Hyperthyroidism

Introduction to hyperthyroidism Hyperthyroidism (hyperthyroidism) is a group of common endocrine diseases caused by a variety of causes of hyperthyroidism and/or increased thyroid hormone levels in the blood circulation. It is characterized by swelling, exophthalmia, neurological and cardiovascular system dysfunction. Pathologically, the thyroid gland can be diffuse, nodular or mixed. basic knowledge The proportion of the disease: 0.001% (the ratio of women to men is about 4-6:1) Susceptible people: good for young men and women Mode of infection: non-infectious Complications: hyperthyroidism

Cause of hyperthyroidism

In recent years, studies have found that the incidence of Graves disease is mainly related to autoimmunity. The hyperthyroidism caused by other lesions has its own characteristics or remains unclear. It is described as follows:

Immunity factor (30%):

In 1956, Adams et al found that long-acting thyroid stimulating hormone (LATS) acts similarly to TSH. It is an immunoglobulin (IgG) produced by B lymphocytes, an autoantibody against the thyroid gland, and can be associated with thyroid subcellular cells. In combination with ingredients, excitatory thyroid follicles secrete thyroid hormone and cause hyperthyroidism. 60% to 90% of patients with hyperthyroidism have increased LATS. Later, LATS-P substance is also found to be an IgG. It is only excited by human thyroid tissue, also known as human thyroid gland. Stimulating immunoglobulin (HTSI), more than 90% of patients with hyperthyroidism are positive.

1. Direct evidence of the immune mechanism of hyperthyroidism is:

(1) A variety of antibodies against thyroid cell components, such as thyroid stimulating antibodies (TISI) against TSH receptors, or TSH receptor antibodies (TRAb), which are capable of interacting with TSH receptors or The combination of related tissues further activates cAMP and strengthens thyroid function. This antibody can pass through the placenta tissue, causing neonatal hyperthyroidism, or incomplete treatment after hyperthyroidism, and the antibody continues to be positive, leading to recurrence of hyperthyroidism.

(2) In terms of cellular immunity, it was confirmed that these anti-systems were produced by B lymphocytes, and there were sensitized T lymphocytes against thyroid antigen in the blood of patients with hyperthyroidism. Lymphocytes were activated by phytohemagglutinin (PHA) during hyperthyroidism. LATS is produced. PHA stimulates T lymphocytes and then stimulates B lymphocytes to produce immunoglobulins that stimulate thyroid gland, such as TSI, which cause hyperthyroidism. Organ-specific autoimmune diseases are caused by inhibitory T lymphocytes (Ts). Functional defects cause immune dysregulation, so the immune response is a complex result involving the interaction of T and B lymphocytes and phagocytic cells. It is thought to be mainly related to the reduction of inhibitory T lymphocyte function related to gene defects. Ts function deficiency can lead to T cell sensitization, which causes B cells to produce TRAb and cause hyperthyroidism.

2. The indirect evidence is:

(1) A large amount of lymphocytes and plasma cells infiltrate after the thyroid gland and the eyeball;

(2) The number of lymphocytes in the peripheral blood circulation increases, which may be accompanied by lymph nodes, and the reticuloendothelial tissue of the liver and spleen;

(3) Other autoimmune diseases may occur simultaneously or sequentially with the patient and his relatives;

(4) Blood anti-thyroid antibodies, TRAb and anti-parietal cell antibodies and anti-myocardial antibodies in patients and their relatives;

(5) There are IgG, IgA and IgM in the thyroid and blood.

The cause of the initiation of Graves' disease is currently thought to be due to hereditary defects in the immune monitoring and regulatory functions of patients with Ts cells. When there are factors such as foreign trauma, or when there are infectious factors, the immune system is destroyed. Loss of control, T lymphocyte proliferation, functional variability, secretion of a large number of TSI autoantibodies under the action of Ts cells, causing disease, and more traumatic and family history, as a predisposing factor, found in recent years, white Human hyperthyroidism HLA-B8 is twice as high as normal people, Asian Japanese HLA-BW35 is increased, foreign Chinese HIA-BW46 positive susceptibility is increased, B13, B40 is more obvious, these have attracted attention.

Genetic factors (20%):

Clinically, it is not uncommon to find familial Graves disease. The same twins have Graves disease up to 30% to 60%, and ectopic eggs are only 3% to 9%. Family history investigation can also affect other species except for hyperthyroidism. Thyroid diseases such as hypothyroidism, or TSI positive in family members, suggest that Graves disease has a family genetic predisposition, which may be autosomal recessive, autosomal dominant, or polygenic.

Other causes of illness (10%):

(1) hyperactive nodular goiter or adenoma. In the past, it was considered that this disease was not an autoimmune disease. Because no blood was detected in IgG, TSI, IATS, etc., in 1988, a single nodule was reported in China. Serum thyroglobulin antibody and microsomal antibody were detected, the positive rate was 16.9% (62/383), and the multiple nodule positive rate was 54.7% (104/190). The hyperplastic thyroid tissue in these nodules was not regulated by TSI. It has become a hyperactive or hyperactive thyroid nodule or adenoma. Currently, the incidence of thyroid adenoma and cancer is also caused by tumor genes.

(2) The secretion of TSH from pituitary tumors increases, causing pituitary hyperthyroidism, such as hyperthyroidism associated with TSH secretory tumor or acromegaly.

