[Recurrent abdominal colic, myalgia and mononeuritis multiplex]. / Rezidivierende abdominelle Koliken, Myalgien und Mononeuritis multiplex.

The case of a 30-year-old male, who presented with a three months history of fever, night sweats, weight loss and myalgia is reported. Subsequently abdominal cramps, bloody diarrhea and mononeuropathy multiplex developed. An abdominal and renal angiogram showed changes of vascular structures diagnostic for polyarteritis nodosa. An immunosuppressive treatment (Prednisolon 100 mg/day and Cyclophosphamid 200 mg/day) was started. However, diffuse peritonitis as the aftermath of bowel infarction, which comprised the total length of the jejunum and the proximal parts of the ileum, developed at the third week of this treatment. Despite immediate surgical resection of the ischemic bowel septic complications occurred and the patient died.

Functional results of radioiodine therapy with a 300-Gy absorbed dose in Graves' disease.

The aim of this study was to assess the results of high-dose radioiodine therapy given to 43 patients with recurrent hyperthyroidism due to Graves' disease between 1986 and 1992. We chose an intrathyroidal absorbed dose of 300 Gy and determined the applied activity individually, which ranged from 240 to 3120 MBq with a median of 752 MBq. Hyperthyroidism was eliminated in 86% of cases after 3 months and in 100% after 12 months. No patient required a second radioiodine treatment. The incidence of hypothyroidism was 63% after 3 months and 93% after 18 months. Neither the pretherapeutic thyroid-stimulating immunoglobulin level nor the degree of co-existing endocrine ophthalmopathy was correlated with the time at which hypothyroidism developed. Patients with previous radioiodine therapy developed hypothyroidism earlier than patients with previous thyroid surgery. The results show that ablative radioiodine therapy with a 300-Gy absorbed dose is a very effective treatment of hyperthyroidism in Graves' disease, but it should be restricted to patients with recurrent hyperthyroidism combined with severe co-existing disorders or episodes of unfavourable reactions to antithyroid drugs.

[Global 99mTc uptake in the differential diagnosis of a normal thyroid,goiter with euthyroidism and thyroid autonomy in an area of iodine deficiency]. / Nativer 99mTc-uptake in der Differentialdiagnostik von unauffälliger Schilddrüse, Struma mit Euthyreose und Schilddrüsenautonomie in einem Jodmangelgebiet.

Global TcTU was determined in 568 patients without any specific thyroid drug intake--54 with normal thyroid, 274 with goitre and euthyroidism and 240 with thyroid autonomy. 57 patients with autonomy and overt hyperthyroidism were the only group with TcTU values significantly higher than normals. Common to all groups was a large scatter of the TcTU values. In 332, the effects of individual iodine supply were studied by measuring the iodine concentration in spot urine samples. There was a significant inverse correlation between the TcTU values and the urinary iodine excretion in the groups of normal thyroids and of goitres with euthyroidism. In the group with autonomy an effect of iodine supply could only be seen in cases of greatly increased urinary iodine excretion, resulting in very low TcTU values. Out of 20 patients with autonomy and iodine contamination, only 4 showed overt hyperthyroidism. The large scatter of TcTU values in all groups may be explained by the persistent iodine deficiency as well as by the frequent exposure to unknown amounts of iodine in patients with thyroid disease. Therefore, the spontaneous TcTU alone cannot identify a small group of patients with autonomy and high risk of iodine-induced hyperthyroidism, from a very large group of patients with goitre.

TcTU before and after exogeneous TSH suppression in diagnosing thyroid autonomy.

In 104 euthyroid patients with goiter and suspected thyroid autonomy two thyroid scintiscans with quantification of the TcTU were performed before (TcTUo) and after exogeneous TSH suppression (TcTUs). In 15 patients with subnormal TSH before suppression the TcTUs revealed no difference to the TcTUo. In contrast to the TcTUo, in euthyroid patients the TcTUs is not relevantly influenced by individual iodine supply. In euthyroid goitreous patients with normal TSH a TcTUo less than 2.0% resulted in a TcTUs less than 1.1% in all 22 cases and, therefore, in these patients a scintiscan after TSH suppression is not necessary, because no relevant mass of functional autonomous tissue can be expected. In all other patients with normal TSH only the TcTUs is relevant for identification of thyroid autonomy. Autonomy with a TcTUs greater than 1.5% and, consequently, with a suspected higher risk of hyperthyroidism after iodine contamination was found in 19% (17/89) of the goitreous patients with normal TSH.

[Thyroid diagnosis in general practice]. / Schilddrüsendiagnostik in der Praxis.

The selection of appropriate diagnostic procedures in presumptive thyroid diseases should be based on clinical signs and symptoms. To exclude primary thyroid dysfunction, basal TSH levels measured by a sensitive system should be employed. Further hormonal analyses are indicated in patients with suppressed TSH levels (fT4J, fT4 or the T4/TBG ratio and total T3) and in those with elevated TSH (fT4J, T4/TBG ratio without total T3). When TSH levels are partially suppressed thyroid autonomy must be excluded. Thyroid antibodies may be employed in patients with spontaneous hypothyroidism and hyperthyroidism, homogeneous technetium uptake with no eye signs. In patients with thyroid enlargement, ultrasound investigation including volumetry is the first line investigation. Nodular abnormalities must be investigated by technetium uptake in euthyroid and hyperthyroid individuals. Cytological investigations are indicated in cold nodules, especially in those showing reduced echogenicity.

