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1、ThyrotoxicosisIntroductionThyrotoxicosis is the constellation of clinical findings that arise when the peripheral tissues are presented with and respond to an excess of thyroid hormonefree thyroxine (T4) and free triiodothyronine (T3). Hyperthyroidism refers to sustained increases in thyroid hormone
2、 synthesis and secretion by the thyroid gland. The prevalence of hyperthyroidism is estimated at 2% for women and 0.2% for men. About 15% of cases occur in patients older than 60 years.甲状腺毒症 简介 甲状腺毒症是一组临床症候群，出现在甲状腺激素，即游离甲状腺素（T4）和游离甲状腺素（T3）过量时，外围组织的临床表现。甲状腺功能亢进症是指甲状腺合成和分泌甲状腺激素持续增加。甲状腺功能亢进症的患病率估计女性为 2
3、，男性为 0.2。约 15的病例发生在 60岁以上患者。 The most common causes of thyrotoxicosis in Western society are Graves disease, autonomous single nodules (also known as toxic hot nodules), multiple functioning nodules (also called toxic multinodular goiter), and thyroiditis. The pathogenesis in each of these condition
4、s is different (Table 42-1). However, the initial therapy is similar and focuses on blocking the peripheral effects of thyroid hormone excess and reducing thyroid hormone overproduction where present.在西方社会，甲状腺毒症最常见的病因是 Graves病，单发结节（又称毒热结节），多发功能性结节（也称为毒性多结节性甲状腺肿）和甲状腺炎。上述疾病的发病机制不同（表 42-1）。但目前主要的治疗方法是类
5、似的，主要是阻断过量甲状腺激素对周围组织的作用，并减少甲状腺激素的生成。Etiology and PathogenesisGraves disease is the most common cause of hyperthyroidism in patients younger than 40 years (Fig. 42-1). The pathophysiology represents one of the classic receptor antibody disease states due to thyroid-stimulating hormone (TSH) receptor
6、autoantibodies that continuously stimulate the thyroid gland as TSH agonists. Intrathyroidal lymphocytic infiltrate is the initial abnormality (Fig. 42-2). As in other autoimmune disease states, females are more commonly affected than males. Autonomously functioning thyroid nodules are discrete and
7、function independently of the pituitary-thyroid negative feedback loop. Thyroiditis is characterized by inflammation, with thyroidal damage leading to release of T4 and T3 without active formation of T4 and T3. Transient hypothyroidism typically follows, with the rare development of permanent hypoth
8、yroidism. Other rare causes of hyperthyroidism include (1) TSH-secreting pituitary tumors, (2) struma ovarii, (3) iodine-induced hyperthyroidism (Jod-Basedow), (4) hyperthyroidism mediated by human chorionic gonadotropin, (5) metastatic follicular thyroid cancer, and (6) factitious thyrotoxicosis ca
9、used by surreptitious thyroid hormone ingestion.病因和发病机制 小于 40 岁的患者中，Graves 病是甲状腺功能亢进症中最常见病因（图 42-1）。甲状腺毒症的病理生理表现是典型的受体抗体疾病，促甲状腺激素（TSH）受体的自身抗体，作为 TSH 受体激动剂，持续刺激甲状腺。最主要的异常是甲状腺内淋巴细胞在浸润。和其他自身免疫性疾病一样，女性较男性易患。自主功能性甲状腺结节是离散的，而且功能独立于垂体 - 甲状腺的负反馈回路。甲状腺炎的特点是炎症导致甲状腺破坏，导致 T4 和 T3 释放而不是其活性形式，进而是一过性甲减，很少发展为永久性甲减。
10、甲亢的其他很少见的病因包括：（1）垂体的促甲状腺激素瘤，（2）甲状腺肿样卵巢瘤，（3）碘致甲状腺功能亢进（4）人绒毛膜促性腺激素介导的甲状腺功能亢进症，（5）转移性甲状腺滤泡癌症，和（6 私自甲状腺激素摄入引起的人为甲状腺毒症。Clinical PresentationCommon symptoms of thyrotoxicosis include nervousness, emotional lability, fatigability, heat intolerance, weight change (usually weight loss), appetite change (usua
11、lly increased), myopathic symptoms, increased frequency of bowel movements, sweating, menstrual irregularities (usually oligomenorrhea), and central nervous system disturbance. Common signs include hyperactivity; tachycardia or atrial arrhythmias; systolic hypertension; warm, moist, smooth skin; sta
12、re and eyelid retraction; tremor; hyperreflexia; and muscle weakness. Palpitations are a prominent symptom in elderly patients, as is cardiac failure. Generally, elderly patients present with less florid features of thyrotoxicosis and commonly exhibit cardiac symptoms or dementia.临床表现 甲亢的常见症状包括精神紧张，
13、情绪不稳，易疲劳，怕热，体重变化（通常体重减轻），食欲改变（通常是食欲增加），肌病症状，排便次数增多，出汗，月经不调（通常经过少），以及中枢经系统紊乱。常见的体征包括多动，室性心动过速或房性心律失常;收缩期高血压; 皮肤湿热，滑，凝视和眼睑回缩，震颤，反射亢进;和肌无力。在老年患者中心衰和心悸是突出的症状。一般情况下，老年患者很少表现甲状腺毒症的全部典型临床症状，通常表现心脏症状或痴呆Graves DiseaseA triad of manifestations define the disease: (1) hyperthyroidism and goiter; (2) ophthalmop
14、athy, clinically evident in 10% to 25% of patients, with a higher prevalence in men and in those who smoke; and (3) dermopathy in the form of localized myxedema, which is a skin thickening typically limited to the pretibial area. About 4% of patients with clinically evident ophthalmopathy have thyro
15、id dermopathy.Graves病 Graves病是由三个表现定义的疾病：（1）甲亢和甲状腺肿大; （2）眼病，临床上 10到 25的患者有明显的眼病，男性和吸烟者的发病率较高。（3）局部粘液性水肿性皮肤病，皮肤增厚，一般仅限于胫前区。临床上明显的眼病患者中，约 4有甲状腺皮肤病。 The onset of the disease is usually insidious. Some patients may notice the gradual development of goiter and its associated symptoms, including difficult
16、y in fastening the collar button, fullness in the neck, or a choking sensation. Slightly more than one half of the patients experience symptoms of ophthalmopathy (i.e., grittiness and tearing of the eyes, retro-ocular pressure, photophobia, a staring appearance, and the development of diplopia (Fig. 42-3). The thyroid gland is diffusely enlarged and may be firmer, and an audible bruit may be auscultated. Radioactive iodine imaging reveals diffuse radioiodine uptake, alth
