Dolor y edema de miembros inferiores por dermopatía tiroidea: presentación inusual de la enfermedad de Graves en una paciente adolescente / Lower limb pain and edema due to thyroid dermopathy: an unusual presentation of Graves disease in an adolescent patient

La enfermedad de Graves es un proceso inmunomediado en el que autoanticuerpos se dirigen contra el receptor de tirotrofina. Por su acción estimulante sobre la glándula tiroides, se genera crecimiento glandular difuso y aumento de la hormonogénesis. Se caracteriza por el comienzo subagudo de síntomas constitucionales, neuromusculares, cardiovasculares, gastrointestinales y oculares, seguidos en algunos casos de la aparición de manifestaciones cutáneas como la dermopatía tiroidea o mixedema. En pediatría la enfermedad de Graves es infrecuente (aunque es la causa más frecuente de hipertiroidismo), pero la cronología de aparición de los síntomas está bien descrita; es rara la aparición de dermopatía en ausencia de otros síntomas de hipertiroidismo y sin afectación ocular. Se presenta el caso de una paciente de 15 años con dermopatía tiroidea por enfermedad de Graves sin oftalmopatía ni otros síntomas de hipertiroidismo clínico asociados.

Graves disease is an immune-mediated process characterized by the presence of autoantibodies to thyrotropin receptors. Its stimulating action on the thyroid gland causes diffuse glandular growth and increased hormone production. Graves disease is characterized by a subacute onset of non-specific, neuromuscular, cardiovascular, gastrointestinal, and eye symptoms, sometimes followed by skin manifestations, such as thyroid dermopathy or myxedema. In pediatrics, Graves disease is rare (although it is the most frequent cause of hyperthyroidism). However, the chronology of symptom onset has been well described; the development of dermopathy in the absence of other symptoms of hyperthyroidism and without eye involvement is rare. Here we describe the case of a 15-year-old female patient with thyroid dermopathy due to Graves disease without eye disease or other associated clinical symptoms of hyperthyroidism.

Características de orbitopatía asociada al tiroides y tasa de requerimiento de cirugía / Thyroid-associated orbitopathy characteristics and surgery requirement rate

RESUMO Objetivo: Conheça as características demográficas e clínicas da Órbita Associada da Tiroide (OAT), bem como a taxa de exigência da cirurgia orbital em pacientes do Centro Médico Nacional do Oeste. Métodos. Estudo observacional, transversal, descritivo e retrospetivo realizado analisando os registos de pacientes diagnosticados com OAT tratados num centro de cuidados de terceiro nível de janeiro de 2005 a julho de 2016. Os resultados. Um total de 236 órbitas de 118 pacientes foram avaliados, com uma idade média de 47,3 (13,2 anos, 74,6% eram do sexo feminino e 25,4% masculinos. 4,2% dos doentes foram tratados com hipotiroidismo, 94,1% com hipertireoidismo e 1,7% com goiter tóxico difuso. 44,9% dos doentes estudados com restrição de movimento ocular,10,2% com queratopatia de exposição e 51,7% com hipertensão intraocular. 34,7% dos doentes avaliados no serviço necessitaram de descompressão orbital, 16,1% de cirurgia palpebral e 8,5% de correção do hatrabisma. Na gestão conservadora destes doentes, 48,3% exigiam o uso de lubrificantes tópicos dos olhos, enquanto 52,5% dos pacientes necessitavam do uso de hipotensivos oculares em número variável. As conclusões. A OAT foi associada principalmente ao hipertiroidismo, sendo mais comum em pacientes do sexo feminino entre os 40 e os 59 anos; mais de 50% dos pacientes necessitaram do uso de hipotensivos oculares. Da mesma forma, a gestão cirúrgica foi realizada em mais de 50% dos pacientes, sendo a descompressão orbital a intervenção mais frequente.

