Hyperthyroidism in the elderly
Introduction
Introduction to hyperthyroidism in the elderly Hyperthyroidism, referred to as hyperthyroidism, is a group of common endocrine diseases caused by increased thyroid synthesis and secretion of thyroid hormones, which can occur at any age. The prevalence of hyperthyroidism in the elderly is about 0.4% to 2.3%, accounting for 10% to 15% of all hyperthyroidism patients, and women are higher than men. Older hyperthyroidism is significantly different from other age groups in many aspects such as the etiology and clinical manifestations. basic knowledge Sickness ratio: 0.0001% Susceptible people: the elderly Mode of infection: non-infectious Complications: Hyperthyroidism, angina pectoris, myocardial infarction, arrhythmia, congestive heart failure, atrioventricular block, A-s syndrome, diarrhea, coma, shock, dysphagia, myasthenia gravis, anemia, diabetes, elderly, rheumatoid arthritis, lupus erythematosus, dry syndrome Thrombocytopenic purpura
Cause
The cause of hyperthyroidism in the elderly
Genetic factors (25%):
Genetic factors: A group of 204 first-degree relatives of patients with Graves disease in eastern Guangdong found that the prevalence of first-degree relatives of hyperthyroidism patients was 3.23%, and the prevalence of hyperthyroidism in first-degree relatives of normal people in the region was only 0.145%. The difference is 22.3 times, the heritability is 68.6%±3.8%, close to high heritability, the genetic pattern tends to be polygenic, the other group is 600 cases of Graves hyperthyroidism, 200 cases of chronic lymphocytic thyroiditis, 52 cases of thyroid adenoma In 48 cases of papillary carcinoma and 800 control subjects, the first and second relatives of the family found that hyperthyroidism, chronic lymphocytic thyroiditis and thyroid tumors may be polygenic, and there is a risk of recurrence between the three diseases, but the nipple The prevalence of relatives of cancer was not significantly different from that of the control group.
Iodine induced (25%):
It is also an important cause of hyperthyroidism. It is safe for normal people to consume 100-200g of iodine every day. If the daily intake exceeds 200g or more, it may induce hyperthyroidism. Drugs commonly used in the elderly, such as amiodarone 200mg Organic iodine 75mg, free iodine 6mg, and easy to discharge after entering the body is easy to accumulate; organic iodine contrast agent 100ml containing about 30g of iodine, both greatly exceed the safe intake, the exact mechanism of iodine-induced hyperthyroidism is still unclear, may exist with these patients Thyroid dysfunction or potential hyperthyroidism (such as Plummer's disease, Graves' disease, etc.).
Environmental factors (25%):
Mental or work stress, disputes, anger, infection, surgery, trauma and other factors can induce or aggravate the disease, and more than 80% of patients can find the predisposing factors.
Cause
(1) Thyroid: including toxic diffuse goiter (Graves disease), toxic nodular goiter, toxic thyroid adenoma, iodothyroid, hyperthyroidism caused by subacute and chronic lymphatic thyroiditis.
(2) pituitary (rare).
(3) iatrogenic: hyperthyroidism caused by excessive intake of thyroid hormone.
Common hyperthyroidism in the elderly is toxic diffuse and toxic nodular goiter, and hyperthyroidism caused by chronic lymphatic thyroiditis.
2. Classification
According to different causes, hyperthyroidism can be divided into many types. The hyperthyroidism of the elderly can be mainly divided into the following types:
(1) Autoimmune hyperthyroidism:
1 toxic diffuse goiter (Graves disease) accounts for about 60% to 70% of hyperthyroidism.
2 chronic lymphocytic thyroiditis (Hashimoto thyroiditis, Hashimoto thyroiditis) with hyperthyroidism.
3 subacute painless lymphocytic thyroiditis with hyperthyroidism.
(2) Toxic nodular goiter:
1 toxic multinodular goiter (Plummer disease).
2 toxic single nodular goiter (toxic thyroid adenoma).
(3) Iodine-induced hyperthyroidism.
(4) Subacute non-suppurative thyroiditis with hyperthyroidism.
(5) Pituitary secretion of thyroid stimulating hormone (TSH) adenoma hyperthyroidism.
(6) Thyroid cancer causes hyperthyroidism.
(7) ectopic secretion of TSH hyperthyroidism: mostly caused by malignant tumor secretion of ectopic TSH.
(8) Hyperthyroidism caused by exogenous thyroid hormone.
Among the elderly, the most common is autoimmune thyroid disease caused by hyperthyroidism, followed by toxic nodular goiter, thyroid nodules in the elderly are very common, accompanied by hyperthyroidism is not necessarily a toxic nodular goiter Iodine-induced hyperthyroidism is also common in the elderly, and other types of hyperthyroidism are rare in the elderly.