(3) subacute thyroiditis, chronic lymphocytic thyroiditis, painless thyroiditis, etc. can be associated with hyperthyroidism.

(4) hyperthyroidism caused by hyperthyroidism, known as iodine, such as thyroid gland patients with excessive iodine, taking thyroid tablets or levothyroxine sodium (L-T4) too much can cause hyperthyroidism, a small number of patients taking amine iodine Ketone drugs can also cause hyperthyroidism.

(5) ectopic endocrine tumors can cause hyperthyroidism, such as ovarian tumors, choriocarcinoma, digestive system tumors, respiratory tumors and breast cancer and other secretory thyroid stimulating hormone can cause clinical hyperthyroidism.

(6) Albright syndrome is clinically characterized by multiple fibrous dysplasia, skin pigmentation, elevated blood AKP, and may be associated with hyperthyroidism.

(7) Familial hyperglobulinemia (TBG) can cause hyperthyroidism, which may be due to familial genetic defects or medication.

Pathogenesis

The thyroid gland of Graves disease is diffusely enlarged, symmetrical, asymmetric, with a complete capsule, smooth surface, abundant blood flow, follicular and follicular epithelial cell proliferation, from cuboid to columnar, between Lymphocytes and plasma cells infiltrate, liver, spleen, thymus and lymph nodes and other hyperplasia, lymphocytes in peripheral blood increase, reflecting the pathological basis of autoimmunity, electron microscopic thyroid follicular epithelial cells increased microvilli, increased glial droplets Golgi apparatus hypertrophy, rough endoplasmic reticulum and mitochondria increased, lysosomes increased, thyroid is functionally active.

At the time of hyperthyroidism, the body is affected by multiple systemic organs, body striated muscle steatosis, edema, horizontal stripes disappear, vacuolar degeneration, degeneration of the nucleus, myocardial degeneration, necrosis of myocytes, mononuclear cell infiltration, mucopolysaccharide deposition, eyeball Prominent, extraocular muscle edema hypertrophy, myocyte fat change, lymphocyte infiltration, mucopolysaccharide deposition, optic nerve edema or atrophy, skin can be symmetrically thickened, subcutaneous edema, collagen fiber swelling, lysis and separation, extracellular fluid Mucopolysaccharide staining is enhanced, and there are mononuclear cells, which occur in the anterior and lower limbs of the tibia. The liver is swollen, the liver cells are degenerative, the glycogen is reduced, the endocrine glands are affected, and the gonads and adrenal glands can occur in critically ill patients. Decreased function, osteoporosis and bone decalcification are common, osteoclast activity is enhanced, bone resorption is more than bone formation, and bone deformity and pathological fracture can occur in severe cases. Young adults are rare, and older women are more common.

Hyperthyroidism prevention

1. There should be restrictions on the date of iodine supplementation in inland areas (iodine-deficient areas), and thyroid tablets should also be time-limited;

2, census physical health, should be measured thyroid B ultrasound or thyroid function to early detection of hyperthyroidism patients, passive detection of hyperthyroidism patients, the condition is often delayed for 2 to 3 years.

Hyperthyroidism Complications, hyperthyroidism

1, hyperthyroid heart disease

16 to 73 years old can be ill, the incidence rate of 13.4% to 21.8% of patients with hyperthyroidism, often occurs 2 to 3 years after hyperthyroidism, in addition to the typical clinical manifestations of hyperthyroidism, the electrocardiogram often has sinus tachycardia, atrial fibrillation Tremor, atrial flutter, atrioventricular block, ventricular premature contraction, myocardial injury and cardiac hypertrophy, etc., the heart enlargement can be aortic valve type, or left and right heart enlargement, heart disease can be improved after the cure of hyperthyroidism, The disease should often be differentiated from myocarditis, coronary heart disease, rheumatic heart disease and other heart enlargement diseases.

2, hyperthyroidism periodic paralysis

This disease occurs mostly in male young adults, often mixed with hyperthyroid myopathy, hyperthyroidism with normal potassium, abnormal electromyogram, and periodic paralysis of hyperthyroidism:

(1) Blood potassium <3.5mmol/L, abnormal potassium metabolism;

(2) Abnormal potassium distribution: elevated blood sugar can cause potassium to move from the outside to the inside of the cell;

(3) The excitability of the central nervous system is enhanced, and the vagus nerve promotes the release of insulin to promote further abnormalities in potassium distribution;

(4) Immune factors can cause IATS, LATS-P, T3 and T4 levels to increase, and thyroid hormones promote potassium levels;

(5) The high adrenergic state of hyperthyroidism can promote the decrease of potassium level and the occurrence of hyperthyroidism periodic paralysis. This type should be related to Bartters syndrome, familial periodic paralysis, hypomagnesemia, hyperaldosteronism. , myasthenia gravis and drug-induced hypokalemia.

3, hyperthyroidism

The incidence accounts for 1% to 2% of hyperthyroidism. The elderly are more common, often associated with infection, trauma, surgery, childbirth, overwork, sudden withdrawal, drug reaction and other complications, resulting in hyperthyroidism, sympathetic activity. The function is strengthened and the crisis is caused. In the early stage of the crisis, the fever can reach above 39 °C, the pulse rate is 120-160 beats/min, restlessness, loss of appetite, nausea, vomiting, diarrhea, mental paralysis, sweating, lethargy, development. To half coma and coma, coma patients indicate that there is a crisis, very dangerous, elevated white blood cells, abnormal liver function, GPT, GOT, bilirubin, etc. can be elevated, may have dehydration, hypotension, electrolyte imbalance, acidosis , heart failure and pulmonary edema, serum T3, T4, FT3, FT4 can be elevated, the mortality rate is high, must be rescued locally.

