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[Cardiovascular manifestations of hyperthyroidism. Clinical significance and preoperative preparation].

More than 200 years ago, Caleb Parry described cardiological manifestations of hyperthyroidism. Interaction of thyroid hormones and sympathoadrenal system (responsible for rhythm disorders) and direct effect of thyroid hormones on the cardiac muscle (responsible for occurrence of hypertrophy and cardiac insufficiency) have been recognized as the pathophysiological basis of cardiovascular disorders of patients with hyperthyroidism. The aim of the study was to retrospectively analyze surgically treated patients with different types of hyperthyreosis, and establish the incidence and clinical significance of the left ventricular dysfunction related to duration and treatment of hyperthyreosis. Evaluation of left ventricular function was based on the ejection fraction during exercise. Signs of hypertrophy were echocardiographically, radiographically and electrocardiographicaly recorded. Over the period 1993-1997 at the Surgical Department of the institute of Endocrinology in Belgrade 423 patients with hyperthyreosis were operated: 293 (69.26%) patients had Graves-Basedow's disease, 74 (17.49%) toxic adenoma, and 58 (13.28%) toxic polynodal struma. The average duration of the disease in patients with Graves-Basedow's hyperthyreosis was 5 yrs, and the average age of patients was 29 yrs; the average duration of hyperthyreosis in patients with toxic adenoma was 1.2 yrs, and in cases of toxic polynodal struma 17 yrs. Pathological response of ejection fraction during exercise was recorded in 60% of patients. Signs of hypertrophy of the left chamber were recorded in 17% of subjects, and insufficiency of the left chamber with congestive stasis in the lungs in 4.6% of patients. The most common ECG changes were: synus tachycardia, higher voltage of P and T waves, elevated amplitude of QRS complex, prolonged P-Q and shortened Q-T intervals. In 20% of cases atrial fibrillation was evidenced. One patient had ECG signs of myocardial infarction. Clinical features of left ventricular dysfunction in hyperthyroidism include: occurrence in younger patients with history of hyperthyroidism, progressive course and occurrence of congestive cardiac failure as well as reversible nature of all cardiac changes after radical therapy of hyperthyreosis which can be medical, surgical or irradiation.

Cardiomegaly↗

[Is surgical treatment of hyperthyroidism in pregnancy reasonable?].

Hyperthyroidism is second to diabetes mellitus as the most common endocrinopathy in pregnancy. It is usually caused by Graves' disease. The appropriate treatment is the only way to prevent the incidence of dangerous complications both to mother and foetus, including thyrotoxic crisis. Most cases of hyperthyroidism during pregnancy can be successfully treated with thyrostatics (propylotiouracil, methylotiouracil in the lowest efficient doses). However, the surgical treatment (sub-total thyroidectomy within the second trimester of gestation, soon after the euthyroid state following short medication is reached) is still an elective approach in selected cases: 1) allergy to antithyroid drugs, 2) large compressive goitre, 3) suspicion of thyroid cancer, 4) patients who require large doses of antithyroid drugs to reach and sustain euthyroid state, 5) poor patient compliance, 6) extremely rare resistance to antithyroid drugs. The study included 24 cases of pregnant women, who underwent surgery due to hyperthyroidism. The analysis of indications to surgery and postoperative pregnancy, birth and puerperium course was performed. All the patients gave birth on time to healthy children. No negative influence of neither preoperative antithyroid treatment nor surgical procedure on pregnancy delivery, further psychomotoric children's development and health was found during 36 months (+/- 20 months) of postoperative follow up. It indicates on usefulness, efficacy and safety of surgical treatment in selected cases of hyperthyroidism during pregnancy.

Adult↗

[Hyperthyroidism, jaundice, and pulmonary hypertension].

Although the most frequent cause associated to the alteration of hepatic function tests that some hyperthyroid patients show is concomitant heart insufficiency, some cases without heart insufficiency and normalisation of hepatic tests after normalising the thyroid function have been described. There is also some evidence of hyperthyroid patients with pulmonary arterial hypertension, with no clear cause, coming back later to normal figures or substantially descending, after the treatment for hyperthyroidism. We show the concrete case of a 66 years woman, who has a due to toxic multinodular goiter hyperthyroidism with jaundice and serious pulmonary hypertension associated, unexplainable by further causes, both regressing with normalisation of thyroid function with no evidence of associated autoimmune pathology. Following, the physiopathology explanations about this unusual association found in literature, are commented.

