Iatrogenic thyrotoxicosis and the role of therapeutic plasma exchange.

Thyroid storm or severe thyrotoxicosis results from extreme thyroid hormone elevation. Therapy includes medical management to prevent hormone production, release, recycling, and peripheral conversion while stabilizing adrenergic tone. Thyroid dysfunction is the usual cause but it can be due to excessive thyroid hormone ingestion. Therapeutic plasma exchange (TPE) has been used to rapidly remove protein-bound thyroid hormone. American Society for Apheresis guidelines make a weak recommendation to perform TPE in selected patients in the treatment of thyrotoxicosis based on low quality evidence. We present a case of excessive thyroid replacement hormone ingestion treated by TPE. The patient presented with the clinical picture of thyroid storm, including cardiovascular compromise and massively elevated total and free T3 (525 ng/dL, nl 80-200 ng/dL and 28 pg/mL, nl 2.0-3.5 11 pg/mL), which failed medical therapy. A single, one plasma volume TPE was performed. Both total and free T3 demonstrated substantial declines immediately after TPE with the patient's mental status returning to near-normal. Thyroid hormone extraction efficiency and collection efficacy were calculated as 37.1% and 40.8%, respectively. Prior to discharge on day 6, the patient's compounding pharmacy indicated that a "bad batch" of bovine thyroid gland derived replacement hormone had been produced. TPE appears to be effective in removing protein bound thyroid hormone in extreme iatrogenic thyrotoxicosis.

Anti-ruthenium antibodies mimic macro-TSH in electrochemiluminescent immunoassay.

BACKGROUND: Macro-hormones are circulating conjugates of hormones with immunoglobulins, which often artefactually elevate biochemical test results. Particularly when causing only moderate elevation no suspicion will be raised. By far the most frequently encountered macro-hormone is macro-prolactin. Here we report a female patient with rheumatoid arthritis who had persistently and grossly elevated thyroid stimulating hormone (TSH) but normal free thyroxine in electrochemiluminescent assays. Although clinically euthyroid, she was put on thyroxine therapy which caused hyperthyroid symptoms. METHODS: An analytic interference by macro-TSH was assumed by dilution experiments, polyethylene-glycol-precipitation, the addition of a heterophilic antibody blocking reagent and size exclusion chromatography. RESULTS: Further workup, however, revealed the presence of anti-ruthenium antibodies. CONCLUSIONS: To our knowledge this is the first report of anti-ruthenium antibodies selectively interfering with a TSH assay and causing erratic gross elevation of TSH mimicking macro-TSH.

Reagentless electrochemiluminescent detection of protein biomarker using graphene-based magnetic nanoprobes and poly-L-lysine as co-reactant.

This work described the construction of a reagentless and ultrasensitive electrochemiluminescence (ECL) immunosensor using poly-L-lysine as a co-reactant with Ru(bpy)3(2+) for signal amplification and magnetic Fe3O4 loaded graphene nanosheet as nanoprobes, which can achieve an impressive detection limit of 0.03 pg/mL human total 3,3',5-triiodothyronine (T3), a kind of diagnostic markers of thyroid disease. The bionanoprobes were prepared based on the coimmobilization of Ru(bpy)3(2+) and T3 detection antibody on the Fe3O4 loaded graphene nanosheet and the sensing interface was achieved by assembling T3 capture antibody on the gold nanoparticles (AuNPs) loaded electro-deposited L-lysine film modified bare glass carbon electrode (GCE). ECL responses were generated from the modified electrodes described above by just immersing them in phosphate buffer solutions (PBS) based on the sandwich-type immunoreactions. T3 was measured quantitatively in the range from 0.1 pg/mL to 10 ng/mL, which exhibits sufficiently high sensitivity and stability. The reagentless ECL immunoassay is a promising approach for the detection of a wide range of molecular analytes.

Enantiorecognition of triiodothyronine and thyroxine enantiomers using different chiral selectors by HPLC and micro-HPLC.

This paper deals with the chiral separation of triiodothyronine (T3) and thyroxine (T4) by HPLC and micro-HPLC. The separation of T3 and T4 is of great pharmaceutical and clinical interest, since the enantiomers exhibit different pharmacological activities. The HPLC measurements were performed on a chiral stationary ligand-exchange phase using l-4-hydroxyproline bonded via 3-glycidoxypropyltrimethoxysilane to silica gel as a selector. Also a chiral teicoplanin (Chirobiotic) phase was used. In micro-HPLC the chiral separation behaviour of l-4-hydroxyproline, and of the macrocyclic antibiotics teicoplanin and teicoplanin aglycone was investigated for the enantioseparation of T3 and T4. l-4-Hydroxyproline was bonded to 3 microm and the glycopeptide antibiotics were bonded to 3.5 microm silica gel and separations were accomplished by microbore HPLC columns (10 cmx1 mm I.D.). With both techniques and all chiral selectors investigated T3 and T4 were baseline resolved. micro-HPLC was found to be superior to analytical HPLC with respect to low consumption of packing material, mobile phase and analyte.