Hyperthyroidism: When the condition of hyperthyroidism is uncontrolled, due to infection, fatigue, mental stress, inadequate preoperative preparation, and radiation factors such as radioactive 131 iodine treatment, the condition is intensified, mainly showing an increase in body temperature and a rapid increase in pulse rate. Irritable, nausea, vomiting, diarrhea, sweating, even consciousness, coma, life-threatening conditions, high mortality, with the improvement of medical standards, it has been rare in recent years, should be based on prevention, once found, should be active Treatment, treatment principle is to inhibit the production and secretion of thyroid hormone, reduce the response of brain and surrounding tissues to thyroid hormone and general symptomatic treatment. It is reported in the literature that some people take more active measures to remove blood thyroid hormones from the body, such as transfusion therapy and peritoneum. Dialysis.

Hyperthyroidism: Exophthalmos can occur simultaneously with hyperthyroidism. It can also occur before or after hyperthyroidism. The severity of eye disease is not parallel with hyperthyroidism. Some patients have no obvious hyperthyroidism, but eye disease is very serious. It can be divided into benign according to the severity of the disease. Exophthalmos and infiltrative exophthalmos, the former manifested as widening of the eyelids, contraction of the eyelids, gaze, reduction of blinking and mild exophthalmos; the latter may show excessive tearing, fear of light, ash slag in the eye, conjunctival edema and congestion In the orbit, tissue edema, limited eye movement, double vision, visual field defect, and even loss of vision, blindness, benign exophthalmos are more common, generally bilateral prominence, sometimes visible monocular protrusion; invasive exophthalmos are rare, For benign exophthalmos, no special treatment is needed, only hyperthyroidism can be treated. Invasive patients can take thyroid tablets while treating with antithyroid drugs. The disease is severe with adrenal cortex hormones, and a few need eye radiation therapy or eye. Surgical treatment, no matter which treatment is used, eye treatment during the treatment period (lifting the bed when sleeping, wearing sunglasses to avoid light and dust when going out, eye drops, eye cream or eye mask) It is very important. Hyperthyroidism is more common in chronic myopathy with slower onset. Patients often complain that it is difficult to stand up and go upstairs. In addition, myopathy is more special with periodic paralysis and myasthenia gravis. Rarely, mainly for the treatment of hyperthyroidism, in addition to symptomatic treatment, there is no special treatment.

Hyperthyroidism Symptoms Common symptoms Goiter, goiter, iodine, acne, eye disease, metabolism, thyroid hormone, high thyroid hormone, especially easy to starve thyroid peroxide...

The clinical manifestations of hyperthyroidism include thyroid enlargement, irritability, irritability, insomnia, tremors in both hands, fear of heat, excessive sweating, damp skin, excessive appetite but weight loss, weight loss, palpitations, and rapid pulse rate (pulse rate often in every minute) More than 100 times, rest and sleep are still fast), increased pulse pressure (mainly due to increased systolic blood pressure), endocrine disorders (such as menstrual disorders) and weakness, fatigue, and proximal limb muscle atrophy. Among them, the increase of pulse rate and increase of pulse pressure are particularly important, and can often be used as an important indicator to judge the degree of disease and the therapeutic effect.

1, clinical symptoms

Hyperthyroidism can occur at any age, most of the ages are 20 to 40 years old, and the incidence of women is higher than that of men, about 4:1, but in endemic goiter areas, women are slightly more than men, about 4:3. Young women often have puberty hyperthyroidism, and the symptoms are mild. Some people are self-healing after puberty without treatment.

Older patients are more likely to see "occult" or "indifferent" hyperthyroidism than younger ones. Their neurological and emotional symptoms are mild, and the incidence of exophthalmos is also less. When hyperthyroidism is complicated, the clinical manifestations are variable, 20 to 40 years old. The incidence of young and middle-aged people is more common, but in recent years, the number of elderly hyperthyroidism is increasing, the onset is slow, and there are many history of trauma and family history. The course of disease is prolonged after the onset, several years of unhealed, high recurrence rate, and various complications can occur.

(1) Energy metabolism and abnormal metabolism of sugar, protein and fat: basal metabolic rate (BMR) increased during hyperthyroidism, can be annoying heat, sweating, weight loss, low work efficiency, muscle wasting, fatigue, fatigue, negative balance of protein metabolism Cholesterol declines or normal, subcutaneous fat disappears, fat metabolism accelerates, hepatic glycogen and muscle glycogen are decomposed, glycogen is increased, blood sugar can be increased or postprandial hyperglycemia occurs, and abnormal glucose metabolism can occur in diabetes. .

(2) water and salt metabolism and vitamin metabolism disorders: thyroid hormone can promote diuretic, potassium and magnesium, so hyperthyroidism is prone to hypokalemic periodic paralysis and hypomagnesemia, calcium and phosphorus run faster, often high urinary calcium With high urinary phosphorus and high urinary magnesium; for a long time, bone decalcification and osteoporosis can occur, when there is calcium deficiency after the occurrence of hypocalcemia, a small number of patients can develop secondary hyperparathyroidism, Due to poor absorption of hyperthyroidism, rapid metabolism and high consumption, vitamin B1, C, D and other vitamin deficiency and trace element deficiency can occur.

