The diagnosis of typical cases of hyperthyroidism caused by female endocrine disorders is generally not difficult. The clinical manifestations of mild patients, or the cases of the elderly and children are few and atypical, and the diagnosis often needs the help of laboratory examination.
(1) The clinical manifestations with diagnostic significance pay special attention to fear of heat, hyperhidrosis, excitement, hyperalgesia with emaciation, tachycardia at rest, special eye signs, goiter, etc. If vascular murmurs and tremors are found on the thyroid gland, it is more diagnostic.
(2) Under normal thyroid function test, the concentrations of T3, rT3 and T4 in the blood of hyperthyroidism patients all increased, and T3 increased more obviously than T4. Lower TSH can only be seen in sensitive immunoradiometric tests.
The etiology of this disease is unknown, so the treatment without cause mainly controls the hypermetabolic group. Deduct unfavorable factors such as mental stress. At the initial stage of treatment, we should give proper rest and various supportive therapies, and supplement enough calories, sugar, protein, various vitamins and other nutrients to correct the consumption caused by this disease. The basic methods to control hyperthyroidism group are: ① antithyroid drugs; ② Radioisotope iodine; ③ operation.
Hyperthyroidism is a general term for diseases characterized by high metabolism. Due to various reasons, the feedback control mechanism of normal thyroid secretion is lost, and thyroxine in circulation is abnormally increased.
2 drug therapy
At present, there are three main methods to treat hyperthyroidism: medical treatment, 13 1I radiotherapy and surgical treatment. In the elderly, medical medication is the most basic method, and 13 1I radiotherapy is also a common method. Due to physical conditions, surgery for the elderly is relatively rare.
2. 1 internal medicine drug therapy
The drugs for treating hyperthyroidism are mainly thiourea drugs, including thiouracil and imidazole. Methimazole (Tabazol), propylthiouracil (PTU), carbimidazole (which can be decomposed into Tabazol in vivo) and Methylthiouracil (MTU) are commonly used in China. The latter is seldom used now. The mechanism of action of thiourea drugs is mainly to inhibit the activity of thyroid peroxidase and block tyrosine iodination, thus inhibiting the synthesis of thyroid hormone. These drugs do not affect thyroid iodine? Hong Na. ? Why don't you make a fool of yourself? Why not turn your head and play with porcelain? В? Parrot? What's the matter with you, Benju? how much is it? Generally, hyperthyroidism patients need to take medicine for 2 ~ 4 weeks before their clinical symptoms can be relieved. If there is a large amount of iodine in patients before treatment, the synthesis and reserve of thyroid hormone will increase, which will lead to the prolonged onset time of antithyroid drugs. As far as the mechanism of drug action is concerned, PTU can inhibit the transformation from T4 to T3 in peripheral tissues. Therefore, many doctors prefer propylthiouracil (PTU). From the clinical practice, methimazole (tabazole) is more effective and methimazole (tabazole) is cheaper. Therefore, methimazole (tabazole) can be the first choice.
Drug treatment process can be roughly divided into three stages:
(1) symptom control stage: it usually takes 1 ~ 3 months, and the dosage is generally 30 ~ 40 mg of methimazole (tabazole) or 300 ~ 400 mg of propylthiouracil (PTU) every day, 3 ~ 4 times. In order to relieve symptoms, especially the increase of heart rate, β -blockers such as propranolol can be added. Most patients need to take propranolol because antithyroid drugs are still ineffective 2 ~ 4 weeks after starting treatment.
(2) Drug dosage decreasing stage: generally it takes 2 ~ 3 months. When the clinical symptoms are basically relieved and the thyroid function tests TT3, FT3, TT4 and FT4 return to normal, drug reduction can be started. The first dose reduction can generally reduce the daily dose 1/3. After that, most patients can reduce the dose of 1 time within about 1 month, and the daily dose is 5mg of methimazole or 50 mg of propylthiouracil (PTU). 40mg of thyroid powder (tablets) or 50 ~ 100 μ g of levothyroxine should be added before the dosage reduction, so as to prevent hypothyroidism caused by overdose of antithyroid drugs and prevent goiter during treatment.
