Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial...
-
Upload
oliver-parker -
Category
Documents
-
view
217 -
download
0
Transcript of Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial...
![Page 1: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/1.jpg)
Graves’ Disease
![Page 2: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/2.jpg)
The Case (1)
55 F Graves’ disease diagnosed at 彰基
one year ago Initial presentation: sweating, good
appetite, easy nervousness Physical examination: enlarged thyr
oid gland about 5 cm in diameter at both lobes
PTU 1# bid
![Page 3: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/3.jpg)
The Case (2)
95/7/17: MVP, TVP 7/22: Af i RVR (HR 220) →Amiodarone 7/23: Bradycardia, conscious change
→ Pericardiocetesis, 580mL 7/24: Re-op PTU 1# qd during 7/19-7/24, then DC HR↑, free T4: 4.53, TSH<0.15 on 8/11 Newmazole 1# tid since 8/15
![Page 4: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/4.jpg)
![Page 5: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/5.jpg)
Graves’ disease
60 to 80% of hyperthyroidism Autoimmune disorder Common between 30 and 40
years Woman, 0.5 per 1000 Family history
![Page 6: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/6.jpg)
Clinical Presentation
Manifestations of hyperthyroidism: hypermetabolic state
Manifestations of Graves’ disease: Ophthalmopathy Localized dermopathy Thyroid acropachy
![Page 7: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/7.jpg)
![Page 8: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/8.jpg)
Diagnostic Modality
Decreased TSH Increased free T4 and incr
eased T3 TSHR-Ab Thyroid radioactive iodine
uptake and scan
![Page 9: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/9.jpg)
Treatment
Anti-thyroid drugs Radioactive iodine therapy (RAI) Surgery
![Page 10: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/10.jpg)
Anti-thyroid drugs
Propylthiouracil Carbimazole → Methimazole Both inhibit thyroid peroxidase PTU also inhibits T4 to T3 conversio
n Immunomodulatory action?
![Page 11: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/11.jpg)
Adverse effects
Rash Arthralgias Urticaria GI symptoms Agranulocytosis
![Page 12: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/12.jpg)
Drug Therapy
The Titration regimen is just as effective as the Block-Replace regimen with a significantly lower incidence of adverse effects.
The optimal duration of anti-thyroid drug therapy for the Titration regimen is 12–18 months.
There is no benefit from continued T4 replacement after a course of anti-thyroid treatment.
![Page 13: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/13.jpg)
Radioactive Iodine Therapy 131I Long latency period Contraindication: pregnancy, lactat
ion, ophthalmopathy? Only slight increased risk of mortali
ty from thyroid cancer but no other malignancies
Nausea, pain
![Page 14: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/14.jpg)
ATD vs. RAI (1)
![Page 15: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/15.jpg)
ATD vs. RAI (2)
![Page 16: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/16.jpg)
Surgery
Young age Male sex Pregnancy/lactation Patient preference Large or nodular goiter Inability to tolerate ATDs
![Page 17: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/17.jpg)
Complications
Thyroid storm or thyrotoxic crisis Hypothyroidism Recurrent hyperthyroidsim Recurrent laryngeal nerve injury Hypoparathyroidism
![Page 18: Graves’ Disease. The Case (1) 55 F Graves’ disease diagnosed at 彰基 one year ago Initial presentation: sweating, good appetite, easy nervousness Physical.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b9354/html5/thumbnails/18.jpg)
Conclusions
Current treatment for Graves’ disease is effective, but the ideal treatment is still not available.
Further understanding about immunologic processes involved should allow better diagnostic methods and treatments.