(3) Abnormal symptoms of skin muscle metabolism: negative balance of protein metabolism, negative balance of creatine, balance of negative nitrogen, decrease of ATP, decrease of creatine phosphate, prone to hyperthyroid myopathy, ocular muscle weakness, myasthenia gravis, or frequent Soft palate, mucous edema in the skin, more common in the eyelids and tibia, nails become soft or deformed and infected.

(4) Cardiovascular symptoms: thyroid hormone excites myocardial sympathetic nerve, enhances catecholamine action, tachycardia, arrhythmia, heart sound enhancement, pulse pressure increase, even heart enlargement, apical systolic murmur, elderly people prone to atrial Fibrillation, angina pectoris and even hyperthyroidism occur simultaneously with coronary heart disease, leading to heart failure.

(5) mental and nervous system symptoms: thyroid hormone can excite neuromuscular, prone to mental stress, irritability, agitation, insomnia, dizziness, care, irritability, multi-word, hand shake, hyperreflexia, hyperthyroidism can occur in severe cases Mental illness and autonomic dysfunction.

(6) Digestive system symptoms: thyroid hormone can increase bowel movements, hunger, appetite, increased stool frequency, indigestion diarrhea, nutrition and malabsorption, severe hypoproteinemia and ascites, and cachexia Bedridden, more common in the elderly.

(7) Endocrine and reproductive system symptoms: Endocrine system function may be disordered during hyperthyroidism, the most common is gland function, female amenorrhea and irregular menstruation, male impotence, but female pregnancy is not affected, care should be taken to prevent hyperthyroidism during childbirth Crisis and heart failure.

(8) Goiter: generally symmetrical, a small part of asymmetrical enlargement, divided by I °, II °, III °, most diffuse enlargement, often vascular murmurs and tremors, thyroid also Increase, or cystic thyroid, nodular enlargement, but the symptoms of hyperthyroidism are not reduced.

(9) Exophthalmos: The eyeball protrudes beyond 16mm as a prominent eye. Generally, there are benign exophthalmos and malignant exophthalmos (invasive exophthalmos). The former is more common. In the past, some people thought that the exophthalmary system was caused by pituitary secretion. Therefore, at present, the eye is caused by autoimmune factors, namely:

1 thyroglobulin and anti-thyroglobulin complex deposited on the ocular muscle cell membrane caused by edema and lymphocyte infiltration, extraocular muscle hypertrophy, resulting in exophthalmos and extra-muscular muscle paralysis;

2 After the ball, fat and connective tissue cells have an immune response. In severe cases, the upper and lower iliac crests can not be closed, the eyeball regulation is poor, the contusion reflex is dysregulated, the sympathetic nerve activity is hyperthyroidism, the eyelid is retracted, the eye crack is widened and gaze, and the intraocular pressure is malignant. Increased, can cause corneal ulcers, perforation, conjunctival congestion, edema and even blindness.

(10) Localized mucinous edema: Symmetrical invasive skin lesions occur in front of the tibia. They can also occur in the fingers, palmar back and ankle joints. The skin is thickened and toughened, and brownish red varies in size. Plaque skin nodules, uneven, and the area gradually expands and merges, resembling a leather leg. This patient is positive for LATS, LATS-P, TGA, and TMA.

(11) Apathetic hyperthyroidism: contrary to the typical typical hyperthyroidism symptoms, the mood is indifferent and not easy to be excited. The characteristics are:

1 older women than men;

2 daze, lethargy, depression;

3 thin, weak, face old and old;

4 dry skin, rough and less sweat;

5 eyelid edema drooping, but obvious eye is less common;

6 thyroid nodules or adenoma or cystadenomatous changes;

7 muscle atrophy, thin and multi-cachexia state;

8 arrhythmia, atrial fibrillation or sinus arrhythmia, general heart rate 90 ~ 120 times / min, with heart enlargement, insufficient blood supply or chronic heart failure;

9 The condition is heavier and the performance is atypical. It is easy to be misdiagnosed and cannot be properly treated. A hyperthyroid crisis can occur.

More than 10 cases of anemia, stomach disease, high blood pressure, high blood lipids, hyperviscosity and immune dysfunction.

(12) T3 type hyperthyroidism: In 1957, this type of hyperthyroidism refers to clinical manifestations of hyperthyroidism, while serum T4, FT4, TSH, 131I, PBI is normal, only T3, FT3 is elevated, more common in the onset of hyperthyroidism, recurrence Type hyperthyroidism, hyperthyroidism in the area of thyroid and treatment, can also be seen in diffuse hyperthyroidism, nodular hyperthyroidism or thyroid adenoma hyperthyroidism, T3 type hyperthyroidism is not inhibited by exogenous T3.

(13) T4 type hyperthyroidism: clinical manifestations of hyperthyroidism, while serum T3, FT3, TSH, PBI and 131I uptake, T4, FT4 increased, more common in Graves disease and nodular hyperthyroidism, general poor nutrition, useful drug history After T2 loading, the T4 synthesis increased, or the surrounding tissue had T4 deiodination disorder, which reduced T3 and increased rT3.