(3) Maintenance period: The maintenance dose is generally 5 ~ 15mg methimazole (Tabazol) or 50 ~ 150 mg propylthiouracil (PTU) per day, and most patients take 5mg methimazole (Tabazol) or 50 mg propylthiouracil (PTU) twice a day. If the maintenance dose is too small, the recurrence rate of hyperthyroidism will increase. At this stage, continue to take thyroid powder (tablets) or levothyroxine, and the dose will remain unchanged in principle until the drug is stopped.
2.2 13 1I radiotherapy
This method is a convenient, safe and effective method to treat hyperthyroidism, especially for the elderly. After the patient took a proper amount of 13 1I, it was quickly absorbed by the thyroid gland. Among the rays released during the decay of 13 1I, alpha rays mainly irradiate cells, destroy thyroid cells and reduce thyroid function. Iodine should be avoided within 2 weeks before taking 13 1I. According to the thyroid size and iodine absorption rate, take131i once. Generally, the symptoms of hyperthyroidism begin to relieve in 2 ~ 3 weeks after taking the medicine, and the symptoms are relieved in 1 ~ 3 months. If necessary, consider the second treatment after 6 ~ 9 months. Patients with severe hyperthyroidism can take antithyroid drugs and propranolol after taking 13 1I 1 ~ 7 days. It is reported in China that the cure rate is above 80% and the total effective rate is above 95%. The main complication of this treatment is hypothyroidism. Temporary hypothyroidism caused by 3 ~ 6 months after treatment can be recovered within 1 year; The incidence of permanent hypothyroidism increases with the time after treatment. According to foreign statistics, 20% of patients developed hypothyroidism in the first two years of treatment, and the average annual incidence rate thereafter was 3.2%. Domestic literature reports that the incidence of hypothyroidism is mostly lower than that of foreign countries, but there are also reports that 748 patients have been followed up. After treatment 1 1 year, the cumulative prevalence rate has reached about 50%. The cause of permanent hypothyroidism is related to radiation dose and individual sensitivity to radiation, and it is not excluded that it is related to the existence of autoantibodies TGAb and TMAb.
A few people take 13 1I 2 ~ 3 days, and then feel suffocated and have thyroid pain. Occasionally complicated with hyperthyroidism crisis. Therefore, in the treatment of 1 week, we should pay close attention to the changes of the condition.
2.3 Surgical treatment
Subtotal thyroidectomy is also an effective method to treat hyperthyroidism. Surgical indications are:
(1) The thyroid gland was obviously enlarged (above ⅲ degree) with obvious vascular murmur, but it did not shrink obviously after drug treatment.
(2) Nodular goiter or toxic adenoma.
(3) The drug treatment effect is not ideal, and it recurs many times.
(4) Long-term drug treatment is difficult or difficult to adhere to. Patients must be treated with antithyroid drugs. After thyroid function (mainly TT4, FT4, TT3 and FT3) returns to normal, they should make adequate preoperative preparations, including taking Lugol's solution three times a day, with a drop of 10 each time, and the operation can only be performed after 2-3 weeks. Anti-thyroid drugs can be taken for 5 ~ 7 days before operation. 90% of patients can get satisfactory results by surgical treatment. But it can still recur after operation. A few patients may also have hypothyroidism, especially after Hashimoto's hyperthyroidism surgery. Therefore, such patients are generally not suitable for surgical treatment. Surgical treatment should be contraindicated for hyperthyroidism patients who cannot tolerate surgery, invasive exophthalmos and various thyroiditis. Elderly patients with hyperthyroidism are often accompanied by chronic diseases such as coronary heart disease, poor cardiopulmonary function, hypertension, etc., and the risk of surgery increases, so surgical treatment should be cautious.
Hyperthyroid heart disease should be treated by internal medicine or 13 1I radiotherapy, and surgery is contraindicated. The management principle of thyroid heart disease is to effectively control hyperthyroidism. After hyperthyroidism control, most heart conditions can return to normal or improve obviously. But the elderly are often accompanied by organic heart diseases such as coronary heart disease and pulmonary heart disease. Therefore, whether the changes of thyroid heart disease can completely return to normal depends on the basic situation of the heart. In the treatment of hyperthyroid heart failure, besides cardiotonic drugs such as digoxin, β -blockers such as propranolol (propranolol) and atenolol (aminoacyl-propranolol) can also achieve good results when used properly.
