ABSTRACT
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.
Subject(s)
Humans , Female , Adult , Middle Aged , Aged , Thyroid Hormones/physiology , Osteoporosis, Postmenopausal/physiopathology , Graves Disease/complications , Immunoglobulins, Thyroid-Stimulating/physiology , Graves Ophthalmopathy/complications , Glucocorticoids/adverse effects , Reference Values , Thyrotropin/physiology , Absorptiometry, Photon , Bone Density/drug effects , Bone Density/physiology , Case-Control Studies , Graves Disease/physiopathology , Graves Disease/drug therapy , Fractures, Bone/etiology , Fractures, Bone/physiopathologyABSTRACT
OBJECTIVE: To determine the role of peak systolic velocity, end-diastolic velocity and resistance indices of both the right and left inferior thyroid arteries measured by color-flow Doppler ultrasonography for a differential diagnosis between gestational transient thyrotoxicosis and Graves' disease during pregnancy. METHODS: The right and left inferior thyroid artery-peak systolic velocity, end-diastolic velocity and resistance indices of 96 patients with thyrotoxicosis (41 with gestational transient thyrotoxicosis, 31 age-matched pregnant patients with Graves' disease and 24 age- and sex-matched non-pregnant patients with Graves' disease) and 25 ageand sex-matched healthy euthyroid subjects were assessed with color-flow Doppler ultrasonography. RESULTS: The right and left inferior thyroid artery-peak systolic and end-diastolic velocities in patients with gestational transient thyrotoxicosis were found to be significantly lower than those of pregnant patients with Graves' disease and higher than those of healthy euthyroid subjects. However, the right and left inferior thyroid artery peak systolic and end-diastolic velocities in pregnant patients with Graves' disease were significantly lower than those of non-pregnant patients with Graves' disease. The right and left inferior thyroid artery peak systolic and end-diastolic velocities were positively correlated with TSH-receptor antibody levels. We found an overlap between the inferior thyroid artery-blood flow velocities in a considerable number of patients with gestational transient thyrotoxicosis and pregnant patients with Graves' disease. CONCLUSIONS: This study suggests that the measurement of inferior thyroid artery-blood flow velocities with colorflow Doppler ultrasonography does not have sufficient sensitivity and specificity to be recommended as an initial diagnostic test for a differential diagnosis between gestational transient thyrotoxicosis and Graves' disease during pregnancy.
Subject(s)
Adult , Female , Humans , Pregnancy , Graves Disease , Pregnancy Complications , Thyroid Gland/blood supply , Thyrotoxicosis , Ultrasonography, Doppler, Color , Arteries , Blood Flow Velocity/physiology , Diagnosis, Differential , Epidemiologic Methods , Graves Disease/physiopathology , Pregnancy Complications/physiopathology , Thyroid Gland , Thyrotoxicosis/physiopathologyABSTRACT
OBJECTIVE: Assessment of thyroid blood flow gives valuable information about underlying functional status. Colour Flow Doppler Sonography (CFDS) is a powerful tool which displays tissue blood flow and vascularity. Colour Flow Doppler Sonography of the thyroid gland in different subsets of patients with Graves' disease was studied to define its role in initial diagnosis and management. METHODS: Eighty consecutive patients with Graves' disease (both treated and untreated) presented to hospital between August 2007 and February 2008. All patients were evaluated with CFDS of the thyroid for size, vascularity and peak systolic velocity (PSV) of the Inferior Thyroid Artery (ITA). Pertechnate scan and thyroidal autoantibody levels were done in selected cases. The patients were divided into Untreated Graves' disease (n = 31), Graves' disease on treatment but hyperthyroid (n = 26) and euthyroid Graves' disease on therapy (n = 23). Mann-Whitney U-test was used for statistical analysis and a p-value of less than 0.05 was considered significant. RESULTS: Thyroid blood flow, as assessed by PSV of ITA, was significantly higher in untreated Graves' disease than in Graves disease on treatment but hyperthyroid and euthyroid Graves respectively (61.5 ± 19.5 versus 42.9 ± 24.7 versus 32.2 ± 12.9 cm/s, p < 0.05). Parenchymal vascularity of the thyroid gland was higher in hyperthyroid patients than in euthyroid patients irrespective of therapy. In both groups on therapy, the dose of carbimazole correlated with the vascularity of the gland (r = 0.492 versus 0.564, p < 0.05). Colour Flow Doppler Sonography parameters correlated significantly with pertechnate scan results giving comparable sensitivity and specificity. CONCLUSION: Assessment of thyroid blood flow by CFDS is an effective marker in the initial diagnosis of Graves' disease. Vascularity of the gland can predict long term disease course while on medical therapy.
