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Common diseases also have "alternative"
toxic diffuse goiter (Graves disease), the most common type of
hyperthyroidism.
This hyperthyroidism is not caused by adenomas and nodules of the thyroid gland, nor is it caused by excessive secretion of thyroid-stimulating hormone secreted by the pituitary gland or inflammatory lesions of the thyroid gland, but refers to a class of diseases with diffuse enlargement of the thyroid gland accompanied by hyperthyroidism [1].
The typical clinical manifestations of this disease are that patients will have clinical manifestations such as heat intolerance and sweating, palpitation, increased eating and stool frequency, weight loss, hand trembling, irritability, and some patients will even have periodic paralysis
.
During physical examination, there will be symptoms such as neck enlargement and bulging eyes, and in severe cases, it will also be accompanied by symptoms such as eyelid edema and vision loss, and thyroid bruit will occur on auscultation [2, 3].
Everyone knows the common clinical manifestations, so today let's understand the atypical manifestations of such diseases through a case ~
clubbing fingers, barrel-shaped chest, "rubber legs".
.
.
.
It's also this disease!
▎ Cases
After the patient Lao Hu caught a cold, he developed a cough that lasted for half a month, so he went to the respiratory medicine clinic of the hospital
.
The attending doctor found a physical examination of the barrel-shaped chest and rales
in the lungs.
Clubbing fingers can be seen, and both lower limbs are swollen
.
Consider chronic respiratory diseases
of old age.
So the proposed diagnosis is chronic bronchitis, emphysema, chronic cor pulmonale? Right heart insufficiency
.
However, long-term treatment according to this disease is ineffective
.
After multidisciplinary consultation, Graves disease
was diagnosed.
After systemic anti-nail treatment, Lao Hu's condition was relieved
.
This case is an elderly patient, according to the patient's clinical symptoms and signs, combined with relevant auxiliary examinations, the diagnosis of pulmonary heart disease cannot be established
.
In addition, clubbing is not exclusive to
respiratory diseases such as COPD.
Barrel chest is the second sign of mistreatment, which is due to emphysema in older age rather than obstructive pulmonary disease [4].
When it was the turn of the endocrinology consultation, the endocrinologist carefully examined the body and found a new sign, that is, the patient's thyroid isthmus was swollen and he could hear a vascular bruit.
Combined with the appearance of myxedema in both lower limbs causing rubber legs, hypothyroidism
is considered at the initial diagnosis.
However, thyroid ultrasound showed bilateral diffuse thyroid enlargement, and the results of the full thyroid function test were also very different from the initial diagnosis.
.
.
.
Just when other consultation experts were puzzled, the endocrinology consultant speculated according to the patient's age, low and depressed mood, could it be that this is a special type of hyperthyroidism, apathetic hyperthyroidism?! Therefore, it is recommended to try anti-nail therapy to observe the efficacy
first.
After anti-nail treatment, the patient's clinical symptoms improved significantly, and it was finally diagnosed as Graves' apathetic type
.
In addition, the third manifestation that is easy to cause misdiagnosis in this case is "edema of both lower limbs"
.
However, this is not caused by right heart insufficiency due to cor pulmonale, but by hyperthyroidism
myxedema.
The distinguishing points between myxedema and right heart insufficiency caused by edema are: myxedema skin is rough like rubber, the edema site is not depressed, and the right heart insufficiency causes edema pressure to have depressions, leaving finger marks
.
Disease-related knowledge, learn about it~
■Pulmonary heart disease
Cor pulmonaleum is caused by pulmonary hypertension or pulmonary vascular disease caused by bronchio-pulmonary tissue, which is divided into acute and chronic diseases, and the causes are bronchial disease, lung disease, thoracic movement disorders, pulmonary vascular diseases, etc
.
Symptoms of cor pulmonale: patients may present with cough, phlegm, palpitations after activity, dyspnea, and decreased
labor endurance during the compensatory phase.
In the noncompensated stage, patients may have manifestations of pulmonary encephalopathy such as worsening dyspnea, decreased appetite, lethargy, and coma, in addition to bilateral lower limb edema, abdominal distension, nausea and other manifestations of right heart failure [4].
■Clubbing
Mainly due to the current hypoxia, as long as it can cause the blood oxygen saturation in the patient's arterial blood to decrease, clubbing can appear
.
When certain diseases cause the blood oxygen saturation in the arterial blood to decrease, it will stimulate the active substances in the human body, such as prostaglandins or certain substances to expand blood vessels, thereby pumping more blood into the end of the human body, to relieve the hypoxic state at the end of the patient, which also leads to the production
of clubbing.
Any disease that causes hypoxia can cause clubbing, such as diseases in the presence of lungs, such as lung cancer, obstructive pulmonary disease caused by chronic bronchitis, or due to cardiac insufficiency, heart failure, valvular heart disease, endocarditis disease, etc
.
