IOVS Journal of Neuroscience
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Originally published In Press as doi:10.1167/iovs.07-1433 on February 22, 2008
 (Investigative Ophthalmology and Visual Science. 2008;49:2409-2415.)
© 2008 by The Association for Research in Vision and Ophthalmology, Inc.
DOI:  10.1167/iovs.07-1433
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
iovs.07-1433v1
49/6/2409    most recent
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Chong, K. K. L.
Right arrow Articles by Pang, C.-P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chong, K. K. L.
Right arrow Articles by Pang, C.-P.

Association of CTLA-4 and IL-13 Gene Polymorphisms with Graves’ Disease and Ophthalmopathy in Chinese Children

Kelvin K. L. Chong,1 Sylvia W. Y. Chiang,1 Gary W. K. Wong,2 Pancy O. S. Tam,1 Tsz-Kin Ng,1 Yi-Jun Hu,1,3 Gary H. F. Yam,1 Dennis S. C. Lam,1 and Chi-Pui Pang1

1From the Departments of Ophthalmology and Visual Science and 2Paediatrics, The Chinese University of Hong Kong; and the 3Joint Shantou International Eye Center, Shantou University Medical College, Shantou, China.


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
PURPOSE. The frequency of childhood Graves’ disease (GD) in Hong Kong Chinese is among the highest in the world but childhood Graves’ ophthalmopathy (GO) appears to have milder clinical severity than does the adult disease. This study was conducted to investigate CTLA-4 and IL-13 polymorphisms in Chinese pediatric patients with GD and GO.

METHODS. Recruited for the study were 177 childhood patients with GD (age range, 2–16 years) and 151 unrelated control subjects (age range, 4–16 years) for genotype analysis of IL-13 single-nucleotide polymorphisms (SNPs) (–1112C/T and 2044G/A), CTLA-4 SNPs (–318C/T, 49A/G, and CT60A/G), and the repeat length of (AT)n in the 3' untranslated region (UTR) of CTLA-4.

RESULTS. The patients with GD revealed higher frequencies of CTLA-4 49 GG genotype and G alleles than did the control subjects (P = 0.005 and P = 0.03, respectively). The CT60 GG genotype and G alleles were more prevalent in GD (P = 0.07 and P = 0.02, respectively). The CTLA-4 SNPs (–318C/T, 49A/G, and CT60A/G) were in the same haplotype block, and the CGG haplotype was associated with GD (P = 0.0071) but not GO. The shortest allele of (AT)n was protective against GD (P = 8.4 x 10–6). The IL-13 SNPs did not affect GD or GO risk. IL-13 –1112C/T was associated with IgE elevation (P = 0.044) and 2044G/A with proptosis (P = 0.02), but these associations became insignificant after Bonferroni correction (P = 0.22 and 0.10, respectively).

CONCLUSIONS. Three SNPs and the AT repeat length in CTLA-4 conferred susceptibility to childhood GD, whereas IL-13 polymorphisms did not. No association was found between CTLA-4 and IL-13 with GO.

Graves’ disease (GD) is an organ-specific autoimmune disorder characterized by the presence of thyroid-stimulating hormone (TSH) receptor antibodies leading to hyperthyroidism and goiter.1 It is the most common cause of childhood and juvenile thyrotoxicosis.2 A previous epidemiologic study showed a rising incidence of childhood GD in the Chinese population in Hong Kong,3 where the reported incidence of childhood GD was about eight times higher than that reported in Europe.

Graves’ ophthalmopathy (GO) is an autoimmune process strongly linked to GD. It affects the orbital connective tissues and extraocular muscles.4 Proptosis, eyelid retraction, restrictive strabismus, periorbital swelling, conjunctival chemosis, and injections cause both functional disabilities and cosmetic sequelae. In less than 5% of the affected individuals, irreversible visual loss may result from dysthyroid optic neuropathy, uncontrolled intraocular pressure, or exposure keratopathy secondary to malignant exophthalmos.5 Hyperthyroidism can be treated with antithyroid drugs, radioactive iodine, or thyroidectomy, alone or in combination. It is often the ophthalmopathy that leads to disfigurement and long-term visual impairment.6 A questionnaire survey estimated that the prevalence of GO among patients with GD who were younger than 18 years was ~33% in Europe.7 It has been suggested that childhood/juvenile GO is less severe than the adult counterpart.8 We combined the data in four reports on childhood GO9 10 11 12 and found that it was present in 42 (23%) of 182 subjects with childhood GD, compared with 118 (18%) of 1050 adults with the disease.13 14 Lid retraction, soft tissue congestion, and proptosis are the predominant findings in childhood GO, but not restrictive myopathy or dysthyroid optic neuropathy. We have reported that 63% of children with GD had positive ocular findings and 23% were NOSPECS (no change, only signs, soft tissue changes, proptosis, extraocular motility problems, corneal complications, and sight loss) class 3 or higher.9 None of them had vision-threatening complications or debilitating strabismus. The disease course of GO is unpredictable and may worsen, independent of the endocrine status. As current treatment of GO is often unsatisfactory, we acknowledge the need to identify the predisposing genetic and environmental factors associated with development of GO in patients with GD, regardless of age.15 16

