Thyroid and Parathyroid disorders

Содержание

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Key points of the lecture

Graves' disease: definition, history, causes, symptoms and signs,

Key points of the lecture Graves' disease: definition, history, causes, symptoms and
taking diagnosis and treatment.
Hypothyroidism: definition, causes, symptoms and signs, taking diagnosis and treatment.
Hashimoto's thyroiditis: definition, epidemiology, symptoms and signs, treatment.
Hypoparathyroidism: definition, causes, symptoms and signs, taking diagnosis, treatment, first aid.

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The main thyroid and parathyroid disorders include:

Graves' disease
Hypothyroidism
Hashimoto’s thyroiditis
Hypoparathyroidism

The main thyroid and parathyroid disorders include: Graves' disease Hypothyroidism Hashimoto’s thyroiditis Hypoparathyroidism

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Graves' disease

Graves' disease is an autoimmune disease of a thyroid.
It most

Graves' disease Graves' disease is an autoimmune disease of a thyroid. It
commonly affects the thyroid, frequently causing it to enlarge to twice its size or more (goitre), become overactive, with related hyperthyroid symptoms such as increased heartbeat, muscle weakness, disturbed sleep, and irritability.
It can also affect the eyes, causing bulging eyes (proptosis). It affects other systems of the body, including the skin, heart, circulation and nervous system.

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History

Graves' disease owes its name to the Irish doctor Robert James Graves,

History Graves' disease owes its name to the Irish doctor Robert James
who described a case of goiter with exophthalmos in 1835.
However, the German Karl Adolph von Basedow independently reported the same constellation of symptoms in 1840.
As a result, on the European Continent, the terms Basedow's syndrome, or Basedow's disease are more common than Graves' disease.

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Epidemiology and causes

Graves' disease affects up to 2% of the female population,

Epidemiology and causes Graves' disease affects up to 2% of the female
sometimes appears after childbirth, and has a female: male incidence of 5:1 to 10:1.
It has a strong hereditary component; when one identical twin has Graves' disease, the other twin will have it 25% of the time.
Smoking and exposure to second-hand smoke is associated with the eye manifestations but not the thyroid manifestations.

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Pathophysiology

There appears to be a genetic predisposition for Graves' disease.
Graves'

Pathophysiology There appears to be a genetic predisposition for Graves' disease. Graves'
disease is an autoimmune disorder, in which the body produces antibodies to the receptor for thyroid-stimulating hormone (TSH).
These antibodies cause hyperthyroidism because they bind to the TSH receptor and chronically stimulate it. The TSH receptor is expressed on the follicular cells of the thyroid gland, and the result of chronic stimulation is an abnormally high production of T3 and T4.

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Exophthalmos

It`s protrusion of the eyeball from the orbit, caused by disease,

Exophthalmos It`s protrusion of the eyeball from the orbit, caused by disease,
especially hyperthyroidism, or injury.
The infiltrative exophthalmos that is frequently encountered has been explained by postulating that the thyroid gland and the extraocular muscles share a common antigen which is recognized by the antibodies.

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Classical clinical features (triad) of Graves' disease
Goiter is an enlarged thyroid gland

Classical clinical features (triad) of Graves' disease Goiter is an enlarged thyroid
and is of the diffuse type.
Exophthalmos (protuberance of one or both eyes).
Rapid heart beats or palpitations.

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Other main symptoms and signs

Fatigue
Weight loss with increased appetite
Muscle weakness
Non-pitting edema

Other main symptoms and signs Fatigue Weight loss with increased appetite Muscle
(pretibial myxedema) is lumpy and reddish skin of the lower legs
Tremor
Excessive sweating

Heat intolerance
Nervousness, irritability, emotional lability, panic attacks
Diplopia (double vision) and sensitivity to light
Oligomenorrhea and amenorrhea
Diarrhea

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Graves' disease Symptoms

Graves' disease Symptoms

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Gigantic goiter in woman 32 year old

Gigantic goiter in woman 32 year old

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Graves' ophthalmopathy

Thyroid-associated ophthalmopathy is one of the most typical symptoms of

Graves' ophthalmopathy Thyroid-associated ophthalmopathy is one of the most typical symptoms of
Graves' disease.
The ocular manifestations that are relatively specific to Graves' disease include soft tissue inflammation, proptosis (protrusion of one or both globes of the eyes), corneal exposure, and optic nerve compression.
These more general symptoms include lid retraction, lid lag, and a delay in the downward excursion of the upper eyelid, during downward gaze.

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Diagnosis

Another sign of Graves' disease is hyperthyroidism – overproduction of the thyroid

Diagnosis Another sign of Graves' disease is hyperthyroidism – overproduction of the
hormones T3 and T4.
Other useful laboratory measurements in Graves' disease include thyroid-stimulating hormone (TSH, usually low in Graves' disease due to negative feedback from the elevated T3 and T4), and protein-bound iodine (elevated).
Thyroid-stimulating antibodies may also be detected serologically.