Hyperthyroidism is the most common cause of autoimmune thyroid disease. Graves disease and Hashimoto's thyroiditis with hyperthyroidism are representative. There are many anti-thyroid antibodies in this patient, mainly TSH receptor antibody (TRAb), thyroid gland. Globulin antibody (TGAb), thyroid cell microsomal antibody (TMAb) or thyroid peroxidase antibody (TPOAb), TRAb is mainly produced by lymphocytes or plasma cells infiltrated in the thyroid gland, which can specifically bind to TSH receptor, TRAb There are at least two types of antibodies: thyroid stimulating antibody (TSAb) and thyroid stimulating blocking antibody (TSBAb). When TSAb binds to TSH receptor on thyroid cell membrane, the cell membrane adenosine cyclase is activated and cAMP mediated. Increased synthesis and secretion of thyroid hormone can also stimulate the proliferation of thyroid epithelial cells, leading to hyperthyroidism and thyroid enlargement. TSBAb acts in contrast to TSAb, which inhibits adenylyl cyclase activity and blocks cAMP release after binding to TSH receptor. Lead to thyroid atrophy and dysfunction, therefore, TSAb is the main cause of autoimmune hyperthyroidism, mainly in patients with Graves disease, TSAb, when TSAb dominates When the potential is reduced or disappeared, the hyperthyroidism tends to be relieved. Individual Graves patients also have TSBAb predominance at a certain stage, and hypothyroidism appears. TGAb and TMAb (TPOAb) are destructive autoimmunity. Sexual antibodies, which are associated with thyroid destruction and thyroid dysfunction, are mainly found in patients with Hashimoto's thyroiditis. Patients with Hashimoto's thyroiditis can develop hyperthyroidism due to the presence of TSAb, or thyroid tissue destroyed by TGAb and TMAb in a short period of time. More, a large amount of thyroid hormone released from the cells into the blood caused by transient hyperthyroidism, toxic nodular hyperthyroidism caused hyperthyroidism, mainly due to nodules secrete thyroid hormone (hot nodules), the exact cause is still unclear.
Hyperthyroidism caused by thyroid cancer is very rare, because in cancer cells, even if the papillary carcinoma or follicular carcinoma is better than normal, its function is mostly lower than normal, so it is generally expressed as "cool nodules" or "cold nodules", but If the amount of cancer tissue is large, such as thyroid cancer with systemic metastasis, the total amount of thyroid hormone secreted by cancer cells can also cause hyperthyroidism. A very small number of thyroid cancers can cause hyperthyroidism as "hot nodules".
Various thyroiditis causes hyperthyroidism, mainly due to the release of a large number of thyroid cells, the release of thyroid hormone into the blood, causing increased thyroid hormone and hyperthyroidism in the blood circulation. This hyperthyroidism is usually temporary, often accompanied by serum thyroglobulin ( TG) rises.
Prevention
Prevention of hyperthyroidism in the elderly
Primary prevention: prevention against causes and risk factors.
1 Strengthen health education, enhance people's self-care awareness, change bad lifestyles, eating habits, cultivate good psychological quality and maintain a good attitude.
2 Prevent viral and bacterial infections and remove the triggering factors for infections against autoimmune diseases.
3 Careful use of iodine to prevent functional goiter and use of iodine-containing drugs.
4 Take part in appropriate exercise and activities.
5 Suspected people with hyperthyroidism immediately checked for eight items and thyroid color ultrasound.
Secondary prevention: The subject is hyperthyroidism, the purpose is to prevent early complications, to control the condition through reasonable treatment, to avoid various aggravating factors, to prevent further arrhythmia, heart failure and hyperthyroidism.
Tertiary prevention: It is aimed at preventing the prevention of hyperthyroidism in patients with hyperthyroidism, preventing heart failure due to hyperthyroidism, severe arrhythmia, and preventing the deterioration of the hyperthyroid crisis from endangering the life of the patient.
1. Risk factors and interventions
(1) genetic susceptibility: such as Graves disease autoimmune disease, autoimmune defects are controlled by genetic genes, this disease has a very obvious family aggregation phenomenon, the homology of hyperthyroidism in identical twins is 50%, the disease occurs Associated with certain histocompatibility complex (MHC), such as HADR antigen or HCAB8, B46, etc., mental factors, such as trauma, anger is an important predisposing factor, can lead to decompensation of TS cell population, can also promote The production of cytotoxicity.
(2) Immune cross-reaction: Thyroid-specific genes include TSH receptor gene, peroxidase gene, thyroid non-specific genes including HLA gene, protein carrier gene, cytokine gene, receptor gene of TCR cells, and type 1 diabetes The similarity between genes, bacteria, viruses, and antigens of human proteins is common, and immunological cross-reactivity can occur. In recent years, it has been proposed that bacteria or viruses can initiate autoimmune thyroid disease through three possible mechanisms:
1 molecular mimicry, a similar molecular structure between the infectious agent and the TSH receptor in the epitope, causing the antibody to cross-react with its own TSH receptor, for example, in Yersinia's enterocolitica It has a TSH receptor-like substance, and in this patient, 72% contains a Yersin antibody.
2 Infectious factors directly act on thyroid and T lymphocytes, induce cytokines, induce MHC class II, HLA-DR is expressed in thyroid cells, and T lymphocytes are provided with autoantigens as immune response targets.