The principles for dealing with hyperthyroidism crisis are as follows:
① Fully block the synthesis of thyroid hormone, and take methimazole (Tabazol) 60 ~ 100 mg orally every day (except for the crisis caused by thyroid surgery) for 3 ~ 4 times.
② In order to inhibit the release of synthetic thyroid hormone, 30 drops of Lugol's iodine solution were taken orally (nasal feeding) immediately, and then 30 ~ 40 drops every 6 hours; Or sodium iodide 1.0g is dissolved in 500ml of 5% glucose solution, and intravenous drip is given for 8 ~ 1 2h1time. Iodine should be supplemented after taking antithyroid drugs 1h or at the same time in an emergency.
③ To block the effect of thyroid hormone on peripheral tissues, β -blockers can be used, and propranolol (20 ~ 40 mg) can be taken orally every 4 hours 1 time; Or intravenous propranolol (propranolol) 1mg, used up within 5 minutes, and then intravenous drip of 5 ~ 10 mg every hour. Guanethidine can also be taken orally, daily 100 ~ 200 mg, divided into three times.
④ Glucocorticoid therapy: intravenous hydrocortisone 200 ~ 400 mg per day or dexamethasone 15 ~ 30 mg per day.
⑤ Remove the inducing factors, and actively treat those caused by infection.
⑥ Symptomatic treatment and supportive treatment, cooling the patients with high fever, adopting hibernation therapy when necessary, absorbing oxygen, fully replenishing fluids and restoring electrolyte balance. Supplement enough glucose and vitamins.
⑦ If the condition does not improve after the above treatment for 24 ~ 48h, hemodialysis or peritoneal dialysis can be considered to rapidly reduce the level of thyroid hormone in blood circulation.
3 diet health care
1. Don't eat dairy products for at least three months. Do not drink coffee, tea, nicotine and stimulating drinks.
2. Patients with hyperthyroidism can often eat foods that can inhibit thyroxine synthesis, such as peanuts and perilla seeds. Cold foods such as watermelon, kidney beans, celery and day lily can be used for those who are angry. People with yin deficiency can use foods that can nourish yin, such as fungus, mulberry, turtle and duck. People with spleen deficiency can use foods that can strengthen the spleen and stop diarrhea, such as yam, Euryale ferox, apple, jujube, mustard and so on.
3. Eat more foods with high potassium content and foods rich in calcium and phosphorus.
4. In addition to foods with high iodine content, patients should avoid warm and spicy foods, such as peppers, cinnamon, ginger, mutton, strong tea and coffee.
5. Limit dietary fiber, and eat less foods containing more dietary fiber, such as bran, cabbage, apples and carrots. Hyperthyroidism patients are often accompanied by symptoms of increased defecation or diarrhea.
4 preventive health care
1. Take the medicine on time: Take the medicine on time and according to the doctor's advice, and do not stop taking the medicine or change the dosage at will. When the dosage and other drugs need to be reduced or increased, the doctor's consent should be obtained to avoid accidents.
2. Emotional adjustment: Mental stimulation is a common cause of this disease, and the symptoms are often aggravated by anxiety, emotional anxiety and mental stress. Therefore, hyperthyroidism patients should pay attention to it.
Adjust the mood, cultivate one's morality and cultivate one's mind. Don't get angry when something happens, rest quietly, often listen to elegant and beautiful music, and form the habit of planting flowers, raising fish and raising birds, so as to cultivate your mind and gradually eliminate mental symptoms. Family and colleagues should also
Compassion and comfort, understanding and care, avoid direct conflict.
5 pathological causes
According to the etiology of hyperthyroidism, it can be divided into three categories: primary, secondary and hyperthyroidism adenoma.
(1) Primary hyperthyroidism is the most common, which means that hyperthyroidism and goiter occur at the same time. Most patients are between 20 and 40 years old. Gland enlargement is diffuse, bilateral symmetry, often accompanied by exophthalmos, so it is also called exophthalmos.
