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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Lucknow
On Sep 2018




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On Aug 2018




Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".



Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Original article / research
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : BC01 - BC04 Full Version

Clinical Association of TSH Receptor Antibody and Related Autoimmune Markers with Subclinical Graves’ Disease: A Study from Eastern Indian Population


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/52706.16354
Rajani Kanta Mondal, Rana Bhattacharjee, Kheya Mukherjee, Debojyoti Bhattacharjee, Shubho Chowdhury

1. Postgraduate Trainee, Department of Biochemistry, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India. 2. Assistant Professor, Department of Endocrinology and Metabolism, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India. 3. Associate Professor, Department of Microbiology, ID & BG Hospital, Kolkata, West Bengal, India. 4. Associate Professor, Department of Biochemistry, IPGME&R and SSKM Hospital, Kolkata, West Bengal, India. 5. Internee, Department of Biochemistry, Murshidabad Medical College and Hospital, Berhampore, West Bengal, India.

Correspondence Address :
Debojyoti Bhattacharjee,
39 Russa Road South First Lane, Kolkata, West Bengal, India.
E-mail: debojyoti1979@rediffmail.com

Abstract

Introduction: Graves’ Disease (GD), the leading cause of hyperthyroidism is caused by interaction between various autoantibodies generated as a result of autoimmune dysregulation in genetically suspected individuals.

Aim: To study the prevalence of serum levels of Thyroid Stimulating Hormone (TSH) Receptor Antibody (TRAb), Anti Thyroid Peroxidase Antibody (Anti TPOAb) and Anti Thyroglobulin Antibodies (Anti TgAb) in subclinical cases of GD.

Materials and Methods: This was a hospital based cross-sectional study conducted in the Department of Biochemistry, in a tertiary care hospital, over a period of one and half years from January 2019 to June 2020. A total of 120 patients with subtle symptoms of GD of age 30 to 60 years and same number of age and sex matched healthy controls were enrolled for the study. Collection of data was done and serum TRAb was estimated by Enzyme Linked Immunosorbent Assay (ELISA), while AntiTPO and AntiTg antibodies were measured using Electrochemiluminescence Immunoassay (ECLIA).

Results: Serum levels of all the three antibody titres were found to be significantly higher in cases compared to controls. When diagnosis and differentiation of GD was done between cases and controls based on TRAb positivity (80.0%) or negativity (18.0%), it was found to have a sensitivity of 80.0% and specificity 98.3%. TRAb also had positive and negative predictive values of 97.9% and 84.3%, respectively. TRAb positive cases also had higher levels of Anti TPO and Anti TgAb in comparison to TRAb intermediate or negative group.

Conclusion: Prevalence of high titres of autoantibodies especially TRAb are pathognomonic of early GD. Their detection in covert stages of disease shall provide insight into predicting outcome and frame management strategies in patients with this thyroid disorder.

Keywords

Autoimmunity, Hyperthyroidism, Thyroid antibodies, Thyroid stimulating hormone

Graves’ disease, also known as toxic diffuse Goitre, is an autoimmune disease that affects the thyroid (1). It is the most common cause of hyperthyroidism (60-80%) apart from toxicmultinodular goitre and toxic adenomas (2),(3). The exact cause is unclear; however, it is believed to involve a combination of genetic and environmental factors. Multiple nucleotide polymorphisms in Human Leukocyte Antigen-DR isotype (HLA-DR), immunoregulatory Cytotoxic T Lymphocyte-associated Protein 4 (CTLA-4), CD25, Protein Tyrosine Phosphatase non receptor type 22 (PTPN22), FCRL3, CD226 genes as well as Thyroid Stimulating Hormone Receptor (TSHR) have been implicated to the development of GD (4). The primary character of autoimmune thyroid disease is presence in serum of antibodies against Thyroid Peroxidase (TPO), Thyroglobulin (Tg) and the TSHR. T cell-mediated autoimmunity is also demonstrated against the three primary thyroid antigens which on exposure to thyroid antigens or to similar peptide sequences elaborate various cytokines. Circulating autoantibodies specific to GD are directed against the TSHR and are mostly stimulatory in nature (5). These antibodies compete against the natural TSH hormone for binding to its cell membrane receptors in different organs. Downstream mechanism including adenylate cyclase mediated multiple signaling pathways are now activated. Subsequently infiltration of extraocular muscles by activated T cells occurs. There is release of cascade of cytokines like Interferon-γ (IFN-γ), Tumour Necrosis Factor (TNF), and Interleukin-1 (IL-1). In eye, this results in fibroblast activation, accumulation of glycosaminoglycans within the eye muscles that osmotically trap water causing muscle swelling (6).