3 Infectious factors produce superantigen molecules that induce T lymphocytes to respond to their own tissues.
(3) excessive iodine supplementation and the use of iodine-containing drugs can cause hyperthyroidism: eg, iodine-containing contrast agents are still in clinical use, the elderly have arrhythmia, sometimes with anti-arrhythmia when heart failure must use amiodarone, China implements nationality Iodine in patients with Graves disease, the incidence rate has an increasing trend, iodine is not only a raw material for thyroid hormone synthesis, but also can enhance the antigenicity of thyroid tissue components, induce immune response on the basis of the original genetic susceptibility defects, This situation often occurs after iodine supplementation in iodine-deficient areas. According to foreign experience, after 3 to 5 years of iodine supplementation, the incidence of various autoimmune thyroid diseases has returned to the level before iodine supplementation, anti-thyroid drugs (ATD). Treatment, Graves disease also affects the efficacy of iodine intake, and the time required to control thyroid function to a normal state is prolonged. In addition, excessive iodine intake also reduces the long-term remission rate of AVG treatment of Graves disease, so even patients with Graves disease, even In the subclinical stage, that is, no hyperthyroidism, only the serum TSH level is reduced, and the patient should also limit the intake of iodine to reduce the onset and affect the therapeutic effect.
2. Community intervention
Actively mobilize all aspects of society to form a practical social medical service system that is most conducive to the health of the elderly. It provides health education services, preventive injections, regular medical examinations, medication guidance and psychology. Medical health guidance, timely detection of hyperthyroidism patients and standardized treatment and monitoring, taking preventive measures for susceptible populations.
In summary, avoiding trauma, preventing infection, rational use of iodine-containing drugs, and appropriate iodine supplementation are important in intervening in the occurrence of hyperthyroidism.
Complication
Complications of hyperthyroidism in the elderly Complications, hyperthyroidism, angina pectoris, myocardial infarction, arrhythmia, congestive heart failure, atrioventricular block, A-s syndrome, diarrhea, coma, shock, dysphagia, myasthenia gravis, anemia, diabetes, elderly, rheumatoid arthritis, lupus, dryness syndrome, idiopathic Thrombocytopenic purpura
1. Hyperthyroidism (A heart disease)
It is a common complication of hyperthyroidism. The domestic report accounts for 8.6% to 17.5% of hospitalized hyperthyroidism patients. The rate of hyperthyroidism combined with hyperthyroidism is higher in the elderly.
(1) The main mechanism of causing heart disease:
1 due to increased thyroid hormone, systemic hypermetabolism, increased tissue oxygen consumption, promote tachycardia, increased myocardial load, myocardial hypoxia, leading to angina, myocardial infarction.
2 high thyroid hormone activation activates the ATPase of myocardial cell membrane, which increases the sensitivity of myocardial -adrenergic receptor to catecholamine, increases myocardial excitability and contractility, and is prone to ectopic beat points, leading to arrhythmia.
3 due to the increase of sinus node and atrioventricular node function under the action of high thyroid hormone, combined with increased sensitivity of myocardial to catecholamines, increased heart rate and increased contractility, causing myocardial relaxation, systolic overload, leading to heart enlargement and heart failure, old age Due to factors such as coronary heart disease, the heart foundation is poor, and the incidence of nail disease is significantly increased.
(2) Diagnostic criteria for nail disease: The effect of hyperthyroidism on the heart is ubiquitous. For example, the electrocardiogram changes, but it cannot be considered as a heart disease. Therefore, it must be met to meet certain criteria before diagnosis. There is no unified diagnostic standard, and the principle is generally followed. for:
1 heart enlargement.
2 obvious arrhythmia (atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, conduction block and frequent premature contraction, etc.).
3 congestive heart failure.
4 angina pectoris, acute myocardial infarction.
5 After the control of hyperthyroidism, the heart damage is obviously improved or disappeared. In the case of the diagnosis of hyperthyroidism, one of the above conditions is consistent with any one of the 1 to 4 plus the fifth, and other causes of heart disease are excluded. The diagnosis of nail disease can be established. Atrial fibrillation (including paroxysmal or persistent) has the highest incidence, followed by heart enlargement and heart failure. Heart failure is more common in the elderly, with III degree atrioventricular block and even A-S syndrome. And sick sinus syndrome is also reported.
2. Hyperthyroidism
This disease is the most serious complication of hyperthyroidism, the mortality rate is as high as 60% to 80%, the elderly are particularly dangerous. Under the condition that the hyperthyroidism is not controlled, it is the most common inducement caused by stress stimulation, such as serious infection, trauma, surgery, etc. Factors, in the operation of hyperthyroidism when the hyperthyroidism is not fully controlled or in patients with severe hyperthyroidism, 131 iodine radiation therapy did not take the necessary measures, can also lead to hyperthyroidism crisis.
(1) Pathogenesis: The occurrence of hyperthyroidism may be caused by many factors: 1 release of a large amount of thyroxine into the blood circulation; 2 increase of free thyroxine in the blood; 3 abnormal reaction of the body to thyroid hormone; 4 increase of adrenergic activity ; 5 thyroid hormone clearance in the liver is reduced.
(2) Clinical features: Hyperthyroidism caused by diffuse and nodular goiter can cause crisis, typical clinical manifestations of high fever, sweating, tachycardia, frequent vomiting and diarrhea, paralysis, even coma, shock, electrolytes Unbalanced, and eventually died of respiratory and circulatory failure. Most patients have obvious goiter. Older patients may have only abnormal heart, especially arrhythmia or gastrointestinal symptoms, and more obvious causes of the disease.
