anti-adrenal cellular hypersensitivity in addison's disease

13 Pages·2006·1.13 MB·English

Clin. exp. Immunol. (1969) 5, 341-353.
ANTI-ADRENAL CELLULAR HYPERSENSITIVITY
IN ADDISON'S DISEASE
II. CORRELATION WITH CLINICAL AND SEROLOGICAL FINDINGS
J. NERUP AND G. BENDIXEN
Medical Department A andMedical DepartmentP,
Copenhagen University Hospital, Rigshospitalet, Copenhagen
(Received 18 April 1969)
SUMMARY
Previous observations suggesting the existence in idiopathicAddison's disease ofa
state ofanti-adrenal cellularhypersensitivity is extended to a larger material com-
prising thirty cases ofidiopathic Addison's disease and seven cases oftuberculous
Addison's disease. The specific anti-adrenal humoral and cellular hypersensitivity
is evaluated by means of the indirect immunofluorescence technique and the
leucocyte migration test, respectively.
Anti-adrenal cellular hypersensitivity was demonstrable in46% ofpatientswith
idiopathic Addison's disease butinnocase ofAddison's disease ofunquestionable
tuberculous origin. Anti-adrenal cellular hypersensitivity could be demonstrated
morefrequently inmales (eight out ofeleven) thaninfemales (sixout ofnineteen).
Anti-adrenalhumoralhypersensitivity, i.e. occurrence ofcirculatinganti-adrenal
antibody, could be demonstrated in 7300 ofthepatientswithidiopathic Addison's
disease. Humoral and/or cellular anti-adrenal hypersensitivity was found in 9000
ofthe patients with idiopathic Addison's disease.
No correlation was observed between the occurrence of anti-adrenal cellular
hypersensitivity, and the duration ofclinical illness and the presence or absence of
anti-adrenal antibody.
In two patients with diabetes mellitus humoral as well as cellular anti-adrenal
hypersensitivitywasdemonstrated, althoughtheyhadnoclinicalsignsofAddison's
disease.
INTRODUCTION
The histopathological picture of the adrenal glands in idiopathic Addison's disease is
dominated by a massive infiltration ofmononuclear cells. This consistent finding might be
an indication of the presence and possible pathogenetic importance of organ-specific,
cellular hypersensitivity directed against adrenocortical components, and it was con-
sequently decided to investigate whether this kind ofreactivity couldbe detected in patients
Correspondence: DrJ.Nerup, MedicalDepartmentA,Rigshospitalet,Blegdamsvej,2100Copenhagen D,
Denmark.
341
342 J. Nerup and G. Bendixen
with idiopathic Addison's disease. The existence ofanti-adrenal cellular hypersensitivity in
this condition was confirmed by means ofthe leucocyte migration test(LMT)inaprevious
study (Nerup, Andersen & Bendixen, 1969). In a selected material offifteen patients with
idiopathic Addison's disease a specifically altered reactivity of this type to human foetal
adrenocortical components was demonstrated in nine. It was not possible, however, from
this material, to evaluate ifthe occurrence of circulating anti-adrenal antibody was corre-
lated to anti-adrenal cellular hypersensitivity.
The occurrence of organ-specific anti-adrenal antibody in patients without overt idio-
pathic Addison's disease is extremely rare but is sometimes found in patients with diabetes
mellitus (Irvine, Stewart & Scarth, 1967; Nerup & Binder, 1969). For this reason three
diabetics with circulating anti-adrenal antibody were included in the present study.
The purpose ofthis communication is to decide the occurrence in idiopathic Addison's
disease of organ-specific anti-adrenal cellular hypersensitivity in relation to anti-adrenal
humoral hypersensitivity, aetiology, sex, age, duration ofdisease, clinical type ofAddison's
disease and the co-existence ofother clinical disorders.
MATERIAL AND METHODS
Patients
Thirty-seven cases of Addison's disease were examined. The relevant clinical data are
summarized in Tables 1 and 2. The group ofidiopathic Addison's disease comprised thirty
cases. Nineteen were females (age 22-59 years) and eleven were males (age 22-63 years).
TABLE 1. Clinical summary ofpatients withidiopathicAddison'sdisease
Interval between Associated
Case clinical diagnosis Clinical disease Diagnostic
No. Name Sex Age andimmunological type (ageatonset) criteria
study
1 MKCL F 26 2years 7 months Chronic Secondary Clinicalfeatures,
amenorrhoea hyponatraemia,
(24) hyperkaliaemia.