(14) Hyperthyroidism with abnormal T4, T3 and TBG: Graves disease may be associated with elevated TBG, mostly familial or genetically related, due to increased TBG synthesis or slow degradation, and increased TBG may also be related to medication, such as Perphenazine, estrogen and drug use, etc., certain diseases such as myeloma, infectious hepatitis, connective tissue disease and porphyria can increase TBG, T3, T4, T3/T4 increase its TBG value Increased or decreased, the thyroid hormone spectrum changes, T3 hyperthyroidism accounts for about 12%, T4 hyperthyroidism accounts for about 3.5%, and typical hyperthyroidism accounts for 84.5%, TBG deficiency is mostly congenital familial low TBG. Low TBG may also be caused by infection, surgical stress, nephrotic syndrome, androgen, glucocorticoids and phenytoin.

(15) familial hyperthyroidism with hyperthyroidism: family members have more than 2 episodes, can be peers or upper and lower generations, more family hereditary, but also due to environmental factors or immune factors, and its thyroid function is more For hyperthyroidism, it can also be normal.

(16) recurrent hyperthyroidism: clinically seen hyperthyroidism, the general course of treatment is 2 to 3 years, most can be cured, and a small number of patients can be relapsing, that is, recurrence in a few years, the longest course of disease is nearly 30 years, this type Patients are more reluctant to undergo surgery and 131I radiotherapy, but related to the patient's own medication history, that is, treatment for half a year to 1 year to stop the drug, re-diagnosis.

(17) hyperthyroidism: menstrual disorders or amenorrhea during hyperthyroidism, but pregnancy, pregnancy can aggravate hyperthyroidism, so it is unfavorable for both mother and baby, so the condition is moderately severe hyperthyroidism should try to avoid pregnancy, such as pregnancy, feasible abortion Mild hyperthyroidism can continue pregnancy. Because the thyroid gland gradually develops after 12 weeks, it has the functions of iodine absorption and synthetic hormone, and has a reaction function to TSH. Therefore, the diagnosis and treatment of 131I or 125I should be disabled, and a small amount of anti-thyroid drugs should be applied. Should not be treated with surgery, should be alert to the occurrence of hyperthyroidism during childbirth, postpartum medication should not breastfeed.

(18) Iodothymidine type: In 1821, Coindet found that endemic goiter is often tachycardia, weight loss, appetite hyperactivity, insomnia, tremor, etc. In 1900, Breuer called iodothyroid, ie Job-Basedow disease. In 1928, Kinball reported that nearly 4% of iodothyroidism occurred after the application of iodized salt in the endemic goiter in the United States. In China, 403 cases of iodothyroid occurred in 11,500 cases in 1976-1979, accounting for 3.5%. 6.3:1, age 9 to 66 years old, average goiter disease course 10.9 years, more than II °, can be nodular, or mixed type, this type is called iatrogenic hyperthyroidism, that is, patients with thyroid gland or thyroid tablets L-T4 tablets are too long, the dosage is too large, and the consumption of kelp, seaweed, and octopus in the coastal areas is excessive. The treatment of this type can be restored to normal after stopping the drug or avoid eating kelp containing more iodine. , can also return to normal.

1. Clinical manifestations of high metabolism.

2. Diffuse thyroid enlargement.

3, laboratory tests: serum thyroid stimulating hormone (TSH) decreased, serum total thyroxine (TT4), total triiodothyronine (TT3), serum free triiodothyronine (FT3) and serum free Thyroxine (FT4) can be increased, the diagnosis of Graves disease can be established, thyroid stimulating antibody (TS-Ab) positive or TSH receptor antibody (TR-Ab) positive, can further confirm that the disease is autoimmune thyroid hyperthyroidism (Graves disease), because Graves disease is a kind of autoimmune thyroid disease, it can also be positive for thyroid peroxidase antibody (TPO-Ab) and thyroglobulin antibody (TG-Ab).

A small number of patients with TSH decreased, FT4 was normal, but serum free triiodothyronine (FT3) increased, can be diagnosed as T3 type hyperthyroidism, total thyroxine (TT4) and total triiodothyronine (TT3) due to The effect of thyroid hormone-binding globulin levels is second to FT4 and FT3 in the diagnosis of hyperthyroidism.

131I uptake rate: 24h uptake rate increased, peak intake was advanced.

Clinical manifestations: Hyperthyroidism is a systemic disease, and all systemic systems can be abnormal. Taking toxic diffuse goiter as an example, the characteristic clinical manifestations are summarized in three aspects:

1 increased metabolism and high sympathetic stimulating performance, patients often have more food, easy to starve, weight loss, weakness, heat, sweating, wet skin, but also fever, diarrhea, easy to excite, active, insomnia, heart rate increase Fast, severe heart rhythm, heart enlargement, and even heart failure.

2 The thyroid gland is a diffuse symmetric edema of varying degrees. The degree of swelling is not necessarily parallel to the condition. Due to the dilatation of the blood vessels in the gland and the acceleration of blood flow, murmurs can be heard on the swollen thyroid gland, or you can feel like a cat. The same vibrations as the asthma.

