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In hyperthyroidism we differentiate two main forms: (1) hyperthyroidism due to Basedow's (Graves') disease, always characterized by endocrine eye signs, frequently with goiter; (2) hyperthyroidism due to nodular goiter or to Plummers' disease, without endocrine exophthalmos. The clinical diagnosis includes typical complaints (e.g., weight loss, heat intolerance, sweating) and findings (e.g., tachycardia, tremor, soft-warm skin). The technical diagnosis includes in vivo (scintigraphy, RI-uptake, X-ray examination) and in vitro (T3-RIA, T4-assay, TRH response to TRH) tests.
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PMID:[Hyperthyroidism: diagnosis (author's transl)]. 10 1

A 41-year-old woman is described, first hospitalized in the neurosurgical department for a transient ischemic attack with left hemiparesis followed after 6 hours by tonic-clonic seizures starting from the left hemiface and quickly generalized. Brain computed tomography (CT) scan and magnetic resonance imaging were normal. Clinically the patient presented tremor, tachycardia, generalized muscle weakness, and profuse diaphoresis. T4 and T3 were elevated. The patient was transferred from the neurosurgical to the medical department where a thyroid storm due to autoimmune Graves' disease with normal thyrotropin (TSH) values responsive to thyrotropin-releasing hormone (TRH) stimulation was diagnosed. A syndrome of inappropriate secretion of TSH was suspected in an unusual presentation as autoimmune Graves' hyperthyroidism. The TSH alpha-subunit and alpha-subunit/TSH molar ratio were normal, which supported the diagnosis of non-neoplastic inappropriate secretion of TSH. However, severe autoimmune Graves' hyperthyroidism is very rare indeed because autoantibodies to thyroid antigens are generally non-detectable in such patients. Our patient was treated initially with barbiturates, then with dexamethasone, Lugol's solution, methimazole and propranolol. Treatment of this patient proved difficult, and definitive improvement was obtained only after triiodothyroacetic acid administration, but methimazole and propranolol administration could not be discontinued. Fine needle aspiration biopsies of the thyroid in 2 occasions showed follicular or follicular-papillary proliferation with lymphocytic infiltration as in chronic thyroiditis. The patient is now in good clinical conditions and is followed up regularly. Autoimmune Graves' hyperthyroidism may be associated in extremely rare instances with non neoplastic inappropriate secretion of TSH.
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PMID:Thyroid storm with encephalopathic symptoms due to Graves' disease and inappropriate secretion of thyrotropin. 129 37

Graves' disease was found in a 41-year-old, married male patient with Klinefelter's syndrome. The patient began having finger tremor 5 years previously, and developed palpitation and weight loss 3 months prior to examination. He had a diffuse goiter, exophthalmos, and atrial fibrillation. Plasma levels of T3, T4 and free T4 were 2.8 ng/ml, 16.6 micrograms/dl and 4.5 ng/dl respectively. [123I] uptake was 53%, and TSH receptor antibody was 75%. Although he had no gynecomastia, his general physical appearance was that of typical eunuchoism. Chromosome studies showed a karyotype of 47,XXY. A diagnosis of Graves' disease associated with Klinefelter's syndrome was made.
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PMID:A case of Graves' disease associated with Klinefelter's syndrome. 212 24

The records of 25 patients older than 75 years of age with the diagnosis of hyperthyroidism were reviewed. The mean age of the group (22 women and three men) was 81.5 years, the eldest being 95 years old. Twenty-one patients had Graves' disease, three had multinodular goiter, and one had toxic adenoma. Major presenting symptoms included weight loss (44 percent), palpitations (36 percent), and weakness (32 percent). The average number of thyrotoxic symptoms was only two per patient. Two patients were asymptomatic. Clinical signs included fine skin (40 percent), tremor (36 percent), atrial fibrillation (32 percent), and tachycardia (28 percent). The thyroid was palpable in only three patients with Graves' disease. Mean blood thyroxine level was 15.6 micrograms/dl (range, 11.5 to 24); blood triiodothyronine level was elevated in only half of the patients. One patient had triiodothyronine toxicosis. Mean 24-hour radioiodine uptake was 52 percent. Five patients had normal uptake. No correlation could be established between age, clinical symptoms, signs, and hormone blood levels. Because signs and symptoms of hyperthyroidism in the very old may be too subtle for clinical diagnosis, all elderly subjects should have periodic screening of blood thyroxine levels.
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PMID:Thyrotoxicosis in the very old. 376 92