Corticotrophin stimulation
test
2 ALOJ F 29 12years 2months Acute - Clinical features,
hyponatraemia,
hyperkaliaemia. Low urine
steroids
3 ESA F 48 13 years Acute Clinical features,
hyponatramia,
hyperkaliaemia.
Corticotrophinstimulation
test
4 KJJ F 45 4months Chronic Diffuse non- Clinical features,
toxic goitre hyponatraemia,
hyperkaliaemia.
Corticotrophinstimulation
test
Anti-adrenal, cellular hypersensitivity. II 343
TABLE 1. Continued
5 JSG F 29 5 years 5months Chronic Diffuse non- Clinicalfeatures,
toxicgoitre hyponatraemia,
hyperkaliaemia.
Corticotrophin stimulation
test
6 IOML F 51 16years 11 months Acute Climacteric Clinicalfeatures, lowurine
praecox (28) steroids. Corticotrophin
stimulation test
7 ESJH F 36 9years 7months Chronic - Clinicalfeatures,
hyponatraemia, lowurine
steroids. Corticotrophin
stimulationtest
8 MBF F 24 2years 7months Chronic Climacteric Clinicalfeatures,
praecox (22). hyperkaliaemia, lowurine
Diffusenon- steroids. Corticotrophin
toxicgoitre stimulationtest
9 EET F 43 12years 7months Chronic Non-toxic Clinicalfeatures,
goitre. Small hyperkaliaemia. Kepler's
fibrous test
opacity, left
lung
10 ET F 58 5years 8 months Chronic Nodularnon- Clinicalfeatures,
toxicgoitre. hyponatraemia,
Postoperative hyperkaliaemia.
myxoedema. Plasmacortisol,
Small fibrous 1-7 ug/100 ml
opacity, left
lung
11 EMT F 48 13 years 8 months Chronic Pulmonary Clinicalfeatures, low urine
tuberculosis steroids
1944and 1954
12 JJ F 22 7years Chronic Diffusenon- Clinicalfeatures,
toxicgoitre. hyponatraemia,
Bronchial hyperkaliaemia.
asthma Corticotrophin stimulation
test
13 BP F 26 1 year Chronic Graves' Clinicalfeatures,
disease (15) hyponatraemia, lowurine
steroids. Corticotrophin
stimulationtest
14 ESN F 59 9years 6months Chronic Diabetes Clinicalfeaturesonly
mellitus (23)
15 GJ F 54 9years 11 months Chronic Clinical features,
hyponatraemia,
hyperkaliaemia.
Corticotrophin stimulation
test
16 LFN F 35 14years 11 months Chronic Clinicalfeatures,
hyperkaliaemia. Lowurine
steroids
344 J. Nerup and G. Bendixen
TABLE 1. Continued
Interval between Associated
Case clinical diagnosis Clinical disease Diagnostic
No. Name Sex Age and immunological type (age at onset) criteria
study
17 MP F 45 4years 10months Acute Polypi Clinicalfeatures,
ventriculi hyponatraemia,
(45) hyperkaliaemia.
Corticotrophinstimulation
test
18 KP F 24 11 years 4months Chronic - Clinical features,
hyponatraemia, lowurine
steroids. Corticotrophin
stimulation test
19 EDN F 30 11 years 3 months Chronic Diffuse non- Clinicalfeatures,
toxicgoitre. hyponatraemia,
Epilepsia hyperkaliaemia. Low urine
steroids
20 JT M 23 1 year lmonth Chronic Clinicalfeatures,
hyperkaliaemia. Lowurine
steroids. Corticotrophin
stimulationtest
21 VP M 29 5 years Chronic Clinical features.
Corticotrophinstimulation
test
22 FPF M 21 1 year 10months Chronic Diabetes Clinical features,
mellitus hyponatraemia,
(18) hyperkaliaemia.
Corticotrophin stimulation
test
23 PB M 48 3 years 11 months Chronic Clinical features.
Corticotrophin stimulation
test
24 MK M 24 3 years 11 months Chronic Clinical features,
hyponatraemia,
hyperkaliaemia.
Corticotrophin stimulation
test
25 EAVR M 61 5 years 10months Chronic Diabetes Clinical features,
mellitus (54) hyponatraemia,
hyperkaliaemia, lowurine
steroids
26 FJ M 26 7 years 7 months Chronic Diabetes Clinical features,
mellitus (23) hyponatraemia,
hyperkaliaemia.
Corticotrophin stimulation
test
27 CQ M 67 7 years 8 months Chronic - Clinical features,
hyponatraemia,
hyperkaliaemia.
