Autoimmune Polyglandular Failure Mark S. Anderson, MD, PhD - - PDF document

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Autoimmune Polyglandular Failure

Mark S. Anderson, MD, PhD Professor UCSF Diabetes Center

Goals

• Review clinical Autoimmune Polyglandular

Failure syndromes

• Disease spectrum
• Broad treatment, diagnostic recommendations
• Highlight newly discovered mechanism of

disease for APS type I

• May have applications to more common

autoimmune diseases

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Definitions

Autoimmune Polyglandular Failure broadly divided into two major categories:

• APS type I (Whitaker’s Syndrome,

APECED)

• APS type II (Schmidt’s Syndrome)

APS I (%)

APS II (%)

Comparative Frequency Less Common More Common Onset Infancy/early childhood Late childhood/adulthood Heredity Autosomal Recessive Polygenic Gender Male = Females Female Predominance Genetics AIRE gene; no HLA association HLA association; DR/DQ Hypoparathyroidism 77-89 None Mucocutaneous candiditis 73-100 None Ectodermal dysplasia 77 None Addison’s Disease 60-86 70-100 Type 1 Diabetes 4-18 41-52 Autoimmune thyroid disease 8-10 70 Pernicious anemia 12-15 2-25 Gonandal failure Females 30-60 3.5-10 Males 7-17 5 Vitiligo 4-13 4-5 Alopecia 27 2 Autoimmune hepatitis 10-15 Rare Malabsorption 10-18 Rare

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APS I: Epidemiology

• First description in 1929
• Synonyms: Whitaker’s, Polyglandular

Autoimmune Disease Type 1, APECED

• Prevalence variable - rare outside clusters
• Phenotype typically emerges in childhood
• Males and females equally affected

APS I: Clinical Features

• Major components:

(1) Chronic mucocutaneous candidiasis (2) Chronic hypoparathyroidism (3) Autoimmune adrenal insufficiency

• 2 of the 3 required for diagnosis
• Multiple minor clinical features

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APS I: Clinical Presentation

# Cases (n=41) Betterle, JCEM 1998; 83(4):1050

Mucocutaneous Candidiasis

• Most frequent major clinical feature (93%)
• Presents: 1 month to 21 years of age
• Affects nails, dermis, oral, vaginal, and

esophageal mucosa

• Chronic infection associated with carcinoma
• Treated PRN. Fluconazole and/or Nystatin

S&S

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Why Candida? Hypoparathyroidism

• Second major clinical manifestation
• Occurs in 73-90% of APS 1 patients
• Presents: 3 months to 44 years of age
• Diagnosis: Ionized Ca/PTH
• Nalp5 autoantibodies as a marker

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• riginal article

The new engl and jour nal of medicine

Autoimmune Polyendocrine Syndrome Type 1 and NALP5, a Parathyroid Autoantigen

Mohammad Alimohammadi, M.D., Peyman Björklund, Ph.D., Åsa Hallgren, B.Sc., Nora Pöntynen, M.Sc., Gabor Szinnai, M.D., Noriko Shikama, Ph.D., Marcel P. Keller, Ph.D., Olov Ekwall, M.D., Ph.D., Sarah A. Kinkel, B.Sc., Eystein S. Husebye, M.D., Ph.D., Jan Gustafsson, M.D., Ph.D., Fredrik Rorsman, M.D., Ph.D., Leena Peltonen, M.D., Ph.D., Corrado Betterle, M.D., Ph.D., Jaakko Perheentupa, M.D., Ph.D., Göran Åkerström, M.D., Ph.D., Gunnar Westin, Ph.D., Hamish S. Scott, Ph.D., Georg A. Holländer, M.D., and Olle Kämpe, M.D., Ph.D.

Addison’s Disease

• Third major manifestation to appear
• Presents: 6 months to 41 years of age
• Adrenal cortex Ab (anti-21 Hydroxylase)

near 100% at Dx.

