Thyroid Graves 2

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Blood Vascular          Enlarge lymphnodes-Thymus

System                  Enlarged-Increased serum IgG

                        Lymphocytic infiltrations of

                        thyroid

Eye                     Infiltration ophthalmopathy

Skin                    Pretibial Myxoedema-Vitiligo

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Fig 31.9a & b

Diagnosis is based on a good clinical examination and establishing the existence of high levels of thyroid hormone by measuring T4 and T3. Non-suppressible high uptake of I131 by the thyroid is also of use.

      Some of the manifestations are also due to the disturbance in the immune mechanism and are classified in Table 31.2

Table 31.2

Signs and Symptoms

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*  Cardiovascular                   *  Reproductive System

   - Dyspnea on Exertion              - Scanty menses

   - Palpitation

   - Rapid pulse > 90

   - Ventricular fibrillation      * Skin

                                    * Loss of curl of hair

                                    * Increased perspiration

                                    * Increased pigmentation

                                    * Warm skin

*  CNS

   - Nervousness                   * Thyroid

   - Irritability                  * Smooth generalized firm

   - Insomnia                         enlargement

                                    * Vascular thrill

                                    * Bruit

* GIT

   - Increased appetite

   - Increased frequency stool

* Neuromuscular

   - Tremors(Hands)

   - Musle wasting

   - Hyperactive reflex

   - Eye(lid lag-increased Palpebral fissure)

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12.3 Treatment

      Surgery is the method recommended for moderate and severe toxicity in those above forty years of age, especially those patients with large goitres producing pressure distortion of trachea (Dysphagia).

      Before thyroidectomy, the patient is rendered euthyroid by the use of Neomercazole (30-40 mg OD) for 4-8 weeks.

      Propranolol 10-40 mg QID can also be used to control symptoms quickly.

      Lugol’s iodine is also required to reduce the vascularity of the the thyroid gland.

      Radio iodine can be used to ablate the gland in all other cases

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Thyroid Graves deseas 1

GRAVE'S DISEASE

      Grave’s disease manifests with hyperthyroidism (toxicity) predominantly in females below the age of 40 years. The etiology is unknown, but it has an autoimmune basis and psychic stress (Examination, marriage) have been known to precipitate the disorder. There is a family incidence and a close relationship to Hashimoto’s thyroiditis. There is also evidence of a disturbance of the immune system (Table 31.1)

      The factors found in the serum of patients with Grave’s disease are:

*     antimicrosomal antibodies (TMAb) and

*     anti-thyroglobulin antibodies (TgAb)

*     in addition there are antibodies against TSH

      receptor(TRAb)

*     and a stimulator of thyroid function (TSI)

      These antibodies sometimes disappear when the patient is treated with antithyroid drugs

12.1 Pathology

      The thyroid gland is moderately enlarged repesenting a diffuse hypertrophy and hyperplasia. On microscopy,

*     there is an increased height of the follicular cells

*     with decreased amount of colloid with scalloping and

*     interspersed areas of lymphocytic infiltration

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Thyroid Thyroiitis

10 THYROIDITIS

      Inflammatory disease of the thyroid occurs in four different varieties:

10.1 Septic or suppurative thyroiditis is due to sterepto or staphylococcus infected and is extremely rare

10.2 de Quervain’s thyroiditis, also known as subacute or granulomatous thyroiditis is most likely due to a viral infection. The onset is usually acute following a throat infection. The ESR is raised but there is no rise of WBC

10.2.1 Treatment is with aspirin in some cases. Predinisolone 5-10mg a day will be required

10.3 Autoimmune or lymphocytic thyroiditis (Hashimoto’s). The thyroid is moderately enlarged non-tender and has a firm lobulated surface, it may progress to hypothyroidism. Thyroid antibodies (TRC, TMA) are demonstrable. Cytology can be of help in diagnosis.

10.3.1 Treatment is with replacement of thyroid hormones for hypothyroidism

10.4 Reidels thyroiditis is characterised by an overgrowth of fibrous tissue and presents with a hard (woody thyroid) gland. Its presentation is like a carcinoma and a biopsy is the only means of diagnosis

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Thyroid multinodular goitre

9.2 NODULAR GOITRE

      The large majority of these goitres produce a cosmetic defect or cause pressure symptoms (respiratory distress, dysphagia). Some, however, may present with symptoms of excess thyroid hormone (Toxic Goitre)

      The symptoms in toxic goitre are similar to those of Grave’s Disease, except for those due to disturbed immune system which are absent. A single nodule in the thyroid can also produce excess hormones and present with all the clinical features of toxicity.

      The diagnosis is established by measuring thyroid hormones in the serum and a scan helps to establish the autonomously functioning nodule (AFN)

      Treatment of surgery after control of the hyperfunction of the thyroid with Neomercazole.

9.3 Goitre and Carcinoma

      The risk of Carcinoma developing in a multinodular goitre is small.

      However, carcinoma can co-exist with a multinodular goitre (4-17%).

      In cases of solitary nodule Fig. 31.6 is viewed by surgeons with greater suspicion, since it represents a focal replication of thyroid cells. An I131 scan and a fine needle aspiration cytology may further help to come to a decision. In most cases, a hemithyroidectomy is recommended

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