Chiral separation of T3 enantiomers using stereoselective antibodies as a selector in micro-HPLC.

This work deals with the application of stereoselective antibodies against L-T3 as a tailor-made chiral selector in micro-HPLC. The separations were performed in microbore columns using commercially available anti-L-T3 antibodies chemically bonded to 5 microm silica gel. The enantiomers of T3 were baseline separated under mild continuous isocratic elution conditions using 10 mM phosphate buffer, pH 7.4. The D-enantiomer eluted with the void volume, while the L-enantiomer was retained by the antibody phase and eluted second. An indirect competitive and non-competitive enzyme linked immunosorbent assay (ELISA) was used for testing the stereoselectivity of anti-L-T3 antibodies.

Direct separation and quantitative analysis of thyroxine and triiodothyronine enantiomers in pharmaceuticals by high-performance liquid chromatography.

A rapid reversed-phase type HPLC method for the simultaneous separation and analysis of D- and L-thyroxine (D- and L-T(4)) and triiodothyronine (T(3)) was developed using a quinine-derived chiral stationary phase and applied for a quantitative assay of the enantiomeric impurity of the drugs in pharmaceutical formulations of levothyroxine. The influence of operating parameters has been studied for the optimization of the separation and also in order to gain an insight into the retention mechanism. Validation of the method included linearity, precision and accuracy which revealed R.S.D. values of <3.3% for intra-assay precision and percent error ranging from -6 to +2.1% for various defined validation samples, proving satisfactory accuracy. Quantitation was performed over the range of 0.5-500 microg ml(-1) with limits of detection and quantitation lower than 0.1 and 0.5 microg ml(-1), respectively, for both analytes. Further, the determination of 0.1% impurity, of D-T(4) as well as L- and D-T(3) in levothyroxine sodium tablets proved to be feasible.

Comparison of different methods for iodothyronines extraction from animal tissues.

Four different methods for thyroid hormones concentration in various tissues have been compared. The methods involve homogenization, extraction with 95% ethanol and assay of iodothyronines by a highly sensitive RIA. The method described by Chopra et al. has been selected and used for further estimations as the most reliable and convenient for a continuous laboratory work. The T4 levels (means +/- SE) found in the liver, kidney and skeletal muscle were 22.49 +/- 2.19, 14.89 +/- 1.56 and 8.33 +/- 1.73 ng per g wet tissue. The T3 contents were 8.53 +/- 1.08, 9.52 +/- 0.69 and 4.90 +/- 0.76 ng per g wet tissue, respectively.

Changes in tissue and blood concentrations of thyroid hormones in developing chum salmon.

The changes in tissue and blood concentrations of thyroxine (T4) and triiodothyronine (T3) were examined during development of the chum salmon (Oncorhynchus keta). Extraction methods previously established for tissue T4 were also validated for tissue T3, by parallel displacement curves to T3 standard in the radioimmunoassay and by the same elution patterns of immunoreactivity in a HPLC system. The T3 concentration of the eggs just after fertilization (4-9 ng/g) was lower than the T4 concentration (5-15 ng/g). Both T4 and T3 concentrations in the whole body decreased steadily during yolk absorption, primarily due to the decline of the hormone content in the yolk. Both T4 and T3 were detected in blood plasma at later stages of yolk absorption, and the plasma levels increased toward the end of yolk absorption. At the end of yolk absorption, when the larvae emerge from the gravel bed, a transient increase in whole body concentrations of T4 and T3 was observed. Plasma levels of T4 were always greater than the T3 levels. Thyroid follicles began to develop during the early stages of yolk absorption. These findings suggest important roles of maternal thyroid hormones for developing salmon embryos during yolk absorption.

Increased sensitivity of triiodothyronine antibodies for radioimmunoassay after removal of endogenous antigen by simple laboratory procedures.

Conventionally produced antibodies against triiodothyronine (T3) are known to possess high amounts of endogenously produced T3 associated with them. We felt that such antibodies would work better for T3 radioimmunoassay (RIA) after prior removal of the antigen. With this in view, we attempted dissociation and subsequent removal of T3 from antisera by two different methods, viz. dialysis and alcohol extraction. It was possible to remove T3 to an extent of 77% by alcohol extraction and 60% by dialysis. Resultant antisera fail to demonstrate any increase in the titre. However, when standard curves were generated using these antisera, the assays became more sensitive and it was possible to detect T3 in concentrations as low as 6.25 pg. The affinity constants of these antisera calculated from the respective Scatchard plots were found to have increased after both dialysis treatment was well as alcohol extraction. This was thought to be due to rendering some of the high affinity binding sites on the antibodies free of antigen after treatment. Serum T3 levels were measured in 68 patients with various thyroid status using both treated as well as untreated antiserum. The difference between the average values of serum T3 concentration estimated using various antisera before and after the treatment was not statistically significant. Our results suggested that a simple procedure like stripping of antigen from antibodies could be of help for acquiring high affinity and high sensitivity antibodies for this purpose.