3 eye changes, due to excessive sympathetic excitation, can show large ocular fissure, eyelid retraction, blink reduction, gaze state or scared expression, and some patients due to eye muscle involvement, eye movement is restricted, resulting in visual Double diplopia or conjunctiva, corneal edema, can also be ulcerated, patients often have eyeballs, severe eye lesions may have optic nerve head and / or retinal edema, hemorrhage, optic nerve damage can cause vision loss, and even blindness.

There are also a small number of patients whose performance is not exactly the same as above. Some older patients have only a few symptoms or signs, or only highlight the symptoms of a certain system, such as obvious weight loss or irregular heart rhythm; some patients are weak, fatigue, burnout, Mental apathy; some manifestations of mental disorders; can also be seen with limb tremors or recurrent limb weakness or sputum to see a doctor, some patients are not diffuse thyroid enlargement, but one side or one side A part of the patient is swollen, and a very small number of patients may be accompanied by limited mucinous edema in front of the lower leg, which is manifested in thyroid limb disease at the end of the hand and foot or male breast hyperplasia.

In hyperthyroidism, the thyroid gland secretes too much thyroid hormone (T4 and T3), the total T4 and T3 in the blood combined with thyroid protein and the unbound free T4 and free T3 are increased; the ability of the thyroid to take up 131 iodine is also enhanced; Increased blood thyroid hormone inhibits the secretion of pituitary thyroid stimulating hormone, so thyroid stimulating hormone is reduced, and thyroid stimulating hormone is rarely increased after stimulation with thyroid stimulating hormone releasing hormone. For patients with clinical manifestations that are not typical, experimental examination is important. If the blood combined with thyroid hormone protein is normal, there is no abnormal effect on thyroid hormone binding. The total T4 and total T3 in the blood test can reflect the condition, and the free T4 is directly measured. The free T3 is good, but the method is complicated, in order to eliminate the protein. For the influence of the measurement, the total T4 and T3 are measured simultaneously, and the T3 resin uptake test is often measured simultaneously. The random index is calculated by multiplying the total T4 and T3 by mathematics, which can reflect the hormone secretion and the basal metabolic rate. The required equipment is simple and convenient. If the operation is correct, it is helpful for diagnosis, estimation of the condition, observation of curative effect, etc., but this method lacks specificity.

Hyperthyroidism: Hyperthyroidism is unfavorable for pregnancy. Antithyroid drugs can pass through the placenta and may cause miscarriage, premature birth and fetal death. After pregnancy, symptoms of hyperthyroidism may worsen. During pregnancy, fetal retention and abortion are based on The details are carefully decided.

2, classification of hyperthyroidism

(1) Thyroid hyperthyroidism: Hyperthyroidism is hyperactive, and the synthesis and secretion of hormones increase.

1 diffuse goiter with hyperthyroidism: also known as toxic diffuse goiter, exophthalmia goiter, Grayes disease, Basedow disease, etc., this type is most common in hyperthyroidism, accounting for about 90%, mainly due to autoimmune mechanisms, Thyroid stimulating hormone (TSH) receptor antibody (TRAb) is often detected in patients, and clinical symptoms such as high metabolic syndrome, exophthalmia, and diffuse thyroid enlargement are common in clinic.

2 multinodular goiter with hyperthyroidism: also known as toxic multinodular goiter, Plummer disease, this type of cause is unknown, common in patients with thyroid nodules for many years, more common in middle-aged and elderly, slow onset, mild symptoms Exophthalmia is rare, thyroid radionuclide imaging shows a slight diffuse increase in thyroid absorption 131I, but there is scattered nodular concentration, TSH or exogenous thyroid hormone can not change its iodine absorption function.

3 autonomic hyperfunctional thyroid adenoma or nodules: the etiology of this type is unknown, the vast majority of patients with a single adenoma, and occasionally multiple nodules, more common in middle-aged women, slow onset, mild symptoms, There is no exophthalmia, more T3 type hyperthyroidism, thyroid radionuclide imaging shows a single "hot nodule" in the thyroid (131I concentration at the nodule), and occasionally multiple "hot nodules", while the rest Glandular iodine absorption function is reduced or disappeared; this nodule does not accept TSH regulation, so it is called autonomic hyperfunction.

4 neonatal hyperthyroidism: infants born to pregnant women with hyperthyroidism may suffer from hyperthyroidism, the incidence of which is closely related to the concentration of TRAb in the mother's body, because TRAb can cause hyperthyroidism in the fetus through the placenta, but the child's hyperthyroidism is 1 to 3 after birth. Months often relieve themselves, and very few mothers have no history of hyperthyroidism, which may be related to their own immune disorders.

5 iodine-derived hyperthyroidism (referred to as iodothyroid): due to long-term excessive intake of iodine, more common in endemic goiter areas, occasionally in non-local polynodular goiter areas, long-term use of iodine-containing drugs such as amiodarone ( Ethyl amiodarone is also a common cause of this disease. The thyroid gland may have defects in the disease. Excessive iodine intake is only an inducement. Clinical symptoms of hyperthyroidism are mild, and exophthalmos are rare. Common thyroid nodules (see other types of hyperthyroidism). ·Iodine-induced hyperthyroidism).

6 primary thyroid cancer causes hyperthyroidism: some primary thyroid cancer can secrete a large amount of thyroxine, which leads to hyperthyroidism.

(2) Secondary hyperthyroidism: various causes lead to an increase in the concentration of TSH in the blood, which in turn causes hyperthyroidism.

