Parry-Graves’ disease is the most common cause of hyperthyroidism and consists in excessive secretion of thyroid hormone, is hereditary in most of the cases, like many other thyroid diseases. Known as Graves’ disease, Graves disease or Parry disease, is a disorder with three major symptomatic manifestations:
- hyperthyroidism with diffuse goiter
These three events can not occur together, and their evolution can be independent.
Graves’ disease is a relatively common condition that can occur at any age, but is more frecventain 3rd and 4th decades of life. The disease is more common in women with a predominance of 7:1 in regions where goiter is endemic , the ratio is lower in areas with endemic goiter .
The causes are unknown and on various events and their evolution , it might be several factors responsible for the entire syndrome .
In Graves’ disease thyroid gland is diffusely enlarged , has a low consistency and is highly vascularized . Symptoms of a patient with Graves ‘disease – Parry are divided into those associated with hyperthyroidism and thyrotoxicosis reflect those specific to Graves’ disease .
The patient is irritable , has very high blood pressure or very low , nausea , vomiting or diarrhea , tachycardia ( rapid heart beat ) or chest pain , fever , confusion or drowsiness, shortness of breath or tiredness can be symptoms of heart failure. The patient may have symptoms of Graves ophthalmopathy and exophthalmos ( eyeball proeminarea outside the orbit ) or redness , weight loss even if the amount of food a person eats normal or even higher than usual, dysphagia ( difficulty swallowing ) , swollen neck and myxedema especially in the posterior part of the leg ( thickened skin , tall and with a look of orange peel can also be present pruritus and hyperpigmentation ) .
Diagnosis is relatively easy on the basis of signs and symptoms evident.
Treatment aims to limit the amount of thyroid hormones produced by the thyroid gland . In general , the choice of anti – thyroid therapy long term is preferred in children and adolencence yes , young adults and pregnant women , but can be a success in older patients .
Severe and progressive ophthalmopathy of Graves’ disease is the most difficult part of the Treaty. Fortunately , in most patients ophthalmopathy follows a benign course that is largely independent of hyperthyroidism and even severe oftalmopatiamoderat may improve with time, even if some exoftlamie and ophthalmoplegia ( paralysis of an eye muscle motor ) may persist . Conduct therapeutic ophthalmopathy of Graves’ disease have always done with an ophthalmologist . Severe Dermatopatia can be improved by topical application of corticosteroids .
Pathological changes are hypertrophy (increase in volume of a tissue or an organ through the increase in cell volume that is represented ) and hyperplasia ( benign growth of tissue volume by multiplying the cells that it is ) parenchyma . This hyperplasia is usually associated with lymphocytic infiltration appearance reflecting immune disease and correlate with the anti- thyroid antibodies in the blood. After treatment with iodine may occur gland enlargement and hardening .
Graves’ disease – Parry is associated with hyperplasia and lymphocytic infiltration generalized and sometimes with enlarged spleen or thymus aa ( small endocrine gland located in the chest cavity , between the two lungs ) . Thyrotoxicosis can cause degeneration fibrelormusculare ribbed, heart enlargement , diffuse fatty infiltration or fibrosis of the liver , skeletal deliming and loss of tissue .
Ophthalmopathy is characterized by an inflammatory infiltrate in the content orbit with lymphocytes, mast cells and plasma cells .
Orbit is commonly hypertrophic muscles due to lymphocytic infiltration and edema , along with lipids are responsible for increasing the content orbit that produces proeminarea eyeball. Eye muscle fibers degenerate and eventually produce fibrosis .
Dermatopatia of Parry – Graves’ disease is characterized by thickening of the dermis and is manifested in the rear part of the legs being called myxedema.
Causes of Graves’ disease-Parry are unknown and on various events and their evolution, it might be several factors responsible for the entire syndrome.
Regarding hipertitoidia disorder is caused by the interruption mechanism homeostaticcare normally regulates hormonal secretion. This alteration hoemostatic mechanism of the body is determined by the presence in plasma thyroid stimulating immunoglobulins of IgG class, developed by lymphocytes.
Thus, although there are no known cases of Graves’ disease, an immune globulin or a family of immunoglobulins directed against the TSH receptor (thyrotropic pituitary hormone) mediates stimulation of thyroid.
Causes ophthalmopathy and skin diseases are also less known but fell ophthalmopathy was assumed the existence of an antigen in tissues of the orbit, antigen react with the thyroid.
Signs and symptoms
The events are divided into those that reflect hyperthyroidism and thyrotoxicosis associated with Graves’ disease -specific .
