CLINICAL
IMMUNOLOGY
AND
IMMUNOPATHOLOGY
9, 327-334 (1978)
Thyroglobulin-Anti-Thyroglobulin Glomerulonephritis Radioiodine DAVID
Immune Complicating Therapy’s2
Complex
W. PLOTH,**~
ANNETTE FITZ,* DOUGLAS SCHNETZLER,* JOHN SEIDENFELD,* AND CURTIS B. WILSON,?
*Department of internal Medicine, University of Iowaa Hospitals. 52240. and tDepartment of Immunopathology. Scripps Clinic Foundation. La Jolla, Calgornia 92037
Iowa City, loh>a and Research
Received April 25, 1977 A case of glomerulonephritis, apparently secondary to documented deposition of thyroglobulin-anti-thyroglobulin immune complexes, is reported. A 26-year-old man developed acute glomerulonephritis 10 days after administration of i3i I for treatment of thyrotoxicosis. Four months later, retreatment with i3i I for persistent hyperthyroidism was followed by exacerbation of the glomerulonephritis. Serologic studies revealed low levels of circulating anti-thyroglobulin antibody and three of four sera were positive for circulating immune complexes after the onset ofthe second episode or the acute exacerbation. Light microscopic study of renal biospy material revealed a picture of acute exudative glomerulonephritis. Electron microscopy demonstrated subepithelial electrondense deposits, supporting the diagnosis of immune complex glomerulonephritis. Immunohistologic studies confirmed the presence of IgG. C:,, and thyroglobulin in a granular pattern in glomeruli in the renal biopsy. The immunopathologic studies coupled with previous experimental observations support the etiologic significance of thyroglobulin-antithyroglobulin immune complexes in the patient’s renal disease.
INTRODUCTION
Glomerular deposition of immune complexes (IC) appears to be the immunopathogenic mechanism responsible for the development of the majority of cases of glomerulonephritis in man. Both exogenous and endogenous antigens can be involved; however, in most patients the nature of the antigen remains to be identified (1). Nuclear antigens, for example, are identifiable in immune complex formation in systemic lupus erythematosus (2) and in its counterpart in New Zealand mice (3). Anti-thryoglobulin antibodies are implicated in experimental thyroiditis (4) and thyroglobulin (TG) anti-TG antibody IC deposition can cause glomerular injury in this model, particulary when thryoid damage is induced, increasing the amount of TG available for immune complex formation (5). Two examples of TG anti-TG antibody IC glomerulonephritis have been tentatively identified in man, one by elution study, the other by direct immunofluorescence ’ The immunopathologic studies were supported by USPHS Contract AI-42505. L This is Publication No. 1273 from the Department of Immunopathology, Scripps Clinic and Research Foundation. ) Present address and reprint requests to: D. W. Ploth, M.D., Division of Nephrology, University of Alabama Medical Center. University Station, Birmingham. Alabama 35294. 327 0090- 1229/78/0093-0327$01.00/0 Copyright 0 1978 by Academic Press. Inc All rights of reproduction in any form reserved.
328
PLOTH
ET AL
identification of TG in the glomerular IC deposits (6, 7). Herein, we report a disease process in a patient similar to the animal model of thyroiditis, in which an initial bout and an exacerbation of apparent acute TG anti-TG antibody IC glomerulonephritis developed in close temporal relationship to radioactive iodine therapy for Grave’s disease. CASE REPORT
The patient, a 26-year-old Caucasian male, presented to his physician on September 20, 1973, with complaints of a 59-lb weight loss, tremor, nervousness, and eye prominence (see graphic summary in Fig. 1). He was referred to the Iowa City Veterans Administration Hospital, where 600 mg daily of propylthiouracil was instituted for hyperthyroidism on October 1. On November 25, the patient developed a low-grade fever and exudative tonsillitis. Throat culture demonstrated a non-Group A p-hemolytic streptococcus and he was started on oral penicillin; the propylthiouracil was discontinued. On November 30, 1973, he was again evaluated for clinical hyperthyroidism. Studies revealed a T3 uptake of 48% (normal, 24-35%), a T4 uptake of 14.6 kg% (normal, 4-l 1 pg%), and a 24 hr thyroid uptake of 60% (normal ~35% at 24 hr). Thyroid scanning revealed a three- to fourfold increase in thyroid size with
FIG. variable
1. Clinical ordinate
Antdhvroqlobulm Anthodv c; u/ml AS0 Todd Units
0
U A WC/ Wr RIG costs Pmkin anRC
0 0 0
4 IS6
167 I66
O... 167 166
b4r 0’ I7LI
summary. Significant clinical events and laboratory scales as related to time on the abscissa.
