Graves' disease, myxedema, and papillary thyroid carcinoma / Doença de Graves, mixedema e carcinoma papilífero de tireoide

Graves' disease (GD) is the leading cause of hyperthyroidism and diffuse toxic goiter in iodine-sufficient geographi-cal areas. GD is associated with classical manifestations such as ophthalmopathy and thyroid dermopathy, in addi-tion to diffuse goiter, which may be the site of carcinomas, as a complication. Case report: A 52-year-old woman presented with goiter and symptoms compatible with hyperthyroidism, such as heat intolerance, weight loss, fati-gue, increased sweat, tachycardia, fine tremors, increased intestinal transit, anxiety, emotional lability, insomnia, exophthalmos, and pretibial myxedema. A complementary investigation confirmed the diagnosis of hyperthyroidism (high free T4 and total T3 levels and low thyroid-stimulating hormone - TSH levels). Ultrasound images showed dif-fuse enlargement of the thyroid lobes by approximately 10 times and the presence of three thyroid nodules, one of which was larger than 2 cm with heterogeneous echogenicity and vascularization throughout the nodule; ultrasoun-d-guided fine needle aspiration revealed cytology compatible with Bethesda IV; scintigraphy revealed a low uptake area (cold nodule) amid a diffuse high-uptake goiter. A thyroidectomy was performed, and the anatomical specimen diagnosis revealed papillary thyroid carcinoma in the right lobe, with adjacent parenchyma compatible with GD. Histopathological examination of the skin showed the presence of myxedema compatible with Graves' dermopathy. The patient evolved with the normalization of TSH levels and a reduction of cutaneous manifestations. Conclusion:GD abnormalities may not be restricted to the classic clinical manifestations, and a careful investigation may reveal the coexistence of carcinomas. (AU)

A doença de Graves (DG) é a principal causa de hipertireoidismo e bócio difuso tóxico em áreas geográficas com iodo suficiente. DG está associada a manifestações clínicas clássicas como oftalmopatia e dermopatia da tireoide, além do bócio difuso, que pode ser sítio de carcinomas, como uma complicação. Relato de caso: Mulher de 52 anos apresentou bócio e sintomas compatíveis com hipertireoidismo como intolerância ao calor, emagrecimento, fadiga, sudorese aumentada, taquicardia, tremores finos, trânsito intestinal aumentado, ansiedade, labilidade emocional, insônia, exoftalmia e mixedema pré-tibial. A investigação complementar confirmou o diagnóstico de hipertireoidis-mo (níveis elevados de T4 livre e T3 total; níveis baixos de hormônio estimulante da tireoide - TSH). As imagens ultrassonográficas mostraram aumento difuso dos lobos tireoidianos em aproximadamente 10 vezes e a presença de três nódulos tireoidianos, um dos quais, maior que 2 cm, com ecogenicidade e vascularização heterogêneas em todo o nódulo, cuja punção aspirativa por agulha fina guiada por ultrassom revelou citologia compatível com Bethesda IV; e a cintilografia evidenciou uma área de baixa captação (nódulo frio) em meio a um bócio difuso de alta captação. Foi realizada tireoidectomia e o diagnóstico da peça anatômica revelou carcinoma papilífero de tir-eoide em lobo direito, com parênquima adjacente compatível com DG. O exame histopatológico da pele mostrou a presença de mixedema compatível com dermopatia de Graves. A paciente evoluiu com normalização dos níveis de TSH e redução das manifestações cutâneas. Conclusão: As anormalidades da DG podem não estar restritas às manifestações clínicas clássicas, e uma investigação criteriosa pode revelar a coexistência de carcinomas, (AU)

The polymorphic inheritance of DIO2 rs225014 may predict body weight variation after Graves' disease treatment

