Basedow: diagnosis and medical treatment

2021-07-27 09:58 PM

Basedow's is the most common cause of hyperthyroidism, an autoimmune, familial disease, most seen in women aged 20 to 50 years.

Basedow is a disease of hyperthyroidism caused by uncontrolled overactivity of the thyroid gland leading to increased thyroid hormone production, causing tissue and metabolic damage.

Basedow is the most common cause of hyperthyroidism.

It is an autoimmune, familial, disease that most commonly affects women aged 20-50.

Definite diagnosis

Clinical symptoms

Goiter:

Tumor diffuse, typical angiomas, homogeneous, bilateral, mobile when swallowing, painless, no signs of compression.

Eye manifestations:

The true protrusion on one or both sides.

Contraction of the ciliary muscle to varying degrees.

Loss of upper eyelid synergism.

Eyelid edema, ophthalmoplegia...

Signs of hyperthyroidism:

General signs: thin, despite eating a lot...

Cardiovascular: palpitations, palpitations. Tachycardia frequently above 90 beats/min, increased with emotion. Auscultation of the heart may have a mechanical systolic murmur due to increased output.

Gastrointestinal: increased intestinal motility, diarrhea.

Neuro-muscular: hand tremor, diffuse tremor, distal predominance, rapid, frequent, increased with emotion. Muscle atrophy, proximal limb predominance, with reduced muscle strength, stool sign (+). Basedow may be accompanied by myasthenia gravis.

Hypokalemia may occur in young male patients, causing paralysis of the lower extremities.

Slight increase in skin temperature, fear of heat, sweating.

Psychiatric disorders: excitability, depression, sexual dysfunction, decreased libido...

Other signs: tanning, hair loss, hot skin, male breast enlargement...

Anterior tibial myxedema:

Yellow or red-orange lesions, rough skin.

Usually bilaterally symmetrical, in the lower leg or instep.

Press is not concave, no pain.

Subclinical symptoms

Specific tests:

Thyroid hormone FT3, FT4 increased, TSH decreased (normal FT4 12 - 22pmol/l; TSH 0.27 -4.2pUI/ml).

Antibody to TSH receptor (TRAb) is elevated.

Other tests:

Complete blood count may show iron deficiency anemia, microcytic or macrocytic anemia due to lack of iodine or vitamin B12 or concomitant Biermer's disease.

Reduce cholesterol, blood triglycerides.

There may be hypokalemia.

Thyroid ultrasound (typical); thyroid gland is enlarged, diffuse, hypoechoic, no nodules.

Thyroid scintigraphy (123l, 131l," mTc) showed a larger-than-normal thyroid, uniformly and uniformly irradiated, and increased radioiodine concentration.

Electrocardiogram: usually sinus tachycardia, can see atrial fibrillation, extrasystoles, left ventricular thickening if there are cardiovascular complications.

Differential diagnosis

Hyperthyroidism due to L-thyroxine treatment

Have a history of taking L-thyroxine.

No ocular manifestations.

The concentration of radioactive iodine in the thyroid gland is low.

Blood iodine, urinary iodine increased.

Tumor (single or multiple) thyroids toxic nodule

There are signs of thyrotoxicosis.

No ocular manifestations.

Clinical examination or ultrasound: detect thyroid nodules.

Scans have hot nuclei, other areas of the thyroid gland do not capture radioactivity.

Hyperthyroidism due to subacute thyroiditis

Fever and pain in the thyroid gland.

There is an inflammatory syndrome: increased erythrocyte sedimentation rate, increased CRP.

Iodine concentration scintigraphy is reduced.

Hyperthyroidism is transient and resolves within a few weeks or months.

Hyperthyroidism due to TSH .-secreting pituitary tumor

Very rare.

TSH and FT4 both increased.

MRI scan: detect the pituitary tumor.

Other causes

Hyperthyroidism due to menopause.

Paracancerous hyperthyroidism.

Cardiovascular complications

Atrial fibrillation

Other less common arrhythmias: atrial flutter, extrasystoles...

Heart failure.

Coronary failure is also often aggravated by hyperthyroidism, requiring prompt treatment of both coronary insufficiency and hyperthyroidism.

Eye complications

Graves' eye complications can appear before, during, or after the detection of Graves' disease. Radiation treatment can make eye complications worse.

Some common eye complications

Conjunctivitis, conjunctivitis, keratitis, the sensation of entanglement, caused by eyes not closed, cornea and sclera not well protected

Paralysis of oculomotor muscles.

Malignant protrusion: infiltrating the posterior ocular tissue and rectus muscle causing the eyeball to fill up first, sometimes the patient can't close the eye and has inflammation and ulceration of the cornea. In severe cases, the eyeball can rupture.

To solve

The treatment I 131 is not indicated for Graves' patients with severe ocular manifestations.

Patients with protruding eyes: corticosteroid treatment.

Orbital radiation therapy or orbital decompression surgery.