Corticotrophinstimulation
test
Anti-adrenal, cellular hypersensitivity. II 345
TABLE 1. Continued
28 SCJB M 49 11 years 9 months Chronic Bronchial Clinical features,
asthma hyponatraemia,
hyperkaliaemia.
Corticotrophin stimulation
test
29 FBO 38 month Chronic Hereditary Clinicalfeatures,
M 1
telangiectasia, hyponatraemia, low
calcification plasmacortisol.
oftheright Corticotrophin
adrenal gland stimulationtest
(35)
30 HPHC M 61 5 years 6months Acute Smallfibrous Clinicalfeatures,
opacity, hyponatraemia,
right lung hyperkaliaemia.
Corticotrophin stimulation
test
TABLE 2. Clinical summary ofpatients withtuberculous Addison's disease
Interval between Associated
Case clinical diagnosis Clinical disease Diagnostic
No. Name Sex Age andimmunological
type (ageatonset) criteria
study
31 RPN F 67 17 years 5 months Chronic - Clinicalfeatures,
hyponatraemia,
hyperkaliaemia.
Corticotrophin stimulation
test
32 HA F 59 1 month Chronic Breastcancer Clinicalfeatures,
(56) hyponatraemia,
hyperkaliaemia.
Corticotrophin stimulation
test
33 AACP M 55 3 months Chronic Clinicalfeatures,
hyperkaliaemia, lowurine
steroids. Corticotrophin
stimulationtest
34 VJP M 64 5 years 6months Chronic Clinicalfeatures,
hyperkaliaemia.
Corticotrophin stimulation
test
35 KMJ M 50 12years 2months Chronic Clinicalfeatures,
hyponatraemia,
hyperkaliaemia
36 KOM M 72 14years Chronic Clinical features,
hyponatraemia,
hyperkaliaemia, lowurine
steroids
37 HNSK M 66 8years 1 month Chronic Clinicalfeatures.
Corticotrophin stimulation
test
346 J. Nerup and G. Bendixen
The group ofpatients with tuberculous Addison's disease consisted ofseven cases, aged
50-72 years at the time ofimmunological study.
Allcaseswere seenby one oftheauthors (J.N.) andtheirrecords reviewed. Thediagnosis
was based on typical history, abnormal pigmentation, arterial hypotension, serum electro-
lyte disturbances, low urine steroids, low plasmacortisolvaluesandcorticotrophinstimula-
tion tests. The diagnosiswas felt to be sufficiently substantiated in all cases, althoughinten
cases (Nos. 2, 9, 10, 11, 14, 16, 19, 25, 35 and 36) no corticotrophin stimulation test was
performed. Addison's disease was considered to be oftuberculous aetiology ifcalcification
ofthe adrenal glands and/or signs ofhaematogenously disseminated tuberculosis could be
demonstrated.
In fourpatients (cases Nos. 9, 10, 11 and 30) pleural or pulmonal lesions ofquestionable
significance were demonstrated by radiological examination of the chest, but no signs of
haematogenously disseminated tuberculosis were found. These cases were included in the
group ofpatients with idiopathic Addison's disease.
IncaseNo. 29a diagnosis ofhereditary telangiectasiawasclinicallyandhistopathologic-
allyverified 3yearsbeforethepresentstudy. Atthistimecalcificationintherightsuprarenal
region was radiologically demonstrated although he had no symptoms or signs ofadrenal
insufficiency or tuberculous infection. A haemorrhage in a telangiectasic adrenal lesion
might be responsible for the calcification, and might also have initiated the adrenal insuffi-
ciencywhichwas manifest 3 years later. As itwasimpossibletodecidethetruepathogenesis
ofthis case, it was included in the idiopathic group.
Associated diseases are indicated in Tables 1 and 2. It is noteworthy that four of the
patients with idiopathic Addison's disease had diabetes mellitus and that three females had
precocious menopause in spite of adequate treatment of their adrenal insufficiency. One
patient had Graves' disease at the age of 15. Seven of the nineteen female patients had
non-toxic goitres.
Table 3 summarizes the clinical data ofthe three diabetics with circulating anti-adrenal
antibody, but without demonstrable signs ofAddison's disease.
TABLE 3. Clinical summary of patients with circulating anti-adrenal
antibody, but without Addison's disease
CaseNo. Name Sex Age Diseases
38 AKJ F 65 years Diabetesmellitus.
Myxoedema
39 IJ F 59years Diabetesmellitus.
Hashimoto's disease
40 EB F 77years Diabetesmellitus.
Thyrotoxicosis.
Exophthalmus.