ABSTRACT Objective: We aimed to investigate the role of DIO2 polymorphisms rs225014 and rs12885300 in Graves' disease patients, mainly for controlling body weight following treatment. Subjects and methods: We genotyped 280 GD patients by the time of diagnosis and 297 healthy control individuals using a TaqMan SNP Genotyping technique. We followed up 141 patients for 18.94 ± 6.59 months after treatment. Results: There was no relationship between the investigated polymorphisms with susceptibility to GD and gain or loss of weight after GD treatment. However, the polymorphic inheritance (CC+CT genotype) of DIO2 rs225014 was associated with a lower body weight variation after GD treatment (4.26 ± 6.25 kg) when compared to wild type TT genotype (6.34 ± 7.26 kg; p = 0.0456 adjusted for the follow-up time). This data was confirmed by a multivariate analysis (p = 0.0138) along with a longer follow-up period (p = 0.0228), older age (p = 0.0306), treatment with radioiodine (p-value = 0.0080) and polymorphic inheritance of DIO2 rs12885300 (p = 0.0306). Conclusion: We suggest that DIO2 rs225014 genotyping may have an auxiliary role in predicting the post-treatment weight behavior of GD patients.

Severe cholestatic syndrome secondary to Graves' disease

This paper reports a case of severe cholestasis as an atypical manifestation of Graves' disease. It discusses the pathophysiology, the diagnosis and the investigation of this complication of hyperthyroidism as well as the impact of this finding on the therapeutic options for managing the disease. (AU)

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.

Respuesta al tratamiento de la Enfermedad de Graves-Basedow en pacientes pediátricos / Response to Graves-Basedow Disease treatment in pediatric patients

Objetivos: Describir la respuesta clínica y bioquímica al tratamiento del hipertiroidismo por enfermedad de Graves en pacientes pediátricos. Diseño: Estudio retrospectivo. Institución: Instituto Nacional de Salud del Niño, Lima, Perú. Participantes: Niños con enfermedad de Graves. Métodos: Se incluyó 32 pacientes con diagnóstico de hipertiroidismo por Enfermedad de Graves, entre 1996 a 2007. Se consideró remisión, cuando se encontraban asintomáticos y bioquímicamente eutiroideos, luego de 6 meses de suspendido el tratamiento; y recaída, si luego de este periodo de tiempo, se encontró valores hormonales alterados. Principales medidas de resultados: Remisión o recaída luego del tratamiento. Resultados: Al diagnóstico, la edad promedio fue 10,5 años (3,2 a 17,9 años); 26 pacientes (81,2 por ciento) fueron de sexo femenino, 13 (40,6 por ciento) púberes y 19 (59,3 por ciento) pre-púberes. Los síntomas y signos más frecuentes fueron bocio, sudoración, nerviosismo, pérdida de peso, taquicardia y exoftalmos. Se usó metimazol como primera opción terapéutica a una dosis inicial promedio de 0,78 mg/kg/ día (0,4 a 2 mg/kg/día). La TSH (57,1 por ciento) y el T4L (50 por ciento) alcanzaron valores normales entre los 6 y 8 meses. Se observó remisión en 11 pacientes (34,3 por ciento), 3 (9,3 por ciento) sufrieron recaída, 12 (37,5 por ciento) pasaron a tratamiento con radioyodo (I131) y 6 (18,7 por ciento) continuaron recibiendo metimazol. La remisión de la enfermedad se alcanzó a los 2,81±0,91 años de tratamiento (rango de 1.5 a 4,8); 4,1 por ciento remitió luego del primer año, y 35,3 por ciento, 37,5 por ciento y 25 por ciento luego del segundo, tercer y cuarto año de tratamiento, respectivamente. La edad promedio de los que recibieron I131 fue 14,6 años (7,1 a 19,6 años), a una dosis alrededor de 7mCi. El 75 por ciento de ellos remitió a los 0,64± 0,60 años (rango de 0,16 a 1,5 años). Conclusiones: El hipertiroidismo por enfermedad de Graves es de relativa frecuencia en...