Single-step, quantitative derivatization of amino, carboxyl, and hydroxyl groups in iodothyronine amino acids with ethanolic pivalic anhydride containing 4-dimethylaminopyridine.

Reaction of thyroxine with ethanol and pivalic anhydride in the presence of 4-dimethylaminopyridine quantitatively forms N,O-dipivalyl thyroxine ethyl ester. Other iodothyronines react similarly and the procedure is moisture insensitive. Apparently this reaction is successful, in contrast to similar procedures reported for the derivatization of alpha-amino acids, because it overcomes the problem in other procedures of irreversible side reactions arising from an oxazolone intermediate.

Coupling of iodotyrosine catalyzed by human thyroid peroxidase in vitro.

The coupling of iodotyrosine (coupling reaction) is one of the least studied in the formation of thyroid hormone, particularly in human thyroid diseases. This paper describes a method of measuring iodotyrosine coupling catalyzed by human thyroid peroxidase (TPO) in vitro. There were two important requirements to demonstrate the coupling reaction: 1) thyroglobulin with a low thyroid hormone content, and 2) partially purified TPO. Thyroglobulin with low thyroid hormone content was obtained from Grave's and follicular adenoma tissues after propylthiouracil (PTU) therapy and L-T4 therapy, respectively. TPO was prepared from Graves' thyroid by solubilizing the 100,000 X g pellet of thyroid homogenate with sodium deoxycholate and trypsin, followed by Sephacryl S-300 gel filtration. Before the coupling reaction, thyroglobulin was iodinated with chloramine-T and potassium iodide, followed by dialysis. The coupling reaction was carried out by incubating newly iodinated thyroglobulin with TPO, diiodotyrosine, a coupling stimulator, and a H2O2-generating system (glucose and glucose oxidase) for 20 min at 37 C. After thyroglobulin was digested with Pronase, the thyroid hormone content of the thyroid digest was measured by RIA. Coupling activity was measured by the amount of newly formed T3 (nanograms of T3 per mg thyroglobulin). The time course of coupling reaction showed a progressive increase in coupling activity up to 30 min, and the reaction was temperature and pH dependent, with a pH optimum of 7.0. Coupling activity in the presence of H2O2 and TPO was 43 +/- 5.0 ng T3/mg thyroglobulin (mean +/- SD of triplicate samples), and addition of diiodotyrosine to the H2O2-TPO system caused a nearly 3-fold increase in coupling activity. This method has potential utilization for measurement of peroxidase coupling activity, since there was a linear relationship between the measured coupling activity and the amount of added TPO when the TPO concentration was over 3 micrograms/300 microliter. Methimazole (MMI) and PTU had similar potencies in inhibiting the TPO-catalyzed coupling reaction, whereas MMI was distinctly more potent than PTU as an inhibitor of TPO-mediated iodination in vitro. The different potencies of MMI in the two reactions suggest that different inhibitory mechanisms may be involved in iodination and coupling. The reducing agent, sodium metabisulfite, was also found to be a more potent inhibitor of the TPO-mediated coupling reaction than of the TPO-mediated iodination reaction. The method of iodotyrosine coupling described here may be useful to investigate the coupling step of thyroid hormone formation in human thyroid diseases.

Use of guanidine hydrochloride in the purification by reversed-phase high-performance liquid chromatography of thyroxinyl- and triiodothyronylpeptides derived from thyroglobulin.

When peptides containing thyroid hormones are first solubilized in 6 M guanidine hydrochloride they can be perfectly separated by reversed-phase high-performance liquid chromatography on an octadecylsilica column using conventional elution conditions (trifluoroacetic acid-acetonitrile).

High-performance liquid chromatographic separation of iodoamino acids for tracer turnover studies of thyroid hormones in vivo.

A reversed-phase high-performance liquid chromatographic technique was developed to separate radioiodinated thyroxine (T4), 3,5,3'-triiodothyronine (T3), 3,3',5'-triiodothyronine (rT3) and two diiodothyronines (3,3'-T2 and 3',5'-T2), in extracts from either serum or urine. Chromatography was performed with 10-micron C18 silica gel, packed in a glass column (3 X 300 mm); the mobile phase was methanol-water (55:45) adjusted to pH 3 with H3PO4, at a flow-rate of 1.2 ml/min and a pressure of 2800 p.s.i. The results demonstrate the ability of the system to yield a clear-cut separation of the iodothyronines involved in in vivo turnover studies, i.e., T4, T3, rT3, and the two T2 compounds together.

