ABSTRACT
Aim: To present a case of acromegaly with coexisting thyrotoxicosis and to emphasize the relevance of screening the screening the thyroid before initiating treatment for thyrotoxicosis. Presentation of the Case: A 55-year-old lady presented with palpitations, and weight loss of two months’ duration. She also noted her fingers and toes had swollen up, inability to incise properly since two years. Upon examination, she had morphological features clinically diagnostic of acromegaly. Her thyroid was enlarged was on investigation found to have biochemical evidence of thyrotoxicosis. Fine needle aspiration cytology of the thyroid yielded colloid goiter. Insulin like growth factor-1 was elevated. Serum growth hormone after an oral glucose tolerance test was elevated. Magnetic resonant imaging (MRI) of the brain revealed a hypo enhancing focal lesion of size 11X10X12 mm at the pituitary region with delayed contrast enhancement suggestive of pituitary adenoma. Patient was started on anti-thyroid medications and referred to higher centre, and is awaiting surgery for pituitary adenoma. Discussion: Among patients with acromegaly the incidence of thyroid diseases is around 78% and it has the most common presentation being nodular thyroid disease as the initial presentation. It is uncommon to see patients presenting with symptoms of thyrotoxicosis initially, who had florid morphological features of acromegaly. The prevalence of toxic nodular goiter to the tune of 14.3% in acromegaly. Goiters seen in acromegaly were euthyroid or autonomous, are due to the elevated growth hormone levels independent of TSH action. In about 13 to 17%, thyroidectomies were performed before acromegaly was diagnosed. When patients with acromegaly presents with a weight loss should arouse the possibilities of thyroid cancer or hyperthyroidism. Conclusion: Screening the thyroid is important, as inadvertent thyroidectomies were performed before acromegaly was diagnosed. When acromegaly co-exists with thyroid dysfunction, the burden of cardiovascular abnormality should be addressed especially, to reduce the morbidity and mortality rate.
ABSTRACT
INTRODUÇÃO: O hipertireoidismo é caracterizado pelo aumento da síntese e liberação dos hormônios tireoidianos pela glândula tireoide. A tireotoxicose refere-se à síndrome clínica decorrente do excesso de hormônios tireoidianos circulantes, secundário ao hipertireoidismo ou não. Este artigo descreve diretrizes baseadas em evidências clínicas para o manejo da tireotoxicose. OBJETIVO: O presente consenso, elaborado por especialistas brasileiros e patrocinado pelo Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia, visa abordar o manejo, diagnóstico e tratamento dos pacientes com tireotoxicose, de acordo com as evidências mais recentes da literatura e adequadas para a realidade clínica do país. MATERIAIS E MÉTODOS: Após estruturação das questões clínicas, foi realizada busca das evidências disponíveis na literatura, inicialmente na base de dados do MedLine-PubMed e posteriormente nas bases Embase e SciELO - Lilacs. A força das evidências, avaliada pelo sistema de classificação de Oxford, foi estabelecida a partir do desenho de estudo utilizado, considerando-se a melhor evidência disponível para cada questão. RESULTADOS: Foram definidas 13 questões sobre a abordagem clínica inicial visando ao diagnóstico e ao tratamento que resultaram em 53 recomendações, incluindo investigação etiológica, tratamento com drogas antitireoidianas, iodo radioativo e cirurgia. Foram abordados ainda o hipertireoidismo em crianças, adolescentes ou pacientes grávidas e o manejo do hipertireoidismo em pacientes com oftalmopatia de Graves e com outras causas diversas de tireotoxicose. CONCLUSÕES: O diagnóstico clínico do hipertireoidismo, geralmente, não oferece dificuldade e a confirmação diagnóstica deverá ser feita com as dosagens das concentrações séricas de TSH e hormônios tireoidianos. O tratamento pode ser realizado com drogas antitireoidianas, administração de radioiodoterapia ou cirurgia de acordo com a etiologia da tireotoxicose, as características clínicas, disponibilidade local de métodos e preferências do médico-assistente e paciente.
INTRODUCTION: Hyperthyroidism is characterized by increased synthesis and release of thyroid hormones by the thyroid gland. Thyrotoxicosis refers to the clinical syndrome resulting from excessive circulating thyroid hormones, secondary to hyperthyroidism or due to other causes. This article describes evidence-based guidelines for the clinical management of thyrotoxicosis. OBJECTIVE: This consensus, developed by Brazilian experts and sponsored by the Department of Thyroid Brazilian Society of Endocrinology and Metabolism, aims to address the management, diagnosis and treatment of patients with thyrotoxicosis, according to the most recent evidence from the literature and appropriate for the clinical reality of Brazil. MATERIALS AND METHODS: After structuring clinical questions, search for evidence was made available in the literature, initially in the database MedLine, PubMed and Embase databases and subsequently in SciELO - Lilacs. The strength of evidence was evaluated by Oxford classification system was established from the study design used, considering the best available evidence for each question. RESULTS: We have defined 13 questions about the initial clinical approach for the diagnosis and treatment that resulted in 53 recommendations, including the etiology, treatment with antithyroid drugs, radioactive iodine and surgery. We also addressed hyperthyroidism in children, teenagers or pregnant patients, and management of hyperthyroidism in patients with Graves' ophthalmopathy and various other causes of thyrotoxicosis. CONCLUSIONS: The clinical diagnosis of hyperthyroidism usually offers no difficulty and should be made with measurements of serum TSH and thyroid hormones. The treatment can be performed with antithyroid drugs, surgery or administration of radioactive iodine according to the etiology of thyrotoxicosis, local availability of methods and preferences of the attending physician and patient.