parameters
are noted
on the
IMMUNE
COMPLEX
GLOMERULONEPHRITIS
AND
THYROGLOBULIN
329
homogenous uptake. Anti-TG antibodies were not present in the serum. Urinalysis was normal. On December 6, 1973, the patient received 7.2 mCi of radioactive iodine with a calculated dose of 3250 rads to the thyroid gland. He was discharged to start propylthiouracil 5 days later. On December 15, he noted lethargy, a dry cough, vomiting, facial swelling, and diplopia, and he was readmitted on December 17. The urinary sediment contained red blood cells (RBC) and probable RBC casts. The patient remained normotensive without complaints or arthralgias, skin rash, or flank pain. Several creatinine clearances were in the range of 100-l 10 ml/min, with 24 hr quantitative protein excretions of 16.5 g (12-17-73) and 8 g (12-26-73). Serum creatinine was 1.8 mg/dl upon admission and fell slowly to 1.O mg/dl. Serum C, level was slightly decreased on the day of admission. AS0 titer was 166 Todd units. Direct Coombs and antinuclear antibody (ANA) studies were negative, and urine cultures revealed no growth. TG antibody titers were not obtained. Clinically, the glomerulonephritis improved without treatment and the patient was discharged on December 28, 1973, to be followed in the clinic. On followup evaluation on January 15, 1974, the patient was still hyperthyroid clinically. Urinalysis revealed persistent proteinuria and microscopic hematuria, creatinine clearance was 170 mVmin and quantitative urinary protein excretion was 4.3 g/24 hr. Repeat serum C, was normal and the AS0 titer was unchanged. Propylthiouracil was reinstituted at 300 mg/day. The patient returned again on February 12 for outpatient follow-up relating that he had improved symptomatically, but was not yet normal. Tri-iodothyronine was elevated at 345 r&d1 (normal, 80-240 ngldl). He remained normotensive. Repeat urinalysis revealed persistent microscopic hematuria without RBC casts. Creatinine clearance was 165 ml/min and quantitative urinary protein excretion was 2.5 g/24 hr. Serum creatinine was 0.9 mg/dl. The propylthiouracil was continued. Persistent complaints of hyperthyroidism on April 16, 1974, prompted repeat thyroid evaluation. Twenty-four-hour radioactive iodine uptake was 44% and T3 and T4 values were at the upper limit of normal. On April 17, the patient was retreated with 10 mCi of radioactive iodine with an estimated 4400 rads delivered to the gland. At home, 12 hr later, he noted the onset of fatigue and malaise. Twenty-four hours after the radioactive iodine, he developed a fever of 101°F associated with chills, abdominal cramping pain, diarrhea, and later nausea and vomiting. April 19, the patient returned to the hospital because of decreased urine volume, dark urine, and edema. He appeared hypermetabolic and was normotensive. Laboratory evaluation revealed microscopic hematuria and large numbers of RBC casts. Twenty-four-hour urine collections revealed creatinine clearance of 105 mYmin with 450 mg of protein. Serum C, the day after admission was normal. A repeat AS0 titer was unchanged and streptozyme tests for streptokinase and hylauronidase and C-reactive protein were negative. Circulating anti-TG antibody was not detected on April 22; however, subsequent sera were positive undiluted on April 26, 29, and 30. Circulating immune complexes were detected in three of the four samples obtained during the acute episode. A percutaneous renal biopsy was performed on April 24. Serum creatinines remained less than 1 mg/dl, RBC casts decreased in number, and urinary output improved with a 2.5-kg weight loss. The patient symptomatically improved and was discharged on May 1.
