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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 #
Cas
es (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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original article
T h e n e w e ng l a nd j o u r na l o f m e dic i n e
n engl j med 358;10 www.nejm.org march 6, 20081018
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.
From University Hospital, Uppsala Uni-versity, Uppsala, Sweden (M.A., P.B., Å.H., O.E., J.G., F.R., G.Å., G.W., O.K.); Univer-sity of Helsinki and the National Public Health Institute, Biomedicum Helsinki (N.P., L.P.), and the Hospital for Children and Adolescents, Helsinki University Hos-pital ( J.P.) — both in Helsinki; Laboratory of Pediatric Immunology, University of Basel, and the University Children’s Hos-pital — both in Basel, Switzerland (G.S., N.S., M.P.K., G.A.H.); the Walter and Eliza Hall Institute of Medical Research and the University of Melbourne — both in Park-ville, Victoria, Australia (S.A.K., H.S.S.); the Institute of Medicine, University of Bergen, and Haukeland University Hos-pital — both in Bergen, Norway (E.S.H.); and the University of Padua, Padua, Italy (C.B.). Address reprint requests to Dr. Kämpe at the Department of Medical Sci-ences, Uppsala University Hospital, SE 75185, Uppsala, Sweden, or at [email protected].
N Engl J Med 2008;358:1018-28.Copyright © 2008 Massachusetts Medical Society.
A BS TR AC T
BACKGROUNDAutoimmune polyendocrine syndrome type 1 (APS-1) is a multiorgan autoimmune disorder caused by mutations in AIRE, the autoimmune regulator gene. Though re-cent studies concerning AIRE deficiency have begun to elucidate the molecular pathogenesis of organ-specific autoimmunity in patients with APS-1, the autoanti-gen responsible for hypoparathyroidism, a hallmark of APS-1 and its most common autoimmune endocrinopathy, has not yet been identified.
MethodsWe performed immunoscreening of a human parathyroid complementary DNA library, using serum samples from patients with APS-1 and hypoparathyroidism, to identify patients with reactivity to the NACHT leucine-rich-repeat protein 5 (NALP5). Subsequently, serum samples from 87 patients with APS-1 and 293 controls, includ-ing patients with other autoimmune disorders, were used to determine the frequency and specificity of autoantibodies against NALP5. In addition, the expression of NALP5 was investigated in various tissues.
ResultsNALP5-specific autoantibodies were detected in 49% of the patients with APS-1 and hypoparathyroidism but were absent in all patients with APS-1 but without hypo-parathyroidism, in all patients with other autoimmune endocrine disorders, and in all healthy controls. NALP5 was predominantly expressed in the cytoplasm of para-thyroid chief cells.
ConclusionsNALP5 appears to be a tissue-specific autoantigen involved in hypoparathyroidism in patients with APS-1. Autoantibodies against NALP5 appear to be highly specific and may be diagnostic for this prominent component of APS-1.
Copyright © 2008 Massachusetts Medical Society. All rights reserved. Downloaded from www.nejm.org at COLUMBIA UNIV HEALTH SCIENCES LIB on August 5, 2008 .
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
0
Cum
ulat
ive
Surv
ival
(%)
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 organ-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=37600&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 organ-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
D21
S156
D
21S4
16
D21
S224
D
21S2
35
D21
S212
D
21S1
225
D21
S49
PFK
L D
21S1
71
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
63-6
7
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 or deletion frameshift
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Where is the AIRE gene expressed?
Real Time-PCR Analysis of Different Tissue Types
0102030405060708090
100
Thym
usLy
mph
Nod
eSp
leen
Panc
reas
Stom
ach
Saliv
ary
Kid
ney
Live
rLu
ngH
eart
Adr
enal
Ova
ryEy
eTh
yroi
d0102030405060708090
100
Thym
usLy
mph
Nod
eSp
leen
Panc
reas
Stom
ach
Saliv
ary
Kid
ney
Live
rLu
ngH
eart
Adr
enal
Ova
ryEy
eTh
yroi
d
Arbit
rary U
nits
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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
o
o
cpen
in
cpenin
f
f
Ovary Stomach Retina
mu
p
m
m
p
mu
o
o
cpen
in
cpenin
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
CD
R1
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_athemoglobin 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 0.014101820_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 IVlachrymal 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 0.014102998_at cytochrome P450 1a2 liver, lung, duodenum 20.99 1.01 0.048 0.0868 0.043 0.014101115_at lactotransferrin mammary gland, uterus 19.78 1 0.051 0.0320 0.043 0.01492353_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 0.01492546_r_at prostaglandin D brain, epididymis 22.82 1.26 0.055 0.0001 0.063 0.01496153_at neutrophilic granule granulocytes 28.46 1.72 0.060 0.0246 0.063 0.014160899_at Purkinje cell protein 4 brain, eye (lens) 32.67 2.09 0.064 0.0327 < 0.02 0.014161815_f_at major urinary protein I liver 31.23 2.04 0.065 0.0704 0.043 0.014
98858_atglucose 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 0.01494775_at oxytocin 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 IIembryo, 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 0.01494707_s_at amelogenin ameloblast cells 34.69 2.57 0.074 0.0328 < 0.02 0.014103235_at preproneuropeptide y brain 19.54 1.47 0.075 0.0143 0.043 0.014
103887_atS100 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_atα-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_atinter-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