Although genetic predisposition to GD has been established by several twin studies and genetic linkage analysis,17 18 19 20 the contribution of genetic factors to GO remains conflicting. GO has been shown to be associated with HLA alleles, tumor necrosis factor-{alpha}, and interferon-{gamma} gene polymorphisms,21 22 23 24 but not with interleukin (IL)-1{alpha}, IL-1β, IL-1 receptor antagonist,25 IL-1 receptor 1, IL-4 receptor, IL-6, IL-10, or transforming growth factor-β.26 Cytotoxic T-lymphocyte antigen-4 (CTLA-4) is a key negative regulator of T-cell activation and proliferation during the immune response and thereby may influence T-cell-mediated autoimmune diseases such as GD and GO.27 CTLA-4 single nucleotide polymorphisms (SNPs) have been described in adult GD: –318C/T in the promoter region, +49A/G in exon 1, CT60A/G at position 8358, and a dinucleotide (AT)n repeat in the 3' untranslated region (UTR) with variant lengths.28 29 Positive associations between CTLA-4 polymorphisms and GD have been reported in different ethnic populations28 29 30 31 32 33 including our Chinese pediatric cohort.30 For GO, however, no association with CTLA-4 A49G was found in a study involving two populations: Polish-Caucasian and Japanese.31 Also, another Caucasian study indicated environmental factors but not genes to be more influential on GO predisposition.34 A more recent report on Chinese patients with GD added conflicting results. GO was unassociated with the +49A and CT60 polymorphisms, but weakly with the +49A-CT60G haplotype.35

IL-13 is an important immunoregulatory protein produced primarily by activated T helper 2 cells.36 It upregulates CD23/Fc{epsilon}RII and major histocompatibility complex (MHC) class II expression and promotes immunoglobulin E (IgE) isotype switching in human B cells.37 An early study of in situ immunostaining showed IgE positivity in leukocytes and muscle fibers of orbital tissues of patients with GO, but not in non-Graves tissues.38 Serum IgE levels has been found to be elevated in 29% of hyperthyroid Graves’ patients.39 Levels of serum IgE and IL-13 may be indicators of remission or recurrence of GD.40 Two SNPs in the IL-13 locus have been shown to affect biological functions. SNP –1112C/T is located in the 5'-flanking region, and it regulates gene transcription.41 The other one is SNP 2044G/A located in exon 4, which causes an amino acid exchange from arginine to glutamine at codon 130 and possibly affects ligand-receptor interactions.42

We conducted a hospital-based, case-control study to investigate the association of polymorphisms in CTLA-4 and IL-13 with the development of GD and GO in Chinese subjects younger than 16 years.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Patient Recruitment and Clinical Information
We invited 177 unrelated Chinese children with GD at the Pediatric Endocrine Clinic of the Prince of Wales Hospital, Hong Kong, to participate in our study. They were all younger than 16 years at diagnosis. Diagnosis of GD was based on the typical clinical features of hyperthyroidism, diffuse enlargement of the thyroid gland, increased free thyroxine or triiodothyronine levels, suppressed thyroid stimulating hormone levels, positive thyrotrophin-receptor autoantibodies, and the presence of antimicrosomal or antithyroglobulin antibodies. Transient neonatal hyperthyroidism was excluded. Information regarding sex, age at onset of GD, treatment of hyperthyroidism, personal history of cigarette smoking, systemic diseases, and family history of autoimmune thyroid disease was obtained. We also recruited 151 local Chinese children matched by age and sex as control subjects. They did not have a family history or biochemical evidence of autoimmune thyroid disease and had tested negative for thyroid autoantibodies (Serodia-ATG/AMC; Fujirebio, Tokyo, Japan).

GO was classified according to the NOSPECS system recommended by the American Thyroid Association.43 Normal upper eyelid position was 1.5 mm below the superior limbus, and normal lower eyelid position at the level of the inferior limbus in primary gaze. Proptosis was measured by the Hertel exophthalmometer and defined as the anteroposterior protrusion of the globe >19 mm from the lateral orbital rim in either eye or any discrepancy in the degree of protrusion of the two eyes by >1 mm.44 Keratopathy was examined by fluorescein staining under slit lamp microscopy. All patients were clinically euthyroid for more than 3 months at the time of ocular examination and were categorized according to the highest NOSPECS class ever recorded in them.

This study was approved by the Ethics Committee of the Chinese University of Hong Kong and was conducted in accordance with the Declaration of Helsinki. Written parental consent was obtained from each participating subject after explanation of the nature of the study.