Very little data are available from India, especially from eastern part with regard to the prevalence of autoimmune thyroid markers in general population especially for TRAb. Moreover, the correlation between TRAb titre level in GD cases in relation to severity of complications has not been assessed. Although both GD and Hashimoto’s thyroiditis belong to different pathogenic mechanism, most of the contributing factors are similar for all autoimmune thyroid disorders. Immunogenicity of various autoantigens seem to vary depending on the state of presentation of clinical sign and symptoms and degree of severity. Hence, this study has been designed to explore the prevalence and titres of thyroid autoimmunity such as TRAb, Anti TPOAb, Anti TgAb in early clinical stages of GD in comparison to normal control population visiting a tertiary care hospital in Kolkata, West Bengal, India.

Material and Methods

The present study was a cross-sectional hospital-based study conducted in the Department of Biochemistry and Department of Endocrinology and Metabolism in a tertiary care hospital in Kolkata, West Bengal, India. A total of 120 clinically suspected patients of GD between 30 to 60 years of age, attending the outpatient department and same number of age and sex matched healthy controls were selected for the study. Collection of data was done over a period of one and half years from January 2019 to June 2020. The study principles and procedures adhered to the ethical standards formulated in the Helsinki Declaration (1975, revised in 1983) and was approved by the institutional ethics committee (IPGME&R/IEC/2019/063, dated 04.02.2019).

Inclusion criteria: Patients with mild features of thyrotoxicosis attributable to GD like mild thyroid gland enlargement, eye signs with serum TSH level below and Free T4 (FT4), Free T3 (FT3) levels in upper level of normal reference range for individual parameter were included in the study.

Exclusion criteria: Patients treated for GD or symptoms and biochemical features of GD of more than three months duration and autoimmune thyroiditis cases with clinical and biochemical features of frank thyrotoxicosis were excluded from the study.

Serum obtained via centrifugation from clotted blood samples were analysed for routine thyroid function test parameters like FT4, FT3 and TSH using a solid-phase, enzyme-labeled chemiluminescent competitive immunoassay (IMMULITE 1000, Siemens, ADVIA Centaur, Siemens). Estimation of TRAb was done by Immunoenzymometric assay (Enzyme Linked Immunosorbent Assay Kit, RSR Limited, UK) (7). Anti TPOAb levels were measured using solid phase enzyme linked chemiluminescent immunoassay while Anti TgAb were assayed using competitive immunoassay using direct chemiluminescent technology (IMMULITE 1000, ADVIA Centaur, Siemens) (8),(9).

Statistical Analysis

Statistical Package for Social Sciences (SPSS) 20 (IBM) statistical software was used for data analysis. All values were expressed as Mean±Standard Deviation (SD). Continuous variables between cases of GD and normal population were compared using Student’s t-test. Analysis of variance (ANOVA) was performed for comparing titre levels of autoimmune markers in cases. Probability value p-value <0.05 was considered to be statistically significant at a confidence limit of 95.0%.

Results

Comparative results between levels of various autoimmune markers in cases and controls were significantly tilted in favour of cases of GD compared to controls (p-value <0.05; (Table/Fig 1)). In cases, there was significant association between titres of all three autoantibodies (p-value <0.05; (Table/Fig 2)).Among the cases (n=120), 96 were positive for presence of TRAb (>1.5 u/L). Two cases were in the intermediate group (TRAb value between 1.1 to 1.5 u/L). A total of 22 cases were negative for the presence of TRAb (value ≤1.0 u/L).

