Graves' disease pathophysiology: Difference between revisions
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{{CMG}};{{AE}}{{MehdiP}} | {{CMG}};{{AE}}{{MehdiP}} | ||
==Overview== | ==Overview== | ||
Genetic factors, anti [[thyrotropin receptor]] antibodies, [[T cells]], [[B cells]] and thyroid epithelial cells involvement are the main pathologic features of Graves' disease. | Genetic factors, anti [[thyrotropin receptor]] [[Antibody|antibodies]], [[T cells]], [[B cells]] and thyroid [[epithelial]] cells involvement are the main [[Pathological|pathologic]] features of Graves' disease. | ||
==Pathophysiology== | ==Pathophysiology== | ||
Several factors may contribute | Several factors may contribute to Graves' disease pathogenesis. The following are the main aspects of Graves' diseases pathophysiology.<ref name="pmid24460189">{{cite journal |vauthors=Tomer Y |title=Mechanisms of autoimmune thyroid diseases: from genetics to epigenetics |journal=Annu Rev Pathol |volume=9 |issue= |pages=147–56 |year=2014 |pmid=24460189 |pmc=4128637 |doi=10.1146/annurev-pathol-012513-104713 |url=}}</ref> | ||
===Initiating factors=== | ===Initiating factors=== | ||
Genetic factors are important in | Genetic factors are important in the development of Graves' disease. These factors include genes encoding for:<ref name="pmid9440642">{{cite journal| author=Hahn BA, Saunders WB, Maier WC| title=Differences between individuals with self-reported irritable bowel syndrome (IBS) and IBS-like symptoms. | journal=Dig Dis Sci | year= 1997 | volume= 42 | issue= 12 | pages= 2585-90 | pmid=9440642 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9440642 }} </ref><ref name="pmid24460189">{{cite journal |vauthors=Tomer Y |title=Mechanisms of autoimmune thyroid diseases: from genetics to epigenetics |journal=Annu Rev Pathol |volume=9 |issue= |pages=147–56 |year=2014 |pmid=24460189 |pmc=4128637 |doi=10.1146/annurev-pathol-012513-104713 |url=}}</ref> | ||
*[[Thyroglobulin]] | *[[Thyroglobulin]] | ||
*[[Thyrotropin receptor]] | *[[Thyrotropin receptor]] | ||
| Line 22: | Line 22: | ||
Graves' disease is an [[autoimmunity|autoimmune]] disorder, in which the body produces antibodies to the receptor for [[thyroid-stimulating hormone]] (TSH). These are [[IgG|IgG1]] subclass of antibodies.<ref name="pmid2168443">{{cite journal |vauthors=Weetman AP, Yateman ME, Ealey PA, Black CM, Reimer CB, Williams RC, Shine B, Marshall NJ |title=Thyroid-stimulating antibody activity between different immunoglobulin G subclasses |journal=J. Clin. Invest. |volume=86 |issue=3 |pages=723–7 |year=1990 |pmid=2168443 |pmc=296786 |doi=10.1172/JCI114768 |url=}}</ref> | Graves' disease is an [[autoimmunity|autoimmune]] disorder, in which the body produces antibodies to the receptor for [[thyroid-stimulating hormone]] (TSH). These are [[IgG|IgG1]] subclass of antibodies.<ref name="pmid2168443">{{cite journal |vauthors=Weetman AP, Yateman ME, Ealey PA, Black CM, Reimer CB, Williams RC, Shine B, Marshall NJ |title=Thyroid-stimulating antibody activity between different immunoglobulin G subclasses |journal=J. Clin. Invest. |volume=86 |issue=3 |pages=723–7 |year=1990 |pmid=2168443 |pmc=296786 |doi=10.1172/JCI114768 |url=}}</ref> | ||
These antibodies cause [[hyperthyroidism]] because they bind to the TSH receptor and [[chronic (medicine)|chronically]] stimulate it. The TSH receptor is expressed on the [[follicular cells]] of the thyroid gland (the cells that produce thyroid hormone), and the result of chronic stimulation is an abnormally high production of T3 and T4. This in turn causes the clinical symptoms of [[hyperthyroidism]], and the enlargement of the thyroid gland visible as [[Goitre|goiter]]. | These antibodies cause [[hyperthyroidism]] because they bind to the TSH receptor and [[chronic (medicine)|chronically]] stimulate it. The TSH receptor is expressed on the [[follicular cells]] of the thyroid gland (the cells that produce thyroid hormone), and the result of chronic stimulation is an abnormally high production of T3 and T4. This in turn causes the clinical symptoms of [[hyperthyroidism]], and the enlargement of the thyroid gland, visible as a [[Goitre|goiter]]. The stimulation of thyroid hormone production by these antibodies is uncontrolled by the hypothalamic pituitary axis.