Genotyping
Genomic DNA was extracted from peripheral venous blood collected from patients and control subjects. SNPs IL-13 –1112C/T (rs1800925), IL-13 2044G/A (rs20541), CTLA-4 –318C/T (rs5742909), and CTLA-4 CT60A/G (rs3087243) were identified (Taqman SNP Genotyping assay; Applied Biosystems, Inc. [ABI], Foster City, CA). After polymerase chain reaction (PCR), the signals were analyzed by a sequence-detection system (Prism 7000 and SDS software ver. 1.1; ABI). SNP CTLA-4 +49A/G (rs231775) was detected by PCR restriction fragment length polymorphism (PCR-RFLP), forward primer: 5'-GCTCTACTTCCTGAAGACCT-3', reverse primer: 5'-AGTCTCACTCACCTTTGCAG-3'.45 After restriction digestion with Fnu4HI (New England BioLabs, Beverly, MA), the genotype was revealed on 12% polyacrylamide gel by ethidium bromide staining and UV illumination. The dinucleotide (AT)n repeats in CTLA-4 were genotyped by PCR: forward primer 5'-GATGCTAAAGGTTGTATTGC-3' labeled with 6FAM at the 5'end and reverse primer 5'-TGGTGTATTAGTGTCCTG-3'.28 The PCR products were analyzed (model 3130xl analyzer; ABI), and the fragment lengths determined (GeneMapper, ver. 4.0; ABI). Sequencing was performed on approximately 25% of randomly selected samples, to confirm the genotype results.

Statistics
Distribution of genotypes and alleles among groups were compared using {chi}2 tests unless otherwise specified. Bonferroni corrections were made for multiple comparisons, and statistical significance was defined as corrected P (Pc) < 0.05. Odds ratios (ORs) in the different models were calculated to assess the genotype-phenotype correlation, and only those models with significant correlation are presented. In case of additive genetic model inheritance, the probability for Armitage’s trend test was also computed (ORdom = OR of the dominant model; ORrec = OR of the recessive model; ORhet = OR of heterozygote compared with wild-type). Previous studies indicate that smoking, age, male sex, and radioactive iodine affect the development of or the progression of GO in adults.46 47 48 49 These factors were controlled using multivariate logistic regression analyses. Interaction between CTLA-4 and IL-13 polymorphisms for the disease trait was assessed by logistic regression. Haplotype analyses were performed with Haploview 4.0, and the association between haplotypes and phenotypes were computed with permutation test (performed 1000 times). All statistical analyses were performed with commercial software (SPSS, ver. 15.0; SPSS Chicago, IL).


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
Patients’ Demographic and Clinical Data
Among the 177 patients with GD, 111 had NOSPECS grades recorded, 92 (83%) were girls and 19 (17%) were boys. Median (mean ± SD) age at presentation was 11 (11.2 ± 2.8) years (range, 2–16). Mean ± SD duration between onset of GD and ocular assessment was 60.6 ± 42 months. All patients were followed up by a single pediatric endocrinologist. Antithyroid drug was used as the initial treatment of hyperthyroidism. The relapse after stopping drug treatment was treated with radioactive iodine in 17 (15%) patients, and all received timely thyroxine supplementation. Thyroidectomy was performed in five (4%) patients, and both radioactive iodine and thyroidectomy in one (1%) patient in whom follicular and papillary carcinoma developed. Nine (8%) patients were current smokers and three (3%) were ex-smokers. Forty-three (32%) had a positive family history of autoimmune thyroid disease. Except one who had a sibling with Hashimoto thyroiditis, all other affected family members had GD.

Patients were categorized according to NOSPECS into the following classes: 38 (34%) in class 0, 15 (14%) in class 1, 11 (10%) in class 2, 14 (13%) in class 3, 6 (5%) in class 4, and 27 (24%) in class 5. There was no case of dysthyroid optic neuropathy. Defining NOSPECS class 3 or above as clinically evident GO, we found that advancing age of GD onset (P = 0.945), male sex (P = 0.594), and family history of autoimmune thyroid disease (P = 0.611) were not associated with risk for GO in our pediatric cohort. The use of radioactive iodine or not (61.1% vs. 38.7% treated, P = 0.078), and cigarette smokers or nonsmokers (66.7% vs. 39.4%, P = 0.079) were linked with GO but the differences did not reach statistical significance.

Genotyping
The observed genotype distributions of all SNPs CTLA-4 –318C/T, CTLA-4 +49A/G, CTLA-4 CT60A/G, IL-13 –1112C/T, and IL-13 2044G/A, but not the dinucleotide (AT)n repeats in the 3'UTR of CTLA-4, attained Hardy-Weinberg equilibrium in the control subjects (Table 1) . None of the genotype frequencies showed a differences between the sexes. Patients with GD presented with a significantly higher portion of CTLA-4 +49 GG genotypes and G allele compared with control (Pc = 0.005 and Pc = 0.03, respectively). The +49GG genotype significantly increased the risk of GD in a dominant model (OR = 4.59, 95% CI = 1.917–10.985). Likewise, for CTLA-4 CT60A/G, GG genotypes and G alleles were more prevalent in patients with GD compared with the prevalence in control subjects (Pc = 0.07 and Pc= 0.02, respectively). The CT60G allele conferred susceptibility to GD in both dominant and recessive models (ORdom = 3.734, 95% CI = 1.178–11.832; ORrec = 1.721, 95% CI = 1.089–2.719). An allele dosage effect was observed with P for Armitage’s trend test = 0.005, as the risk of GD increased significantly when both CT60G alleles were present.