330
PLOTH
El AL
At his clinic visit in January, 1976, he was euthyroid and employed full time. He continued to be normotensive and his creatinine remained less than 1 mgidl. Urinalysis demonstrated persistent microscopic hematuria without qualitative proteinuria. METHODS
Routine laboratory methodology was applied in the analysis of blood and urine chemical parameters. Anti-TG antibody titers were determined with TG-sensitized latex particles (Hyland Laboratories, Division of Travenol Laboratories. Costa Mesa, Calif.) using known nonreactive and reactive control sera. Serum samples from the patient were studied for the presence of circulating immune complexes using a modification of the Raji cell radioimmunoassay (8). The renal biopsy material was subdivided and portions were fixed in formalin for light microscopy and in 4% glutaraldehyde for transmission electron microscopy. A portion was also snap frozen for immunofluorescence studies. Cryostat sections obtained from the snap-frozen renal biopsy material were studied by immunofluorescence using monospecific antisera for IgG, IgA, IgM, C,, fibrinogenrelated antigens, and albumin (9). The specificity of the staining was determined by absorption of the specific antigen. In addition, cryostat sections from the biopsy were studied for TG deposits by indirect immunofluorescence using a mouse antiserum raised to human, bovine, and equine thyroglobulins (10). The second antibody for this study was a goat anti-mouse IgG antiserum which had been absorbed with human serum to prevent cross-reactivity with the human immunoreactants present. Specificity of the reaction was shown by absorbing the mouse antisera with human TG (kindly supplied by W. 0. Weigle). RESULTS
Light microscopy of the renal biopsy material showed a diffuse exudative and proliferative glomerulonephritis involving nearly all glomeruli (Fig. 2). Electron microscopy revealed thickening of the glomerular basement membrane with variably sized electron-dense deposits predominantly on the subepithelial surface (Fig. 3). Notably absent were electron-dense deposits in the mesangium. Direct immunofluorescence studies of the renal biopsy demonstrated 3+ distinct granular deposits of IgG in six of eight glomeruli present for evaluation (Figs. 4A and B); 1+ quantities of IgM, and 3+ quantities of C, accompanied the IgG deposits. No IgA, albumin, or fibrinogen-related antigen deposition was observed. Weak. but definite, granular deposits of TG were observed in a distribution similar to that described for IgG when sections from the biopsy were studied by indirect immunofluorescence (Fig. 40. The specificity of the reaction was confirmed when it was blocked by prior absorption of the reagent with isolated human TG. DISCUSSION
The patient’s clinical renal course was that of acute glomerulonephritis with hematuria, RBC casts, proteinuria, edema, marginal oliguria, and a slight decrease in renal function. Although the second episode or exacerbation. was
IMMUNE
COMPLEX
GLOMERULONEPHRITIS
AND
THYROGLOBULIN
331
FIG. 2. Light photomicrograph of glomerulus. Most glomeruli in the biopsy specimen appeared similar to the one shown. Diffuse exudation of polymorphonuclear leukocytes (arrows) and early diffuse proliferative changes were observed. (magnification x240)
more severe than the first clinically, creatinine clearance was better preserved and protein excretion was less quantitatively. Initially, the etiology of the first episode, which followed the administration of 1311 by 10 days, was thought possibly to be related to the antecedent streptococcal sore throat of 3 weeks earlier, although only non-Group A organisms had been recovered in cultures and subsequent serologic findings were not supportive for this diagnosis. After retreatment with 1311 for persistent hyperthyroidism, the patient demonstrated a serum sickness-like exacerbation of the nephritis soon after the second radioactive iodine exposure. The renal biopsy material obtained during the second acute episode showed acute exudative and proliferative glomerulonephritis associated with electron microscopic and immunofluorescent findings indicative of IC glomerulonephritis. Circulating immune complexes were demonstrated during the acute episode. TG was demonstrated in glomerular IC deposits, confirming that TG anti-TG antibody IC were responsible, at least in part, for the IC accumulation and presumably the subsequent glomerulonephritis. TG anti-TG antibody IC disease has been systematically examined in the rabbit by Weigle and Nakamura (11). Rabbits immunized with heterologous or chemically altered homologous TG develop circulating anti-TG antibody and thyroiditis. TG anti-TG antibody IC glomerulonephritis can develop in these immunized rabbits, particularly when the thryoid is damaged and caused to release TG from
332
PLOTH
ET AL
FIG. 3. Electron photomicrograph of the glomerulus. Electron microscopy revealed dense deposits (arrows) along the subepithelial surface of the basement membrane (BM). Focal thickening of the BM was observed as well as focal condensation (FC) of the epithelial cell foot processes. The portions of the endothelial cell (END) seen appear normal. (magnification x7875)
radiation damage (12). TG and anti-TG antibody could be demonstrated in the severely involved glomeruli of immunized rabbits that develop the lesion. The patient presented demonstrates strong presumptive evidence of a similar immunopathogenic process in man. The temporal relationship of the radioactive iodine therapy and the overt glomerulonephritis observed on two occasions with immunofluorescent demonstration of TG in the glomerular IC deposits are reasonable evidence to support a TG anti-TG antibody IC mechanism as a source of the observed glomerulonephritic syndrome. The interval between retreatment with IX11 and the second glomerulonephritic episode was unusually brief (24 to 38 hrl when taken in the context of observed thyroglobulin release apparent in the human as reported by Robbins ( 13). Although the brief time interval would appear to be against possible formation of TG anti-TG immune complexes, reservations must be made for the unknown effects of prior radioiodine therapy, probable leak of thyroglobulin with thyroid inflammation alone ( 141, and documented circulating immune complexes in untreated thyrotoxicosis (151. It seems that enhanced thyroglobulin release may have occurred earlier than expected under these unique circumstances. Unfortunately, insufficient serum samples were available to document the serologic events which accompanied the development of the glomerular lesion, although low levels of circulating immune complexes were identified.