OBJETIVO: La evaluación del flujo sanguíneo tiroideo ofrece una valiosa información acerca del estatus funcional subyacente. La sonografía del flujo con Doppler a color (CFDS) es un poderoso instrumento que muestra el flujo del tejido sanguíneo y la vascularidad. La sonografía con Doppler a color, de la glándula tiroides en diferentes subconjuntos de pacientes con la enfermedad de Graves, fue estudiada para definir su papel en el diagnóstico inicial y el tratamiento. MÉTODOS: Ochenta pacientes consecutivos con la enfermedad de Graves (con y sin tratamiento) acudieron al hospital entre agosto de 2007 y febrero de 2008. Mediante CFDS, a todos los pacientes les fueron evaluados el tamaño del tiroides, la vascularidad y la velocidad del pico sistólico (PSV) de la arteria tiroidea inferior (ATI). En casos seleccionados, se realizaron gammagrafías con pertecnetato y estudios de los niveles de anticuerpos tiroideos. Los pacientes fueron clasificados tomando como criterios: la enfermedad de Graves sin tratamiento (n = 31), la enfermedad de Graves con tratamiento pero hipertiroideos (n = 26), y la enfermedad de Graves eutiroidea bajo terapia (n = 23). La prueba U de Mann-Whitney fue utilizada para el análisis estadístico, y un valor p menor de 0.05 fue considerado significativo. RESULTADOS: El flujo sanguíneo tiroideo tal cual fue evaluado mediante PSV de ATI, fue significativamente más alto en la enfermedad de Graves sin tratamiento que en otros grupos (61.5 ± 19.5 versus 42.9 ± 24.7 versus 32.2 ± 12.9 cm/s, p < 0.05). La vascularidad parenquimal de la glándula tiroides fue mayor en los pacientes hipertiroideos, independientemente de la terapia. En los dos grupos bajo terapia, las dosis de carbimazol estaban en correlación con la vascularidad de la glándula (r = 0.492 versus 0.564, p < 0.05). Los parámetros de la sonografía del flujo con Doppler a color guardaban una correlación significativa con los resultados de la gammagrafía de pertecnetato, arrojando sensibilidad y especificidad comparables. CONCLUSIÓN: La evaluación del flujo sanguíneo del tiroides mediante CFDS es un marcador efectivo en el diagnóstico inicial de la enfermedad de Graves. La vascularidad de la glándula puede predecir el curso de la enfermedad a largo plazo, bajo terapia médica.
Subject(s)
Adult , Female , Humans , Male , Middle Aged , Young Adult , Graves Disease , Ultrasonography, Doppler, Color , Blood Flow Velocity , Graves Disease/physiopathology , Thyroid Gland/blood supply , Thyroid GlandABSTRACT
A Doença de Graves constitui a forma mais comum de hipertireoidismo e três abordagens terapêuticas são atualmente utilizadas: uso de medicamentos antitireoideanos, cirurgia e iodo radioativo (I 131). Os efeitos do o I 131 e a indução precoce de hipotireoidismo são conseqüências da destruição induzida do I131 sobre o parênquima tireoideano. São poucos relatos encontrados na literatura acerca dos efeitos da radioioterapia sobre a laringe e conseqüentemente na produção vocal. OBJETIVO: Avaliar os efeitos agudos sobre a voz da radioiodoterapia em pacientes com hipertireoidismo por Doença de Basedow Graves. MATERIAL E MÉTODO: Estudo de corte contemporâneo longitudinal, prospectivo. Procedimentos: Investigação vocal, mensuração do tempo máximo fonatório de /a/ e relação s/z, análise freqüência fundamental (Software Praat), laringoscopia e análise perceptivo-auditiva em três momentos: pré-dose, 4 dias e 20 dias pós dose. Momentos baseados no perfil inflamatório do tecido tireoideano. RESULTADOS: Não houve mudanças estatisticamente significantes nos aspectos vocais e laringológicos nos três momentos avaliados. CONCLUSÃO: A radioiodoterapia não afeta a qualidade vocal.
