Enthusiasm is like fire, maybe it is a kind of endocrine disease!

*It is only for medical professionals to read for reference.
Can you think of what disease this is? Case brief introduction The patient is a 21-year-old female with a half-year course of illness
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Clinical manifestations: The patient began to suffer from fever six months ago, which did not attract attention
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He complained of exophthalmos 3 days ago, no palpitations, fatigue; no nausea, vomiting, chest tightness, and shortness of breath
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 Past history: No special medical history
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 Physical examination: T: 36.
2℃ P: 90 beats/minute R: 20 beats/minute BP: 117/81mmhg, specialist examination: clear, excited, thin body, moist skin; eye examination: slightly protruding eyeballs, Darymple Symptoms (+), Stellwag sign (+); Thyroid examination: thyroid swelling of second degree, no tenderness and nodules, can move up and down with swallowing, double superiors can hear vascular murmurs; no anterior tibial mucin edema; heart: heart rate 90 Beats/minute, the heart rhythm is uniform; the tendon reflex is hyperreflexive; the hand shake (+)
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 Laboratory examination: Three items of thyroid function: FT3>46.
08pmol/L, FT4>77.
23pmol/L, TSH 0.
012mIU/L; Thyroid antibody: TSHRAb 36.
15IU/L, TG 0.
12ng/ml, TPOAb 332.
26IU/ml
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Thyroid examination: the size of the left thyroid lobe is about 27mm×21mm, the size of the right thyroid lobe is about 26mm×19mm, the thickness of the isthmus is about 8.
5mm, the capsule is smooth, the parenchymal echo is thickened, and the distribution is uneven, showing a "honeycomb" shape (Figure A) , No obvious space-occupying lesions were seen inside
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Blood flow signal (CDFI): Abundant blood flow signals can be seen in the thyroid gland, showing a "fire sea" sign (Figure B)
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 Figure A Figure BQ: What is the most likely diagnosis? A.
Hashimoto’s thyroiditis B.
Subacute thyroiditis C.
Hyperthyroidism (toxic diffuse goiter) D.
Simple goiter E.
Nodular goiter Answer Click the blank space below to get the answer.
Hyperthyroidism (toxic diffuse goiter) Diagnosis basis 1.
The patient was female, 21 years old, who was afraid of heat for half a year, and was found to have exophthalmos for 3 days; 2.
Weight loss, emotional excitement, moist skin; Eye examination: mildly prominent eyeballs, Darymple syndrome (+), Stellwag sign (+) ; Thyroid examination: second degree thyroid enlargement, no tenderness and nodules, can move up and down with swallowing, double superior can hear vascular murmur; no anterior tibial mucin edema; heart: heart rate 90 beats per minute, regular heart rhythm
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Tendon hyperreflexia
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Hand shake (+)
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 3.
Three items of thyroid function: FT3>46.
08pmol/L, FT4>77.
23pmol/L, TSH 0.
012mIU/L; Thyroid antibody: TSHRAb 36.
15IU/L, TG 0.
12ng/ml, TPOAb 332.
26IU/ml; thyroid color Doppler ultrasound : Thyroid enlargement, diffuse parenchymal disease and abundant blood supply: consider hyperthyroidism
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 Knowledge Expansion Hyperthyroidism (hyperoidism) is abbreviated as hyperthyroidism, which refers to the hypermetabolism caused by the excessive production of thyroid hormone by the thyroid gland itself, and the sympathetic nerves are too excited, the patient's eating and defecation frequency increases, but the body mass decreases, and the patient may have symptoms at the same time Thyrotoxicosis with symptoms such as vision loss, eyelid edema, or exophthalmos, and its causes include diffuse toxic goiter (Graves disease), nodular toxic goiter, thyroid autonomic hyperfunctioning adenoma (Plummer disease), and Hashimoto's hyperthyroidism and so on
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 The prevalence of hyperthyroidism is 1%, of which more than 80% is caused by Graves disease
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The treatment principles of hyperthyroidism corresponding to different causes are different, and some thyroid nodules may become malignant, so the diagnosis of the cause of hyperthyroidism is particularly important
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Different etiologies can cause different lesions of the thyroid parenchyma, which are manifested in different ultrasound images.