Common manifestations of thyrotoxicosis in Graves’ disease are :
- emotional lability
- increase intestinal peristalsis
- excessive sweating
- heat intolerance .
Weight loss is also a common symptom , despite maintaining or increasing appetite .
Patients have a muscle weakness with loss of power , often manifested by weight when climbing stairs .
In women before menopause there is a tendency of developing oligomenorrhea (decreased blood flow during the menstrual cycle ) and amenorrhea (absence of menstrual cycle ) .
- dyspnea (difficulty breathing )
- elderly patients worsening angina or heart failure.
In general , symptoms of nervousness dominate the clinical picture in younger individuals while the elders prevailed cardiovascular symptoms and myopathy. Usually the patient is anxious, agitated and nervous .
The skin is warm and moist , velvety appearance , is currently palmar erythema ( skin redness ) . The separation of nail from its bed is common, especially on the ring finger ( onycholysis – nail Plummer ) also is fine and silky hair . It is characteristic of a fine tremor of the fingers and tongue , along with overactive reflexes .
Ocular signs are the characteristic staring with increasing palpebral apertures , slow blink and slowness of movement and impaired eyelid to brow lifting upward direction of gaze . These symptoms usually improve after correction of thyrotoxicosis and must be differentiated from the characteristic infiltrative ophthalmopathy of Graves’ disease .
- Cardiovascular changes include increasing the arterial pulse pressure , sinus tachycardia , atrial arrhythmias (especially atrial fibrillation ) , while increasing heart and heart failure .
- Manifestations of Graves’ disease – Parry are :
- hiperfunctionala diffuse goiter ,
- ophthalmopathy and
- occurring in various combinations with variable frequency , goiter is the most common . May develop premature graying of hair and patches of vitiligo are not specific to Graves’ disease but are common to other autoimmune diseases .
Diffuse toxic goiter can be asymmetric and lobular , and the presence of thyroid breath usually means tireotoxicoxei existence , but this sign is rarely present in other forms of thyroid hyperplasia .
Infiltrative ophthalmopathy of Graves’ disease has clinical signs can be divided into two components:
- spastic signs : eyes fixed , slow motion eyelids and eyelid retraction , which are present in thyrotoxicosis and are responsible for facies ” scared ” and
- Signs mechanical ptosis ( drooping eyelids ) with ophthalmoplegia ( paralysis of an eye muscle motor ) and oculopatie failure characterized by chemosis (swelling or swelling of the conjunctiva ) , conjunctivitis , periorbital edema and potential complications like corneal ulceration , optic neuritis and atrophy optics.
When protruding progresses rapidly and becomes the main concern in Graves’ disease – Parry , is called progressive exophthalmos , and if severe , it is called malignant exophthalmos . The term refers to the weakness ophthalmoplegia protruding eye muscles that cause an alteration of gaze upward convergent strabismus with varying degrees of diplopia ( double vision ) . Exophthalmos is unilateral at onset but usually progresses to become bilateral . Dermopatia usually occurs in the posterior part of the leg and is called pretibial myxedema or localized . It is not late symptom and not a manifestation caused by hypothyroidism .
About half of the cases occur during the active stage of thyrotoxicosis and ophthalmopathy virtually all patients . The affected region is usually defined to healthy skin being thickened, raised and orange peel appearance , may be present pruritus and hyperpigmentation . The most common way of presenting edema without well ( do not let the pressure of the finger ago) , but lesions can look posters, nodular or polypoid .
Hippocratic fingers of the hand or foot ( toes in watch glass , nails curved and ends of the fingers ) may accompany changes in the dermis ( acropachie thyroid ) .
When Graves’ disease – Parry is severe , the diagnosis is easily made .
Thyrotoxicosis is manifested by :
- keeping weight loss despite appetite
- emotional irritability
- heat intolerance
- accelerated intestinal transit .
When associated with a diffuse enlargement of the thyroid gland , often accompanied by a thrill and especially when associated with ophthalmopathy clinical picture is almost unique . In such conditions , diagnosis is based on signs and symptoms and laboratory tests revealed an undetectable TSH , increased RAIU ( radioactive iodine uptake test for the determination of thyroid ), increased T4 , T3 , serving more as landmark to evaluate treatment than that required for diagnostic help .
In less severe cases , when ophthalmopathy missing , diagnosis can be difficult because symptoms are mild thyrotoxicosis similar to those of other diseases . This makes it likely diagnosis dehipertiroidie goiter , but shall be required careful palpation for toxic multinodular goiter present accurate , toxic adenoma or subacute thyroiditis .