Secondary hyperthyroidism is rare, such as nodular goiter secondary hyperthyroidism; The patient first had nodular goiter for many years, and then developed hyperthyroidism symptoms. The onset age is mostly over 40 years old. Glands are nodular enlargement, bilateral asymmetry and no exophthalmos, which is easy to cause myocardial damage.
③ Hyperfunctional adenoma is rare. There is a single autonomous high-functioning nodule in the thyroid gland, and the thyroid tissue around the nodule is atrophied. The patient has no exophthalmos.
5. 1 pathophysiology
The etiology of primary hyperthyroidism has not been fully understood. Because the TSH concentration in patients' blood is not high, some of them are lower than normal. Even TSH stimulation can not stimulate the increase of TSH concentration in the blood of these patients. Later, two kinds of autoantibodies were found in the patient's blood, so it was determined that primary hyperthyroidism was an autoimmune disease.
Among the two antibodies, one is a substance that can stimulate thyroid function, and its effect is similar to TSH, but its action time is longer than TSH (the half-life of TSH is only 30 minutes, and the substance is 25 days), so it is called "long-acting thyroid hormone"; The other is "thyrotropin immunoglobulin", both of which are G-type immunoglobulins, which are derived from lymphocytes and can inhibit TSH and bind with TSH receptor, thus enhancing the function of thyroid cells and secreting a large number of T3 and T4.
As for the etiology of secondary hyperthyroidism and hyperfunctional adenoma, it is not completely clear. The low concentration of long-acting thyrotropin in patients may be related to the disorder of spontaneous secretion of nodules themselves.
6 disease diagnosis
(1), musculoskeletal system: 70% of hyperthyroidism patients will have different degrees of muscle atrophy. If it develops into chronic myopathy, it will show weakness and atrophy of proximal muscles, and male patients will be accompanied by periodic paralysis.
(2) Abnormal mental nervous system: This symptom often brings mental burden to the family. The patients are neurotic, talkative, irritable and violent, nervous and anxious, restless and insomnia, inattention, and memory loss. Occasionally, the patient will have hallucinations until schizophrenia. However, the symptoms of hyperthyroidism occasionally appear silence, depression and indifference, which is in sharp contrast with the common hyperactivity. Stretch out your limbs.
(3) Hypermetabolic syndrome: Do you often feel tired, weak, hungry, overeating and emaciated? Do you often fear hot sweating? Your skin is warm and moist, which may be accompanied by low fever, but you may have a high fever in an emergency. If so, it is likely to be a typical hypermetabolic symptom.
(4) Eye symptoms: Is there a phenomenon that the upper vision is not wrinkled and the lower vision is delayed? If there is, it is largely a manifestation of hyperthyroidism.
(5) Digestive system: Eat too much and lose weight obviously. If the elderly, there may be symptoms such as loss of appetite, anorexia and diarrhea, which will bring great damage to the health of the elderly.
(6), reproductive system: female patients often have decreased menstrual flow until amenorrhea, men will have impotence, and very few male patients have breast development reversal.
(7) Thyroid enlargement: This is also a common symptom, mostly symmetrical and diffuse, but the degree of enlargement has no obvious relationship with the severity of hyperthyroidism, so patients with quite enlarged thyroid need not worry. Goiter can feel a certain degree of noise in the blood vessels as swallowing moves up and down.
(8) Cardiovascular system: Patients will feel chest tightness, palpitation, shortness of breath and rapid heart rate. If hyperthyroidism is not effectively treated, symptoms such as atrial fibrillation, heart enlargement and heart failure will often occur, which will almost affect the life and health of patients.
6. 1 type
There are many kinds of hyperthyroidism, among which Graves' disease is the most common. The onset of toxic diffuse goiter is related to genetic and autoimmune factors, but whether there are hyperthyroidism symptoms is also related to some inducing factors (environmental factors). If these inducing factors are avoided, it is possible to avoid the symptoms of hyperthyroidism, or delay the symptoms of hyperthyroidism, or alleviate the symptoms of hyperthyroidism.
Clinically, in addition to the typical hyperthyroidism, there are the following common:
(1)T3 hyperthyroidism. T3 hyperthyroidism refers to a kind of hyperthyroidism with clinical manifestations, but serum TT4 and FT4 are normal or even low, and only T3 is elevated.
