Blackwell Science, LtdOxford, UKCEIClinical and Experimental Immunology0009-9104Blackwell Publishing Ltd, 2004 1372 225233 Review Type 2 autoimmune

polyglandular syndrome C. Betterle et al.

Clin Exp Immunol 2004; 137:225233

doi:10.1111/j.1365-2249.2004.02561.x

REVIEW

Autoimmune polyglandular syndrome Type 2: the tip of an iceberg?

C. BETTERLE*, F. LAZZAROTTO* & F. PRESOTTO *Unit of Endocrinology and Unit of 3rd Internal Medicine, Department of Medical and Surgical Sciences, University of Padua, Italy

(Accepted for publication 3 June 2004)

SUMMARY
Autoimmune polyglandular syndromes (APS) are conditions characterized by the association of two or more organ-specic disorders. Type 2 APS is dened by the occurrence of Addisons disease with thyroid autoimmune disease and/or Type 1 diabetes mellitus. Clinically overt disorders are considered only the tip of the autoimmune iceberg, since latent forms are much more frequent. Historical, clinical, genetic, and immunological aspects of Type 2 APS are reviewed. Furthermore, data on 146 personal cases of Type 2 APS are also reported. Keywords autoimmune polyglandular syndrome autoimmune Addisons disease thyroid autoimmune disease Type 1 diabetes mellitus

HISTORICAL BACKGROUND OF TYPE 2 AUTOIMMUNE POLYGLANDULAR SYNDROME

The association between Addisons disease and diabetes mellitus was rst reported in 1886 by Oegle [1], but in the original description adrenocortical failure ensued from bilateral tuberculous destruction of the adrenal glands. During the subsequent 75 years, only 15 other cases were mentioned with this association [2]. Moreover, the combined occurrence of Addisons disease and chronic lymphocytic thyroiditis was rst reported in two patients by Schmidt in 1926 [3], neither of whom had clinical signs of thyroid dysfunction. From that time, the coexistence of Addisons disease and autoimmune thyroid disease has come to be known as Schmidts syndrome. To further investigate this clinical association, a few years later Wells studied 20 patients with Addisons disease revealing that a lymphocytic inltration of the thyroid glands was far more common in patients with idiopathic Addisons disease than in those with tuberculous adrenal insufciency [4]. The relationship between these three glands was revealed in 1931, when Rowntree and Snell [5] reported the rst case with Addisons disease, hyperthyroidism and diabetes mellitus, and one year later Gowen [6] described a patient affected by Addisons disease, hypothyroidism and diabetes mellitus. This last patient died of diabetic ketoacidosis, and postmortem investigation showed that some islets of Langerhans had lymphocytic inltrations similar to that seen in the adrenal and the thyroid glands, thus revealing for the rst time that the pancreas can be involved

in the same pathological process affecting both thyroid and adrenals. The relationship between Addisons disease and diabetes mellitus was extensively reviewed in 1959 by Beaven et al. [7] on 66 cases, and some years later by Solomon et al. [8] on 113 cases. Diabetes mellitus was found to be the disease heralding the syndrome in 5763% of the cases, while Addisons disease preceded diabetes mellitus in 2335% and the two diseases appeared to be simultaneous in 810% of the cases; in 4% of the patients the sequence of the diseases was not specied. Many patients with this association died within one year by the time of the clinical diagnosis. Post-mortem investigation of these patients showed adrenals with atrophy and lymphocytic inltration in 74%, tuberculous inammation in 22%, and a neoplasia in 2% of the cases, denoting that the majority of them were affected by autoimmune Addisons disease. Unfortunately, no data were reported about the histopathological features of pancreatic islets in these cases. In the same years, Carpenter reviewed 142 cases with Schmidts syndrome [9]. In the vast majority of cases, the thyroid autoimmune disease was Hashimotos thyroiditis or idiopathic myxedema, and in the remaining cases Graves disease. The link between Schmidts syndrome and diabetes mellitus was conrmed in this review, where 28 patients (20%) were found to suffer also from diabetes mellitus [9]. The complete triad of Addisons disease, thyroid autoimmune disease and Type 1 diabetes mellitus is also termed Carpenters syndrome.

THE DISCOVERY OF AUTOIMMUNE DISEASES

Correspondence: Prof. C. Betterle, Unit of Endocrinology, Department of Medical and Surgical Sciences, Via Ospedale Civile 105, I-35125 Padova, Italy. E-mail: corrado.betterle@unipd.it 2004 Blackwell Publishing Ltd

During the 1950s and 1960s some discoveries greatly improved our knowledge about autoimmune diseases. In 1956, Roitt and Doniach [10] found that patients with Hashimotos thyroiditis had

225

226

C. Betterle et al.
designated as idiopathic were included into the group of the autoimmune disorders, like chronic atrophic body gastritis, pernicious anaemia, chronic hypoparathyroidism, premature ovarian failure, vitiligo, alopecia, autoimmune hepatitis, myasthenia gravis, and so on. In fact, they revealed the presence of circulating autoantibodies to the relevant autoantigen(s) of the target organs (parietal cells, intrinsic factor, liver-kidney microsomes, steroidproducing cells, acetylcholine receptor, etc.), or met the above mentioned criteria [19]. It was only in 1974 that Type 1 diabetes mellitus, one of the three main diseases occurring in Type 2 APS, entered this group, when Bottazzo et al. [20] demonstrated that patients affected by Type 1 diabetes mellitus and other autoimmune endocrinopathies had circulating autoantibodies to the pancreatic islets.

circulating autoantibodies reacting to thyroid self antigens. In the same year, Adams and Purves [11] recognized that patients with Graves disease had a serum factor dened as long-acting thyroid stimulator (LATS), later found to be an immunoglobulin G binding to the TSH receptor [1214]. Also in 1956, Rose and Witebsky [15] demonstrated that a lymphocytic thyroiditis similar to the spontaneous human disease can be induced in animals by immunization with autologous thyroid extracts in Freund adjuvant. Early after, Anderson described the presence of circulating autoantibodies to extracts of adrenal cortex in patients with idiopathic Addisons disease, suggesting an autoimmune pathogenesis of this form of adrenal insufciency [16]. Based on these ndings, Witebsky established some criteria that ideally should be fullled in order to dene a disease as autoimmune in origin [17]: (1) direct demonstration of free circulating autoantibodies and/or of cell-mediated autoimmunity, (2) recognition of the specic antigen against which antibodies are directed, (3) production of antibodies against the same antigens in experimental animals, (4) appearance of pathological changes in the corresponding tissues of an actively sensitized experimental animal that are similar to those in the human disease. These postulates have been subsequently revised by Bona and Rose, who proposed the following lines of evidence: (1) direct (transfer of the disease by pathogenic antibody or pathogenic T cells), (2) indirect (reproduction of the disease in experimental animal models, isolation of autoantibodies or self reactive T cells), and (3) circumstantial (association with other autoimmune diseases in the same individual or in the same family, lymphocytic inltration of the target organ, association with particular HLA-haplotypes or aberrant expression of HLA class II antigens on the affected organ, favourable response to immunosuppression) [18]. Besides Hashimotos thyroiditis, Graves disease and Addisons disease, in the following years many other diseases initially

