Characteristics of Allergy in Autoimmune Thyroid Diseases Ildikó

Characteristics of allergy in autoimmune thyroid diseases

Ildikó Molnár MD, PhD, EndoMed, Hungary

ImmunSum, Baltimore, 2014 Relationship between allergic responses and thyroid autoimmunity

IgE levels  IgE deposits are present in Graves’ thyroid and orbital tissues (Werner SC et al., N Engl Med, 1972;287:421-425.; Raikow RB et al., Ophthalmol. 1990; 97:629-635.)  Elevated IgE levels associated with hyperthyroid Graves’ disease (Akira S et al., J Clin Endocrinol Metab 1999; 84:3602-3605.; Takashi Y et al., J Clin Endocrinol Metab 2000; 85:2775- 2778.)  Evidence of immunglobulin E autoantibodies to thyrotropin receptor (TSH rec) and thyroid peroxidase (TPO) (Metcalfe R et al., J Clin Endocrinol Metab 2002;87:1754-1761.; Gou J et al., Clin Immunol Immunopathol 1997; 82: 157-162.) Th2-derived cytokine profils  Elevated serum levels of IL-5 and IL-13 cytokines. (Hidaka Y et al., Thyroid 1998; 8:235-239.; Ichiro K et al., J Clin Endocrinol Metab 2001; 86:3540-3544.) Allergic rhinitis associated frequently with Graves’ disease (Amino N et al., Thyroid 2003; 13:811-814.; Hidaka Y et al., Thyroid 1996; 6: 349-351.) Common key factors regulate the immune responses in both allergic and autoimmune conditions (Rottem M et al., Dev Immunology 2002; 9: 161-167.)

ImmunSum, Baltimore, 2014 Previous results  Graves’ ophthalmopathy associated with increased total IgE serum levels.

Molnár I et al., Eur J Med Rev 1996; 1:543-546.

 Hyperthyroid Graves’ ophthalmopathy demonstrated elevated serum IL-5 levels compared to patients who had no eye signs.

Molnár I , Abstract: ACT International Suppl., 2000; 2: 220.

 Decreased serum levels of nerve growth factor (NGF) associated with hyperthyroid Graves’ ophthalmopathy compared to those who had no eye signs.

Molnár I et al., Cytokine 2006; 35: 109-114.

 A difference in the balance shift of IL-12/IL-5 between Graves’ patients with and without ophthalmopathy was demonstrated.

Molnár I , Autoimmunity 2007; 40:31-37.

ImmunSum, Baltimore, 2014 Patients and methods  324 patients were investigated, of whom 149 suffered from Graves’ disease (57 with ophthalmopathy), 110 had Hashimoto’s thyroiditis, and 65 euthyroid goitre formed controls.  Allergen-specific IgE detection was carried out with immunoblot method using commercial AllergyScreenTM test (MEDIWISS Analytic GmbH, Germany) and Kodak camera was used for evaluation. The levels of thyroid hormones and antibodies were measured using commercial kits in a fully automated way, except TSH receptor antibody,that was measured with radioimmunoassay (Brahms Diagnostics,Germany).  Chi-squared with Yates correction and Mann-Whitney nonparametric comperative tests were used for statistical analysis. Parameters Graves’disease Hashimoto’s Controls n=149 thyroiditis n=110 n=65 Age (years) 49 ± 13 50 ± 14 48 ± 13 Gender (male / 28 / 121 6 / 104 4 / 61 women) Duration of thyroid disease 71 ± 81 44 ± 57 38 ± 45 (months) ImmunSum, Baltimore, 2014 Respiratory allergens

ImmunSum, Baltimore, 2014 Prevalence of allergic symptoms in autoimmune thyroid diseases

Allergic Graves’disease Hashimoto’s Controls symptoms (n=149) thyroiditis (n=65) Total (n=110) No 94 63 54 211 (63,1%) (57,3%) (83,1%) (65,1%) a a Rhinitis * 11 20 10 41 (7,4%) (18,2%) (15,4%) (12,7%) Conjunctivitis 37 b 21 c 0 b, c 58 (24,8 %) (19,1%) (17,9%) Urticaria 7 5 1 13 (4,7%) (4,5%) (1,5%) (4%) Asthma 0 1 0 1 (0,9%) (0,3%) Total 149 110 65 324

a P < 0,014 , b P< 0,0001 and c P< 0,0004 after Yates correction *P<0,0007 after Yates correction between Graves’ patients with (n=57) and without (n=92) eye signs:32 (9,9%) vs 5 (1,5%). ImmunSum, Baltimore, 2014 The month of the onset of autoimmune thyroid diseases was similar to those characterized by the seasonal allergic attack