We describe a 29-year-old male with thyroid hormone resistance. He was first seen because of a goiter, and was considered to have hyperthyroid Graves' disease. Despite subtotal thyroidectomy followed by radioiodine therapy, serum thyroxine levels were elevated with high serum TSH levels. Baseline thyroid function showed serum thyroxine of 16.6 micrograms/dl, free thyroxine of 4.60 ng/dl, triiodothyronine of 197 ng/dl, and TSH of 34 microU/ml. Triiodothyronine administration by gradually increased doses of 75, 150, 225, 300, and 375 micrograms/d over a 25-day period resulted in gradual reduction of serum TSH and T4 levels, but serum TSH still responded to TRH even during this period. The basal metabolic rate was--14% and showed a minimal rise even with large doses of triiodothyronine. The results led to the diagnosis of generalized thyroid hormone resistance including the pituitary gland. Increased pulse rate, finger tremor and emotional lability in the patient suggest that the severity of peripheral refractoriness to the hormone may vary from tissue to tissue. In addition, a reduced thyroidal responsiveness to TSH as a consequence of inappropriate radioiodine therapy was observed in this patient.
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PMID:Resistance of peripheral tissues and pituitary to thyroid hormone. 644 Jul 79

Two male patients with 'Hashitoxicosis', who revealed histologic pictures of adenomatous goiter in addition to findings of chronic thyroiditis, are described. Case 1. A 55-year-old man was admitted on May 7, 1981, for evaluation of hyperthyroidism. He had exophthalmos with positive Moebius and von Graefe's signs, and a firm, asymmetrically enlarged non tender thyroid gland with multiple cysts. The BMR was +60%, T4 26.4 micrograms/dl, free T4 7.2 ng/dl, T3 5.62 ng/ml and 24 hr radioiodine uptake 49.5%. TSH was undetectable and did not respond to TRH. 123I scan showed multiple defects in the bilateral upper poles of the thyroid gland. Antithyroglobulin and antimicrosomal antibodies were positive. He then underwent a total thyroidectomy with removal of multinodular goiter. The mutinodular goiter was associated with cystic degeneration which contained the thyroid hormone-rich fluid. Histologic examination revealed multiple adenomatous nodules and lymphocytic infiltration and degeneration in the surrounding tissues of the nodules. Case 2. A 43-year-old man was admitted on May 14, 1975, because of an 8 month history of hand tremor, weight loss (5 kg), facial and upper palpebral edema and an enlarged thyroid. He had mild exophthalmos and a firm, asymmetrically enlarged thyroid gland with multiple nodules. The BMR was +35%, T4 20.0 micrograms/dl, T3(Resomat) 0.78 ng/ml and PBI 20.0 micrograms/dl. TSH was 1.0 muU/ml and responded slightly to TRH. 24 hr radioiodine uptake was 84.4% and did not respond to T3 administration. Antithyroglobulin and antimicrosomal antibodies were positive. 123I scan showed diffusely increased uptake and no defects. Histologic examination of the biopsy specimen of the thyroid gland showed multiple adenomatous nodules in addition to typical findings of chronic thyroiditis in the surrounding tissues of the nodules. From the above observations, it is suggested that multiple adenomatous nodules accompanying chronic thyroiditis show clinical features resembling Basedow's disease rather than Plummer's disease.
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PMID:[2 cases of Hashitoxicosis with histological features of adenomatous goiter]. 668 93

beta-blockers have been accepted as a reasonable adjunct therapy for the treatment of hyperthyroidism. They lessen the sympathetic symptoms such as tachycardia and finger tremor. On the other hand, many studies have demonstrated a decrease in 3, 3', 5-triiodothyronine (T3) during treatment with beta-blockers (especially propranolol). The purpose of this study is to clarify the effect of arotinolol (alpha 1, beta-blocker) on the thyroid functions and autonomic nerve systems (ANS) of patients with Graves' disease. Arotinolol 20mg a day p.o. was given to untreated patients with Graves' disease (n = 16) for 2 weeks. Blood sampling and the ANS function-tests were done before and after the treatment. In addition, the in vitro effects of arotinolol on the cAMP production and the radioactive iodine uptake (RAIU) using rat thyroid cell line FRTL5 were evaluated to examine the direct influence on thyroid cells. Arotinolol improved hyperthyroid symptoms including tachycardia, but had no effect on ANS function-tests. It is of interest that not only T3 but also T4 decreased after the arotinolol treatment. We therefore suspected the direct suppressive effects of arotinolol on the thyroid. There were, however, no in vitro inhibitory effects on the cAMP production and the RAIU in TSH-stimulated FRTL5 cells. The reason why serum T4 levels in patients with untreated Graves' disease have decreased after the treatment of arotinolol could not be clarified. In conclusion, arotinolol is a very useful drug for the initial therapy of patients with Graves' disease to reduce the serum thyroid hormone levels and symptoms of hyperthyroidism when combined with antithyroid drugs.
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PMID:[The effect of arotinolol on the thyroid function and the autonomic nerve systems]. 768 Jun 18

