内科学英文课件:Hyperthyroidism-甲状腺功能亢进症.ppt
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内科学英文课件:Hyperthyroidism-甲状腺功能亢进症.ppt
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Hyperthyroidism甲状腺功能亢进症DepartmentofEndocrinologyandMetabolismdiseases,RenJiHospital,SchoolofMedicine,ShanghaiJiaoTongUniversityParafollicularCellsColloidFollicularCellsGeneralIntroductionofThyroidFollicleFollicles:
theFunctionalUnitsoftheThyroidGlandRegulationofthyroidhormoneRegulationofthyroidhormonesecretionsecretionRegulationofthyroidhormoneRegulationofthyroidhormonesecretionsecretionTRHTSH.(Cold,Emotions)TSHTH.TRH/TSHStimulatingtestTHTSH(Negativefeedback)StimulateInhibitHyperthyroidism(甲亢)isdefinedasanoveractivethyroidgland,whichproducesandsecretesexcessiveamountsofthyroidhormones-triiodothyronine(T3)andthyroxine(T4).Hyperthyroidism(甲亢)isdefinedasanoveractivethyroidgland,whichproducesandsecretesexcessiveamountsofthyroidhormones-triiodothyronine(T3)andthyroxine(T4).Thyrotoxicosis(甲状腺毒症)Hyperthyroidism(甲亢)isdefinedasanoveractivethyroidgland,whichproducesandsecretesexcessiveamountsofthyroidhormones-triiodothyronine(T3)andthyroxine(T4).Thyrotoxicosis(甲状腺毒症)isclinicalsyndromewhentissuesareexposedtoexcessiveconcentrationsofthyroidhormones.Hyperthyroidismsustainedoverproductionandreleaseofhormonebythethyroiditself1.Gravesdisease2.multiplenodularthyrotoxicosis(多结节性毒性甲状腺肿)多结节性毒性甲状腺肿)3.plummerdisease/toxicthyroidadenoma(自主功能性甲状腺腺瘤)(自主功能性甲状腺腺瘤)4.iodine-inducedhyperthyroidism(碘甲亢碘甲亢)5.neonatalhyperthyroidism(新生儿甲亢新生儿甲亢)6.pituitaryTSHoma(垂体垂体TSHTSH腺瘤腺瘤)7.others(甲状腺癌等甲状腺癌等)EtiologyofthyrotoxicosisNon-thyroidthyrotoxicosisnotoverproductionofthyroidhormonesbythyroid1.subacutethyroiditis(亚急性甲状腺炎亚急性甲状腺炎)2.asymptomaticthyroiditis(无症状型甲状腺炎无症状型甲状腺炎)3.chroniclymphocyticthyroiditis(桥本甲状腺炎桥本甲状腺炎)4.postpartumthyroiditis(产后甲状腺炎产后甲状腺炎PPT)5.HCGrelatedhyperthyroidism(HCG相关性甲亢相关性甲亢)6.Iatrogenichyperthyroidism(医源性甲状腺激素替代医源性甲状腺激素替代)7.Ectopicgoiterwithhyperthyroidism(异位甲状腺激素产生异位甲状腺激素产生)EtiologyofthyrotoxicosisGRAVESDISEASE(GD)ItiswrongtosayGravesdisease(Graves病病)ashyperthyroidism(甲亢甲亢)inbrief.甲亢甲亢GDHyperthyroidismThyrotoxicosisGravesDiseaseGravesdisease(GD)pathogenesishistopathologyclinicalpresentationlaboratoryandspecialexamsdiagnosisanddifferentialdiagnosistreatmentOutlineofGDOrgan-specificautoimmunediseaseDiffusetoxicgoiterSymptoms:
thyroidenlargement,thyrotoxicosis,exophthalmos(突眼),pretibialmyxedema(胫前黏液性水肿)Morecommonlyinwomen,Female:
Male=46:
1SubclinicalhyperthyroidismisusuallyreferredtoaGDstatewithnormalT3T4,decreasedTSH,andnoclinicalsymptomsofhyperthyroidismPathogenesisAbnormalitiesofimmunesystemBcellsproduceTSH-R-Ab(TRAb)TRAbTSAb:
stimulatingIgG-hyperfunction-直接病因TSBAb:
inhibitoryIgG-hypofunctionandantagonistofTSAbTGI(thyroidgrowthimmunoglobulins):
growth-stimulatingIgGTSH-R+TRAbmimictheactionofTSH-hyperfunctionandgoiterHereditary(geneticfactors)HLA-B8、DR3、DQA1*0501、HLA-Bw46CTLA-4GD-1,-2,and-3EnvironmentandInfectioninfectivefactors(Yersiniaenterocolitica)stress(physicaloremotional)Estrogen,pregnancy,childbirthPathogenesisHistopathologyThyroidgoiter:
symmetrical(对称),diffuse(弥漫性)follicles:
hyperplasticcolumnwithscantcolloid(滤泡细胞增生肥大,呈柱状、胶质少),papillaryprojections(乳头样突起)vascularityincreased(血管增生)lymphocytesandplasmacellsinfiltration(淋巴细胞和浆细胞浸润)Thevolumeoforbitalcontentsisenlargedbecauseofincreasesinretrobulbarconnectivetissueandadiposetissue眼球后脂肪和结缔组织水肿、浸润、体积增大Theextraocularmusclesareswollen,andsomefibersexhibitlossofstriation,fragmentation,andlymphocyticinfiltration眼外肌肌炎,淋巴细胞浸润、肌纤维水肿、断裂、坏死,眼外肌体积增大眼肌增大及纤维化使眼肌自身的活动障碍,引起复视。