Ultrasound, as the first choice for thyroid diseases, can provide accurate diagnostic evidence for the diagnosis of the cause of hyperthyroidism
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Ultrasound diagnosis of hyperthyroidism (toxic diffuse goiter) path analysis 1.
Hyperthyroidism (toxic diffuse goiter) sonographic manifestations: thyroid enlargement is symmetrical, uniform or uneven
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The edges of the thyroid glands on both sides are relatively irregular, and the thyroid gland may be lobulated, the capsule is not smooth, and the boundary is not clear
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The upper and lower thyroid arteries are thickened, and the thyroid can show dilated blood vessels
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In older persons with a longer course of disease, bilateral thyroid glands may show scattered, focal hypoechoic and hyperechoic symptoms
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After treatment, the author repeatedly reported that the echo within the thyroid was uneven and enhanced, with enhanced light bands, or scattered network and honeycomb echoes.
Some patients resembled Hashimoto's thyroiditis echoes
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CDFI showed that the blood supply of the entire thyroid was significantly increased, showing a "fire sea" sign, with colored blood flow surrounding the thyroid capsule
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The flow velocity of the superior and inferior thyroid arteries is significantly increased, the resistance is reduced, and the blood flow velocity of the internal thyroid arteries is increased, showing a low resistance blood flow spectrum
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2.
Evaluation of hyperthyroidism (toxic diffuse goiter): Under normal physiological conditions, the left and right upper and lower thyroid arteries are responsible for the blood supply of the thyroid, and the inner diameter of the blood vessels is about 2mm
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The right superior thyroid artery is easier to show in ultrasound images.
As the main blood supply channel, changes in its blood flow parameters can reflect changes in gland function, and the maximum blood flow velocity is an important indicator
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 An increase in the Vmax of the superior thyroid artery represents an increase in the blood flow to the thyroid.
The Vmax of the superior and inferior thyroid arteries in patients with toxic diffuse goiter is significantly increased.
When the patient is in a state of hyperthyroidism, the internal diameter of the superior thyroid artery increases at least> 2 mm, Vmax Even up to 70 cm/s, the characteristics of ultrasound images are consistent with pathological changes in thyroid hyperplasia and vascular hyperplasia
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Detecting the peak flow velocity of the upper and lower thyroid arteries is more sensitive than detecting the blood supply in the thyroid to diagnose hyperthyroidism
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 Although other thyroid diseases, such as subclinical hypothyroidism, can also cause an increase in thyroid artery Vmax, the degree of increase is significantly lower than that of hyperthyroidism
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Studies have shown that this phenomenon of increased blood flow and increased flow velocity is significantly related to the patient's high FT3 and FT4 levels, so we can judge the condition of hyperthyroidism based on the results of ultrasound images
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3.
Differential diagnosis of hyperthyroidism (toxic diffuse goiter) 1) Hashimoto's thyroiditis 2) Subacute thyroiditis Subacute thyroiditis only shows local enlargement of the area of ​​inflammation
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In subacute thyroiditis, the enlarged part is flaky and hypoechoic, and the boundary is blurry
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Color Doppler showed that the blood supply of the entire thyroid gland was not increased or the lesion area was slightly increased in subacute thyroiditis
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In subacute thyroiditis, the flow velocity of the superior thyroid artery is normal or slightly increased
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Subacute thyroiditis has obvious squeezing pain
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Reference materials: [1] Wang Yang, Du Xiaozhou, Liu Qian.
Comparison of the value of high-frequency ultrasound and color Doppler ultrasound in diagnosing female hyperthyroidism[J].
China Maternal and Child Health Care,2021,36(11):2655- 2657.
[2] Xiong Aimin, Shi Huazheng, Peng Min, Wang Xiumei.
Comparison of the diagnostic value of color Doppler ultrasound and enhanced CT for recurrence or metastasis of papillary thyroid carcinoma after surgery[J].
Journal of Northwest National Defense Medical Science,2018,39( 04): 250-253.
[3] Li Quanshui, Ultrasound Medicine for Superficial Organs.