(3) Treatment principles:
1 protect the body organs, prevent functional failure: fever, lighter, use a large amount of aspirin, because it can increase the patient's metabolic rate, but also compete with thyroid hormone thyroid binding protein to increase free hormones, high fever When active physical cooling, if necessary, artificial hibernation, due to significant increase in metabolism, should give oxygen, due to high fever, vomiting and a lot of sweating, need to add water, correct electrolyte imbalance, add sugar and vitamins, apply corticosteroid treatment.
2 reduce circulating thyroid hormone levels: oral or gastric tube nasal feeding large doses of thiourea antithyroid drugs (propyl thiouracil 600 ~ 1000mg / d or methimazole 60 ~ 100mg / d), can be quickly (within 1h) Prevent the organic binding of iodide in the thyroid gland, and then maintain the amount. After using the thiourea drug for 1 hour, start the iodine (30 drops of the compound iodine solution, or the compound iodine solution 3~4ml/d). The production of additional thyroid hormone produced by the iodine used is completely inhibited.
3 reduce the surrounding tissue response to thyroid hormone: anti-sympathetic drugs can reduce the effect of surrounding tissue on catecholamines, commonly used propranolol (orally every 6h, 40 ~ 80mg per day; or intravenous injection of 1 ~ 5mg), reserpine and and so on.
4 Control incentives: actively deal with the causes of various diseases that cause crisis, including the use of antibiotics to treat infections.
(4) Prognosis:
The first 3 days after the start of treatment is the key moment for rescue. If the treatment is successful, the patient will improve within 1 to 2 days after treatment, and recover within 1 week. After the crisis is restored, the iodine and corticosteroids can be gradually reduced.
2. Chronic thyroid hyperthyroidism
(1) Diagnosis: Chronic hyperthyroidism is a neurosis of the hyperthyroidism, a complication of muscles. The diagnosis is based on: 1 clinical diagnosis of hyperthyroidism with or without chronic muscle weakness and muscle atrophy, 2 muscles The electrical diagram shows that the time limit of the exercise unit is shortened to highlight the characteristic myopathy type change, and the 3 muscle tissue lesions are mainly caused by myogenic damage, and 4 other neuromuscular lesions are caused by other causes.
(2) Clinical features: Most patients with onset of symptoms of thyroid hormones, a few with muscle weakness of the limbs as the first symptom, or thyroid hormone increased performance and muscle loss occur simultaneously, most of the muscle weakness appears in the upper limbs and / or The proximal end of the lower extremity may have difficulty swallowing.
(3) treatment and prognosis: treatment with anti-thyroid drugs, after the control of hyperthyroidism, the myopathy will be gradually cured, and the treatment of hyperthyroidism for 3 to 5 months, myopathy can completely return to normal.
3. Other
Hyperthyroidism has a variety of immune diseases such as myasthenia gravis, pernicious anemia, diabetes, rheumatoid arthritis, glomerulonephritis, lupus erythematosus, Sjogren's syndrome, idiopathic thrombocytopenic purpura, crust, etc. It is rare in clinical practice.
Symptom
Symptoms of hyperthyroidism in the elderly Common symptoms Rage, weight loss, ocular hallucinations, blockade, fatigue, nausea, abdominal pain, diarrhea, weakness
The clinical manifestations of hyperthyroidism mainly include T3, T4 hypersecretion group, goiter and eye signs, but in the elderly, the clinical manifestations of hyperthyroidism are not typical, often treated with a special performance, easily misdiagnosed.
1.T3, T4 secretory syndrome
(1) High-metabolic syndrome group: Due to excessive secretion of T3 and T4, the three major nutrients of sugar, fat and protein are hypermetabolized, oxidation is accelerated, heat production and heat dissipation are significantly increased, so that patients often complain of heat and sweat, and the skin is moist. It is obvious in the palms of the hands, the back, the neck, the chest and the underarms. It can have low heat and high fever in crisis. Due to more energy consumption, protein catabolism accelerates to cause negative nitrogen balance, resulting in excessive consumption of muscles and other tissues. The weight loss is weak, the patient often complains of fatigue and weight loss, and about 80% of the elderly patients with hyperthyroidism can see weight loss, which is a more important clue to the elderly hyperthyroidism.
(2) Mental nervous system: T3, T4 acts on the nervous system and often makes patients nervous, prone to excitement, irritability, hyperactivity, sometimes lack of concentration, sometimes hallucinations, delusions, paranoia, and even suicide. Thoughts and violent episodes, etc., are easily misdiagnosed as mental illnesses. These conditions are common in younger hyperthyroidism patients, and the elderly account for only 25%. Sometimes elderly people with hyperthyroidism are stupid, lethargic, depressed and indifferent, and appear to be aging. Even the cachexia, this condition is called "apathetic hyperthyroidism", often only a certain symptom is outstanding, may be due to long-term hyperthyroidism has not been diagnosed and treated, leading to extreme failure of various organs of the body, and easy to induce crisis, should be Be alert, such as the eyelids are slightly closed, the tongue is extended, the hands are stretched forward and there is a slight rhythmic tremor, sometimes the whole body vibrates; the tendon reflexes are active or hyperactive, and the reflection time is shortened.