Graves's disease is the most common cause of hyperthyroidism. There are three current therapeutic options: anti-thyroid medication, surgery, and radioactive iodine (I 131). There are few data in the literature regarding the effects of radioiodine therapy on the larynx and voice. The aim and the AIM: os this study was: to assess the effect of radioiodine therapy on the voice of Basedow-Graves patients. MATERIAL AND METHOD: A prospective study was done. Following the diagnosis of Grave's disease, patients underwent investigation of their voice, measurement of maximum phonatory time (/a/) and the s/z ratio, fundamental frequency analysis (Praat software), laringoscopy and (perceptive-auditory) analysis in three different conditions: pre-treatment, 4 days, and 20 days post-radioiodine therapy. Conditions are based on the inflammatory pattern of thyroid tissue (Jones et al. 1999). RESULTS: No statistically significant differences were found in voice characteristics in these three conditions. CONCLUSION: Radioiodine therapy does not affect voice quality.
Subject(s)
Adolescent , Adult , Female , Humans , Male , Middle Aged , Graves Disease/radiotherapy , Iodine Radioisotopes/therapeutic use , Larynx/radiation effects , Voice/radiation effects , Analysis of Variance , Auditory Perception/physiology , Cohort Studies , Graves Disease/blood , Graves Disease/physiopathology , Laryngoscopy , Prospective Studies , Phonation/physiology , Time Factors , Thyrotropin/blood , Thyroxine/bloodABSTRACT
Las manifestaciones cardiovasculares del hipertiroidismo son frecuentes, y en ocasiones dominan el cuadro clínico. Con frecuencia, la enfermedad se manifiesta por un estado circulatorio hiperdinámico, con disminución de la resistencia vascular periférica, aumento de la volemia y del volumen minuto cardíaco. La dilatación de las cavidades cardíacas con insuficiencia tricuspídea grave e insuficiencia cardíaca derecha sin hipertensión pulmonar constituye una forma inusual de presentación. Se presenta el caso de una joven paciente, portadora de enfermedad de Graves Basedow, sin antecedentes cardiovasculares, que evoluciona en el transcurso de un mes con edema de miembros inferiores, palpitaciones, diarrea, pérdida de peso y fiebre. Al examen clínico se evidencian taquicardia con pulso irregular, signos de insuficiencia cardíaca derecha acompañado de un intenso soplo regurgitante que aumentaba con la inspiración. Por radiografía de tórax y ecocardiograma se constata cardiomegalia e insuficiencia tricuspídea grave sin hipertensión pulmonar. El cuadro se resuelve en forma rápida luego del tratamiento con propranolol, corticoides y diuréticos, con reversión de la arritmia y franca mejoría de los signos y síntomas. Se analizan en forma breve los efectos de las hormonas tiroideas en el aparato cardiovascular y se postulan probables mecanismos fisiopatológicos de la insuficiencia cardíaca en el hipertiroidismo.
Cardiovascular manifestations of hyperthyroidism are frequent and sometimes are relevant in the clinical picture. Usually an hyperdynamic circulatory state hallmarks the disease with low peripheral resistance, increased intravascular volume and cardiac output. However, right chamber dilatation with tricuspid valve regurgitation and cardiac failure are unusual. We present the case of a young woman with Graves-Basedow disease without cardiovascular history who complained about palpitations, peripheral edemas, weight loss and fever. The clinical findings were tachycardia with irregular pulse, right heart failure and regurgitant tricuspid murmur that increased with inspiration. The chest radiograph and the echocardiogram showed right ventricular dilatation and severe tricuspid regurgitation without pulmonary hypertension. The treatment with propranolol, corticosteroids and diuretics was successful. The patient was asymptomatic with sinus rhythm. We discuss the effects of thyroidal hormones on the cardiovascular system and postulate pathophysiologic mechanisms of heart failure in hyperthyroidism.