View this table:
[in this window]
[in a new window]

  		TABLE 1. CTLA-4 and IL-13 Gene Polymorphisms in Patients with GD and Control Subjects

 
The three SNPs in CTLA-4 (–318C/T, +49A/G, and CT60A/G) were in the same haplotype block (with D' = 1.0; Fig. 1 ). Haplotype frequencies are shown in Table 2 . The most common haplotype, CGG, was significantly increased in patients with GD when compared with its presence in control subjects (75.1% vs. 65.6%, Pc = 0.033, OR = 1.588, 95% CI = 1.132–2.227). The CAA haplotype decreased the susceptibility to GD significantly (15.5% vs. 24.8%, Pc = 0.017; OR = 0.557; 95% CI = 0.378–0.821).


Figure 1
View larger version (31K):
[in this window]
[in a new window]

  		FIGURE 1. CTLA-4 –318C/T (rs5742909), +49A/G (rs231775), and CT60A/G (rs3087243) are in the same LD block.

 

View this table:
[in this window]
[in a new window]

  		TABLE 2. Haplotype Frequencies of CTLA-4 Gene Polymorphisms in Patients with GD and Control Subjects

 
We identified 14 allele lengths for (AT)n repeats in the 3'UTR in CTLA-4 in our cohort (Table 3) . The shortest allele (192 bp) conferred a protective effect against GD (P = 8.4 x 10–6; Pc = 0.00,012; OR = 0.436, 95% CI = 0.301–0.631). Although a 208-bp allele may link with GD (OR = 1.719; 95% CI = 1.183–2.498), such linkage was statistically insignificant after Bonferroni correction (P = 0.004; Pc = 0.056). No significant difference was detected in the distribution of the allele length when comparing GO with non-GO patients.


View this table:
[in this window]
[in a new window]

  		TABLE 3. Distribution of Variant Length of CTLA-4 Dinucleotide (AT)n Repeats

 
For the two SNPs in IL-13, the genotype and allele frequencies were not different between patients with GD and control subjects (Table 1) . –1112C/T was associated with an increased serum IgE level (P = 0.044, Pc = 0.22; ORhet = 2.363, 95% CI = 1.104–5.059) and 2044G/A with proptosis (P = 0.02, Pc = 0.1). Both did not reach statistical significance after Bonferroni correction (Tables 4 5) . The AA homozygous genotype of 2044G/A occurred rarely in patients with proptosis, only 1 (4.5%) in 22, but a quarter (22/89, 24.7%) of patients without proptosis (Table 5) . No association was found between the polymorphisms investigated herein with the serum level of antimicrosomal or antithyroglobulin antibodies (results not shown). Logistic regression showed the absence of gene-gene interaction between IL-13 and CTLA-4 (P > 0.05).


View this table:
[in this window]
[in a new window]

  		TABLE 4. Association of IL-13 and CTLA-4 SNPs with IgE Level in Patients with GD

 

View this table:
[in this window]
[in a new window]

  		TABLE 5. Association of CTLA-4 and IL-13 SNPs with Different Manifestation of GO (NOSPECS Class 2, 3, or 4)

 

   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
Childhood/adolescent GD is rare in Caucasians but a higher prevalence is observed among the Chinese population in Hong Kong.3 Therefore, we were able to follow-up a large cohort of pediatric Chinese patients with GD and to study the association of four CTLA-4 and two IL-13 gene polymorphisms in patients with GD and GO under the age of 16. Ours is the first genotyping study on this age group of patients. Although it has been argued that childhood GD and GO is clinically and/or phenotypically distinct from adult-onset GD and GO,50 it still remains to be confirmed empirically and experimentally whether different times of disease onset are due to fundamental differences in genetic or immunologic mechanisms.

CTLA-4 genotype distribution and allele frequencies determined in Chinese children in this study were different from those in Caucasians but similar to those in Japanese.50 In particular, the G allele at +49A/G and CT60A/G were the most prevalent among Chinese. Our results confirmed that the presence of at least one G allele (GG or AG) at either locus confers susceptibility to GD in Chinese children. Haplotype analysis also confirmed that +49G/CT60G confers a significant risk for GD, whereas +49A/CT60A correlates with a protective effect. Although located in the same haplotype block, –318C/T does not associate with an increased risk of GD, which may be due to its low allele frequency (~10%) in our study population.

A recent meta-analysis16 suggested that, apart from the original and the extended study from Vaidya et al.,51 52 there was no evidence of a significant association between CTLA-4 +49G and GO. A study on five CTLA-4 SNPs in Chinese adult patients with GD showed that the –318T allele played a protective role in GO, particularly among male patients.53 Our results in children revealed no association of the –318T allele with GD/GO. The –318T allele frequency in our cohort was much lower (10% vs. 25%). The discrepancy may be due to population stratification: The study by Han et al.53 was based in Chongqing in southwestern China, and ours in Hong Kong in the south. What should also be considered is the notion of dissimilar genetic or etiologic contribution to childhood GD in our study against adult onset GD in theirs. It is noted that the recent International HapMap project reported the T allele frequency in Han Chinese in Beijing to be 11% in Rel22/phase II April 2007.54