Absence of thyroid enlargement makes it less likely the diagnosis of Graves’ disease but does not rule . In moderate cases laboratory investigations have a very important and highly sensitive analysis of the determination of TSH or TRH stimulation test were crucial . In addition, all patients with heart failure for no apparent reason should be investigated for the presence of thyrotoxicosis .
Examination of radioactive iodine is also important , except cazulin that overproduction of thyroid hormones is caused by an increased intake of iodine RAIU values are increased in all diseases that cause hyperthyroidism , including Graves’ disease .
Differentiation must be made between the symptoms of other diseases that mimic netiroidiene signs and symptoms of thyrotoxicosis , for example :
- mistenia gravis and muscular dystrophy
- intraorbital or intracranial disease
- pituitary tumors .
The main methods of treatment of hyperthyroidism in Graves’ disease was to limit the amount of thyroid hormone produced by the gland . Lasting affection may be associated with progressive thyroid failure , likely due to chronic thyroiditis with hypothyroidism or decrease the occurrence of thyroid reserve . These characteristics have important implications in the choice of treatment and response to treatment.
The first major mode of approach is the administration of antithyroid agents that block chemical hormones effect manifested as long as the medicine and may also accelerate the progression to autoimmune remission in their effect . Their main utility is to control tireotoxicitatea active, while remission expect .
The second major mode of approach is removal of thyroid tissue , thereby limiting hormone production . In general , the choice of anti – thyroid therapy long term is preferred in children and adolencence yes , young adults and pregnant women , but can be a success in older patients . Antithyroid therapy in selected patients for long-term control can be achieved almost always satisfactory if given a sufficient dose of medication. In most patients propylthiouracil may be used at a dose of 100 – 150mg every 6-8 hours or methimazole used in a tenth of the dose of propylthiouracil .
The main adverse effect of antithyroid medication is leukopenia (low white blood cell count ) and can occasionally produce allergic rash , sensitivity to drugs , hepatitis , drug fever or altralgii (joint pain ) .
Treatment with iodine is useful for iodine inhibits the release of thyroid hormone hiperfunctionala and effect improvement occurs faster than with agents that inhibit the synthesis of hormones , but their effect is incomplete and transient , so it is used in combination with antithyroid agents . This therapy is used primarily in patients with thyrotoxic crisis or imminent present in patients with severe heart disease .
It also uses radioactive iodine therapy is a relatively simple and less expensive treatment of thyrotoxicosis associated with Graves’ disease – Parry . The main disadvantage of radioiodine therapy in the dose usually is hypothyroidism tend to occur with a frequency that increases with time .
Surgical treatment , consisting tireoidectomia subtotal is performed before the introduction of radioiodine therapy and is used in younger patients on antithyroid treatment is ineffective. In pregnant patients with a history of Graves’ disease – Parry stimulation tests should be conducted in Q3 of pregnancy , treatment with antithyroid drugs administered in the lowest dose is preferable to surgery, which should not be done in any case in quarters 1 and 3 of pregnancy. The main disadvantage of treatment with antithyroid agents is able to induce fetal hypothyroidism because T3 and T4 antithyroid drugs cross the placenta and protect the fetus to the mother not hypothyroid .
Radioactive iodine therapy is contraindicated in pregnant women and all women with the possibility to procreate and requiring treatment with radioactive iodine have done a pregnancy test first .
Severe and progressive ophthalmopathy Graves’ disease is the component – Parry most difficult to treat. Fortunately , in most patients ophthalmopathy follows a benign course that is largely independent of hyperthyroidism and even moderately severe ophthalmopathy may improve with time, even if some exoftlamie and ophthalmoplegia ( paralysis of an eye muscle motor ) can persist . In more severe cases , with progressive exophthalmos , chemosis , ophthalmoplegia or loss of vision should be given high doses of prednisone ( 100-200mg/zi ), it is usually effective to reduce lanivelul efecteleedematoase and infiltrating the globe. After relieving symptoms is reduced to the minimum dose effective to reduce the effects of glucocorticoid excess . Orbital irradiation may also be useful in some patients with acute manifestations with severe infiltration , especially when given concurrently with corticosteroids . Conduct therapeutic ophthalmopathy of Graves’ disease have always done with an ophthalmologist .
Dermatopatia severe Graves’ disease – Parry can be improved by topical application of corticosteroids , only 10% of patients obtained a complete remission and 40-50 % shows a partial remission .