<ref name="pmid18719020">{{cite journal |vauthors=Morshed SA, Latif R, Davies TF |title=Characterization of thyrotropin receptor antibody-induced signaling cascades |journal=Endocrinology |volume=150 |issue=1 |pages=519–29 |year=2009 |pmid=18719020 |pmc=2630889 |doi=10.1210/en.2008-0878 |url=}}</ref><ref name="pmid26361261">{{cite journal |vauthors=Pujol-Borrell R, Giménez-Barcons M, Marín-Sánchez A, Colobran R |title=Genetics of Graves' Disease: Special Focus on the Role of TSHR Gene |journal=Horm. Metab. Res. |volume=47 |issue=10 |pages=753–66 |year=2015 |pmid=26361261 |doi=10.1055/s-0035-1559646 |url=}}</ref> | ||
===T Cells and B Cells=== | ===T Cells and B Cells=== | ||
Both [[T cells]] and [[B cells]] are necessary for the development of Graves' disease. | Both [[T cells]] and [[B cells]] are necessary for the development of Graves' disease.<ref name="pmid5358896">{{cite journal |vauthors=Weaver DH, Maxwell JG, Castleton KB |title=Mallory-Weiss syndrome |journal=Am. J. Surg. |volume=118 |issue=6 |pages=887–92 |year=1969 |pmid=5358896 |doi= |url=}}</ref> | ||
====T Cells==== | ====T Cells==== | ||
In Graves’ disease, autoreactive T cells against the thyrotropin receptor have escaped both central (thymic) and peripheral editing. | * In Graves’ disease, autoreactive T cells against the thyrotropin receptor have escaped both [[Thymus#Phases of thymocyte maturation|central (thymic)]] and [[Thymus#Phases of thymocyte maturation|peripheral]] editing. | ||
Receptors on these CD4+ helper T cells interact with MHC class II molecules through which thyrotropin-receptor peptides are presented. | * Receptors on these [[CD4+ T cells|CD4+ helper T cells]] interact with [[MHC class II]] molecules through which thyrotropin-receptor peptides are presented. | ||
Intrathyroidal T cells are particularly reactive to thyroid antigens and predominantly have the Th2 phenotype.<ref name="pmid2531154">{{cite journal |vauthors=Martin A, Schwartz AE, Friedman EW, Davies TF |title=Successful production of intrathyroidal human T cell hybridomas: evidence for intact helper T cell function in Graves' disease |journal=J. Clin. Endocrinol. Metab. |volume=69 |issue=6 |pages=1104–8 |year=1989 |pmid=2531154 |doi=10.1210/jcem-69-6-1104 |url=}}</ref> | * Intrathyroidal T cells are particularly reactive to thyroid antigens and predominantly have the Th2 phenotype.<ref name="pmid2531154">{{cite journal |vauthors=Martin A, Schwartz AE, Friedman EW, Davies TF |title=Successful production of intrathyroidal human T cell hybridomas: evidence for intact helper T cell function in Graves' disease |journal=J. Clin. Endocrinol. Metab. |volume=69 |issue=6 |pages=1104–8 |year=1989 |pmid=2531154 |doi=10.1210/jcem-69-6-1104 |url=}}</ref> | ||
====B Cells==== | ====B Cells==== | ||
B cells develop into antibody-producing plasma cells in a process requiring second signals. | * B cells develop into antibody-producing [[plasma cells]] in a process requiring second signals. | ||
The first of these signals is provided by antigen binding to the B cell receptor and the second by CD40 on the B cell surface interacting with CD40 ligand on T cells. | * The first of these signals is provided by antigen binding to the B cell receptor and the second by [[CD40]] on the B cell surface interacting with CD40 ligand on T cells. | ||
These interactions result in the production of critical cytokines, such as interleukin-4, which promote antibody secretion and T-cell support of class switching. | * These interactions result in the production of critical [[cytokines]], such as [[interleukin-4]], which promote antibody secretion and T-cell support of class switching. | ||
