Graves’ disease ( synonyms: Basedow’s disease, Perry, Flajani , Graves ) – an autoimmune disease characterized by diffuse nym thyroid enlargement with considerable tion increase its gormonal Noah activity and leads to intoxication with thyroid hormone – hyperthyroidism.
Accurate data on the distribution of diffuse toxic goiter (DTZ) are not available. According to various authors, about 0.2% of the population suffers from this disease. Women get sick more often than men. This relation to represent approximate 5: 1, 10: 1. Children suffer from DTZ much less often than hypothyroidism. Distribution of DTZ around the world more uniform but than endemic goitre.
Etiology .
There are many theories and pref expansions occurrence of diffuse toxic goiter.
- Among them, an important place is given to hereditary konstitu tional predisposition to Thoroe can occur when nebla gopriyatnyh living conditions. These infections can be attributed, CCA cially angina, negative emo tion. Previously it was thought that this re crucial role played by hypersecretion of TSH. However, studies the last they have shown that the TSH blood levels may not always be high, normal. As of Latter-time primary role Chorus ik- long-acting thyroid stimulants.
- Currently, more than welcome and parcel is considered to be the hypothalamic-pituitary theory. According to this theory the cause vozniknove Nia and development of hyperthyroidism is the initial hypersecretion tireoliberina . This leads to thrust perstimulyatsii pituitary giperse Crezia TSH (thyroid stimulating hormone).
In terms gipersekre tion TSH produced no roofing to TSH “normal”, but also anomalous ny TSH, combined with increased secretion in some cases zkzoftalmicheskogo factor. Anomalies ny TSH immunologic al pects clearly different from normal Nogo TSH. In addition, it is more stable and its half-life Mr. vein 15 days, while the norm mal TTG 30-60 minutes. Thus, an abnormal TSH constant but stimulates thyroid function, you zyvaya gland hyperplasia. According Vyshen amount of thyroid 122 hormone inhibits blood vyrabot ku normal TSH, but gives no wish to set up the production of abnormal TSH, leading to disease progression.
If the normal amount of ti reoidnyh hormones manifests ana parabolic action, promoted Noah, – on the contrary, catabolic, Wuxi Lebanon breakdown of proteins, are mobilizing tion of fat depot, breakdown of glycogen. All this leads to dehydration, demineralization, myasthenia gravis and pohu Denmark. Designated value at given and autoimmune processes. A number of thyroid-stimulating antigens IgM , Ig’G , IgE , LATS, etc. are very often found in the blood of patients . But a correlative relationship between the number of immunoglobulins, the thyroid gland and the severity of thyrotoxicosis has not been established. Not only have not figured out yet whether immunoglobulins cause or a consequence of hyperthyroidism. One to many researchers in the etiopathogenesis of hyperthyroidism certain value at given LATS-protector, a factor that protects from LATS inter action with the antigen. It was found that the thyroid-stimulating immunoglo Bulin inhibit the action of TSH on the membrane thyrocytes themselves STI Muliro secretion of thyroid Mountains Mons.
Pathological anatomy.
The thyroid gland, as a rule, increases five or more times – at first diffusely, with a soft consistency, hardens over time, nodes form. Gistolo logically marked polymorphism of follicles. The follicle epithelium becomes cylindrical, sometimes multilayered. The accumulation of lymphocytes and the formation of lymphoid follicles are noted, the intralfollicular colloid becomes liquid, weakly stained with eosin. In what Nation in the gland grows connective tissue, often with hearth vy character. Thyrotoxic YaV Lenia maximally expressed at epithelial hyperplasia and thyroid at least lymphoid hyper plasia.
Clinical symptoms of Diffuse Toxic Goiter.
The disease may just Bevan sharply for a few weeks, even days, in other cases – the whole ma slowly over several months.
Most patients Ms luetsya on palpitations, restless, anxiety, and weight loss.
