Caracterización de pacientes controlados por enfermedad de Basedow Graves en un hospital universitario / Clinical features of patients with Basedow Graves disease seen at a university hospital

Background: Basedow Graves disease (BGD) is the leading cause of hyperthyroidism. The characteristics of patients seen at a university hospital may differ from those described in the general population. Aim: To describe the clinical features of patients with BGD seen at a university hospital. Material and Methods: Review of medical records of all patients seen at our hospital between 2009 and 2014 with the diagnosis of thyrotoxicosis, hyperthyroidism or BGD. Clinical features, laboratory results and treatments were recorded. Results: We reviewed clinical records of 272 patients; 15 had to be excluded due to incomplete data. BGD was present in 77.9% (n = 212). The mean age of the latter was 42 years (range 10-81) and 76% were women. Ninety six percent were hyperthyroid at diagnosis and thyroid stimulating hormone was below 0.1 mIU/L in all patients. Median free thyroxin and triiodothyronine levels were 3.26 ng/dl and 3.16 ng/ml, respectively. Thyrotropin-receptor antibodies were positive in 98.5% and 85.7% had positive thyroid peroxidase antibodies. Graves orbitopathy (GO) was clinically present in 55% of patients. Of this group, 47% had an active GO, 26% had a moderate to severe disease and 7.8% had sight-threatening GO. As treatment, 26% received radioiodine, 44% anti-thyroid drugs exclusively, 28% underwent thyroidectomy and 2% did not require therapy. Conclusions: In this group of patients, we observed a greater frequency of severe eye disease and a high rate of surgical management. This finding could be explained by referral to highly qualified surgical and ophthalmological teams.

Therapeutic Plasmapheresis Enabling Radioactive Iodine Treatment in a Patient with Thyrotoxicosis

Therapeutic plasma exchange (TPE) is one possible treatment for patients resistant to conventional antithyroid drugs or requiring urgent attention for thyrotoxicosis. We report a 35-yr-old man with thyrotoxicosis, ultimately attributed to Graves' disease in whom antithyroid drug used initially was soon discontinued, due to abnormal liver function, and replaced by Lugol's solution. Three weeks later, an escape phenomenon (to Lugol's solution) was apparent, so we performed TPE to control the thyrotoxicosis. Two courses of TPE by a centrifugal type machine resulted in diminished levels of thyroid hormone levels, which then rebounded after another two courses of membrane filtration type TPE. However, the patient could be treated with radioactive iodine therapy without any complications at present.

An Interesting Case of Thyrotoxicosis with Choreoathetosis - A Rare Association.

Thyrotoxicosis may present with spectrum of movement disorders. Though tremor is most frequently associated, chorea has also been reported rarely. A rare case of thyrotoxicosis in a young female presenting with choreoathetotic movement is reported here. The choreoathetotic movement in this case was attributed to thyrotoxicosis based on clinical and biochemical criteria after exclusion of other causes.

Consenso brasileiro para o diagnóstico e tratamento do hipertireoidismo: recomendações do Departamento de Tireoide da Sociedade Brasileira de Endocrinologia e Metabologia / The Brazilian consensus for the diagnosis and treatment of hyperthyroidism: recommendations by the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism

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.

Autoimmune thyrotoxicosis with achalasia cardia.

We report a case of autoimmune thyrotoxocosis in an 11-year-old boy with achalasia cardia. This case explores autoimmunity as an etiological factor for achalasia based on several autoimmune conditions that have been associated with it.

Thyrotoxicosis in children: treatment and outcome.

OBJECTIVES: To study the treatment modalities and the outcome of treatments of children with thyrotoxicosis or Graves' disease. MATERIAL AND METHOD: A retrospective study of 56 patients diagnosed with thyrotoxicosis from January 1992 to December 2004 was conducted. There were 44 girls and 12 boys (female to male ratio 3.7:1). The average age at diagnosis was 11.9 +/- 3.4 years. RESULTS: All patients were initially treated with antithyroid drugs, either propylthiouracil (n = 53) or methimazole (n = 3). All patients achieved euthyroidism within 8.4 +/- 3.3 weeks. Eleven patients are still on the treatment, and 45 patients have completed the treatment. Of these 45 patients, 38 (84.4%) remitted after antithyroid drug treatment of an average duration of 37.4 +/- 16.5 months (range 12-90), 4 patients (8.9%) chose radioactive iodine treatment and three patients (6.7%) underwent thyroidectomy. Of the 38 patients remitted with antithyroid drugs, eleven (28.9%) relapsed within 4-24 months. The relapsed patients remitted with a second course of antithyroid drugs in three patients, underwent radioactive iodine in seven patients, and thyroidectomy in one patient. Therefore, of the total 45 patients who had completed the treatment, 30 patients (66.7%) remitted with antithyroid drugs, eleven patients (24.4%) received radioactive iodine, and four patients (8.9%) underwent thyroidectomy. Using stepwise multivariate logistic regression, the authors could not identify any factors (including age, gender, family history of thyroid diseases, size of goiter, level of free T4, dosage and duration of antithyroid drugs) that would predict the remission of thyrotoxicosis with antithyroid drugs. CONCLUSION: Antithyroid drugs should remain the first-line therapy for treatment of thyrotoxicosis in children with a remission rate of 66.7%. The patients who are noncompliant or relapse after treatment with antithyroid drugs should be treated with radioactive iodine.

