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*Only for medical professionals to read for reference to neck swelling? This thyroid case is a bit complicated.
.
.
Swollen neck is one of the reasons why many patients with thyroid disease come to the endocrinology department.
The case we are going to talk about this time also came from this.
However, the actual situation may be more complicated than imagined.
Let's see it together! Case Express Medical History: A 46-year-old female patient was admitted to the hospital for "found neck swelling for 3 days".
He has no special medical history, and his elder sister and younger brother have a history of hyperthyroidism and are under treatment with anti-hyperthyroidism drugs.
Since the onset of the onset, there was no palpitation, shaking hands, fear of heat and sweating, weight loss, and stool 2 to 3 times a day a few days before the treatment, the texture was normal.
Physical examination: no exophthalmos, second degree thyroid enlargement, tough texture, no tenderness, no masses, vascular murmurs can be heard.
There is no abnormality in the lungs, the heart rate is 70 beats/min, the rhythm is uniform, the abdomen is not abnormal, and there is no edema in the lower extremities.
There was no tremor in his hands.
Preliminary examination: Thyroid-stimulating hormone (TSH) <0.
01μIU/ml (0.
38～4.
31), free triiodothyronine (FT3) 3.
65ng/dl (0.
78～1.
86), serum free thyroxine (FT4) is 9.
37pg /ml (1.
8～3.
8), thyroid peroxidase antibody (TPO-Ab)>1000IU/ml, anti-thyroglobulin antibody (TgAb)>2000IU/ml.
Thyroid ultrasound showed that the thyroid gland was diffusely enlarged, the parenchymal echo showed a network-like change, and the two leaves were scattered in multiple isoechoic and slightly hyperechoic clusters.
A narrow hypoechoic halo was seen around, the border was clear, the largest was 8.
1×6.
1mm, and the surrounding abnormal echo See the circular blood flow signal, and the remaining thyroid blood flow signal shows a fire sea sign. Q1: Based on the existing auxiliary examinations, what diagnosis should the patient consider? A1: The patient's TPO-Ab and TgAb were extremely high, and ultrasound showed diffuse thyroid enlargement, parenchymal echo showed network-like changes, and thyroid function suggested thyrotoxicosis, but the symptoms were mild.
Combined with medical history and physical signs, subacute thyroiditis, painless thyroiditis, TSH tumor, iatrogenic hyperthyroidism, etc.
can be excluded.
Hashimoto's thyrotoxicosis should be considered.
In addition, the diagnosis of thyroid nodules is established, and the possibility of inflammation is not excluded.
There is no malignant sign on ultrasound.
Follow-up observation is 6-12 months.
Q2: What is Hashimoto's thyrotoxicosis? How to diagnose? What diseases need to be differentiated from? A2: Hashimoto's thyrotoxicosis has a narrow sense and a broad sense-Hashimoto's thyrotoxicosis in a narrow sense refers to the destruction of follicles caused by Hashimoto's thyroiditis, and thyroid hormones are released into the blood.
Hashimoto's thyrotoxicosis in a broad sense also includes Hashimoto's thyroiditis combined with Graves' disease (ie Hashimoto's hyperthyroidism).
The clinical manifestations of Hashimoto's thyrotoxicosis and pure Graves' disease are similar, and the two need to be carefully differentiated! The identification methods are as follows: Table 1 Identification methods (click to view the larger image) Q3: Which type of Hashimoto's thyrotoxicosis is most likely to be the patient? What other checks need to be done? A3: The patient's symptoms of hyperthyroidism are mild, combined with thyroid signs (audible and vascular murmur) and ultrasound (thyroid blood flow signal shows the fire sea sign) may indicate the existence of Graves disease, consider Hashimoto's combined Graves disease, that is, Hashimoto's hyperthyroidism.
Thyroid-stimulating hormone receptor antibody (TRAb) and thyroid isotope scanning are also required.
If identification is difficult, thyroid puncture can also be performed to clarify the pathological type.
Auxiliary test report: TRAb>300IU/ml, thyroid isotope scan showed that thyroid iodine intake was irregularly concentrated and sparse, and the imaging density was uneven; in addition, the patient refused to undergo thyroid puncture.
Q4: It is often encountered in clinical practice that a patient is positive for TPO-Ab, TgAb and TRAb at the same time.
Can Hashimoto's thyroiditis be diagnosed with positive TPO-Ab and TgAb? Should Graves' disease be considered when TRAb is positive? A4: TPO-Ab, TgAb positive is not a diagnosis condition for Hashimoto's thyroiditis.
TRAb includes Thyroid Stimulating Antibody (TSAb) and Thyroid Inhibitory Antibody (TSBAb).
The former is a specific antibody for Graves disease and the latter is one of the causes of hypothyroidism.
At present, most hospitals cannot distinguish between them, so TRAb is positive.
It is not necessarily Graves' disease.