Pretibialmyxoedema
Controls
Sixty-nine subjects (sixteen healthy persons and fifty-three patients with various medical
diseases, but without signs of endocrine disorders) were tested for anti-adrenal cellular
Anti-adrenal, cellular hypersensitivity. II 347
hypersensitivity bymeans ofthe LMTasdescribedbelow. Theresultswereusedforcalcula-
tion ofa normal range. The sixty-nine controls were not matched for age and sex.
Immunofluorescence technique
Serum antibody against cytoplasmic components of adrenocortical cells was demon-
strated bymeans ofanimmunofluorescence technique asdescribed by Blizzardetal. (1962).
In the present experiments monkey (Cercopithecus aetiops) adrenal glands were used as
antigen (Nerup et al., 1966).
Leucocyte migration test (LMT)
The LMT was performed according to a capillary tube migration technique using leuco-
cytes from human peripheral blood. The technique is described in details by Soborg &
Bendixen (S0borg & Bendixen, 1967; Bendixen & S0borg, 1969). The method enables
quantitative evaluation ofthe in vitro migration ofwashed, peripheral human leucocytes.
The influence of an antigen upon the migration is expressed as a migration index, MI,
which is calculated in the following way:
Ml -X
-
whereMxisthemean24-hrmigrationareaofaseriesof antigen-containingcultures,andMO
the mean 24-hr migration area in a series ofantigen-free cultures. Values for MI less than
unityindicate an inhibition, andvalues higherthan unityastimulation. Lyophilized,pooled
homogenate of nine foetal, human adrenal glands extracted with Hanks's balanced salt
solutionat40Cfor24 hr, was usedasantigen. The supernatant was separatedbycentrifuga-
tion (1000gfor20min)and standardized byprotein determination. Inpilotexperiments the
highest, non-toxicdose ofsupernatant proved to be 200pg protein/ml culture medium and
this dose was used routinely in the experiments. The organ-specificity of the antigen was
ensured in a previous series ofexperiments. (Nerup et al., 1969). The reproducibility ofthe
LMT was ensured by using series of identically treated cultures in each experiment as
previously described (Bendixen & S0borg, 1969). Severalpatients wereexaminedrepeatedly
with weekly intervals and showed consistently reproducible reactivity with MI-variations of
less than 10%. So far it is not known whether spontaneous alterations of the reactivity
may occur during the course ofdisease, but such fluctuations have not yet been observed.
RESULTS
Twenty-two ofthe thirty patients with idiopathic Addison's disease (730%) had anti-adrenal
antibody in serum demonstrable by the immunofluorescence technique applied. This
frequency of anti-adrenal antibody in idiopathic Addison's disease is in accordance with
findings in a larger series ofpatients in this laboratory (Nerup etal., 1966).
The normal range ofthe LMT with 200 pg adrenal protein/ml culture medium was cal-
culated on the basis ofexaminations ofsixty-nine controls, and turned out to be 0-84-1 12
(mean MI: 0-98 +2 SD). The normal range and the outcome of the LMT in the Addison
material is illustrated in Fig. 1. It appears that abnormal low MI values were found in
fourteen out ofthirtypatients (46%) withidiopathic Addison's disease (casesNos. 1, 3,4,6,
12, 19, 20,21, 22, 23, 25, 27, 28 and29). Oftheeightpatientswithoutanti-adrenalantibody,
five had MI values below normal range.
348 J. Nerup and G. Bendixen
MI (a) (b) MI
0~~~~~~~
10 0
050__ 0050
FIG. 1. Leucocyte migration test (LMT) with human, foetal adrenal extract in thirty-seven
patientswith Addison's disease. (a)Idiopathic,(b)tuberculous. 9,Withanti-adrenalantibody
in; rum; c, without anti-adrenal antibody in serum. Hatched areas, normal range (mean
±2 SD). MI, Migration indices.
Anti-adrenal humoral and/or cellular hypersensitivity was demonstrated in twenty-seven
ofthe thirty patients with idiopathic Addison's disease (900).
OnlyonepatientwithtuberculousAddison'sdiseasehadanMIvaluebelownormalrange.
This case (No. 34) was discussed in a previous report (Nerup et al., 1969).
MI
V
1000 r',.z,'/ ;V,.
?
V~~~~
A A A
0 50
IA
5 10 15
Time (years)
FIG. Migration indices (MI) ofthirty patients with idiopathic Addison's disease correlated
withtimeinterval betweenclinical diagnosisandimmunological study. A, Males; v, females.
Hatched area, normal range (mean +2 SD).
