Edema in thyrotoxicosis

Medico-social examination with thyrotoxicosis

Medico-social examination with thyrotoxicosis

Thyrotoxicosis is a multi-systemic disease characterized by
Hyperthyroidism with diffuse goiter, ophthalmopathy and dermopathy (prstibialnaya
myxedema).

Epidemiology. Diffuse toxic goiter occurs in 0.2-0.5% of the population.
Mostly people of working age are ill, women are 5 times more likely
men.

Etiology and pathogenesis. In the development of the disease, great importance is attached to
genetic defect in the VI chromosome linked to the HLA system (B8, DR3,
DR4). Hereditary factor was noted in 60% of patients, mental trauma - in
80%. Up to 20% are cases of thyrotoxicosis after infectious diseases
(influenza, tonsillitis, less often tuberculosis). The disease is of an autoimmune nature:
antibodies are produced that stimulate receptors for thyroid-stimulating hormone
(TTG) on thyroid cells. There is an autonomous hyperthyroidism
gland and its hyperplasia. Excess of T3 and T4 (hyperthyroidism) is accompanied by
activation of catecholamine production and mitochondrial function, a violation of
processes of oxidative phosphorylation,excessive release of energy and hypermetabolism. Ophthalmopathy and pretybial myxedema are caused by the action of cytotoxic lymphocytes and cytotoxic antibodies tropic to the antigens of the eye muscles, retrobulbar and pretybial tissue.

Clinic. Patients complain of irritability, fatigue, a feeling of heat,
weight loss, muscle weakness, palpitation, increased appetite,
more frequent stools, pain and a feeling of sand in the eyes. There is fussiness,
anxiety, quick speech, tremor of outstretched fingers; food
lowered, moist and hot skin, moderate swelling (pretybial
myxedema), muscle tone is reduced. Eye symptoms: eye shine,
symptoms Gref, Koher, Delrymple, Mobius, exophthalmos, edema of the eyelids and their
pigmentation, impaired closure of the eyelids, injected sclera and conjunctiva,
limitation of mobility of eyeballs. Thyroid gland enlarged. Can
note functional systolic murmur over large vessels.
Tachycardia, heart rhythm disturbances (extrasystole, ciliated
arrhythmia), systolic murmur, heart failure. Often increased
liver.
The most severe complication is thyrotoxic crisis. The basis of his
lies a sharp increase in the content of T3 and T4. The reason is subtotal
strumectomy in a patient with persistent thyrotoxicosis, the outcome of a severe,
timely not diagnosed toxicosis, severe infections,
emotional stress, inadequate therapy. High hypermetabolism is revealed
and excess heat production against a background of a sharp increase in activity
catecholamines and acute adrenal insufficiency. Characteristic
hyperthermia (more than 39 ° C), urofusive sweat, marked tachycardia, often
tachysystolic form of atrial fibrillation, acute cardiac
insufficiency, progressive drop in arterial pressure, nausea,
vomiting, loose stool, tremendous tremor, restlessness, excitement, then
apathy, sopor, coma.

In assessing the violations of functions take into account:

The degree of enlargement of the thyroid gland (goiter).

1 tbsp. - when swallowing, an enlarged isthmus is probed, while examining the gland
not visible; II century. - easy to feel both lobes and isthmus, the gland is visible when
swallowing movements; III century. - The gland is clearly visible when viewed; IV century. -
pronounced goitre, gland changes the configuration of the neck; V tbsp. - goiter very large
sizes.

I degree - low severity of clinical symptoms, loss of initial mass
body up to 10%, tachycardia to 100 beats / min. ophthalmopathy 1 tbsp. gripper 131J
after 24 hours to 60%, increase in T4 and T3 in the blood to 30% -50% of the norm or
isolated increase in T3 at normal T4 concentration. Treatment always
effectively. The mild course of thyrotoxicosis causes a mild disorder
endocrine function, the functions of other systems are not violated.

II degree - distinct polyorganic symptoms, the loss of the original
body weight up to 20%, tachycardia up to 120 beats / min. arterial hypertension, CH
I-II FC art. (NYHA), ophthalmopathy I-II st. capture of 131J in 24 hours to 75%,
increased T3, T4 blood more than 50% of the norm. Treatment is often effective. Average
the degree of severity of thyrotoxicosis causes moderate dysfunction
endocrine, cardiovascular and central nervous systems, vision.