The positive rate of thyroid autoantibodies can be seen in the following table: Table 2 The positive rate of thyroid autoantibodies is based on thyroid isotope scanning and TRAb, combined with the above data to consider the diagnosis of Hashimoto's hyperthyroidism.
Such patients are easily complicated by hypothyroidism, or hyperthyroidism and hypothyroidism alternately occur.
Q5: In this case, the thyroid ultrasound showed a sea of fire sign.
Is this a unique manifestation of Graves' disease? A5: In Graves disease, thyroid hormone synthesis and secretion are hyperactive, and T3 and T4 have the effect of promoting the proliferation, dilation and congestion of thyroid blood vessels.
The blood supply is increased, blood flow signals are abundant, and even "fire sign"; Hashimoto's thyroiditis can also be The color Doppler shows the "fire sea sign", and its mechanism is different from Graves' disease.
Hashimoto's thyroiditis is due to mild hypothyroidism and increased serum TSH.
TSH stimulates TSH receptors to increase the secretion of T3 and T4.
The latter can promote blood vessel proliferation and result in a rich blood supply.
However, when the peak systolic flow rate of the superior thyroid artery was measured, the flow rate in patients with Hashimoto's thyroiditis was lower than that in patients with Graves disease.
This patient's TSH decreased, which is considered to be caused by Graves' disease.
Q6: How to determine the next treatment plan? A6: Patients with Hashimoto's hyperthyroidism are the first choice to treat with antithyroid drugs.
Hashimoto's hyperthyroidism requires a small dose to start, such as methimazole (MMI) 5-10mg/d.
In addition, according to the relevant guidelines of the American Thyroid Association in 2017, the initial daily therapeutic dose of MMI is determined according to the level of FT4: FT4 is 1 to 1.
5 times the upper limit of normal, the initial dose of MMI is 5 to 10 mg/d; FT4 is 1.
5 to 2 times the upper limit of normal, The initial dose of MMI is 10-20 mg/d; FT4 is 2 to 3 times the upper limit of normal, and the initial dose of MMI is 30-40 mg/d.
This method of starting dose can be used as a general treatment for hyperthyroidism.
Patients were treated with MMI 10 mg/d, and thyroid function monitoring should be performed once every 3 to 4 weeks.
Follow-up results: TSH<0.
01μIU/ml (0.
38～4.
31), FT3 and FT4 were normal after 4 weeks, TSH<0.
01μIU/ml, FT3 was normal, FT4 decreased slightly after 7 weeks, MMI dose was adjusted to 5mg/d, The degree of goiter is lessened than before, and the follow-up is continuing now.
.
.
Swollen neck is one of the reasons why many patients with thyroid disease come to the endocrinology department.
The case we are going to talk about this time also came from this.
However, the actual situation may be more complicated than imagined.
Let's see it together! Case Express Medical History: A 46-year-old female patient was admitted to the hospital for "found neck swelling for 3 days".
He has no special medical history, and his elder sister and younger brother have a history of hyperthyroidism and are under treatment with anti-hyperthyroidism drugs.
Since the onset of the onset, there was no palpitation, shaking hands, fear of heat and sweating, weight loss, and stool 2 to 3 times a day a few days before the treatment, the texture was normal.
Physical examination: no exophthalmos, second degree thyroid enlargement, tough texture, no tenderness, no masses, vascular murmurs can be heard.
There is no abnormality in the lungs, the heart rate is 70 beats/min, the rhythm is uniform, the abdomen is not abnormal, and there is no edema in the lower extremities.
There was no tremor in his hands.
Preliminary examination: Thyroid-stimulating hormone (TSH) <0.
01μIU/ml (0.
38～4.
31), free triiodothyronine (FT3) 3.
65ng/dl (0.
78～1.
86), serum free thyroxine (FT4) is 9.
37pg /ml (1.
8～3.
8), thyroid peroxidase antibody (TPO-Ab)>1000IU/ml, anti-thyroglobulin antibody (TgAb)>2000IU/ml.
Thyroid ultrasound showed that the thyroid gland was diffusely enlarged, the parenchymal echo showed a network-like change, and the two leaves were scattered in multiple isoechoic and slightly hyperechoic clusters.
A narrow hypoechoic halo was seen around, the border was clear, the largest was 8.
1×6.
1mm, and the surrounding abnormal echo See the circular blood flow signal, and the remaining thyroid blood flow signal shows a fire sea sign. Q1: Based on the existing auxiliary examinations, what diagnosis should the patient consider? A1: The patient's TPO-Ab and TgAb were extremely high, and ultrasound showed diffuse thyroid enlargement, parenchymal echo showed network-like changes, and thyroid function suggested thyrotoxicosis, but the symptoms were mild.
Combined with medical history and physical signs, subacute thyroiditis, painless thyroiditis, TSH tumor, iatrogenic hyperthyroidism, etc.
can be excluded.
Hashimoto's thyrotoxicosis should be considered.
In addition, the diagnosis of thyroid nodules is established, and the possibility of inflammation is not excluded.