Subject(s)
Adult , Female , Humans , Graves Disease/complications , Heart Failure/etiology , Tricuspid Valve Insufficiency/etiology , Adrenergic beta-Antagonists/therapeutic use , Echocardiography, Doppler , Graves Disease/physiopathology , Heart Failure/diagnosis , Heart Failure/drug therapy , Propranolol/therapeutic use , Radiography, Thoracic , Tricuspid Valve Insufficiency/diagnosis , Tricuspid Valve Insufficiency/drug therapy , Vasodilation/drug effectsABSTRACT
Hyperthyroidism is a clinical situation where there is excess thyroid hormones in the circulation due to increased synthesis of hormone from a hyperactive thyroid gland. Common causes are Graves' disease, toxic multinodular goitre and toxic solitary nodule. Excess thyroid hormones in the circulation are also found in thyroiditis (hormone leakage) and excess exogenous thyroxine intake. Thyrotoxicosis is the term applied when there is excess thyroid hormone in the circulation due to any cause. Thyrotoxicosis can be easily diagnosed by high serum level of thyroxine (T4) and triiodothyronine (T3) and low serum level of thyroid stimulating hormone (TSH). Hyperthyroidism is confirmed by high isotope (I 131 or Tc99) uptake by the thyroid gland, while in thyroiditis it will be low. Treatment of hyperthyroidism depends on the underlying cause. Antithyroid drugs, 1131 therapy and surgery are the options of treatment of hyperthyroidism. Surgery is the preferred treatment for toxic adenoma and toxic multinodular goitre, while 1131 therapy may be suitable in some cases. Antithyroid drugs and 1131 therapy are mostly preferred for Graves' disease. Beta-adrenergic blockers are used for symptomatic relief in most patients of thyrotoxicosis due to any cause. Other rare causes of hyperthyroidism like, amiodarone induced thyrotoxicosis, choriocarcinoma, thyrotropin secreting pituitary tumour are difficult to diagnose as well as to treat.
Subject(s)
Graves Disease/physiopathology , Humans , Hyperthyroidism/diagnosis , Risk Factors , Thyrotoxicosis/diagnosisSubject(s)
Humans , Male , Female , Graves Disease/physiopathology , Eye Diseases , Graves Disease/therapyABSTRACT
Auto-anticorpos anti-receptores de TSH (TSHRAbs) foram avaliados por dois diferentes métodos [TRAb, como porcentagem de inibiçäo de ligaçäo do TSH por anticorpos séricos e produçäo de AMP cíclico em cultura de células CHO expressando o receptor de TSH humano recombinante (CHO-rhT-SHR)] em 52 pacientes (36F/16M) com moléstia de Graves-Basedow (DGB), tanto antes do tratamento como aos 6 e 12 meses de terapia contínua com metimazol (40-60mg/dia) e L-tiroxina (100pg/dia); outros 20 pacientes tireotóxicos (12F/8M) foram tratados com doses individualizadas de radioiodo. Os TSHRAbs determinados pelo radioreceptorensaio foram positivos em 47/52 pacientes (90,4 por cento) com valor médioñEPM de 56,7ñ3,9 por cento, diminuindo significantemente aos 6 (40,5ñ3,2 por cento) e 12 meses (43,5ñ4,7 por cento) de terapêutica, bem como após radioiodo (30,7ñ4,5 por cento). Os TSHRAbs foram discriminados pelo bioensaio em todos os 52 pacientes com DGB ativa (1122ñ409 por cento). Após 6 e 12 meses de terapêutica houve decréscimo (näo significante) dos valores iniciais. Nenhum indivíduo do grupo controle normal (n= 80) apresentou TSHRAbs detectado por qualquer dos métodos. Portanto, a sensibilidade da pesquisa dos anticorpos pelo bioensaio, nos 52 pacientes com DGB ativa, foi maior que nos mesmos indivíduos avaliados pelo radioreceptorensaio. Houve correlaçäo positiva (r= 0,59; p<0,001) entre TRAb e CHO-rhTSHR. Concluímos que a pesquisa dos TSHRAbs, realizada quer pelo radioreceptorensaio como pelo bioensaio, constitui recurso útil para se avaliar a atividade autoimune na DGB.
Subject(s)
Humans , Male , Female , Adolescent , Adult , Middle Aged , Autoantibodies , Graves Disease/drug therapy , Receptors, Thyrotropin , Cyclic AMP/analysis , Antithyroid Agents , Biological Assay , Graves Disease/physiopathology , Methimazole , Iodine Radioisotopes/therapeutic useABSTRACT
El hipotiroidismo y el bocio eutiroideo son las entidades tiroideas que se presentan con mayor frecuencia en la edad pediátrica. El hipertiroidismo o tirotoxicosis se presenta en 15 por ciento de los pacientes pediátricos con disfunción tiroidea. La enfermedad de Graves es la causa más frecuente de hipertiroidismo en niños y adolescentes, y se caracteriza por la elevada producción de autoanticuerpos estimuladores del receptor de tirotropina, que inducen la secreción autónoma de hormonas tiroideas y sus efectos en los tejidos periféricos. La triada clásica de manifestaciones comprende la presencia de bocio, datos sistémicos de hipertiroidismo y oftalmopatía; la dermopatía es poco frecuente en este grupo de edad. En fases iniciales del padecimiento predominan los síntomas neuropsiquiátricos. El manejo en estos pacientes continúa siendo controversial. Ninguna de las modalidades de tratamiento ha mostrado superioridad. Se describen otras causas menos frecuentes de hipertiroidismo que deben considerarse en el diagnóstico diferencial.