When hyperthyroidism is under control, eye correction surgery, the rectification of rectus muscle, and orthopedic blepharospasm can be performed.

Acute hyperthyroidism

Circumstances of occurrence: abrupt discontinuation of synthetic antithyroid, surgical intervention, or radioactive iodine therapy in patients with uncontrolled hyperthyroidism. Severe infection, psychological stress or pathology in patients with hyperthyroidism.

Symptoms: frequent, irregular tachycardia, high fever, vomiting, nausea, diarrhea, extreme fatigue, jaundice, acute liver failure. There may be heart failure, confusion, panic.

Treatment: medical emergency, the main treatment is to reduce circulating thyroid hormone levels in the blood as well as reduce hormone formation.

High-dose PTU or methimazole (PTU: 12-18 tablets, thyrozole: 6-8 tablets...).

Lugol (used after synthetic antithyroid drugs) to inhibit hormone release.

Beta-blockers (intravenously or orally) to control heart rate.

Intravenous corticosteroids.

Severe prognosis, high mortality.

Severe exhaustion

By not taking or quitting.

Internally medical treatment

Synthetic thyroid resistance

Indications: first choice for young patients < 50 years old, first treatment, diffuse tumor.

Usually results for patients with mild hyperthyroidism, small goiter.

The duration of treatment is 18-24 months.

Commonly used drugs:

+ Thiamazol (carbimazol, metimazol, thyrozol).

Initial dose 15-40mg/day, divided into 1-2 times (mild hyperthyroidism dose 15mg, average dose 20-30mg, severe dose over 40mg/day). take medicine after eating.

Adjust dose as the patient gradually returns to euthyroidism.

Maintenance dose: 5-10mg/day.

+ Propylthiouracil (PTU)

Initial dose: 300-400mg/day, divided into 2-3 times. take medicine after eating.

Reduce dose gradually as the patient gradually returns to euthyroidism.

Maintenance dose: 50 - 150mg/day.

Side effects:

Agranulocytosis or agranulocytosis (neutropenia): common in the first weeks of treatment, patients have a sore throat, high fever, and are very susceptible to sepsis.

Increase liver enzymes.

Allergic skin rash.

Treatment with beta-blockers to relieve symptoms of hyperthyroidism

Metoprolol (Betaloc, Betaloc zok) tablets 25 and 50mg, dose 25-100mg/day.

Atenolol (Tenormin) 50mg tablet, dose 25-100mg/day.

Bisoprolol (Concor) tablets 2.5 and 5mg, dose 2.5 - 10mg/day.

Propranolol (Inderal) tablet 40mg, dose 40-240mg/day.

Supportive treatment with sedatives, rest regimen...

Surgical treatment

Indications for surgical treatment: suspected cancer, single or multinodular goiter, patients who want to be cured immediately but refuse radiation treatment, pregnant women intolerant of synthetic antithyroid drugs.

The success rate is high if the surgeon is experienced.

Always preoperative medical treatment: need to treat euthyroidism to reduce the risk of acute hyperthyroidism. Administer lugol 1 week before surgery to reduce hormone synthesis and reduce bleeding in the grave.

Complications: hypothyroidism, recurrent nerve damage, hematoma, laryngeal edema, hypoparathyroidism.

Treatment of iodine-131

Indications: elderly patients, heart failure, weak health or having complications of medical treatment, relapse after medical or surgical treatment.

Contraindications: pregnant and lactating women.

Radiation preparation: synthetic antithyroid drugs if severe hyperthyroidism (not necessary if mild disease), stop the drug before radiation at least 3 days. A beta-blocker may be given to control symptoms. Concentration I 131 must be measured.

The dose of radioactive iodine is 80-120mCi X thyroid volume x 100/24-hour iodine concentration.

Effective treatment: achieving euthyroidism in more than 80% of patients.

Symptoms:

10 - 30% of patients develop hypothyroidism 2 years after I 131 therapy and an additional 5% each year thereafter.

May cause or worsen Graves' eye disease, especially in smokers.

Treatment of some special types: must be treated at a specialized level

Basedow in pregnant women.

Basedow in the elderly or people with cardiovascular disease.

Basedow has eye complications.

Monitoring and prevent disease

Patients undergoing medical treatment

Clinical examination and hormone testing FT4, TSH (possibly TRAb) monthly during treatment.

Test enzymes AST, ALT, white blood cell formula in the first months.

After stopping treatment: re-mosaic 3 - 6 months during the first year and annually thereafter to see if there is a recurrence.

The recurrence rate is about 50%.

Patients undergoing surgical treatment

Examination and testing to see if euthyroid or hypothyroidism is achieved after surgery.

If hypothyroidism is present, replacement therapy with L-thyroxine is required.

Patients treated with iodine-131

Due to the high risk of hypothyroidism, it is necessary to have tests to detect and treat promptly.

Replacement therapy with L-thyroxine in the presence of hypothyroidism.

Note: eye disease may be aggravated by iodine-131 treatment. Prophylactic treatment with prednisolone is recommended.