IL-13 gene polymorphisms were associated with GD but not GO in the Japanese population.55 Such association could not be replicated in the Chinese subjects of this study. Several studies suggested that IL-13 polymorphisms may affect serum IgE level, which in turn could be related to GO severity.41 42 56 Presence of IL-13 mRNA and IgE had been detected in thyroid and orbital tissues of patients with GD.38 57 58 In one study, a higher serum IgE level occurred in about a third of those with hyperthyroid GD, who had slower recovery in reduction in thyroid stimulating hormone receptor antibody levels during methimazole and/or prednisolone treatment.39 These may suggest a difference in the autoimmune processes in a subgroup of patients with GD with elevation of IgE.39 Still, our results may indicate an association of IL-13 –1112C/T on IgE level and IL-13 2044G/A on development of proptosis (Table 5) , the number of patients was small, and the associations were statistically insignificant after Bonferroni correction. Our preliminary observation may imply involvement of IL-13 in certain clinical manifestations of GO, provided that it is confirmed in a large cohort of patients and different ethnic origins. –1112C/T has been shown to regulate gene transcription and cause IgE elevation.41 42 On the other hand, 2044G/A leads to R130Q, a substitution of a positively charged arginine with a neutral glutamine. Computer modeling suggests that this polymorphism affects ligand receptor interactions.59 R130 is a moderately conserved amino acid residue in humans, monkeys, and cattle.60 The R130Q variant has been shown to be more active in mediating activities than is wild-type IL-13.60 It has also been shown to associate with allergic asthma, probably due to its enhancement of allergic inflammation.61 Proptosis and diplopia have been reported as ophthalmic complications in patients with allergic fungal sinusitis.62 Whether IL-13 2044G/A exerts any biological effects that ultimately contribute to the development of proptosis warrants further investigation.

Phenotypic definition of GO is a confounding factor in genetic studies of GO.16 Although numerous classification schemes for GO have been proposed over the years,63 new grading systems are still being sought, indicating inadequacies in the existing ones.64 NOSPECS classification is the most widely used, but it lacks step-wise progression across the grading system. An individual with GO can have more than one grade, which may change with time or treatments. There can also be improvement with time, irrespective of treatment. For example, patients with severe soft tissue congestion and proptosis and requiring immunosuppressants or surgical decompression are given a lower grade (class 3) than are patients with lid retraction, lagophthalmos, and corneal punctate epitheliopathy requiring only topical lubricants (class 5). Patients with extraocular motility disturbance (class 4) may not experience proptosis (class 3) or soft tissue changes (class 2) during the whole disease course. Clinically evident GO in pediatric patients is often defined as class II (soft tissue involvement) or higher, whereas some diagnosed GO in the presence of upper lid retraction only, with or without lid lag (class 1).11 Most genetic studies on adult GO use class 3 to define clinically evident GO.16 At this moment, we believe that class 3 and higher should be uniformly used to define clinically evident ophthalmopathy, because milder forms are difficult to quantify objectively. In a Japanese study on HLA genotype,50 only class 3 or 4 patients were included as clinically evident GO. Class 0 patients were assigned as no GO. Patients in all other classes were not included. No consensus has been reached as to whether pediatric GO should use the same classification criteria as adults.16

In conclusion, our results showed that CTLA-4 –318C +49G CT60G haplotype conferred susceptibility to childhood GD in Hong Kong Chinese, whereas IL-13 was not associated with GD. No association between these gene polymorphisms and the development of GO was detected. Recent progress in the clinical management of GO, including the use of tumor necrosis factor-{alpha} blockage, anti-CD20 antibodies, and contraindication of PPAR-{gamma} agonist, all stemmed directly from basic research. We should seek a better understanding of the underlying pathophysiology and predicting outcome of GD/GO at onset and to identify family members at risk. Such information should help to improve disease management and allow earliest intervention in GO, a distressing condition with long-term disability, even after achieving euthyroidism.


   Footnotes
 
Submitted for publication November 7, 2007; revised January 22, 2008; accepted April 16, 2008.

Disclosure: K.K.L. Chong, None; S.W.Y. Chiang, None; G.W.K. Wong, None; P.O.S. Tam, None; T.-K. Ng, None; Y.-J. Hu, None; G.H.F. Yam, None; D.S.C. Lam, None; C.-P. Pang, None

The publication costs of this article were defrayed in part by page charge payment. This article must therefore be marked "advertisement" in accordance with 18 U.S.C. §1734 solely to indicate this fact.

Corresponding author: Chi-Pui Pang, Department of Ophthalmology and Visual Sciences, The Chinese University of Hong Kong, Hong Kong Eye Hospital, 147K Argyle Street, Kowloon, Hong Kong; cppang{at}cuhk.edu.hk.