Thyrotoxic vomiting: a case report

A post menopausal female with severe vomiting and weight loss in association with elevated hormone levels is presented. Signs and symptoms of thyrotoxicosis were not evident at presentation. Possible pathophysiological mechanisms and treatment are discussed. Antithyroid therapy with carbimazole and propranlol induced rapid resolution of her symptoms and marked improvement in well-being. Radioactive iodine ablation of her thyroid gland was performed later and she has remained asymptomatic.

Treatment of thyroid hot nodules by percutaneous ethanol injection

Twenty-eight patients with autonomously functioning thyroid nodules of 2-6 cm diameter were selected. Fifteen patients were clinically and biochemically hyperthyroid. Depending on the nodule size, 2-4 ml of 95% ethanol was injected into the nodules. There were no major complications. Thyroid scans were done at two-month intervals and repeated injections were done only if the hot nodules were still present. 71.4% needed only one, 25% needed two, and 3.6% needed three injections for complete ablation of the hot nodules. On follow-up examination all nodules had shrunken in size and those patients with hyperthyroidism showed improvement of their symptoms. The hormone levels also returned to normal range.Repeated thyroid scans showed disappearance of the hot nodule and gradual resumption of function of the previously suppressed thyroid tissue. This study shows that percutaneous ethanol injection is a safe and cheap alternative to surgical and radioiodine ablation of AFTN's and this can be achieved in most cases in one or two sessions. Importantly, with this method, the chance of future hypothyroidism will be nil

O coraçäo no hipertiroidismo / The heart in hyperthyroidism

Sintomas e sinais cardiovasculares säo frequentes no hipertiroidismo. Neste artigo revisamos os avanços no entedimento do mecanismo de açäo dos hormônios tiroidianos no coraçäo, a fisiopatologia, o quadro clínico, o diagnóstico e o tratamento das manifestaçöes cardíacas no hipertiroidismo.

Outcome of 3 forms of therapy for diffuse toxic goiter in an area of iodine deficiency

In order to evaluate the long-term effects of antithyroids and ablative therapy on patients with diffuse toxic goiter [TDG] in an iodine deficient region, 206 patients were studied in Tehran. Hyperthyroidism recurred in 50% of 80 patients treated with methimazole [MMI], from one week to 48 months after cessation of therapy. Another 40 patients remained in remission. Of 102 patients treated with radioactive iodine [RAI], 45% became hypothyroid, 49% were euthyroid and 6% had relapse. The rate of hypothyroidism was 58% and that of relapse was 17% in 24 patients who underwent subtotal thyroidectomy. By the end of 4 years of follow-up, 50% treated with antithyroids, 51% given RAI and 25% of patients who had surgery have remained euthyroid. This study demonstrates good rate of remission after antithyroid therapy and high rate of hypothyroidism following thyroidectomy for patients with TDG in an area of iodine deficiency

cardiac index by echocardiography as a reliable parameter for effective treatment in thyrotoxic heart disease

15 patients with clinically overt thyrotoxicosis were studied, age range 20-45 years. [fmean 34.2 +/- 7.3] one male, 14 females. Serum T3, T4 were elevated in all patients before treatment [T3 range 278-600 ng%-normal 80-200 ng%] and [T4 range 14.4 -24 ng%-normal 5-13 ng%]. Cardiac index was markedly increased in all patients [5.46 +/- 0.65 L/min/m2] .After treatment by neomercozole for 2-5 weeks marked improvement in symptomatology; palpibation [84%], tremor [77%] and nervousness [61.5%] with marked reduction in heart rate in all patients. [P<0.001], the cardiac index in all patients dropped in a highly significant manner [P<0.001]. It is evident from this study that Echocardiography and the measurement of cardiac index could be of additional value in diagnosis and assessment of benifet in medically treated thyrotoxcosis

Exoftalmo endocrino - acompanhamento da exoftalmometria durante a fase de eritiroidismo / Endocrin exoftalmos - follow up of the exophtalmometry during the phase of euthryroidean

The exophthalmometry was performed in one group of euthyroidean patients who became euthyroidean after hyperthyroidism treatment. After different periods of time new exophthalmometry was done. In all the cases the variations ranged from +3 to -3 mm of the initial value

Exoftalmo endocrino - acompanhamento da exoftalmometria durante o tratamento da tireotoxicose / Endocrine exophtalmus - exophtalmometric follow-up during thyreotoxicosis treatment

A exoftalmometria foi executada em 20 pacientes hipertireoideos no início e no final do terapêutica anti-tireóidiana. As variaçöes exoftalmométricas observadas estiveram compreendidas entre +2 a -2mm do valor inicial em 85% das vezes