IMMUNE
COMPLEX
GLOMERULONEPHRITIS
AND
THYROGLOBULIN
333
Flc. 4. Light photomicrographs of immunohistologic studies on renal biopsy material. (A) Granular deposits of IgG are seen diffusely along the glomerular basement membrane in the patient’s renal biopsy. (B) The granular nature of the individual deposits can be seen when capillary loops are examined at high power (arrows). (C) TG can be seen corresponding to the location of the distinct granular deposits of IgG (arrows) observed in B. A and B were stained with fluoresceinated antihuman IgG: C was stained by indirect immunofluorescence with mouse antihuman TG. (magnification: A x 187: B and C x300)
The remaining unsolved problem is the complete integration of the known immunopathogenic sequence in the rabbit model and in our patient. Namely, what were the factors that led to the spontaneous initiation of the anti-TG antibody immune response. In the realm of speculation is the possibility that radioiodineinduced thyroid injury may have been involved. If, however, such speculation were true, we would anticipate a more frequent incidence of similar clinical consequences with radioiodine therapy. The etiology of the patient’s hyperthyroidism was not established by histologic evaluation, and, therefore, any contribution of preceeding thyroiditis was not defined. However, anti-TG antibodies have been reported to be present spontaneously in 17 to 59% of patients with various thyroid diseases (15). The incidence of TG anti-TG antibody immune complex disease in thyroiditis patients, with or without therapeutic manipulations, is unknown. It does not, however, appear to be a common problem. It is important, though, to remember that, when anti-TG immune responses are present, nephritogenic immune complexes can occasionally form when therapeutic manipulations alter or make TG available to form soluble, circulating immune complexes. Conceivably, immunosuppression to reduce circulating anti-TG antibody levels could also
334
PLOTH
ET AL.
result in the formation of soluble immune complexes by altering relative antigen/antibody ratios; however, unless the amount of TG available for immune complex formation was unusually large, the complexes might go unnoticed clinically. Important is the premise that endogenous thyroglobulin can, within yet to be defined constraints, act as an antigen and in the proper clinical setting can be yet another cause of immune complex disease in man. ACKNOWLEDGMENTS The authors wish to thank Dr. Richard Peterson, Dr. Constance Pittman. Dr. Jacob Robbins. Mr. Earl Bergland, and Mrs. Marli West for their help in processing laboratory specimens and making data available to us. The secretarial assistance of Ms. Pam Gunnin and Ms. Pauline Pess is gratefully acknowledged.
REFERENCES I. Wilson, C. B., and Dixon, F. .I.. In “The Kidney” (B. M. Brenner and E. J. Rector. Eds.). pp. 838-908. W. B. Saunders, Philadelphia, 1976. 2. Koffler. D., Agnello, V., and Kunkel, H. G., Amer. J. P~rhl. 74, 109, 1974. 3. Lambert, P. H.. and Dixon, F. J., .I. Exp. Med. 127, 507, 1968. 4. Weigle. W. 0.. J. Exp. Med. 122, 1049, 1965. 5. Wiegle, W. O., and Nakamura, R. M.. CIirz. Esp. ~mmutw/. 4, 645, 1969. 6. Koffler. D., Sandson, J., and Kunkel, H. G., J. C/in. Znx~st. 47, 55a. 1968. 7. O’Regan, S., Fong, J. S. C.. Kaplan. B. S.. de Chadarevian, I. P., Lapointe. N.. and Drummond. K. N.. C&f. Imrrnmol. Itnm~rnctpatlzol. 6. 341, 1976. 8. Theofilopoulos. A. N.. Wilson, C. B.. and Dixon, F. J.. ./. C‘li~r. Irl~,c,sr. 57. I6Y. IY7h. 9. Wilson, C. B.. In “Manual of Clinical Immunology” (N. R. Rose and H. Friedman. Eds.r, p. hY2. American Society of Microbiology, Washington, D. C.. 1976. IO. Clagett, J. A., Wilson, C. B.. and Weigle. W. 0.. .J. Exp. kf~d, 140, 1439. lY74. I I. Weigle, W. 0.. and Nakamura, R. M.. ./. I~~nrrr~ol. 99. 223. 1967. I?. Weigle. W. O., and High, G. J.. J. Imnrr~~ol. 98, 1105. 1967 13. Robbins. J., J. Biol. Chem. 208. 377. 1954. 14. Kalderon, A. E., Bogaars, H. A., and Diamond, I.. A,IJ~,~..I. .LIctl. 55. 485. 1973. 15. Calder, E. A., Penhale. W. J.. Barnes, E. W.. and Irvine. W. J.. fkit. h4~ti. ./. 2, 30. 1974.