Autoantibodies in organ-specic autoimmune diseases During the past two decades, many enzymes, hormones and receptors have been identied as the targeted autoantigens in organ-specic autoimmune diseases, as reviewed by Song et al. [21]. The role of these autoantigens has been claimed to be crucial in initiating and perpetuating the autoimmune response, but their natural intracellular localization has raised many doubts on their unique responsibility in triggering autoimmunity. Nevertheless, their discoveries greatly improved the methods for the detection of organ-specic autoantibodies [22]. Moreover, International Committees coordinated standardization programmes in order to improve sensitivity, specicity and reproducibility of autoantibody determination among the various laboratories [2325]. It was only in 1985 that thyroid microsomal antibodies were identied to react against the thyroid peroxydase, and subsequent investigations recognized numerous organ-related specic autoantigens involved in organ-specic autoimmunity (Table 1).

Table 1. Main organ-specic autoimmune diseases and recognized relevant autoantigen targets

Target organ Thyroid

Disease Graves disease Hashimotos thyroiditis Idiopathic myxoedema Addisons disease Gonadal failure Hypoparathyroidism Type 1 diabetes mellitus

Autoantigens TSH-receptor Thyroid peroxydase Thyroglobulin 21-hydroxylase P450 side-chain cleavage enzyme 17a-hydroxylase Calcium-sensing receptor Glutamic acid decarboxylase Tyrosine-phosphatase like Insulin H+/K+ pump ATPase Intrinsic factor Transglutaminase Tryptophan hydroxylase P450 (IID6, IA2) 68, 49, 43 kD from human pituitary membrane (?) SOX9, SOX10 Tyrosinase Tyrosine hydroxylase Acetylcholine receptor

Reference [26] [27,28] [10] [29] [30] [31] [32] [33] [34] [35] [36] [37] [38] [39] [40] [41] [42] [43] [44]

Adrenal cortex Gonads Parathyroid Endocrine pancreas

Stomach Intestine Liver Pituitary Skin

Body chronic atrophic gastritis Pernicious anaemia Celiac disease Idiopathic malabsorption Chronic autoimmune hepatitis Lymphocytic hypophysitis Infundibuloneurohypophysitis Vitiligo Alopecia Myasthenia gravis

Muscle

TSH, thyroid stimulator hormone. Autoantibodies may exert both stimulating (Graves diseases) or blocking (idiopathic myxedema, atrophic variant of Hashimotos thyroiditis) activity. 2004 Blackwell Publishing Ltd, Clinical and Experimental Immunology, 137:225233

Type 2 autoimmune polyglandular syndrome

All the studies aimed at recognizing the antigen-antibody reactions contributed to improve the diagnosis of autoimmune diseases, as well as permit the early detection of individuals at risk for the future development of organ-specic autoimmune diseases. As a consequence of these discoveries, many diagnostic tests that employed the immunouorescence technique on cryostat sections of human or animal tissues were progressively substituted by RIA or ELISA tests using cloned autoantigens [30,32,33,4548].

227

CLASSIFICATION OF AUTOIMMUNE POLYGLANDULAR SYNDROMES

In general, organ-specic autoimmune diseases do not cluster casually, but reveal preferential associations. In 1980, Neufeld and Blizzard [49] published a classication of the autoimmune polyglandular syndromes (APS) on clinical grounds indicating the existence of four main distinct types (Table 2). Type 2 APS, or Schimidts syndrome, is characterized by the obligatory occurrence of autoimmune Addisons disease (which represents the pivotal disease) in combination with thyroid autoimmune diseases and/or with Type 1 diabetes mellitus.

[52]. A spontaneous form of Type 2 APS has also been described in a boxer dog affected by primary hypothyroidism and partial adrenocortical deciency: the autopsy study has demonstrated thyroid atrophy and lymphocytic adrenalitis with complete destruction of the zona fasciculata and reticularis [53]. Apart from these spontaneous models, there are animal models of experimentally induced autoimmune endocrine diseases obtained after environmental perturbation (e.g. viruses, toxic substances), thymectomy procedures, or genetic manipulation. For example, some strains of mice infected with cytomegalovirus may give rise to a Type 2 APS with lymphocytic inltration of the adrenals, pancreatic islets, liver, myocardium, salivary glands, and circulating organ-specic autoantibodies are also detectable [54]. An APS affecting thyroid, adrenals, ovary, pancreatic islets, and stomach in various combination has been shown in mice treated with cyclosporin A at birth followed by removal of the thymus [55]. This last observation suggests that polyglandular autoimmunity ensues from a more profound T-cell disturbance than that required for the induction of a single organ disease. Despite the stimulating information provided by animal models, data in animals do not necessarily reect human disease in vivo. No infectious agents or noticeable immunodeciency states have been indeed demonstrated in human Type 2 APS.

TYPE 2 AUTOIMMUNE POLYGLANDULAR SYNDROME

Epidemiology The frequency of Type 2 APS in humans is rare, being described in about 1445 per 100 000 inhabitants [50,51]. However, recent observations revealed that the disease is much more frequent if one considers also the cases with subclinical forms (see below). Animal models Animal models exist for several autoimmune diseases and may serve to focus on autoimmune targets and the immune mechanisms involved in the pathogenesis of self-aggression. Spontaneous models, such as the NOD mouse for Type 1 diabetes mellitus, are believed to reect their human counterparts. Moreover, animal manipulation by means of drugs, infectious agents, or genetic engineering may be helpful to unveil possible ethiopathological factors in triggering autoimmunity. Unfortunately, spontaneous animal models of Type 2 APS are rare. The White Leghorn Chicken is an obese inbred strain which develops a lymphocytic thyroiditis, but can also develop adrenal cortex autoantibodies. However, no clear impairment of the corresponding target organs usually occur, so the syndrome remains solely at subclinical level

Table 2. Classication of autoimmune polyglandular syndromes (APS).

