Hyperthyroidism Syndrome Research Articles

MON-439 Graves’ Disease and Papillary Thyroid Cancer: A Rare Clinical Case?

Background: Nodules on the background of Graves’ disease are less common among men than among women, but more than one in three patients have carcinoma. Despite the improvement of diagnostic methods, most often thyroid cancer is a random histological finding after thyroidectomy for Graves’ disease. Clinical case: A 55-year women complained of discomfort in the neck, sweating, irritability, palpitation. From anamnesis: in 2012 she was diagnosed with thyrotoxicosis syndrome. For 5 years, the patient was treated with thyrostatics, but when trying to reduce the dose, the syndrome of thyrotoxicosis recurred. In March 2017, the patient’s condition worsened, at the time of treatment she took Thyrosol 30 mg/day. Objectively: hypersthenic body type, BMI 33 kg/m2. Thyroid gland visually was increased in volume, dense with palpation, homogeneous, mobile. Elevated titer of antibodies to the TSH receptor was discovered, according to the ultrasound - increase thyroid gland 30.2 cm3, hyperechogenic formation of the left lobe 10х10х9 mm with hypoechoic rim, clear smooth contours, intranodular blood flow. As a result, the Graves’ disease, goiter grade 2, manifest thyrotoxicosis was verified, surgical treatment was recommended. Thyroidectomy, histological examination was performed: Graves’ disease was confirmed, papillary microcarcinoma with metastasis to 1 regional lymph node was revealed. Diagnosed: papillary thyroid cancer I st (pT1aN1aM0x), 2 clinical group. The patient was prescribed suppressive therapy with L-thyroxine 100 µg/day, against which after 3 months TSH reached the target values (0.2–0.5 Mme/l). Taking into account the histological characteristics of the tumor, the nature and volume of the lesion, age, the patient belongs to the group of intermediate cancer risk of progression of cancer. According to scintigraphy residual functioning thyroid tissue (20x15 mm) was detected. Radioiodine therapy was carried out in a specialized hospital. Suppressive therapy of L-thyroxine 150 µg/day, target values of TSH 0.1 - 0.5 Mme/l was recommended. After 6 months, TSH reached target values, and according to the results of ultrasound of thyroid gland no data for structural relapse was found. Conclusion: Patients with long-existing, often recurrent Graves’ disease and questionable effect of conservative therapy, in the presence of nodular formation should be assigned to the risk group for the presence of thyroid cancer and carefully examined, because the need for further surgery depends on it.

Itching as the onset of pain (part 2)

Itching of the skin is a particularly unpleasant subjective sensation that causes the need to scratch. Physiological itching occurs in response to environmental irritants (friction, insect crawling, temperature changes, etc.) and disappears after elimination of the cause. Pathological itching is caused by changes in the skin or throughout the body and causes a strong need to get rid of itching by combing or any other method. Itching is a common symptom of local (dermatological) or general (systemic) disease. It can be limited (localized) or diffuse (generalized).One of the causes of itching is often noted endocrine diseases and metabolic disorders: hyper- and hypofunction of the thyroid gland, diabetes mellitus and hyperparathyroidism. In thyroid hyperfunction, generalized (inconstant and little-pronounced) itching of the skin is observed in the clinical picture only in 10 % of patients. It is accepted that itching of the skin in thyrotoxicosis syndrome is due to increased activity of kinin in combination with an increase in major metabolism and an increase in body and skin temperature (123).Itching caused by impaired bile secretion is characteristic of many diseases of the liver: primary biliary cirrhosis, sclerosing cholangitis, viral hepatitis caused by cholestasis medications and other causes of obstructive jaundice. It is in these cases that prurigo is usually generalized, but in some typical cases it is more pronounced on the feet and palms. With this pathology, itching is caused by obstruction of the biliary tract, however, and to this day, no close correlation has been found between serum bilirubin and the severity of itching.If it was previously thought that itching in pathology of the peripheral or central nervous system, such as multiple sclerosis, neuropathy, compression or irritation of nerves (e.g., paraesthetic dorsalgia, brachioradial itching) is also a significant symptom, then modern studies prove that in more cases, itching is not characteristic of most pathologies of the nervous system, so after a detailed anamnesis, examination and initial research, the patient should be referred to a related specialist, except in cases of about obvious postherpetic neuropathy, painless paresthesia, or brachioradial itching, which can often be guided in the provision of primary care.Instead, there are some psychological conditions and a number of psychiatric illnesses (obsessive-compulsive disorders, depression, and parasite illusions) that are most commonly diagnosed with the exclusion method. Neurotic squabbles are scattered on the body of the excorii, covered with scales that may occur in any area of the body that the patient may reach, but are often limited by limbs.