Meaning of serum free-thyroxin values in nonthyroidal illnesses: seven methods compared.

Serum free thyroxin (FT4) was determined in 40 patients with various nonthyroidal illnesses. We studied seven methods: (1) a free thyroxin index calculated from total T4 and triiodothyronine resin uptake; (2) a free T4 index determined by enzyme inhibitor assays (Abbott's "Tetrazyme" and "Thyrozyme"); (3) a free T4 index calculated from total T4 and thyroxin-binding globulin; (4) free T4 by equilibrium dialysis; (5) Amersham's free T4 RIA; (6) Clinical Assays' one-step free T4 RIA; and (7) Clinical Assays' two-step free T4 RIA. Approximately half of the free T4 results were in the euthyroid range and the other half in the hypothyroid range by methods 1, 2, 5, and 6. Results for free T4 by methods 3 and 7 were similar to those by equilibrium dialysis (method 4), the percentages of patients with results in the euthyroid range being 68%, 65%, and 76%, respectively.

Radioimmunoassay of triiodothyronine (T3) and thyroxine (T4). An assay with both the bound and free fraction of the hormone present in the counting vessel.

A radioimmunoassay for triiodothyronine T3 and thyroxine T4 without any manual separation is described. By the use of an aqueous two-phase system the free hormone was separated from the immunologically bound fraction and lifted out of the counting area of the gamma counter. The coefficient of correlation between results obtained with this method and with a conventional RIA was 0.97 and 0.93 for T3 and T4, respectively.

Isolation of radioactive iodothyronines for kinetic studies: a comparison of two methods.

A method based on the principle of gel separation followed by antibody extraction (GSAE) has been developed for isolation of radioactive thyroxine (T4), 3,5,3'-triiodothyronine (T3), 3,3'5'-triiodothyronine (rT3), 3,3'-diiodothyronine (3,3'-T2), 3',5'-diiodothyronine (3',5'-T2) and 3'monoiodothyronine (3'-T1) in serum. This method was used for the estimation of the metabolic clearance rate (MCR( of the iodothyronines using the single injection, non-compartmental approach, and was compared to the conventional trichloroacetic acid precipitation/ethanol extraction (TCA-E) technique. The GSAE method excluded the co-determination of radioactive iodine ad iodoproteins, whereas the co-determination of radiolabelled daughter iodothyronines was found negligible. The relative difference of duplicate estimation of MCR was approximately 10%. Using the TCA-E method for isolation of tracer, the MCR of T4, T3 and rT3 was underestimated to a minor degree (20%), whereas the MCRs of 3,3'-T2, 3'5'-T2 and 3'-T1 were 20-40% of the estimated by the GSAE method. In conclusion the GSAE method was found suitable for kinetic studies of iodothyronines, whereas the TCA-E method cannot be used for turnover studies of 3,3'-T2, 3'5'-T2 or 3'T1.

Incomplete separation of radioiodinated thyroid hormones in serum using specific antibodies.

Alkaline Sephadex G-25 columns were used to separate labelled 3,5,3',5'-thyroxine, 3,5,3'-triiodothyronine, 3,3',5'-triiodothyronine and 3,3'-diiodothyronine from the serum binding proteins followed by a quantitative elution of each hormone by coupling to its respective antibody. It is shown that although these antibodies (diluted 1:1500-1:100 000) in our radioimmunoassays are highly specific they show a high degree of non-specific binding when they are used in the concentrations necessary to get a maximal recovery of the hormones in column separating experiments.

The relative merits of polyethyleneglycol as a separating agent in the radioimmunoassay of thyroid hormones.

Polyethyleneglycol (PEG) has been recommended as a separating agent in the assay of some peptide hormones (Desbuquois, B. and Aurbach, G.D. (1971) J. Clin. Endocrinol. 33, 732) and several substances of low molecular weight (Ratcliffe, J.G. (1974) Br. Med. Bull. 30, 32). In the present study the PEG-separation technique has been modified and adapted for the assay of thyroid hormones. Separation with PEG has the advantage of being cheap, rapid and relatively non-susceptible to disturbances as compared with the charcoal and double-antibody-solid phase techniques. The influence of different buffer systems, varying pH and ionic strength, on the precipitation process with PEG also has been investigated. Of the different systems tested barbital buffer containing 0.1% human serum albumin proved to be the best, preferably in the presence of bovine gamma-globulin. In the radioimmunoassay of T3 variations in pH and ionic strength are of minor importance whereas in the radioimmunoassay of T4 the adherence to a certain pH is recommended. Barbital buffer containing 0.1% bovine serum albumin was inadequate in the T3 radioimmunoassay, while Tris and phosphate buffers did not give satisfying results for either radioimmunoassay.