B cells initially produce IgM, which can be class-switched to IgG or IgE. Intrathyroidal B cells have reduced mitogenic responses but spontaneously secrete anti–thyrotropin-receptor antibodies. <ref name="pmid27797318">{{cite journal |vauthors=Smith TJ, Hegedüs L |title=Graves' Disease |journal=N. Engl. J. Med. |volume=375 |issue=16 |pages=1552–1565 |year=2016 |pmid=27797318 |doi=10.1056/NEJMra1510030 |url=}}</ref> | * B cells initially produce [[IgM]], which can be class-switched to [[IgG]] or [[IgE]]. | ||
Intrathyroidal B cells have reduced mitogenic responses but spontaneously secrete anti–thyrotropin-receptor antibodies. <ref name="pmid27797318">{{cite journal |vauthors=Smith TJ, Hegedüs L |title=Graves' Disease |journal=N. Engl. J. Med. |volume=375 |issue=16 |pages=1552–1565 |year=2016 |pmid=27797318 |doi=10.1056/NEJMra1510030 |url=}}</ref> | |||
===Thyroid Epithelial Cell Involvement=== | ===Thyroid Epithelial Cell Involvement=== | ||
These cells express important organ specific antigens, such as the thyrotropin receptor, thyroglobulin, and thyroperoxidase. | * These cells express important organ specific antigens, such as the [[thyrotropin receptor]], [[thyroglobulin]], and [[thyroperoxidase]]. | ||
Thyroid epithelial cells release several chemokines and thus may participate in the recruitment of immune cells.<ref name="pmid12794165">{{cite journal |vauthors=Armengol MP, Cardoso-Schmidt CB, Fernández M, Ferrer X, Pujol-Borrell R, Juan M |title=Chemokines determine local lymphoneogenesis and a reduction of circulating CXCR4+ T and CCR7 B and T lymphocytes in thyroid autoimmune diseases |journal=J. Immunol. |volume=170 |issue=12 |pages=6320–8 |year=2003 |pmid=12794165 |doi= |url=}}</ref> | * Thyroid epithelial cells release several [[chemokines]] and thus may participate in the recruitment of immune cells.<ref name="pmid12794165">{{cite journal |vauthors=Armengol MP, Cardoso-Schmidt CB, Fernández M, Ferrer X, Pujol-Borrell R, Juan M |title=Chemokines determine local lymphoneogenesis and a reduction of circulating CXCR4+ T and CCR7 B and T lymphocytes in thyroid autoimmune diseases |journal=J. Immunol. |volume=170 |issue=12 |pages=6320–8 |year=2003 |pmid=12794165 |doi= |url=}}</ref> | ||
In addition, they act as MHC class II and have the potential to present thyroid antigens to T cells. Also, their CD40 expression suggests the potential for direct, productive interactions between thyroid epithelium and antigen-specific T cells in Graves’ disease.<ref name="pmid9245555">{{cite journal |vauthors=Faure GC, Bensoussan-Lejzerowicz D, Bene MC, Aubert V, Leclere J |title=Coexpression of CD40 and class II antigen HLA-DR in Graves' disease thyroid epithelial cells |journal=Clin. Immunol. Immunopathol. |volume=84 |issue=2 |pages=212–5 |year=1997 |pmid=9245555 |doi= |url=}}</ref><ref name="pmid10482365">{{cite journal |vauthors=Smith TJ, Sciaky D, Phipps RP, Jennings TA |title=CD40 expression in human thyroid tissue: evidence for involvement of multiple cell types in autoimmune and neoplastic diseases |journal=Thyroid |volume=9 |issue=8 |pages=749–55 |year=1999 |pmid=10482365 |doi=10.1089/thy.1999.9.749 |url=}}</ref> | * In addition, they act as [[MHC class II]] and have the potential to present thyroid antigens to T cells. | ||
* Also, their [[CD40]] expression suggests the potential for direct, productive interactions between thyroid epithelium and antigen-specific T cells in Graves’ disease.<ref name="pmid9245555">{{cite journal |vauthors=Faure GC, Bensoussan-Lejzerowicz D, Bene MC, Aubert V, Leclere J |title=Coexpression of CD40 and class II antigen HLA-DR in Graves' disease thyroid epithelial cells |journal=Clin. Immunol. Immunopathol. |volume=84 |issue=2 |pages=212–5 |year=1997 |pmid=9245555 |doi= |url=}}</ref><ref name="pmid10482365">{{cite journal |vauthors=Smith TJ, Sciaky D, Phipps RP, Jennings TA |title=CD40 expression in human thyroid tissue: evidence for involvement of multiple cell types in autoimmune and neoplastic diseases |journal=Thyroid |volume=9 |issue=8 |pages=749–55 |year=1999 |pmid=10482365 |doi=10.1089/thy.1999.9.749 |url=}}</ref> | |||