Subject(s)
Child , Graves Disease/physiopathology , Graves Disease/therapy , Hyperthyroidism/physiopathology , Eye Diseases/physiopathology , Skin Diseases/physiopathology , Thyroid Diseases/etiologyABSTRACT
CONTEXT: Surface HLA-DR antigen is usually only expressed by antigen-presenting cells (APC). In autoimmune thyroid disease, follicle cells function as APC, thus expressing HLA-DR. However, non-autoimmune thyroid diseases may also express surface class II antigens. OBJECTIVE: To evaluate the presence and pattern of HLA class II expression in autoimmune and non-autoimmune thyroid disorders. DESIGN: Retrospective: histopathological and immunohistochemical analysis. LOCATION: Referral center, university hospital. SAMPLE: Ten histologically normal thyroids, 11 GravesÆ disease, 7 HashimotoÆs thyroiditis, 10 atoxic multinodular goiter and 3 toxic adenomas were analyzed by immunohistochemistry, using a monoclonal antibody anti-HLA-DR. MAIN MEASUREMENTS: The presence of these antigens in thyroid follicular cells and their relation to inflammatory infiltrate was evaluated. The pattern of HLA-DR expression in thyroid follicular cells was analyzed: membrane, cytoplasmic or both. RESULTS: Although HLA-DR antigens were sparsely present in one of the 8 normal thyroids, in 6 of the 9 atoxic multinodular goiter and in 2 of the 3 toxic adenomas a net positivity could be seen in large areas. In all 5 HashimotoÆs thyroiditis and in 7 of the 10 GravesÆ disease cases. This expression occurred in follicle cells either in contact with inflammatory cells or not. In non-autoimmune thyroid disease, HLA-DR positivity was essentially cytoplasmic, whereas in GravesÆ disease and Hashimoto thyroiditis it was mainly in cell membranes. CONCLUSIONS: It is suggested that the HLA class II expression on the surface of follicle cells could be related to auto-antigen presentation to the immune system by these cells, leading to inflammation
Subject(s)
Humans , Thyroid Diseases/immunology , Thyroiditis, Autoimmune/immunology , HLA-DR Antigens/analysis , Genes, MHC Class II/immunology , Thyroid Diseases/pathology , Thyroiditis, Autoimmune/pathology , Immunohistochemistry , Graves Disease/physiopathology , Graves Disease/immunology , Retrospective Studies , Immunoenzyme Techniques , Antibodies, Monoclonal/analysisABSTRACT
Se hace una revisión bibliográfica de las principales características de la orbitopatía tiroidea y se menciona la experiencia de nuestro servicio
Subject(s)
Humans , Exophthalmos/classification , Exophthalmos/diagnosis , Exophthalmos/etiology , Exophthalmos/drug therapy , Graves Disease/physiopathology , Diagnosis, DifferentialABSTRACT
Objetivo. Presentar un caso de oftalmopatía de Graves (oftalmopatía tiroidea autoinmune) posterior a radioterapia en cuello, con buena respuesta al tratamiento médico. Caso. Fue un varón de 51 años de edad con linfoma de Hodgkin esdatio IIIB, tratado con quimio- y radio-terapia en manto que desarrolló oftalmopatía tiroidea autoinmune clase III. La tomografía axial computarizada de órbitas mostró cambios característicos de oftalmopatía tiroidea; las pruebas de función tiroidea, incluyendo anticuerpos y estimulación con hormona estimuladora de tirotrofina, fueron normales o negativas. El tratamiento con prednisona, seguido de radioterapia externa retrocular derecha, produjo desaparición de los síntomas y reducción de exoftalmus
Subject(s)
Humans , Male , Middle Aged , Eye Diseases/diagnosis , Eye Diseases/etiology , Eye Diseases/physiopathology , Eye Diseases/radiotherapy , Graves Disease/diagnosis , Graves Disease/etiology , Graves Disease/physiopathology , Graves Disease/radiotherapy , Hodgkin Disease/physiopathology , Hodgkin Disease/radiotherapy , Radiotherapy/adverse effectsABSTRACT