Objectives: To describe the clinical and biochemical response to treatment of hyperthyroidism. Design: Retrospective study. Setting: Instituto Nacional de Salud del Niño, Lima, Peru. Participants: Children. Methods: From 1996 to 2007 32 patients with diagnosis of hyperthyroidism were studied. Remission was defined when patients were asymptomatic and biochemically euthyroid 6 months after the end of treatment; relapse when altered hormone levels were found after this period of time. Main outcome measures: Remission or relapse following treatment. Results: Mean age at diagnosis was 10.5 years (3.2-17.9 years), 26 patients (81.2 per cent) were female; 13 (40.6 per cent) were pubertal and 19 (59.3 per cent) prepubertal. The most frequent symptoms and signs were: goiter, sweating, nervousness, weight loss, tachycardia and exophthalmos. Methimazole was used as first therapeutic option. Initial dose was 0.78mg/kg/day (0.41-2mg/kg/day) average. TSH (57.1 per cent) and FT4 (50 per cent) reached normal values between 6 and 8 months. Remission was observed in 11 patients (34.3 per cent), 3 (9.3 per cent) relapsed, 12 (37.5 per cent) then received treatment with radioiodine (I-131) and 6 (18.7 per cent) continued receiving methimazole. Remission was achieved after 2.81 ± 0.91 years of treatment (range 1.5-4.8), 4.1 per cent after the first year, and 35.3 per cent, 37.5 per cent and 25 per cent respectively after the second, third and fourth year of treatment. Average age of those receiving I-131 was 14.6 years (7.1-19.6 years), at a dose about 7mCi; 75 per cent of them showed remission after 0.64 ± 0.60 year (range 0.16-1.5 years). Conclusions: Hyperthyroidism due to Graves disease is relatively common in children. Remission was obtained in 34.3 per cent of patients treated with methimazole in 2.81 ± 0.91 years average and remission was achieved in 75 per cent of patients treated with I131, in 0.64 +/- 0.60 years average...

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.

Doença de Graves na infância / Graves? disease in childhood

Relatamos um caso de doença de Graves na infância que, embora raro mas com manejo fácil, seu tratamento ainda é controverso. Foi iniciado o tratamento com drogas antitireoideanas (DAT), mas a paciente apresentou efeitos colaterais. Como apresentava descompensação do hipertireoidismo e intolerância às DAT, a radioablação com 131I foi indicada. Três semanas após a terapia actínica a paciente evoluiu com hipotireoidismo. Foi introduzida levotiroxina, com doses ajustadas através de acompanhamento ambulatorial.

Hipertireoidismo congênito / Congenital hyperthyroidism

Objetivo: Relatar a importância de suspeitar e reconhecer o quadro clínico do hipertireoidismo congênito, dado sua infrequência. Descrição: Os autores relatam um caso de hipertireoidismo congênito diagnosticado em recém-nascido de parto normal com 32 semanas, o qual permaneceu internado por prematuridade, baixo peso de nascimento (sem necessidade de suporte ventilatório), vômitos e dificuldade para ganhar peso. A criança se apresentava taquicárdica, com aspecto de desnutrido e exoftalmia. Foi diagnosticada doença de Graves materna com aproximadamente 29 semanas de gestação, sendo iniciado seu tratamento com propiltiouracil e cloridrato de propranolol. Comentários: Concluímos que a suspeita clínica e o diagnóstico pré-natal de doença de Graves materna evitam danos ao feto e possibilitam adequado tratamento e acompanhamento ainda durante a gestação. O tratamento com propiltiouracil ainda é o melhor para a gestante e para reduzir complicações.