In cases who were positive for TRAb (n=96), Anti TPOAb and Anti Tg Ab levels were higher than the upper limit of normal reference range in 95.8% and 82.3% cases, respectively. In comparison, among TRAb negative cases only 74.5% and 55.7% had high values of Anti TPOAb and Anti TgAb titres, respectively (Table/Fig 3). In 92 cases presenting with high Anti TPOAb levels, 76 had high AntiTg Ab titres. In reverse, all cases with high Anti TgAb had high levels of Anti TPOAb. In controls (n=120), two cases were TR Ab positive and 118 were TR Ab negative. One TR Ab positive control had higher Anti TPOAb (>40IU/mL) level. AntiTg Ab were within normal limits in both the TRAb positive controls. Overall, 26 controls were positive for Anti TPOAb (> 35 IU/mL) but had normal Anti TgAb levels. Anti TgAb was higher in 13 controls (>40IU/mL) but all had normal Anti TPOAb level. In 79 controls there was no evidence of presence of significant titres of any the three antithyroid antibodies.

When diagnosis and differentiation of GD was done between subclinical cases and controls based on TRAb positivity or negativity, it yielded a sensitivity of 80.0% and specificity 98.3%. TRAb also had positive and negative predictive values of 97.9% and 84.3%, respectively.

Discussion

The specific objective of this study was to elucidate the appearance of TRAb, Anti TPOAb and Anti TgAbs in serum along with concomitant biochemical changes in thyroid hormone status in subclinical GD.

In GD features of hyperthyroidism prevails over a backdrop of certain degree of chronic thyroiditis and which eventually culminates in thyroid hypofunction. Conversely, thyrotoxicosis may sometimes appear as the initial clinical symptom in patients with pre-existing Hashimoto’s thyroiditis.

The present study population had cases of GD with high percentage of TRAb positivity (80.0%). Among these TRAb positive cases, 96.0% had high titres of Anti TPOAb and 82.0% had high Anti TgAb. This prevalence of high autoimmune markers in cases was indicative of the underlying autoimmune mechanism that was prevalent in the thyroid milieu and responsible for the thyroid dysfunction in cases.Whether TRAb negative patients could develop GD or not is an ambiguous issue.The present study had a minor count of two TRAb negative cases.

This being a rarity, clinical features, thyroid function test abnormalities, other related autoimmune antibody profile and imaging modalities are used in combination to arrive at a conclusive diagnosis in such cases (10). The thyroid gland itself harbours B cells that acts as the site for intrathyroidal autoantibody secretion in autoimmune thyroid disease. In mice suffering from Severe Combined Immunodeficiency (SCID mice) and having a deficiency of both T and B lymphocytes, transplantation of Graves thyroid tissue, results in the evolution and detection in serum of various human thyroid autoantibodies, including TRAb. However, following management of GD by thyroidectomy and radioiodine, some patients continue to secrete autoantibody as evidence for antibody production from extrathyroidal sources (11). Our study results had shown a positive association between the levels of all three autoimmune markers. This indicates that this underlying pathogenesis is unique for the development of all autoimmune thyroid disorders and is implicated for gradual development of clinical symptoms.GD represents only a part of the spectrum which presents itself in diverse forms from euthyroid state to subclinical entities and ultimately overt disease.

Thyroid hormone receptors belong to a subfamily of G-Protein-Coupled seven-transmembrane Receptors (GPCR). In GD, binding of circulating TRAb autoantibodies causes activation of TSHR and the adenylate cyclaselinked signallingcascades. This plays a pivotal role in controlling thyrocyte growth and accentuated thyroid hormone secretion (12). In patients of GD, TRAb are primarily stimulatory in nature. Other varieties of TRAb are also existent, like a TSH receptor blocking antibody and a neutral form of antibody with no effect on the receptor (13).

So far, with the existent diagnostic modalities TRAb is not detectable in normal population. Hence, detection of significant TRAb titres in cases is pathognomonic of GD in presence or absence of florid symptoms. Experimental evidence exists of induction of Graves like hyperthyroidism in mice by injecting plasmid or intact eukaryotic cells expressing the TSHR (14). Transplacental transfer of maternal TRAb can induce foetal hyperthyroidism. Higher the maternal TRAb concentrations, the higher the risk for the foetus to develop hyperthyroidism (15).