Objetivo. Conocer la frecuencia de asociación entre enfermedad de Graves-Basedow y cáncer del tiroides. Diseño. Estudio retrospectivo, observacional, transversal. Sede. Servicio de cirugía general de un hospital general. Pacientes y métodos. Se revisaron los expedientes clínicos de 681 pacientes a quienes se les efectuó tiroidectomía entre 1978 y 1994. El diagnóstico de enfermedad de Graves-Basedow se realizó cumpliendo criterios clínico, hormonal y gammagráfico. Todos los pacientes fueron llevados a eutiroidismo mediante la administración de drogas anti-tiroideas como metamizol, bloqueadores beta y lugol. Se hizo estudio histológico transoperatorio y definitivo de la pieza quirúrgica en su oportunidad y una revisión en retrospectiva por un solo patólogo con objeto de confirmar o modificar el diagnóstico inicial. Resultados. En 161 enfermos, de los 681 sujetos a quienes se hizo tiroidectomía, se encontró hipertiroidismo (23 por ciento), de este grupo únicamente en dos pacientes se comprobó carcinoma del tiroides (carcinoma papilar) (1.2 por ciento). Conclusión. La asociación hipertiroidismo-cáncer del tiroides es muy baja
Subject(s)
Adolescent , Adult , Middle Aged , Humans , Male , Female , Adrenergic beta-Antagonists/therapeutic use , Antithyroid Agents , Dipyrone/therapeutic use , Graves Disease/physiopathology , Hyperthyroidism/physiopathology , Thyroid Neoplasms/diagnosis , ThyroidectomyABSTRACT
A abordagem da oftalmopatia de Graves (OG) tem evoluído muito nos últimos anos, propiciando o emprego de intervençoes terapêuticas mais precoces e com melhores resultados. Nesta revisao sao discutidos os aspectos controversos e os avanços na compreensao físiopatológica da OG, especialmente no campo da imunologia, assim como o papel das citocinas no processo inflamatório retrocular. Com o desenvolvimento das técnicas de imagem como a ultrasonografia e, especialmente, a ressonância magnética, tem ocorrido um grande avanço na determinaçao da presença ou nao da atividade inflamatória que irá conduzir a diferentes medidas terapêuticas. As várias possibilidades de tratamento sao discutidas, tais como tratamento clínico, radioterápico ou cirúrgico, sendo enfatizada a necessidade prévia da determinaçao da intensidade do processo inflamatório para a escolha correta da modalidade teripêutica. Para a obtençao de resultados satisfitórios no tratamento destes doentes há necessidade da presença de uma equipe multidisciplinar que inclua o endocrinologista, oftalmologista, radiologista e eventualmente um profissional para o apoio psicológico. As crescentes pesquisas no campo da biologia molecular e da imunologia estao trazendo contribuiçoes marcantes na compreensao desta patologia.
Subject(s)
Humans , Male , Female , Adult , Middle Aged , Graves Disease , Graves Disease/diagnosis , Graves Disease/physiopathology , Graves Disease/therapyABSTRACT
O bócio difuso tóxico, a oftalmopatia e o mixedema pré-tibial constituem a tríade clássica da doença de Graves. A inexistência de um modelo animal, além do difícil acesso aos tecidos-alvos, torna complexa a investigaçao etiopatogênica da oftalmopatia. Existem fortes evidências de que a oftalmopatia de Graves está intrinsecamente ligada ao processo auto-imune da tireóide. Porém o mecanismo de sua patogênese continua obscuro. Nao se encontraram ainda auto-anticorpos específicos e nem uma predisposiçao imunogenética consistente com a presença da oftalmopatia. Além disso, a participaçao de auto-antígenos tem sido de difícil comprovaçao, embora uma candidata provável seja a proteína 72 KDa, presente nas células foliculares da tireóide. Parece, contudo, que o mecanismo patogênico primário na oftalmopatia seria a estimulaçao de fibroblastos, resultante de citocininas linfocitárias. O fato de o acometimento do tecido conjuntivo limitar-se primariamente à órbita e à regiao pré-tibial ainda nao foi esclarecido. Uma provável explicaçao seria a possibilidade de os fibroblastos nessas regioes diferirem fenotipicamente dos fibroblastos de outras regioes. A oftalmopatia está presente clinicamente em 25 por cento a 50 por cento dos pacientes com doença de Graves e hipertireoidismo, ocorrendo ocasionalmente na tireoidite de Hashimoto e raramente na doença de Plummer e no bócio multinodular tóxico. Embora muitos pacientes com hipertireoidismo de Graves nao