(2)T4 hyperthyroidism, also known as thyroxine hyperthyroidism, refers to a hyperthyroidism with elevated serum TT4 and FT4 and normal TT3 and FT3. Turner first reported the name of T4 hyperthyroidism in 0975. Its clinical manifestations are the same as typical hyperthyroidism, which can occur in Graves' disease, toxic nodular goiter or subacute thyroiditis, and it is more common in middle-aged and elderly people with poor general conditions. Such as severe infection, operation and malnutrition. Laboratory examination showed that serum TT4 and FT4 were elevated, while TT3 and FT3 were normal. The thyroid uptake rate of 13 1I was significantly increased, and the thyroid slice or T3 inhibition test was abnormal.
This disease needs to be differentiated from acute stress hyperthyroidism (pseudo T4 hyperthyroidism). The so-called stress hyperthyroidism refers to patients with acute or chronic systemic diseases. Due to these diseases, patients' serum TT4 and FT4 increased, while TT3 and FT3 were normal or decreased. There is no evidence of hyperthyroidism except for a few patients with goiter. After the primary disease is cured, the above laboratory indexes will return to normal in a short time.
(3) hyperthyroidism in children. After 3 years old, the incidence rate gradually increased. The incidence rate was the highest at 1 1- 16 years old, with more girls than boys. All children have diffuse goiter and typical hypermetabolic syndrome, and exophthalmos is more common.
(4) hyperthyroidism in the elderly. Due to the physiological changes of the elderly, the functions of various organs in the whole body have declined to varying degrees, the thyroid tissue has been fibrosed and atrophied to some extent, the secretion of thyroid hormone has decreased, and the response of peripheral tissues to thyroid hormone has also changed. The clinical characteristics of hyperthyroidism in the elderly are: the thyroid gland is often not enlarged, or slightly enlarged, mostly accompanied by nodules; Exophthalmos is not obvious or prominent, hypermetabolic syndrome is not obvious, lack of appetite, fear of heat and sweating, irritability and other symptoms; Often complicated with angina pectoris and even myocardial infarction and other heart diseases, it is prone to arrhythmia and heart failure, especially persistent atrial fibrillation; The patient shows indifference and no desire, and in severe cases, he is sleepy or unconscious.
(5) indifferent hyperthyroidism. This type is a special manifestation of hyperthyroidism. Contrary to the symptoms of typical hyperthyroidism, it is a kind of hyperthyroidism with nerve inhibition. The clinical manifestations of indifferent hyperthyroidism are loss of appetite, nausea, chills, dry skin, apathy and depression, and indifference to surrounding things; Mental thinking activities are slow, while answering questions slowly, sometimes it is difficult to concentrate and lazy to talk less; Palpitation is common, often accompanied by heart enlargement, congestive heart failure, atrial fibrillation, sunken eye socket, dull eyes and even drooping eyelids.
(6) Concealed hyperthyroidism. Concealed hyperthyroidism refers to a kind of hyperthyroidism that has no typical hyperthyroidism symptoms, but manifests as a systemic disease. Clinical classification includes ① mental type, with mental abnormality as the outstanding performance. The patients showed inattention, inattention, hallucinations, delusions, depression, dementia, paranoia and mania, and even suicidal thoughts and rage attacks. ② Gastrointestinal type, often characterized by diarrhea. The frequency of stool varies from several times a day to more than a dozen times. It is mushy or watery and contains undigested food. Some patients mainly show vomiting or abdominal pain. Gastrointestinal hyperthyroidism has vomiting and diarrhea, often accompanied by water and electrolyte disorders. If it is not treated properly, it is easy to induce hyperthyroidism crisis and endanger life. ③ Myopathy is characterized by muscle weakness and periodic paralysis. Symptoms of hyperthyroidism are not obvious or appear late. Clinical manifestations are acute and chronic hyperthyroidism myopathy and periodic paralysis.