A case of hyperthyroidism occurring in a 68 year old man receiving lithium carbonate (1 g/day) for 5 years is reported. The clinical history of the patient, treated for bipolar affective disorder, was remarkable for transient hypothyroidism followed several months later by tremor, increased free thyroxine and triiodothyronine, and decreased TSH levels which led to lithium withdrawal. Two months later, clinical and biological signs were unchanged, Tc99m-scan displayed a homogeneous and increased isotope uptake. In this setting, high levels of autoantibodies against TSH-receptor, and grade I exophthalmos and slightly ocular muscle enlargement at CT-scan favored the diagnosis of Graves' disease (perhaps facilitated by lithium therapy). Carbimazole treatment was effective in controlling hyperthyroidism. Review of the literature disclosed 44 cases of hyperthyroidism occurring in lithium-treated patients. Most of these cases concerned specific thyroid diseases, particularly with an autoimmune mechanism. There is also evidence for an actual role of lithium in increasing intrathyroid iodide pool and for an impact of lithium on the immune system. Thus, the hypothesis that lithium may trigger the development of an autoimmune thyroid disease in predisposed patients deserves further investigation.
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PMID:[Lithium therapy and hyperthyroidism: disease caused or facilitated by lithium? Review of the literature apropos of a case of hyperthyroidism preceded by transient hypothyroidism]. 808 84

Various diseases often occur after delivery but the systemic examinations have not been studied before. Thyroid dysfunction frequently (4.4%) occurs after delivery through an immune rebound mechanism. If postpartum women complain of the symptoms caused by thyrotoxicosis (palpitation, weight loss, increased sweating, finger tremor, fatigue) or hypothyroidism (edema, cold intolerance, hoarseness, sleepiness, fatigue), it is essential to examine thyroid hormones, thyroid stimulating hormone, anti-thyroid microsomal antibody (MCHA) and anti-TSH receptor antibody. To predict who will develop postpartum thyroid dysfunction, the measurement of MCHA during pregnancy is useful because 62% of the subjects with positive MCHA show thyroid dysfunction after delivery. The individuals at high risk of postpartum onset of Graves' thyrotoxicosis can be found early in their pregnancy by the detection of thyroid stimulating antibody (TSAb). Other autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, autoimmune hypophysitis and so on, also could develop after delivery. These findings indicate that laboratory tests in the postpartum period are essential to diagnose postpartum onset of autoimmune diseases and the measurement of autoantibodies in early pregnancy is useful for prediction of their onset in the postpartum period.
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PMID:[Postgravid health care and laboratory tests]. 855 72

We report a rare case of Basedow's disease associated with high output heart failure and angina pectoris over the age of 80 years. An 85-year-old woman was admitted with palpitation, finger tremor, hyperidrosis and weight loss. Basedow's disease was diagnosed by physical (diffuse goiter) and laboratory (free T3 19.4 pg/ml, free T4 > 8.0 ng/dl, TSH < 0.1 microU/ml, TRAb positive, 123I uptake high) findings and was treated with methimazole. Chest oppression and dyspnea on exertion with negative T wave, cardiomegaly and pulmonary congestion appeared after methimazole. Cardiac catheterization showed a high cardiac output (CI 5.01/min/m2, PCW 26 mmHg, PA 57/26 mmHg, RA 15 mmHg) and a significant coronary stenosis (LAD [symbol: see text] 99%). High output heart failure and angina pectoris responded to treatment. They subsequently worsened, because she stopped taking methimazole for a month and serum levels of thyroid hormones increased again. After retreatment with methimazole, serum levels of thyroid hormones decreased to within normal limits, and high output heart failure and angina pectoris also improved.
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PMID:[An 85-year-old case of Basedow's disease associated with high output heart failure and angina pectoris]. 864 96


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