ABSTRACT Objective. To know the demographic and clinical characteristics of Thyroid Associated Orbitopathy (TAO), as well as the requirement rate of orbital surgery in patients of the Orbit Service in the National Medical Center of the West, IMSS. Methods. Observational, cross-cutting, descriptive and retrospective study carried out analyzing the records of patients diagnosed with TAO and treated at a third-level care center from January 2005 to July 2016. Results. A total of 236 orbits of 118 patients were valued, with an average age of 47.3 ± 13.2 years, 74.6% were female and 25.4% male. 4.2% of patients were treated with hypothyroidism, 94.1% with hyperthyroidism and 1.7% with diffuse toxic goiter. 44.9% of patients studied had eye movement restriction,10.2% exposure keratopathy and 51.7% intraocular hypertension. 34.7% of patients valued in the service required orbital decompression, 16.1% palpebral surgery and 8.5% strabism correction. In the conservative management of these patients 48.3% required the use of topical eye lubricants, while 52.5% required the use of eye hypotensives in variable numbers. Conclusions. TAO was mainly associated with hyperthyroidism, being more common in female patients between the age of 40 and 59; more than 50% of patients required the use of eye hypotensives. Likewise, surgical management was performed in more than 50% of patients, with orbital decompression being the most frequent intervention.

Clinical characteristics of Graves / 中南大学学报(医学版)

OBJECTIVES@#A variety of causes can lead to cholestasis, however, cholestasis caused by Graves' disease is usually overlooked clinically. Here we analyze the clinical characteristics of Graves' disease associated cholestasis so as to have a better understanding for the disease.@*METHODS@#We retrospectively collected 13 inpatients' data who suffered from the Graves' disease associated cholestasis in the Department of Infectious Disease of Xiangya Hospital from January 2000 to December 2018. The characteristics of the patients' age, gender, liver function, thyroid function, coagulation function, the special cardiac examination, treatment, and follow-up data were analyzed.@*RESULTS@#Thirteen patients, including 10 males and 3 females with the age range from 33 to 55 (median 43) years old presented cholestasis, pruritus, and hypermetabolic symptoms. The levels of total bilirubin (TBIL), direct bilirubin (DBIL), glutamic-pyruvic transferase, glutamic-oxaloacetic transferase, alkaline phosphosphatase, and gamma glutamyl transpeptidase were 170.4-976.7 (median 388.8) µmol/L, 93.2-418.1 (median 199.2) µmol/L, 25.1-182.1 (median 106.4) U/L, 38.2-265.7 (median 59.7) U/L, 105.3-332.0 (median 184.5) U/L, and 20.7-345.1 (median 47.6) U/L, respectively. The levels of free triiodothyronine (FT@*CONCLUSIONS@#Graves' disease can cause cholestasis, with the low incidence. The symptoms of cholestasis can be improved or even eradicated with the cure of the Graves' disease. The cholestasis may be idiopathic. For patients with cholestasis and hyperthyroidism, Graves' disease should be considered for differential diagnosis.

Acquired reactive perforating collagenosis in association with prostate adenocarcinoma, chronic lymphocytic leukemia, and Graves disease

Abstract Acquired reactive perforating collagenosis is a rare skin disorder characterized by the presence of umbilicated pruritic papules and nodules. Transepidermal elimination of altered and perforating bundles of basophilic collagen from the epidermis is a characteristic histologic feature of acquired reactive perforating collagenosis. Along with its well-known association with systemic diseases such as diabetes mellitus, chronic renal failure, and dermatomyositis, there are reports of acquired reactive perforating collagenosis being associated with malignancies. Herein, we present a case of acquired reactive perforating collagenosis associated with chronic lymphocytic leukemia, prostate adenocarcinoma, and Graves's disease. Clinicians are required to be more vigilant in evaluating patients with acquired reactive perforating collagenosis due to its unique association with malignancies and other systemic diseases.