IMMUNOLOGY
AND
IMMUNOPATHOLOGY
9, 327-334 (1978)
Thyroglobulin-Anti-Thyroglobulin Glomerulonephritis Radioiodine DAVID
Immune Complicating Therapy’s2
Complex
W. PLOTH,**~
ANNETTE FITZ,* DOUGLAS SCHNETZLER,* JOHN SEIDENFELD,* AND CURTIS B. WILSON,?
*Department of internal Medicine, University of Iowaa Hospitals. 52240. and tDepartment of Immunopathology. Scripps Clinic Foundation. La Jolla, Calgornia 92037
Iowa City, loh>a and Research
Received April 25, 1977 A case of glomerulonephritis, apparently secondary to documented deposition of thyroglobulin-anti-thyroglobulin immune complexes, is reported. A 26-year-old man developed acute glomerulonephritis 10 days after administration of i3i I for treatment of thyrotoxicosis. Four months later, retreatment with i3i I for persistent hyperthyroidism was followed by exacerbation of the glomerulonephritis. Serologic studies revealed low levels of circulating anti-thyroglobulin antibody and three of four sera were positive for circulating immune complexes after the onset ofthe second episode or the acute exacerbation. Light microscopic study of renal biospy material revealed a picture of acute exudative glomerulonephritis. Electron microscopy demonstrated subepithelial electrondense deposits, supporting the diagnosis of immune complex glomerulonephritis. Immunohistologic studies confirmed the presence of IgG. C:,, and thyroglobulin in a granular pattern in glomeruli in the renal biopsy. The immunopathologic studies coupled with previous experimental observations support the etiologic significance of thyroglobulin-antithyroglobulin immune complexes in the patient’s renal disease.
INTRODUCTION
Glomerular deposition of immune complexes (IC) appears to be the immunopathogenic mechanism responsible for the development of the majority of cases of glomerulonephritis in man. Both exogenous and endogenous antigens can be involved; however, in most patients the nature of the antigen remains to be identified (1). Nuclear antigens, for example, are identifiable in immune complex formation in systemic lupus erythematosus (2) and in its counterpart in New Zealand mice (3). Anti-thryoglobulin antibodies are implicated in experimental thyroiditis (4) and thyroglobulin (TG) anti-TG antibody IC deposition can cause glomerular injury in this model, particulary when thryoid damage is induced, increasing the amount of TG available for immune complex formation (5). Two examples of TG anti-TG antibody IC glomerulonephritis have been tentatively identified in man, one by elution study, the other by direct immunofluorescence ’ The immunopathologic studies were supported by USPHS Contract AI-42505. L This is Publication No. 1273 from the Department of Immunopathology, Scripps Clinic and Research Foundation. ) Present address and reprint requests to: D. W. Ploth, M.D., Division of Nephrology, University of Alabama Medical Center. University Station, Birmingham. Alabama 35294. 327 0090- 1229/78/0093-0327$01.00/0 Copyright 0 1978 by Academic Press. Inc All rights of reproduction in any form reserved.
328
PLOTH
ET AL
identification of TG in the glomerular IC deposits (6, 7). Herein, we report a disease process in a patient similar to the animal model of thyroiditis, in which an initial bout and an exacerbation of apparent acute TG anti-TG antibody IC glomerulonephritis developed in close temporal relationship to radioactive iodine therapy for Grave’s disease. CASE REPORT
The patient, a 26-year-old Caucasian male, presented to his physician on September 20, 1973, with complaints of a 59-lb weight loss, tremor, nervousness, and eye prominence (see graphic summary in Fig. 1). He was referred to the Iowa City Veterans Administration Hospital, where 600 mg daily of propylthiouracil was instituted for hyperthyroidism on October 1. On November 25, the patient developed a low-grade fever and exudative tonsillitis. Throat culture demonstrated a non-Group A p-hemolytic streptococcus and he was started on oral penicillin; the propylthiouracil was discontinued. On November 30, 1973, he was again evaluated for clinical hyperthyroidism. Studies revealed a T3 uptake of 48% (normal, 24-35%), a T4 uptake of 14.6 kg% (normal, 4-l 1 pg%), and a 24 hr thyroid uptake of 60% (normal ~35% at 24 hr). Thyroid scanning revealed a three- to fourfold increase in thyroid size with
FIG. variable
1. Clinical ordinate
Antdhvroqlobulm Anthodv c; u/ml AS0 Todd Units
0
U A WC/ Wr RIG costs Pmkin anRC
0 0 0
4 IS6
167 I66
O... 167 166
b4r 0’ I7LI
summary. Significant clinical events and laboratory scales as related to time on the abscissa.