(3) Cardiovascular system: Due to hypermetabolism, thyroid hormone acts directly on the myocardium and peripheral vascular system, sympathetic activity is enhanced, catecholamines are released, and thyroid hormone can enhance myocardial sensitivity to catecholamines, so that heart rate increases, myocardial Increased contraction force, increased stroke volume, resulting in increased systolic blood pressure, combined with hyperthyroidism, vascular dilatation, peripheral resistance decreased, so that systolic blood pressure increased, diastolic blood pressure is slightly lower, resulting in increased pulse pressure difference, blood circulation is also increased, can be aggravated for a long time The burden of the heart, the patient complained of palpitations, chest tightness, shortness of breath, increased after the activity, severe cases can lead to hyperthyroidism, but the diagnosis must exclude rheumatic heart disease, coronary heart disease and high heart disease, etc., common signs are as follows: 1 tachycardia, Mostly sinus, usually 90 ~ 120 times / min, rest and general sedatives are difficult to relieve, is one of the characteristics of this disease, but about 40% of elderly patients with hyperthyroidism heart rate <100 times / min; 2 arrhythmia, by Early pulsation is the most common, atrial, ventricular and borderline can occur, especially in pre-atrial contractions, sometimes paroxysmal or persistent atrial fibrillation and room Occasionally, atrioventricular block, in elderly patients, atrial fibrillation and conduction block are relatively common, some scholars suggest that the possibility of a new type of atrial fibrillation should be considered to exclude hyperthyroidism; 3 heart sounds and murmurs, due to increased cardiac contraction First heart sound hyperthyroidism, mitral valve area often has I ~ II systolic murmur, diastolic murmur is rare; 4 cardiac hypertrophy, enlargement or even failure, often right ventricular congestive heart failure, more common in the elderly The above cardiovascular performance is generally improved or completely disappeared after hyperthyroidism control.
(4) Digestive system: excessive appetite, but significantly reduced body weight, is one of the characteristics of this disease, but in elderly patients, less than 1/4 of the appetite, and 1/3 to 1/2 of the patients anorexia, May be associated with other gastrointestinal symptoms, such as abdominal pain, nausea and refractory vomiting; hyperthyroidism often accompanied by diarrhea, but in the elderly may also have constipation, the liver may be slightly enlarged, liver function damage may have elevated alanine aminotransferase, liter The high amplitude is not large, and it can be recovered after the control of hyperthyroidism. A few may have jaundice, but severe jaundice is rare.
(5) Musculoskeletal system: due to excessive thyroxine acting on muscles, promoting the decomposition of creatine and phosphocreatine, inhibiting phosphocreatine kinase activity, mitochondrial energy metabolism disorder, and muscle uptake of creatine; skeletal muscle, myocardial And biochemical changes such as extraocular muscles gradually progress to pathological changes, because the proximal muscles contain rich mitochondria, so the most muscular disease first involves the proximal muscles, such as the scapular and pelvic muscles, mostly limited to the trunk and Limb muscles, symmetric distribution, scapular and pelvic belt muscles can appear symmetric atrophy, clinical manifestations of acute and chronic myopathy, patients complained of weakness, difficulty in action, especially on the floor, erect standing and continuous combing, , more common in Young and middle-aged males, but the elderly also occasionally have periodic paralysis as the primary manifestation. Sometimes hyperthyroidism is also associated with myasthenia gravis. In addition, excessive thyroxine can accelerate bone resorption and osteogenesis, but osteolytic bone resorption activities. More active, intracellular calcium and magnesium rate turnover, urinary calcium excretion increased, intestinal calcium absorption decreased, combined with systemic hyperthyroidism, bones Insufficient white matter matrix, resulting in osteoporosis, especially in older women who have been menopausal, osteoporosis can be more obvious, increasing the risk of fracture, very few pathological fractures, especially cone compression fractures Or femoral neck fracture, blood calcium is more normal, but free calcium can be increased, serum alkaline alkaline phosphatase activity is increased, urinary hydroxyproline, pyridinol and deoxypyridinoline excretion increased, bone density decreased.
(6) Blood system: Most patients with hyperthyroidism have red blood cell count, normal size and shape, normal hemoglobin concentration; neutrophils often decrease, so the total number of peripheral white blood cells is reduced, sometimes less than 3.0×109/L, but lymphocytes are absolutely Values and percentages and monocytes increase; platelet life is shortened and skin is prone to purpura.
2. Goiter
Goiter is one of the main clinical manifestations of patients with hyperthyroidism, but many elderly patients often have no obvious goiter. For Graves' disease, the goiter is generally diffusely enlarged, bilaterally symmetrical, and the isthmus is enlarged, moving up and down with swallowing. , soft, long-term patients are more tough, the left and right leaves can sometimes touch the tremor and listen to vascular murmurs, especially above, suggesting that blood supply is rich, one of the characteristics of this disease, occasionally swollen thyroid is located in the sternum In the posterior mediastinum, radionuclide or X-ray imaging is required to find out that the goiter can be clinically simply divided into three degrees: I degree, the thyroid enlargement is not obvious, and only the diameter can be reached. Within 3cm; II degree, palpation or visual inspection can be seen when swallowing, but the swelling does not exceed the sternocleidomastoid muscle; III degree, the thyroid is significantly enlarged, exceeding the sternocleidomastoid muscle, but the degree of goiter is generally There is no obvious relationship between the severity of hyperthyroidism.