Adapted from [49] Type 1 Type 2 Type 3 Chronic candidiasis, Chronic hypoparathyroidism, Addisons disease (at least two present) Addisons disease (always present) and Thyroid autoimmune diseases, and/or Type 1 diabetes mellitus Thyroid autoimmune diseases associated with other autoimmune diseases (excluding Addisons disease and/or hypoparathyroidism) Combination of organ-specic autoimmune diseases not included in the previous groups

Type 4

Clinical features In 1981, Neufeld [56] reviewed from the literature and from personal cases 224 patients affected by Type 2 APS. This author reported that the syndrome began after 20 years of age in 84% of the cases with an increased prevalence in middle-aged women. Thyroid autoimmune diseases (encompassing Hashimotos thyroiditis, primary myxedema, symptomless autoimmune thyroiditis, Graves disease, isolated ophthalmopathy) were present in 69% and Type 1 diabetes in 52% of the cases. Clinical aspects and laboratory ndings of the components of the syndrome are similar when the diseases occur isolated or in the context of APS. However, these aspects are beyond the aims of the present paper and have been extensively treated in previous excellent reviews [5760]. Minor autoimmune diseases might also occur, like vitiligo, chronic atrophic gastritis, or hypergonadotropic hypogonadism (Table 3), but they were less frequent if compared to Type 1 APS. In the following years, other investigators studied further groups of patients from Italy [61], Sweden [62], Norway [63], and Germany [64]. Since 1970, we have studied 146 patients with Type 2 APS, and their main clinical features are summarized in Table 3. Thyroid autoimmune disease was diagnosed with a greater frequency and Type 1 diabetes with a lower frequency in comparison to the reports of Neufeld, indicating that the clinical combinations may vary according to the different populations examined. Other minor autoimmune diseases have been diagnosed in patients with Type 2 APS, with a frequency ranging from 1 to 12% [51] (Table 3). As far as clinical combinations concern, among our patients 129 (884%) had two main diseases, while only 17 (116%) had the complete tri-glandular syndrome (Carpenters syndrome). The most frequent association was Addisons disease and Hashimotos thyroiditis, while the least was Addisons disease, Graves disease and Type 1 diabetes mellitus (Table 4). The mean ages at the clinical onset of the different diseases in our patients with Type 2 APS are summarized in Table 5. The diseases more frequently diagnosed in the youngest patients were vitiligo, followed by Type 1 diabetes and hypergonadotropic

2004 Blackwell Publishing Ltd, Clinical and Experimental Immunology, 137:225233

228
Table 3. Clinical features of patients with Type 2 APS

C. Betterle et al.
Table 5. Ages of onset of the different autoimmune diseases in patients
with Type 2 APS and frequency of the relevant antibodies From Neufeld et al. [56] Personal data 146 4 0 133/13 100% 88% 23% 12% 10% 3% 4% 2% 2% 0 0

Patients (no.) Female/Male ratio Family history of Type 2 APS Adults/Children Main diseases Addisons disease Thyroid autoimmune diseases Type 1 diabetes mellitus Minor diseases Vitiligo Hypergonadotropic hypogonadism Chronic autoimmune hepatitis Alopecia Pernicious anaemia Seronegative arthritis Myasthenia gravis Adenohypophysitis n.r., not reported.

224 18 n.r. n.r. 100% 69% 52% 45% 36% n.r. 05% <1% n.r. n.r. n.r.

Autoimmune disease Vitiligo Type 1 diabetes mellitus Hypergonadotropic hypogonadism Graves disease Addisons disease Pernicious anaemia Alopecia Chronic thyroiditis Chronic atrophic gastritis Autoimmune chronic hepatitis

Frequency of the relevant Mean age at autoantibody at disease onset (years) (range) disease onset (%) 277 (943) 284 (263) 290 (1840) 334 (758) 346 (185) 355 (3437) 386 (3252) 402 (1280) 454 (1665) 516 (4261) None 70 100 80 91 100 None 97 70 100

i.e. less than 1 years from the clinical diagnosis.

Table 4. Prevalence of the main autoimmune diseases in Type 2 APS

patients (personal data)

Endocrine diseases Addisons disease + chronic thyroiditis Addisons disease + Graves disease Addisons disease + Type 1 diabetes mellitus Addisons disease + chronic thyroiditis + Type 1 diabetes mellitus Addisons disease + Graves disease + Type 1 diabetes mellitus

No. of cases 82 31 16 14 3

Prevalence (%) 561 212 109 96 20

hypogonadism. Among thyroid autoimmune disorders, Graves disease usually preceded, whereas Hashimotos thyroiditis followed Addisons disease.

Humoral immunity The frequencies of the relevant autoantibodies detectable at the clinical onset of the diseases constituting Type 2 APS are summarized in Table 5. As a rule, the frequency of antibodies against adrenal cortex detected by immunouorescence on normal human adrenal glands and/or to 21-hydroxylase measured by radioimmunoassay [65] was relatively stable over time. Similar trends were found for antibodies to thyroid and gonadal antigens. By contrast, antibodies to endocrine pancreas (classical islet cell antibodies, glutamic acid decarboxylase or tyrosine phosphataselike antibodies) revealed a rapid decline in the course of time, being around 50% in Type 1 diabetes patients with long-standing disease. In addition, vitiligo and alopecia in Type 2 APS were not associated with any autoantibody specicity, thus different from patients with the same diseases in the context of Type 1 APS [41,43,66].

Cellular immunity in the target organs The pathological hallmark of autoimmune thyroiditis is lymphoplasmacytic inltration. Frequently, lymphocytes are organized into well-developed germinal centres. Thyroid follicles are of reduced size and variable degrees of brosis are present. The inltrating T cells are mainly CD8+, but also CD4+ T cells are present, many of which are activated as they express HLA class II molecules [67,68]. The pattern of insulitis in newly diagnosed Type 1 diabetes is characterized by an inltration of lymphocytes, which are primarily T lymphocytes [69]. The majority of the inltrating lymphocytes are of T cytotoxic/suppressor phenotype, with a few B cells and macrophages. Some of the T lymphocytes show the markers of cell activation [70]. In the advanced phases acinar cell atrophy is usually found. The pattern of inltration of adrenals in Addisons disease at the onset is characterized by a widespread mononuclear cell inltrate consisting of lymphocytes, plasma cell and macrophages. Residual cortical nodules of regenerating cells secondary to high levels of corticotropin (ACTH) may be seen, but in the advanced stages of the disease, brosis and atrophy greatly predominate. In contrast to autoimmune thyroiditis and Type 1 diabetes, there has been no phenotypic characterization of inltrating lymphocytes [71]. Studies on histopathology of the target organs involved in Type 2 APS have given results similar to those observed in isolated autoimmune forms. Adjacent organs or tissues non directly targeted by the autoimmune reaction are typically spared by the autoimmune attack. Imaging Regarding the imaging of the involved glands, cross-sectional imaging techniques, such as computed tomography (CT) and nuclear magnetic resonance (NMR) are able to show the adrenals with a resolution and clarity unimagined even 20 years ago. This has brought about a remarkable improvement in the diagnosis and characterization of adrenal insufciency. As a rule, corticoadrenal failure due to autoimmune adrenalitis, both as isolated form or as component of APS syndromes, shows normal or