Cholestasis secondary to hyperthyroidism in Graves disease: report of one case / Colestasia en un paciente con hipertiroidismo por enfermedad de Graves: informe de un caso

ABSTRACT Hyperthyroidism can induce elevation in several liver function tests including aminotransferases, alkaline phosphatases and, less frequently, serum bilirubin. These alterations are usually mild and asymptomatic. We report a 26 year-old male presenting with palpitations, progressive jaundice, choluria and generalized itching. Laboratory tests were compatible with hyperthyroidism and a mild elevation of bilirubin, alkaline phosphatases and gamma glutamyl transpeptidase. A liver biopsy showed portal hepatitis with canalicular cholestasis. The patient was treated temporarily with glucocorticoids, cholestyramine and betablockade. Thereafter, he was treated with radioactive iodine, after which serum bilirubin decreased steadily until normalization in ten weeks.

El hipertiroidismo puede producir elevación de aminotransferasas, fosfatasas alcalinas y, menos frecuentemente, de bilirrubina sérica. Habitualmente, estas alteraciones son leves y asintomáticas. Reportamos un hombre de 26 años con hipertiroidismo secundario a enfermedad de Basedow-Graves, que debutó con un cuadro colestásico, inicialmente estudiado por sospecha de patología hepática autoinmune que incluyó biopsia hepática. Posteriormente, se diagnosticó hipertiroidismo que fue tratado con glucocorticoides, colestiramina y beta bloqueo como puente a terapia definitiva con radioyodo. La evolución mostró disminución progresiva hasta la normalización de bilirrubina sérica.

Restless Legs Syndrome, and symptoms of Restless Syndrome in patients with Graves disease: a cross-sectional survey

OBJECTIVES: Restless legs syndrome (RLS) is a frequent comorbid condition associated with distinct unrelated diseases. While the incidence of RLS has not been definitively confirmed, RLS-like symptoms have been reported in a section of Asian population who also had hyperthyroidism. The prevalence of RLS is generally low in Asian populations. Under these circumstances, we hypothesized that in a population where RLS is common, such as in Brazil, RLS could manifest as a comorbid ailment alongside Graves' disease, a common hyperthyroid condition. METHODS: In a cross-sectional survey, 108 patients who presented with Graves' disease were analyzed for restless legs or associated symptoms. RESULTS: Twelve patients (11.1%) displayed symptoms of RLS prior to the incidence of Graves' disease. These patients experienced worsening of the symptoms during their hyperthyroid state. Six patients (5.6%) developed RLS, consequent upon the incidence of Graves' disease as per the consensus of the panel of the experts. Fifteen patients (13.9%) also presented with RLS-like symptoms without any discernible circadian feature of the syndrome. CONCLUSION: Our findings confirm that Graves' disease might trigger restless legs-like symptoms, while the condition of hyperthyroidism could also be complicated by definite RLS.

Tiroidectomía en polineuropatía desmielinizante aguda para paciente con enfermedad de Graves: a propósito de un caso / Thyroidectomy in acute demyelinating polyneuropathy for a patient with Graves' disease: a case report

RESUMEN Existen pocos estudios que describan las complicaciones neuromusculares del hipertiroidismo. Presentamos el caso de una mujer de 36 años con antecedente de enfermedad de Graves en manejo médico, quien presentó compromiso motor y sensitivo progresivo en extremidades inferiores hasta comprometer la marcha. La electromiografía fue compatible con polineuropatía desmielinizante aguda, la resonancia nuclear magnética sugirió síndrome de Guillain-Barré. Se proporcionó manejo con plasmaféresis y se ajustó tratamiento tiroideo presentando mejoría transitoria. Posteriormente presentó deterioro neurológico con debilidad ascendente y compromiso deglutorio; a pesar de inicio de ciclo de inmunoglobulina persistió empeoramiento clínico con requerimiento de soporte ventilatorio; se decidió realizar tiroidectomía, que resultó en mejoría clínica y resolución del cuadro.