An objective The investigations dovanii from the beginning seen fussiness and haste of patients with dressing and undressing. Characterized thorns tahipsihiya , fast sensing acclimatizes. Employability preserves nyaetsya disproportionate to the severity of bolevaniya. On the thyroid gland is listened zhuzh zhanie – a symptom of Gutmann. Cha hundred notes subfebrilitet syndrome ( Locatelli ). Increased appetite that an agreed increased energy consumption. The thyroid gland in all patients, with few exceptions, diffuse or diffuse nodular An increase to 3-4 degrees. As a rule, all patients in depend ing on the gravity and duration of the disease lose weight from 5 to 40 kg and more, look older than their age. The skin, especially on the palms, wet, hyponychial on darling fingers act im- ed. On the palms, even in people over nyatyh heavy physical labor, no blisters. The skin on the face is smooth, without wrinkles. In about 40% of cases, especially in men, Eye symptoms of thyrotoxicosis are observed ( see details ):
- exophthalmos (effervescence),
- Krause symptom – increased eye gloss,
- Delrimple’s symptom – wide opening of the palpebral fissure (surprised look),
- Shtelvag symptom – a rare blink,
- Gref’s symptom – when lowering the eye down, the upper eyelid lags behind and the sclera strip is visible,
- Kocher symptom – moving the gaze from the bottom up, the lower eyelid lags behind and the sclera strip is also visible,
- Rosenbach symptom – tremor of the eyelids with closed eyes,
- Moebius symptom is a violation of the convergence of the eyeballs (the ability to fix different objects at close range), Ellinek’s symptom is eyelid pigmentation.
Ophthalmopathy , exophthalmos (beak-eyed eyes) are the result of autoimmune damage to extraocular oculomotor muscles, excessive synthesis of glucose aminoglycans and other connective tissue components in retrobulb.
Patients with Graves’ disease sometimes when bavlyayut weight ( “fat Basedow”). Cause of obesity at the same time remains camping is not quite clear. Apparently, this is an agreed simultaneous lesions eat food diencephalic centers. Graves’ disease with obesity, usually accompanied nied by exophthalmos.
In some patients the differential fuznaya skin pigmentation as in gipokortitsizm . It happens, and lo Calne especially on the eyelids (Symp that Jellinek). In some instances, s, conversely, there is depigmen ting – vitiligo. It is assumed that the mechanism of pigmentary disorders exchange and darkening of the skin related to the metabolism of tyrosine, which is the precursor P & G ment with copious secretion of TSH or hypocorticoidism (Schmid syndrome w). In later stages of DTZ at approximately 3% of the marked spot pretibial Myxedema. Muscular system with Vreme it atrophies as an effect of markedly Vie enhanced catabolism and obezvozhizaniya , its strength is reduced by the sword of myasthenia gravis (thyrotoxic myopathy).
In light of CCA -singular change is not observed. From other glands of the endocrine system, mild hypocorticism with a decrease in libido is noted . Of the internal organs, the heart suffers the most. While increasing INDICATES systolic and especially E nutny volume reaching 6-10 lit. moat per minute at rest at a rate of 2-3 liters.
Overloading of the heart with leads to hypertrophy and dilatation. As an effect of Wier originated ventricular dilatation is the relative lack atriozentrikulyarnyh valves on what and auscultated systolic murmur at the apex and other precardiac points. Time to get the heart zheniya correlates with tyazhe Stu, disease duration and age of the patients. If soche Tania hypertensive heart failure takes a progressive course. If the pain is nye not get time respectively stvuyuschego treatment, there ext rasistoly, often stomach and then atrial fibrillation. Sco growth blood flow increases and magnesian time is 6-10 seconds. (norm 12-16 seconds). Ha acteristic constant tachycardia – 100-140 bpm. in minutes The ECG – sinus sovaya tachycardia, direction of electron and an insulating axis is usually the norm -formal. There is a decrease wills tazha teeth P and T. The inversion of the T wave and displacement of the ST segment are more a reflection of thyrotoxic infarction than boxe -stationary failure. It should be noted that patients with DTZ usually do not suffer from coronary atherosclerosis. In severe cases, particularly in older, soon fuss repents atrial fibrillation after Corollary myocardiodystrophy.
The liver is affected in particular cha severe forms. In this case, in addition to the CE discord hepatitis and jaundice may occur, in severe forms of bo existing illness – diarrhea and abdominal pain. Ed to may come thyrotoxic crisis, what about the often observed after subtotal thyroidectomy . Production of adrenal steroid hormones and their consumption is increasing dramatically, which VPO investigation leads to a relative Noah adrenal insufficiency STI.
Severe Graves’ disease in children hold your Vaeth growth, while moderate hyperthyroidism, on the contrary, even incentives liruet it. In old age often found toxic hell noma that develops against the backdrop of susche stvuyuschego goiter and, as a rule, about the tech heavy, with exophthalmos.
