内科学英文课件：Hyperthyroidism-甲状腺功能亢进症.ppt

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