
Danes. The statistical methods used was the Fisher's exact test, and the relative risk was estimated by the cross-ratio (Svejgaard et al. 1974).
511
HLA
Table 1. in Graves' disease.
antigens
Controls
Patients
Antigen Number
Frequency %>
Number
Frequency °/o
HLA-A28 HLA-Awl9
1967 1967 1967 1967 1967 1967 1967 1967
31.1 56.6 26.9 17.3 9.6 10.1 10.0 17.8
86 86 86 86 86 86 86 86
44 51 33 17 4 4 11
HLA B5 HLA B7 HLA B8 HLA B12 HLA B13 HLA B14 HLA- B18 HLA B27 HLA- Bwl5 HLA- Bwl6 HLA Bwl7 HLA Bw21 HLA- Bw22 HLA- Bw35 HLA- Bw37 HLA- Bw40 HLA- Bw41
1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1967 1492 1967 1492
10.6 26.8 23.7 25.2 4.3 4.5 7.1 8.6 17.9
5 20 47 21
5.4 7.7 3.5 3.8 13.1 2.1 17.9 1.7
86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86 86
HLA-Cwl HLA-Cw2 HLA-Cw3 HLA-Cw4
426 426 426 426
8.4 11.0 37.0 17.1
86 86 86 86
4 7 27
HLA Dwl HLA Dw2 HLA Dw3 HLA- Dw4 HLA- Dw5 HLA- Dw6 HLA- Dw7 HLA- Dw8
91 157 157 157 34 89 157 157
18.9 23.6 21.0 17.2 8.8 18.0 9.6 8.9
29 86 86 86 9 29 86 45
21 26 51 15
HLA-A1 HLA-A2 HLA-A3 HLA-A9 HLA-A10 HLA-A11
512
20
4 1 5 6 15 1 6 7 4 15 1 21 1
12
11 21 15 4
Relative risk
1.8 0.9
1.3 1.0 0.4 0.4 1.1 1.2
0.0084 0.34 0.15 0.53 0.033 0.023 0.50 0.37
0.5 0.7 2.8 0.8 0.9 0.4 0.7 0.7 0.8 2.1 0.8 1.2 1.0 1.2 0.8 1.2 1.0
0.10 0.27 0.24 0.31 0.048 0.35 0.64 0.59 0.34 0.45 0.28 0.58
0.39 0.6 0.6 0.6
0.011 0.18 0.042 0.13
1.1 1.1 3.9
0.5 0.4 1.7 x 10-6 0.4 0.6 0.5 0.14 0.26
0.86 1.3 1.2 1.7 0.48
0.045 0.091 5.7 x 10-6 0.23 0.50
RESULTS
We found an increased frequency of HLA-B8 of 47 per cent (P 5.7 x 10-6, relative risk 2.8) and Dw3 of 51 per cent (P 1.7 x 10"6, relative risk 3.9) com¬ pared with 23.7 and 21 per cent in the controls (Table 1). The associations remained significant after multiplication of the P-value by the number of anti¬ gens tested. Thirty-five of the patients had lid retraction or eye profusion and the anti-microsomal or anti-thyroglobulin antibodies were detectable in 68 per cent (43 of 63 patients). Y. ent. serotype 3 antibodies (titre ^ 10) were found in 51 per cent (40 of 78 patients). No association between the HLA deter¬ minants and these features was found (Table 2), and there was no association with sex or age. On the other hand, in patients with relapse of Graves' disease the frequency of HLA-B8 and Dw3 increased even more to 54 and 65 per cent (P=7.4x lu6, and 3.9 x 10s), while in the patients without relapse the fre¬ quencies were only 33 per cent, and did not differ statistically significant from the controls (P 0.24 and 0.18). The risk to get relapse of the disease in pa=
=
=
Table 2. The association between HLA-Dw3 and some characteristical features of Graves' disease. HLA-Dw3 Total
Patients with relapse Patients without relapse Patients with eye involvement Patients without eye involvement Patients with thyroid antibodies (titre ;> 4) Patients without thyroid antibodies (titre < 4) Patients with yersinia antibodies (titre ¡> 10) Patients without yersinia antibodies (titre < 10)
Present
Absent
31(65%) 6 (33 %>)
17 12
48 18
18
(51 °/o)
17
35
26
(51 %>)
25
51
23
(53 %>)
20
43
12(60°/o)
8
20
(53 °/o)
19
40
20(53%)
18
38
21
Significance P-value*
0.01É
66
1.0
86
0.19
63
1.0
78
Fisher's exact test.