In the past decade, different high-affinity monoclonal TRAbs with agonist activity belongingto the immunoglobulin G1 subclass have been characterised. The hypervariable Fab region on the heavy chain binds to aromatic amino acid rich receptor causing stimulating effects on cyclic Adenosine Monophosphate (cAMP) production (16). Detectable levels of TRAb only in patients with GD is testament that these autoantibodies demonstrate disease exclusivity. In contrast, high prevalence of Tg antibodies and TPO assays, a (80-100%) detectable TRAb with discernible thyroid-stimulating activity is seen in GD (17).

TRAb levels are decreased on remission of GD and on persistence they predict recurrence (18). In keeping with this hypothesis highest titres of TRAb are noted in patients with the most severe orbitopathy. The level correlates directly with the severity of Graves orbitopathy. Quantitation of TRAb thus is a useful marker for diagnosis and assessing disease activity in GD.

Moreover, serum TRAb estimation in pregnancy is useful to predict the likelihood of developing neonatal thyrotoxicosis. TRAb possesses prognostic relevance in treated GD patients especially in response to immunosuppressive treatment (19). Unfortunately, in cases with low or negative titres, the utility of this test is questionable. In this minority section of GD who remain TRAb negative even with modern Thyroid binding assays. it is speculated that they have intrathyroidal TRAb production which does not spill over to circulation (20).

The bone of contention as far as the treatment of GD patients with antithyroid drugs is concerned is to determine the appropriate duration of treatment. Antithyroid therapy modulates the course of the underlying autoimmune process, but complete remission after withdrawal of treatment is likely to occur only if the disorder has entered an inactive phase. Transition from an active state of disease to dormant state is heralded by the decline in the levels of TRAb. This is only likely to occur after prolonged treatment of GD.

Multiple factors have been implicated in preventing recurrence. These include a natural transformation of stimulating TRAb to blocking antibodies, simultaneous progression of concomitant autoimmune thyroiditis and iodine deficiency. These confounding factors have made the predictive value of TRAb measurement in GD recurrence extremely contentious. The situation is further complexed by non-persistent TRAb titres which makes prediction of clinical outcome in GD based on these values much more difficult.

Hence, convention warrants unabated traeatment with antithyroid drugfor about 6 to 12 months. Tapering or drug withdrawal is indicated only when TRAb disappear and serum TSH level become normal. Our study results unveil the high level of autoimmune mechanism in GD as evident by the high level of TRAb titres in majority of the subclinical cases. This was further evident as significant percentage of cases had elevated antiTPO level prior at the onset of thyroid dysfunction in comparison to the controls. Our set of results showed that significant difference existed between cases and controls in terms of anti TPOAb level in a greater study population in comparison to the combined assessment of antiTPO and anti TgAb (96% vs 75%). Hence, no significant advantage was achieved from estimation of dual in cases. Anti TPOAb thus only can be used as a discrete marker.

In reverse, when the merit of anti TgAb positivity was assessed alone and compared to the combined antiTPO and anti TgAb, lesser section of cases had isolated anti TgAb elevation. These observations clearly verified that anti TgAb is not a favourable parameter and should always be combined with anti TPO.

A two-year assessment conducted in San Carlos USA, for appearance of thyroid autoantibodies had shown that 68.6% of study subjects had high anti TPOAb values prior to development of subclinical hyperthyroidism. In 14.4% of cases synchronicity was observed between rise in anti TPOAb levels and onset of clinical features of hyperthyroidism. In 2 cases (1.7%) anti TPOAb titres had risen following the onset of subclinical or overt hyperthyroidism. However, 18 (15.3%) had normal anti TPOAb titre (21). The results show good similar congruence with findings of Hutfless SM et al., where the pre-existent high antiTPO (57.0%) and antiTg (47.0%) autoantibodies were observed prior to the diagnosis of GD (22).

Parameters to predict relapse would help customise treatment to specific patient types in GD. However, as evident from previous study, Anti TPOAb was not sensitive in this regard (23). In an epidemiological community survey conducted in Cochin, subclinical and overt hyperthyroidism was present in 1.6% and 1.3% of subjects (24). Among the detected hyperthyroid cases one third had positive anti TPOAb levels and of them 39.0% had discernible goitre. High percentage of autoantibodies in cases and their prevalence in normal population as well, indicates the preponderance to develop autoimmune thyroid disorders in genetically susceptible individuals in India. In this study, high level of sensitivity and specificity (80.0% and 98.3%, respectively) of TRAb has been shown to pose good predictive value to diagnose and differentiate GD from normal population in early stages of disease.