ABSTRACT There are few studies that describe the neuromuscular complications of hyperthyroidism. We present the case of a 36-year-old woman with a history of Graves' disease in medical management, who presented motor and sensitive involvement in the lower limbs until compromising gait. Electromyography was compatible with acute demyelinating polyneuropathy, nuclear magnetic resonance suggested Guillain-Barré syndrome. Management with plasmapheresis was indicated, and thyroid therapy was adjusted with transient improvement. Subsequently, she presented neurological deterioration with ascending weakness and swallowing compromise; despite an immunoglobulin cycle regimen, clinical worsening persisted with the requirement of ventilatory support; thyroidectomy was performed resulting in clinical improvement and resolution of the condition.

Enfermedad de Graves-Basedow e hiperplasia tímica: una asociación que no nos debe extrañar / raves-Basedow disease and thymic hyperplasia: an association that must not surprise us

RESUMEN El aumento del tamaño del timo asociado a hiperplasia tímica (HT) es frecuente en los pacientes con enfermedad de Graves-Basedow (EGB), si bien es poco habitual detectarla en la práctica clínica diaria. Presentamos el caso de una mujer de 38 años con EGB, a quien se le detectó de manera incidental un aumento del timo. La paciente no tenía síntomas compresivos locales y la tomografía computarizada demostró engrosamiento homogéneo de mediastino anterior sugestivo de HT. Durante la evolución, se evidenció reducción del tamaño tras el control de la función tiroidea con fármacos antitiroideos. La presencia de algunas características radiológicas como aumento difuso y homogéneo de la glándula, ausencia de invasión de estructuras vecinas, calcificaciones o imágenes quísticas, sugiere la presencia de una HT. En estos casos, el tratamiento del hipertiroidismo y un control expectante son actitudes razonables. Conocer esta evolución puede evitar intervenciones diagnósticas o terapéuticas innecesarias.

ABSTRACT Thymic enlargement associated with thymic hyperplasia (TH), in patients with Graves-Basedow disease (GBD) is common, although it remains largely unrecognized in routine clinical practice. We present the case of a 38 year-old woman with GBD, to whom an incidental thymic enlargement was detected. The patient did not have local compressive symptoms and the computerized tomography showed homogenous thickening of the anterior mediastinum suggestive of TH. During evolution, a reduction in size was observed after thyroid function was controlled by anti-thyroid drugs. The presence of some radiological features such as diffuse and homogeneous gland enlargement, absence of invasion of neighboring structures, calcifications or cystic images suggests the presence of TH. In these cases treatment of hyperthyroidism and expectant management are reasonable responses. Recognizing this evolution can avoid unnecessary diagnostic or therapeutic interventions.

TSH-receptor antibodies may prevent bone loss in pre- and postmenopausal women with Graves' disease and Graves' orbitopathy

ABSTRACT Objective Thyrotoxicosis is established risk factor for osteoporosis due to increased bone turnover. Glucocorticoids often administered for Graves' orbitopathy (GO) have additional negative effect on bone mineral density (BMD). Our aim was to examine the influence of thyroid hormones, TSH, TSH-receptor antibodies (TRAb) and glucocorticoid treatment on bone in women with Graves' thyrotoxicosis and Graves' orbitopathy (GO). Subjects and methods Forty seven women with Graves' disease, mean age 55.6 ± 12.8 (23 women with thyrotoxicosis and 24 hyperthyroid with concomitant GO and glucocorticoid therapy) and 40 age-matched healthy female controls were enrolled in the study. We analyzed clinical features, TSH, FT4, FT3, TRAb, TPO antibodies. BMD of lumbar spine and hip was measured by DEXA and 10-year fracture risk was calculated with FRAX tool. Results The study showed significantly lower spine and femoral BMD (g/cm2) in patients with and without GO compared to controls, as well as significantly higher fracture risk. Comparison between hyperthyroid patients without and with orbitopathy found out significantly lower spine BMD in the first group (p = 0.0049). Negative correlations between FT3 and femoral neck BMD (p = 0.0001), between FT4 and BMD (p = 0.049) and positive between TSH and BMD (p = 0.0001), TRAb and BMD (p = 0.026) were observed. Fracture risk for major fractures and TRAb were negatively associated (p = 0.05). We found negative correlation of BMD to duration of thyrotoxicosis and cumulative steroid dose. Conclusions Our results confirm the negative effect of hyperthyroid status on BMD. TRAb, often in high titers in patients with GO, may have protective role for the bone, but further research is needed.