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

  1. Bellur S, Prabhakar , Bahn RS, Smith TJ. Current perspective on the pathogenesis of Graves’ disease and ophthalmopathy. Endocr Rev. 2003;24:802–835.[Abstract/Free Full Text]
  2. Lavard L, Ranlov I, Perrild H, Anderson O, Jacobsen BB. Incidence of juvenile thyrotoxicosis in Denmark 1982–1988: a nationwide study. Eur J Endocrinol. 1994;130:565–568.[Abstract/Free Full Text]
  3. Wong GW, Cheng PS. Increasing incidence of childhood Graves’ disease in Hong Kong: a follow-up study. Clin Endocrinol. 2001;54:547–550.[CrossRef][Medline][Order article via Infotrieve]
  4. Bahn RS, Heufelder AE. Pathogenesis of Graves’ ophthalmopathy. N Engl J Med. 1993;329:1468–1475.[Free Full Text]
  5. Carter JA, Utiger RD. The ophthalmopathy of Graves’ disease. Ann Rev Med. 1992;43:487–495.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  6. Yeatts RP. Quality of life in patients with Graves ophthalmopathy. Trans Am Ophthalmol Soc. 2005;103:368–411.[Medline][Order article via Infotrieve]
  7. Krassas GE, Segni M, Wiersinga WM. Childhood Graves’ ophthalmopathy: results of a European questionnaire study. Eur J Endocrinol. 2005;153:515–521.[Abstract/Free Full Text]
  8. Krassas GE. Treatment of juvenile Graves’ disease and its ophthalmic complication: the ‘European way’. Eur J Endocrinol. 2004;150:407–414.[Abstract]
  9. Chan W, Wong GW, Fan DS, Cheng AC, Lam DS, Ng JS. Ophthalmopathy in childhood Graves’ disease. Br J Ophthalmol. 2002;86:740–742.[Abstract/Free Full Text]
  10. Gruters A. Ocular manifestations in children and adolescents with thyrotoxicosis. Exp Clin Endocrinol Diabetes. 1999;107(suppl 5)S172–S174.[Web of Science][Medline][Order article via Infotrieve]
  11. Uretsky SH, Kennerdell JS, Gutai JP. Graves’ ophthalmopathy in childhood and adolescence. Arch of Ophthalmol. 1980;98:1963–1964.
  12. Young LA. Dysthyroid ophthalmopathy in children. J Pediatr Ophthalmol Strabismus. 1979;16:105–107.[Web of Science][Medline][Order article via Infotrieve]
  13. Krassas GE, Gogakos A. Thyroid-associated ophthalmopathy in juvenile Graves’ disease: clinical, endocrine and therapeutic aspects. J Pediatr Endocrinol Metab. 2006;19:1193–1206.[Web of Science][Medline][Order article via Infotrieve]
  14. Prummel MF, Bakker A, Wiersinga WM, et al. Multicenter study on the characteristics and treatment strategies of patients with Graves orbitopathy: the first European Group on Graves’ Orbitopathy experience. Eur J Endocrinol. 2003;148:491–495.[Abstract]
  15. Bartalena L, Marcocci C, Pinchera A. Graves’ ophthalmopathy: a preventable disease?. Eur J Endocrinol. 2002;146:457–461.[Abstract]
  16. Bednarczuk T, Gopinath B, Ploski R, Wall JR. Susceptibility genes in Graves’ ophthalmopathy: searching for a needle in a haystack?. Clin Endocrinol. 2007;67:3–19.[CrossRef][Medline][Order article via Infotrieve]
  17. Villanueva R, Tomer Y, Greenberg DA, et al. Autoimmune thyroid disease susceptibility loci in a large Chinese family. Clin Endocrinol. 2002;56:45–51.[CrossRef][Medline][Order article via Infotrieve]
  18. Vaidya B, Imrie H, Perros P, et al. The cytotoxic T lymphocyte antigen-4 is a major Graves’ disease locus. Hum Mol Gen. 1999;8:1195–1199.[Abstract/Free Full Text]
  19. Brix TH, Kyvik KO, Christensen K, Hegedus L. Evidence for a major role of heredity in Graves’ disease: a population-based study of two Danish twin cohorts. J Clin Endocrinol Metab. 2001;86:930–934.[Abstract/Free Full Text]
  20. Tomer Y, Greenberg DA, Concepcion E, Ban Y, Davies TF. Thyroglobulin is a thyroid specific gene for the familial autoimmune thyroid diseases. J Clin Endocrinol Metab. 2002;87:404–407.[Abstract/Free Full Text]
  21. Ohtsuka K, Nakamura Y. Human leukocyte antigens associated with hyperthyroid Graves ophthalmology in Japanese patients. Am J Ophthalmol. 1998;126:805–810.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  22. Buzzetti R, Nistico L, Signore A, Cascino I. CTLA-4 and HLA gene susceptibility to thyroid-associated orbitopathy. Lancet. 1999;354:1824.[Web of Science][Medline][Order article via Infotrieve]
  23. Siegmund T, Usadel KH, Donner H, Braun J, Walfish PG, Baden-hoop K. Interferon-gamma gene microsatellite polymorphisms in patients with Graves’ disease. Thyroid. 1998;8:1013–1017.[Web of Science][Medline][Order article via Infotrieve]
  24. Kamizono S, Hiromatsu Y, Seki N, et al. A polymorphism of the 50 flanking region of tumor necrosis factor a gene is associated with thyroid-associated ophthalmopathy in Japanese. Clin Endocrinol. 2000;52:759–764.[CrossRef][Medline][Order article via Infotrieve]