Month for thyroidal onset Graves’disease Hashimoto’s Controls and seasonal (n=149) thyroiditis (n=65) Total allergic attack is (n=110) common No 77 90 48 215 (81,9%) (92,8%) (78,7%) (85,3%) Common 17 a 7 a,b 13 b 37 (18,1%) (7,2%) (21,3%) (14,7%) Total 94 97 61 252*

a P < 0,04 and b P< 0,02 * No exact data were given in 72 cases

ImmunSum, Baltimore, 2014 Prevalence of allergen-specific IgE in autoimmune thyroid diseases

Allergen Graves’disease Hashimoto’s Controls groups (n=149) thyroiditis (n=65) Total (n=110) D (dust mite I-II) 33 25 7 65 (22,1%) (22,7%) (10,8%) (20,1%) T (alder, birch, hazel) 25 a 7 a 6 38 (16,8%) (6,4%) (9,2%) (11,7%) W (mugwort, plantain, 35 b 12 b 10 57 ragweed) (23,5 %) (10,9%) (16,4%) (17,6%) G (grass-mixture) 30 14 7 51 (20,1%) (12,7%) (10,8%) (15,7%) E (cat, dog and others 40 23 19 82 epithelia, feather-mixture) (26,8%) (20,9%) (29,2%) (25,3%) M (molds*) 10 4 4 18 (6,7%) (3,6%) (6,2%) (5,6%) Total 149 110 65 324 a b P < 0,02 and P< 0,015 * Alternaria,Aspergillus, Cladosporium, Penicillium ImmunSum, Baltimore, 2014 Hashimoto’s Graves’ disease (n=149) Graves’ disease (n=149) thyroidiitis (n=110)

Controls (n=65) Hashimoto’s thyroidiitis (n=110) Controls (n=65)

10 P<0.02 12,0 8 P<0.02 P<0.01 9 7 10,0 8 P<0.05 P<0.02 6 7 P<0.02 8,0 P<0.04

specific specific IgE(%) 5 -

6 specific IgE(%)

- specific specific IgE(%)

- P<0.04 5 6,0 4 4 3 4,0 3 2 2 P<0.02 2,0

1 1 Prevalence of allergen Prevalence

0 0,0 of allergen Prevalence 0 Prevalence of allergen Prevalence Dust Alder Alder Birch Hazel Ragweed Grass- Hamster Dust- mite II (T2) (T2) (T3) (T4) (W1) mixture epithelia mite II (D2) (Gx) (E84) (D2)

ImmunSum, Baltimore, 2014 Graves’ ophthalmopathy Hashimoto’s thyroiditis Graves’ disease without eye signs

30 P<0.04 * 25

10 specific IgE levels (IU/ml) levels IgE specific - * 5

Allergen 0 D1 D2 T2 T3 T4 W1 Gx G12 W6 E1 E2 E84 (dust-mite) (alder) (birch) (hazel) (ragweed) (rye pollen) (cat) (dog) (hamster I II (grass-mixture) (mugwort) epithelia)

ImmunSum, Baltimore, 2014 30 P<0,01

P<0,012 Patient groups 25 Graves'diseases without ophthalmopathy 20 Graves' ophthalmopathy P<0,046 15 P<0,021 P<0,033

specific IgE levels (IU/ml) -

5 Allergen 0 T2 T3 T4 W1 Gx G12 E1 E5 M2 alder birch hazel ragweed grass- rye pollen cat dog cladosporium mixture epithelia

ImmunSum, Baltimore, 2014 Allergen-specific IU/ml Class IgE content <0,35 0 none 0,35 – 0,69 1 low 0,7 – 3,4 2 increased 3,5 – 17,4 3 significantly increased 17,5 – 49,9 4 high 50 - 100 5 very high >100 6 extremely high

ImmunSum, Baltimore, 2014 35 Patient groups

Hyperthyroid Euthyroid Hypothyroid 30 Class 1-2 3-4

specific IgE levels (IU/ml) -

5 Allergen 0 D1 D2 T2 T3 T4 W1 Gx G12 E1 E5 dust-mite alder birch hazel ragweed grass- rye pollen cat dog I II mixture epithelia

ImmunSum, Baltimore, 2014 Graves’ disease 30 TSH receptor antibody negative

TSH receptor antibody positive 25

specific IgE levels (IU/ml) -

5 P<0,032 Allergen 0 D1 D2 T2 T3 T4 W1 Gx G12 W6 W9 E1 E5 M2 M3 dust-mite alder birch hazel ragweed rye pollen plantain cat dog cladosporium I II grass-mixture mugwort epithelia aspergillus ImmunSum, Baltimore, 2014 Graves’ disease 30 anti-TPO negative anti-TPO positive