Resistance to Anti-Thyroid Drugs in Graves’ Disease: Clinical-Biological Characteristics and Alternative Therapy in Tropical Area

Background: Resistance to anti-thyroid drugs (ATDs) is a rare entity recently described. We report two African observations in the treatment of Graves’ disease. Case 1: A 19-year-old Senegalese woman presented on admission with thyrotoxicosis syndrome associated with diffuse goitre and Grave’s orbitopathy. TSH levels were low (0.005 mIU/ml; N = 0.27 - 4.20) and fT4 elevated (60 pmol/L; N = 12 - 22]. Combination therapy with propranolol (40 mg/day) and carbimazole (starting dose of 45 mg/day and increased to 60 mg/day) was initiated. In view of the persistence of symptoms despite good therapeutic compliance, carbimazole was replaced by methimazole with an initial starting dose of 40 mg/day, followed by 60 mg/day. Despite the change in therapy, clinical symptoms of thyrotoxicosis persisted, and fT4 levels remained elevated. The patient was diagnosed with resistance to ATDs in Graves’ disease. Total thyroidectomy following 10 days of preoperative preparation with 1% Lugol’s solution was performed successfully. Case 2: A 22-year-old woman was referred for continued management of Graves’ disease with elevated thyroid-stimulating hormone receptor antibody (TRAb) levels (34 UI/mL; N

Costus Root Extract Alleviates Blood Biochemical Derangements of Experimentally-Induced Hypo- and Hyperthyroidism in Mice

Objectives: Thyroid hormones regulate all metabolic activities; therefore, it is not amazing that hepatic; renal dysfunctions and lipid alterations are commonly detected in patients with thyroid disorders. This study estimated some biochemical changes in post pubertal hyperthyroid and hypothyroid mice and their impacts on liver and kidney functions and also on changes in the lipid pattern. In addition, the ameliorating role of Costus root extract supplementation was examined. Material and Methods: A total of 60 male Swiss albino mice were randomly divided into 5 groups; control, control with costus extract, hypo- and hyper-thyroids post-treated with costus root extract. Results: Present results revealed that, a significant increase in serum thyrotropin (TSH), alanine transaminase (ALT) and aspartate transaminase (AST), alkaline phosphatase (ALP), creatinine, urea, potassium, chloride, cholesterol and triglycerides levels in hypothyroid mice compared to control. On the other hand; a significant decrease in serumthyroxine (T4), tri‐iodothyronine (T3), albumin, total protein and calcium ions levels in hypothyroid mice compared to control. In contrast to hypothyroidism, a significant increase in serum T3, ALT, AST, ALP, creatinine, urea, sodium, potassium, chloride and total proteins levels in hyperthyroid mice compared to control. On the other hand; a significant decrease in serum TSH, T4, albumin, calcium ions cholesterol and triglycerides levels in hyperthyroid mice compared to control. Treatments of mice with Costus root extract in both hypo- and hyperthyroidism modulates the measured serum parameters.
 Conclusions: Our results could propose that the extract of Costus roots can be used as an adjuvant co-therapy in hypo- and hyperthyroidism syndromes with propylthiouracil and Eltroxin replacement therapy, respectively

Differential diagnosis of thyrotoxicosis syndrome in postpartum period

Differential diagnosis of thyrotoxicosis syndrome in postpartum period

Синдром тиреотоксикоза: трудности диагностики и лечения (случай амиодарон-индуцированного тиреотоксикоза)

Синдром тиреотоксикоза: трудности диагностики и лечения (случай амиодарон-индуцированного тиреотоксикоза)

Hemodynamics and oxygen delivery in thyroid surgery patients under total intravenous anaesthesia

AIM – to study the indicators of central hemodynamics and oxygen delivery in patients with thyrotoxicosis syndrome during the operation of thyroidectomy with the use of total intravenous anesthesia (TIVA). MATERIALS AND METHODS The study included 41 thyrotoxicosis syndrome patients (diffuse thyrotoxic goiter – 28 patients (68.3%), multinodular goiter – 12 (29.3%) and toxic adenoma – 1 patient (2.4%)) who underwent surgery under TIVA propofol with trachea intubation and mechanical lung ventilation. Doppler-echocardiography (Doppler-EchoCG) study was performed preoperatively, in the perioperative period systolic (SBP), diastolic (DBP) blood pressure, mean BP (MBP), pulse pressure (PP), heart rate (HR) were measured. Indices of central hemodynamics (cardiac output (CO), cardiac index (CI)) were studied using the esCCO™ method. Oxygen delivery (DO2) and peripheral vascular resistance (PVR) were calculated. The input data for calculating the indices of central hemodynamics, oxygen delivery were measured at the following stages: 1st stage – initial examination of the anesthesiologist; 2nd stage – patient's admission to the operating room; 3rd stage – after introductory anesthesia and intubation of the trachea; 4-th stage – the beginning of the operation; 5th stage – removal of thyroid gland; 6th stage – after suturing wounds (end of operation); 7th stage – 24 hours after the operation. RESULTS and DISCUSSIONAt the 1st stage the SBP, DBP, MBP, PP, HR were assessed as the same as the reference levels. At the 2nd stage, the amount of MBP increased by 8.21±0.02% compared to the first stage. At the third stage, the lowest indicators of MBP, PP, SBP, DBP were noted. At the third stage MBP was noted 68.17±1.12 mm Hg. The decrease was 34.61±0.88% (significant difference with the 2-nd stage, p

