Thyrotoxicosis.

Diffuse toxic
goiter
 Клинический случай 1
• Больная Д., 32 лет, поступила в эндокринологическое отделение с жалобами на общую
слабость, сердцебиение, похудание за 6 месяцев на 10 кг, потливость, раздражительность,
бессонницу, тремор рук и выраженную слабость. Полгода назад перенесла сильный стресс
(конфликт в семье). С этого времени почувствовала нарастающую слабость, плохой сон и
снижение массы тела при сохраненном аппетите.
• Объективно: общее состояние удовлетворительное. Питание пониженное. Кожные покровы
бледные, повышенной влажности. Тремор кистей и пальцев рук, тремор век. Рост 170 см., вес
50 кг. Положительны симптомы Кохера, Грефе, Мебиуса и Штельвага. Дыхание везикулярное,
хрипов нет. Тоны сердца ритмичные, 1 тон усилен, на верхушке сердца систолический шум,
проводится во все точки и на сосуды шеи. Пульс 120 ударов в минуту, АД 140/80 мм рт. ст.
Контуры передней поверхности шеи деформированы. При пальпации щитовидная железа
увеличена в размерах и видна на глаз, плотнее обычной, безболезненная, подвижная.
Вопросы:
• 1. Выделите клинические синдромы.
• 2. Какой диагноз у пациентки?
• 3. Опишите правильное проведение и оценку симптомов Краузе, Мебиуса, Кохера и
Дальримпля. Какие еще глазные симптомы знаете
• 4. Рассчитайте ИМТ.
• 5. Назовите методы специфической диагностики данного заболевания.
• 6. Чем обусловлены изменения со стороны сердечно-сосудистой системы?
• 7. План лечения
THYROTOXICOSIS is a clinical syndrome caused by
the action of excess thyroid hormones on target
tissues. ("poisoning by thyroid hormones")

HYPERTHYROISIS - an increase in thyroid function

(which can be both pathological and
physiological (for example, during pregnancy).
 THYROTOXICOSIS SYNDROME (HYPERTHYROISIS) (1999)

1. Hyperthyroidism due to increased production of thyroid

hormones:
• diffuse toxic goiter
• (multi)nodular toxic goiter, toxic adenoma
• iodine-induced hyperthyroidism
• hyperthyroid phase of autoimmune thyroiditis
• TSH-mediated hyperthyroidism:
A) TSH - producing pituitary adenoma
B) syndrome of inadequate secretion of TSH (resistance of
thyrotrophs to thyroid hormones) • trophoblastic hyperthyroidism
• toxicosis of pregnant women
2. Conditions caused by the production of
thyroid hormones outside the thyroid gland:
• struma ovarii
• metastases of thyroid cancer producing
thyroid hormones
3. Thyrotoxicosis not associated with hyperproduction of thyroid
hormones (passive entry of thyroid hormones into the blood):
• drug-induced thyrotoxicosis (overdose of thyroid hormone
preparations)
• subacute lymphocytic thyroiditis (thyrotoxic stage)
• thyrotoxicosis due to increased tissue sensitivity to thyroid
hormones
• acute lymphocytic thyroiditis (rare)
• chronic lymphocytic thyroiditis (rare)
• subacute granulomatous thyroiditis (thyrotoxic stage)
Diffuse toxic goiter (DTG) (Graves-
Basedow's disease) is an organ-
specific autoimmune disease
characterized by a persistent
pathological increase in the
production of thyroid hormones
under the influence of thyroid-
stimulating antibodies, usually
diffuse enlarged thyroid gland
followed by dysfunctional conditions
of various organs and systems that
develop in individuals with hereditary
predisposition.
►Of the total number of patients suffering from
thyrotoxicosis, DTG accounts for 80% of all its
cases. The peak incidence occurs at 30-40 years of
age. DTG is more common in women, the ratio of
female patients to male is 5:1
 Etiology
• Hereditary predisposition: With DTG, a polygenic type
of inheritance takes place. The inheritance of DTZ
involves genes 2, 6, 12, 13, 14, 20 chromosomes, a
gene localized on the X chromosome.DTZ is often
combined with the carriage of antigens HLA-B8, DR3,
DW3, DQA1, DRB1, DQB1.Provoking factors:
mental trauma, infectious and inflammatory diseases
(flu, rheumatism, tuberculosis, etc.), traumatic brain
injury, smoking, the use of iodine preparations in large
doses, toxins, pregnancy, increased insolation
 WHO SIZE CLASSIFICATION (1992)

• 0 degree - the goiter is not palpable and not visible

(less than the distal phalanx of the patient's thumb).
Grade
• 1 - there is a formation on the neck corresponding
to an enlarged thyroid gland, which is palpable,
moves when swallowing, but is not visible in the
normal position of the neck (larger than the distal
phalanx).
• Grade 2 - a tumor on the neck, visible in the normal
position of the head and corresponding to an
enlarged thyroid gland on palpation.
►S-m Krause - a gleam in the eyes,
► S-m Grefe - the area of ​sclera is exposed between the
upper eyelid and the edge of the iris when looking
down,
► S-m Kocher - the same thing when looking up,
►S-m Geoffroy - inability to form wrinkles on the
forehead,
► S-m Shtelvaga - rare blinking (the norm is 6-8 times per
minute),
►S. Möbius - weakness of convergence,
►St. Stasinsky (s. red cross) - injection of scleral vessels in
the form of a cross extending from the iris,
►S-m Jellinek - pigmentation of the eyelids,
► S-m Dalrymple - when looking directly, a strip of sclera
is revealed between the upper eyelid and the iris,
►S-m Botkin - the same thing when fixing the gaze on a
close object,
► S-m Rosenbach - tremor of closed eyelids,
► C-m cilia - inability to completely close the eyes, cilia
are visible,
► S-m Reprev-Melikhova - an angry look,
►S-m Zenger-Enrout - pillow-shaped swelling of the
eyelids
 Classification
• 1)subclinical;
• 2)manifest (explicit);
• 3) complicated.
Ultrasound of the thyroid gland:
1. diffuse increase (total volume in women up to
18 ml, in men - up to 25 ml.). The shares
increase to a greater extent than the isthmus -
like a "butterfly". Estimation of the sizes
Shch.Zh.
2. The echo structure is heterogeneous.
3. Isoechoic or diffuse hypoechogenicity.
4. Increased blood flow
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