CRAW DIFFUSION TOXIC

From Big Medical Encyclopedia

CRAW DIFFUSION TOXIC (synonym: bazedova disease, ekzoftalmichesky craw) — the disease with a characteristic clinical picture, to-rogo is the cornerstone diffusion increase and the hyperfunction of a thyroid gland causing disbolism and development of pathological changes in various bodies and systems. The term «craw diffusion toxic» is entered into a wedge, classification of diseases of a thyroid gland of the International congress of the socialist countries by a problem of a local craw (1961). Sometimes the applied term «thyrotoxicosis» defining a condition of toxic defeat of fabrics and bodies at various diseases is unacceptable for nomenclature designation of a specific disease. The term «ekzoftalmichesky craw» is unsuccessful since an exophthalmos — a non-constant symptom of a disease.

The first a wedge, the observation made by Parri (S. N. of Parry) in 1786, is published in 1825; G. Flajani in 1802 and R. J. Graves in 1835 described patients with tachycardia and an exophthalmos. In 1840 it is mute. the doctor from Merzeburga K. Bazedov provided the accurate description of 4 patients with three constant symptoms («a merzeburgsky triad»): craw (see), exophthalmos (see) and tachycardia (see). In 1886 P. J. Mobius for the first time pointed to a pathogenetic role of a thyroid gland in development of a disease. Surgical treatment — a resection of a thyroid gland, successfully applied by Tiyo (P. J. Tillaux, 1880), was widely carried out by T. Kokher (1907) and other surgeons. Results of operational treatment are considerably improved by Plummer (H. S. Plummer, 1923) who administered the drugs of iodine in preoperative preparation. The first strumectomy concerning 3. of t. in Russia it is manufactured in 1893 by I. D. Sarychev; in 1929 operation was considerably modified by A. V. Martynov. In the USSR the technique of a subtotal subfascial resection of a thyroid gland developed by O. V. Nikolaev (1952) is eurysynusic. In 1942 two groups of researchers: Hertts, Roberts, Evans (S. Hertz, A. Roberts, Pi. D. Evans, 1942) and Hamilton, Laurence (J. G. Hamilton, J. H. Lawrence, 1942) at the same time for the first time applied therapy by a radioiodine — «radio iodresection» of a thyroid gland. In 1943 the effective method of conservative treatment was offered by thyreostatic drugs [Astvud (E. Century of Astwood) with sotr.]. In the USSR questions of an etiology, pathogeny, clinic and treatment 3. of t. were successfully studied by V. D. Shervinsky (1926), N. A. Shereshevsky (1962), B. V. Petrovsky (1961), V. G. Baranov (1966), etc.

3. of t. — one of widespread endocrine diseases; according to Trotter (W. R. Trotter, 1962), incidence 3. of t. makes 0,19% among women, 0,03% among men. The disease develops at any age, but is the most frequent in 30 — 50 years. In all age groups of the woman are ill more often than men.

The etiology

the Aetiology is definitely not established. Believe that development of a disease is preceded by the compensated disturbances of activity of a thyroid gland (genetic, autoimmune or inflammatory genesis). Adverse factors (mental injuries, respiratory infections, an aggravation hron, tonsillitis, overheating in the sun) can cause activation of activity of a thyroid gland and development of a disease in such persons. According to N. A. Shereshevsky (1957), mental injuries in the anamnesis are established at 80% of patients, infectious diseases — at 10%.

V. G. Baranov (1966) specifies that to development 3. of t. the special form of neurosis — the neurocirculatory dystonia considered by it as a prestage 3 precedes. of t. Also adverse heredity — transfer of a disease on recessive type matters.

Pathogeny

Leading role of hyperproduction of iodinated thyroid hormones in development 3. of t. it is confirmed as creation of pilot models with introduction animal high doses of thyroid hormones, and elimination of the majority of its symptoms after the corresponding surgical or conservative treatment. Mechanisms of resistant hyperfunction of a thyroid gland are not clear. Experimental and the wedge, attempts to connect strengthening of an intratireoidny hormonogenesis and products of hormones with thyritropic activation of gipotalamogipofizarny system did not yield accurate results. In 1958 D. D. Adams revealed in blood of patients 3. of t. a stimulator of activity of a thyroid gland — «it is long the operating thyroid stimulator» (long acting thyreoid stimulator — LATS) different from thyritropic hormone of a hypophysis duration of effect. Its maximum action during the testing on mice and Guinea pigs is determined by increase in a radioiodine in blood in 7 — 16 hours whereas thyritropic hormone renders the same effect in 1,5 — 3 hours. LATS has specific properties of immunoglobulin and interacts with tissue of a thyroid gland; assume that it is an antibody and is developed by lymphocytes. Existence of LATS in blood of most of patients 3. of t. in the absence of increase in level of thyritropic hormone formed the basis for creation of the theory of an autoimmune pathogeny of a disease. According to this theory, hyperfunction of a thyroid gland is connected with influence of an antibody — LATS (or a LATS protector) on hypothetical thyroid antigen, a so-called depressor of function of a thyroid gland. However V. G. Baranov and B. V. Potin (1977) consider tireostimuliruyushchy substrate of blood of patients 3. of t. as a special transport form of the thyritropic hormone which is in a complex with carrier protein. An essential role in a pathogeny 3. of t. plays dysfunction of sympaticoadrenal system.