2004 Blackwell Publishing Ltd, Clinical and Experimental Immunology, 137:225233

Type 2 autoimmune polyglandular syndrome

minuscule adrenal glands bilaterally [72]. We evaluated the adrenal glands in 57 patients Type 2 APS at the onset of Addisons disease by CT or NMR, and in 50 of them we found normal adrenal patterns, while in the remaining cases the adrenals were reduced in volume consistent with gland atrophy. Ultrasound technique has also greatly enhanced the diagnosis of thyroid autoimmune diseases in the recent years, and a diffuse or multifocal hypoechoic pattern has claimed to be typical of autoimmune thyropathy, both in goitrous or in chronic atrophic thyroditis and in Graves thyrotoxicosis [73]. Unfortunately, the imaging of endocrine pancreas in patients with Type 1 diabetes has proven to be frustrating, and no reliable imaging procedures of the insulitis process are routinely available so far.

229

Genetic susceptibility Type 2 APS is a combination of three of autoimmune diseases and for many years it was believed that the genetic prole of patients with Type 2 APS could be inuenced by the disease accompanying Addisons disease. In 1986, Addisons disease was reported to be linked with DR3 and/or DR4 aplotypes and this association was found to be independent from the presence or the absence of Type 1 diabetes [74]. Subsequently, it was found that in patients with Type 2 APS there was an association with HLA-DR3/DQB1*0201 haplotype when Addisons disease was not combined to pancreatic autoimmunity, and with HLA-DR4/DQB1*0302 when Addisons disease was combined to pancreatic autoimmunity [74]. In this study, however, patients with pancreatic autoimmunity included also nondiabetic subjects with islet cell antibodies, many of whom did not necessarily develop diabetes. Subsequent investigation evaluating a large group of Norwegian patients with Addisons disease demonstrated that those with Type 2 APS were signicantly associated with DRB1*04; DQA1*03; DQB1*0302 and DRB1*03; DQA1*0501; DQB1*02, independently from the presence of Type 1 diabetes. Furthermore, it was demonstrated that HLADRB1*01; DQA1*01; DQB1*0501 haplotype conferred protection against Addisons disease [63]. Other genes have been studied in Type 2 APS patients. A polymorphism of the cytotoxic T lymphocyte antigen4 (CTLA-4) gene was found to be associated with Addisons disease in the context of Type 2 APS in English, but not in Norwegian, Finnish or Estonian patients [76]. Recently, mutations in the AIRE gene (typically found in Type 1 APS) have been investigated in Addisonian patients with Type 2 APS, but this gene was not found to be implicated [77,78]. We studied for the class II HLA haplotype 54 patients with Type 2 APS affected by Type 1 diabetes and/or thyroid autoimmune diseases. Our investigation conrmed that DRB1*03; DQB1*02, DRB1*04; DQB1*03 and DRB1*03,*04 were signicantly associated with Addisons disease (P < 00001, P < 001 and P < 00005, respectively), independent from the presence of diabetes mellitus or the form of thyroid autoimmune disease [79]. Furthermore, we demonstrated a negative association with DRB1*01; DQB1*05 (P < 00001) and DRB1*13 (P < 002). Similar data have been reported in Type 2 APS patients from Norway [63]. Incomplete forms of Type 2 APS In his original review Neufeld had established that a patient could be classied as having Type 2 APS if affected by thyroid autoimmune disease or Type 1 diabetes mellitus, and if at least one

member in the family had Type 2 APS [49]. However, a positive family history for Type 2 APS is in truth exceptional (Table 3). Moreover, from the clinical point of view, hardly ever the syndrome blows up simultaneously with two or three main autoimmune diseases in one individual, while it usually initiates with a single disease (i.e. Type 1 diabetes mellitus, Graves disease, Hashimotos thyroiditis, or Addisons disease), and sometimes even with a minor disease (e.g. vitiligo, pernicious anaemia, premature ovarian failure, alopecia, chronic atrophic gastritis) (Table 5). After a variable period of latency, a proportion of these subjects may develop the other components of the syndrome. For this reason, it is of considerable importance to identify among patients with a single disease those at risk for future development of the fully expressed Type 2 APS. The only way to become acquainted with this is to screen patients with one organ-specic autoimmune disease for the circulating autoantibodies relevant to the other main diseases at the clinical diagnosis and every two or three years. Large population studies have dened their frequency. For example, in patients with Type 1 diabetes but no clinical adrenal failure, autoantibodies to the adrenal cortex (markers of potential Addisons disease) are found with a frequency of 0416% [80 83]. In patients with thyroid autoimmune diseases with no clinical adrenal failure, autoantibodies to the adrenal cortex are present in about 1% of the cases [81,82], while in those with Addisons disease without overt thyroid disease, autoantibodies to the thyroid are present in 4058% of the cases [8486]. Moreover, patients with Addisons disease but no clinical manifestations of Type 1 diabetes, pancreatic autoantibodies are present in about 620% of them [51,8587]. We designated these conditions as incomplete APS, therefore extending the concept of Type 2 APS to the forms not yet fully expressed at clinical level. Antibody positive individuals are considered at high risk of developing clinical dysfunctions and will require to be further studied by using specic functional/morphological tests (i.e. determination of thyroid hormones, TSH and thyroid examination by ultrasound in patients with antibodies to thyroid, oral or intravenous glucose tolerance test in those with antibodies to endocrine pancreas, or ACTH test in those with antibodies to adrenal cortex). This approach will identify the patients with potential Type 2 APS (if functional tests are normal) or with subclinical Type 2 APS (if functional tests are abnormal). In the case of a positive antibody test despite normal function of the relevant organ, appropriate follow ups are advisable. In this way, well be able not only to initiate early treatment of the incoming autoimmune disease in patients already affected by one endocrine disorder, but possibly to prevent the clinical outbreak of the ongoing autoimmune disease. Early recognition and treatment of a second or third complicating autoimmune endocrine disease, like acute adrenal failure in one patient with Type 1 diabetes mellitus or hypothyroidism in one with Addisons disease, may be crucial and life-saving in some cases. Table 6 summarizes the frequency of the organ-specic autoantibodies detected in patients with one of the diseases composing Type 2 APS and the cumulative risks of developing clinical diseases in positive cases. Bearing in mind that the estimated prevalence of the autoimmune diseases constituting Type 2 APS ranges from 14 to 2375 cases per 100 000 individuals [88] and that the prevalence of the other relevant autoantibodies in each autoimmune disease varies from 05 to 48% (Table 6), it may be inferred that the prevalence of the incomplete forms of Type 2 APS is much more frequent (up to 150 cases per 100 000 individuals) than the complete form