3. Eye sign
Including benign exophthalmos and infiltrative exophthalmos, benign exophthalmos often asymptomatic, only eye signs: 1 eye crack widening, gaze, gaze, general eyesight <18mm; 2 upper eyelid retraction () contraction, When the eyeball is looking down, the upper eyelid cannot be rotated; when the eyeball is looking up, the forehead skin cannot be wrinkled; 4 when the near object is seen, the two eyes are cohesive, and most of the above eye diseases are caused by excessive adrenaline stimulation. After thyrotoxicosis is effectively controlled, the eye syndrome often recovers on its own and the prognosis is good.
Infiltrative exophthalmos often have symptoms, patients often complain of light, double vision, vision loss, foreign body sensation, pain, tingling, tearing, eye movement reduced, even fixed, general eyesight > 19mm, sometimes up to 30mm Left and right, the eyesight of the two eyes can be different, there may be one side of the eye, due to the high eye, the eyelids can not be closed, the conjunctiva and cornea are often exposed, especially when sleeping, susceptible to external stimuli, causing congestion, edema, and then infection, conjunctiva often Eversion bulging of varying degrees of conjunctivitis with exudation, keratitis also occurs, can form corneal ulcers and total ocular inflammation, resulting in blindness, infiltrative exophthalmos mainly due to connective tissue edema, hyperplasia, cell and fat infiltration In addition, extraocular muscle lymphocyte infiltration, edema, muscle fiber rupture and necrosis or paralysis are unique to Graves' disease. About 5% of patients with hyperthyroidism may appear before the onset of hyperthyroidism, or may be delayed until 15 to 15 after onset of hyperthyroidism. 20 years later, and its deterioration or improvement is often not affected by the clinical course of hyperthyroidism. The degree of exophthalmos is not significantly related to the condition of hyperthyroidism. About 5% of the cases may have no hyperthyroidism. Euthyroid exophthalmos or Graves' disease, the exact pathogenesis is not clear, it is generally believed that is the result of the combined effects of humoral and cellular immunity.
Examine
Examination of hyperthyroidism in the elderly
1. General inspection
(1) Blood routine: The total number of white blood cells is reduced, the absolute value and percentage of lymphocytes are increased, and hemoglobin is mostly normal.
(2) blood sugar: thyroxine on the one hand increases the utilization of glucose in surrounding tissues, and at the same time promotes the decomposition of glycogen and accelerates the absorption of glucose in the intestine. The fasting blood glucose is normal, and the peak blood glucose is increased after a meal or oral glucose tolerance test. Diabetes-like, plasma insulin also increased, but there is no obvious delay in insulin secretion. The change of glucose metabolism caused by hyperthyroidism itself returns to normal after the control of hyperthyroidism. For example, after the original diabetic hyperthyroidism, diabetes can be aggravated.
(3) Blood lipids: The synthesis and decomposition of cholesterol and triacylglycerol are enhanced when hyperthyroidism, but the decomposition is more than synthesis, so blood cholesterol is often low, triacylglycerol can also be slightly lower, and free fatty acids and glycerol are elevated.
(4) Others: liver function tests may have elevated transaminase and alkaline phosphatase, a small number of patients with increased bilirubin; blood calcium, especially free calcium, increased trend, serum bone alkaline phosphatase isoenzyme activity and bone calcium The level of hormone increased, the excretion of urinary calcium and phosphorus and fecal calcium and phosphorus increased, and the excretion of urinary hydroxyproline, pyridinol and deoxypyridinoline increased.
2. Thyroid function test
(1) Determination of basal metabolic rate: The basal metabolic rate refers to the amount of heat generated per square meter of body surface area per hour after the human body is fasted for 14 to 16 hours, and the absolute resting position and ambient temperature are between 16 and 20 °C. The range is -10% to 15%, and about 95% of patients with hyperthyroidism are higher than normal. The degree of increase is consistent with the severity of the disease. Clinically, 15% to 30% is light, 30% to 60% is medium, and >60% is heavy. However, there are many factors influencing the determination of basal metabolic rate. For the diagnosis and evaluation of curative effect, other influencing factors such as pregnancy, fever, cardiopulmonary insufficiency, anemia and malignant tumor should be excluded. The following formula is commonly used in clinical practice: the method is fasted for 12 hours. After 8 hours of sleep, the pulse rate and blood pressure were measured in the morning when lying still, and then calculated by the formula.