• Anti-adrenal Ab’s positive predicitive value
• Traditional management with corticosteroid

replacement

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APS I: Minor Clinical Features

• Hypergonadotropic

hypogonadism

• Autoimmune

hypothyroidism

• Type I diabetes
• Hypophysitis
• Pernicious anemia
• Atrophic gastritis
• Malabsorption
• Chronic active hepatitis
• Vitiligo
• Alopecia
• Ectodermal dystrophy
• Keratoconjunctivitis
• Cellular/humoral defects
• Asplenia
• Cholelithiasis

Betterle et al. JCEM 83:1049-1055, 1998

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Hypergonadotripic Hypogonadism

• Present in 17-50% of APS 1 patients
• Anti-Cyp450side chain or 17-OH

autoantibodies have predictive value

• Onset: pre-pubertal to age 40
• Fertility counseling

Diabetes Mellitus Type 1

• DM type 1 in 10% patients with APS 1
• Most with DM: anti-GAD+
• Many patients anti-GAD+ that do not

progress to DM

• Fasting glucose and A1C also

recommended

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Autoimmune Thyroid Disease

• Hashimoto’s thyroiditis or atrophic

thyroiditis in 10% of patients with APS 1

• Again presence of antibodies common
• Grave’s also seen in some patients but more

rare

• Monitor TSH and antibodies

Autoimmune Gastrointestinal Disease

• Pernicious anemia in 11-13% patients
• Mean age of onset 20 years
• Parietal cell & intrinsic factor autoantibodies
• Malabsorption in 18-22% patients
• celiac disease, pancreatic insufficiency,

infections, intestinal lymphangectasia

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Chronic Active Hepatitis

• Prevalence of 10 -25% of APS 1 patients
• Presentation: 5-21 years of age
• Variable clinical course
• Autoantibodies: LKM, smooth muscle,

mitochondrial, P450IA2

• Responsive to corticosteroids and

azathioprine

Autoimmune Skin Disease

• Vitiligo in 8-13% of patients
• Presents: 1 month to 15 years of age
• Complement-fixing melanocyte autoantibodies
• Alopecia in 29-32% of patients
• Presents: 3-30 years of age
• Total hair loss commonly seen, psychological

impact important

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Prognosis

• Prior to 1970 mortality was 70% by age 30
• Mortality now 10-15% over 50 years

Betterle, JCEM 1998; 83(4):1054

100 90 80 70 60 50 40 30 20 10 Cumulative Survival (%) 0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 Years follow-up

APS 1 Clinical Recommendations

• Affected patients have lifetime susceptibility to multiple
• rgan-specific autoimmune diseases. Vigilant follow-up

by an endocrinologist at least quarterly with replacement Rx carefully monitored.

• Particular attention to hypocalcemia and a low threshold

for working up at risk syndromes is essential

• Immunosuppression only used in non-endocrine

autoimmune diseases (i.e. autoimmune hepatitis)

• ?Role of genetic testing and counseling now that the

causative gene has been identified On Web: http://www.geneclinics.org/servlet/access? prg=j&db=genetests&site=gt&id=8888890&fcn=c&qry=3 7600&res=&key=hJaU-ilZlicSw&show_flag=c

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APS II

• 1926 Schmidt described lymphocytic

infiltrate of thyroid and adrenal in two patients

• Definition varies from author to author

APS II Definition

• Co-existence of two or more of any of these

three autoimmune diseases:

• Type 1 diabetes
• Autoimmune thyroid disease
• Addison’s disease

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APS II Clinical Syndromes

• Major components
• Type 1 diabetes
• Autoimmune thyroid disease
• Addison’s disease
• Minor components
• Gonadal failure
• Vitiligo
• Pernicious anemia and/or autoimmune Gastritis
• Celiac disease
• Alopecia