apresentem evidências clínicas de oftalmopatia, o uso de métodos diagnósticos por imagem - como, p.ex., ultra-sonografia, tomografia computadorizada e a ressonância magnética da órbita - comprova o envolvimento ocular na maioria dos pacientes. Outra importante observaçao é que aproximadamente 10 por cento dos pacientes com oftalmopatia nao apresentam hipertireoidismo, embora a maioria apresente evidências laboratoriais de doença auto-imune da tireóide (anticorpo antiperoxidase ou anticorpo anti-receptor TSH). Em adiçao, existe uma relaçao direta entre o início do hipertireoidismo e da oftalmopatia. Independente de qual comece primeiro, o outro se desenvolverá em 18 meses em 85 por cento dos pacientes afetados 10). Achados histopatológicos do tecido orbitário dos pacientes com oftalmopatia de Graves sugerem dois mecanismos patológicos (5,l1):1.Processo inflamatório da musculatura extra-ocular, com infiltrado linfocitário e edema. 2.Proliferaçao dos tecidos adiposo e conjuntivo. Sisson (l5), através de cultura de fibroblastos retroorbitários, demonstrou que linfócitos de pacientes com oftalmopatia de Graves podem estimular a síntese de glicosaminoglicans. Além disso, também foi observado que imunoglobulinas de pacientes com oftalmopatia podem estimular essa mesma síntese. Bolonkin et al.(4) demonstraram a presença de receptor de TSH no tecido retroorbitário, sugerindo que anticorpos estimulantes da...
Subject(s)
Humans , Autoantigens/physiology , Autoimmunity , Graves Disease/etiology , Graves Disease/complications , Graves Disease/physiopathology , Thyroid Diseases/complicationsABSTRACT
Tecem alguns comentários a respeito da oftalmopatia de Graves, incluindo seus aspectos patogênicos, clínicos e terapêuticos. Apresentam um caso de cada subtipo clínico da oftalmopatia de Graves, mostrando sua evoluçäo com o tratamento
Subject(s)
Humans , Aged , Graves Disease/physiopathology , Graves Disease/drug therapyABSTRACT
One hundred patients who underwent bilateral subtotal thyroidectomy for Graves' disease between January 1980 and September 1984 have been evaluated. The observation period ranged from 5 to 9 years, the average being 6.2 years. Postoperative thyroid function was evaluated with T3, T4 and TSH and compared with their clinical manifestations. Eighty-two patients became euthyroid, 14 patients had recurrence and 4 patients developed hypothyroidism. The thyroid hormone level of euthyroid patients were in an unstable state up to 5 years after the operation. Sixteen variables which might influence the postoperative recurrence and hypothyroidism were analyzed but no statistically significant factors were determined, although recurrences were found frequently in patients over 30 years, the patients with lower infiltration of lymphocytes and absent of fibrosis of thyroid tissue. The results obtained in the present study suggest that mean 6.0 gm of remnant thyroid is suitable for maintaining euthyroidism postoperatively in a majority of patients. In addition, patients should be followed closely for many years and should undergo hormonal determination periodically because recurrence and hypothyroidism can occur at 5 years or more after the operation.
Subject(s)
Adolescent , Adult , Female , Humans , Male , Chi-Square Distribution , Follow-Up Studies , Graves Disease/physiopathology , Logistic Models , Middle Aged , Prognosis , Thyroid Gland/physiopathology , Thyroidectomy/methodsABSTRACT
Relatamos o caso de um paciente do sexo masculino, de 58 anos de idade, com história de bócio e oftalmopatia, sem hipertireoidismo na análise laboratorial, com dosagens de T3, T4, TSH normais durante o acompanhamento de 10 anos. A captaçaä aumentada de I 131, a falta de resposta ao teste do TRH e a presença de anticorpos antitireglobulina e LATS em altos títulos caracterizaram o paciente como portador da doença de Graves eutireóidea. O estudo anatomopatológico da tireóide revelou tireoidite crônica de Hashimoto. Discutimos o caso, mostrando a relaçäo entre a doença de Graves e a tireoidite de Hashimoto.