Yersinia infections and Graves’ disease

Background. The most common thyroid disease, accompanied by thyrotoxicosis syndrome, is Graves' disease (GD). Information about the role of Yersinia in the development of this disease is contradictory.
 Aims. To study the significance of Yersinia (Y.) enterocolitica and Y. pseudotuberculosis in the development of Graves' disease.
 Materials and methods. 78 patients with GD. Identification of antibodies to Y. was carried out by the following methods: 1. agglutination test (AT) with suspensions of live virulent cultures Y. pseudotuberculosis, Y. enterocolitica O:3 and O:9; 2. indirect hemagglutination test (IHET) with the use of erythrocyte diagnosticum; 3. determination of IgA and IgG antibodies against pathogenicity factors of Y. enterocolitica strains by immunoblotting (30 patients with GD).
 Results. Diagnostically significant titers of antibodies to Y. pseudotuberculosis and Y. enterocolitica were obtained in all patients with GD by AT. The greatest total thyroid volume determined by ultrasound investigation (p = 0.010) and the maximum duration of the disease (p = 0.040) were determined in the group of patients with the maximum antibody titer. No significant relation was found between the titer of antibodies to Yersinia and the levels of thyroid hormones stimulating the thyroid antibodies.The test for detection of IgA antibodies by immunoblotting was negative in 30 patients with GD (9 patients with a titer of antibodies by AT 1:800 – 1:1600, 17 – 1:400, 4 – 1:200). In all cases with the maximum antibody titer in AT, the positive IgG antibodies to the antigens YopM (Yop2a), YopH (Yop2b), V-antigen, YopD were found. The GD duration in patients with negative titers of antibodies by the immunoblotting test was less than with the positive one (p = 0.010). The privative clinical and anamnestic data and negative results by IHET confirmed the absence of active and/or transferred Yersinia infections in all the examined patients with GD.
 Conclusions. The cross-reacting antibodies to the antigens of Y. enterocolitica are determined in the serum of GD patients by AT and immunoblotting. The diagnostic titer of these antibodies is more often detected in patients with greater GD duration and larger volume of the thyroid gland. The absence of a link between the titer of these antibodies and the levels of thyroid hormones, the antibodies to the thyrotropin receptors of pituitary, as well as negative results by IHET with a diagnosticum that does not contain outer membrane proteins of pathogenic Yersinia, deny the trigger role of Yersinia infections as an initiating factor in the development of GD.

Синдром тиреотоксикоза аутоиммунного генеза (клинический случай и обзор литературы)

Синдром тиреотоксикоза аутоиммунного генеза (клинический случай и обзор литературы)

The central hemodynamics assessment methods in thyrotoxicosis patients under inhaled anesthesia