There is no malignant sign on ultrasound.
Follow-up observation is 6-12 months.
Q2: What is Hashimoto's thyrotoxicosis? How to diagnose? What diseases need to be differentiated from? A2: Hashimoto's thyrotoxicosis has a narrow sense and a broad sense-Hashimoto's thyrotoxicosis in a narrow sense refers to the destruction of follicles caused by Hashimoto's thyroiditis, and thyroid hormones are released into the blood.
Hashimoto's thyrotoxicosis in a broad sense also includes Hashimoto's thyroiditis combined with Graves' disease (ie Hashimoto's hyperthyroidism).
The clinical manifestations of Hashimoto's thyrotoxicosis and pure Graves' disease are similar, and the two need to be carefully differentiated! The identification methods are as follows: Table 1 Identification methods (click to view the larger image) Q3: Which type of Hashimoto's thyrotoxicosis is most likely to be the patient? What other checks need to be done? A3: The patient's symptoms of hyperthyroidism are mild, combined with thyroid signs (audible and vascular murmur) and ultrasound (thyroid blood flow signal shows the fire sea sign) may indicate the existence of Graves disease, consider Hashimoto's combined Graves disease, that is, Hashimoto's hyperthyroidism.
Thyroid-stimulating hormone receptor antibody (TRAb) and thyroid isotope scanning are also required.
If identification is difficult, thyroid puncture can also be performed to clarify the pathological type.
Auxiliary test report: TRAb>300IU/ml, thyroid isotope scan showed that thyroid iodine intake was irregularly concentrated and sparse, and the imaging density was uneven; in addition, the patient refused to undergo thyroid puncture.
Q4: It is often encountered in clinical practice that a patient is positive for TPO-Ab, TgAb and TRAb at the same time.
Can Hashimoto's thyroiditis be diagnosed with positive TPO-Ab and TgAb? Should Graves' disease be considered when TRAb is positive? A4: TPO-Ab, TgAb positive is not a diagnosis condition for Hashimoto's thyroiditis.
TRAb includes Thyroid Stimulating Antibody (TSAb) and Thyroid Inhibitory Antibody (TSBAb).
The former is a specific antibody for Graves disease and the latter is one of the causes of hypothyroidism.
At present, most hospitals cannot distinguish between them, so TRAb is positive.
It is not necessarily Graves' disease.
The positive rate of thyroid autoantibodies can be seen in the following table: Table 2 The positive rate of thyroid autoantibodies is based on thyroid isotope scanning and TRAb, combined with the above data to consider the diagnosis of Hashimoto's hyperthyroidism.
Such patients are easily complicated by hypothyroidism, or hyperthyroidism and hypothyroidism alternately occur.
Q5: In this case, the thyroid ultrasound showed a sea of fire sign.
Is this a unique manifestation of Graves' disease? A5: In Graves disease, thyroid hormone synthesis and secretion are hyperactive, and T3 and T4 have the effect of promoting the proliferation, dilation and congestion of thyroid blood vessels.
The blood supply is increased, blood flow signals are abundant, and even "fire sign"; Hashimoto's thyroiditis can also be The color Doppler shows the "fire sea sign", and its mechanism is different from Graves' disease.
Hashimoto's thyroiditis is due to mild hypothyroidism and increased serum TSH.
TSH stimulates TSH receptors to increase the secretion of T3 and T4.
The latter can promote blood vessel proliferation and result in a rich blood supply.
However, when the peak systolic flow rate of the superior thyroid artery was measured, the flow rate in patients with Hashimoto's thyroiditis was lower than that in patients with Graves disease.
This patient's TSH decreased, which is considered to be caused by Graves' disease.
Q6: How to determine the next treatment plan? A6: Patients with Hashimoto's hyperthyroidism are the first choice to treat with antithyroid drugs.
Hashimoto's hyperthyroidism requires a small dose to start, such as methimazole (MMI) 5-10mg/d.
In addition, according to the relevant guidelines of the American Thyroid Association in 2017, the initial daily therapeutic dose of MMI is determined according to the level of FT4: FT4 is 1 to 1.
5 times the upper limit of normal, the initial dose of MMI is 5 to 10 mg/d; FT4 is 1.
5 to 2 times the upper limit of normal, The initial dose of MMI is 10-20 mg/d; FT4 is 2 to 3 times the upper limit of normal, and the initial dose of MMI is 30-40 mg/d.
This method of starting dose can be used as a general treatment for hyperthyroidism.
Patients were treated with MMI 10 mg/d, and thyroid function monitoring should be performed once every 3 to 4 weeks.
Follow-up results: TSH<0.
01μIU/ml (0.
38～4.
31), FT3 and FT4 were normal after 4 weeks, TSH<0.
01μIU/ml, FT3 was normal, FT4 decreased slightly after 7 weeks, MMI dose was adjusted to 5mg/d, The degree of goiter is lessened than before, and the follow-up is continuing now.