Estruma ovárico asociado con enfermedad de graves / Struma ovarii associated with Graves' disease

El hipertiroidismo se define como la producción excesiva de hormonas tiroideas a partir de tejido tiroideo maduro eutópico o ectópico. La prevalencia general de hipertiroidismo es 1.2%, y la causa más frecuente es la enfermedad de Graves. El estruma ovárico representa el 1% de todos los tumores ováricos y es una causa infrecuente de hipertiroidismo ectópico. Su comportamiento es benigno en más del 90% de los casos; usualmente asintomáticos, sólo el 8% se presentan con tirotoxicosis, y es infrecuente su asociación con enfermedad de Graves. Se comunica el caso de una paciente con esta infrecuente asociación.

Hyperthyroidism is defined as an excessive production of thyroid hormones by eutopic or ectopic mature thyroid tissue. The overall prevalence of hyperthyroidism is 1.2% and the most common cause is Graves' disease. Struma ovarii represents 1% of all ovarian tumors and is an uncommon cause of ectopic hyperthyroidism. It is benign in >90% of the cases; usually asymptomatic, and only 8% are presented with thyrotoxicosis, being rare its association with Graves' disease. We report the case of a patient with this association.

Multifocal oral melanoacanthoma associated with Addison's disease and hyperthyroidism: a case report

SUMMARY Oral melanoacanthoma is a mucocutaneous, pigmented, rare, benign, and probably reactive lesion. This paper reports for the first time in the literature a case of multifocal oral melanoacanthoma in a patient diagnosed with Addison's disease and concomitant Graves' disease with hyperthyroidism. The patient presented with oral pigmented lesions, which were hypothesized to be mucosal pigmentation associated with Addison's disease. Due to their unusual clinical pattern, these oral lesions were biopsied and diagnosed as oral melanoacanthoma on histopathology and immunohistochemistry for HMB-45. At the moment of this report, the patient was being treated for her systemic conditions, but the lesions had not regressed. Reactive hyperpigmentation of the skin and mucous membranes may be found in Addison's disease and hyperthyroidism. This case reinforces the hypothesis of a reactive nature for oral melanoacanthoma and highlights the need for investigation of endocrine disorders in patients with multifocal oral melanoacanthoma.

Tormenta tiroidea asociada a disfunción multiorgánica / Thyroid storm associated with multiorganic dysfunction

La tormenta tiroidea es una condición infrecuente y potencialmente fatal. En la literatura han sido descritas varias presentaciones inusuales de la misma; sin embargo, la disfunción multiorgánica es rara vez vista. Aquí describimos un caso en una mujer de 36 años de edad con enfermedad de Graves subyacente no diagnosticada hasta entonces, quien inició su sintomatología con una tormenta tiroidea. Su score de Burch y Wartofsky fue de 50/140. Desarrolló falla hepática aguda, falla renal aguda, acidosis láctica, falla cardíaca, bicitopenia, coagulopatía y rabdomiolisis. La disfunción multiorgánica se revirtió gracias a la pronta instauración de los esteroides, ciclofosfamida, plasmaféresis y posterior tiroidectomía. La dificultad reside en reconocer las variadas presentaciones de la enfermedad y ofrecer un tratamiento apropiado cuando se enfrenta a las contraindicaciones o las fallas terapéuticas del tratamiento convencional.

Thyroid storm is a rare and potentially fatal condition. Unusual presentations in patients with thyroid storm have been described but multiorganic dysfunction is uncommonly seen. We describe the case of a 36-year-old woman with unknown underlying Graves´s disease who developed thyroid storm. The thyroid storm score of Burch and Wartofsky was 50/140. This was complicated by acute liver failure, acute kidney injury, lactic acidosis, heart failure, bi-cytopenia, coagulopathy and rhabdomyolysis. The severe multiorgan dysfunction was reversed by prompt institution of steroids, cyclophosphamide and plasma exchange before thyroidectomy. Main difficulty lies in recognizing its varied presentations and offering appropriate treatment when physician faces either failure or contraindications of conventional therapy.