==Pathogenesis of Extrathyroidal Manifestations== | ==Pathogenesis of Extrathyroidal Manifestations== | ||
*The immune pathogenesis of ophthalmopathy and hyperthyroidism are similar. The orbital process primarily targets fibroblasts. | *The immune pathogenesis of ophthalmopathy and hyperthyroidism are similar. The orbital process primarily targets [[fibroblasts]]. | ||
*T cells may contribute to | |||
*Orbital fat and extraocular muscles expand from accumulating hyaluronidase-digestible material and adipogenesis.<ref name="pmid20181974">{{cite journal |vauthors=Bahn RS |title=Graves' ophthalmopathy |journal=N. Engl. J. Med. |volume=362 |issue=8 |pages=726–38 |year=2010 |pmid=20181974 |pmc=3902010 |doi=10.1056/NEJMra0905750 |url=}}</ref> | * T cells may contribute to ophthalmopathy through their interaction with fibroblasts.<ref name="pmid9792671">{{cite journal |vauthors=Cao HJ, Wang HS, Zhang Y, Lin HY, Phipps RP, Smith TJ |title=Activation of human orbital fibroblasts through CD40 engagement results in a dramatic induction of hyaluronan synthesis and prostaglandin endoperoxide H synthase-2 expression. Insights into potential pathogenic mechanisms of thyroid-associated ophthalmopathy |journal=J. Biol. Chem. |volume=273 |issue=45 |pages=29615–25 |year=1998 |pmid=9792671 |doi= |url=}}</ref> | ||
*Fibrocytes present antigens to T cells and when activated by thyrotropin or thyroid-stimulating immunoglobulins, fibrocytes release cytokines that have been implicated in Graves’ disease, they can differentiate into adipocytes or myofibroblasts and thus might contribute to the tissue remodeling in ophthalmopathy. | * Orbital fat and extraocular muscles expand from accumulating [[hyaluronidase]]-digestible material and adipogenesis.<ref name="pmid20181974">{{cite journal |vauthors=Bahn RS |title=Graves' ophthalmopathy |journal=N. Engl. J. Med. |volume=362 |issue=8 |pages=726–38 |year=2010 |pmid=20181974 |pmc=3902010 |doi=10.1056/NEJMra0905750 |url=}}</ref> | ||
*Insulin-like growth factor 1 (IGF-1) receptor is involved in Graves' disease ophthalmopathy.<ref name="pmid18832736">{{cite journal |vauthors=Douglas RS, Naik V, Hwang CJ, Afifiyan NF, Gianoukakis AG, Sand D, Kamat S, Smith TJ |title=B cells from patients with Graves' disease aberrantly express the IGF-1 receptor: implications for disease pathogenesis |journal=J. Immunol. |volume=181 |issue=8 |pages=5768–74 |year=2008 |pmid=18832736 |pmc=2562248 |doi= |url=}}</ref> | |||
*Fibrocytes present antigens to T cells and when activated by thyrotropin or thyroid-stimulating immunoglobulins, fibrocytes release cytokines that have been implicated in Graves’ disease, they can differentiate into [[Adipocyte|adipocytes]] or [[Myofibroblast|myofibroblasts]] and thus might contribute to the tissue remodeling in ophthalmopathy. | |||
*[[Insulin-like growth factor 1]] (IGF-1) receptor is involved in Graves' disease ophthalmopathy.<ref name="pmid18832736">{{cite journal |vauthors=Douglas RS, Naik V, Hwang CJ, Afifiyan NF, Gianoukakis AG, Sand D, Kamat S, Smith TJ |title=B cells from patients with Graves' disease aberrantly express the IGF-1 receptor: implications for disease pathogenesis |journal=J. Immunol. |volume=181 |issue=8 |pages=5768–74 |year=2008 |pmid=18832736 |pmc=2562248 |doi= |url=}}</ref> | |||
==References== | ==References== | ||
Latest revision as of 20:34, 16 November 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Seyedmahdi Pahlavani, M.D. [2]
Overview
Genetic factors, anti thyrotropin receptor antibodies, T cells, B cells and thyroid epithelial cells involvement are the main pathologic features of Graves' disease.