2004 Blackwell Publishing Ltd, Clinical and Experimental Immunology, 137:225233

230

C. Betterle et al.
Table 6. Incomplete forms of Type 2 APS

Clinical manifestation Thyroid autoimmune diseases Type 1 diabetes mellitus Addisons disease Addisons disease Minor autoimmune diseases (e.g. alopecia, vitiligo, pernicious anaemia)

Prevalence per 100 000 2375 192 14 14 150400

Autoantibodies to: Adrenal cortex or 21-hydroxylase Adrenal cortex or 21-hydroxylase TPO and/or Tg GAD, IA2, insulin Adrenal cortex and Endocrine pancreas and/or thyroid

Frequency (%) 051 0516 4048 620 051

Risk of future disease (%) ~30 ~30 ~50 From 5 to 90* ~10

TPO, thyroid peroxydase; Tg, thyroglobulin; GAD, glutamic acid decarboxylase; IA2, second antigen of islet cells. From [8086]. From [88]. *On the basis of the number of positive antibodies [87].

(1445 cases per 100 000 individuals) [50,51]. However, only a proportion of the patients with the incomplete forms will develop a complete clinically overt syndrome (Table 6).

Pathogenesis The paradox of autoimmunity and the consequent diseases represent one of the mysteries that still bewilder immunologists, and several questions remain unanswered. Organ-specic autoimmune diseases develop in genetic susceptible individuals under the stimulation of environmental factors. As a consequence, these individuals produce specic humoral and cell-mediated immune responses against the constituents of the bodys own tissues, and may involve one or more organs. A persistent defective capacity has recently been described in CD4 + CD25+ regulatory T cells, a subset of specialized T lymphocytes involved in suppression of autoreactivity, in patients with Type 2 APS but not in patients with single autoimmune endocrinopathy or in normal healthy controls [89]. However, these data have been observed in a small number of patients and require further investigation. To explain multiple organ involvement in APS, Tadmor et al. [90] have hypothesized that organs derived from the same embryonal germ layer share common specic antigens. However, if this hypothesis may explain the pathogenesis of Type 3 APS (e.g. thyrogastric autoimmune syndrome where both tissues are derived from the endodermal layer), it does not clarify Type 2 APS, in that the adrenal cortex is of mesodermal origin, while the thyroid and the pancreas are of endodermal origin. It still remains unclear why autoimmunity is focused on proteins typically present in endocrine tissues and not in other organs of the same germ layer, how the immune system selectively recognizes these autoantigens, and why multiple organs may be involved in the same individual on different occasions. Another crucial question is if the break of the immune tolerance in (Type 2) APS induces the simultaneous activation of multiple autoreactive clones of lymphocytes, or if this occurs at different times in the course of the life. The observation that at the onset of the heralding autoimmune disease further autoantibodies to other endocrine organs are frequently detectable is in agreement with the rst hypothesis. However, the fact that other autoantibodies may be absent at the onset of the heralding disease but appear at a future time is in favour of the second hypothesis. Furthermore, it should be kept in mind that even if autoimmunity starts at the same time, the target organs may be destroyed with different latency periods owing to the various size of the implicated glands and/or the ability of the different endocrine cells

to regenerate after the autoimmune injury. Obviously, the immunological mechanisms involved are also crucial in the development of the autoimmune disease and the intervention of activated self-reacting T cell is considered to be necessary in the majority of the cases to achieve full destruction of the target organ [91]. In fact, in Addisons disease, chronic lymphocytic thyroiditis and in Type 1 diabetes the relevant circulating autoantibodies that precede, accompany, and follow the clinical diagnosis of these endocrine disorders are not pathogenic in vivo. Nevertheless, some circulating autoantibodies, such as those stimulating the TSHreceptor in Graves disease or those blocking the TSH-receptor in the atrophic variant of chronic thyroiditis, as well as those to the intrinsic factor in pernicious anaemia, are pathogenic in vivo. It is conceivable that the coexistence of blocking antibodies to the TSH receptor (which prevent the regenerating effects of its natural ligand TSH) and inltrating autoreactive T cells in the thyroid may give rise to an accelerated form of hypothyroidism with atrophy. On the other hand, the presence of stimulating antibodies to the TSH receptor in a chronic lymphocytic thyroiditis may result in a slow-onset hypothyroidism, in mixed forms of thyroid dysfunction as the case of Hashitoxicosis [58,68], or in thyroid yoyo syndrome [92].

Therapy The therapies regarding the different components of Type 2 APS are similar whether they occur as single or in multiple association with other autoimmune diseases. However, it is worth remembering that the thyroid hormone replacement therapy in patients with autoimmune hypothyroidism and misdiagnosed adrenal insufciency can precipitate an adrenal failure owing to the action of thyroxine in enhancing hepatic corticosteroid metabolism. In addition, some patients with Addisons disease show a reversible increase in thyrotropin levels, regardless of the presence of thyroid autoantibodies, that is related to the loss of the inhibitory effects of glucocorticoids on thyrotropin secretion [93]. Moreover, a reduction in insulin requirement may be the rst sign of Addisons disease in a patients with Type 1 diabetes mellitus. Thus, before initiating the therapy with thyroxine or simply modifying insulin dosage, it is prudent to investigate the possible coexistence of an underlying adrenal insufciency [94].

CONCLUSIONS
It is now well established that organ-specic diseases frequently occur in privileged clusters of association and Type 2 APS is

2004 Blackwell Publishing Ltd, Clinical and Experimental Immunology, 137:225233

Type 2 autoimmune polyglandular syndrome

considered one of the most typical. Clinically overt syndrome is considered only the tip of the iceberg, since latent forms are much more frequent. Organ-specic autoantibody screening in patients with monoglandular autoimmune endocrinopathies undoubtedly facilitates the identication of those at risk of developing a future APS. Early identication and treatment of another autoimmune endocrine disease may be critical and even life-saving. Currently, management of these disease is restricted to the pharmacological replacement therapy. However, progress in understanding the inner immunological mechanisms implicated in these conditions, should allow common treatments aimed to prevent or at least dampen the progression to irreversible multiple organ damage.