7 inspection method
Mainly depends on the typical clinical manifestations, sometimes combined with some special examinations. The special examination methods commonly used for hyperthyroidism are as follows:
1. basal metabolic rate can be calculated according to pulse pressure and pulse rate, and can also be measured by basal metabolic string tester. The latter is reliable and the former is simple. The common formula is: basal metabolic rate = (pulse rate+pulse pressure)-11. Basal metabolic rate should be measured when completely quiet and empty. Normal value. When it rises to +20%-30%, it is mild hyperthyroidism /30%-60% is moderate, and 160% or more is severe.
2. Determination of thyroid uptake rate 13 1. The normal thyroid intake in 13 1 24 hours is 30%~40% of the total human body. If the thyroid intake of 13 1 exceeds 25% of the total human body within 2 hours, or it is 14.
3. Determination of T3 and t 4 in serum At the onset of hyperthyroidism, T3 in serum is about 4 times as normal, while T4 is only 2.5 times as normal. Therefore, T3 determination is highly sensitive to the diagnosis of hyperthyroidism.
8 complications
1. Hyperthyroid heart disease is a common complication of hyperthyroidism, which accounts for about 8.6% ~ 17.5% of hospitalized hyperthyroidism patients in China. The incidence of hyperthyroidism complicated with thyroid heart disease in the elderly is high.
(1) The main mechanisms of thyroid heart disease are: ① Angina pectoris and myocardial infarction due to the increase of thyroid hormone, hypermetabolism, increased tissue oxygen consumption, tachycardia promotion, increased myocardial load and myocardial hypoxia; (2) Hyperthyroidism activates myocardial cell membrane ATPase, which increases the sensitivity of myocardial β -adrenergic receptor to catecholamine, and increases the excitability and contractility of myocardium, which is easy to produce ectopic beats and lead to arrhythmia; ③ The function of sinoatrial node and atrioventricular node is enhanced under the action of high thyroid hormone, and the sensitivity of myocardium to catecholamine is increased. The acceleration of heart rate and the enhancement of contractility lead to myocardial relaxation and contraction overload, which leads to heart enlargement and heart failure. Due to the influence of coronary heart disease and other factors, the elderly have poor heart foundation and the incidence of thyroid heart disease has increased significantly.
(2) Diagnostic criteria of thyroid heart disease: Hyperthyroidism has universal effects on the heart, such as ECG changes, but it cannot be considered as thyroid heart disease. Therefore, we must meet certain standards to make a diagnosis. At present, there is no unified diagnostic standard, and the general principles are: ① enlargement of the heart; ② obvious arrhythmia (atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, conduction block and frequent premature beats, etc.). ); ③ Congestive heart failure; ④ Angina pectoris and acute myocardial infarction; ⑤ The cardiac damage was obviously improved or disappeared after hyperthyroidism control. In the case of hyperthyroidism, the diagnosis of thyroid heart disease can be established by satisfying any one of the above conditions (1 ~ 4), adding the fifth one and excluding other causes of heart disease. The incidence of atrial fibrillation (including paroxysmal or persistent) is the highest, followed by cardiac enlargement and heart failure, and complete heart failure is more common in the elderly. ⅲ atrioventricular block, even Asperger's syndrome and sick sinus syndrome have been reported from time to time.
2. Hyperthyroidism crisis This disease is the most serious complication of hyperthyroidism, and the mortality rate is as high as 60% ~ 80%. Older people are especially dangerous. Under the condition of uncontrolled hyperthyroidism, stress stimuli, such as severe infection, trauma and surgery, are the most common inducing factors. Surgery or 13 1 iodine radiotherapy can also lead to hyperthyroidism crisis.
(1) Pathogenesis: The occurrence of hyperthyroidism crisis may be caused by many factors: ① a large amount of thyroxine is released into the blood circulation; ② Free thyroxine in blood increased; ③ The body reacts abnormally to thyroid hormone; ④ Adrenergic activity increased; ⑤ The clearance rate of thyroid hormone in liver decreased.
(2) Clinical features: Diffuse and nodular goiter caused by hyperthyroidism can lead to crisis. Typical clinical manifestations are high fever, sweating, tachycardia, frequent vomiting and diarrhea, delirium and even coma and shock. Electrolyte imbalance eventually leads to respiratory and circulatory failure and death. Most patients have obvious goiter. Elderly patients may only have cardiac abnormalities, especially arrhythmia or gastrointestinal symptoms. You can find out the obvious cause of this disease.