[Results of radioiodine treatment of patients with immunogenic and non-immunogenic hyperthyroidism using different focal doses]. / Ergebnisse der Radiojod-Behandlung von Patienten mit immunogener und nicht-immunogener Hyperthyreose bei Anwendung unterschiedlicher Herddosen.

The aim of this study was to check the efficacy of radioiodine (131I) therapy (RIT) in a large number of patients (n = 506) suffering from immunogenic or non-immunogenic hyperthyroidism (Graves' disease, Plummer's disease). Since there is no causal cure for immunogenic hyperthyroidism RIT provides, like all other modalities, only a moderate rate of success which is clearly dose-related. Applying 60 Gy, normal thyroid function can be achieved in only 54% of the cases. A dose of 150 Gy succeeds in 86% of the cases. The solitary decompensated autonomous adenoma (DAA) can be eliminated surgically as well as by RIT with a high degree of success (95%). Contrary to surgery, RIT does not have any noticeable early or late morbidity. The high rate of success of RIT in patients with DAA could be confirmed in two groups with different follow-up periods (16 and 65 months). As expected, the rate of hypothyroidism increased from 11% in the early group to 23% in the late group. Multinodular autonomous adenomas can be eliminated successfully using RIT as well. The concept to apply a dose of 400 Gy to the total functional autonomous tissue as determined by ultrasound yields better results (95%) than 150 Gy to the whole thyroid gland as measured by ultrasound (88%). The rate of hypothyroidism as shown by these results (up to a maximum of 62% after RIT of Graves' disease using 150 Gy) is the lesser evil compared to remaining or recurrent hyperthyroidism since these patients can be treated with thyroid hormones without problems.

[Endocrine orbitopathy: a comparison of computerized tomographic results and orthoptic findings]. / Endokrine Orbitopathie: Gegenüberstellung computertomographischer Ergebnisse und orthoptischer Befunde.

The correlation between the loss of function of the extrinsic rectus eyemuscles and their appearance on computed tomography images in patients with Graves' disease was examined. Pathologic changes of a single rectus eyemuscle normally blockade the movement of the corresponding antagonistic muscle. This is caused by the impossibility to relax due to fibrotic alterations. Nevertheless there are some hints, which indicate, that in some cases, especially concerning the lateral rectus muscle, the inherent function of the thickened muscle is restricted.

Hypertrophy and hyperplasia during goitre growth and involution in rats--separate bioeffects of TSH and iodine.

Goitre growth was investigated in rats receiving a low iodine diet (less than 0.1 microgram iodine/g) and either 1 g/l KClO4 or 1 g/l propylthiouracil (PTU), or a combination of KClO4 or PTU with 50.82 nmol/1 T3 in tap water for 3 weeks. To investigate goitre involution, rats with iodine-deficient goitres were treated for 3 weeks either with T3 (0.5 microgram T3/day = 0.768 nmol/day), iodide (0.5 or 2.7 micrograms KI/day) or a combination of T3 with both iodide doses. Histology together with total DNA distinguished between hypertrophy and hyperplasia of the gland. During goitre growth there was highly significant correlation between goitre weight and TSH serum level (r = 0.93, P less than 0.001). Thyroid total DNA, however, was only weakly correlated to TSH but was inversely related to the degree of iodine deficiency. During goitre regression, TSH levels were normalized, histological signs of hypertrophy had disappeared, and thyroid weight was nearly normalized in all therapy groups. Total DNA, however, was normalized only with 2.7 micrograms KI/day (95 +/- 18 micrograms DNA/gland), and still elevated in all other groups. The highest DNA levels were found under T3 therapy (143 +/- 21 micrograms DNA/gland) and under 0.5 microgram KI/day (161 +/- 19 micrograms DNA/gland). Reduction of total DNA was independent of TSH, but followed replenishment of the iodine content of the glands. We conclude that TSH mainly induces hypertrophy, whereas thyroid hyperplasia is mainly regulated by the intracellular iodine content.

Evidence of in vivo iodine-induced hyperthyroidism in hyperfunctional autoimmune and autonomous human thyroid tissue xenotransplanted to nude mice.

The effect of different doses of continuous iodine infusion on xenotransplanted human thyroid tissue from toxic adenoma, and Graves' disease was examined using 131I scintigraphy in athymic nude mice. In spite of pretreatment with high iodine doses (1.25 micrograms or 12.5 micrograms 131I per day via i.p. implanted minipumps, Alzet 2002), the radioactivity localized in the transplanted tissue of toxic adenoma was more than 50% of the radioactivity in the transplants of the controls without iodine pretreatment 2 h after 131I injection, which was not a significant difference. Moreover, after high iodine treatment the 131I turnover rate in the thyroid transplants of toxic adenoma increased significantly. A tendency to an increased turnover rate was already observed with the lower dose. In contrast to that the transplants of Graves' disease tissue and mouse thyroids responded to high iodine treatment with a significant decrease in 131I retention. Serum of an untreated patient with active Graves' disease or injections of TSH increased 131I retention and the 131I turnover rate in the transplanted tissue of Graves' disease significantly (P less than 0.01). Iodine turnover was still increased after high iodine treatment. These results again show that thyroid tissue of toxic adenoma remains hyperfunctional after transplantation to athymic nude mice in contrast to thyroid tissue of Graves' disease which loses all signs of hyperfunction, when no exogenous stimulator is administered. In addition, these data clearly demonstrate, for the first time under in vivo conditions, that high iodine doses accelerate iodine turnover and thus presumably hyperfunction of human toxic adenoma in a dose-dependent manner as well as of the activated thyroid in Graves' disease.