231

23

24

25

REFERENCES
1 Oegle JW. On disease of the brain as result of diabetes mellitus. St Georges Hosp Report 1866; 1:15788. 2 Wehrmacher WH. Addisons disease with diabetes mellitus. Arch Int Med 1961; 108:1828. 3 Schmidt MB. Eine biglandulare Erkrankung (Nebennieren und Schilddrse) bei Morbus Addisonii. Verh Dtsch Ges Pathol 1926; 21:21221. 4 Wells HG. Addisons disease with the selective destruction of the suprarenal cortex. Arch Pathol 1930; 10:499523. 5 Rowntree LG, Snell AM. A Clinical Study of Addisons Disease. Mayo Clinic Monographs. Philadelphia: W.B. Saunders, 1931. 6 Gowen WM. Addisons disease with diabetes mellitus. N Engl J Med 1932; 207:5779. 7 Beaven DW, Nelson Don H, Renold AE, Thorn GW. Diabetes mellitus and Addisons disease. N Engl J Med 1959; 261:44354. 8 Solomon N, Carpenter CCJ, Bennet IL, JrMcGehee Harvey A. Schmidts syndrome (thyroid and adrenal insufciency) and coexistent diabetes mellitus. Diabetes 1965; 14:3004. 9 Carpenter CCJ, Solomon N, Silverberg SG, Bledsoe T, Northcutt RC, Klinenberg JR, Bennett IL, McGehee Harvey A. Schmidts syndrome (thyroid and adrenal insufciency): a review of the literature and a report of fteen new cases including ten instances of coexistent diabetes mellitus. Medicine 1964; 43:15380. 10 Roitt IM, Doniach D, Campbell PN, Hudson RV. Autoantibodies in Hashimotos disease. Lancet 1956; 2:8201. 11 Adams DD, Purves HD. Abnormal responses in the assay of thyrotropins. Proc University Otago Meed School 1956; 34:112. 12 Kriss JP. Inactivation of long-acting thyroid stimulator (LATS) by antik anti-1 antisera. Clin Endocrinol 1968; 28:14404. 13 Adams DD, Kennedy TH. Occurrence in thyrotoxicosis of a gammaglobulin which protects LATS from neutralization by an extract of thyroid gland. J Clin Endocr Metab 1967; 27:1737. 14 Smith BR, Hall R. Thyroid-stimulating immunoglobulins in Graves disease. Lancet 1974; 2:427. 15 Rose NR, Witebsky E. Studies on organ specicity. V. Changes in thyroid glands of rabbits following active immunization with rabbit thyroid extracts. J Immunol 1956; 76:41727. 16 Anderson JR, Goudie RB, Gray KG, Timbury GC. Autoantibodies in Addisons disease. Lancet 1957; 1:11234. 17 Witebsky E, Rose NR, Terplan K, Paine JR, Egan RW. Chronic thyroiditis and autoimmunization. J Am Med Assoc 1957; 164:143947. 18 Rose NR, Bona C. Dening criteria for autoimmune diseases. (Witebskys postulates revisited). Immunol Today 1993; 14:4269. 19 Todd I, Bottazzo GF. Laboratory investigation of autoimmune endocrine diseases. Clin Immunol Allergy 1985; 5:61338. 20 Bottazzo GF, Florin-Christensen A, Doniach D. Islet cell antibodies in diabetes mellitus with autoimmune polyendocrine deciencies. Lancet 1974; 2:127982. 21 Song YH, Li Y, Maclaren NK. The nature of autoantigens targeted in autoimmune endocrine diseases. Immunol Today 1996; 17:23223. 22 Miles J, Charles P, Riches P. A review of methods available for the

26

27

28

29 30

31

32

33

34

35

36

37

38

39 40

41

42

identication of both organ and non-organ-specic autoantibodies. Ann Clin Biochem 1998; 35:1947. Greenbaum CJ, Palmer JP, Kuglin B, Kolb H and participating laboratories. Insulin autoantibodies measured by radioimmunoassay methodology are more related to IDDM than those measured by enzyme-linked immunosorbent assay: results of the fourth International Workshop on the standardisation of insulin autoantibody measurement. J Clin Endocrinol Metab 1992; 5:10404. Greenbaum CJ, Palmer JP, Nagataki S, Yamaguchi Y, Molenaar JL, Van Beers WAM, Maclaren NK, Lernmark A. Improved specicity of ICA assays in the Fourth International Immunology on Diabetes Serum Exchange Workshop. Diabetes 1992; 41:15704. Bingley PJ, Bonifacio E, Mueller PW. Diabetes Antibody Standardization Program: rst assay prociency evaluation. Diabetes 2003; 52:112836. Rapoport B, Chazenbalk GD, Jaume JC, McLachlan SM. The thyrotropin (TSH) receptor: interaction with TSH and autoantibodies. Endocr Rev 1998; 19:673716. Portman L, Hamada N, Heinrich G, De Groot LJ. Anti-thyroid peroxydase antibody in patients with autoimmune thyroid diseases: possible identication with anti-microsomal antibody. J Clin Endocr Metab 1985; 61:10013. Czarnocka B, Ruf J, Ferrand M, Carayon NP, Lissitsky S. Purication of the human thyroid peroxydase and its identication as the microsomal antigen involved in autoimmune thyroid diseases. FEBS Lett 1985; 190:14752. Winqvist O, Karlsson FA, Kampe O. 21-hydroxylase, a major autoantigen in Addisons disease. Lancet 1992; 339:155962. Chen S, Sawicka J, Betterle C, Powell M, Prentice L, Volpato M, Rees Smith B, Furmaniak J. Autoantibodies to steroidogenic enzymes in autoimmune polyglandular syndrome, Addisons disease, and premature ovarian failure. J Clin Endocr Metab 1996; 81:18716. Li Y, Song Y, Raiss N, Connor E, Schartz D, Muir A, Maclaren N. Antibodies to the extracellular domain of the calcium-sensing receptor in patients with acquired hypoparathyroidism. J Clin Invest 1996; 97:9104. Baekkeskov S, Aanstoot HJ, Christgau S et al. Identication of the 64K autoantigen in insulin-dependent diabetes as the GABA-synthesizing enzyme glutamic acid decarboxylase. Nature 1990; 347:1516. Rabin DU, Pleasic SM, Shapiro JA, Hicks JM, Goldstein DE, Rae PMM. Islet cell antigen 512 is a diabetes-specic islet antigen related to protein tyrosine phosphatases. J Immunol 1994; 152:31838. Palmer JP, Asplin CM, Clemons P, Lyen K, Tatpati O, Raghu PK, Paquette TL. Insulin antibodies in insulin-dependent diabetics before insulin treatment. Science 1983; 222:13379. Burnam P, Mardh S, Norberg L, Karlsson A. Parietal cell antibodies in pernicious anemia inhibit H+,K+ adenosine triphosphatase, the proton pump of the stomach. Gastroenterology 1989; 96:14348. Taylor KB, Roitt IM, Doniach D, Couchman KG, Shapland C. Autoimmune phenomena in pernicious anemia: gastric antibodies. Br Med J 1962; 2:134752. Dieterich W, Ehnis T, Bauer M, Donner P, Volta U, Riecken EO, Schuppan D. Identication of tissue transglutaminase as the autoantigen of celiac disease. Nat Med 1997; 7:797801. Ekwall O, Hedstrand H, Grimelius L et al. Identication of tryptophan hydroxylase as an intestinal autoantigen. Lancet 1998; 352:27983. Manns MP. Autoimmune diseases of the liver. Clin Laboratory Med 1992; 12:2540. Nishiki M, Murakami Y, Azawa Y, Kato Y. Serum antibodies to human pituitary membrane antigens in patients with autoimmune lymphocytic hypophysitis and infundibuloneurohypophysitis. Clin Endocrinol 2001; 54:32733. Hedstrand H, Ekwall O, Olsson MJ et al. The transcription factors SOX9 and SOX10 are vitiligo autoantigens in autoimmune polyendocrine syndrome Type 1. J Biol Chem 2001; 276:353905. Song YH, Connor E, Li Y, Zorovich B, Balducci P, Maclaren NK.