Valoración del hiper e hipotiroidismo post operatorio en la enfermedad de graves basedow / Assessment of postoperative hyper-and hypothyroidism in severe basedow's disease

La enfermedad de Graves es una enfermedad autoinmune que tiene múltiples factores que la mantienen y que aún no pueden ser determinados. En este trabajo se investigo, sin haber precedentes, el factor de proliferación celular en relación a la función tiroidea post operatoria como principal objetivo de esta tesis, además de otros factores como las tiroiditis autoinmune que potencialmente podría estar asociada a la enfermedad de Graves y que se comportaría como otro factor causal de disfunción tiroidea. El objetivo de este trabajo fue analizar parámetros que podrían estar relacionados individualmente Otras características: (fibrosis, presencia de células oxifilas o de Hürthle y/o claras, cristales de oxalato de calcio, etc.); Evaluación semicuantitativa de las tiroiditis linfocíticas (según criterio de Williams y Doniach); presencia de centros germinales; patología nodular asociada El peso de la glándula tiroides extirpada de los 228 casos estudiados osciló entre 23 y 248 g (promedio 77.50 g). La extensión de los infiltrados linfocitarios (tiroiditis linfocitaria) en las tiroides examinadas histológicamente fue leve en 61 casos (27%), moderado en 88casos (38%), severo en 36 casos (16%) y difuso en 2 casos (1%). No hubo tiroiditis en 41casos (18%). Ochenta y seis (37%) de los 228 casos estudiados mostraron la presencia de centros germinales asociados a tiroiditis moderada o severa a difusa. 3ª Etapa: Patología molecular tisular de proliferación celular, usando Ki67. Para la aplicación de la técnica inmunohistoquímica fueron seleccionadas mujeres con rangosde edad entre 20 y 39 años, que no hubieran recibido tratamiento prequirúrgico, o solamente tratadas con b bloqueantes y el estudio anátomo patológico haya sido de patrón histológico clásico, con tiroiditis ausente o leve a moderada. Fueron divididas en 3 grupos de 10 casos cada uno de acuerdo a la evolución post operatoria...

Graves` disease is an autoimmune disease that has multiple factors thatmaintain and that may not yet be determined. This work investigating, without precedent, the factor of cell proliferation in thyroid function post operative as a main objective of this thesis, apart from other factors such as autoimmune thyroiditis which could potentially be associated with Graves disease and lead as another causal factor of thyroid dysfunction. The objective was to analyze parameters that could be linked individually or in conjunction with recurrence ofhyperthyroidism and hypothyroidism surgical post after thyroidectomy hereinafter "keel": The work was made out of a total of 575 patients with Graves – Basedow`s disease, which is the most common cause of hyperthyroidism (60-80% of cases), and is characterized by the triad "hyperthyroidism, diffuse goiter, and ophtalmopaty" were surgicallytreated in the hospital Oñativia of the town of Salta from 1970 until 2006...

Evaluación del tratamiento de pacientes con enfermedad de Graves Basedow y su relación con indicadores de necesidades básicas insatisfechas / Medical treatment evaluation in patients with Graves Basedow disease in relation to indicators of unsatisfied basic needs

El objetivo del presente trabajo fue, evaluar el cumplimiento del tratamiento médico de pacientes con diagnóstico de enfermedad de Graves Basedow y la evolución de la misma (remisión o recidiva) en relación a indicadores de necesidades básicas insatisfechas (NBI). Se practicó la revisión retrospectiva de 156 pacientes con diagnóstico de enfermedad de Graves Basedow, los cuales tuvieron un seguimiento entre 3 y 36 años (: 9.6 años), evaluándose en cada caso los diferentes tratamientos de inicio instituidos (metimazol-MMI-, yodo radiactivo o cirugía). De los pacientes que iniciaron y continuaron el tratamiento médico con metimazol (n=140), se revisó el cumplimiento y la eficacia del mismo, relacionándolo con los indicadores de privación (NBI). De los 156 pacientes estudiados, (137 mujeres Y 19 hombres), con una edad : 42.3 años, el tratamiento de inicio fue: con metimazol en 144, con radio yodo en 6 y con cirugía en 6 pacientes. De los 144 casos que comenzaron el tratamiento con MMI, 140 lo continuaron; de los cuales el 42,86% (n=60), presentaron indicadores de necesidades básicas insatisfechas mientras que el 57.14% (n=80) no presentaron indicadores de NBI. De los 140 pacientes que continuaron el tratamiento médico, el 24,28% (n=34), presentaron remisión de la enfermedad. El 90% de los casos que presentaron algún indicador/es de NBI no cumplieron con el tratamiento vs. el 17.5% de los pacientes NO NBI. La enfermedad remitió con tratamiento con metimazol en el 3.3% de los casos con NBI y en el 40% de los casos NO NBI. Teniendo en cuenta los resultados obtenidos, creemos que podría ser de utilidad, evaluar en los casos de pacientes con enfermedad de Graves Basedow la presencia de indicadores de privación, antes de instituir el tratamiento antitiroideo apropiado.