Anti-adrenal, cellular hypersensitivity. II 349
0 50
20 50 80
Age(years)
FIG. 3. Migration indices(MI) ofthirtypatientswithidiopathicAddison's diseasecorrelated
with the patient's age at the time ofdiagnosis. A, Males; v, females. Hatched area, normal
range(mean ±2SD).
Two ofthe three diabetics with circulating anti-adrenal antibody, but withoutAddison's
disease(casesNos.38and39)hadMIvaluesbelownormalrange(0.81 and079,respectively).
Both had associated thyroid disease, and-decreasing need ofinsulin.
MI
V V
1 1 1 i I
20 50 80
Age (years)
FIG. 4. Migrationindices(MI)ofthirtypatientswithidiopathicAddison'sdiseasecorrelated
withthepatient'sageatthetimeofimmunologicalstudy.A,Males; v,Females.Hatchedarea,
normalrange (mean ±2SD).
B
350 J. Nerup and G. Bendixen
The MI values were notcorrelated to the duration ofthe disease as estimated by the time
intervalbetweendiagnosisandimmunologicalstudy.Thisappears fromFig.2,whichfurther
shows that anti-adrenal cellular hypersensitivity was morefrequent in males (eight out of
eleven)thaninfemales(sixoutofnineteen)withidiopathicAddison'sdisease. TheMIvalues
were uncorrelated to the age at the time ofclinical diagnosis (Fig. 3) and to the age at the
presentimmunological study(Fig. 4). Five ofthepatients withidiopathic Addison's disease
had symptoms ofadrenalinsufficiencyforonlyafewdays orweeksbeforethediagnosiswas
established (acute cases), whereas in twenty-five patients symptoms had been present for
several months before admission to hospital (chronic cases). These two clinical types of
idiopathic Addison's disease as well as the occurrence ofassociated clinical disorders were
unrelated to the occurrence of anti-adrenal cellular hypersensitivity as demonstrated by
means ofthe LMT.
DISCUSSION
In order to diagnose with certainty a state ofadrenal insufficiency, it is necessary to carry
through an appropriate investigation ofthe adrenal function. Acorticotrophinstimulation
test with either ACTH or fi1-24 corticotrophin (Synacthen®) in adequate dose for the
adequateperiodoftimeisconsideredthefinaldiagnosticcriterion. Inseveralcases,however,
immediate, specific treatment ofthe adrenal insufficiency was imperative, and the cortico-
trophin stimulation test was not undertaken. In such cases the diagnosis of Addison's
diseaserestsuponclinicalsymptomsandsigns,electrolytedisturbances,lowurinesteroidsand
lowplasma cortisol values. The extent to which these criteria are fulfilled is indicated as far
as the present material is concerned.
The differential diagnosis ofidiopathicAddison's disease is reached by way ofexclusion.
Objectivefindingsinfourpatients ofthisgroup(cases Nos.9, 10,11 and30)werecompatible
with previous tuberculous infection ofthe lung, but no signs ofhaematogenously dissemin-
ated tuberculosis was found. It may be disputed whether or not these findings have any
connection with the pathogenesis in the four cases named, but according to the differential
diagnostic criteria applied in the present series, they were regarded as cases of Addison's
disease ofthe idiopathic type. Anti-adrenal cellular hypersensitivity was demonstrated by
means ofthe leucocyte migrationtest. Experimentalresearchinanimalshas establishedthat
an antigen-induced inhibition in vitro ofthe migration ofimmunocompetent cells indicates
a state ofcellular hypersensitivity (Rich & Lewis, 1932; Moen & Swift, 1936; Raffel, 1948;
Heilman,Howard &Carpenter, 1958;Darlington &Scherago, 1960; Svejcar &JohanovskS,
1961; George &Vaughan, 1962; David etal., 1964a; David, Lawrence & Thomas, 1964b).
Inmanithasbeendemonstrated thatcellsfromspleen(Citron, 1958), lymphnodes(Thor,
1967) and peripheral blood (S0borg & Bendixen, 1967; S0borg, 1967, 1968) possess the
capacity for a similar specific in vitro reaction as an indication ofcellular hypersensitivity.
The migration inhibition induced by adrenocortical components in peripheral blood cell
cultures from patients with Addison's disease may accordingly be regarded as an in vitro
indication of a state of cellular hypersensitivity directed against immunogenic adreno-
cortical components.
The reactivity was demonstrated only in patients with Addison's disease and was never
observed in consecutive normal controls and the reactivity was only induced by adrenal
extract, not by similar preparations ofhuman kidney, intestinal mucosa or liver.
With the human foetal adrenal extract as antigen anti-adrenal cellular hypersensitivity