Aim: To assess the central hemodynamics using calculation forms and invasive-noninvasive systems on the background of using inhaled minimal-streaming anesthesia at thyroidectomies in patients with thyrotoxicosis.Materials and methods. The study included 44 patients with the syndrome of thyrotoxicosis (diffuse thyrotoxic goiter – 31 patients (70,45 %), multi-node goiter – 10 (22,74 %) and toxic adenoma – 3 patients (6,81 %)), operated under the general anesthesia as inhaled anesthesia by sevoflurane by the method of minimal stream (FGF=400 ml/min., Sev 3,0 vol%). Women – 40 patients (91,9 %), men – 4 (9,1 %) patients. Mean age 47,61±2,39 years, BMI 25,89±0,53 c.u, body surface area 1,82±0,02 m2. The assessment of systolic arterial pressure (АPs), diastolic (APd), mean AR (MAP), sphygmic pressure (SP), HR, mean pressure in the aorta, (MPA). There was studied the index of the proper minute volume of blood circulation (PMCB) based on values of the proper main metabolism (PMM). The parameters of the central hemodynamics were studied intraoperationally (after patient’s intubation) after esophageal dopplerography on the apparatus Cardio Q ("Deltex Medical", Great Britain) and esCCO™ method (monitor Vismo, Nihon Kohden). esCCO™ method (calculative continuous heart ejection) and calculative formulas by: Starr, Lillier-Shtrander, Tsander, RU No. 2481785.Results and discussion. Calculative indices by M.M. Savitsky formula don’t reliably differ comparing with the objective instrumental method of hemodynamics control by DopplerEchoCG and can be used as initial indices for the comparison with instrumental and calculative ones. At the analysis of APs, APd, MAP, SP in control points, it was observed, that at patient’s admission to a surgical room MAP and MPA on 2 control reliably (р<0,001) increased by 7,3 % and 6,7 % respectively comparing with 1 control, connected with the natural anxiety of a patients before the surgical intervention. After the input anesthesia the reliably (р<0,001) lowest indices of MAP, MPA, SP, APs, APs on 3 control by Wilcoxon criterion were observed. They were stabilized at following stages of anesthesia. MVB and HI on all control points, according to the data of calculative formulas by Starr, Lillier-Shtrander and Tsander, have reliably (p<0,05) lower values by Wilcoxon criterion than according to instrumental data by DopplerEchoCG. The calculative indices MVB and HI, according to the RU No.2481785 have reliably (p<0,05) higher values by Wilcoxon criterion on all control points than by DopplerEchoCG instrumental data. MVB, GPVR, HI, obtained using the method of esCCO Vismo monitoring had the least degree of deviations from DopplerEchoCG data. Spearmen correlation between these indices was 0,83 (strong direct connection, p<0,05). Spearmen correlation is absent between indices of the calculative formulas of Starr, Lillier-Shtrander and Tsander and data of DopplerEchoCG (rs=–0,07 and rs=–0,14 respectively). The indices by the data of the patent RU No.2481785 have rather high mistake by the data of DopplerEchoCG comparing with esCCO method, but demonstrate the moderate correlation with them rs=0,38 (p<0,05). There is the strong direct correlation between indices of the invasive CardioQ EDM and non-invasive esCCO method (rs=0,75;p<0,05). Among calculative indices, the most correlation with data of esCCO method is demonstrated by indices by the patent С RU No. 2481785 (rs=0,38, p<0,05), indices by Starr, Lillier-Shtrander and Tsander formulas have no correlation with esCCO method.Conclusions. Calculative indices by M. M. Savitsky formula don’t reliably differ comparing with DopplerEchoCG data and can be used as initial indices for the comparison with instrumental and calculative ones.Calculative indices by the data of Starr, Lillier-Shrander and Tsander formulas underestimate MVB, HI and have no correlations comparing with instrumental assessment methods. Indices by the patent RU No.2481785 give overestimated values of MVB and HI, but have the moderate correlation (rs=0,38; (p<0,05) with both DopplerEchoCG and esCCO data.After the input anesthesia there is observed the reliable (p<0,05) decrease of MVB and HI by doth data of invasive monitoring – esophageal dopplerography by Cardio Q system, and non-invasive esCCO™ monitoring method (calculative continuous hearth ejection), stabilized at 5-6 stages of the operation.There is the moderate correlation between indices of data of invasive (Cardio Q) and non-invasive (esCCO™) monitoring at the level rs=0,75 (p<0,05).esCCO method allows to study fluctuations of the central hemodynamics at equal stages of anesthesia maximally effectively, it is a simple non-invasive method of control of the central hemodynamics with the high degree of correlation with DopplerEchoCg indices

Personalised immunomodulating treatments for Graves' disease: fact or fiction?

Although Graves' disease has been recognised for more than 100 years, its physiopathological mechanisms are incompletely understood. Treatment strategies today mainly focus on suppression of thyroid hormone production by use of antithyroid drugs or radio-iodine, but neglect the underlying immunological mechanisms. Although Graves' disease is often seen as a prototype for an autoimmune mechanism, it is more likely to be a heterogeneous syndrome showing characteristics of both autoimmunity and immunodeficiency. The interplay of these two mechanisms may well characterise the physiopathology of this disease and its complications. Immunodeficiency may be either genetically determined or secondarily acquired. Various triggering events lead to autoimmunity with stimulation of the thyroid gland resulting in the clinical syndrome of hyperthyroidism. Also, relapse risk differs from patient to patient and can be estimated from clinical parameters incorporated into the Graves' Recurrent Events After Therapy (GREAT) score. Accurate risk stratification may help to distinguish high-risk patients for whom a more definitive treatment approach should be used from others where there is a high probability that the disease will recover with medical treatment alone. Several smaller trials having found positive effects of immunosuppressive drugs on recurrence risk in Graves' disease; therefoore, there is great potential in the use of novel immunomodulating drugs in addition to the currently used antithyroid drugs for the successful treatment of this condition. Further in-depth exploration of susceptibility, triggering factors and immunological mechanisms has the potential to improve treatment of Graves' disease, with more personalised, risk-adapted treatment strategies based on the different physiopathological concepts of this heterogeneous condition.

