Download 05. Grave`s disease. Hyper-and hypoparathyroidism

Graves’ disease
Department of Internal Medicine № 2
Hyperthyroidism (thyrotoxicosis)
Toxic diffuse goiter.
Grave’s disease - is the condition resulting from the
effect of excessive amounts of thyroid hormones on
body tissues.
Thyrotoxicosis is a main syndrome
Enlargment of thyroid gland
Etiology and predisposing factors
• Defect of T
lymphocytes
suppressors
Genetic predisposition,
conferred by genes close
proximity to the major
histocompatibility complex
(HLA DR3, B8)
Autoimmune disorders, which
can be provoked by:
• insolation;
• stress;
• acute infections;
• hormone disbalance
(pregnancy and others)
Pathogenesis
Insufficiency of T suppressors
Increasing function of B lymphocyte
Toxic influence of lymfocytes
Secretion of thyroid – stimulating
immunoglobulin (TSI)
The thyroid
Secretion of T4, T3
Thyrotoxicosis
Pathologic changes in different organs and systems
Clinical manifestations
The clinical presentation may be dramatic or subtle.
Dysfunction of
- the nervous system
- the cardiovascular system
- the gastrointestinal system
- the pulmonary system
- the endocrine organs
- katabolic syndrome
- ectodermal changes
Degrees of thyroid gland
enlargement
(WHO, 1986, 1994)
0-we can’t see or palpate thyroid gland;
IA- we can palpate but can’t see;
IBthyroid gland can be seen when patient
put head back;
II –thyroid gland can be seen in normal
position of the head.
III – thyroid gland can be seen from the
distance of 5 meters or more
0 –goiter is
absent
1- we
can
palpate but
can’t see
2 – thyroid gland
can be
palpated and
seen
Degrees of severity
Mild
Moderate
Severe
Heart beat under 100 100 - 120
less than 10 – 20 %
Weight
10 %
loss
over 120
rare
Changes
from
organs and
systems
- ophthalmopathy
- signs of heart
failure І – ІІ А
-ophthalmopathy
-dystrophic
changes from
inner organs
-thyroid storm
decreased
patients cant
work
Work
capacity
normal
more than 20 %
Treatment
I.
1. Antithyroid drugs.
2. Drugs to ameliorate thyroid hormone
effects .
II. 131I - therapy
III. Surgery.
Thyroid storm
•
•
•
•
•
•
•
Thyroid storm is a life- threatening emergency
requiring prompt and specific treatment.
In is characterized by abrupt onset of more severe
symptoms of thyrotoxicosis, with some exacerbated
symptoms and signs atypical of uncomplicated Graves
disease:
fever;
marked weakness and muscle wasting;
extreme restlessness with wide emotional swings;
confusion;
psychosis or even coma;
hepatomegaly with mild jaundice;
the patient may present with cardiovascular collapse
or shock.
Thyroid storm results from:- untreated or
•
•
•
•
•
•
•
•
•
•
inadequately treated thyrotoxicosis
It may be precipitated by:
infection;
trauma
surgery;
embolism;
diabetic acidosis;
fright;
toxemia of pregnancy;
labor;
discontinuance of antithyroid medication;
radiation thyroiditis.
Treatment of thyroid storm
- Iodine-30 drops Lugol’s solution/day orally in 30g 4 divided
doses; or 1 to 2 gr. sodium iodide slowly by i/v drip
- Propylthiouracil (merkazolil) - 900 to 1200 mg/day orally or by
gastric tube.
- Propranolol - 160mg/day orally in 4 divided doses; or 1mg
slowly i/v g 4h under careful monitoring; a rate of administration
should not exceed 1mg/min; a repeat 1mg dose may be given
after 2 min i/v glucose solutions .
- Correction of dehydration and electrolyte imbalance cooling
blanket for hypertermia.
- Digitalis if necessary.
- Treatment of underlying disease such as infection.
- Corticosteroids-100 to 300mg hydrocortisone/day i/v.
- Iodine in pharmacological doses inhibits the release of T3 to T4
within hours and inhibits the organification of iodine, a transitory
effect lasting from a few days to a week (”escape
phenomenon”.)