Download קליניקה וסימנים אופייניים לשים לב בטבלה: הכל מסודר לפי סדר שכיחות הטבלה

‫**‬
‫‪NORMAL VALUES:‬‬
‫‪TSH= 0.5-4.7 T3=60-181 T4=4.5-10.9 fT4=0.8-2.7‬‬
‫** הכרטיסיה דנה בהיפרטירואידיזם מרכזי בו ‪ T3,FT4‬מוגברים ו ‪ TSH‬יתכן מוגבר או בטווח הנורמה (אך לא נמוך)‬
‫קליניקה וסימנים אופייניים‬
:‫לשים לב בטבלה‬
‫ הכל מסודר לפי סדר שכיחות‬.1
.‫ הטבלה הנ"ל מתארת מאפיינים דומים של טירוטוקסיקוזיס מסיבות שונות‬.2
:‫לגראבס יש מאפיינים ייחודיים‬
*** Graves' ophthalmopathy (Fig. 335-7A ). This condition is also called thyroidassociated ophthalmopathy, as it occurs in the absence of Graves' disease in 10% of
patients. Most of these individuals have autoimmune hypothyroidism or thyroid
antibodies.
Many scoring systems have been used to gauge the extent and activity of the orbital
changes in Graves' disease. The "NO SPECS" scheme is an acronym derived from the
following eye changes:
0 = No signs or symptoms
1 = Only signs (lid retraction or lag), no symptoms
2 = Soft tissue involvement (periorbital edema)
3 = Proptosis (>22 mm)
4 = Extraocular muscle involvement (diplopia)
5 = Corneal involvement
6 = Sight loss
Although useful as a mnemonic, the NO SPECS scheme is inadequate to describe the eye
disease fully, and patients do not necessarily progress from one class to another.
*** Thyroid dermopathy occurs in <5% of patients with Graves' disease (Fig. 335-7B ),
almost always in the presence of moderate or severe ophthalmopathy. Although most
frequent over the anterior and lateral aspects of the lower leg (hence the term pretibial
myxedema), skin changes can occur at other sites, particularly after trauma. The typical
lesion is a noninflamed, indurated plaque with a deep pink or purple color and an
"orange-skin" appearance. Nodular involvement can occur, and the condition can rarely
extend over the whole lower leg and foot, mimicking elephantiasis.
Thyroid acropachy refers to a form of clubbing found in <1% of patients with Graves'
disease (Fig. 335-7C ). It is so strongly associated with thyroid dermopathy that an
alternative cause of clubbing should be sought in a Graves' patient without coincident
skin and orbital involvement.
Features of Graves' disease. A. Ophthalmopathy in Graves' disease; lid retraction,
periorbital edema, conjunctival injection, and proptosis are marked. B. Thyroid
dermopathy over the lateral aspects of the shins. C. Thyroid acropachy.
Evaluation of thyrotoxicosis. aDiffuse goiter, positive TPO antibodies, ophthalmopathy,
dermopathy; bcan be confirmed by radionuclide scan. TSH, thyroid-stimulating hormone.
TSH-secreting pituitary adenoma is a rare cause of thyrotoxicosis. It can be
identified by the presence of an inappropriately normal or increased TSH level in a
patient with hyperthyroidism, diffuse goiter, and elevated T4 and T3 levels (Chap. 333).
Elevated levels of the subunit of TSH, released by the TSH-secreting adenoma, support
this diagnosis, which can be confirmed by demonstrating the pituitary tumor on MRI or
CT scan. A combination of transsphenoidal surgery, sella irradiation, and octreotide may
be required to normalize TSH, as many of these tumors are large and locally invasive at
the time of diagnosis. Radioiodine or antithyroid drugs can be used to control
thyrotoxicosis.
Pituitary adenoma. Coronal T1-weighted postcontrast MR image shows a
homogeneously enhancing mass (arrowheads) in the sella turcica and suprasellar region
compatible with a pituitary adenoma; the small arrows outline the carotid arteries.