2004 Blackwell Publishing Ltd, Clinical and Experimental Immunology, 137:225233

232

C. Betterle et al.
65 Betterle C, Volpato M, Pedini B, Chen S, Rees-Smith B, Furmaniak J. Adrenal-cortex autoantibodies (ACA) and steroid-producing cells autoantibodies (StCA) in patients with Addisons disease: comparison between immunouorescence and immunoprecipitation assays. J Clin Endocr Metab 1999; 84:61822. 66 Peterson P, Pitkanen J, Sillanpaa N, Krohn K. Autoimmune polyendocrinopathy candidiasis ectodermal dystrophy (APECED): a model disease to study molecular aspects of endocrine autoimmunity. Clin Exp Immunol 2004: 135:34857. 67 Livolsi VA. The pathology of autoimmune thyroid disease: a review. Thyroid 1994; 4:3339. 68 Weetman A, McGregor AM. Autoimmune thyroid disease: further developments in our understanding. Endocrine Rev 1994; 15:788830. 69 Gepts W. Pathologic anatomy of the pancreas in juvenile diabetes. Diabetes 1965; 14:61933. 70 Bottazzo GF, Dean BM, McNally MacKay EH, Swift PGF, Gamble R. In situ characterization of autoimmune phenomena and expression of HLA-molecules in the pancreas in diabetic insulitis. N Engl J Med 1985; 313:35360. 71 McNicol AM. Istopathology of adrenal glands in Addisons disease. In: Bhatt HR James VHT Besser GM Bottazzo GF Keen H, eds. Advances in Thomas Addisons Diseases. Bristol: Journal of Endocrinology Ltd, 1994:511. 72 Doppman JL. Adrenal imaging. In: DeGroot LJ Jameson JL, eds. Endocrinology, 4th edn. Philadelphia: W.B. Saunders, 2001:174766. 73 Raber W, Gessl A, Nowotny P, Vierhapper H. Thyroid ultrasound versus anti-thyroid peroxydase antibody determination: a cohort study of 451 subjects. Thyroid 2002; 12:72531. 74 Maclaren N, Riley W. Inherited susceptibility to autoimmune Addisons disease is linked to human leukocyte antigens-DR3 and/or DR4, except when associated with Type 1 autoimmune polyglandular syndrome. J Clin Endocr Metab 1986; 62:4559. 75 Huang W, Connor E, Dela Rosa T et al. Although DR3-DQB1*0201 may be associated with multiple component diseases of the autoimmune polyglandular syndromes, the human leukocyte antigen DR4DQB1*0302 haplotype is implicated only in beta-cell autoimmunity. J Clin Endocr Metab 1996; 81:255963. 76 Kemp EH, Ajjan RA, Husebye ES et al. A cytotoxic T lymphocyte antigen-4 (CTLA-4) gene polymorphism is associated with autoimmune Addisons disease in English patients. Clin Endocrinol 1998; 49:60913. 77 Vaidya B, Pearce S, Kendall-Taylor P. Recent advances in the molecular genetics of congenital and acquired primary adrenocortical failure. Clin Endocrinol 2000; 53:40318. 78 Meyer G, Donner H, Herwig J, Bohlest H, Usadel KH, Badenhoop K. Screening for an AIRE-1 mutation in patients with Addisons disease, Type 1 diabetes, Graves disease and Hashimotos thyroiditis as well as in APECED syndrome. Clin Endocrinol 2001; 54:3358. 79 Albergoni P, Gazzola MV, Slanzi E, Carcassi C, Dal Pra C, Moscon A, Betterle C. HLADR and DQ associations with autoimmune Addisons disease in Italian patients. Genes Immunity 2003; 4 (Suppl. 1):S35. 80 Riley WJ, Maclaren N, Neufeld M. Adrenal autoantibodies and Addisons disease in insulin-dependent diabetes mellitus. J Pediatr 1980; 97:1915. 81 Betterle C, Volpato M, Rees-Smith B et al. I. Adrenal cortex and steroid 21-hydroxylase autoantibodies in adult patients with organ-specic autoimmune diseases: markers of low progression to clinical Addisons disease. J Clin Endocr Metab 1997; 82:9328. 82 Betterle C, Volpato M, Rees Smith B et al. II. Adrenal cortex and steroid 21-hydroxylase autoantibodies in children with organ-specic autoimmune diseases: markers of high progression to clinical Addisons disease. J Clin Endocrinol Metab 1997; 82:93942. 83 YuL, Brewer KW, Gates S et al. DRB1*04 and DQ Alleles: expression of 21-hydroxylase autoantibodies and risk of progression to Addisons disease. J Clin Endocr Metab 1999; 84:32835. 84 McHardy-Young S, Lessof MH, Maisey M. Serum TSH and thyroid