parameters
are noted
on the
IMMUNE
COMPLEX
GLOMERULONEPHRITIS
AND
THYROGLOBULIN
329
homogenous uptake. Anti-TG antibodies were not present in the serum. Urinalysis was normal. On December 6, 1973, the patient received 7.2 mCi of radioactive iodine with a calculated dose of 3250 rads to the thyroid gland. He was discharged to start propylthiouracil 5 days later. On December 15, he noted lethargy, a dry cough, vomiting, facial swelling, and diplopia, and he was readmitted on December 17. The urinary sediment contained red blood cells (RBC) and probable RBC casts. The patient remained normotensive without complaints or arthralgias, skin rash, or flank pain. Several creatinine clearances were in the range of 100-l 10 ml/min, with 24 hr quantitative protein excretions of 16.5 g (12-17-73) and 8 g (12-26-73). Serum creatinine was 1.8 mg/dl upon admission and fell slowly to 1.O mg/dl. Serum C, level was slightly decreased on the day of admission. AS0 titer was 166 Todd units. Direct Coombs and antinuclear antibody (ANA) studies were negative, and urine cultures revealed no growth. TG antibody titers were not obtained. Clinically, the glomerulonephritis improved without treatment and the patient was discharged on December 28, 1973, to be followed in the clinic. On followup evaluation on January 15, 1974, the patient was still hyperthyroid clinically. Urinalysis revealed persistent proteinuria and microscopic hematuria, creatinine clearance was 170 mVmin and quantitative urinary protein excretion was 4.3 g/24 hr. Repeat serum C, was normal and the AS0 titer was unchanged. Propylthiouracil was reinstituted at 300 mg/day. The patient returned again on February 12 for outpatient follow-up relating that he had improved symptomatically, but was not yet normal. Tri-iodothyronine was elevated at 345 r&d1 (normal, 80-240 ngldl). He remained normotensive. Repeat urinalysis revealed persistent microscopic hematuria without RBC casts. Creatinine clearance was 165 ml/min and quantitative urinary protein excretion was 2.5 g/24 hr. Serum creatinine was 0.9 mg/dl. The propylthiouracil was continued. Persistent complaints of hyperthyroidism on April 16, 1974, prompted repeat thyroid evaluation. Twenty-four-hour radioactive iodine uptake was 44% and T3 and T4 values were at the upper limit of normal. On April 17, the patient was retreated with 10 mCi of radioactive iodine with an estimated 4400 rads delivered to the gland. At home, 12 hr later, he noted the onset of fatigue and malaise. Twenty-four hours after the radioactive iodine, he developed a fever of 101°F associated with chills, abdominal cramping pain, diarrhea, and later nausea and vomiting. April 19, the patient returned to the hospital because of decreased urine volume, dark urine, and edema. He appeared hypermetabolic and was normotensive. Laboratory evaluation revealed microscopic hematuria and large numbers of RBC casts. Twenty-four-hour urine collections revealed creatinine clearance of 105 mYmin with 450 mg of protein. Serum C, the day after admission was normal. A repeat AS0 titer was unchanged and streptozyme tests for streptokinase and hylauronidase and C-reactive protein were negative. Circulating anti-TG antibody was not detected on April 22; however, subsequent sera were positive undiluted on April 26, 29, and 30. Circulating immune complexes were detected in three of the four samples obtained during the acute episode. A percutaneous renal biopsy was performed on April 24. Serum creatinines remained less than 1 mg/dl, RBC casts decreased in number, and urinary output improved with a 2.5-kg weight loss. The patient symptomatically improved and was discharged on May 1.