APS II Epidemiology

• Onset late childhood to adulthood, peak is

in third decade

• Females more commonly affected; at least

3:1 ratio

• Genetics complex; HLA DR/DQ

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APS I (%)

APS II (%)

Comparative Frequency Less Common More Common Onset Infancy/early childhood Late childhood/adulthood Heredity Autosomal Recessive Polygenic Gender Male = Females Female Predominance Genetics AIRE gene; no HLA association HLA association; DR/DQ Hypoparathyroidism 77-89 None Mucocutaneous candiditis 73-100 None Ectodermal dysplasia 77 None Addison’s Disease 60-86 70-100 Type 1 Diabetes 4-18 41-52 Autoimmune thyroid disease 8-10 70 Pernicious anemia 12-15 2-25 Gonandal failure Females 30-60 3.5-10 Males 7-17 5 Vitiligo 4-13 4-5 Alopecia 27 2 Autoimmune hepatitis 10-15 Rare Malabsorption 10-18 Rare

Addison’s Disease

• 50% of APS II cases present with Addison’s
• Adrenal cortex Ab (anti-21 Hydroxylase) near 100% at Dx
• Anti-adrenal Ab’s positive predicitive value
• Diagnosis based on Cortrosyn Stimulation Test, elevated

ACTH, and clinical picture (hyponatremia, hyperkalemia).

• Traditional management with corticosteroid replacement

(including mineralocorticoid rx)

• ** Should be ruled out in suspected APS patients starting

thyroid replacement

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Diabetes Mellitus Type 1

• Screening with fasting glucose and anti-

GAD, I-A2, insulin Antibodies

• **Patients with co-existing Addison’s are

excellent candidates for treatment with Glargine Insulin for prevention of hypoglycemia.

Celiac Disease

• Relatively common in APS II patients
• Disease risk very strong correlation with HLA-DQA1*0501

DQB1*0201

• Seen in >90% of cases
• Also a risk allele for other APS II syndromes
• Antibody screening with anti-transglutaminase and anti-

endomysial antibodies as a screen. If positive small bowel biopsy if diagnosis still uncertain.

• Antibody tests are excellent screen with anti-endomysial

sensitivity and specificity 90 and 98%

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Gonadal Autoimmunity

• Occurs before age 40 in 10-20% of female

patients

• Anti-Cyp450side chain or 17-OH

autoantibodies have predictive value for disease

• Fertility counseling

Autoantibody Screening

Disease Autoantibody Sens/Spec

Type 1 DM GAD, I-A2,Insulin Addison’s 21-OH Thyroid TPO, Tg, TSI All generally>90% Sens BUT **Spec <90% Ovarian Cyp450side chain Pernicious Anemia Parietal Cell Celiac Endomysial, Gliadin **>90%/98%

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APS II Clinical Recommendations

• Affected patients have lifetime susceptibility to multiple
• rgan-specific autoimmune diseases. Vigilant follow-up

by an endocrinologist at least bi-annually with replacement Rx carefully monitored.

• Celiac disease should be screened for with autoantibody

testing

• Females are at risk for premature ovarian failure and this

should be carefully assessed

• Screening for Vit B12 deficiency at least annually
• ** in newly diagnosed patients care must be taken with

starting thyroid replacement to rule out Addison’s disease.

Given the severity of autoimmunity in these syndromes, can they provide a clue as to how autoimmune disease occurs?