The objective of the present paper was to evaluate the compliance of medical treatment in patients with Graves Basedow disease diagnosis and the disease evolution (remission or relapse) in relation to indicators of unsatisfied basic needs. A retrospective review of 156 patients with Graves Basedow diagnosis was performed. They were followed up between 3 and 36 years (: 9.6 years), in each case, evaluating the different initial treatments implemented (methimazole-MMI, radioactive iodine or surgery). In those patients who started and followed medical treatment with methimazole (n= 140), compliance and efficacy were reviewed in relation to deprivation indicators. Out of the 156 patients studied (137 women and 19 men), with a mean age of : 42.3 years old, the initial treatment was: 144 patients with methimazole, 6 patients with radioiodine and 6 patients submitted to surgery. Out of the 144 cases who started treatment with MMI, 140 continued with it, of which 42.86% (n=60) showed unsatisfied basic needs indicators whereas 57.14% (n= 80) did not present indicators of unsatisfied basic needs. Out of the 140 patients who continued the medical treatment, 24.28 (n= 34) showed disease remission. Concerning the cases that showed some indicators of unsatisfied basic needs, 90% did not comply with the treatment versus 17.5% which did not present unsatisfied basic needs. The disease showed remission with methimazole treatment in 3.3% of the cases with unsatisfied basic needs and in 40% of the cases which did not present unsatisfied basic needs. Taking into account the results obtained, we believe that in the cases of patients with Graves Basedow disease, it might be useful to evaluate the presence of deprivation indicators before implementing the appropriate antithyroid treatment.

Conversión a hipotiroidismo en tratamiento con I131 por hipertiroidismo secundario a enfermedad de Graves Hospital de San José, enero 2005 - diciembre 2008 / Time to development of hypothyroidism following I131 therapy for hyperthyroidism due to Graves disease San José Hospital, January 2005 - December 2008

El hipertiroidismo tiene alta prevalencia e incidencia en Colombia y requiere diagnóstico y tratamiento adecuados por los riesgos cardiovasculares y oftalmológicos que conlleva. Debido a los diferentes resultados el tiempo de conversión a hipotiroidismo pos administración de I131 hallados en la literatura, se realizó un estudio de cohorte retrospectiva en pacientes con enfermedad de Graves que recibieron I131 en los servicios de endocrinología, medicina interna y medicina nuclear del Hospital de San José, de enero de 2005 a diciembre de 2008. El objetivo principal fue establecer el tiempo mediano de conversión a hipotiroidismo y el secundario fue determinar si la edad tiene influencia. Se revisaron diez referencias bibliográficas, catorce revistas y tres textos guía. El análisis de sobrevida se basó en curvas de Kaplan-Meyer mediante el empleo del programa estadístico STATA 10; 89 historias clínicas cumplieron con los criterios de inclusión. El 76% de los pacientes con enfermedad de Graves manejados con I131 presentaron conversión a hipotiroidismo en los primeros seis meses, el resto en el curso de los seis meses siguientes con un pico a los nueve. El tiempo mediano fue de seis meses. La eficacia se registra a los seis meses y es un marcador de eficacia terapéutica para hipotiroidismo por enfermedad de Graves. Cuando no hay conversión, se recomienda el seguimiento estricto de los pacientes con el fin de elegir la terapéutica apropiada.

