Department of Internal Medicine № 2 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 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) Defect of T lymphocytes suppressors

Pathogenesis Insufficiency of T suppressors The thyroid 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 Weight loss 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 cant work

Treatment 1. Antithyroid drugs. 2. Drugs to ameliorate thyroid hormone effects . 131I - therapy 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”.)