Other rare causes such as idiopathic hypertrophic osteoarthropathy, systemic amyloidosis, chronic sepsis, syringomyelia, myxedema after thyroidectomy in chronic mountain sickness, left atrial myxoma and other diseases may have clubbing changes and need to be carefully identified
.
This case is due to atypical signs, i.
e.
, thick skin, patchy or nodular folds, and finally bark-like
.
Due to secondary infection and pigmentation, the soft tissues of the fingers are swollen and clubbing
.
The clubbing finger caused by respiratory diseases accounts for 75%~80% of all clubbing fingers, and the clubbing finger is the first sign
that causes misdiagnosis by respiratory doctors.
■Barrel-shaped chest
Also known as "emphysema", it refers to the increase in the anteroposterior diameter of the thoracic cage, sometimes almost equal to the left and right diameters, barrel-shaped, the slope of the ribs becomes smaller, the angle between it and the spine is often greater than 45 °, the intercostal space is widened and full, and the upper abdominal angle is increased.
It is seen in patients with severe emphysema, but can also be seen in the elderly or those with
a short and fat body.
The primary disorder needs to be treated to relieve dyspnea symptoms and, if necessary, surgery to correct the deformity
.
■Myxedema
It can be divided into generalized myxedema (also known as true myxedema) and pretibial myxedema (thyrotoxic mucinosis).Pretibial myxedema is a metabolic disorder
characterized by scattered or diffuse mucin deposits within the skin and microscopic collagen breakup.
Mucin is found in the matrix and is composed of proteoglycans and glucosamine glycans, these acidic mucopolysaccharides produced by fibroblasts are highly hygroscopic and able to bind 1000 times their own volume of water, which is essential to maintain the moisture of the dermis while maintaining the volume and texture
of the dermis.
Under normal circumstances, chondroitin sulfate and heparin, which belong to mucopolysaccharides sulfate, are the basic dermal
mucins.
In certain diseases, fibroblasts produce a large number of abnormal acidic mucopolysaccharides, usually hyaluronic acid, and these acidic mucopolysaccharides (mucin) accumulate in large quantities in the dermis to form various mucus states
.
This can be confirmed
by special staining such as glue iron and toluidine blue of Asin blue.
The absence of staining after tissue culture with hyaluronidase confirms the presence of mucin, as the water contained in mucin is lost during the procedure and is not visible under conventional HE staining, so a possible increase in mucin may be considered when there is a
large gap in the collagen bundle.
At present, it is believed that this disease, like the protruding eye in hyperthyroidism, is a manifestation of autoimmune diseases, and the evidence includes:
1.
This disease is almost often accompanied by Graves disease, which has been considered an autoimmune disease
.
2.
Graves patients with hyperthyroidism, exophthalmos, and pretibial myxedema may be found in serum long-acting thyroid-stimulating factor (LATS).
3.
LATS is also present
in anterior tibial myxedema fluid and biopsy specimens.
4.
LATS participates in activating lymphocytes to promote fibroblast production of a large amount of mucin [5, 6].
Finally, I would like to remind everyone that the most common Graves disease also has alternative manifestations, and it must be clinically screened to prevent misdiagnosis and mistreatment
.
(Note: The characters in the article are pseudonyms) References: [1] Li Changqi, Jiang Shuwen, Dong Jinglin
, eds.
New progress in the diagnosis and treatment of hyperthyroidism[M]Heilongjiang Science and Technology Press.
Harbin 1996 First Edition 188-208 [2] Chinese Medical Association, Clinical Pharmacy Branch of Chinese Medical Association, Journal of Chinese Medical Association, etc.
Guidelines for rational drug use in the primary level of hyperthyroidism[J].
Chinese Journal of General Practitioners,2021,20(5):515-519.
DOI:10.
3760/cma.
j.
cn114798-20210317-00249 [3] Guidelines for the diagnosis and treatment of common diseases at the grassroots level.
Guidelines for the primary care of hyperthyroidism (2019).
DOI:10.
3760／cma.
j.
issn.
1671-7368.
2019.
12.
002.
[4] Ge Junbo, Xu Yongjian.
Internal Medicine.
9th edition [M].
People's Medical Publishing House, 2018 [5] Chinese Endocrine Society, etc
.
【Guidelines and Consensus】Guidelines for the diagnosis and treatment of hyperthyroidism and other causes of thyrotoxicosis in ChinaChinese Journal of Endocrinology and Metabolism, 2022,38(8): 700-748 [6] Huynh CN,Pearce JV,Kang L,Celi FS.
Weight Gain After Thyroidectomy:A Systematic Review and Meta-Analysis.
J Clin Endocrinol Metab.
2021 Jan 1; 106(1):282291.
doi:10.
1210/clinem/dgaa754.
PMID:33106852; PMCID: PMC776563
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