(TPO: thyroid peroxidase) 25

specific IgE levels (IU/ml) -

5 Allergen 0 D1 D2 T2 T3 T4 W1 Gx G12 W6 W9 E1 E5 M1 M2 M3 dust-mite alder birch hazel ragweed rye pollen plantain cat dog penicillium aspergillus I II grass-mixture mugwort epithelia cladosporium ImmunSum, Baltimore, 2014

35 Graves’ disease 30 anti-Htg negative

25 anti-Htg positive (Htg: human thyroglobulin) 20

15 * specific IgE levels (IU/ml) P<0,046 - 10

Allergen * 0 D1 D2 T2 T3 T4 W1 Gx G12 W6 W9 E1 E5 dust-mite alder birch hazel ragweed grass- rye pollen plantain cat dog I II mixture mugwort epithelia ImmunSum, Baltimore, 2014 50 Graves’disease 45 without ophthalmopathy 40

(IU/ml) anti-Htg negative 35 anti-Htg positive 30 (Htg: human thyroglobulin) 25 **P<0,03 20 *P<0,044 **

specific IgE levels 15 - 10 *

5 Allergen 0 D1 D2 T2 T3 T4 W1 Gx G12 W6 W9 E1 E5 dust-mite alder birch hazel ragweed grass- rye pollen plantain cat dog I II mixture mugwort epithelia ImmunSum, Baltimore, 2014 Patient groups

60 None

anti-TPO + 50 (IU/ml) TSH rec antibody + 40

30 *P<0,024

20 specific IgE levels - *

10 Allergen 0 * D1 T2 W1 Gx E1 Dust-mite I Alder Ragweed Grass-mixture Cat epithelia

ImmunSum, Baltimore, 2014 Conclusions

 Allergic rhinitis and conjunctivitis was more frequent in autoimmune thyroid diseases.  However, the attack of allergic rhinitis was higher in Hashimoto’s thyroiditis and allergic conjunctivitis in Graves’ disease.  Seasonal allergic attack can play as an inducer or aggravator role in the development of Graves’ disease.  The prevalence of allergen-specific IgE levels against trees and weeds were more frequent in Graves’ disease than in Hashimoto’s thyroiditis.  Allergen-specific IgE levels were lower in Graves’ ophthalmopathy compared to those without eye signs, as well as lower compared to Hashimoto’s thyroiditis.  Hyperthyroidism was associated with elevated allergen-specific IgE levels resulting in a higher class degree. (Except cat epithelia.)  The presence of antithyroid antibodies influenced the allergen-specific IgE levels. TSH receptor antibody positive and sometimes anti-thyroid peroxidase positive patients showed higher IgE levels, but anti-thyroglobulin (Htg) positivity was associated lower IgE levels, particularly in Graves’ ophthalmopathy.  The frequent presence of allergic conjunctivitis in Graves’ disease can lead to a difficulty in the diagnosis of ophthalmopathy.

ImmunSum, Baltimore, 2014 Food allergens

ImmunSum, Baltimore, 2014 Prevalence of food allergen-specific IgE in autoimmune thyroid diseases

Allergen Graves’disease Hashimoto’s Controls groups (n=149) thyroiditis (n=65) Total (n=110) F17 (hazelnut) 13 a (8,7%) 1 a (0,9%) 2 (3,1%) 16 (4,9%) F35 (potato) 16 b, c (10,7%) 3 b (2,7%) 1c (1,5%) 20 (6,2%) F85 (celery) 24 d (16,1%) 5d (4,5%) 4 (6,2%) 33 (10,2%) F31 (carrot) 25 e (16,8 %) 6 e (5,5%) 4 (6,2%) 35 (10,8%) F25 (tomato) 10 f (6,7%) 1f (0,9%) 0 11 (3,4%) F33 (orange) 17 g,h (11,4%) 3 g (2,7%) 1 h (1,5%) 21 (6,5%) F4 (wheat flour) 22 i (14,8%) 4 i (3,6%) 3 (4,6%) 29 (9%)

Total 149 110 65 324

a P < 0.01, b P< 0.03, c P<0.04, d P<0.01, e P<0.01, f P<0.03, g P<0.02, h P<0.03 and i P<0.01 with Yates corrections. ImmunSum, Baltimore, 2014 Graves’ disease without (n=92) Hashimoto’s Graves’ disease (n=149) Graves’ disease with ophthalmopathy thyroiditis (n=110) Controls (n=65) (n=57) Controls (n=65)