Relación entre linfocitos T reguladores (T regs) y anticuerpos anti-receptores de TSH (TRab) y el riesgo de cáncer de tiroides en enfermedad de Graves / Relationship between T regulatory lymphocytes (Tregs) and TSH receptor antibodies (TRab) on risk of thyroid cancer in Graves disease

Durante los últimos años se ha estudiado la relación entre enfermedad de Graves (EG), TSH, TRAb y cáncer de tiroides, existiendo estudios que demuestran mayor prevalencia y agresividad del cáncer de tiroides en pacientes con EG, mientras otros refutan estos hallazgos sugiriendo que serían producto del sesgo de selección. Aquellos estudios que plantean una relación causal entre EG y el desarrollo de cáncer de tiroides, la atribuyen a la presencia de autoanticuerpos TSI, que estimularían el foco de malignidad. Se cree que las citoquinas producidas localmente en pacientes con EG trabajarían en conjunto con los TRAb para determinar la agresividad del cáncer papilar de tiroides en estos pacientes. Dentro de las células reclutadas por el tumor para evadir la respuesta inmune se encuentran los linfocitos Treg, que estarían elevados en paciente con EG, llevando a la disminución de la respuesta inmune y creando un ambiente permisivo para la proliferación celular. Por tratarse de una línea de investigación reciente, no existe consenso sobre el tema y sus implicancias en el tratamiento de los pacientes con EG. La finalidad de este artículo es realizar una revisión de la literatura que exponga y contraste la información disponible a la fecha.

In recent years the relationship between Graves’ disease (GD), TSH, TRAb and thyroid carcinoma has been studied. Research studies show a higher prevalence and aggressiveness of thyroid carcinoma in patients with GD, however other researchers refute these findings suggesting it’s due to selection bias. Increasing evidence suggests a causal relationship between GD and the development of thyroid carcinoma, mainly because of the existence of TSI autoantibodies that could stimulate the focus of malignancy. It is believed that cytokines produced locally in patients with GD work alongside with TRAb regulating the aggressiveness of papillary thyroid carcinoma in these patients. Within the cells recruited by the tumor to elude the immune system we find Treg lymphocytes, which have been found to be increased in patients with GD, leading to a diminished immune response, creating a permissive environment for cell proliferation. Since this is a relatively new line of research, there is no consensus on the subject and its relevance for the treatment of patients with GD. The aim of this article is to show recent literature available on the subject.

Diplopia vertical persistente pós-facectomia e tireoidopatia associadas / Persistent vertical post-facectomy and associated thyroid disease

RESUMO Os autores relatam o caso de uma paciente feminina de 69 anos que desenvolveu diplopia vertical persistente após facectomia extracapsular sob anestesia peribulbar. Paciente apresentava história de tireoidopatia tratada o que tornou a condcução da diplopia mais complexa. Os autores enfatizam a necessidade de se realizar propedêutica orbitária detalhada para se descartar quadros restritivos da musculatura extraocular associados à diplopia pós-facectomia.

ABSTRACT The authors report a case of a 69 year-old woman who developed persistent vertical deviation and diplopia after extracapsular cataract surgery and had a positive past history of thyroid disease. The authors emphasize the need of for detailed orbit propedeutics in order to rule out restrictive strabismus associated with post-facectomy diplopia.

