1. Department of Internal Medicine № 2
Graves’ disease
Department of Internal Medicine № 2

5. Hyperthyroidism (thyrotoxicosis) Toxic diffuse goiter.
Grave’s disease - is the condition resulting from the effect of excessive amounts of thyroid hormones on body tissues.
Thyrotoxicosis is a main syndrome
Enlargment of thyroid gland

6. Etiology and predisposing factors
Genetic predisposition, conferred by genes close proximity to the major histocompatibility complex (HLA DR3, B8)
Autoimmune disorders, which can be provoked by:
insolation;
stress;
acute infections;
hormone disbalance (pregnancy and others)
Defect of T lymphocytes suppressors

8. Pathogenesis Insufficiency of T suppressors The thyroid
Increasing function of B lymphocyte
Toxic influence of lymfocytes
Secretion of thyroid – stimulating immunoglobulin (TSI)
The thyroid
Secretion of T4, T3
Thyrotoxicosis
Pathologic changes in different organs and systems

12. Clinical manifestations
The clinical presentation may be dramatic or subtle.
Dysfunction of
the nervous system
the cardiovascular system
the gastrointestinal system
the pulmonary system
the endocrine organs
katabolic syndrome
ectodermal changes

23. Degrees of thyroid gland enlargement (WHO, 1986, 1994)
0-we can’t see or palpate thyroid gland;
IA- we can palpate but can’t see; IB- thyroid gland can be seen when patient put head back;
II –thyroid gland can be seen in normal position of the head.
III – thyroid gland can be seen from the distance of 5 meters or more
0 –goiter is absent
1- we can palpate but can’t see
2 – thyroid gland can be palpated and seen

24. Degrees of severity Mild Moderate Severe Heart beat Weight loss
under 100
over 120
Weight loss
less than 10 %
10 – 20 %
more than 20 %
Changes from organs and systems
rare
- ophthalmopathy
- signs of heart failure І – ІІ А
-ophthalmopathy
-dystrophic changes from inner organs
-thyroid storm
Work capacity
normal
decreased
patients cant work

26. Treatment 1. Antithyroid drugs.
2. Drugs to ameliorate thyroid hormone effects .
131I - therapy
Surgery.

27. Thyroid storm
Thyroid storm is a life- threatening emergency requiring prompt and specific treatment.
In is characterized by abrupt onset of more severe symptoms of thyrotoxicosis, with some exacerbated symptoms and signs atypical of uncomplicated Graves disease:
fever;
marked weakness and muscle wasting;
extreme restlessness with wide emotional swings;
confusion;
psychosis or even coma;
hepatomegaly with mild jaundice;
the patient may present with cardiovascular collapse or shock.

29. Thyroid storm results from:- untreated or inadequately treated thyrotoxicosis
It may be precipitated by:
infection;
trauma
surgery;
embolism;
diabetic acidosis;
fright;
toxemia of pregnancy;
labor;
discontinuance of antithyroid medication;
radiation thyroiditis.

31. Treatment of thyroid storm
Iodine-30 drops Lugol’s solution/day orally in 30g 4 divided doses; or 1 to 2 gr. sodium iodide slowly by i/v drip
Propylthiouracil (merkazolil) to 1200 mg/day orally or by gastric tube.
Propranolol - 160mg/day orally in 4 divided doses; or 1mg slowly i/v g 4h under careful monitoring; a rate of administration should not exceed 1mg/min; a repeat 1mg dose may be given after 2 min i/v glucose solutions .
Correction of dehydration and electrolyte imbalance cooling blanket for hypertermia.
Digitalis if necessary.
Treatment of underlying disease such as infection.
Corticosteroids-100 to 300mg hydrocortisone/day i/v.
Iodine in pharmacological doses inhibits the release of T3 to T4 within hours and inhibits the organification of iodine, a transitory effect lasting from a few days to a week (”escape phenomenon”.)