The thyrotoxicosis syndrome: risks for an anesthesiologist

Aim : to analyze anesthetic risks and anesthesia particularities in patients with thyrotoxicosis syndrome who were undergone thyroidectomy in a specialized endocrinology center. Materials and methods . During the period January 2015 – April 2017, thyroidectomy was performed in 402 patients with thyrotoxicosis syndrome in the Department of Anaesthesiology and Intensive Care of the Ukrainian Scientific and Practical Center of Endocrine Surgery, Transplantation of Endocrine Organs and Tissue. Surgical interventions were performed under conditions of general anesthesia with mechanical ventilation by using either the low-flow / minimally-flow inhalation anesthesia (LFA/MFA) with sevoflurane or the total intravenous anesthesia (TIVA) with propofol. We assessed the physical status on the American Association of Anaesthesiologists (ASA) clfssification, the frequency of concomitant pathology, the particularities of the anesthesia according to reports of anesthesiologists. Results and discussion . Among patients with thyrotoxicosis syndrome, the 298 (74,1%) patients were the patients with diffuse toxic goiter (DTG) in the stage of drug compensation or subcompensation, 104 (25,9%) patients were with a multinodular goiter (MNG) with thyrotoxicosis. Only 22.1% of the total had minimal anesthesia risk – ASA I according to the ASA classification. 77.9% of patients had one or more concomitant pathologies. The ones of the most difficult patients for planned anesthesia were patients with grade III and IV ASA, whose were 20.9%. The number of concomitant pathologies ranged from one to six per patient, total 25 types of concomitant pathology were identified. The peculiarities of anesthesia were noted in 85 cases, which is amounted to 21.1% from the total number of anesthesia., The anesthesia peculiarities were noted in 73 (22.8%) among the LFA/MFA patients and in 12 (14.6%) cases of TIVA propofol patients (no significant difference between groups according to the ?2 (Pearson) criterion). No fatal case was observed. Conclusions . The thyrotoxicosis syndrome impairs the ASA physical status. There was 77.9% of patients with thyrotoxicosis, who had one or more concomitant pathologies – ASA II–IV class. 20.9% of the patients had ASA III and IV. The most frequent concomitant pathology in patients with DTG was dysmetabolic cardiomyopathy (55.0%), in MNG patients was arterial hypertension (64.3%). A significant difference was revealed between patients with DTG and MNG in the frequency of occurrence of dysmetabolic cardiomyopathy, endocrine ophthalmopathy, atrial fibrillation, arterial hypertension, coronary heart disease, heart failure, kidney disease. The deviations from the normal anaesthesia process were noted in 85 cases according to anesthesiologists reports, which was 21,1% from the total anaesthesia number. The anaesthesia particularities were noted in 73 cases (22.8%) of the LFA/MFA patients and in 12 cases (14.6%) in the TIVA propofol patients (no significant difference between groups according to the  2 (Pearson) criterion).

Anesthesia in patients with thyrotoxicosis syndrome: a challenge for an anesthesiologist or routine?

Aim: to analyze anesthetic risks and anesthesia particularities in patients with thyrotoxicosis syndrome who undergone thyroidectomy in a specialized endocrinology center. Materials and methods. During the period January 2015 – April 2017 thyroidectomy was performed in 440 patients with thyrotoxicosis syndrome in the Department of Anesthesiology and Intensive Care of the Ukrainian Scientific and Practical Center of Endocrine Surgery, Transplantation of Endocrine Organs and Tissues. Surgical interventions were performed under conditions of general anesthesia with mechanical ventilation by using either the low-flow / minimally-flow inhalation anesthesia (LFA/MFA) with sevoflurane or the traditional in clinic total intravenous anesthesia (TIVA) with propofol. We assessed the physical status according to American Association of Anesthesiologists (ASA) classification, the frequency of concomitant pathology, the particularities of the anesthesia according to reports of anesthesiologists. Results and discussion. Among patients with thyrotoxicosis syndrome the most common diagnosis was moderate or severe diffuse toxic goiter (DTG) in the stage of drug compensation or subcompensation – 298 (68%), 104 (23%) patients had multinodular goiter (MNG) with thyrotoxicosis, the rest of patients had toxic adenoma – 22 (5%), also there were 12 (3%) patients with relapse of previously operated DTG or MNG. In 4 (1%) cases a combined pathology – papillary cancer in the background of MNG with thyrotoxicosis took place. Only 23.9% of the total had minimal anesthesia risk – ASA I. 76.1% of patients had one or more concomitant pathologies. The most difficult patients for planned anesthesia – with ASA grade III and IV – constitute 21.1% of cases. The number of concomitant pathologies ranged from one to six per patient, total 25 types of concomitant pathology were identified. The peculiarities of anesthesia were noted in 74 cases (16.8%). The anesthesia peculiarities were noted in 57 (16.3%) cases of LFA/MFA and in 17 (18.7%) cases of TIVA (no significant difference between groups according to the χ2 (Pearson) criterion). No fatal case was observed. Conclusions. The thyrotoxicosis syndrome impairs the ASA physical status. The most frequent concomitant pathology in patients with DTG was dysmetabolic cardiomyopathy (55.0%), in MNG patients – arterial hypertension (64.3%). A significant difference was revealed between patients with DTG and MNG in the frequency of dysmetabolic cardiomyopathy, endocrine ophthalmopathy, atrial fibrillation, arterial hypertension, coronary heart disease, heart failure etc. A personified approach to the choice of type of anesthesia and a thorough analysis of the anesthesia peculiarities are needed.