Aged↗

[Value of total thyroidectomy in amiodarone-induced hyperthyroidism].

The potential severity of amiodarone-induced hyperthyroidism, particularly in severe cardiopathy cases, necessitates a regular clinic and biologic thyroid control. The break in amiodarone and a medical treatment (synthetic antithyroid drugs, steroids, perchlorate of potassium) can be ineffective. The authors report the case of a patient with an right ventricle arythmogenic dysplasia, without thyroid history, who came back 3 years after the introducing of amiodarone with major hyperthyroidism. After failure of medical treatment, a total thyroidectomy permitted to quickly stop hyperthyroidism and to early reintroduce amiodarone. Surgery seems to be the radical treatment when hyperthyroidism doesn't respond to the medical treatment and when the cardiopathy requires amiodarone.

Adult↗

[Increased serum PIVKA-II levels in hyperthyroidism].

PIVKA-II has been practically used as a tumor marker of hepatocellular carcinoma. On the other hand, increased serum PIVKA-II concentration was reported in a Japanese patient who had hyperthyroidism without liver diseases. To evaluate whether thyroid hormone is related with serum PIVKA-II, we examined serum PIVKA-II concentrations in patients with various thyroid diseases. Eight patients with Hashimoto disease, 24 patients with Graves' disease, and 8 healthy subjects were studied. There was no significant difference of serum PIVKA-II levels among the three groups. However, serum PIVKA-II concentrations(mean +/- SD mAU/ml) in hyperthyroidism(37 +/- 27) were significantly higher than those in hypothyroidism(16 +/- 9) and normal controls(12 +/- 4) (p < 0.05 and p < 0.01, respectively). When hyperthyroid patients were treated by antithyroid drug or isotope, serum PIVKA-II concentrations decreased in accordance with the decrease of serum FT4 concentrations. Our data indicate that serum PIVKA-II concentration was increased in patients with hyperthyroidism, but further in vivo studies are necessary to clarify the mechanism related to increased serum PIVKA-II by thyroid hormone.

Adolescent↗

[Clinical study on hyperthyroidism of yang hyperactivity type due to yin deficiency treated by jiakang ning capsule].

OBJECTIVE: To investigate the effect of Jiakang Ning (JKN) capsule on hyperthyroidism. METHODS: Eighty-five cases of hyperthyroidism were divided into JKN group (24 cases), JKN with low dose Tapazol group (35 cases) and Tapazol control group (26 cases) at random. The effects were evaluated by total effective rate, using principal symptoms, body weight, EKG, thyroid hormone and atrial natriuretic peptide (ANP) after 6 months. RESULTS: The total effective rates of three groups were 83.8%, 97.1%, 88.5% respectively, and there were insignificant difference among them statistically (P > 0.05). The first two groups had better effect in principal symptoms than Tapazol control group (P < 0.05). There were similar results in adjusting thyroid dysfunction and abnormal EKG, decreasing ANP and increasing body weight among those three groups (P > 0.05). CONCLUSION: The effect on hyperthyroidism treatment by JKN capsule was satisfactory. The combination of Chinese herbs with western medicine could enhance the curative effect of hyperthyroidism without obvious side-effects.

Adolescent↗

[Body weight gain after radioiodine therapy in hyperthyroidism].