513 Acta endocr. 86, 3
33
tients with HLA-B8 and Dw3 is 81 and 84 per cent (26 of 32, and 31 of 37 patients) compared to 65 and 59 per cent (22 of 34, and 17 of 29 patients) in HLA-B8 and Dw3 negative patients. This is statistically significant in case of HLA-Dw3 (P 0.02, Table 2). =
DISCUSSION
The finding of the increase of HLA-B8 in Caucasian patients with Graves' disease was first reported by Grumet et al. (1973), and was later confirmed (Grumet et al. 1974; Whittingham et al. 1975; Thomsen et al. 1975; Thorsby et al. 1975; Jaffiol et al. 1976). However, Nelson 8c Pollet (1975) could not verify this observation. In the present study the prevalence of HLA-B8 was found to be 47 per cent of the patients with Graves' disease in accordance with the previous studies. From combined analysis of all studies known by the HLA and Disease Registry in Copenhagen it appears that the increase of HLA-B8 is of prime importance. The increase of HLA-Al is probably due to linkage disequilibrium with B8. In a normal population there is also an asso¬ ciation between HLA-B8 and Dw3. An increase of HLA-Dw3 was reported by us (Thomsen et al. 1975) in a preliminary sample of 39 patients included in this report. This finding was confirmed by Thorsby et al. (1975) in a small series. In the present study HLA-Dw3 was found to be increased to 54 per cent in accordance with these investigators. In a Japanese population where the HLA-B8 antigen is absent, the HLA-Bw35 antigen is increased to the same extent as B8 in the Caucasian population (Konishi et al. 1976). Moreover, in the Japaneses the association with HLA-Bw35 seems to be secondary to an increase of a HLA-D determinant (HO) which is different from HLA-Dw3 (Sazazuki, personal communication), and HLA-Dwl, which is associated with HLA-Bw35 in Caucasians (Thomsen, unpublished). Attempt to correlate different characteristic features of the disease with the HLA system has given conflicting results. Thorsby et al. (1975) found an as¬ sociation between HLA-B8 and the presence of thyroid antibodies, and Ludwig et al. (1976) have reported an association between Cw3 and ophthalmopathy. Kotulla et al. (1976) tried to correlate the presence of thyroid stimulating immunoglobulins studied by human receptor assay with the HLA system but could not find any assocation. We could not find correlation between the HLA anti¬ gens studied and exophthalmos, thyroid antibodies, sex or age. In an earlier study increased frequency of Y. ent. serotype 3 antibodies in patients with Graves' disease as well as non-toxic goitre was found (Bech et al. 1974, 1977). Lidman et al. (1974, 1976) have shown a transient immunofluorescence of the thyroid cell membrane in patients with acute yersiniosis. In pa¬ tients with increased susceptibility to thyroid diseases the lipopolysaccharides 514
of the Y. ent. could have special affinity to the thyroid cell membrane and give rise to development of abnormal thyroid function. If this hypothesis is correct. an association with the HLA system might be demonstrable. We could not find any clear association between any of the studied antigens and the pre¬ sence of Y. ent. antibodies in the serum, but the serum samples were obtained at different times after disease onset which might have influenced the results. It was striking that the course of the disease seems to be genetically deter¬ mined as the frequency of HLA-B8 and Dw3 was higher in patients with relapse of Graves' disease in contrast to patients without relapse. The frequency of Dw3 was higher than B8, and furthermore, all B8 positive patients were also Dw3 positive. Thus, the disease association was more closely related to Dw3 than B8. The same characteristic has been shown in juvenile diabetes mellitus and idiopathic Addison's disease (Thomsen et il. 1975). In conclusion we have shown an increased frequency of HLA-B8 and Dw3 in patients with Graves' disease. Characteristics as eye involvement and thyroid antibodies could not be correlated to the investigated HLA markers, while the course of the disease seems to be genetically influenced. The HLA-Dw3 deter¬ minant was more firmly associated with the disease than B8 in patients with relapse of Graves' disease. The different prevalence of B8 and Dw3 in patients with and without relapse of Graves' disease after antithyroid treatment in¬ dicates a heterogeneity of the disease entity.
