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Type 1 Diabetes and Autoimmune Polyglandular Syndrome: a Clinical Review

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Type 1 Diabetes and Autoimmune Polyglandular Syndrome: a Clinical Review REVIEW type 1 diabetes and autoimmune polyglandular syndrome: a clinical review A. Van den Driessche, V. Eenkhoorn, L. Van Gaal, C. De Block* Department of Diabetology and Endocrinology, Antwerp University Hospital, Edegem, Belgium, *corresponding author: tel.: 32-3-821 32 78, fax: 32-3-825 49 80, e-mail: [email protected] abstraCt Keywords type 1 diabetes mellitus (t1dM) results from autoimmune Autoantibodies, autoimmune polyglandular syndrome, destruction of insulin-producing β cells and is characterised type 1 diabetes mellitus by the presence of insulitis and β-cell autoantibodies. up to one third of patients develop an autoimmune polyglandular syndrome. fifteen to 30% of t1dM subjects introduCtion have autoimmune thyroid disease (hashimoto’s or graves’ disease), 5 to 10% are diagnosed with autoimmune gastritis Type 1 diabetes mellitus (T1DM), arising through a complex and/or pernicious anaemia (AIG/PA), 4 to 9% present interaction of immune, genetic and environmental factors, with coeliac disease (Cd), 0.5% have addison’s disease results from autoimmune destruction of insulin-producing (AD), and 2 to 10% show vitiligo. these diseases are β cells. T1DM is characterised by the appearance of characterised by the presence of autoantibodies against insulitis and the presence of β-cell autoantibodies.1 In up to thyroid peroxidase (for hashimoto’s thyroiditis), TSH one third of patients the autoimmune attack is not limited receptor (for graves’ disease), parietal cell or intrinsic to β cells, but expands into an autoimmune polyglandular factor (for AIG/PA), tissue transglutaminase (for Cd), syndrome.2-8 Of type 1 diabetic subjects, 15 to 30% have and 21-hydroxylase (for AD). early detection of antibodies autoimmune thyroid disease (Hashimoto’s or Graves’ and latent organ-specific dysfunction is advocated to alert disease), 5 to 10% are diagnosed with autoimmune gastritis physicians to take appropriate action in order to prevent and/or pernicious anaemia (AIG/PA), 4 to 9% present with full-blown disease. coeliac disease (CD), 0.5% have Addison’s disease (AD), hashimoto’s hypothyroidism may cause weight gain, and 2 to 10% show vitiligo (table 1).2-8 hyperlipidaemia, goitre, and may affect diabetes control, In this clinical review we will discuss prevalence, menses, and pregnancy outcome. in contrast, graves’ predisposing factors (age, immune, genetic, hyperthyroidism may induce weight loss, atrial fibrillation, environmental), clinical presentation, and suggestions for heat intolerance, and ophthalmopathy. autoimmune screening, follow-up and treatment of patients with type 1 gastritis may manifest via iron deficiency or vitamin b12 diabetes and/or autoimmune polyglandular syndrome. deficiency anaemia with fatigue and painful neuropathy. Clinical features of coeliac disease include abdominal discomfort, growth abnormalities, infertility, low bone autoimmunity mineralisation, and iron deficiency anaemia. adrenal insufficiency may cause vomiting, anorexia, hypoglycaemia, Organ-specific autoimmunity is frequent in T1DM subjects. malaise, fatigue, muscular weakness, hyperkalaemia, This might be due to the fact that these patients show multiple hypotension, and generalised hyperpigmentation. immunological abnormalities. These include an imbalance here we will review prevalence, pathogenetic factors, in B and T lymphocytes, or an increased tendency to react clinical features, and suggestions for screening, follow-up strongly against certain antigens or a (genetically determined) and treatment of patients with t1dM and/or autoimmune poor ability to develop tolerance to autoantigens.1,6 Individuals polyglandular syndrome. with one autoimmune disease are known to be at increased risk for other autoimmune processes.3 © Van Zuiden Communications B.V. All rights reserved. december 2009, vol. 67, no 11 376 table 1. Prevalence of organ-specified autoantibodies and autoimmune diseases disease or AB general population type 1 diabetes mellitus Coeliac disease addison’s hypothyroidism Type 1 diabetes mellitus 2-3% xxx 12-14% 4% anti-islet AB 1-3% 85-90% Coeliac 0.5% 1-8% xxx 5% 4% transglutaminase AB 0.5-1% 8-12% 99% Addison’s 0.005% 0.5% xxx 21-hydroxylase AB 0-0.6% 0.7-3% 83-90% Hypothyroidism 5-9% 30% 3-12% 14-21% xxx aTPO 2-10% in adults 15-30% in adults 18% 23-40% 47-83% 1-4% in children 5-22% in children Graves’ 0.1-2% 6-10% 10-20% TSH receptor AB ? ? Pernicious anaemia/ 2% for AIG 5-10% for AIG autoimmune gastritis 0.15-1% for PCA 2-4% for PCA 6% 2% PCA 2.5 - 12% 15-25% in adults 10-15% in children AB = antibody; AIG = autoimmune gastritis; pCa = parietal cell antibodies; t1dM = type 1 diabetes mellitus. Most of the autoimmune