Diagnostic and Therapeutic Challenges of De Quervain Thyroiditis in Sub-Saharan Africa: Illustration with Two New Cases in Dakar

Introduction: De Quervain’s subacute thyroiditis is an inflammatory granulomatosis with clinical presentation some time atypical leading eventually to misdiagnosis or inadequate treatment. In our area, physician should be aware of this possible etiology in presence of recent and acute features of thyrotoxicosis with or without painful firm goiter. We illustrate this fact with two new observations from Sub-Saharan Africa. Observations: Our first patient is a 70-year-old Guinean woman presenting a painful nodular and hard goiter at palpation. Her history was recent in a context of deterioration of the general state with a sub clinical thyrotoxicosis syndrome. The diagnosis of probable malignant thyroid tumor was evoked initially and a thyroidectomy considered. She presented an important biological inflammatory syndrome and biological peripheral hyperthyroidism. Neck ultrasound examination showed heterogeneous patchy decreased echogenicity. The diagnosis of subacute De Quervain’s thyroiditis was set up. A corticosteroid therapy at a rate of 20 mg/day of prednisone was begun with a fast degression of dose. After 3 weeks of treatment, we noticed total clinical recovery normalization of biological parameters. The second observation was about a 52-year-old Senegalese women living in Bamako. She presented cervical pains evolving for 2 months in a context of flu-like syndrome associated with thyrotoxicosis and marked biological inflammatory syndrome. The thyroid ultrasound showed global heterogeneity with characteristic aspect of “geography map” leading to the diagnosis of subacute thyroiditis. A combination therapy with low dose of prednisone, ß-blockers and tranquillizers. We noticed fast disappearance of clinical and biological signs. At 5 mg per day of prednisone, there were moderate signs of relapse with rapid favorable evolution after few days under increased dose of prednisone up to 10 mg/day. Conclusion: De Quervain’s thyroiditis can appear under misleading features opening out to make wandering diagnosis. A good clinical evaluation coupled with hormonal and ultrasound thyroid examination may help for right management. The use of low dose of corticosteroid had enabled us to obtain a fast control of main clinical and biological abnormalities.

State of bone tissue in patients with thyrotoxicosis syndrome

Оbjective. To determine the influence of thyroid functional state on bone mineral density indexes from data of ultrasound densitometry and laboratory methods of research.Materials and methods. 80 patients of reproductive age with thyrotoxicosis syndrome were recruited. The thyroid functional state was estimated by means of determination of thyroid-stimulating hormone (TSH) basal concentrations and free thyroxine in the blood serum. Subjects were invited to attend quantitative ultrasound densitometry (Sahara), and a fasting blood sample from which osteocalcin, serum N-terminal propeptide of type 1 procollagen and crosslinks were also measured.Results. Frequency of bone mineral density disorders in patients with thyrotoxicosis syndrome was 52,7%, including osteopenia in 40% and osteoporosis in 12.7%. A basic factor that results in the decline of bone mineral density in patients with thyrotoxicosis syndrome is excessive products of thyroid hormones, and also TSH-suppressive doses of levothyroxine. Ultrasound densitometry showed significant decrease of bone mineral density indexes and increase of frequency of osteopenia and osteoporosis as compared to healthy persons.Conclusions. Complex approach is the first brought to the estimation of bone metabolism state in patients with thyrotoxicosis syndrome. It contains an ultrasound densitometry and laboratory methods of research. Set factors (excessive products of thyroid hormones, reception of preparations of thyroid hormones in TSH-suppressive doses) and mechanisms of negative influence (stimulation of osteoclastic activity, decline of osteoblastic activity) on the state of bone metabolism in patients with thyrotoxicosis syndrome.

