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Abstract
We have studied the role of eye muscle and thyroid autoimmunity in patients with Graves’ hyperthyroidism with or without ophthalmopathy in an area of relatively low iodine intake. Antibody dependent cell mediated cytotoxicity (ADCC) and complement mediated antibody dependent cytotoxicity (CMAC) against thyroid and eye muscle cells, and levels of antibodies against TSH receptor antigen and the thyroid microsomal antigen (thyroid peroxidase) were determined in three groups of patients: (1) thyrotoxic with exophthalmos (TX;, n= 28), (2) thyrotoxic without ophthalmopathy (GR, n= 10), and (3) euthyroid ophthalmopathy (EU, n= 12). The thyroid glandular mass of the EU group was significantly less (P<0.01) compared with TX or GR. Mean (±SD) TSH receptor antibody (TRAb) level was 27±14% in EU which was significantly lower compared with TX (52.4±20%) and GR (59±18%). The prevalence of microsomal antibodies were similar and not significantly different in the three groups. on the other hand the prevalence of positive ADCC and CMAC tests was significantly greater, and at higher levels, in EU (ADCC THY CELLS 10.9±8.9% SL, ADCC Eye muscle= 25.9±20% SL, CMAC= 70.2±43% SL) and TX (ADCC THY CELLS= 9.3±9.2% SL, ADCC Eye muscle= 20.1±19% SL, CMAC= 62.4±30% SL) compared to GR (ADCC THY CELLS= 4.4±9.5% SL, ADCC Eye muscle= 7.7±6.7% SL, CMAC= 24.7±23% SL). These results suggest that in EU and TX immunological cytotoxicity against eye muscle and thyroid cell surface antigens is enhanced and support the view that eye disease may occur in patients with Graves’ hyperthyroidism due to a thyroid cytotoxic antibody which cross-reacts with an eye muscle cell surface antigen. In three patients of the EU group a fine needle biopsy showed a Hashimoto's thyroiditis and 8 subjects were mildly hypothyroid after 12 months of observation. We concluded that patients with euthyroid exophthalmos represent an evolutive form of Graves’ disease unable to sustain a hyperthyroid state due to intensive cytotoxic aggression, leading to clinical and histological chronic thyroiditis.