Limitation(s)

A major limitation of the study was the limited population enrolled for the work. Multicentric studies are further required in this regard to correlate titre of various antibodies with disease severity and its early detection in covert stage. Nevertheless, the study is one of its kind in the context of paucity of studies conducted so far to determine the prevalence of TRAb in subclinical GD and normal euthyroid population.

Conclusion

Prevalence of high titres of autoantibodies especially TRAb are pathognomonic of early GD. Their detection in covert stages of disease shall provide insight into predicting outcome and frame management strategies in patients with this specific thyroid disorder. A common understanding of molecular interplay in GD is that TRAb is known to enhance expression of thyroid antigens. In GD, breakdown of immune tolerance and subsequent thyroid infiltration by activated T cell are caused not as a result of autoantibody-induced insult. There exists in GD a contemporaneous state of autoimmune thyroiditis leading to formation autoantibodies against TPO and Tg as well. The assessment of autoimmune markers especially TRAb in covert stages of GD shall help clinicians predict outcome and frame management strategies in patients with this disorder.

References

1.
Brent GA. Clinical practice. Graves disease. N Engl J Med. 2008;358(24):259-605.https://pubmed.ncbi.nlm.nih.gov/18550875. [crossref] [PubMed]
2.
Menconi F, Marcocci C, Marinò M. Diagnosis and classification of Graves disease. Autoimmun Rev. 2014;13(4-5):398-402. https://pubmed.ncbi.nlm.nih.gov/24424182. [crossref] [PubMed]
3.
Mizukoshi T, Noguchi S, Murakami T, Futata T, Yamashita H. Evaluation of recurrence in 36 subacute thyroiditis patients managed with prednisolone. Intern Med. 2001;40:292-95. https://pubmed.ncbi.nlm.nih.gov/11334386. [crossref] [PubMed]
4.
Stathatos N, Daniels GH. Autoimmune thyroid disease.CurrOpinRheumatol. 2012;24:70-75. http://journals.lww.com/corheumatology/Abstract/2012/01000/Autoimmune_thyroid_disease.11.aspx. [crossref] [PubMed]
5.
Morshed SA, Latif R, Davies TF. Characterisation of thyrotropin receptor antibody-induced signaling cascades.Endocrinology. 2009;150(1):519. https://www.researchgate.net/publication/23186077. [PubMed] [PubMed]
6.
Ando T, Latif R, Daniel S, Eguchi K, Davies TF. Dissecting linear and conformational epitopes on the native thyrotropin receptor. Endocrinology. 2004;145(11):5185-93. https://www.uptodate.com/contents/pathogenesis-of-graves-disease/abstract/38. [crossref] [PubMed]
7.
Bolton J, Sanders J, Oda Y, Chapman C, Konno R, Furmaniak J, et al. Measurement of thyroid stimulating hormone receptor autoantibodies by ELISA. Clin Chem. 1999;45:2285-87. https://academic.oup.com/clinchem/article/45/12/2285/5643293. [crossref] [PubMed]
8.
Feldt-Ramussen U. Analytical and clinical performance goals for testing autoanitbodies to thyroperoxidase, thyroglobulin, and throtropin receptor. Clin Chem. 1996;42:160-63. [crossref]
9.
Kasagi K, Kousaka T, Higuchi K, Iida Y, Misaki T, Alam MS, et al. Clinical significance of measurements of antithyroid antibodies in the diagnosis of Hashimoto’s thyroiditis: comparison with histological findings. Thyroid. 1996;6:445-49. https://issuu.com/clinics.office/docs/e-book_67_5_. [crossref] [PubMed]
10.
Zoephel K, Roggenbuck D, Schott M. Clinical review about TRAb assay’s history. Autoimmun Rev. 2010;9(10):695-700. https://www.sciencedirect.com/science/article/pii/S1568997210001047. [crossref] [PubMed]
11.