Pathophysiology
Several factors may contribute to Graves' disease pathogenesis. The following are the main aspects of Graves' diseases pathophysiology.[1]
Initiating factors
Genetic factors are important in the development of Graves' disease. These factors include genes encoding for:[2][1]
- Thyroglobulin
- Thyrotropin receptor
- HLA-DRβ-Arg74
- The protein tyrosine phosphatase nonreceptor type 22 (PTPN22)
- Cytotoxic T-lymphocyte–associated antigen 4 (CTLA4)
- CD25
- CD40
Hypermethylation of genes involved in encoding thyrotropin receptor and proteins involved in T-cell signaling is another important factor.[3]
Anti Thyrotropin Receptor Antibodies
Graves' disease is an autoimmune disorder, in which the body produces antibodies to the receptor for thyroid-stimulating hormone (TSH). These are IgG1 subclass of antibodies.[4]
These antibodies cause hyperthyroidism because they bind to the TSH receptor and chronically stimulate it. The TSH receptor is expressed on the follicular cells of the thyroid gland (the cells that produce thyroid hormone), and the result of chronic stimulation is an abnormally high production of T3 and T4. This in turn causes the clinical symptoms of hyperthyroidism, and the enlargement of the thyroid gland, visible as a goiter. The stimulation of thyroid hormone production by these antibodies is uncontrolled by the hypothalamic pituitary axis.[5][6]
T Cells and B Cells
Both T cells and B cells are necessary for the development of Graves' disease.[7]
T Cells
- In Graves’ disease, autoreactive T cells against the thyrotropin receptor have escaped both central (thymic) and peripheral editing.
- Receptors on these CD4+ helper T cells interact with MHC class II molecules through which thyrotropin-receptor peptides are presented.
- Intrathyroidal T cells are particularly reactive to thyroid antigens and predominantly have the Th2 phenotype.[8]
B Cells
- B cells develop into antibody-producing plasma cells in a process requiring second signals.
- The first of these signals is provided by antigen binding to the B cell receptor and the second by CD40 on the B cell surface interacting with CD40 ligand on T cells.
- These interactions result in the production of critical cytokines, such as interleukin-4, which promote antibody secretion and T-cell support of class switching.
- B cells initially produce IgM, which can be class-switched to IgG or IgE.
Intrathyroidal B cells have reduced mitogenic responses but spontaneously secrete anti–thyrotropin-receptor antibodies. [9]
Thyroid Epithelial Cell Involvement
- These cells express important organ specific antigens, such as the thyrotropin receptor, thyroglobulin, and thyroperoxidase.
- Thyroid epithelial cells release several chemokines and thus may participate in the recruitment of immune cells.[10]
- In addition, they act as MHC class II and have the potential to present thyroid antigens to T cells.
- Also, their CD40 expression suggests the potential for direct, productive interactions between thyroid epithelium and antigen-specific T cells in Graves’ disease.[11][12]
Pathogenesis of Extrathyroidal Manifestations
- The immune pathogenesis of ophthalmopathy and hyperthyroidism are similar. The orbital process primarily targets fibroblasts.
- T cells may contribute to ophthalmopathy through their interaction with fibroblasts.[13]
- Orbital fat and extraocular muscles expand from accumulating hyaluronidase-digestible material and adipogenesis.[14]
- Fibrocytes present antigens to T cells and when activated by thyrotropin or thyroid-stimulating immunoglobulins, fibrocytes release cytokines that have been implicated in Graves’ disease, they can differentiate into adipocytes or myofibroblasts and thus might contribute to the tissue remodeling in ophthalmopathy.
- Insulin-like growth factor 1 (IGF-1) receptor is involved in Graves' disease ophthalmopathy.[15]
References
- ↑ 1.0 1.1 Tomer Y (2014). "Mechanisms of autoimmune thyroid diseases: from genetics to epigenetics". Annu Rev Pathol. 9: 147–56. doi:10.1146/annurev-pathol-012513-104713. PMC 4128637. PMID 24460189.
- ↑ Hahn BA, Saunders WB, Maier WC (1997). "Differences between individuals with self-reported irritable bowel syndrome (IBS) and IBS-like symptoms". Dig Dis Sci. 42 (12): 2585–90. PMID 9440642.
- ↑ Limbach M, Saare M, Tserel L, Kisand K, Eglit T, Sauer S, Axelsson T, Syvänen AC, Metspalu A, Milani L, Peterson P (2016). "Epigenetic profiling in CD4+ and CD8+ T cells from Graves' disease patients reveals changes in genes associated with T cell receptor signaling". J. Autoimmun. 67: 46–56. doi:10.1016/j.jaut.2015.09.006. PMID 26459776.
- ↑ Weetman AP, Yateman ME, Ealey PA, Black CM, Reimer CB, Williams RC, Shine B, Marshall NJ (1990). "Thyroid-stimulating antibody activity between different immunoglobulin G subclasses". J. Clin. Invest. 86 (3): 723–7. doi:10.1172/JCI114768. PMC 296786. PMID 2168443.
- ↑ Morshed SA, Latif R, Davies TF (2009). "Characterization of thyrotropin receptor antibody-induced signaling cascades". Endocrinology. 150 (1): 519–29. doi:10.1210/en.2008-0878. PMC 2630889. PMID 18719020.
- ↑ Pujol-Borrell R, Giménez-Barcons M, Marín-Sánchez A, Colobran R (2015). "Genetics of Graves' Disease: Special Focus on the Role of TSHR Gene". Horm. Metab. Res. 47 (10): 753–66. doi:10.1055/s-0035-1559646. PMID 26361261.
- ↑ Weaver DH, Maxwell JG, Castleton KB (1969). "Mallory-Weiss syndrome". Am. J. Surg. 118 (6): 887–92. PMID 5358896.
- ↑ Martin A, Schwartz AE, Friedman EW, Davies TF (1989). "Successful production of intrathyroidal human T cell hybridomas: evidence for intact helper T cell function in Graves' disease". J. Clin. Endocrinol. Metab. 69 (6): 1104–8. doi:10.1210/jcem-69-6-1104. PMID 2531154.
- ↑ Smith TJ, Hegedüs L (2016). "Graves' Disease". N. Engl. J. Med. 375 (16): 1552–1565. doi:10.1056/NEJMra1510030. PMID 27797318.
- ↑ Armengol MP, Cardoso-Schmidt CB, Fernández M, Ferrer X, Pujol-Borrell R, Juan M (2003). "Chemokines determine local lymphoneogenesis and a reduction of circulating CXCR4+ T and CCR7 B and T lymphocytes in thyroid autoimmune diseases". J. Immunol. 170 (12): 6320–8. PMID 12794165.
- ↑ Faure GC, Bensoussan-Lejzerowicz D, Bene MC, Aubert V, Leclere J (1997). "Coexpression of CD40 and class II antigen HLA-DR in Graves' disease thyroid epithelial cells". Clin. Immunol. Immunopathol. 84 (2): 212–5. PMID 9245555.
- ↑ Smith TJ, Sciaky D, Phipps RP, Jennings TA (1999). "CD40 expression in human thyroid tissue: evidence for involvement of multiple cell types in autoimmune and neoplastic diseases". Thyroid. 9 (8): 749–55. doi:10.1089/thy.1999.9.749. PMID 10482365.
- ↑ Cao HJ, Wang HS, Zhang Y, Lin HY, Phipps RP, Smith TJ (1998). "Activation of human orbital fibroblasts through CD40 engagement results in a dramatic induction of hyaluronan synthesis and prostaglandin endoperoxide H synthase-2 expression. Insights into potential pathogenic mechanisms of thyroid-associated ophthalmopathy". J. Biol. Chem. 273 (45): 29615–25. PMID 9792671.
- ↑ Bahn RS (2010). "Graves' ophthalmopathy". N. Engl. J. Med. 362 (8): 726–38. doi:10.1056/NEJMra0905750. PMC 3902010. PMID 20181974.
- ↑ Douglas RS, Naik V, Hwang CJ, Afifiyan NF, Gianoukakis AG, Sand D, Kamat S, Smith TJ (2008). "B cells from patients with Graves' disease aberrantly express the IGF-1 receptor: implications for disease pathogenesis". J. Immunol. 181 (8): 5768–74. PMC 2562248. PMID 18832736.