endocrine disorders appear initially Other important genetic factors include the cytotoxic as infiltration of the gland by lymphocytes and macrophages. T lymphocyte-associated antigen-4 (CTLA-4), the MHC This may lead to destruction and atrophy of the gland with I-related gene A (MIC-A) and the protein tyrosine deficiency of its hormone. The destructive process is presumed phosphatase nonreceptor type 22 (PTPN22).11-14 The to be T-cell mediated. Antibodies to certain antigens of the CTLA-4, being expressed on activated CD4+ and CD8+ gland, mostly intracellular enzymes, appear in the blood. These T-cell membranes, inhibits T-cell activation by binding include thyroid peroxidase (for Hashimoto’s thyroiditis), thyroid costimulatory molecules. Polymorphisms within the stimulating hormone (TSH) receptor (for Graves’ disease), CTLA-4 gene have been associated with T1DM and parietal cell or intrinsic factor (for autoimmune gastritis/ autoimmune thyroid disease, particularly the CT60 A/A pernicious anaemia), endomysial or tissue transglutaminase polymorphism, and with Addison’s disease.13,14 The MIC-A (for CD), and 21-hydroxylase antibodies (for AD).2-8 The role protein is expressed in the thymus and is thought to of such antibodies remains unclear, but they are important as interact with a receptor, NKG2D, which may be important diagnostic messengers and appear commonly before clinical for thymic maturation of T cells.15 NKG2D regulates the hormone deficiency. Thus screening for these antibodies priming of human naive CD8+ T cells, providing a possible allows early detection and the potential to prevent significant explanation for the association with autoimmune diseases.16 morbidity related to unrecognised disease. However, the MIC-A polymorphisms have also been linked to T1DM, frequency of screening for and follow-up of patients with (the 5 allele and 5.1 allele),17 coeliac disease (allele 4 and positive autoantibodies remain controversial. 5.1),18,19 and Addison’s disease (allele 5.1).20 The PTPN22 gene is expressed in T cells, encoding for lymphoid tyrosine There are several direct links between genetics and phosphatase (LYP). A specific polymorphism at position autoimmune disease: the developmental maturation of T 620 (Arg → Trp) may decrease that ability of LYP to interact cells in a genetically susceptible individual occurs through with its target molecules and down-regulate T-cell receptor molecular interactions between the T-cell receptor and the signalling.21,22 This has been observed in Graves’ disease HLA-antigen complex. Selection of T cells with receptors and weakly in Addison’s disease.23 likely to contribute to autoreactivity may preferentially occur in the context of specific HLA-DQ alleles that are prone to diabetes, autoimmune thyroid disease, AD, CD, and other autoimmune polyglandular auto-immune diseases.3,9-12 Indeed, disease-prone HLA syndroMes molecules may be ineffective at binding and presenting peptides derived from tissue-specific antigens, and such a In 1866, Ogle was the first to describe the association poor presentation in the thymus could impair mechanisms between diabetes mellitus and Addison’s disease. of negative selection allowing autoreactive T cells to survive However, the adrenal insufficiency in this case was due to the passage through the thymus. Subsequent activation of tuberculosis. In 1910, Parkinson first described a patient these T cells in the context of recognising islet-associated with coexisting diabetes and pernicious anaemia. In 1926, antigens can trigger a poorly regulated immune response Schmidt reported two cases of Addison’s disease associated that results in progressive tissue destruction. with lymphocytic thyroiditis.24 In 1931, Rowntree and Snell Van den Driessche, et al. Type 1 diabetes and autoimmune polyglandular syndrome. december 2009, vol. 67, no 11 377 described the unprecedented findings of an association • Animal models of T1DM (NOD mouse, BB rat) that between Addison’s disease, Graves’ disease and T1DM. show a defect in immunoregulation contributing to the A year later Gowen reported the first case of Addison’s onset of disease. disease, Hashimoto’s thyroiditis and T1DM. The presentation of these autoimmune diseases as One or more β-cell autoantibodies are present in associated disorders led to the definition and classification approximately 90% of new-onset patients with type 1 of autoimmune polyendocrine syndromes I and II, by diabetes.27 They appear to develop sequentially. Insulin Neufeld, Maclaren and Blizzard in 1980.25 Both are autoantibodies are often the first expressed, especially associated with type 1 diabetes in about 20% of cases.3 in younger children.31-33 GADA positivity is suggested to The autoimmune polyendocrine syndrome I (APS-I), represent a propensity for general autoimmunity, while also known as autoimmune polyendocrinopathy,
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