Diffuse toxic goiter

At present, diffuse toxic goiter is considered as a hereditary autoimmune disease that is transmitted in a multifactorial (polygenic) way. Factors provoking the development of the disease: mental trauma, infectious and inflammatory diseases, traumatic brain injuries, diseases of the nasopharynx.

In women, the disease is 8 times more common than in men. Most likely to develop between 30 and 50 years, but it is not uncommon in adolescents and young people, as well as in women during pregnancy and menopause. It occurs in people older than 50 years. There is a significant family predisposition, which led researchers to suggest that the genetic component may play a role in the development of the disease. At the moment, no genetic defect has been found that is uniform for all patients with diffuse toxic goiter, which would indicate the monogenetic nature of the disease. Presumably, a complex complex of several genes plays a role in the development of the disease in combination with environmental factors that have not yet been identified.

Diffuse toxic goiter is characterized by a triad - hyperthyroidism, goiter and exophthalmos (bulging eyes).

Due to the fact that thyroid hormones have many physiological functions, the disease has various clinical manifestations, namely:

• Cardiac : arrhythmia (in particular atrial fibrillation ), tachycardia ( palpitations ), extrasystole, systolic hypertension , increased pulse pressure (the difference between systolic and diastolic pressure), chronic heart failure with peripheral edema , ascites , anasar .
• Endocrine: weight loss, weight loss despite increased appetite, heat intolerance, increased basic metabolism . Premenopausal women may have a decrease in the number and frequency of menstruation (oligomenorrhea) up to complete amenorrhea.
• Dermatological : increased sweating , thyroid acropachia (specific changes in the nails), onycholysis (destruction of the nails), erythema, leg edema (pretibial myxedema in 3-5% of patients with bazedovoy disease, should not be confused with myxedema with hypothyroidism).
• Neurological : tremor (especially noticeable with arms outstretched in weight), weakness , headache , proximal myopathy (difficulty getting up from stools or squats), anxiety, anxiety, insomnia , hyperactivity of tendon reflexes.
• Gastrointestinal : diarrhea (diarrhea) often, nausea and vomiting (relatively rare).
• Ophthalmic : the so-called “thyroid eye disease” characteristic of Bazedov’s disease includes the following symptoms: exophthalmos, Krause symptom — increased eye gloss, Shtelvag symptom — rare blinking, Grefe symptom — lag of the upper eyelid from the edge of the iris when looking down, symptom Kocher - the lag of the eyeball from the movement of the upper eyelid when looking up, the symptom of Elinek - hyperpigmentation around the eyes, the symptom of Dalrympl - expansion of the palpebral fissure, the symptom of Rosenbach - tremor of the eyelids with loose eyes, with mptom Mobius - disturbance convergence symptom Geoffroy - absence namorschivaniya when looking up and lift the upper eyelid, ptosis (dehiscence) lower eyelid, periorbital edema and periorbital tissue overgrowth. Defects in the visual fields and increased intraocular pressure, eye pain and even complete blindness can be the result of compression of the edematous periorbital tissues of the optic nerve or eyeball. The patient may also complain of dryness and a feeling of sand in the eyes or chronic conjunctivitis due to incomplete closure of the eyelids.
• Dental : multiple caries , periodontal disease (rarely).
• Thyrotoxic crisis is of particular danger to life.

Conservative Pharmacological Treatment

The main means of conservative treatment are mercazolil and methylthiouracil (or propylthiouracil). The daily dose of mercazolil is 30-40 mg, sometimes with very large goiter and severe thyrotoxicosis, it can reach 60-80 mg. The maintenance daily dose of mercazolilum is usually 10-15 mg. The drug is taken continuously for 1 / 2-2 years. The dose reduction of mercazolil is strictly individual, it is carried out, focusing on the signs of eliminating thyrotoxicosis: stabilization of the pulse (70-80 beats per minute), increase in body weight, the disappearance of tremors and sweating, normalization of pulse pressure. It is necessary to conduct a clinical blood test every 10-14 days (with maintenance therapy with mercazolil - 1 time per month). In addition to antithyroid drugs, b-blockers, glucocorticoids, sedatives, and potassium preparations are used.

Radioiodine Therapy

Radioiodine therapy (RTI) is one of the modern methods of treating diffuse toxic goiter and other thyroid diseases. During treatment, radioactive iodine ( I-131 isotope) is administered orally in the form of gelatin capsules (in rare cases, I-131 liquid solution is used, more often in Russia). Radioactive iodine, which accumulates in the cells of the thyroid gland, exposes the entire gland to beta and gamma radiation. At the same time, gland cells and tumor cells that have spread beyond its borders are destroyed. Carrying out radioiodine therapy implies mandatory hospitalization in a specialized department.

Surgical Treatment

Absolute indications for surgical treatment are allergic reactions or a persistent decrease in leukocytes observed with conservative treatment, large goiter sizes (enlarged thyroid gland above grade III), cardiac arrhythmias according to the type of atrial fibrillation with symptoms of cardiovascular failure, and pronounced goitre effect of mercazolil.

The operation is performed only when the state of drug compensation is reached, since otherwise a thyrotoxic crisis may develop in the early postoperative period.

Features of treatment in pregnant women

Particularly noteworthy is the problem of treatment in pregnant women due to the possible effect of antithyroid antibodies on the fetus as a result of their transplacental transfer and a similar effect of drugs. All this makes women recommend pregnancy protection. If pregnancy has occurred, then the drug is preferred propylthiouracil.

The prognosis for proper and timely treatment is favorable, but postoperative hypothyroidism may develop after surgical treatment. Patients should avoid sun exposure . The abuse of iodine-containing drugs and foods rich in iodine is unacceptable .

• Clinical endocrinology. Leadership / N. T. Starkova. - 3rd edition revised and supplemented. - St. Petersburg: Peter, 2002. - T. 1. - 576 p. - ("Doctor's Companion"). - ISBN 5-272-00314-4 .