眼肌增大及纤维化使眼肌自身的活动障碍,引起复视。
眼睑挛缩和眼球凸出共存,引起暴露性角膜炎。
眼睑挛缩和眼球凸出共存,引起暴露性角膜炎。
球后组织增生,压力增。
高,压迫视神经引起视神经病变。
球后组织增生,压力增。
高,压迫视神经引起视神经病变。
眼眶炎症及眶引流障碍,引起球结膜水肿和眶周水肿眼眶炎症及眶引流障碍,引起球结膜水肿和眶周水肿HistopathologyOphthalmopathySkinswellingGlycosaminoglycanaccumulationintheskinandsubcutaneoustissue,collagenfiber,connectivetissuedamage(粘蛋白沉积,胶原及结缔组织损伤)Mastcells,macrophagesandfibroblastscellsinfiltration(肥大细胞,吞噬细胞和成纤维细胞浸润)HistopathologyPretibialmyxedema(胫前黏液性水肿)ClinicalPresentationSymptomsandsignsassociatedwithelevatedlevelsofthyroidhormonesGoiterOphthalmopathySpecialmanifestationsHighmetabolismNervoussystemCardiovascularsystemGastrointestinalsystemHematopoieticsystemGonadalsystemMusclesThyrotoxicosis:
Highmetabolism:
DontEvadeFeelingHotAndSweatyPatientsWeightloss(despitenormalenergyintake)FatiguesandweaknessHeatintoleranceandlowfeverIncreasedsweatingGlucoseintoleranceHighmetabolism:
NervoussystemNervoussystemNervousnessEmotionallabilityAnxietyandirritabilityDifficultysleepingHyperactivityandunabletoconcentrateTremorandmuscleweaknessTendonreflexeshyperactivityApathy,depressionandwithdrawninolderpatientsCardiovascularsystemCardiovascularsystemPalpitation(心悸)Tachycardia(心动过速90bpm)Atrialfibrillation(房颤)andotheratrialarrhythmias(室颤)PulsepressureisincreasingAccentuatedheartsounds,systolicejectionorothermurmurs(收缩期杂音)GastrointestinalsystemGastrointestinalsystemIncreasedappetiteHyperdefecationSteatorrhea(脂肪泻)Jaundice(黄疸)ImpairedoftheliverfunctionHematopoieticsystemHematopoieticsystemMildgranulocytopenia(粒细胞减少)Ironorotherhematopoieticnutrientdeficiencyanemia(贫血)Gonadalsystem(性腺)Gonadalsystem(性腺)InfrequentmenstruationorsuppressedmenstruationErectiledysfunctionandoccasionallylossoflibido(性欲)Gynecomastia(男子乳腺发育)MuscleMuscleMuscleweaknessThyrotoxicmyopathy(甲状腺毒性肌病)TPP-thyrotoxicperiodicparalysis(甲亢性周期性瘫痪)MultiplesysteminvolvementNervoussystem肢端肢端GonadalsystemCardiovascularsystemGastrointestinalsystemMusclesSkinappendagesHematopoieticsystemEndocrinesystemCardiovascularsystemGonadalsystemMusclesTPP-thyrotoxicperiodicaralysisClinicalPresentationthyrotoxicosis(hypermetabolicstate)nervousness(精神紧张99%),irritability(烦躁90%),palpitation(心慌88%),tachycardia(心动过速82%),insomnia(失眠60%),fatigue(70%),heatintolerance(70%),excessivesweating(40%),weightloss(75%),withvoraciousappetite(食欲亢进65%)ClinicalPresentationthyroidgoiter(、)、nontenderthrillwithaudiblebruit(震颤、血管杂音)ExophthalmosNon-infiltratingexophthalmosClinicalPresentationmildproptosis,18mm),visualacuritydecrease(视力下降),visualfielddefect(视野缺损),cornealulceration(角膜溃疡),restrictionofeyemovementClinicalPresentationExophthalmosProbabilityofthedevelopmentoforbitopathyinpatientswithGravesdiseasePretibialmyxedemaClinicalPresentationIntheanteriortibial,dorsalfootIntheanteriortibial,dorsalfoot多见于胫前、足背多见于胫前、足背Theskinisthickandhard,likeorangepeelTheskinisthickandhard,likeorangepeel皮肤厚而硬,酷似橘皮皮肤厚而硬,酷似橘皮thyroidstormhyperthyroidheartdiseaseapathetichyperthyroidismT3T4typehyperthyroidismsubclinicalhyperthyroidismpregnancyhyperthyroidismSpecialclinicalmanifestationscomplicationsThyroidstorm(thyrotoxiccrisis)precipitatingfactorsacuteillness:
infection,trauma(创伤),DKAsurgery(especaillyonthethyroid)radiationthyroiditissymptomsandsignsexaggeratedabruptlyfever(39),sweating,vomiting,diarrheaandjaundice(黄疸)increasedheartrate,arrhythmias(心律失常),congestiveheartfailure(充血性心衰),hypotension,shockrestlessness(烦躁),delirium(谵妄),seizures(抽搐),apathy(淡漠),stupor(木僵),coma(昏迷)HyperthyroidcrisisisalifethreateningformHyperthyroidheartdiseasefeaturesasheartenlargementarrhythmiasheartfailureothercausesexcludeddisappearedaftertreatmentApathetichyperthyroidismMorecommoninolderpatientsInsidiousonset,highmetabolicsyndromegroup,eyesymptoms,goiterisnotobviousMainpresentations:
weightloss,heartpalpitations,fatigue,diarrhea,anorexia(厌食),apathy(淡漠),atrialfibrillationeasilybemisdiagnosedDiagnosticclues:
suddenweightloss,newonsetatrialfibrillationT3T4typehyperthyroidismT3hyperthyroidismOnly5%ofhyperthyroidismRatiogeneratingT3andT4disorders,T3T4commonlyiniodinedeficiencyregionandintheelderlypopulationcauses:
GD,toxicnodularthyroidtumorsandhigh-functioningadenomasRemissionrateishigherthanthetypicalhyperthyroidismT4hyperthyroidismcausesiodine-inducedhyperthyroidismhyperthyroidismwithsystemicdisease(peripheraldeiodinaseactivityreducedorlack)Subclinicalhyperthyroidismcauses:
GD,nodulargoiter,thyroidadenomaandotherhigh-functioningdiseaseprocess:
earlystageorconvalescence(恢复期)adverseoutcomesApproximately4-10%peryearforthedevelopmentofsub-clinicalhyperthyroidismtohyperthyroidismImpactonthecardiovascularsystemOsteoporosis,fractureriskPregnancyhyperthyroidismHCGrelatedtohyperthyroidismGestationaltransienthyperthyroidism(GTT)incidence:
2-3%increasedHCGstimulatesTSHreceptornoproptosis,autoantibody(-),peakedat3monthsofpregnancyseverecases:
canbeshort-termATDtherapyhyperthyroidismduringpregnancyWithdiffusegoiter,exophthalmos,thyroidbruitorthrill,TRABpositivediagnosis:
FT3,FT4andTSH,notTT3/TT4adverseconsequencesMother:
miscarriage,prematurebirth,preeclampsia(先兆子痫),placentalabruption(胎盘早剥)Fetus:
preterm(早产),intrauterinegrowthretardation(宫内生长迟缓)Fetalorneonatal(新生儿)hyperthyroidismLaboratoryandSpecialExamsSerumTHandTSHTT3andTT4,FT3andFT4-increasedFT3andFT4arethedirectindexes(0.3%and0.02%)TT3andTT4areinfluencedbyconcentrationofTBG(99.7%and99.98%)rT3-increasedTSH-decreasedTSHreceptorantibodies-TRAb(+)131Iuptake-increased,peakappearedbeforeNormalreferencerange:
3h:
5-25%,24h:
20-45%Imagingexaminationultrasonographyemissioncomputerizedtomography(ECT)DiagnosisandDifferentialDiagnosisconfirmedhyperthyroidismsymptomweightloss,slightfever,diarrhea,tachycardia(心动过速),atrialfibrillation(房颤),fatigue,withdifficultincontrolofDM,heartfailure,liverdiseasesignsdiffusegoiter,exophthalmoshormoneabnormalFT3,FT4,TSHpathogenicdiagnosisTRAb,TgAb(甲状腺球蛋白抗体),TPOAb(甲状腺过氧化物酶抗体)131IuptakeultrasonographyHCGDifferentDiagnosisDifferentDiagnosisTRAbGraves甲亢T3,T4synthesisThyroiditisT3,T4release131IuptakeTreatmentGeneraltreatmentATD-reducingthyroidhormonesynthesisRadioiodinetreatmentreducingtheamountofthyroidtissueOperationGeneralmanagmentabsolutelyavoidiodineseafood,salt,tinctureofiodine(碘酒),drugssuchasCentrum(善存),amiodarone(胺碘酮)restenoughenergyandnutrientssupplement(proteinandvB)sedatives(镇静剂)forrestlessnessandinsomnia(失眠)betablockers(propranolol)fortachycardiaintheearlystagesbeforeantithyroiddrugstakeeffectVaidyaetalClinEndocrinol2008ATDtherapyisthefirstchoiceinEuropeandAsiaAntithyroiddrugs(ATD)agentsmethylthiouracil(MTU)orpropylthiouracil(PTU)300-600mg/dmethimazole(MM)orcarbima
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