ACKNOWLEDGMENTS The study was supported by grants from the Nordic Insulin Foundation and the Danish Medical Research Council.
REFERENCES Bartels E. D.: Heredity in Graves' Disease. Munksgaard, Copenhagen (1941). Bech K., Larsen J. H., Hansen J. E. M. & Nerup J.: Lancet 2 (1974) 951. Bech K., Nerup J. Se Larsen J. H.: Acta endocr. (Kbh.) 84 (1977) 87. Dausset J., Degos L. Se Hors J.: Clin, immunol. immunopath. 3 (1974) 127. Grumet F. C, Konishi J'., Payne R. O. Se Kriss J. P.: Clin. Res. 21 (1973) 493. Grumet F. C, Konishi J., Payne R. O. Se Kriss J. P.: J. clin. Endocr. 39 (1974) 1115. Haverkorn M. J., Hofman B., Masurel N. Se Rood J. J. van: Transplant. Rev. 22
(1975)
120.
Heimann P.: Acta med. scand. 179 (1966) 113. Jaffiol C, Seignalet J., Baldet L., Robin M., Lapinsky H. Se Mirouze
J.: Ann. Endocr. (Paris) 37 (1976) 111. Kissmeyer-Nielsen F. 8c Kjerbye K. E.: Histocompatibility Testing. Munksgaard, Copenhagen (1967). Konishi J., Grumet F. C, Payne R. O., Mori T. Se Kriss J. P.: Internat. Symp. on HLA and Disease. Inserm. Paris (1976) IV-9. 515 33*
Kotulla H. P., Schleusener H. Se Adlkofer F.: Acta endocr. (Kbh.) Suppl. 204 (1976) No. 16. Larsen J. H. In: Dumonde D. C, Ed. Infection and Immunology in Rheumatic Diseases. WHO/A.R.C. Internat. Symp. Blackwell, London (1975). Lidman K., Eriksson U., Fagraeus A. Se Norberg R.: Lancet 2 (1974) 1449. Lidman K., Eriksson U., Norberg R. Se Fagraeus A.: Clin. exp. Immunol. 23 (1976) 429. Ludwig H., Shernthauer G., Mayr W. R. Se Mehdi S. Q.: Clin. exp. Immunol. 23
(1976)
15.
Nelson S. P. 8c Pallet J. E.: Tissue Antigens 5 (1975) 38. Nerup J., Platz P., Andersen O. O., Christy M., Lyngsoe J., Poulsen J. E., Ryder L. P., Thomsen M., Nielsen L. S. 8c Svejgaard A.: Lancet 2 (1974) 864. Svejgaard A., Jersild C, Nielsen J. S. 8- Bodmer W. F.: Tissue Antigens 4 (1974) 95. Svejgaard A., Platz P., Ryder L. P., Nielsen L. S. 8c Thomsen M.: Transplant. Rev. 22
(1975)
3.
Thomsen M., Platz P., Andersen O. O., Christy M., Lyngsoe J., Nerup J., Rasmussen K., Ryder L. P., Nielsen J. S. Se Svejgaard A.: Transplant. Rev. 22 (1975) 125. Thorsby E., Segaard E., Solem J. H. Se Kornstad L.: Tissue Antigens. 6 (1975) 54. Whittingham S., Morris P. J. 8c Martin F. I. R.: Tissue Antigens 6 (1975) 23. Received
on
March 18th, 1977.
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