330
PLOTH
El AL
At his clinic visit in January, 1976, he was euthyroid and employed full time. He continued to be normotensive and his creatinine remained less than 1 mgidl. Urinalysis demonstrated persistent microscopic hematuria without qualitative proteinuria. METHODS
Routine laboratory methodology was applied in the analysis of blood and urine chemical parameters. Anti-TG antibody titers were determined with TG-sensitized latex particles (Hyland Laboratories, Division of Travenol Laboratories. Costa Mesa, Calif.) using known nonreactive and reactive control sera. Serum samples from the patient were studied for the presence of circulating immune complexes using a modification of the Raji cell radioimmunoassay (8). The renal biopsy material was subdivided and portions were fixed in formalin for light microscopy and in 4% glutaraldehyde for transmission electron microscopy. A portion was also snap frozen for immunofluorescence studies. Cryostat sections obtained from the snap-frozen renal biopsy material were studied by immunofluorescence using monospecific antisera for IgG, IgA, IgM, C,, fibrinogenrelated antigens, and albumin (9). The specificity of the staining was determined by absorption of the specific antigen. In addition, cryostat sections from the biopsy were studied for TG deposits by indirect immunofluorescence using a mouse antiserum raised to human, bovine, and equine thyroglobulins (10). The second antibody for this study was a goat anti-mouse IgG antiserum which had been absorbed with human serum to prevent cross-reactivity with the human immunoreactants present. Specificity of the reaction was shown by absorbing the mouse antisera with human TG (kindly supplied by W. 0. Weigle). RESULTS
Light microscopy of the renal biopsy material showed a diffuse exudative and proliferative glomerulonephritis involving nearly all glomeruli (Fig. 2). Electron microscopy revealed thickening of the glomerular basement membrane with variably sized electron-dense deposits predominantly on the subepithelial surface (Fig. 3). Notably absent were electron-dense deposits in the mesangium. Direct immunofluorescence studies of the renal biopsy demonstrated 3+ distinct granular deposits of IgG in six of eight glomeruli present for evaluation (Figs. 4A and B); 1+ quantities of IgM, and 3+ quantities of C, accompanied the IgG deposits. No IgA, albumin, or fibrinogen-related antigen deposition was observed. Weak. but definite, granular deposits of TG were observed in a distribution similar to that described for IgG when sections from the biopsy were studied by indirect immunofluorescence (Fig. 40. The specificity of the reaction was confirmed when it was blocked by prior absorption of the reagent with isolated human TG. DISCUSSION
The patient’s clinical renal course was that of acute glomerulonephritis with hematuria, RBC casts, proteinuria, edema, marginal oliguria, and a slight decrease in renal function. Although the second episode or exacerbation. was
IMMUNE
COMPLEX
GLOMERULONEPHRITIS
AND
THYROGLOBULIN
331
FIG. 2. Light photomicrograph of glomerulus. Most glomeruli in the biopsy specimen appeared similar to the one shown. Diffuse exudation of polymorphonuclear leukocytes (arrows) and early diffuse proliferative changes were observed. (magnification x240)
more severe than the first clinically, creatinine clearance was better preserved and protein excretion was less quantitatively. Initially, the etiology of the first episode, which followed the administration of 1311 by 10 days, was thought possibly to be related to the antecedent streptococcal sore throat of 3 weeks earlier, although only non-Group A organisms had been recovered in cultures and subsequent serologic findings were not supportive for this diagnosis. After retreatment with 1311 for persistent hyperthyroidism, the patient demonstrated a serum sickness-like exacerbation of the nephritis soon after the second radioactive iodine exposure. The renal biopsy material obtained during the second acute episode showed acute exudative and proliferative glomerulonephritis associated with electron microscopic and immunofluorescent findings indicative of IC glomerulonephritis. Circulating immune complexes were demonstrated during the acute episode. TG was demonstrated in glomerular IC deposits, confirming that TG anti-TG antibody IC were responsible, at least in part, for the IC accumulation and presumably the subsequent glomerulonephritis. TG anti-TG antibody IC disease has been systematically examined in the rabbit by Weigle and Nakamura (11). Rabbits immunized with heterologous or chemically altered homologous TG develop circulating anti-TG antibody and thyroiditis. TG anti-TG antibody IC glomerulonephritis can develop in these immunized rabbits, particularly when the thryoid is damaged and caused to release TG from
332
PLOTH
ET AL
FIG. 3. Electron photomicrograph of the glomerulus. Electron microscopy revealed dense deposits (arrows) along the subepithelial surface of the basement membrane (BM). Focal thickening of the BM was observed as well as focal condensation (FC) of the epithelial cell foot processes. The portions of the endothelial cell (END) seen appear normal. (magnification x7875)
radiation damage (12). TG and anti-TG antibody could be demonstrated in the severely involved glomeruli of immunized rabbits that develop the lesion. The patient presented demonstrates strong presumptive evidence of a similar immunopathogenic process in man. The temporal relationship of the radioactive iodine therapy and the overt glomerulonephritis observed on two occasions with immunofluorescent demonstration of TG in the glomerular IC deposits are reasonable evidence to support a TG anti-TG antibody IC mechanism as a source of the observed glomerulonephritic syndrome. The interval between retreatment with IX11 and the second glomerulonephritic episode was unusually brief (24 to 38 hrl when taken in the context of observed thyroglobulin release apparent in the human as reported by Robbins ( 13). Although the brief time interval would appear to be against possible formation of TG anti-TG immune complexes, reservations must be made for the unknown effects of prior radioiodine therapy, probable leak of thyroglobulin with thyroid inflammation alone ( 141, and documented circulating immune complexes in untreated thyrotoxicosis (151. It seems that enhanced thyroglobulin release may have occurred earlier than expected under these unique circumstances. Unfortunately, insufficient serum samples were available to document the serologic events which accompanied the development of the glomerular lesion, although low levels of circulating immune complexes were identified.