AIM: Analysis and follow up of body weight after radioiodine therapy (RITh) of hyperthyroidism, since excessive weight gain is a common complaint among these patients. METHODS: Therapy and body weight related data of 100 consecutive RITh-patients were retrospectively analysed from the time before up to three years after RITh. All patients suffered from hyperthyroidism (Graves' disease or autonomy), but were adjusted to euthyroid levels after RITh. Patients' data were compared to a control group of 48 euthyroid patients out of the same ambulance and during the same time scale. RESULTS: All patients (RITh and controls) gained weight over the time. There was no statistically significant difference in BMI development over three years between RITh-patients and controls (5.5% resp. 4.9% increase). In the first year after RITh, weight gain of the RITh patients was higher indeed, but lower in the follow up, resulting in the same range of weight gain after three years as the controls. Besides that women showed a slightly higher increase of BMI than men, and so did younger patients compared to elder as well as patients with overweight already before RITh. CONCLUSIONS: An initially distinct increase of body weight after RITh of hyperthyroidism is mainly a compensation of pretherapeutic weight loss due to hyperthyroidism. Presupposing adequate euthyroid adjustment of thyroid metabolism after therapy, RITh is not responsible for later weight gain and adipositas.

Adult↗

Plasmapheresis: an effective therapy for refractory hyperthyroidism in the elderly.

Hyperthyroidism in the elderly often presents diagnostic challenges. Elderly patients rarely present with classical signs and symptoms of hyperthyroidism. More commonly, their presentation is ayical which leads to a delay in making a diagnosis. Such delays can sometimes decrease the functional capacity of the affected patient and reduce their chance for recovery. Herein we report a 66-year-old woman whose diagnosis of hyperthyroidism was delayed. Standard therapies were ineffective. Plasmapheresis was performed to control the manifestations of the hyperthyroid state, resulting in improvement in the patient's condition.

Aged↗

Management of hyperthyroidism in Trinidad and Tobago.

A questionnaire study of current practices regarding the investigation and treatment of hyperthyroidism was undertaken in Trinidad and Tobago between December 1999 and March 2000. The study evaluated the choice of laboratory tests requested and the therapeutic choices for a standard patient with hyperthyroidism. In addition, clinical scenarios based upon variations of the standard case (by altering age, gender, goitre size and duration of disease) were also tested. Two hundred and ninety-six questionnaires were sent; 134 (45%) were returned, of which four were excluded for incomplete data. Ninety five per cent of respondents requested biochemical confirmation but the range of tests varied widely. Thyroid scintigraphy was requested by 36% and thyroid ultrasound by 35%. Medical treatment (75%) with antithyroid drugs was the most popular choice for treatment of the standard patient. This did not change significantly if the patient was male. On the other hand, radioiodine (62%) was more popular in the treatment of chronic/relapsing hyperthyroidism (p < 0.005). In the elderly, medical management was still the most popular choice (57%) but the choice of radioiodine therapy was significantly increased compared with that in the standard patient (36% vs 19%) (p<0.005). In a young female with a large goitre and chronic disease, surgical intervention (61%) was the treatment of choice, especially among surgeons and general practitioners; radioiodine was chosen by 28% of respondents (mostly internists). There is need for clear guidelines in investigating thyroid disease but therapeutic choices are well informed and consistent with accepted practice elsewhere. In particular there is a fairly liberal attitude towards radioiodine use in hyperthyroidism.

Attitude of Health Personnel↗

Proinflammatory cytokine levels in hyperthyroidism.

BACKGROUND: Among suspected causes of the osteoporosis frequently seen in untreated thyrotoxicosis are the osteotrophic cytokines. We studied serum levels of osteotrophic cytokines including interlukin (IL)-1, IL-6, IL-8 and tumour necrosis factor alpha (TNF-alpha) in patients with various hyperthyroid states. METHODS: Serum cytokines were detected in 4 groups of SUBJECTS: 14 patients with Graves' disease, 9 patients with toxic nodular goitre, 27 patients with toxic multinodular goitre and 30 euthyroid control subjects. The levels of IL-1-beta, IL-6, IL-8 and TNF-alpha in the serum were determined by the IMMULITE autoanalyzer, using a chemoilluminesence method. RESULTS: Compared with euthyroid control subjects, patients with hyperthyroidism had significantly elevated serum levels of IL-8 (506.8 pg/mL v. 7.0 pg/mL, p < 0.001) and TNR-alpha (18.6 pg/mL v. 8.7 pg/mL, p < 0.05). Levels of IL-1-beta (12.2 pg/mL v. 5.0 pg/mL) and IL-6 (30.3 pg/mL v. 5.3 pg/mL) were also higher in controls, but the differences were not statistically significant. Levels of the cytokines were similar in 14 patients with diffuse goitre compared with 36 patients having nodular goitre. Cytokine levels in 20 premenopausal and 20 postmenopausal women with hyperthyroidism were also similar. INTERPRETATION: We conclude that increased circulating cytokine concentrations observed in patients with hyperthyroidism may derive from the activation of humoral reactions in sites other than the thyroid.