  25. Muhlberg T, Kirchberger M, Spitzweg C, Herrman F, Heberling HJ, Heufelder AE. Lack of association of Graves’ disease with A2 allele of the interleukin-1 receptor antagonist gene in a white European population. Eur J Endocrinol. 1998;138:686–690.[Abstract]
  26. Hunt PJ, Marshall SE, Weetman AP, Bell JI, Wass JAH, Welsh KI. Cytokine gene polymorphisms in autoimmune thyroid disease. J Clin Endocrinol Metab. 2000;85:1984–1988.[Abstract/Free Full Text]
  27. Gough SC, Walker LS, Sansom DM. CTLA. 4 gene polymorphism and autoimmunity. Immunol Rev. 2005;24:102–115.
  28. Hadj Kacem H, Bellassoued M, Bougacha-Elleuch N, Abid M, Ayadi H. CTLA-4 gene polymorphisms in Tunisian patients with Graves’ disease. Clin Immunol. 2001;101:361–365.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  29. Petrone A, Giorgi G, Galgani A, et al. CT60 single nucleotide polymorphisms of the cytotoxic T-lymphocyte-associated antigen-4 gene region is associated with Graves’ disease in an Italian population. Thyroid. 2005;15:232–238.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  30. Yung E, Cheng PS, Fok TF, Wong GW. CTLA-4 gene A-G polymorphism and childhood Graves’ disease. Clin Endocrinol. 2002;56:649.[CrossRef][Medline][Order article via Infotrieve]
  31. Bednarczuk T, Hiromatsu Y, Fukutani T, et al. Association of cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4) gene polymorphism and non-genetic factors with Graves’ ophthalmopathy in European and Japanese populations. Eur J Endocrinol. 2003;148:13–18.[Abstract]
  32. Ueda H, Howson JM, Esposito L, et al. Association of the T-cell regulatory gene CTLA4 with susceptibility to autoimmune disease. Nature. 2003;423:506.[CrossRef][Medline][Order article via Infotrieve]
  33. Furugaki K, Shirasawa S, Ishikawa N, et al. Association of the T-cell regulatory gene CTLA4 with Graves’ disease and autoimmune thyroid disease in the Japanese. J Hum Genet. 2004;49:166–168.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  34. Villanueva R, Inzerillo AM, Tomer Y, et al. Limited genetic susceptibility to severe Graves’ ophthalmopathy: no role for CTLA-4 but evidence for an environmental etiology. Thyroid. 2000;10:791–798.[Web of Science][Medline][Order article via Infotrieve]
  35. Han S, Zhang S, Zhang W, et al. CTLA4 polymorphisms and ophthalmopathy in Graves’ disease patients: association study and meta-analysis. Hum Immunol. 2006;67:618–626.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  36. Chomarat P, Banchereau J. Interleukin-4 and interleukin-13: their similarities and discrepancies. Int Rev Immunol. 1998;17:1–52.[Medline][Order article via Infotrieve]
  37. Punnonen J, Aversa G, Cocks BG, et al. Interleukin 13 induces interleukin 4-independent IgG4 and IgE synthesis and CD23 expression by human B cells. Proc Natl Acad Sci USA. 1993;90:3730–3734.[Abstract/Free Full Text]
  38. Raikow RB, Dalbow MH, Kennerdell JS, et al. Immunohistochemical evidence for IgE involvement in Graves’ orbitopathy. Ophthalmology. 1990;97:629–635.[Web of Science][Medline][Order article via Infotrieve]
  39. Sato A, Takemura Y, Yamada T, et al. A possible role of immunoglobulin E in patients with hyperthyroid Graves’ disease. J Clin. Endocrinol Metab. 1999;84:3602–3605.[Abstract/Free Full Text]
  40. Komiya I, Yamada T, Sato A, et al. Remission and recurrence of hyperthyroid Graves’ disease during and after methimazole treatment when assessed by IgE and interleukin 13. J Clin Endocrinol Metab. 2001;86:3540–3544.[Abstract/Free Full Text]
  41. van der Pouw Kraan TC, van Veen A, Boeije LC, et al. An IL-13 promoter polymorphism associated with increased risk of allergic asthma. Genes Immun. 1999;1:61–65.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  42. Graves PE, Kabesch M, Halonen M, et al. A cluster of seven tightly linked polymorphisms in the IL-13 gene is associated with total serum IgE levels in three populations of white children. J Allergy Clin Immunol. 2000;105:506–513.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  43. Werner SC. Modification of the classification of the eye changes of Graves’ disease: recommendations of the Ad Hoc Committee of the American Thyroid Association. J Clin Endocrinol Metab. 1977;44:203–204.[Free Full Text]
  44. Quant JR, Woo GC. Normal values of eye position and head size in Chinese children from Hong Kong. Optom Vis Sci. 1993;70:668–671.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  45. Sallakci N, Bacanli A, Coskun M, Yavuzer U, Alpsoy E, Yegin O. CTLA-4 gene 49A/G polymorphism in Turkish patients with Behçet’s disease. Clin and Exp Derm. 2005;30:546–550.[CrossRef]
