La cirugía en el tratamiento de la crisis tirotóxica / Surgery for the Treatment of Thyrotoxic Crisis

RESUMEN La crisis tirotóxica es una complicación de la tirotoxicosis mal tratada y se asocia con una elevada mortalidad. Requiere tratamiento médico urgente en unidades de cuidados intensivos. Mujer de 42 años, con antecedentes personales de hipertensión arterial y nódulo tiroideo hiperfuncionante desde hace 18 años, con abandono del tratamiento médico hace dos años, que acude a urgencias con disnea paroxística nocturna, taquicardia, hipertensión arterial, gran bocio y anasarca. Ingresa en la unidad de cuidados intensivos con diagnóstico de crisis tirotóxica e inicia el tratamiento médico con medidas de soporte precisas, la que incluye intubación orotraqueal. Debido a la dificultad de manejo clínico y respiratorio de la paciente, se decide realizar tratamiento quirúrgico urgente. Se practica una tiroidectomía total de bocio multinodular parcialmente intratorácico y una traqueostomía preventiva. El resultado de anatomía patológica fue: bocio multinodular tóxico. La paciente fue dada de alta con función tiroidea normal, cierre de traqueostomía y buena fonación, tras mes y medio de hospitalización. A pesar de que un tratamiento médico conservador es el adecuado de la tirotoxicosis, los síntomas y signos sistémicos de la crisis tirotóxica y sus manifestaciones órgano-específicas, asociados a una persistente dificultad respiratoria por síntomas compresivos derivados del gran bocio, se consideró que la tiroidectomía urgente en este caso estaba indicada, dato que se corroboró ante la buena evolución posoperatoria. El tratamiento de la tirotoxicosis es fundamentalmente clínico, sin embargo, la cirugía puede ser útil ante la dificultad en el manejo clínico(AU)

Abstract The thyrotoxic crisis is a complication of poorly treated thyrotoxicosis and is associated with high mortality. This condition requires urgent medical treatment in intensive care units. A 42-year-old woman, with a personal history of high blood pressure, hyperfunctioning thyroid nodule for 18 years, and abandonment of medical treatment since two years ago, presented to the emergency department with paroxysmal nocturnal dyspnea, tachycardia, high blood pressure, large goiter, and anasarca. She was admitted into the intensive care unit with a diagnosis of thyrotoxic crisis and started to receive medical treatment under precise support measures, including orotracheal intubation. Due to the patient's difficult clinical and respiratory management, it was decided to perform urgent surgical treatment. She was performed a total thyroidectomy of partial intrathoracic multinodular goiter and a preventive tracheostomy. The result of pathological anatomy was toxic multinodular goiter. The patient was discharged with normal thyroid function, tracheostomy closure, and good phonation, after a month and a half of hospitalization. Despite the fact that conservative medical treatment is the adequate one for thyrotoxicosis, the systemic symptoms and signs of the thyrotoxic crisis, and its organ-specific manifestations, associated with persistent respiratory distress due to compression symptoms derived from large goiter, urgent thyroidectomy needed to be indicated in this case, a fact corroborated after good postoperative evolution. The treatment of thyrotoxicosis is fundamentally clinical; however, surgery can be useful given the difficulty in clinical management(AU)

Hyperthyroid Graves’ disease after radioiodine therapy for non-toxic multinodular goiter

Background: Radioiodine treatment has been used to reduce the size of euthyroid multinodular goiter (MNG) as an alternative to surgery. Postradioiodine Graves’ disease is a rare side effect which can occur several months after radioiodine treatment for non-toxic multinodular goiter. Objective: To report two patients who developed hyperthyroid Graves’ disease after radioiodine therapy for non-toxic multinodular goiter. Methods: We report the clinical and laboratory findings of Graves’ disease which occurred after radiotherapy. The literature was reviewed for the incidence and pathogenesis of Graves’ disease after radioiodine therapy. Results: The first case describes a 39-year-old woman presented with hyperthyroidism after repeated radioiodine therapy for non-multinodular goiter. The second case describes a 45-year-old woman who presented with hyperthyroidism after the first dose of radioiodine therapy for non-multinodular goiter. Graves’ disease was confirmed in both cases by the presence of thyrotropin receptor antibody (TRAb). Both patients respond well to methimazole. Conclusion: We demonstrate the rare occurrence of Graves’ disease as the side effect of radioiodine treatment for non-toxic multinodular goiter. They highlight the importance of recognizing patients with hyperthyroidism after radioiodine treatment as they could develop hyperthyroid Graves’ disease following this treatment.

Relationship between thyrotropin receptor gene mutation and toxic multinodular goiter / 中华内分泌代谢杂志

DNA was extracted from thyroid nodular tissue in 16 patients with toxic multinodular goitor (TMG). After PCR, the product of PCR was sequenced, and 3 cases with point mutation (A1964T) and 2 cases with insertion mutation (a G was inserted after nucleotide 1928) in TSH receptor gene were found. It is postulated that these mutations may play an important role in the pathogenesis of TMG.