(3) Treatment principle:
① Protect various organs of the body and prevent functional failure: for those with mild fever, use antipyretics. Taking a large amount of aspirin should be avoided, because it can further improve the metabolic rate of patients and compete with thyroid hormones for thyroid binding protein to increase free hormones. In case of high fever, actively cool down physically and hibernate artificially when necessary. Because metabolism is obviously increased, oxygen should be given. Due to high fever, vomiting and sweating, it is necessary to supplement water, correct electrolyte disorder, and supplement sugar and vitamins. Corticosteroid therapy.
② Lowering the level of circulating thyroid hormones: After oral or nasal feeding with large doses of thiourea antithyroid drugs (propylthiourea pyrimidine 600 ~ 1000 mg/d or methimazole 60 ~1000 mg/d), the organic combination of iodine in thyroid can be quickly prevented (within 1h). Give the maintenance amount later. After using thiourea drugs 1h, iodine can be given again (30 drops of compound iodine solution or 3 ~ 4 ml/d compound iodine solution), which can completely inhibit the production of additional thyroid hormones produced by iodine used.
③ Reduce the response of peripheral tissues to thyroid hormones: Anti-sympathetic drugs can reduce the effect of peripheral tissues on catecholamine. Propranolol is commonly used (oral once every 6 hours, 40 ~ 80mg； per day; Or intravenous injection 1 ~ 5 mg), reserpine and acetamidine.
(4) Control incentives:
Actively respond to various causes leading to the crisis, including the use of antibiotics to treat infections.
(4) Prognosis:
The first three days after the start of treatment is the key moment of rescue. After successful treatment, most patients got better within 1 ~ 2 days after treatment and recovered within 1 week. After crisis recovery, iodine and corticosteroids can be gradually reduced.
2. Chronic hyperthyroidism myopathy
(1) Diagnosis: Chronic hyperthyroid myopathy is a neurological and muscular complication of hyperthyroidism. Diagnostic basis: ① Clinical diagnosis of hyperthyroidism, with or without chronic myotonia and muscular atrophy. ② EMG shows the time limit of motor unit? Tao Tao? What's the matter with you? "Rinse coke gangrene about ≡? Yun┟？ Hey? Hey? What happened? ∪╀ "
(2) Clinical features: Most patients start with symptoms of thyroid hormone increase, and a few patients start with myasthenia of limbs, or thyroid hormone increase and myasthenia occur at the same time. Muscle weakness mostly occurs in the proximal end of upper limbs and/or lower limbs, and some of them may have dysphagia.
(3) Treatment and prognosis: With antithyroid drugs, myopathy will be gradually cured after hyperthyroidism is controlled. After 3 ~ 5 months of hyperthyroidism treatment, myopathy can completely return to normal.
3. Other hyperthyroidism is accompanied by autoimmune diseases such as myasthenia gravis, pernicious anemia, diabetes, rheumatoid arthritis, glomerulonephritis, lupus erythematosus, Sjogren's syndrome, idiopathic thrombocytopenic purpura and scleroderma, but it is rare in clinic.
9 forecast
Many documents have recorded the natural process of hyperthyroidism crisis without special treatment. It is reported that the death rate of hyperthyroidism crisis is above 20% (20% ~ 100%). After successful treatment, it generally improves within 1 ~ 2 days and recovers within 1 week. Thirty-six subcritical patients in Peking Union Medical College Hospital were out of danger within an average of three days after first aid and recovered in seven days (1 ~ 14). The first three days after the start of treatment is the key moment of rescue. After the crisis is cured, iodine can be gradually reduced and corticosteroids can be stopped, and long-term treatment arrangements can be made.