Martin A, Valentine M, Unger P, Yeung SW, Shultz LD, Dabies TF. Engraftment of human lymphocytes and thyroid tissue into Scid and Rag2-deficient mice: absent progression of lymphocytic infiltration. J ClinEndocrinol Metab.1994;79:716-23. https://academic.oup.com/endo/article/140/3/1392/2990707. [crossref] [PubMed]
12.
Chu YD, Yeh CT. The molecular function and clinical role of thyroid stimulating hormone receptor in cancer cells. Cells. 2020;9:1730. https://doi.org/10.3390/cells9071730. [crossref] [PubMed]
13.
Davies TF, Ando T, Lin RY,Tomar Y, Latif R. Thyrotropin receptor-associated diseases: from adenomata to Graves disease. J Clin Invest. 2005;115:1972-83. https://pubmed.ncbi.nlm.nih.gov/16075037. [crossref] [PubMed]
14.
McLachlan SM, Rapoport B. Breaking tolerance to thyroid antigens: changing concepts in thyroid autoimmunity. Endocr Rev.2014;35:59-105. Doi:10.1210/er.2013-1055. [crossref] [PubMed]
15.
Van Dijk MM, Smits IH, Bisschop PH. Maternal thyrotropin receptor antibody concentration and the risk of fetal and neonatal thyrotoxicosis: a systematic review. Thyroid. 2018;28:257-64. [crossref] [PubMed]
16.
Sanders J, Jeffreys J, Depraetere H, Evans M, Richards T, Kiddie A, et al. Characteristics of a human monoclonal autoantibody to the thyrotropin receptor: sequence structure and function. Thyroid. 2004;14(8):560-70. [crossref] [PubMed]
17.
Fröhlich E, Wahl R. Thyroid autoimmunity: role of anti-thyroid antibodies in thyroid and extra-thyroidal diseases. Front Immunol. 2017;8:521. Doi: 10.3389/fimmu.2017.00521. [crossref] [PubMed]
18.
Smith BR, Bolton J, Young S, Collyer A, Weeden A, Bradbury J, et al. A new assay for thyrotropin receptor autoantibodies. Thyroid. 2004;14:830-35. https://www.ncbi.nlm.nih.gov/pubmed/15588379. [crossref] [PubMed]
19.
Roos JCP, Paulpandian V, Murthy R. Serial TSH-receptor antibody levels to guide the management of thyroid eye disease: The impact of smoking, immunosuppression, radio-iodine, and thyroidectomy. Eye.2019;33:212-17. [crossref] [PubMed]
20.
Kamath C, Adlan MA, Premawardhana LD.The role of LDthyrotrophin receptor antibody assays in Graves disease. Journal of Thyroid Research. 2012;8. [crossref] [PubMed]
21.
HussainYS,Hookham JC, Allahabadia A, Balasubramanian SP. Epidemiology, management and outcomes of Graves’ disease-real life data. Endocrine. 2017;56(3):568-78. https://pubmed.ncbi.nlm.nih.gov/28478488. [crossref] [PubMed]
22.
Hutfless SM, Matos P, Talor MV, Caturegli P, Rose NR. Significance of prediagnostic thyroid antibodies in women with autoimmune thyroid disease. J ClinEndocrinolMetab. 2011;96(9):1466-71. [crossref] [PubMed]
23.
Dauksiene D, Dauksa A, Mickuviene N. Independent pretreatment predictors of Graves’ disease outcome. Medicina-(Kaunas). 2013;49(10):427-34. https://www.researchgate.net/publication/261443753_Independent. [crossref]
24.
Usha Menon V, Sundaram KR, Unnikrishnan AG, Jayakumar RV, Nair V, Kumar H. High prevalence of undetected thyroid disorders in an iodine sufficient adult south Indian population. J Indian Med Assoc. 2009;107:72-77. https://www.ijem.in/article.asp?issn=2230-8210;year=2011;volume=15.

DOI and Others

DOI: 10.7860/JCDR/2022/52706.16354

Date of Submission: Oct 04, 2021
Date of Peer Review: Nov 06, 2021
Date of Acceptance: Jan 04, 2022
Date of Publishing: May 01, 2022

Author declaration:
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

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• Plagiarism X-checker: Oct 05, 2021
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