Epidemiological, clinical, therapeutic and evolutive aspects of Basedow-Graves disease in the Depatment of Internal Medicine at CHU Aristide Le Dantec, Dakar (Senegal)

La maladie de Basedow est une affection auto immune associant une thyrotoxicose à des manifestations de fréquence variable comme le goitre, l'ophtalmopathie et le myxœdème prétibial. Son diagnostic est souvent facile, tandis que sa prise en charge demeure encore difficile. L'instauration d'un traitement médical simple expose à un risque de récidive. Au Sénégal et en Afrique Sub-saharienne peu d'études ont porté sur la maladie de Basedow. L'objectif de l'étude était de décrire les aspects épidémiologique, clinique, thérapeutique et évolutif de la maladie de Basedow en milieu hospitalier à Dakar. Il s'agissait d'une étude rétrospective menée du 1er janvier 2010 au 31 décembre 2013 dans le service de Médecine Interne du centre hospitalier universitaire Aristide Le Dantec. Durant la période, 108 patients suivis en consultation externe pour maladie de Basedow, ont été inclus sur un total de 834 patients suivis en consultation externe. le diagnostic a été retenu devant les signes cliniques, biologiques et immunologiques. Cent huit patients, atteints de maladie de Basedow ont été inclus sur un total de 834 consultations. Le sex ratio était de 7,3 et la moyenne d'âge de 34,6 ans. Les principaux motifs de consultation étaient : les palpitations et l'amaigrissement dans respectivement 46,3% et 39,8% des cas. Le syndrome de thyrotoxicose était présent chez 93,5% des patients, un goitre était noté chez 87% des patients et une exophtalmie chez 78,7% des patients. La principale complication était à type de cardiothyréose retrouvée chez 11,1% des patients. Tous les patients ont eu un traitement par antithyroïdiens de synthèse. L'évolution a été favorable dans 19,4% des cas. Une récidive à été notée dans 57% des cas et dans 23,1% des cas les patients ont été perdus de vue. La maladie de Basedow est la cause de la plus fréquente d'hyperthyroïdie. Le tableau est dominé par les manifestations cliniques liées à l'hyper métabolisme de l'organisme. Dans cette étude, il apparait que la thyroïdectomie n'est pas de première intention si l'on connait le nombre élevé de récidive après le traitement médical.

The risk of malignancies in women with long flowing hyperthyroidism in history: a retrospective randomized study

The syndrome of thyrotoxicosis is the second occurrence in endocrine diseases giving way to the only diabetes. The most common cause of hyperthyroidism is Graves' disease. Nodular toxic goiter is following Graves' disease. Then more rare causes are solitary toxic adenoma and thyroiditis. Epidemiological studies carried out at the turn of XX-XXI centuries in the developed countries of Europe and North America have shown that a history of hyperthyroidism episode increases the relative risk of development of ovarian cancer by 80 % and breast cancer by 45-60 %. It has been shown that hyperthyroidism including subclinical one is a risk factor for morbidity and mortality from malignant neoplasms of different localizations as breast cancer, thyroid cancer, pancreatic cancer and lung cancer. In this case, drew the fact that significant differences in the risk of morbidity by specific disease forms depends on the ethnic composition of the population. In Russian Federation the similar epidemiological studies have not been carried out yet. We obtained the results of an epidemiological retrospective multicenter randomized clinical simultaneous analytical comparative study of the “case-control” among women treated for diffuse toxic goiter and nodular toxic goiter in 1999-2009. The study involved 1135 patients with hyperthyroidism in anamnesis. The comparison group included 953 patients with eu- and hyperthyroid status. The risk of malignancies in women with hyperthyroidism in anamnesis was 2.36 (95 % CI 1.63-3.42, p < 0.01). The risk of hormone-dependent tumors was 2.65 ( 95 % CI 1.7-4.13, p < 0.01). The aim: to evaluate the risk of malignancies in women with long flowing hyperthyroidism.

IMMUNOLOGICAL AND MORPHOLOGICAL PREDICTORS OF CLINICAL HETEROGENEITY OF PATIENTS WITH GRAVES' DISEASE (BASED ON RESEARCH OF THE THYROID GLAND OPERATIONAL MATERIAL)