Basal metabolic rate (%) = (pulse rate pulse pressure difference) - 111
Basal metabolic rate (%) = 0.75 × [pulse rate (0.74 × pulse pressure difference)] - 72
(2) Determination of serum total thyroxine (TT4): It is the most commonly used screening test for thyroid function. It can be determined by competitive protein binding assay and radioimmunoassay (RIA). The former method is simple, no need to prepare antibodies, the normal value is 412g/dl, but its specificity is inferior to that of RIA. The normal value of RIA is 7.6±1.3g/dl. The determination of TT4 is not affected by iodine in food and medicine, but it is affected by serum thyroxine binding protein (TBG). The effect is increased or decreased with the increase or decrease of TBG. TBG is increased by estrogen, pregnancy, viral hepatitis and other factors, and is affected by androgen, severe liver disease, hypoproteinemia and prednisone. In addition, TT4 can cause high TT4emia in many acute and chronic diseases due to the reduction of T4 in peripheral tissues to T3, but at this time thyroid function is normal, such as systemic infectious diseases, myocardial infarction, severe liver and kidney dysfunction and malignancy. Tumors, etc., should pay attention to the analysis of TT4, TT4 elevation can not be used as a positive diagnosis of hyperthyroidism.
(3) Serum total triiodothyronine (TT3): measured by RIA, also affected by TBG, the normal value is 100 ~ 150g / dl, early in the early stage of hyperthyroidism often T4 increased earlier and faster, the effect after treatment Observation and recurrence are more sensitive than T4 and are meaningful for the diagnosis of T4 hyperthyroidism. Therefore, T3 determination may be the preferred screening method for hyperthyroidism. In elderly people with normal thyroid function, T3 values are generally normal or decreased, so T3 is very high. May be hyperthyroidism.
(4) Determination of anti-T3: T4 is converted into active T3 in the periphery, and also occludes iodine through the inner ring to form 3,3',5'-triiodothyronine ( rT3), 95%-98% of serum rT3 is from T4, 2%5% is secreted by thyroid, normal value is 0.56~0.92nmol/L (radioimmunoassay), serum rT3 is significantly increased when hyperthyroidism, its level is T3, T4 is parallel, but in severe stress and chronic disease, rT3 is also often increased, so the increase in rT3 cannot be used as a diagnostic criterion for hyperthyroidism.
(5) Determination of serum free T4 (FT4) and free T3 (FT3): Most of the thyroxine in the blood is in a non-free state combined with TBG-based serum protein, and the free thyroxine content is very small, FT4 only accounts for 0.03% of T4, FT3 only accounts for 0.3% of total T3. The determination of free thyroxine is not affected by TBG, and represents the hormone level in tissues. It is the most sensitive and most valuable indicator of thyroid function. It can be determined by RIA. The normal value of FT4 is generally 10 ~ 25pmol / L, the patient with hyperthyroidism is significantly increased; the normal FT3 is 2.2 ~ 6.8 plmol / L, regardless of the light, typical or atypical cases, the diagnostic coincidence rate is higher than TT3 and TT4, the diagnosis of hyperthyroidism The compliance rate is as high as 100%.
(6) Thyroid stimulating hormone (TSH) measurement: serum TSH normal range is 0.3 ~ 5.0mU / L, when hyperthyroidism, feedback inhibition of TSH release, general RIA (normal value 0 ~ 10U / ml) often can not be hyperthyroidism patients and normal Human TSH is distinguished. Recently, TSH-IMA was used to determine TSH. It was found that hyperthyroidism and even subclinical hyperthyroidism decreased TSH. It is the most sensitive indicator for the diagnosis of hyperthyroidism and has a replacement for thyroid stimulating hormone releasing hormone. (TRH) The role of the excitatory test, the increase in TSH can generally exclude the diagnosis of hyperthyroidism, such as hyperthyroidism with increased TSH, only rare in pituitary TSH tumors or pituitary is selectively insensitive to T3 or T4.
(7) TRH stimulation test: intravenous injection of artificially synthesized TRH 200 ~ 500g, under normal conditions, TSH rapidly increased 5 ~ 25U / ml, peaked at 30min, returned to normal at 120min, elevated FT3 and FT4 on pituitary TSH cells There is inhibition, so TSH is not excited by TRH. After TSH stimulation, TSH is not seen in subclinical hyperthyroidism, thyroid function is normal, and pituitary disease is associated with insufficient secretion of TSH. It should be noted during diagnosis. TSH, no need to introduce nuclides into the body, small side effects, simple operation, only 1 ~ 2h, is safer for elderly patients with coronary heart disease, basically replace the T3 inhibition test, but in recent years with the application of TSH-IMA method, TRH excited The trial also has a tendency to be replaced.
(8) Anti-thyroid autoantibodies: A variety of autoantibodies against the thyroid, such as TSH receptor antibodies (TRAb), anti-thyroglobulin and anti-peroxidase antibodies, and second glial antibodies, can be measured in patients with Graves disease. Among them, TRAb positive has not only diagnostic value for Graves (80%-95% positive) disease, but also facilitates follow-up efficacy and judges recurrence after treatment. For example, the end of anti-thyroid drug treatment, TRAb negative, predicts long-term remission of the disease, and vice versa. TRAb is persistently positive and may recur after discontinuation; high titer anti-peroxidase antibodies suggest Hashimoto's thyroiditis.
