Despite a drug half-life of less than a week [12], treatment results in a rapid depletion of circulating lymphocytes which can persist for several years; median recovery of CD4+cells took 35 months [2], whilst B cells returned within 7 months but continued to rise, reaching 124% of baseline 27 months post treatment [13]. disease requiring systemic immunosuppression, with one refractory to multiple immunosuppressants. The remaining patients were treated conservatively. TSH-receptor antibody (TRAb) levels were significantly raised in all cases, when ascertained. We report sight-threatening as well as mild TED in MS patients after treatment with alemtuzumab. Endocrine Mouse monoclonal antibody to Keratin 7. The protein encoded by this gene is a member of the keratin gene family. The type IIcytokeratins consist of basic or neutral proteins which are arranged in pairs of heterotypic keratinchains coexpressed during differentiation of simple and stratified epithelial tissues. This type IIcytokeratin is specifically expressed in the simple epithelia ining the cavities of the internalorgans and in the gland ducts and blood vessels. The genes encoding the type II cytokeratinsare clustered in a region of chromosome 12q12-q13. Alternative splicing may result in severaltranscript variants; however, not all variants have been fully described instability, radioiodine treatment and positive TRAb are all likely risk factors. The data support at least 6-monthly biochemical and clinical assessment with a low CUDC-101 threshold for referral to CUDC-101 an ophthalmologist, particularly for those with higher TRAb levels who may be at greater risk of orbitopathy. Introduction Alemtuzumab (Lemtrada; Campath-1H) is a humanised monoclonal antibody developed in Cambridge to target cells expressing CD52 [1]. This membrane glycoprotein is found on almost all mature leucocytes but critically not on their haematopoeitic precursor CUDC-101 stem cells, allowing for a ‘reboot’ of the immune system with rapid depletion and gradual reconstitution of the immune system [2]. This has made it a helpful agent in the treatment of B-cell chronic lymphocytic leukaemia [3], organ transplantation [4, 5], vasculitides [6], uveitis [7, 8] and most recently as an effective treatment for multiple sclerosis (MS) [9]. It has been shown to decrease both the annualised relapse rate as well as reduce the overall accumulation of disability compared with interferon beta-1a treatment [10, 11]. The drug is administered intravenously over two courses: 12?mg/day for 5 consecutive days, followed by the same dose for 3 consecutive days 12 months later; additional courses may be considered. Despite a drug half-life of less than a week [12], treatment results in a rapid depletion of circulating lymphocytes which can persist for several years; median recovery of CD4+cells took 35 months [2], whilst B cells returned within 7 months but continued to rise, reaching 124% of baseline 27 months post treatment [13]. These temporal changes are likely significant for pathogenesis and will be discussed later. Alemtuzumab is also associated with side effects, such as infusion reactions and infections [14]. However, the principal adverse effect is the development of secondary autoimmunity during immune reconstitution, occurring in 12C48% of treated patients [15, 16]. Reported cases have included Goodpastures syndrome and fatal idiopathic thrombocytopenic purpura, but thyroid autoimmunity is the most common by far representing up to 77% of the cases of autoimmunity [17]. The onset of Graves disease or other thyroid dysfunction peaked at 3 years post treatment but could occur as early as 6 months after treatment or as late as 7 years thereafter [18]. More than 96% of the patients were positive for TRAb [14]. Whilst MS may confer a higher risk of developing Graves disease, the incidence is only around 1C2% [19, 20] and therefore an order of magnitude smaller than that reported after alemtuzumab treatment. Furthermore, patients treated with interferon had a rate of only around 3%. A causative link to alemtuzumab treatment was therefore quickly established. Development of thyroid eye disease is less common, occurring in less than 2% of alemtuzumab-treated MS patients [21]. Consequently, only a handful of cases have been reported in the literature (see Table?2) [22C24]. These have ranged from the mild, requiring no treatment, to more serious disease manifestations requiring orbital wall decompression. Table 2 Cases of alemtuzumab-related thyroid eye disease reported in the literature thead CUDC-101 th rowspan=”1″ colspan=”1″ Number of cases /th th rowspan=”1″ colspan=”1″ Severity /th th rowspan=”1″ colspan=”1″ Time of onset post alemtuzumab /th th rowspan=”1″ colspan=”1″ Treatment /th th rowspan=”1″ colspan=”1″ Underlying disease /th th rowspan=”1″ colspan=”1″ Reference /th /thead 4 patients3 severe br / 1 moderateNot recordedOf severe casesone received radioiodine and one required orbital decompression. No further information availableAll MSDaniels et al. [22]2(a) moderate br / (b) mild(a) 38 months br / (b) 23 months(a) iv methylprednisolone & endocrine control br / (b) lubricants & endocrine control with subsequent thyroidectomyAll MSTsourdi et al. [23]1Mild2 yearsEndocrine control, lubricants, selenium, thyroidectomyMSTrinh et al. [24]1Moderate3 yearsEndocrine control selenium iv methylprednisoloneBone Marrow Transplantation for fanconi anaemiaCima et al. [33]10 patientsRanging from mild to severeRange of 10 months to 4 yearsLubricants to systemic immunosuppression and surgeryAll MSThis series Open in a separate window Until recently, no associations had been found between the risk of developing autoimmunity and the severity of MS, treatment response, total dosage or intervals between.
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