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Autoimmune Thyroiditis – Correlation Between Thyroid Hormone Status and AMA Titre Arun Chopwad, Shweta P. Bijwe. Autoimmune thyroiditis – Correlation between thyroid hormone status and AMA titre. IAIM, 2018; 5(3): 34-43. Original Research Article Autoimmune thyroiditis – Correlation between thyroid hormone status and AMA titre Arun Chopwad1, Shweta P. Bijwe2* 1M.D. Pathology, Seth G.S. Medical College, Mumbai, Maharashtra, India 2M.D.Pathology, IGGMC, Nagpur, Maharashtra, India *Corresponding author email: [email protected] International Archives of Integrated Medicine, Vol. 5, Issue 3, March, 2018. Copy right © 2018, IAIM, All Rights Reserved. Available online at http://iaimjournal.com/ ISSN: 2394-0026 (P) ISSN: 2394-0034 (O) Received on: 20-02-2018 Accepted on: 25-02-2018 Source of support: Nil Conflict of interest: None declared. How to cite this article: Arun Chopwad, Shweta P. Bijwe. Autoimmune thyroiditis – Correlation between thyroid hormone status and AMA titre. IAIM, 2018; 5(3): 34-43. Abstract Background: Thyroiditis is the second most common thyroid lesion next to endemic goitre diagnosed on FNA in iodine (I2) deficient areas. This study was carried out to study correlation between thyroid hormone status with anti-thyroid antibodies in cases of autoimmune thyroiditis diagnosed on FNAC. Aim: To correlate thyroid hormone status with anti-thyroid antibodies in cytologically diagnosed cases of autoimmune thyroiditis. Materials and methods: This was a retrospective study carried out in a tertiary care teaching hospital. 150 cases diagnosed as autoimmune thyroiditis in a two year period from January 2010 to December 2011 formed the study group. The clinical history, TFT, and AMA tires were noted from the medical record available with the patient and also from Endocrinology department records. Results: Incidence of autoimmune thyroiditis was found to be 13.4%. Majority of the patients were females (96.7%), 53.3% of cases were seen in the age group 21-40 years age group. Of the patients with autoimmune thyroiditis, 110(73.3%) patients were euthyroid while 32 (21.3%) patients were hypothyroid at the time of FNAC. Only 8(5.3%) patients showed evidence of hyperthyroidism. 8% patients showed subclinical hypothyroidism. In 97 patients anti-microsomal antibody titre (AMA) was available, 83 were positive i.e.85.6% positivity. Of the cytologically diagnosed cases of autoimmune thyroiditis, 14.4% cases showed AMA negativity. Thus FNAC remains the gold standard for the diagnosis. Conclusion: Autoimmune thyroiditis was seen more commonly in females, majority cases were seen in age group of 21-40 years. Euthyroid autoimmune thyroiditis was common in our study. Anti- microsomal antibody titre (AMA) was available in 97 cases, out of which 83 were positive i.e.85.6% positivity. Of the cytologically diagnosed cases of autoimmune thyroiditis, 14.4% cases showed AMA Page 34 Arun Chopwad, Shweta P. Bijwe. Autoimmune thyroiditis – Correlation between thyroid hormone status and AMA titre. IAIM, 2018; 5(3): 34-43. negativity. Thus FNAC remains the gold standard for the diagnosis in subjects with a clinical diagnosis of Hashimoto’s thyroiditis and negative antibody results. Key words Autoimmune thyroiditis, AMA, TFT. Introduction autoimmune thyroiditis, chronic thyroiditis, and Autoimmune thyroiditis lymphadenoid goiter [7]. There is no internationally accepted classification of autoimmune thyroid diseases. Hashimoto’s / Incidence and distribution of the disease chronic lymphocytic thyroiditis are a part of the The prevalence of autoimmune thyroiditis spectrum of autoimmune thyroid diseases. At one reported in studies varies with the criteria for end of this spectrum is Hashimoto’s thyroiditis, diagnosis, the decade when the study was which usually presents as hypothyroidism and at performed, and the patients studied. other end is Grave’s disease [1]. In favour of this interpretation is the existence of cases sharing Diagnostic criteria have included a positive test features of both disease (sometimes designated for thyroid autoantibodies in serum, an elevated as Hashitoxicosis), suggesting that one may serum thyrotropin concentration, and the evolve into another [2, 3]. presence of lymphocytic infiltration of the thyroid at autopsy. During the past few decades Some investigators consider autoimmune there has been a reported increase in the thyroiditis as a histologic diagnosis that may be incidence of Hashimoto’s thyroiditis, which subdivided into lymphocytic thyroiditis if only could be attributed to newer diagnostic lymphocytic infiltration is present and as modalities such as needle biopsies and Hashimotos thyroiditis if atrophy and oncocytic serological tests, and their increased sensitivity change of the epithelium is seen [1]. Many others when compared to the