Tormenta tiroidea: una urgencia endocrinológica / Thyroid storm: an endocrinological urgency

Thyroid storm is a rare and potentially fatal disease characterized by severe clinical manifestations of thyrotoxicosis. The most common cause of hyperthyroidism is Graves's disease (GD) and infections are the most important precipitating factor. A woman of 33 years with history of hyperthyroidism, hypertension and morbid obesity. She was treated with propylthiouracil for one year, and then suspended controls and treatment 2 years ago. Consult for 2 weeks characterized by dyspnea, cough and expectoration, plus an episode of generalized tonic-clonic seizure. In postictal state, persists with dyspnea and chest pain, which is brought to the emergency room. It is hypotensive, with fever and tachycardia, SatO2 60% on room air. It is intubated and connected to invasive mechanical ventilation. It evolves with monomorphic ventricular tachycardia, requiring cardioversion twice, recovering sinus rhythm. Imaging studies reported bilateral lung disease. CT scan brain and lumbar punture are normal. As is treated as septic shock lung focus. Among its tests: TSH 0.01 mIU/L, T4 T 23.9 ug/dL, T4L 4.77 ng/dL, T3 5.38 ng/ml, with Wartofsky Score: 90. It is managed as TS, treatment is initiated with methimazole, Propranolol, Hydrocortisone. Thyroid ultrasound shows: Goiter with cold nodules. In addition has positive TRAb. She recovers both of system cardiovascular and their respiratory infection. The patient is prepared with amiodarone and lugol for total thyroidectomy. Concordant biopsy with GD.

Graves' Patient with Thymic Expression of Thyrotropin Receptors and Dynamic Changes in Thymic Hyperplasia Proportional to Graves' Disease Activity

Thymic hyperplasia is frequently observed in Graves' disease. However, detectable massive enlargement of the thymus is rare, and the mechanism of its formation has remained elusive. This case showed dynamic changes in thymic hyperplasia on serial computed tomography images consistent with changes in serum thyrotropin receptor (TSH-R) antibodies and thyroid hormone levels. Furthermore, the patient's thymic tissues underwent immunohistochemical staining for TSH-R, which demonstrated the presence of thymic TSH-R. The correlation between serum TSH-R antibody levels and thymic hyperplasia sizes and the presence of TSH-R in her thymus suggest that TSH-R antibodies could have a pathogenic role in thymic hyperplasia.

Hipertiroidismo neonatal: presentación de caso clínico / Neonatal hyperthyroidism. Presentation of clinical case

Tirotoxicosis es el término utilizado para referirse al exceso de hormonas tiroideas. El hipertiroidismo neonatal causado por la Enfermedad de Graves es una patología con incidencia muy baja; apenas el 5% de las tirotoxicosis ocurre en la niñez y el hipertiroidismo neonatal se presenta en menos del 1% de los casos de tirotoxicosis en este grupo etario. Durante la gestación, los TSI (inmunoglobulinas estimulantes de la tiroides) producidos por la madre pasan a través de la placenta hacia el feto, donde igualmente actúan en los receptores de TSH de la tiroides del feto causando sobre-producción de hormonas tiroideas. Encontrar valores elevados de T3, T4 y TSI, además de tener valores bajos de TSH plasmáticas, indicarán el diagnóstico hipertiroidismo neonatal en el recién nacido. Describimos un paciente con antecedente materno de hipertiroidismo (Enfermedad de Graves) no controlado, con incumplimiento del tratamiento. El neonato presentó las siguientes manifestaciones clínicas: exoftalmos, bocio, bajo peso e irritabilidad. Las pruebas de función tiroidea demostraron niveles de T3 y T4 elevados y TSH disminuida. El antecedente de Enfermedad de Graves materna está presente en la mayoría de los casos y sugiere la transferencia de TSI hacia el feto. Las manifestaciones clínicas postnatales presentes concuerdan con las descritas en la literatura; estas junto con los antecedentes orientan al diagnóstico. La confirmación del diagnóstico se logra a través de la evaluación de pruebas de función tiroidea. Se requiere un diagnóstico temprano y tratamiento oportuno para evitar complicaciones, incluso la muerte del paciente...(AU)

Where does her mood come from? An organic approach to a once functional patient / De onde vem seu humor? Uma abordagem orgânica para um paciente previamente funcional