  46. Shine B, Fells P, Edwards OM, Weetman AP. Association between Graves’ ophthalmopathy and smoking. Lancet. 1990;335:1261–1263.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  47. Kendler DL, Lippa J, Rootman J. The initial clinical characteristics of Graves’ orbitopathy vary with age and sex. Arch Ophthalmol. 1993;111:197–201.[Abstract/Free Full Text]
  48. Bartalena L, Marcocci C, Bogazzi F, et al. Relation between therapy for hyperthyroidism and the course of Graves’ ophthalmopathy. N Engl J Med. 1998;338:73–78.[Abstract/Free Full Text]
  49. Bartalena L, Marcocci C, Tanda ML, et al. Cigarette smoking and treatment outcomes in Graves ophthalmopathy. Ann Intern Med. 1998;129:632–635.[Abstract/Free Full Text]
  50. Iwama S, Ikezaki A, Kikuoka N, et al. Association of HLA-DR, -DQ genotype and CTLA-4 gene polymorphism with Graves’ disease in Japanese children. Horm Res. 2005;63:55–60.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  51. Vaidya B, Imrie H, Perros P, et al. Cytotoxic T lymphocyte antigen-4 (CTLA4) gene polymorphism confers susceptibility to thyroid-associated orbitopathy. Lancet. 1999;354:743–744.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  52. Vaidya B, Oakes EJ, Imrie H, et al. CTLA4 gene and Graves’ disease: association of Graves’ disease with the CTLA4 exon 1 and intron 1 polymorphisms, but not with the promoter polymorphism. Clin Endocrinol. 2003;58:732–735.[CrossRef][Medline][Order article via Infotrieve]
  53. Han SZ, Zhang SH, Li R, Zhang WY, Li Y. The common –318C/T polymorphism in the promoter region of CTLA4 gene is associated with reduced risk of ophthalmopathy in Chinese Graves’ patients. Int J Immunogenet. 2006;33:281–287.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  54. http://www.hapmap.org/cgi-perl/snp_details?name=rs5742909&source=hapmap_B36.
  55. Hiromatsu Y, Fukutani T, Ichimura M, et al. Interleukin-13 gene polymorphisms confer the susceptibility of Japanese populations to Graves’ disease. J Clin Endocrinol Metab. 2005;90:296–301.[Abstract/Free Full Text]
  56. Molnar I, Horvath S, Balazs C. Detectable serum IgE levels in Graves’ ophthalmopathy. Eur J Med Res. 1996;1:543–546.[Medline][Order article via Infotrieve]
  57. Ajjan RA, Watson PF, Weetman AP. Detection of IL-12, IL-13, and IL-15 messenger ribonucleic acid in the thyroid of patients with autoimmune thyroid disease. J Clin Endocrinol Metab. 1997;82:666–669.[Abstract/Free Full Text]
  58. Wakelkamp IM, Bakker O, Baldeschi L, Wiersinga WM, Prummel MF. TSH-R expression and cytokine profile in orbital tissue of active vs. inactive Graves’ ophthalmopathy patients. Clin Endocrinol. 2003;58:280–287.[CrossRef][Medline][Order article via Infotrieve]
  59. Heinzmann A, Mao XQ, Akaiwa M, et al. Genetic variants of IL-13 signalling and human asthma and atopy. Hum Mol Gen. 2000;9:549–559.[Abstract/Free Full Text]
  60. Berezin C, Glaser F, Rosenberg J, et al. ConSeq: the identification of functionally and structurally important residues in protein sequences. Bioinformatics. 2004;20:1322–1324.[Abstract/Free Full Text]
  61. Vladich FD, Brazille SM, Stern D, Peck ML, Ghittoni R, Vercelli D. IL-13 R130Q, a common variant associated with allergy and asthma, enhances effector mechanisms essential for human allergic inflammation. J Clin Invest. 2005;115:747–754.[CrossRef][Web of Science][Medline][Order article via Infotrieve]
  62. Coop CA, Ronald W. Allergic fungal sinusitis presenting with proptosis and diplopia: a review of ophthalmologic complications and treatment. Allergy Asthma Proc. 2006;27:72–76.[Web of Science][Medline][Order article via Infotrieve]
  63. Bartley GB. Evolution of classification systems for Graves’ ophthalmopathy. Ophthalmic Plast Reconstr Surg. 1995;11:229–237.[Web of Science][Medline][Order article via Infotrieve]
  64. Dolman PJ, Rootman J. VISA Classification for Graves orbitopathy. Ophthalmic Plast Reconstr Surg. 2006;22:319–324.[CrossRef][Web of Science][Medline][Order article via Infotrieve]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow All Versions of this Article:
iovs.07-1433v1
49/6/2409    most recent
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Chong, K. K. L.
Right arrow Articles by Pang, C.-P.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Chong, K. K. L.
Right arrow Articles by Pang, C.-P.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS