Role of Peripheral Regulatory T Lymphocytes in Patients with Thyroid Associated Ophthalmopathy During Systemic Glucocorticoid Treatment: A Prospective Observational Study

Abstract

Objective

Thyroid-associated ophthalmopathy (TAO) is an autoimmune disorder involving the orbital tissue. This study aimed to understand the role of regulatory T cells (Tregs) in TAO during 12-week systemic glucocorticoid (GC) treatment.

Methods

Thirty-two moderate-severe TAO patients with a clinical activity score (CAS) ≥3/7 or with prolonged T2 relaxation time (T2RT) on at least one side of extraocular muscle (EOM) were enrolled. The percentage of the peripheral CD4⁺CD25(high)CD127(−/low) Tregs was analyzed using flow cytometry before and after the GC treatment. The activity and severity of TAO, T2RT, and the clinical outcomes after the GC treatment were assessed. Their correlation with the peripheral Tregs was investigated.

Results

There was no significant association between the baseline Treg fraction and the activity and severity of TAO or the treatment response. A significant reduction of Tregs was observed after the GC therapy merely in patients without any clinical improvement.

Conclusion

Treg reduction after systemic GC therapy is indicative of a poor therapeutic response. Accordingly, dynamic alterations of Tregs could help to evaluate the effectiveness of the GC treatment.

Keywords

thyroid-associated ophthalmopathy / regulatory T cells / intravenous methylprednisolone / glucocorticoids / T2 relaxation time

References

[1] Rotondo DottoreG, TorregrossaL, CaturegliP, et al.. Association of T and B Cells Infiltrating Orbital Tissues With Clinical Features of Graves Orbitopathy. JAMA Ophthalmol, 2018, 136(6): 613-619

[2] PotgieserPW, WiersingaWM, RegensburgNI, et al.. Some studies on the natural history of Graves’ orbitopathy: increase in orbital fat is a rather late phenomenon. Eur J Endocrinol, 2015, 173(2): 149-153

[3] HiromatsuY, EguchiH, TaniJ, et al.. Graves’ ophthalmopathy: epidemiology and natural history. Intern Med, 2014, 53(5): 353-360

[4] BahnRS. Graves’ ophthalmopathy. N Engl J Med, 2010, 362(8): 726-738

[5] BartalenaL, BaldeschiL, BoboridisK, et al.. The 2016 European Thyroid Association/European Group on Graves’ Orbitopathy Guidelines for the Management of Graves’ Orbitopathy. Eur Thyroid J, 2016, 5(1): 9-26

[6] GormanCA, GarrityJA, FatourechiV, et al.. A Prospective, Randomized, Double-blind, Placebo-controlled Study of Orbital Radiotherapy for Graves’ Ophthalmopathy. Ophthalmology, 2020, 127(4S): S160-S171

[7] Perez-MoreirasJV, Varela-AgraM, Prada-SanchezMC, et al.. Steroid-Resistant Graves’ Orbitopathy Treated with Tocilizumab in Real-World Clinical Practice: A 9-Year Single-Center Experience. J Clin Med, 2021, 10(4): 706

[8] VannucchiG, CampiI, CovelliD, et al.. Efficacy Profile and Safety of Very Low-Dose Rituximab in Patients with Graves’ Orbitopathy. Thyroid, 2021, 31(5): 821-828

[9] KahalyGJ, RiedlM, KönigJ, et al.. Mycophenolate plus methylprednisolone versus methylprednisolone alone in active, moderate-to-severe Graves’ orbitopathy (MINGO): a randomised, observer-masked, multicentre trial. Lancet Diabetes Endocrinol, 2018, 6(4): 287-298

[10] StrianeseD, IulianoA, FerraraM, et al.. Methotrexate for the treatment of thyroid eye disease. J Ophthalmol, 2014, 2014: 128903

[11] HuangY, FangS, LiD, et al.. The involvement of T cell pathogenesis in thyroid-associated ophthalmopathy. Eye (Lond), 2019, 33(2): 176-182

[12] BruskoTM, PutnamAL, BluestoneJA. Human regulatory T cells: role in autoimmune disease and therapeutic opportunities. Immunol Rev, 2008, 223: 371-390

[13] ShaoS, YuX, ShenL. Autoimmune thyroid diseases and Th17/Treg lymphocytes. Life Sci, 2018, 192: 160-165

[14] PawlowskiP, Wawrusiewicz-KurylonekN, EcksteinA, et al.. Disturbances of modulating molecules (FOXP3, CTLA-4/CD28/B7, and CD40/CD40L) mRNA expressions in the orbital tissue from patients with severe graves’ ophthalmopathy. Mediators Inflamm, 2015, 2015: 340934

[15] Rodriguez-MunozA, Vitales-NoyolaM, Ramos-LeviA, et al.. Levels of regulatory T cells CD69(+)NKG2D(+) IL-10(+) are increased in patients with autoimmune thyroid disorders. Endocrine, 2016, 51(3): 478-489

[16] PawlowskiP, GrubczakK, KosteckiJ, et al.. Decreased Frequencies of Peripheral Blood CD4+CD25+CD127-Foxp3+ in Patients with Graves’ Disease and Graves’ Orbitopathy: Enhancing Effect of Insulin Growth Factor-1 on Treg Cells. Horm Metab Res, 2017, 49(3): 185-191

[17] LiC, YuanJ, ZhuYF, et al.. Imbalance of Th17/Treg in Different Subtypes of Autoimmune Thyroid Diseases. Cell Physiol Biochem, 2016, 40(1–2): 245-252

[18] TachibanaS, MurakamiT, NoguchiH, et al.. Orbital magnetic resonance imaging combined with clinical activity score can improve the sensitivity of detection of disease activity and prediction of response to immunosuppressive therapy for Graves’ ophthalmopathy. Endocr J, 2010, 57(10): 853-861

[19] HeY, MuK, LiuR, et al.. Comparison of two different regimens of intravenous methylprednisolone for patients with moderate to severe and active Graves’ ophthalmopathy: a prospective, randomized controlled trial. Endocr J, 2017, 64(2): 141-149

[20] YeX, BoX, HuX, et al.. Efficacy and safety of mycophenolate mofetil in patients with active moderate-to-severe Graves’ orbitopathy. Clin Endocrinol (Oxf), 2017, 86(2): 247-255

[21] ChenW, HuH, ChenHH, et al.. Utility of T2 mapping in the staging of thyroid-associated ophthalmopathy: efficiency of region of interest selection methods. Acta Radiol, 2020, 61(11): 1512-1519

[22] HouK, AiT, HuWK, et al.. Three dimensional orbital magnetic resonance T2-mapping in the evaluation of patients with Graves’ ophthalmopathy. J Huazhong Univ Sci Technolog Med Sci, 2017, 37(6): 938-942

[23] ZieglerSF. FOXP3: of mice and men. Annu Rev Immunol, 2006, 24: 209-226

[24] ArbelaezCA, GlatignyS, DuhenR, et al.. IL-7/IL-7 Receptor Signaling Differentially Affects Effector CD4+ T Cell Subsets Involved in Experimental Autoimmune Encephalomyelitis. J Immunol, 2015, 195(5): 1974-1983

[25] LiuWH, PutnamAL, ZhouXY, et al.. CD127 expression inversely correlates with FoxP3 and suppressive function of human CD4+ T reg cells. J Exp Med, 2006, 203(7): 1701-1711

[26] YuN, LiX, SongW, et al.. CD4(+)CD25 (+)CD127 (low/−) T cells: a more specific Treg population in human peripheral blood. Inflammation, 2012, 35(6): 1773-1780

[27] SeddikiN, Santner-NananB, MartinsonJ, et al.. Expression of interleukin (IL)-2 and IL-7 receptors discriminates between human regulatory and activated T cells. J Exp Med, 2006, 203(7): 1693-1700

[28] LinSC, ChenKH, LinCH, et al.. The quantitative analysis of peripheral blood FOXP3-expressing T cells in systemic lupus erythematosus and rheumatoid arthritis patients. Eur J Clin Invest, 2007, 37(12): 987-996

[29] KawashiriSY, KawakamiA, OkadaA, et al.. CD4+CD25(high)CD127(low/-) Treg cell frequency from peripheral blood correlates with disease activity in patients with rheumatoid arthritis. J Rheumatol, 2011, 38(12): 2517-2521

[30] MatsuzawaK, IzawaS, OkuraT, et al.. Implications of FoxP3-positive and -negative CD4(+) CD25(+) T cells in Graves’ ophthalmopathy. Endocr J, 2016, 63(8): 755-764

[31] GlickAB, WodzinskiA, FuP, et al.. Impairment of regulatory T-cell function in autoimmune thyroid disease. Thyroid, 2013, 23(7): 871-878

[32] MaoC, WangS, XiaoY, et al.. Impairment of Regulatory Capacity of CD4+CD25+ Regulatory T Cells Mediated by Dendritic Cell Polarization and Hyperthyroidism in Graves’ Disease. J Immunol, 2011, 186(8): 4734-4743

[33] SiomkajloM, MizeraL, SzymczakD, et al.. Effect of systemic steroid therapy in Graves’ orbitopathy on regulatory T cells and Th17/Treg ratio. J Endocrinol Invest, 2021, 44(11): 2475-2484

[34] StrehlC, EhlersL, GaberT, et al.. Glucocorticoids-All-Rounders Tackling the Versatile Players of the Immune System. Front Immunol, 2019, 10: 1744

[35] SbieraS, DexneitT, ReichardtSD, et al.. Influence of short-term glucocorticoid therapy on regulatory T cells in vivo. PLoS One, 2011, 6(9): e24345

[36] CariL, De RosaF, NocentiniG, et al.. Context-Dependent Effect of Glucocorticoids on the Proliferation, Differentiation, and Apoptosis of Regulatory T Cells: A Review of the Empirical Evidence and Clinical Applications. Int J Mol Sci, 2019, 20(5): 1142

[37] KikuchiJ, HashizumeM, KanekoY, et al.. Peripheral blood CD4(+)CD25(+)CD127(low) regulatory T cells are significantly increased by tocilizumab treatment in patients with rheumatoid arthritis: increase in regulatory T cells correlates with clinical response. Arthritis Res Ther, 2015, 17: 10

[38] CiccocioppoF, LanutiP, PierdomenicoL, et al.. The Characterization of Regulatory T-Cell Profiles in Alzheimer’s Disease and Multiple Sclerosis. Sci Rep, 2019, 9(1): 8788

[39] Quirant-SanchezB, Hervas-GarciaJV, Teniente-SerraA, et al.. Predicting therapeutic response to fingolimod treatment in multiple sclerosis patients. CNS Neurosci Ther, 2018, 24(12): 1175-1184

[40] MiyabeC, MiyabeY, StrleK, et al.. An expanded population of pathogenic regulatory T cells in giant cell arteritis is abrogated by IL-6 blockade therapy. Ann Rheum Dis, 2017, 76(5): 898-905