Adult↗

Iodine-induced hyperthyroidism--an epidemiological survey several years after institution of iodine prophylaxis in Poland.

In 1997, the obligatory model of iodine prophylaxis was introduced in Poland in order to correct the existing status of mild and/or moderate iodine deficiency. In order to monitor possible side-effects of increased iodine supply, studies on iodine-induced hyperthyroidism were initiated by establishing several regional registers of hyperthyroidism. In the present paper, the results of a two-year monitoring (2000-2001) have been summarized. There are no epidemiological data on hyperthyroidism prior to starting the iodine prophylaxis, but the obtained current data are comparable to observations in other countries, made after iodine supplementation. The incidence of iodine-induced hyperthyroidism did not exceed the acceptable level, thus confirming--together with previous observations on the effectiveness of iodine prophylaxis--the adequacy of applied dose of KI (30 microg/kg NaCl), used for salt iodization in Poland.

Adult↗

A rare coexistence of primary hyperparathyroidism and hyperthyroidism due to toxic nodular goiter--a case report.

The frequent association of thyroid and parathyroid disorders has been reported. Most commonly, hyperthyroidism may coexist with hypercalcemia, but the latter is successfully treated when euthyroidism is achieved. However, the concomitant hyperthyroidism with primary hyperparathyroidism is of a rare occurrence. Moreover, it may frequently go unrecognized. In this paper we report a case of a patient with hypercalcemia due to PTH--secreting parathyroid adenoma associated with hyperthyroidism due to toxic nodular goiter. This case demonstrates the dramatic outcome of those two coexisting disorders. We point out that in patients with primary hyperparathyroidism thyroid function test should always be carried out. A proper, first-line treatment of hyperthyroidism will prevent the deterioration of primary hyperparathyroidism course, and thus surgical parathyroid treatment may safely be introduced.

Female↗

[Iodine-131 therapy for large goiter with hyperthyroidism: clinical observation of 38 cases].

OBJECTIVE: To evaluate the therapeutic efficacy and safety of iodine-131 therapy for large goiter complicated by hyperthyroidism. METHODS: After the diagnosis of large goiter complicated by hyperthyroidism was established, the weight of the patient's thyroid gland was determined, and the doses of iodine-131 calculated according to the formula currently available. After a single dose of oral iodine-131 capsule, the patients were observed for the therapeutic efficacy and side effects. Some patients were given the second or even the third dose of iodine-131. RESULTS: All of the 38 patients were cured by 1 to 3 single doses of iodine-131 therapy, of whom 23 (60.5%) needed only a single dose for the cure, 13 (34.2%) required the second dose, and 2 (5.3%) necessitate a third dose. Hypothyroidism occurred in 4 cases (10.5%), and none of the patients developed hyperthyroidism crisis and dyspnea. CONCLUSIONS: Iodine-131 therapy for serious goiter with hyperthyroidism is safe and effective, which can be used as a routine therapy for this condition.

Adult↗

Increased concentrations of type IV (7 S) collagen in sera of hyperthyroid patients with Graves disease.

Serum concentrations of type IV collagen (7 S) were determined in 29 patients with untreated hyperthyroidism and 30 healthy subjects. Serum 7 S collagen was significantly higher (P less than 0.0001) in the hyperthyroid patients (6.3, SD 1.3, micrograms/L) than in the healthy control subjects (3.9, SD 0.6, micrograms/L). No difference in serum concentrations of 7 S collagen were observed between patients with normal liver function and those with abnormal liver function. Serum concentrations of 7 S collagen correlated positively with serum concentrations of free triiodothyronine (r = 0.41, P less than 0.05). In the hyperthyroid patients, 7 S collagen concentrations in serum gradually fell into the normal range as thyroid function became normalized. Thus, hyperthyroidism is one of the diseases in which serum concentrations of 7 S collagen are increased.