Laboratory reliable mec volume is the determination of blood radioimmunoassay method again separately T 4 and T 3 , the thyroid uptake of I 131 . Normally, of the administered dose of 1 mk I 131 administered in 2 hours, 13% is absorbed after 2 hours, 18% after 4 hours, and 30% after 24 hours. Thyrotoxicosis these numbers dramatically by Witzlaus and reach respectively but 45% to 50% and 60% .. In this case, it should be noted that a slight increase observed in neurotic patients.
Diagnostically important is the visual and graphic examination of hand tremor . There you enhanced calcium division, Blood picture: often neutropenia with relative lymphocytosis.
Classification of Diffuse Toxic Goiter.
According to the severity of the Techa Nia DTZ is divided into 3 degrees.
- I degree – without complications,
- Grade II with accompanied by a significant slimming Niemi, complications of the heart and other organs,
- III ste stump expressed sharp weight loss, expressed hydrochloric heart dilation with the presence of atrial fibrillation.
- There is asymptomatic ( apateticheskaya ) odds ma DTZ, when all the symptoms of the disease manifest very poor but. This form is more often observed in the elderly.
TREATMENT OF Diffuse Toxic Goiter.
- The main drug for the treatment of DTZ is Merkazolil , which has a powerful thyrostatic effect. C sa direct start assigned Mercazolilum 0,005 g (Table 8. Per day). In cases where there is incipient eq zoftalma large doses merkazolila not recommended since filing Leniye synthesis of thyroid hormones may lead to increased secre TTG tion and exophthalmic factor torus. In such cases, one must be satisfied with the appointment of 5-6 tablets. in a day. Mercazolilum assigned to floor Nogo recovery of the patient. After that, a few months desig chaetsya 0,005 1 g once a day, Th cut a day or 1 every 3 days during of Bezhanov relapse.
- To suppress TSH secretion, triiodothyronine hydrochloride is prescribed .
- At the same time, to strictly achieve the effect in the initial period of treatment, ie. E. Per stems of 10-12 days, shows and prednisolone 20-25 mg per day, especially in cases where there is a slope NOSTA to the development of ocular sympto mov and the phenomenon of hypocorticism is noted .
- At the same time, Iodine Preparations are prescribed . It is better to take in the form of a solution of Lugol , 5-10 drops 2 times a day for 20-30 days. After 20-30 days of le cheniya it is recommended to re ryv for 10 days due to the fact that chronic administration of iodine preparations to it develops refractoriness . If necessary, a course le cheniya iodine repeated 2-3 times and more. Instead solution Lugol can assign diiodotyrosine 0.05 g initially 2-3 times a day, then decreasing, adjusted to maintenance doses (0.05-0.1 g per day. Influenced iodine Decrease the creases vascularization of the prostate that is very advantageous in preoperative patients. The gland then becomes soft, the ability creases in volume.
- Successfully used Reserpine 0.25 mg 1-3 times a day, Elenium 0.005 g 1-3 times a day, Seduxen ( Relanium ) 0.005 g 1-2 times a day. In severe tachycardia recommends etsya obzidan ( Inderal ) or Dru Gia adrenoblokiruyuschee prepa Rata. Due to the action of these le a medicament slows heart rate, improves sleep, reduces hand tremor. A very effective so as digitalis preparations, in particular NOSTA Digoxin , 0.25 mg 3 times a day for 1 month -1.5.
- Very effective Radioiodine Therapy (RAYT). Radio active iodine (1 131 ) assigned to a se mi 4-8 Curie at The necessity bridge – again after 8-10 days, is injected into the body in the form of gelatin capsules perorally (sometimes I-131 grout).
- If the patient is very depleted, re Komenda injection of insulin in small doses, 8-12 units in the morning before breakfast, anabolic prep you , such as methandrostenolone , at 0,001-0,002 g per day.
With the correct treatment of DTZ in the vast majority of cases, a significant result can be achieved. After improving the condition of patients, doctors often cancel any treatment, why after a while a relapse of DTZ occurs.
Therefore, after completion of successful treatment and achievement of the euthyroid state of patients with thyrotoxicosis (within 1-2 years), it should be periodically treated with antithyroid drugs, mainly Merkazolil and iodine preparations . Grace complete cure can be achieved with ovarian cancer