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APS I: Genetics

• Autosomal recessive
• Populations specific incidence
• 1 in 25,000 Finland
• 1 in 9,000 Iranian Jewish descent
• Sardinia
• Founder effect and genetic isolation
• No HLA association
• Variable phenotype among siblings

APECED: Genetics

p11-13 q11 q21.1 q21.2 q21.3 q22.11 q22.12 q22.13 q22.2 q22.3

Chromosome 21

D21S156 D21S416 D21S224 D21S235 D21S212 D21S1225 D21S49 PFKL D21S171 Aaltonen, Nature Genetics 1994; 8(1):83

APECED

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APECED Gene

• 1997: Two groups simultaneously reported

isolation of the APECED gene by positional cloning

• 13 kb long, 14 exons, 545 amino acids
• AIRE (autoimmune regulator) protein

Nature Genetics 1997; 17(4):393-398, 399-403

AIRE Protein

L=LXXLL HSR =Dimerization domain NLS =Nuclear Localization Signal PHD=PHD-like domain PRR=Pro rich region SAND=putative DNA binding domain

L

7-11 63-67 299 340 350 407 434 475 516-520 545 aa

L L PHD PHD PRR

280 189 105

SAND HSR NLS

=missense mutation =nonsense STOP mutation =insertion frameshift

• r deletion frameshift

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Where is the AIRE gene expressed? Real Time-PCR Analysis of Different Tissue Types

10 20 30 40 50 60 70 80 90 100 Thymus Lymph Node Spleen Pancreas Stomach Salivary Kidney Liver Lung Heart Adrenal Ovary Eye Thyroid 10 20 30 40 50 60 70 80 90 100 Thymus Lymph Node Spleen Pancreas Stomach Salivary Kidney Liver Lung Heart Adrenal Ovary Eye Thyroid

Arbitrary Units

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Thymus Architecture

Aire is expressed in thymic medullary epithelial cells

c m

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Thymus Architecture Do AIRE knockout mice exhibit autoimmunity?

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Salivary Ovary Retina

V V

KO WT

Multi-organ Immune Infiltrates

KO WT

Ovary Stomach Retina

mu p m m p mu

• c

p en in c p en in f f

Ovary Stomach Retina

mu p m m p mu

• c

p en in c p en in f f

Multi-organ Autoantibodies

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Summary of KO Phenotype

• AIRE knockout mice develop autoimmunity in an organ-

specific pattern that worsens with age

• Careful immunological analysis of the mice and wild-type

controls reveal:

• Many parameters are unchanged
• Increase in medullary epithelial cells in the thymus
• Increase in T cells with an “activated-memory”

phenotype in peripheral lymph nodes

Is the defect in the bone marrow derived or stromal compartment?

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BM Chimera Experiment

1000 Rad

KO

BM Donor

WT WT KO WT KO

Recipient

Infiltrates and AutoAb’s ?

No No Yes Yes

Is the thymus responsible?

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Thymic Transplant Experiment

Thymic Donor Recipient

Infiltrates and AutoAb’s ?

No Yes

WT Athymic Nude dGuo Rx’d Athymic Nude dGuo Rx’d

Newborn

KO

Newborn

What about gene expression in the thymic medullary epithelium?

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Thymic Epithelial Cells

CDR1 B7-1 1.81 0.98 Thymic Epith.

KO WT

Gene Chip Analysis of Medullary Thymic Epithelium KO vs WT

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SOME PERIPHERAL GENE TRANSCRIPS ECTOPICALLY EXPRESSED IN THE THYMUS Insulin GAD 67 IA-2 Retinal S-Ag Crystallin MOG Proteolipid Protein Serum amyloid protein C-reactive protein a-Fetoprotein pancreas eye CNS liver

Gene Chip Analysis of Medullary Thymic Epithelium KO vs WT

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several specific tissues housekeeping

Probe name Gene name Tissue(s) WT signal KO signal KO/ WT t-test p-val FPR Quad FPR SAM 96030_at casein alpha mammary 75.62 1 0.013 0.0417 0.043 0.014 97180_f_at hemoglobin y, beta-like embryonic chain fetal erythrocytes 87.36 1.29 0.015 0.0803 0.279 0.014 100106_at intestinal trefoil factor intestinal goblet cells 74.59 1.99 0.027 0.0504 < 0.02 0.014 101820_at neurotoxin homologue granulocytes, monocytes 29.50 1 0.034 0.1105 < 0.02 0.014 94738_s_at defensin-related cryptdin,related sequence 2 Paneth cells 100.47 3.85 0.038 0.2561 0.164