1 pituitary hyperthyroidism: due to the secretion of a large number of TSH from pituitary tumors, extremely rare, many patients have hyperprolactinemia or acromegaly.

2 ectopic TSH secretion syndrome: very rare, occasionally seen in women with chorionic epithelial cancer (referred to as choriocarcinoma) or hydatidiform mole, or men with testicular villus cancer; sometimes bronchial cancer, gastrointestinal cancer can also cause, because Cancerous tissues secrete TSH-like substances, which leads to hyperthyroidism.

(3) Heterologous hyperthyroidism: other parts of the body have tissues that secrete thyroid hormone, and the thyroid itself has no lesions.

1 Hyperthyroidism caused by ovarian goiter: Some ovarian teratoma is mainly composed of thyroid tissue or all composed of thyroid tissue. It is called ovarian goiter. When ovarian goiter secretes too much hormone, it can cause hyperthyroidism, but it is rare. Strictly speaking, this disease should be called hypersecretion of ectopic thyroid hormone.

2 Hyperthyroidism caused by metastatic tumor of the thyroid gland.

(4) Drug-induced hyperthyroidism:

1 thyroxine (artificial): due to taking too much thyroid hormone, but the thyroid itself has no abnormal function.

2 Iodothymidine: seen in patients who take iodine-containing drugs such as amiodarone (amiodarone) for a long time.

(5) thyroiditis with hyperthyroidism: in the early stage of subacute thyroiditis, chronic lymphocytic thyroiditis (Hashimoto thyroiditis), after radioactive iodine treatment, etc., because the thyroid follicles are destroyed, thyroid hormones spill into the blood circulation, Can cause hyperthyroidism symptoms, but the gland function is not high, even lower than normal, and sometimes in the Hashimoto thyroiditis accompanied by Graves disease, called Hashimotos toxic cosis, but most of these hyperthyroidism is temporary In the later stage, it can be converted into hypothyroidism. Strictly speaking, the above situation cannot be classified as hyperthyroidism, but it is usually classified as a symptom of hyperthyroidism.

Among the above types of hyperthyroidism, Graves' disease is the most common.

3, toxic diffuse goiter with hyperthyroidism

Toxic diffuse goiter with hyperthyroidism, also known as exophthalmia, accounts for 90% of all hyperthyroidism. The disease is an autoimmune thyroid disease (AITD) characterized by the presence of thyroid tissue in the serum. Autoantibodies, clinical manifestations of a multi-system syndrome, including: high metabolic syndrome, diffuse goiter, exophthalmia, etc., due to Graves and Von Basedow in 1835 and 1840, the disease was first detailed Description, it is also known as Graves disease, Basedow disease.

Hyperthyroidism

1. Determination of basal metabolic rate (BMR): hyperthyroidism increased by >15%, and increased or decreased with hyperthyroidism. It can be measured by instrument or calculated by calculation method. The formula is: quiet pulse pulse pressure -111-BMR%.

2. Blood cholesterol is reduced by <150 mg/L (3.9 mmol/L).

3, 24h increased muscle uric acid>100mg/L (760mmol/L), intramuscular creatine phosphokinase (CRK), lactate dehydrogenase (LDH), aspartate aminotransferase (SGOT) increased.

4, peripheral blood cells should be > 4.5 × 109 / L, neutral multinucleated white blood cells should be > 50%, anti-thyroid drugs can be used.

5, thyroid uptake 131I rate increased, female 6h is 9% to 55%, males are 9% to 50%, 24h is 20% to 45%, 3h is 5% to 25%, this experiment is subject to many drugs and iodine The impact of food, so 2 to 3 weeks before the inspection, these factors should be avoided.

6, plasma protein combined with iodine (PRI) normal value of 0.3 ~ 0.63pmol / L, hyperthyroidism increased, > 0.63pmol / L.

7, thyroid hormone: T3 normal value 950 ~ 205g / L, T4 normal value 60 ~ 14.8g / L, resin uptake ratio (RUR) is 0.8 ~ 1.1, free T4 index (FT4I) is 9.6 ~ 16.3, FT3I 6.0 ~ 11.4 Pmol/L, FT4 was 32.5±6.0pmol/L, both hyperthyroidism increased, rT3 normal value was 0.2-0.8mol/L, hyperthyroidism also increased, and sometimes changed earlier than T3 and T4.

8, TSH radioimmunoassay method to determine the normal value of 3 ~ 10mU / L, pituitary hyperthyroidism increased, generally hyperthyroidism TSH at normal levels or decreased.

9, T3 inhibition test: used to identify the thyroid absorption 131I increase in nature, the method is to first measure the 131I value, then oral T3 60g / d (3 times / d), after 6 days, then measure the 131I rate, the results are compared, Oral thyroxine tablets can also be taken 60mg, 3 times / d, and then measured 131I value after 8 days, the results of comparison, normal people and simple goiter in the T3 inhibition test 131I inhibition rate >50%, hyperthyroidism inhibition <50%, Or no inhibition, malignant eyes are not inhibited, pay attention to elderly patients with hyperthyroidism and coronary heart disease patients with arrhythmia should not do this test, because it can cause arrhythmia.