IMMUNE
COMPLEX
GLOMERULONEPHRITIS
AND
THYROGLOBULIN
333
Flc. 4. Light photomicrographs of immunohistologic studies on renal biopsy material. (A) Granular deposits of IgG are seen diffusely along the glomerular basement membrane in the patient’s renal biopsy. (B) The granular nature of the individual deposits can be seen when capillary loops are examined at high power (arrows). (C) TG can be seen corresponding to the location of the distinct granular deposits of IgG (arrows) observed in B. A and B were stained with fluoresceinated antihuman IgG: C was stained by indirect immunofluorescence with mouse antihuman TG. (magnification: A x 187: B and C x300)
The remaining unsolved problem is the complete integration of the known immunopathogenic sequence in the rabbit model and in our patient. Namely, what were the factors that led to the spontaneous initiation of the anti-TG antibody immune response. In the realm of speculation is the possibility that radioiodineinduced thyroid injury may have been involved. If, however, such speculation were true, we would anticipate a more frequent incidence of similar clinical consequences with radioiodine therapy. The etiology of the patient’s hyperthyroidism was not established by histologic evaluation, and, therefore, any contribution of preceeding thyroiditis was not defined. However, anti-TG antibodies have been reported to be present spontaneously in 17 to 59% of patients with various thyroid diseases (15). The incidence of TG anti-TG antibody immune complex disease in thyroiditis patients, with or without therapeutic manipulations, is unknown. It does not, however, appear to be a common problem. It is important, though, to remember that, when anti-TG immune responses are present, nephritogenic immune complexes can occasionally form when therapeutic manipulations alter or make TG available to form soluble, circulating immune complexes. Conceivably, immunosuppression to reduce circulating anti-TG antibody levels could also
334
PLOTH
ET AL.
result in the formation of soluble immune complexes by altering relative antigen/antibody ratios; however, unless the amount of TG available for immune complex formation was unusually large, the complexes might go unnoticed clinically. Important is the premise that endogenous thyroglobulin can, within yet to be defined constraints, act as an antigen and in the proper clinical setting can be yet another cause of immune complex disease in man. ACKNOWLEDGMENTS The authors wish to thank Dr. Richard Peterson, Dr. Constance Pittman. Dr. Jacob Robbins. Mr. Earl Bergland, and Mrs. Marli West for their help in processing laboratory specimens and making data available to us. The secretarial assistance of Ms. Pam Gunnin and Ms. Pauline Pess is gratefully acknowledged.
REFERENCES I. Wilson, C. B., and Dixon, F. .I.. In “The Kidney” (B. M. Brenner and E. J. Rector. Eds.). pp. 838-908. W. B. Saunders, Philadelphia, 1976. 2. Koffler. D., Agnello, V., and Kunkel, H. G., Amer. J. P~rhl. 74, 109, 1974. 3. Lambert, P. H.. and Dixon, F. J., .I. Exp. Med. 127, 507, 1968. 4. Weigle. W. 0.. J. Exp. Med. 122, 1049, 1965. 5. Wiegle, W. O., and Nakamura, R. M.. CIirz. Esp. ~mmutw/. 4, 645, 1969. 6. Koffler. D., Sandson, J., and Kunkel, H. G., J. C/in. Znx~st. 47, 55a. 1968. 7. O’Regan, S., Fong, J. S. C.. Kaplan. B. S.. de Chadarevian, I. P., Lapointe. N.. and Drummond. K. N.. C&f. Imrrnmol. Itnm~rnctpatlzol. 6. 341, 1976. 8. Theofilopoulos. A. N.. Wilson, C. B.. and Dixon, F. J.. ./. C‘li~r. Irl~,c,sr. 57. I6Y. IY7h. 9. Wilson, C. B.. In “Manual of Clinical Immunology” (N. R. Rose and H. Friedman. Eds.r, p. hY2. American Society of Microbiology, Washington, D. C.. 1976. IO. Clagett, J. A., Wilson, C. B.. and Weigle. W. 0.. .J. Exp. kf~d, 140, 1439. lY74. I I. Weigle, W. 0.. and Nakamura, R. M.. ./. I~~nrrr~ol. 99. 223. 1967. I?. Weigle. W. O., and High, G. J.. J. Imnrr~~ol. 98, 1105. 1967 13. Robbins. J., J. Biol. Chem. 208. 377. 1954. 14. Kalderon, A. E., Bogaars, H. A., and Diamond, I.. A,IJ~,~..I. .LIctl. 55. 485. 1973. 15. Calder, E. A., Penhale. W. J.. Barnes, E. W.. and Irvine. W. J.. fkit. h4~ti. ./. 2, 30. 1974.