43

44 45

46

47

48

49

50

51

52

53

54

55

56

57 58 59 60 61

62

63

64

The role of tyrosinase in autoimmune vitiligo. Lancet 1994; 344:104952. Hedstrand H, Ekwall O, Haavik J et al. Identication of tyrosine hydroxylase as an autoantigen in autoimmune polyendocrine syndrome Type 1. Biochem Bioph Res Co 2000; 267:45661. Patrick J, Lindstrom J. Autoimmune response to acetylcholine receptor. Science 1973; 180:8712. Colls J, Betterle C, Volpato M, Rees Smith B, Furmaniak J. A new immunoprecipitation assay for autoantibodies to steroid 21hydroxylase in Addisons disease. Clin Chem 1995; 41:37580. Tanaka H, Powell M, Chen S et al. Autoimmune adrenal diseases a new sensitive assay for measurement of steroid 21-hydroxylase autoantibodies. J Clin Endocr Metab 1997; 82:14406. Karlsson FA, Burman P, Loof L, Olsson M, Scheynius A, Mardh S. Enzyme-linked immunosorbent assay of H+,K+, ATPase, the parietal cell antigen. Clin Exp Immunol 1987; 70:60410. Mariotti S, Anelli S, Ruf J, Bechi R, Czarnocka B, Lombardi A, Carayon P, Pinchera A. Comparison of serum thyroid microsomal and thyroid peroxydase autoantibodies in thyroid diseases. J Clin Endocr Metab 1987; 65:98793. Neufeld M, Blizzard RM. Polyglandular autoimmune diseases. In: Pinchera A Doniach D Fenzi GF Baschieri L, eds. Symposium on Autoimmune Aspects of Endocrine Disorders. New York: Academic Press, 1980:35765. Chen QY, Kukreja A, Maclaren NK. The Autoimmune Polyglandular Syndromes. In: De Groot LJ Jameson JL, eds. Endocrinology, 4th edn. Philadelphia: W.B. Saunders, 2001:58799. Betterle C, Dal Pra C, Mantero F, Zanchetta R. Autoimmune adrenal insufciency and autoimmune polyendocrine syndromes: autoantibodies, autoantigens, and their applicability in diagnosis and disease prediction. Endocr Rev 2002; 23:32764. Koury EL, Bottazzo GF, Pontes de Carvalho LC, Wick G, Roitt IM. Predisposition to organ-specic autoimmunity in obese strain (OS) chickens: reactivity to thyroid, gastric, adrenal and pancreatic cytoplasmic antigens. Clin Exp Immunol 1982; 49:27382. Kooistra HS, Rijnberg A, van den Ingh TS. Polyglandular deciency syndrome in a boxer dog: thyroid hormone and glucocorticoid deciency. Vet Quart 1995; 17:5963. Bartholomaeus WN, ODonoghue H, Foti D, Lawson CM, Shellam GR, Reed WD. Multiple autoantibodies following cytomegalovirus infection: virus distribution and specicity of autoantibodies. Immunology 1988; 64:397405. Sakaguchi S, Sakaguchi N. Organ-specic autoimmune disease induced in mice by elimination of T cell subsets. J Immunol 1989; 142:47180. Neufeld M, Maclaren NK, Blizzard RM. Two types of autoimmune Addisons disease associated with different polyglandular autoimmune (PGA) syndromes. Medicine (Baltimore) 1981; 60:165360. Arlt W, Allolio B. Adrenal insufciency. Lancet 2003; 361:188193. Weetman AP. Graves disease. N Engl J Med 2000; 343:123648. Dayan CM, Daniels GH. Chronic autoimmune thyroiditis. N Engl J Med 1996; 335:99107. Atkinson MA, Eisenbarth GS. Type 1 diabetes: new perspectives on disease pathogenesis and treatment. Lancet 2001; 358:2219. Betterle C, Volpato M, Greggio AN, Presotto F. Type 2 polyglandular autoimmune disease (Schmidt syndrome). J Pediatr Endocr Met 1996; 9:11323. Papadopoulos KI, Hallengren B. Polyglandular autoimmune syndrome type II in patients with idiopathic Addisons disease. Acta Endocrinol (Copenaghen) 1990; 122:4728. Myhre AG, Undelien DA, Lovas K et al. Autoimmune adrenocortical failure in Norway autoantibodies and human leukocyte antigen class II association related to clinical features. J Clin Endocr Metab 2002; 87:61823. Dittmar M, Kahaly GJ. Polyglandular autoimmune syndromes: immunogenetics and long-term follow-up. J Clin Endocr Metab 2003; 88:298392.

2004 Blackwell Publishing Ltd, Clinical and Experimental Immunology, 137:225233

Type 2 autoimmune polyglandular syndrome

antibody studies in Addisons disease. Clin Endocrinol 1972; 1:45 56. Irvine WJ, Barnes EW. Addisons disease and associated conditions with particular references to premature ovarian failure, diabetes mellitus and hypoparathyroidism. In: Gell PH, Coombs RRA, Lachman P, eds. Clinical Aspects of Immunology. Oxford: Blackwell, 1974:1301 54. Zelissen PM, Bast EJ, Croughs RJ. Associated autoimmunity in Addisons disease. J Autoimmun 1995; 8:12130. Betterle C, Spadaccino AC, Presotto F, Zanchetta R, Pedini B, Lai M, Greggio NA, Bottazzo GF. The number of markers of pancreatic autoimmunity increases the risk for Type 1 diabetes mellitus (DM) in Italian and English patients with organ-specic autoimmune diseases (OSAD). Ann NY Acad Sci 2002; 958:27680. Cooper GS, Stroehla BC. The epidemiology of autoimmune diseases. Autoimmunity Rev 2003; 2:11925.

233

85

86 87

88

89 Kriegel MA, Lohmann T, Gabler C, Blank N, Kalden JR, Lorenz H-M. Defective suppression function of human CD4+ CD25+ regulator T cells in autoimmune polyglandular syndrome Type 2. J Exp Med 2004; 199:128591. 90 Tadmor B, Putterman C, Naparstek Y. Embryonal germ-layer antigens: target for autoimmunity. Lancet 1992; 339:9758. 91 Roep BO. Autoreactive T cells in endocrine/organ-specic autoimmunity: why has progress been so slow? Springer Semin Immunopathol 2002; 24:26171. 92 Gillis D, Volp R, Daneman D. A young boy with a thyroid yo-yo. J Pediatr Endocrinol Metab 1998; 11:46770. 93 Kannan CR. Addisons disease. In: Kannan CR, ed. The Adrenal Gland. London: Plenum Medical Book Co, 1988:3196. 94 Schatz DA, Winter WE. Autoimmune polyglandular syndrome II. clinical syndrome and treatment. Endocrinol Metab Clin N Am 2002; 31:33952.

2004 Blackwell Publishing Ltd, Clinical and Experimental Immunology, 137:225233