10, TRH (thyroid stimulating hormone releasing hormone) test: hyperthyroidism T3, T4 increased, feedback inhibition of TRH, stimulate TSH secretion, so after intravenous injection of TRH 300mg, the pituitary still does not secrete TSH or rarely secrete TSH, hyperthyroidism patients TSH not Elevated, the level of TSH in patients with hypothyroidism increased.

11, thyroid antibody test: clinically commonly used thyroglobulin antibody (TGA), thyroid microsomal antibody (TMA) and other antibodies such as anti-nuclear antibody (ANA), anti-smooth muscle antibody (SMA), anti-mitochondrial antibody (AMA) >90% of anti-myocardial antibodies (CMA), anti-parietal cell antibodies (PCA), etc., thyroid stimulating antibodies (TSAb) or thyroid-stimulated immunoglobulin (TSI)-positive hyperthyroidism patients >90% may be positive.

Hyperthyroidism diagnosis

diagnosis

Typical hyperthyroidism has high metabolic symptoms, thyroid enlargement, and ocular protrusion. The diagnosis is not difficult, but about 20% of patients with hyperthyroidism have atypical clinical manifestations, more common in the elderly, older patients, patients with chronic diseases. Or early hyperthyroidism and mild hyperthyroidism patients, symptoms and signs are not typical, often no eyeballs prominent, thyroid enlargement is not obvious, especially some patients with hyperthyroidism symptoms concealed, and some symptoms are more prominent, easily misdiagnosed as another system Diseases, common atypical manifestations have the following:

1, cardiovascular type: with cardiovascular symptoms as prominent symptoms, tachycardia, arrhythmia, angina or heart failure. More common in women or older patients and patients with toxic nodular hyperthyroidism, clinically often diagnosed as coronary heart disease, hypertensive heart disease, arrhythmia and other diseases, this type of hyperthyroidism patients, cardiovascular symptoms can be treated with anti-thyroid drugs Relieve, the effect of treatment with cardiovascular drugs alone is not good.

2, neurological type: with neuropsychiatric symptoms as outstanding performance, patients with nervousness, inattention, emotional irritability, restlessness, insomnia, hallucinations, more common in women, easily misdiagnosed as neurosis or menopausal syndrome.

3, gastrointestinal type: often with diarrhea as a prominent symptom of stool 1 day or even dozens of watery diarrhea, no pus and blood, often misdiagnosed as enteritis, chronic colitis, some patients with abdominal pain as the main symptom, diffuse or Localized abdominal pain, similar to biliary colic, renal colic, ulcer disease, pancreatitis, appendicitis, often diagnosed as acute abdomen and surgical treatment, occasionally a small number of patients with severe vomiting as the main symptoms, and even intractable vomiting Misdiagnosed as gastroenteritis, this type is more common in young, young people.

4, muscle type: with muscle weakness, physical weakness and periodic paralysis as prominent performance, often no exophthalmia, no goiter and other symptoms of hyperthyroidism, or symptoms appear later, more common in middle-aged men, more after the patient's full meal and Ingestion of large amounts of sugary foods occurs.

5, cachexia quality: with weight loss as a prominent symptom, rapid weight loss, muscle atrophy, subcutaneous fat reduction or disappearance, and even cachexia, often misdiagnosed as a malignant tumor, more common in elderly patients.

6, low-heat type: about half of patients with hyperthyroidism have low fever, body temperature is generally <38 ° C, some patients with low fever for the long-term main symptoms, accompanied by weight loss, palpitations and other symptoms, easily misdiagnosed as rheumatic fever, typhoid, tuberculosis, acute bacterial heart Endometritis, etc., mainly seen in young people, the characteristics of this type of low fever, the increase in body temperature is not proportional to the increase in heart rate, the heart rate is faster and more significant, the application of antipyretic drugs is not effective, and the anti-thyroid drug treatment effect is obvious.

7, liver type: with jaundice, upper abdominal pain, liver, elevated transaminase, leukopenia as the main symptoms, often misdiagnosed as liver disease.

In addition to the atypical symptoms mentioned above, there are some atypical signs, such as hyperthyroidism, male gynecomastia, vitiligo, nail and nail bed separation (Plummer A), local hyperpigmentation, hyperglycemia, and more. Drinking more urine, liver palm, hypercalcemia, etc., these need to have further understanding, so as not to misdiagnose.

Differential diagnosis

1. Simple goiter, except for goiter, does not have the above symptoms and signs. Although the 131I uptake rate is sometimes increased, most of the T3 inhibition tests show inhibition, and serum T3 and rT3 are normal.

2, neurosis;

3, autonomous high-function thyroid nodules, radioactivity concentrated in the nodules during scanning: repeated scans after TSH stimulation, visible nodular radioactivity increased;

4, other, tuberculosis and rheumatism often have low fever, hyperhidrosis tachycardia, etc., diarrhea as the main manifestation is often misdiagnosed as chronic colitis, the performance of elderly hyperthyroidism is atypical, often apathy, anorexia, obvious weight loss It is easy to be misdiagnosed as cancer. Unilateral invasive exophthalmia needs to be differentiated from intraorbital and cranial low tumors. Hyperthyroidism with muscle disease needs to be differentiated from familial cycle paralysis and myasthenia gravis.

General hyperthyroidism also needs to be differentiated from simple goiter (endemic goiter), acute thyroiditis, acute thyroiditis, Hashimoto's disease, thyroid tumor, thyroid cancer, autonomic dysfunction.

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