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Treatment

Treatment of Graves' disease includes antithyroid drugs which reduce the production of

Treatment Treatment of Graves' disease includes antithyroid drugs which reduce the production
thyroid hormone, radioiodine (radioactive iodine I-131), and thyroidectomy (surgical excision of the gland).
As operating on a frankly hyperthyroid patient is dangerous, prior to thyroidectomy preoperative treatment with antithyroid drugs is given to render the patient "euthyroid" (i.e. normothyroid).
Treatment with antithyroid medications must be given for six months to two years, in order to be effective.

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Antithyroid drugs

The main antithyroid drugs are carbimazole (in the UK), methimazole (in

Antithyroid drugs The main antithyroid drugs are carbimazole (in the UK), methimazole
the US), and propylthiouracil/PTU. These drugs block the binding of iodine and coupling of iodotyrosines.
The most dangerous side-effect is agranulocytosis.
The most common side effects are rash and peripheral neuritis.

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Radioiodine

Radioiodine (radioactive iodine-131) was developed in the early 1940s at the Mallinckrodt

Radioiodine Radioiodine (radioactive iodine-131) was developed in the early 1940s at the
General Clinical Research Center.
Indications for radioiodine are: failed medical therapy or surgery and where medical or surgical therapy are contraindicated.
Contraindications to RAI are pregnancy (absolute), ophthalmopathy (relative; it can aggravate thyroid eye disease), solitary nodules.

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Surgery

This modality is suitable for young patients and pregnant patients.
Indications are:

Surgery This modality is suitable for young patients and pregnant patients. Indications
a large goitre (especially when compressing the trachea), suspicious nodules or suspected cancer (to pathologically examine the thyroid) and patients with ophthalmopathy.
Both bilateral subtotal thyroidectomy and the Hartley-Dunhill procedure (hemithyroidectomy on one side and partial lobectomy on other side) are possible.

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Hypothyroidism

Hypothyroidism is the disease state in humans and in vertebrates caused by

Hypothyroidism Hypothyroidism is the disease state in humans and in vertebrates caused
insufficient production of thyroid hormones by the thyroid gland. Cretinism is a form of hypothyroidism found in infants.
About three percent of the general population is hypothyroidic. Factors such as iodine deficiency or exposure to iodine-131 (I-131) can increase that risk.

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Causes

Iodine deficiency is the most common cause of hypothyroidism worldwide.
In iodine-replete

Causes Iodine deficiency is the most common cause of hypothyroidism worldwide. In
individuals hypothyroidism is generally caused by Hashimoto's thyroiditis, or otherwise as a result of either an absent thyroid gland or a deficiency in stimulating hormones from the hypothalamus or pituitary.
Hypothyroidism can result from postpartum thyroiditis, a condition that affects about 5% of all women within a year of giving birth.

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Early symptoms and signs in adults

Poor muscle tone (muscle hypotonia)
Fatigue
Cold

Early symptoms and signs in adults Poor muscle tone (muscle hypotonia) Fatigue
intolerance, increased sensitivity to cold
Depression
Muscle cramps and joint pain
Carpal Tunnel Syndrome
Goitre
Thin, brittle fingernails

Thin, brittle hair
Paleness
Osteoporosis
Decreased sweating
Dry, itchy skin
Weight gain and water retention
Bradycardia (low heart rate – fewer than sixty beats per minute)
Constipation

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Late symptoms

Slow speech and a hoarse, breaking voice – deepening of the

Late symptoms Slow speech and a hoarse, breaking voice – deepening of
voice can also be noticed
Dry puffy skin, especially on the face
Abnormal menstrual cycles
Low basal body temperature
Impaired memory
Impaired cognitive function (brain fog) and inattentiveness
Hair loss

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Diagnostic testing

To diagnose primary hypothyroidism, many doctors simply measure the amount of

Diagnostic testing To diagnose primary hypothyroidism, many doctors simply measure the amount
thyroid-stimulating hormone (TSH) being produced by the pituitary gland. High levels of TSH indicate that the thyroid is not producing sufficient levels of thyroid hormone (mainly as T4 and smaller amounts of T3).
However, measuring just TSH fails to diagnose secondary and tertiary hypothyroidism, thus leading to the following suggested blood testing if the TSH is normal and hypothyroidism is still suspected: Free triiodothyronine (fT3), Free levothyroxine (fT4), Total T3, Total T4.

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Hashimoto's thyroiditis

Hashimoto's thyroiditis is an autoimmune disease in which the thyroid

Hashimoto's thyroiditis Hashimoto's thyroiditis is an autoimmune disease in which the thyroid
gland is gradually destroyed by a variety of cell and antibody mediated immune processes. It was the first disease to be recognised as an autoimmune disease.
It was first described by Dr. Hakaru Hashimoto in Japan in 1912. Japanese physician Hakaru Hashimoto (1881−1934) was teacher of the medical school at Kyushu University.