3. Thyroid nuclides imaging
Including thyroid iodine measurement and thyroid scan, if you want to understand thyroid function, radionuclide should not be the first choice for in vivo examination, but other in vitro tests should be performed first, and thyroid iodine absorption rate should be used to diagnose hyperthyroidism. To understand the thyroid function in addition to morphological information (such as to diagnose thyroid nodules or other new biological diseases), thyroid scans must be performed to identify Graves disease and multiple nodules or single toxic adenomas, etc. The nuclides are 131I, 125I, 123I and 99Tc (TcO4 perrhenate ion), of which 99 Tc has low radiation, is not organicized by thyroid, and can be scanned for 30 minutes after intravenous injection, without being affected by antithyroid drugs. Can understand the blood supply of the thyroid, has certain advantages, but 99Tc is not suitable for scanning the posterior sternum or mediastinal goiter.
4. Thyroid ultrasound examination
Can understand the size of the thyroid, the space is cystic or solid, for clinically difficult to detect small nodules, ultrasound is sensitive, in addition to color Doppler ultrasound can still measure the blood flow of the thyroid.
5. Thyroid biopsy
When hyperthyroidism patients need to determine the nature of thyroid nodules, or to identify Graves disease or Hashimoto's thyroiditis, this test can be considered, the majority of the domestic use of fine needle aspiration biopsy (FNAB), the diagnostic accuracy of up to 90% Above, the specificity is high, the operation is simple, safe, and the patient is easy to accept, but it is affected by the level of the author and the experience of observing the cells.
Diagnosis
Diagnosis and diagnosis of hyperthyroidism in the elderly
Diagnostic criteria
Adult hyperthyroidism is typical of clinical manifestations, combined with the results of experimental examination is easy to diagnose, while old hyperthyroidism is no, in the elderly, thyroid secretion is reduced, when hyperthyroidism, although thyroid hormone secretion increased, but may be due to blood thyroid hormone binding Decreased, the tissue's ability to respond to this hormone is weakened and accompanied by other aging changes, leading to the clinical manifestations of elderly hyperthyroidism are more likely to be misdiagnosed, missed diagnosis or delayed diagnosis, but its efficacy is better than adult hyperthyroidism, in order to improve the level of diagnosis and treatment, Not only should you be familiar with the clinical manifestations of general hyperthyroidism, but you must also be familiar with the special manifestations of senile hyperthyroidism. There are many diseases that cause hyperthyroidism in the elderly (Table 1). Because of their different etiology and clinical manifestations, the treatment methods are different. Must be accurately identified.
Geriatric toxic diffuse goiter: toxic diffuse goiter, also known as Graves disease (referred to as GD), is an organ-specific autoimmune disease with increased secretion of thyroid hormone (TH), in addition to goiter and hypermetabolic syndrome There are still exophthalmia and less common sputum mucinous edema or thick fingertips. These manifestations may appear in combination or alone, such as hyperthyroidism without exophthalmos, or severe exophthalmos but lack of hyperthyroidism.
Differential diagnosis
1. Graves disease hyperthyroidism
This disease is the most common type of hyperthyroidism. The thyroid gland is diffusely swollen and has a uniform texture. It is soft or moderate. If it is treated with iodine or excessive iodine intake, it can be hard. If it is accompanied by invented eyes, especially invasive. Exophthalmos, or sacral mucinous edema, is a characteristic evidence of Graves' disease. Nodular goiter is more common in the elderly. It is not easy to identify with Graw's disease when it is associated with Graves disease. It is proved by detecting autoimmune antibodies. The presence of antibodies such as TRAb is conducive to the diagnosis of Graves' disease. The radionuclide scan shows cold nodules or cold nodules, and the thyroid tissue outside the nodules shows uniform radioactivity distribution, which is conducive to the diagnosis of Graves' disease.
2. Hashimoto's thyroiditis with hyperthyroidism
The disease is also a common type of hyperthyroidism in the elderly. The clinical features are thyroid enlargement, tough or hard, uneven surface or nodular shape. The palpation of the nodule is unclear. The thyroid scan shows a radioactive distribution. In the cluster and irregular sparse areas, the autoimmune antibody TGAb, TMAb positive, fine needle aspiration biopsy showed a large number of lymphocytes and pleomorphic glandular epithelial cells, which can help to confirm the diagnosis.
3. Toxic thyroid tumor and Plummer disease
The presence of thyroid nodules is an important feature of this disease, but nodules are not necessarily the disease. The key is to prove the ability to secrete thyroid hormones by themselves, through nuclear scanning, if necessary, with T3 (thyroid tablets) inhibition test to prove Its autonomy of secretion, if the radionuclide scan shows "hot nodules", and the surrounding thyroid tissue function is inhibited, is a characteristic manifestation of this disease; if multiple small nodules, it shows that the radioactive distribution of thyroid tissue is uneven, The spots are increased and are not inhibited by exogenous T3 or thyroid hormone, and autoimmune antibodies are negative.
4. Iodine-induced hyperthyroidism
The patient has a history of excessive iodine intake (amiodarone, iodine contrast agent, etc.), generally small or mild thyroid, hard, no vascular murmur; hyperthyroidism is mild, no exophthalmia; autoimmune antibody detection Negative; thyroid hormone determination is often based on the increase of TT4, FT4, after stopping iodine intake, with the reduction of iodine in the body, hyperthyroidism can be gradually relieved.
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