7 10,0 0,7

P<0.03 P<0.05

P<0.02 P<0.002 9,0 6 0,6 8,0 P<0.04 5 7,0 0,5 6,0 4 0,4 5,0

3 4,0 0,3 specific specific (IU/ml) IgElevels

- 3,0

2 specific (IU/ml) IgElevels 0,2

- specific specific (IU/ml) IgElevels - 2,0 1 0,1

Allergen 1,0 Allergen Allergen 0 0,0 0 F85 F31 F35 F31 F16 celery carrot potato carrot walnuts

ImmunSum, Baltimore, 2014 Patient groups 18 Hyperthyroid Euthyroid Hypothyroid

12 10 * P<0,04 8

specific IgE levels (IU/ml) - 4

2 Allergen 0 ** F16 F35 F85 F31 F33 F4 F5 F14 walnuts potato celery carrot orange wheat flour rye meal soybeans

ImmunSum, Baltimore, 2014 12 Graves’ disease TSH receptor

antibody negative 10 TSH receptor 8 antibody positive

4 specific IgE levels (IU/ml)

- 2

0 Allergen

F17 F13 F16 F2 F78 F35 F85 F31 F25 F23 F33 F49 F4 F5 F14

milk

creb

celery

apple

casein

potato

carrot

tomato

orange

walnuts

paelnuts

rye meal rye

hazelnuts

Soybeans wheat flour wheat ImmunSum, Baltimore, 2014 2,5 Graves’ ophthalmopathy

TSH receptor antibody negative

2 TSH receptor antibody positive

1,5

1 *P<0,045

0,5 specific IgE levels (IU/ml)

- *

Allergen F17 F2 F35 F85 F31 F25 F33 F49 F4 F14

milk

apple

celery

potato

carrot

orange

tomato

hazelnuts Soybeans

ImmunSum, Baltimore, 2014 flour wheat Graves’ disease 9 anti-TPO negative anti-TPO positive

8 (TPO: thyroid peroxidase)

2 specific IgE levels (IU/ml) - 1

Allergen F17 F13 F16 F2 F78 F35 F85 F31 F25 F33 F49 F4 F5 F14

milk

potato

carrot

celery

apple

casein

tomato

orange

walnuts

paelnuts

rye meal rye

hazelnuts

Soybeans wheat flour wheat ImmunSum, Baltimore, 2014 Graves’disease 8 anti-Htg negative anti-Htg positive

7 (Htg: human thyroglobulin)

specific IgE levels (IU/ml) - 1

0 Allergen

F17 F2 F35 F85 F31 F25 F33 F49 F4 F5 F14

milk

apple

carrot

celery

orange

tomato

potato

rye meal rye

hazelnuts Soybeans

wheat flour wheat ImmunSum, Baltimore, 2014 TSH FT4 FT3 TSH rec a-TPO a-Htg

antibody

30 1 25 9 700 270

P<0.01

P<0.03

P<0.001 P<0.004 P<0.007 P<0.021

P<0.042 265

P<0.003 8

1 600

25 260 20 7 500 255

P<0.013 1 20

6 250

15 1 5 400 245 15 P<0.024 240 4 300 1 10 235

10 3

levels levels (ng/dl)

l evels l (pg/ml)evels

3 4 4 200

0 Htg antibofódy levels (IUl/l) 230

TSH levels levels (µU/ml) TSH

TPO antibofódy TPO levels (IUl/l) antibofódy

FT FT 5 2 - 5 Anti 225 0 Anti 100 TSH ereceptor antibody ereceptor antibody TSH levels (IU/l) 1 220

0 0 0 0 0 215 F78 M1 M2 M1 M2 M6 W6 F14 F16 F14 negative positive F78: casein M1: Penicillium M2: Cladosporium M6: Alternaria W6: mugwort F14: soybeans F16: walnuts ImmunSum, Baltimore, 2014 Conclusions

 Food allergen-sensitization was more frequent in Graves’ disease compared to that in Hashimoto’s thyroiditis, and it can affect our daily meals.

 Allergen-specific IgE levels were higher in Graves’ disease, but lower in Hashimoto’s thyroiditis than controls.

 Hyperthyroidism was associated with elevated allergen-specific IgE levels.  Anti-thyroid antibodies influenced the degree of IgE levels:

1. TSH receptor and anti-TPO antibody levels were associated with higher IgE levels. (Except milk and casein allergens). 2. Anti-Htg antibody levels were connected to lower IgE levels.

ImmunSum, Baltimore, 2014 Thank you for your attention !

This study contains works of Erzsébet Kelemen MD, otolaryngologist Láng Antalné, medical laboratory assistant ImmunSum, Baltimore, 2014