Very little research is devoted to the study of communication systemic immunological changes and local immunological changes in the tissue of the thyroid in autoimmune thyrophaties. The goal of the research was to establish immunologic and morphologic predictors of clinical course and functional outcomes of Graves’s disease (GD).Material and methods. We examined 45 patients with GD (14 men and 31 women) aged 18–55 years (47.0 (35.0–53.0)) years, matching the following criteria: a verified diagnosis GD, accommodation in Tomsk oblast and the Tomsk not less than 10 years, the patient's consent for the study. The control group included 30 people, with an average age of (45.3 ± 5.6) years and was comparable by age and sex with GD patients. The study included: definition of the standard for GD hormonal and serological profile (free T4, free T3, and TSH, antibodies to TPO, antibodies to the TSH receptor), the cultivation of mononuclear leukocytes in complete culture medium within 24 hours with subsequent determination of interleukins concentrations (IL-2, IL-4, TNF-alpha) in culture medium using enzyme-linked immunosorbent assay, determination of the number of blood cells carrying membrane-bound receptors to IL-2, IL-4, TNF-R1 by flow laser cytometry on cytometer BD FACS Canto tmΙΙ (USA) using labeled monoclonal antibody, the standard postoperative histological examination of thyroid gland tissue samples and immunohistochemical detection in samples of thyroid tissue receptors to IL-2, IL-4, TNF-alpha.Results. On the basis of the received results it is possible to allocate 2 clinical-immunologic and morphologic cluster of autoimmune hyperthyroidism syndrome in patients with clinical diagnosis of GD. The first includes the formation of 1 and 2 histological options GD (minimally expressed monocytes infiltration, lack of oncocytic transformation of thyroid epithelium), with some clinical characteristics (persistent and pronounced hyperthyroidism, the large size of goiter, higher titer of receptor TSH-antibody and smaller TPO-antibody, diffuse nature of the lesion), and the second – is represented by 3d histological option with oncocytic restructuring of follicular epithelium, expressed the monocyte/macrophage infiltration with the TNF-RI expression and clinical patterns, including: the older age group of patients, the smaller size of goiter, the emergence of “pseudo nodes” ultrasound, reflecting the presence of lymphoid follicles-infiltrates, more lenient for hyperthyroidism. Probably, that the 2nd cluster is a combination of “classical GD” with autoimmune thyroiditis, however, a set of clinical and laboratory-instrumental signs led to the fact that these patients were in the group of GD patients.Conclusion. This approach (combining study of indicators of systemic and local tissue-specific autoimmune inflammation) is a promising from the point of view of separate parts coverage in the autoimmune thyroids diseases pathogenesis, approximating researchers to develop immune based therapeutic technologies.

Association of Graves’ Disease and Systemic Lupus Erythematosus

Summary of Lupus and Basedow Disease Association: The association lupus auto-immune thyroid disease is well known. Lupus is most commonly associated with Hashimoto’s thyroiditis. As for Graves’ disease, it is most often associated with pernicious anaemia, vitiligo, idiopathic purpura and myasthenia gravis. To our knowledge, we report the first case of lupus associated with Graves’ disease in sub-Saharan Africa. Observation: A female patient of 52 years old has been followed since February 2010 for systemic lupus diagnosed on biological and immunological clinical ACR criteria. There was no skin ailment and kidneys involved. Combined treatment with high-dose corticosteroids early and rapid decrease and hydroxychloroquine was established with good clinical and biological evolution. One year later the patient developed thyrotoxicosis syndrome and vascular goitre without exophthalmos associated with the presence of antibodies anti receptor of TSH leading to the diagnosis of Graves’ disease. The patient has been treated with synthetic anti-thyroid and beta blocker allowing the regression of clinical symptoms and the normalization of thyroid hormones. Since then, the patient had not shown other signs of systemic affection. Conclusion: Systemic diseases are often associated with autoimmune thyreopathies. But association of lupus with Graves’ disease has been rarely described in the literature. One should always watch out for the occurrence of thyroid disease in front of any systemic disease and vice versa.

Thyroid diseases during pregnancy: a number of important issues.

The most common thyroid diseases during pregnancy are hyper- and hypothyroidism and their variants including isolated hypothyroxinemia (hypo-T4), autoimmune thyroid disease (AITD) and different types of goiter. AITD represents the main cause of hypothyroidism during pregnancy ranging in prevalence between 5 and 20% with an average of 7.8%. The incidence of isolated hypo-T4 is about 150 times higher compared to congenital hypothyroidism. Prevalence of Graves' disease (GD) ranges between 0.1% and 1% and the Transient Gestational Hyperthyroidism Syndrome between 1 and 3%. Thyroid stimulating hormone (TSH) is a sensitive marker of thyroid dysfunction during pregnancy. Normal values have been modified recently with a downward shift. Thus, the upper normal range is now considered to be 2.5 mUI/mL in the first trimester and 3.0 mUI/mL for the remainder of pregnancy. Most studies have shown that children born to women with hypothyroidism during gestation had significantly lower scores in neuropsychological tests related to intelligence, attention, language, reading ability, school performance and visual motor performance. However, some studies have not confirmed these findings. On the other hand, multiple retrospective studies have shown that the risks of maternal and fetal/neonatal complications are directly related to the duration and inadequate control of maternal thyrotoxicosis. The latter is associated with a risk of spontaneous abortion, congestive heart failure, thyrotoxic storm, preeclampsia, preterm delivery, low birth weight and stillbirth. Despite the lack of consensus among professional organizations, recent studies, which are based on sophisticated analyses, support universal screening in all pregnant women in the first trimester for thyroid diseases.