• 101682_f_at major urinary protein IV

lachrymal gland, parotid gland 26.49 1.2 0.045 0.0392 0.063 0.014 94153_g_at salivary protein 1 salivary gland 22.62 1.06 0.047 0.0712 0.131 0.014 102998_at cytochrome P450 1a2 liver, lung, duodenum 20.99 1.01 0.048 0.0868 0.043 0.014 101115_at lactotransferrin mammary gland, uterus 19.78 1 0.051 0.0320 0.043 0.014 92353_at serine protease (BSSP) hair follicles, brain 18.77 1 0.053 0.1070 1

• 100463_at

gamma-casein precursor mammary gland 21.93 1.17 0.053 0.0596 0.071 0.014 92546_r_at prostaglandin D brain, epididymis 22.82 1.26 0.055 0.0001 0.063 0.014 96153_at neutrophilic granule granulocytes 28.46 1.72 0.060 0.0246 0.063 0.014 160899_at Purkinje cell protein 4 brain, eye (lens) 32.67 2.09 0.064 0.0327 < 0.02 0.014 161815_f_at major urinary protein I liver 31.23 2.04 0.065 0.0704 0.043 0.014 98858_at glucose dependent insulinotropic polypeptide K cells of small intestine 27.16 1.78 0.066 0.0517 < 0.02 0.014 101910_f_at major urinary protein 3 liver 21.02 1.47 0.070 0.0328 0.164 0.014 94775_at

• xytocin

brain 26.59 1.92 0.072 0.0334 1

• 101636_at

salivary protein 2 salivary gland 16.80 1.23 0.073 0.0382 1

• 98623_g_at insulin-like growth factor II

embryo, choroid plexus and leptomeninges in adult 94.85 6.96 0.073 0.1179 < 0.02 0.014 99958_at mast cell protease-2 mast cells 13.70 1.01 0.074 0.0248 0.043 0.014 94707_s_at amelogenin ameloblast cells 34.69 2.57 0.074 0.0328 < 0.02 0.014 103235_at preproneuropeptide y brain 19.54 1.47 0.075 0.0143 0.043 0.014 103887_at S100 calcium binding protein A9 immature BM myeloid cells, monocytes, neutrophils 68.93 5.26 0.076 0.1529 0.279 0.014 162341_r_at aldose reductase many 19.37 1.48 0.076 0.0121 0.279

• 97889_at

fatty acid binding protein intestine 37.46 3.04 0.081 0.0254 0.043 0.014 94045_at α-1-microglobulin/bikunin precursor liver 12.74 1.04 0.082 0.0781 0.279 0.014 100150_f_at preproinsulin II pancreatic islet beta cells 19.70 1.62 0.082 0.1692 < 0.02 0.014 100002_at inter-alpha-inhibitor H3 chain liver, brain 12.07 1 0.083 0.0266 0.043 0.014 98830_at spermine binding protein prostate 13.56 1.13 0.083 0.1047 0.131

• One specific tissue

hematopoietic cells

Top 30 genes down-regulated in KO samples on Affymetrix chip

Model: AIRE Projects a Self- Shadow in the Thymus

TCR MHC + Peptide

Autoreactive T cell Thymic Medullary Cell

AIRE

?

Self Peptides from “Organ Specific” Antigens

Deletion of Autoreactive T cell

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Summary

• The single gene defect behind APECED or

APS 1 highlights the importance of self- antigen presentation in the thymus

• This process may play an important role in

more common autoimmune disorders

• Type 1 Diabetes- Insulin gene risk human

subjects

Summary (Cont)

• New autoantibodies in APS1:
• anti-NALP5- hypoparathyroidism
• anti-IL-22, IL-17 autantobodies- candida