Hyperthyroidism has a high prevalence and incidence in Colombian population and requires diagnostic tools and adequate treatment for it carries risks for cardiovascular problems and ophthalmopathology. A retrospective cohort study was conducted due to the different results found in literature on the time at which hypothyroidism occurred following I131 therapy in patients with Graves Disease who received this treatment at the Endocrinology, Internal Medicine and Nuclear Medicine departments at the San José Hospital, from January, 2005 to December, 2008. The primary objective was to establish the median time to hypothyroidism development and the secondary objective was to determine if it is age-related. Ten bibliographic references were reviewed, 14 journals and three guide texts. The survival analysis was based on the Kaplan-Meier curves using the STATA 10 statistical program. Eighty-nine of the reviewed clinical records met the inclusion criteria. It was found that 76% of patients with Graves Disease who received I131 therapy developed hypothyroidism during the first six months and the remaining patients within the following six months with a peak at nine months. The median time to hypothyroidism development was six months. These findings allow us to state that therapy efficacy may be registered at six months and that it is a marker of therapeutic efficacy for hypothyroidism due to Graves Disease. A strict follow-up is recommended in patients in whom hypothyroidism does not occur in order to select the appropriate treatment regime.

Enfermedad de Basedow Graves en pacientes pediátricos / Graves-Basedow disease in pediatric patients

Objective: Determine differences in the epidemiology, clinical features and diagnosis of Graves-Basedow disease (GBD) in prepubertal and pubertal patients. Method: Retrospective study analyzing medical records of 38 patients with GBD at Pontificia Universidad Católica de Chile between 1992-2007. Statistical analysis was performed with non parametric test of Mann-Whitney U and proportions difference with Fisher Test (SPSS 10.0 for Windows and Graphpad Prism 4). Results: 21 patients were prepubertal and 17 were pubertal, with ages between 3 and 15,9 years. There were more girls than boys in both groups (5:2 and 15:2, respectively; p = 0.2). The most common clinical presentations were diffuse goiter, hyperactivity, frequent bowel movements, insomnia and heat intolerance. The prepubertal group had a taller stature (+2.4 SDS) compared with the pubertal group (+0.2 SDS; p = 0.03) and the most frequent ocular manifestation was exophthalmus in both groups. Conclusions: We did not find any differences in the clinical presentations of Graves-Basedow disease among prepubertal and pubertal patients. Neuropsychiatric symptoms such as hyperactivity and insomnia, together with tall stature are common features in children with GBD.

Objetivo: Determinar si existen diferencias en las características epidemiológicas y clínicas al momento del diagnóstico de hipertiroidismo por Basedow Graves (BG) en sujetos pre-púberes y púberes. Pacientes y Método: Estudio descriptivo y retrospectivo. Universo: Pacientes con diagnóstico de BG en control en endocrinología pediátrica en la Pontificia Universidad Católica de Chile, entre 1991 y abril 2007 (n = 38). Se registraron los hallazgos clínicos y de laboratorio. Se evaluó las diferencias entre los grupos con pruebas no paramétricas (Mann-Whitney U), las diferencias de proporciones con la Prueba de Fisher (SPSS 10.0 para Windows y graphpad Prism 4). Resultados: El rango de edad fue 3 a 15,9 años. Veintiún sujetos eran pre-púberes y 17 eran púberes; hubo más mujeres que hombres (5: 2 y 15: 2, respectivamente; p = 0,2). Los síntomas y signos más frecuentes fueron bocio difuso, hiperactividad, polidefecación, insomnio e irradiación de calor. No hubo diferencias entre los pre-púberes y púberes. El grupo pre-púber tenía talla más alta que su carga genética (+2,4 DS) comparados con los púberes (+0,2 SDS; p = 0,03). El compromiso ocular más frecuente fue el exoftalmo. Conclusión: No encontramos diferencias en la forma de presentación del BG entre los niños pre-púberes y púberes. Los síntomas neuropsiquiátricos tales como hiperactividad e insomnio, y una talla mayor a la esperada para la diana familiar, fueron hallazgos frecuentes en los niños con BG.

