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 syndromeEnlargment 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)

PathogenesisInsufficiency 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; IB- thyroid 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 over 120

Weight loss

less than 10 %

10 – 20 % more than 20 %

Changes from organs and systems

rare - ophthalmopathy

- signs of heart failure І – ІІ А

-ophthalmopathy

-dystrophic changes from inner organs

-thyroid storm

Work capacity

normal decreased patients cant work

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 thyrotoxicosisIt 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”.)