Objective: To report the rare development of manic symptoms in a patient with schizophrenia and discuss its differential diagnosis. Case description: Diagnostic criteria were based on the International Classification of Diseases, 10th edition (ICD-10). A 63-year-old female (diagnosed with schizophrenia since she was 28) was brought to the emergency room with symptoms consistent with manic episode and physical examination suggestive of thyrotoxicosis. Graves' disease was confirmed by subsequent laboratory tests. She was treated successfully with radioiodine ablation, leading to full remission of manic symptoms. Comments: Schizophrenia is a chronic disease that affects about 1% of the population worldwide. The main symptoms of the disorder are altered affection, delusions, and hallucinations. Graves' disease is an autoimmune condition in which antibodies increase the production and release of thyroid hormones. There are reports about the development of mood symptoms in patients with Graves' disease that remit with adequate treatment. .

Objetivo: Relatar um caso raro de desenvolvimento de sintomas maníacos em uma paciente com esquizofrenia e discutir o diagnóstico diferencial desses sintomas. Descrição do caso: Foram utilizados como base os critérios diagnósticos da Classificação Internacional de Doenças, 10ª edição (CID-10). Paciente de 63 anos do sexo feminino e com diagnóstico de esquizofrenia desde os 28 anos foi levada a emergência com sintomas compatíveis com episódio de mania e exame físico sugestivo de tireotoxicose. Doença de Graves foi confirmada por exames subsequentes. A paciente foi tratada com sucesso com ablação por iodo radioativo, levando à remissão dos sintomas maníacos. Comentários: A esquizofrenia é uma doença crônica que afeta cerca de 1% da população mundial. Os principais sintomas do transtorno são o embotamento afetivo, alucinações e delírios. A doença de Graves é uma doença autoimune em que o estímulo humoral aumenta a produção e liberação de hormônios pela tireoide. Há relatos na literatura sobre o desenvolvimento de sintomas maníacos em pacientes com doença de Graves, os quais remitem mediante tratamento adequado. .

Occurrence of osteoporosis & factors determining bone mineral loss in young adults with Graves’ disease.

Background & objectives: There is a paucity of data with conflicting reports regarding the extent and pattern of bone mineral (BM) loss in Graves’ disease (GD), especially in young adults. Also, interpretation of BM data in Indians is limited by use of T-score cut-offs derived from Caucasians. This study was aimed to evaluate the occurrence of osteoporosis in active treatment naive patients with GD and determine the factors predicting BM loss, using standard T-scores from Caucasians and compare with the cut-offs proposed by the Indian Council of Medical Research (ICMR) for diagnosing osteoporosis in Indians. Methods: Patients with GD, >20 yr age without any history of use of anti-thyroid drugs, and normal controls without fracture history, drugs use or co-morbidities underwent BM density (BMD) assessment at lumbar spine, hip and forearm, thyroid function and calcium profile assessment. Women with menopause or premature ovarian insufficiency and men with androgen deficiency were excluded. Results: patients with GD (n=31) had significantly lower BMD at spine (1.01±0.10 vs. 1.13±0.16 g/cm2), hip (0.88±0.10 vs. 1.04±0.19 g/cm2) and forearm (0.46±0.04 vs. 0.59±0.09 g/cm2) compared with controls (n=30) (P<0.001). Nine (29%) and six (19.3%) patients with GD had osteoporosis as per T-score and ICMR criteria, respectively. None of GD patients had osteoporosis at hip or spine as per ICMR criteria. Serum T3 had strongest inverse correlation with BMD at spine, hip and femur. Step-wise linear regression analysis after adjusting for age, BMI and vitamin D showed T3 to be the best predictor of reduced BMD at spine, hip and forearm, followed by phosphate at forearm and 48 h I131 uptake for spine BMD in GD. Interpretation & conclusions: Osteoporosis at hip or spine is not a major problem in GD and more commonly involves forearm. Diagnostic criterion developed from Caucasians tends to overdiagnose osteoporosis in Indians. T3 elevation and phosphate are important predictors of BMD. Baseline I131 uptake may have some role in predicting BMD.