10 pathogenesis
There are many causes of hyperthyroidism, and autoimmune thyropathy is the most common. Graves' disease and Hashimoto's thyroiditis with hyperthyroidism are one of them. There are many antithyroid antibodies in patients with this disease. There are mainly TSH receptor antibody (TRAb), thyroglobulin antibody (TGAb), thyroid cell microsomal antibody (TMAb) or thyroid peroxidase antibody (TPOAb). TRAb is mainly produced by lymphocytes or plasma cells infiltrated in thyroid gland, which can specifically bind TSH receptor. TRAb has at least two antibodies: TSAb and TSBAb. After TSAb binds to TSH receptor on thyroid cell membrane, adenosine cyclase on cell membrane is activated, which leads to the increase of thyroid hormone synthesis and secretion through the mediation of cAMP, and can also stimulate the proliferation of thyroid epithelial cells, leading to hyperthyroidism and goiter. TSBAb has the opposite effect to TSAb. After binding with TSH receptor, TSBab inhibits adenosine cyclase activity and blocks the release of cAMP, resulting in thyroid atrophy and hypofunction. Therefore, TSAb is the main factor causing autoimmune hyperthyroidism. Among Graves' patients, TSAb is the main one. When TSAb is dominant, hyperthyroidism occurs. When TSAb decreases or disappears, hyperthyroidism tends to be relieved. At a certain stage, some Graves patients also showed TSBAb superiority and hypothyroidism. TGAb and TMAb(TPOAb) are destructive autoimmune antibodies, which are related to thyroid damage and thyroid function damage, and mainly exist in Hashimoto's thyroiditis patients. Patients with Hashimoto's thyroiditis can not only produce hyperthyroidism because of TSAb, but also cause transient hyperthyroidism because TGAb and TMAb destroy a large number of thyroid tissues in a short time, and a large number of thyroid hormones are released from cells into the blood. Toxic nodular goiter causes hyperthyroidism, which is mainly due to the spontaneous secretion of thyroid hormone (hot nodule) by nodules, and its exact cause is not clear.
Hyperthyroidism caused by thyroid cancer is very rare, because in cancer cells, even well-differentiated papillary cancer or follicular cancer, its function is mostly lower than normal, so it usually shows as "cold nodules" or "cold nodules". However, if the amount of cancer tissue is large, such as systemic metastasis of thyroid cancer, the total amount of thyroid hormone secreted by cancer cells is too much, which will also cause hyperthyroidism. Very few thyroid cancers, namely "hot nodules", will lead to hyperthyroidism.
All kinds of thyroiditis cause hyperthyroidism, mainly because a large number of thyroid cells are destroyed and thyroid hormones in the cells are released into the blood, which leads to the increase of thyroid hormones in the blood circulation and hyperthyroidism. This hyperthyroidism is usually temporary, usually accompanied by an increase in serum thyroglobulin (TG).
3. Genetic factors and inducing factors
(1) Genetic factors: A study on the first-degree relatives of 204 patients with Graves' disease in eastern Guangdong found that the prevalence of hyperthyroidism in the first-degree relatives of hyperthyroidism patients was 3.23%, while that in the first-degree relatives of normal people in this area was only 0. 145%, with a difference of 22.3 times, and its heritability was 68.6% 3.8%, which was close to high heritability and genetic model. The other group studied 600 cases of Graves hyperthyroidism, 200 cases of chronic lymphocytic thyroiditis, 52 cases of thyroid adenoma, 48 cases of papillary carcinoma and 800 cases of control. It is found that hyperthyroidism, chronic lymphocytic thyroiditis and thyroid adenoma may all be polygenic inheritance, and all three diseases are at risk of recurrence, but there is no significant difference between relatives of papillary carcinoma and control group.
(2) Inducing factors:
① Environmental factors: mental or work stress, disputes, anger, infection, surgery, trauma and other factors can induce or aggravate the disease, and about 80% of patients can find the inducing factors.
② Iodine induction: It is also an important inducement of hyperthyroidism. It is safe for normal people to take 100 ~ 200 micrograms of iodine every day. If the daily intake exceeds 200 micrograms or more, hyperthyroidism may be induced. Drugs commonly used by the elderly, such as amiodarone 200mg, contain 75mg of organic iodine and 6mg of free iodine, which are not easy to be discharged and accumulated after entering the body; Organic iodine contrast agent 100ml contains about 30g of iodine. Both greatly exceeded the safe intake. The exact mechanism of iodine-induced hyperthyroidism is not clear, which may be related to thyroid dysfunction or potential hyperthyroidism diseases (such as Plummer's disease and Graves' disease) in these patients.