older methods [8]. use chronic lymphocytic thyroiditis and Hashimoto’s thyroiditis as synonymous terms [4, Autoimmune thyroiditis is about 15-20 times 5]. more common in women than in men and frequently involves people between the ages of Clinically, chronic autoimmune thyroiditis is said 30 and 50 years of age. to have two forms – A goitrous form which is often referred to as Hashimoto’s thyroiditis and Chronic autoimmune thyroiditis is rare in an atrophic form called atrophic thyroiditis [6]. children younger than five years of age, but it does occur in children and accounts for 40 Grave’s disease – diffuse goiter with percent or more of cases of goiter in adolescents hyperthyroidism, ophthalmopathy or both is thus [9]. a related autoimmune disease but not a form of autoimmune thyroiditis. The prevalence of positive tests for thyroid antibodies increases with age, with frequencies Hashimoto’s thyroiditis was first described in as high as 33 percent in women 70 years old or 1912 by Dr. Hakuru Hashimoto. Based on the older. histological findings, Hashimoto originally used the term “Struma Lymphomatosa.” Over the Etiology and Pathogenesis years, this disease has been called by several The etiology of autoimmune thyroiditis is names including lymphocytic thyroiditis, considered to be multifactorial, involving the Page 35 Arun Chopwad, Shweta P. Bijwe. Autoimmune thyroiditis – Correlation between thyroid hormone status and AMA titre. IAIM, 2018; 5(3): 34-43. interplay of various environmental and genetic peripheral tolerance. Loss of immune tolerance factors. has been associated with genetically determined immune defects or with the lack of regulatory T- The pathogenesis of Hashimoto’s thyroiditis is a cells which impose the suppressive function [14]. complex multistep process which involves This is followed by formation, clonal expansion, various genetic, environmental and and maturation of self-reactive T-lymphocytes immunological factors [10]. Loss of immune and B-lymphocytes in the draining lymph nodes. tolerance to normal thyroid cells leads to production of antibodies directed against thyroid This step is then followed by a central phase of tissue, which causes the destruction of the autoimmunity, characterized by uncontrolled thyroid gland. The initial inflammatory changes production of self-reactive cells and in the disease process are triggered when autoantibodies in response to the presented genetically predisposed individuals are exposed antigens. This process initially occurs in the to the above mentioned environmental factors. lymph nodes but as the disease progresses the The major histocompatibility complex (MHC) production process shifts to the thyroid gland class 2 antigen presenting cells, which include where the development of lymphoid tissue dendritic cells and macrophages, invade the follows. The stimulated B-lymphocytes produce thyroid gland after the initial inflammatory anti-thyroglobulin (TGAB) and anti-thyroid process. These cells present the autoantigen peroxide (ATPO) antibodies which are directed components of the thyroid gland to the immune against thyroid cells. The autoreactive T-cells, system for processing. Among the myriad of which are produced in the disease process, potential auto-antigens, thyroglobulin, the main infiltrate the thyroid gland and mediate protein produced in thyroid tissue, is believed to destruction through cytotoxicity with the aid of play a central role in the pathogenesis of this CD+8 cells. The macrophages which are disease [11]. The thyroglobulin protein has been stimulated in this process produce numerous reported to have approximately 40 different types cytokines which, along with antibodies, initiate of epitopes, which play a vital role in the the process of tissue destruction via apoptosis. pathogenesis of the disease [12]. In contrast to the epitope recognition pattern of normal As a final step in the process, caspases, which are individuals, the epitope recognition pattern of the self-activated through proteolytic cleavage, antibodies in autoimmune thyroid disease is induce enzymes which are directly involved in altered triggering immune and inflammatory the destruction of thyroid gland. In a normal processes [13]. Thyroid peroxide, an enzyme that thyroid gland, the production of new cells and catalyzes the oxidation of iodine, also plays a the destruction of old cells are tightly regulated significant role as an autoantigen in the disease so that a constant proportion of functioning cells pathogenesis. Moreover, 180 different types of is always present. During the course of the thyroid peroxide antibodies have been identified, disease, the control over destruction of cells in thus far. Studies have confirmed that even the thyroid gland is lost. though antibodies against thyrotropin receptor
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