[Diabetic ketoacidosis and thyroid storm occurring while awaiting radical treatment, about 2 cases]

The association of uncontrolled type 1 diabetes and Grave's disease may induce metabolic decompensation leading to the simultaneous occurrence of diabetic ketoacidosis and thyroid storm. This double endocrine emergency, although rare, is known to be life-threatening. Diagnostic difficulties due to an atypical presentation of thyroid storm that can be masked by diabetic ketoacidosis result in delayed diagnosis and treatment and therefore in a fatal outcome. We report two cases in whom early recognition and intensive treatment have led to an improved outcome. Radical treatment of the Grave's disease immediately at the diagnosis of the associated type 1 diabetes may prevent this double complication

[Graves's disease in children and adolescent: study of seven cases]

In spite of its rarity in the paediatric age. Graves' disease constitutes the principal aetiology of hyperthyroidism in child. Our goal is to analyze the clinical and evolutive particularities of Graves's disease in children. We studied retrospectively seven cases of Graves' disease in children enrolled in the pediatrics department of Sousse during ten years period [1993-2002]. There were six girls and one boy [sex - ratio = 0.16] aged 4.5 to 16 years [mean age: nine years and one month].The diagnosis has been established clinically on the presence of classic symptoms of the illness associated to the biological and radiological findings. As part of research of possible associations with this illness, we observed solely in a case, in addition of Graves's disease, the coexistence of Down syndrome and coeliac disease, rarely described., -Among the HLA antigens predisposing the Graves's disease, we only found HLA B8 antigen in a patient. The evolution under antithyroid drug treatment [ATD] has been marked by fast disappearance of functional signs in all patients. However, biological and clinical euthyroiidism was more difficult to achieve. The treatment has been stopped in only one patient after 40 months period. Graves' disease is usually easy to recognize but difficult to treat. Radical treatments [thyroidectomy or radioactive iodine therapy] are indicated in second intention after having tempted ATD beforehand

Oftalmopatía distiroidea / Dysthiroid Ophtalmopathy

La oftalmopatía distiroidea es la causa más frecuente de proptosis uni o bilateral en el adulto. Afecta con más frecuencia a las mujeres entre los 25 y los 50 años, aunque el curso es más agresivo en los hombres. Se relaciona con hipertiroidismo (91%), tiroiditis de Hashimoto (3%) y eutiroidismo (6%). Hisotpatológicamente se observa un aumento de glucosaminoglicanos en el tejido conectivo de grasa orbitaria y músculos extraoculares. Las manifestaciones clínicas son, en orden de frecuencia, la retracción palpebral, la proptosis, la diplopia y la neuropatía óptica por compresión.

[Profile of graves disease in the region of kairouan: about 186 cases]