Adolescent↗

Hyperthyroidism: diagnosis and treatment.

The proper treatment of hyperthyroidism depends on recognition of the signs and symptoms of the disease and determination of the etiology. The most common cause of hyperthyroidism is Graves' disease. Other common causes include thyroiditis, toxic multinodular goiter, toxic adenomas, and side effects of certain medications. The diagnostic workup begins with a thyroid-stimulating hormone level test. When test results are uncertain, measuring radionuclide uptake helps distinguish among possible causes. When thyroiditis is the cause, symptomatic treatment usually is sufficient because the associated hyperthyroidism is transient. Graves' disease, toxic multinodular goiter, and toxic adenoma can be treated with radioactive iodine, antithyroid drugs, or surgery, but in the United States, radioactive iodine is the treatment of choice in patients without contraindications. Thyroidectomy is an option when other treatments fail or are contraindicated, or when a goiter is causing compressive symptoms. Some new therapies are under investigation. Special treatment consideration must be given to patients who are pregnant or breastfeeding, as well as those with Graves' ophthalmopathy or amiodarone-induced hyperthyroidism. Patients' desires must be considered when deciding on appropriate therapy, and dose monitoring is essential.

Antithyroid Agents↗

[Hyperthyroidism and risk of atrial fibrillation or flutter--secondary publication. A population-based study].

We identified all patients with an incident diagnosis of hyperthyroidism in the Danish National Patient Registry, and among those we identified subjects with a diagnosis of atrial fibrillation or flutter that occurred +/- 30 days from the date of the diagnosis of hyperthyroidism. Among 40,628 subjects with hyperthyroidism, 3,362 (8.3%) had a diagnosis of atrial fibrillation or flutter. Male sex, increasing age, ischemic heart disease, congestive heart failure and heart valve disease were associated with an increased risk of atrial fibrillation or flutter in patients with hyperthyroidism.

Adult↗

[Nail susceptibility to fungal infections in patients with hypothyroidism and hyperthyroidism].

Onychomycosis is a frequent disorder in adults. The objective of the study was evaluation of finger and toe nails susceptibility to Candida albicans and a dermatophyte Trichophyton mentagrophytes infection in patients with symptomatic hypothyroidism and hyperthyroidism as compared with healthy persons. The materials comprised finger and toe nails from 23 patients with hypothyroidism (in 8 cases postoperative, and in 15 cases caused by Hashimoto type thyroiditis), and from 27 patients with hyperthyroidism (including 17 cases of Graves-Basedow disease, and 10 with nodular goitre). Nails from 22 healthy persons of similar sex and age distribution served as controls. A significantly more frequent and more intensive than in control group toe nail infection with C. albicans was found in the patients with both hypothyroidism and hyperthyroidism. The enhanced toe nail susceptibility to C. albicans infection did not depend on autoimmunological aetiology of both hypothyroidism and hyperthyroidism.

Adult↗

Proximal weakness of lower limbs as the sole presentation of hyperthyroidism: report of one case.

Most children with acute or chronic flaccid limb weakness have a disorder of motor unit. However, it is very important to exclude cerebral or other upper motor neuron disorders before we approach such patients as pure muscle disorders. In general, neuropathy results in distal limb weakness, myopathy manifests with proximal weakness. There are exceptions, however. Accurate diagnosis in this wide array of disorders is dependent on a careful clinical assessment followed by the appropriate investigations. Here we report a 14-year-old girl who presented with progressive difficulty in rising up from the floor for one month. Neurological examination revealed an obese, clumsy but clear girl with stable vital signs. The muscle power of neck and upper limbs was normal. There was positive Gower sign, but the toe and heel gaits were acceptable. The initial blood work and motor/sensory nerve conduction velocity were unremarkable. Further study for thyroid function showed a hyperthyroid state. The proximal myopathy recovered soon after medical treatment. There were no other symptoms, and signs indicating hyperthyroidism and proximal myopathy of lower limbs was the isolated clinical feature. Hyperthyroid myopathy is common in hyperthyroidism, but is unusual as the sole presenting symptom.

Adolescent↗