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Epidemiology

This disorder is believed to be the most common cause of primary

Epidemiology This disorder is believed to be the most common cause of
hypothyroidism in North America. An average of 1 to 1.5 in a 1000 people have this disease. It occurs far more often in women than in men (between 10:1 and 20:1), and is most prevalent between 45 and 65 years of age.
In European countries, an atrophic form of autoimmune thyroiditis (Ord's thyroiditis) is more common than Hashimoto's thyroiditis.

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Causes

The family history of thyroid disorders is common, with the HLA-DR5 gene

Causes The family history of thyroid disorders is common, with the HLA-DR5
most strongly implicated conferring a relative risk of 3 in the UK.
The underlying specifics of the immune system destruction of thyroid cells is not clearly understood. Various autoantibodies may be present against thyroid peroxidase, thyroglobulin and TSH receptors, although a small percentage of patients may have none of these antibodies present.

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Hashimoto’s thyroiditis histology

Physiologically, antibodies against thyroid peroxidase and/or thyroglobulin cause gradual destruction

Hashimoto’s thyroiditis histology Physiologically, antibodies against thyroid peroxidase and/or thyroglobulin cause gradual
of follicles in the thyroid gland.
It is also characterized by invasion of the thyroid tissue by leukocytes, mainly T-lymphocytes.

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Symptoms and signs

Symptoms of Hashimoto's thyroiditis include weight gain, depression, mania,

Symptoms and signs Symptoms of Hashimoto's thyroiditis include weight gain, depression, mania,
sensitivity to heat and cold, fatigue, panic attacks, bradycardia, tachycardia, high cholesterol, reactive hypoglycemia, constipation, migraines, muscle weakness, cramps, memory loss, infertility and hair loss.
Testing for thyroid-stimulating hormone (TSH) and anti-thyroid antibodies can resolve any diagnostic difficulty.

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Treatment

Hypothyroidism caused by Hashimoto's Thyroiditis is treated with thyroid hormone replacement agents

Treatment Hypothyroidism caused by Hashimoto's Thyroiditis is treated with thyroid hormone replacement
such as levothyroxine or desiccated thyroid extract.
A tablet taken once a day generally keeps the thyroid hormone levels normal. In most cases, the treatment needs to be taken for the rest of the patient's life.

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Hypoparathyroidism

In medicine (endocrinology), hypoparathyroidism is decreased function of the parathyroid glands, leading

Hypoparathyroidism In medicine (endocrinology), hypoparathyroidism is decreased function of the parathyroid glands,
to decreased levels of parathyroid hormone (PTH) and hypocalcemia.
The consequence, hypocalcemia, is a serious medical condition.

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Causes of the hypoparathyroidism

Removal of or trauma to the parathyroid glands in

Causes of the hypoparathyroidism Removal of or trauma to the parathyroid glands
thyroid surgery (thyroidectomy) or other neck surgeries is a recognized cause.
Autoimmune invasion and destruction is the most common non-surgical cause. It can occur as part of autoimmune polyendocrine syndromes.
Magnesium deficiency.

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Signs and symptoms

Tingling lips, fingers, and toes
Muscle cramps
Pain in the

Signs and symptoms Tingling lips, fingers, and toes Muscle cramps Pain in
face, legs, and feet
Abdominal pain
Dry hair
Brittle nails
Dry, scaly skin

Weakened tooth enamel (in children)
Muscle spasms called tetany (can lead to spasms of the larynx, causing breathing difficulties)
Convulsions (seizures)
Tetanic contractions

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Additional symptoms that may be associated with this disease include

Painful menstruation

Additional symptoms that may be associated with this disease include Painful menstruation

Hand or foot spasms
Decreased consciousness
Delayed or absent tooth formation

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Diagnosis

Diagnosis is by measurement of calcium, serum albumin (for correction) and PTH

Diagnosis Diagnosis is by measurement of calcium, serum albumin (for correction) and
in blood.
PTH degrades rapidly at ambient temperatures and the blood sample therefore has to be transported to the laboratory on ice.
Other tests include ECG for abnormal heart rhythms, and measurement of blood magnesium levels.

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Treatment

Severe hypocalcemia, a potentially life-threatening condition, is treated as soon as possible

Treatment Severe hypocalcemia, a potentially life-threatening condition, is treated as soon as
with intravenous calcium (e.g. as calcium gluconate). Generally, a central venous catheter is recommended, as the calcium can irritate peripheral veins and cause phlebitis.
Long-term treatment of hypoparathyroidism is with calcium and Vitamin D3 supplementation (D1 is ineffective in the absence of renal conversion).

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First aid

In the event of a life-threatening attack of low calcium levels

First aid In the event of a life-threatening attack of low calcium
or tetany (prolonged muscle contractions), calcium is administered by intravenous infusion.
Precautions are taken to prevent seizures or larynx spasms.
The heart is monitored for abnormal rhythms until the person is stable.
When the life-threatening attack has been controlled, treatment continues with medicine taken by mouth as often as four times a day.
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