In this retrospective study we tried to determine the epidemiologic, clinical, therapeutic and evolutive features in 186 patients with Graves disease [GD] followed at the ibn el Jazzar hospital in Kairouan during 15 years. GD represents the most frequent cause of hyperthyroidism [67%], mainly in young adults [mean age: 35.8 +/- 12.3 years] with a clear female prevalence [83.9%]. The diagnosis is suggested clinically in presence of a homogeneous [80.6%] and vascular [61.2%] goitre associated or not with an exophtalmy [52.2%]. The most frequent clinical signs of hyperthyroidism are weight loss [81.2%], tachycardia [86%], asthenia [74.4%] and tremor [55.9%]. R-TSH antibodies testing was performed in 35 patients with a rate of positivity of 91,4%. Thyroid scintiscanning was practised in 77,5% of the cases and echography in 23,4%. Antithyroid drug therapy was the only management in 51,5% of the cases with a rate of euthyroidism of 67% [mean follow up of 58,2 months]. Radioactive iodine was given in the event of failure of the Antithyroid drug therapy in 35,8% of the cases with 38.7% of hypothyroidism [mean follow up of 54,6 months]. The surgical treatment was a subtotal thyroidectomy in 89,5% of the cases with euthyroidism in 22.2% of the cases and hypothyroidism in 77.8% [mean follow up of 53.4 months]; hypoparathyroidism represented the major complication of the surgery [transient: 15.9% and definitive: 5.3%]

Tratamiento de la enfermedad de graves con I131: primeros casos en la Unidad de Endocrinología Pediátrica del Hospital Nacional Cayetano Heredia, Lima-Perú / Treatment of graves disease with I131: Case report

Objetivo: Describir la respuesta al tratamiento con I 131 y sus complicaciones, en niños y adolescentes con enfermedad de Graves. Material y Métodos: Se estudiaron retrospectivamente las historias clínicas de los pacientes con diagnóstico de enfermedad de Graves y que recibieron tratamiento con I 131 atendidos hasta 1999 en la Unidad de Endocrinología Pediátrica del Hospital Nacional Cayetano Heredia. Se registraron datos demográficos, peso tiroideo, captación de yodo, dosis de I 131 recibida y evolución clínica y de función tiroidea. Resultados: Se incluyeron 13 pacientes: 1 varón y 12 mujeres. El peso glandular promedio obtenido fue 47,56 + 10,70 gramos. La dosis inicial calculada fue 3,92 + 0,95 mCi, con total de 4,47 + 1,66 mCo y tiempo medio de seguimiento de 2,76 años. Diez pacientes recibieron 1 sola dosis, 2 pacientes dos dosis y un paciente tres dosis, remitiendo el 100 por ciento. Los pacientes que recibieron una sola dosis, mostraron remisión del cuadro en 13,13 semanas y el tiempo promedio de remisión de toda la muestra fue 24,62 semanas. La prevalencia de hipotiroidismo a los 6 meses de inciado el tratamiento fue 66,66 por ciento, y 83,33 por ciento a las 257 semanas. Conclusión: I 131 fue 100 por ciento eficaz en el tratamiento de la enfermedad de Graves de los niños y adolescentes en esta pequeña serie de casos.

prevalence of graves' disease and related factors recurrence following discontinuation of antithyroid agents

Although iodine supply has reached to adequate levels in the recent years in Iran, it is evidently lower than the amount in western countries and USA. Some studies indicate that the quantity of iodine supplies present in food substances is effective in the recurrence of Graves' disease. To determine the prevalence of Graves' recurrence and related factors following dicontinuation of antithyroid agents. In a cross-sectional study based on easy sampling, 204 euthyroid out patients with Graves' disease, treated with methimazole for 12-59 months, were selected and evaluated for the reccurence of disease a year later following the continuation of therapy. Parameters likes age, goiter size at the beginning and end of the treatment, severity of disease [T4 value], drug maintenance dose and the duration of treatment were studied. T test and X[2] were used to analysis the data statistically. The one-year prevalence of disease recurrence following the medicine withdrawal was 44.6%, with a duration of 1-12 months [mean=7]. There was no significant relation between the recurrence of disease and the age, sex, maintenance dose, goiter size before and after the treatment and also the T4 value at the beginning and the duration of treatment. The one-year prevalence of Graves' disease recurrence following antithyroids withdrawal was significantly lower than the values in countries with rich iodine supplies. This finding is in accord with studies indicating that the level of iodine intake is effective in the recurrence of Graves' disease