III degree - loss of initial body weight more than 20%, capture of 131J in 24 hours
more than 75%: an increase in the content of T3, T4 blood is several times higher than normal;
marked changes in the cardiovascular, nervous, muscular systems:
Cardiomyopathy, atrial fibrillation and CH III FK (NYHA); ophthalmopathy
II-III st .; severe encephalopathy, changes in the psyche, myopathy, paralysis;
toxic hepatitis, hepatic insufficiency. Treatment is often effective,
but there may be complications, violations of the functions of various organs and
systems.

I degree - a small exophthalmos (up to 16 mm), a minor edema of the eyelids, can
be positive eye symptoms, the function of the oculomotor muscles is not
is broken, there are no complaints.
II degree - moderate exophthalmos (up to 18 mm) with significant edema and
infiltration of eyelids, conjunctiva; signs of defeat of the muscular apparatus
eyeballs (moderate ophthalmoplegia); complaints about the feeling of "sand" in the
eyes and pressure on the eyeballs, unstable diplopia.
III degree - pronounced exophthalmos (23 mm or more), incomplete closure of the eyelids,
corneal ulcers, persistent diplopia, pain in the eyes, severe limitation
mobility of eyeballs, Moiyr to be signs of atrophy of the optic nerves,
decreased vision, secondary glaucoma.

Basic tests. Capture 131J of the thyroid gland (the norm of 5-21% for 2 hours 16-50%
for 24 hours); determination of the T3 content (norm 1.7-2.8 nmol / L), total
thyroxine-T4 (norm 62-141 nmol / l) and blood TSH (norm 4-10 mIU / l or 0.3-
5.0 ng / l).
Additional functional tests. Assay for inhibition of thyroid function
gland with T3: in healthy individuals there is a decrease in the capture of 131J
thyroid gland more than 50%, with thyrotoxicosis decreased capture 131J
absent. Trial for stimulation of thyroid function with thyroidiberin:
healthy persons the level of TSH increases more than 2 times in 10-40 minutes.
after the administration of thyroidiberin, with thyrotoxicosis increasing the level of TSH is not
occurs. Determine the basal metabolism, cholesterol, protein-bound iodine -
SBS (the norm is 4-8 μg%). Thyroid scans allow you to evaluate
sizes of goiter. Apply ultrasound with a targeted biopsy of suspicious areas and
subsequent histological examination of the biopsy specimen.

Treatment. Thyreostatic drugs - Mercazolil, an average of 30 mg / day,
thiouracil - 200-300 mg / day. (the effect is observed after 2-3 weeks from the beginning
treatment), b-adrenoblockers, lithium carbonate (used in the case of leukopenia
and atranulocytosis), inorganic iodine (Lugol's solution) for 2-3 weeks.
in preparation for surgery and thyrotoxic crisis.

Indication for surgical treatment. no remission after a long
treatment of thyrotoxicosis (1-1,5 years); large goiter causing constriction
surrounding organs; maintenance of euthyrosis with large doses of Mercazolil; the
children and adolescents in case of a large goiter.

Indication for treatment 131J. in patients over 30 with moderately expressed
goiter in the absence of remission (after removal of hyperthyroidism).

Principles of treatment of thyrotoxic crisis. reduction of release into the blood and
synthesis of T3 and T4 in (blockade with preparations of inorganic iodine), replenishment
loss of fluid and electrolytes, decreased activity of sympathoadrenal
system, elimination of acute adrenal insufficiency.

Treatment of ophthalmopathy. liquid limitation, elevated position during
sleep, wearing sunglasses, diuretics, methylcellulose in droplets; in heavy
cases of glucocorticoids, telegamma, gerapia.

Criteria of remission. Clinical: absence of hyperthyroidism during the year and
more after the abolition of antithyroid therapy, a decrease in the size of goiter,
decrease or disappearance of manifestations of ophthalmopathy. Laboratory:
normal seizure of 131J with thyroid gland, blood TSH content within
norms. The normal response at a test with thyroidiborin (an increase in TSH).
Suppression of the capture of 131J by the thyroid gland at a sample with T3 (less than 15%).

Current and forecast. Without treatment, the disease progresses to the point of development
thyrotoxic crisis, atrial fibrillation and heart failure, toxic damage
liver. With a timely start of treatment, the prognosis for patients with mild and
moderate, favorable, all changes are reversible. In severe conditions
organic changes are irreversible. A prediction is combined with ophthalmopathy, which
can progress with euthyroidism and lead to loss of vision.

Criteria VUT. Decompensation of euthyroidism, the occurrence of complications
(atrial fibrillation, heart failure, etc.), progression
ophthalmopathy, intolerance to drug therapy, surgical treatment
and treatment 131 J. In the treatment of Mercazolilum, the mean time to achieve euthyroidism
- 30 days with severe thyrotoxicosis up to 45 days. When treating 131J the timing
Inpatient treatment is 14 days. euthyroidism is achieved after 1.5-3
months. with recurrent goiter after 3-4 months. In surgical treatment
preoperative preparation is from 2 to 40 days. (heavy
thyrotoxicosis), postoperative hospital stay up to 7-25 days; at
thyrotoxic crisis VUT depends on its severity and lasts from 1.5 to 3 months.

Indications for referral to the ITU bureau. Severe forms of the disease;
impossibility of employment through the KEK without a reduction in qualifications or
reduction of workload; complications after radical treatment, including
paresis of larynx and pharynx, hypothyroidism, parathyroid insufficiency, relapse
diseases; endocrine ophthalmopathy 11-111 st. endocrine
Cardiomyopathy with heart rhythm disturbances (atrial fibrillation) and
heart failure; expressed changes in the psyche. Direction
is carried out after adequate therapy in a specialized
endocrinology department.

Required minimum of surveys when sent to the ITU bureau. Hormones
thyroid gland, TTG and antibodies to thyroglobulin, SBI, blood sugar,
cholesterol, triglycerides, total protein and fractions, capture assay, 31J and
scanning of the thyroid gland, consultations of a cardiologist, ophthalmologist,
neurologist, psychiatrist with the defeat of the relevant organs and systems.

Contraindicated types and working conditions.

With thyrotoxicosis of the first degree - heavy physical and mental labor with
significant neuropsychic stress, unfavorable
microclimatic and meteorological conditions, exposure to toxic
substances, vibration, work at a height, with a voltage of vision, night shifts,
frequent business trips.
At a thyrotoxicosis of II degree - average gravity physical and moderate
stress mental work, work with a prescribed pace, driving
profession, work, requiring fine coordination of movements, long
concentration or quick switching of attention, fixation of eyes, acceptance
decisions in the conditions of shortage of time.
With thyrotoxicosis III degree - patients are disabled in normal
production conditions.

I group of disability is defined by patients with extremely severe form
thyrotoxicosis in the presence of severe violations of endocrine and other
systems that reduce the ability to self-service and
movement of the III degree, which requires constant care and extraneous
assistance.

II group of disability is determined by patients with severe thyrotoxicosis
with pronounced and persistent violations of the functions of organs and systems; ineffective
treatment; complications of surgical treatment (parathyroid insufficiency,
uncompensated hypothyroidism); recurrent course of thyrotoxicosis, that
leads to a restriction of the ability to work in II-III degree,
ability to move and self-service II degree.

III group of disability is defined by patients with mild and moderate severity
thyrotoxicosis in the stage of compensation or subcompensation with moderate
violations of the functions of organs and systems, leading to a limitation of ability
to first-degree work, self-service and mobility 0-I
degree, working in contra-indicated types and conditions of the pile, needing
in rational employment, accompanied by a decrease in qualifications or
a decrease in the amount of work. Persons of young age group III disability
is established for the period of retraining, acquisition of an accessible profession
easy physical work or mental work with a moderate
neuropsychic stress.

Rehabilitation. Early diagnosis, clinical examination and timely
adequate thyreostatic therapy; if necessary, radical treatment
(surgical or radiation). Timely diagnosis and treatment of complications.
Rational employment and retraining of disabled people.