Main symptomatology 3. of t. is defined by the thyrocardiac damage to an organism caused as excess products thyroxine (see) and triiodothyronine (see), and, perhaps, sensitization to them peripheral fabrics. Thyrotoxicosis (see) it is characterized by continuous strengthening of dissimilyatorny processes. Forcing of oxidizing processes leads to increase in oxygen consumption, dissociation of oxidizing phosphorylation and reduction of accumulation of energy (formation of makroerg). The disturbance of the energy balance in the beginning compensated by tension of all systems of an organism is reflected further in a condition of internals, first of all cardiovascular system. Increase in permeability of a vascular wall, an exit in fabric of the coarse-dispersion proteins complicating gematotkanevy exchange lead to a hypoxia of fabrics and burden dystrophic process. The metabolism is characterized by acceleration of a catabolism of proteins, a lipolysis and oxidation fat to - t, negative nitrogenous balance, strengthening of a glycogenolysis in a liver and muscles, considerable dehydration of an organism. Developing of an ophthalmopathy is connected with action of humoral factors: LATS and the special ekzoftalmichesky factor which is presumably formed in a hypophysis and also with disturbance of a motive and trophic innervation of eyes. Accumulation of acid mucopolysaccharides in retrobulbar cellulose is the main reason for an exophthalmos; sharp increase in its volume due to active binding of water also causes a protrusion of an eyeglobe. Accumulation in connecting fabric of mucopolysaccharides, hyaluronic and chondroitinsulphuric to - you take place and at localized, or pretibialny, the myxedema which is often accompanying an ophthalmopathy.

The pathological anatomy

the Thyroid gland is increased by 2 — 5 times, sometimes and more. Increase in the sizes of gland not always corresponds to disease severity. Consistence its usually moderately dense; on a section it juicy, plethoric, pink-gray color. Gistol, a picture of body can show different types of goitrous transformation of gland and depends on a type of earlier carried out therapy.

Fig. 1. Microdrug of a thyroid gland at a diffusion toxic craw: shooters specified outgrowths of an epithelium of the papillomatous type growing in a cavity of a follicle; x 300.
Fig. 2. Microdrug of a thyroid gland at a diffusion toxic craw: accumulation of lymphocytes (it is specified by shooters) in interfollikulyarny connecting tkanin

In the absence of preliminary treatment in a thyroid gland diffusion changes with polymorphism of follicles come to light more often; their contours are wrong, the gleam can be slit-like or star-shaped. The follicular epithelium cylindrical, quite often multilayer, forms in a gleam of follicles of growth of papillomatous type (fig. 1). The colloid is liquid, it is weak eozinofilen, contains a large number of rezorbtsionny vacuoles. Blood vessels are overflowed with blood. In interfollikulyarny connecting fabric accumulations of lymphocytes with formation of lymphoid follicles (fig. 2) are found. Epithelial cells are quite often destructively changed, are exfoliated and can be found in a gleam of follicles. The given changes arising in an intact thyroid gland received the name of a bazedovsky craw.

After treatment 3. of t. drugs of iodine the consistence of a thyroid gland becomes more dense, the krovenapolneniye of vessels is less expressed, the follicular epithelium becomes cubic, vacuolation of a colloid considerably decreases. At prolonged use of drugs of iodine gistol, the picture can get all signs characteristic of a bazedovsky craw again.

At treatment 3. of t. thyreostatic drugs (derivatives of thiouracil or an imidazole) within 1 — 2 month the consistence of a thyroid gland becomes softer, the krovenapolneniye of vessels increases, gistol, the picture indicates the increased activity of glands. At use of thyreostatic drugs over a year and stabilization of an euthyroid state a considerable part of a thyroid gland gets a normal structure, in a nek-swarm of a part of follicles the high cylindrical epithelium and considerable vacuolation of a colloid remains, sites of an atrophy of fabric come to light. In an experiment long administration of methylthiouracil in high doses led to development of malignant tumors of a thyroid gland, but in clinic similar observations are absent.

At a severe form 3. of t. there can be changes in cross-striped muscles; between bunches of muscle fibers and separate fibers the lipoblasts located ranks or groups are found, the atrophy of muscle fibers is possible. The most considerable changes are found in oculomotor muscles at an ophthalmopathy: the expressed hypostasis and small-celled infiltration of a stroma, alternation of the atrofichny and sharply bulked up fibers. At severe forms fibrosis of tissues of eye-socket develops. At long disease at a part of patients moderately expressed comes to light osteoporosis (see).

Considerable changes at a severe form of a disease arise in a myocardium and a liver. Heart is quite often increased, his cavities are expanded. As showed pilot studies, increase in weight of a myocardium is connected with hydration of fabric. At gistol, a research in perikapillyarny spaces the plazmorragichesky exudate comes to light, hypostasis and a razvolokneniye of muscular tissue, partial disappearance of cross striation in cardiomyocytes, polynuclear and lymphocytic infiltration of a stroma, sometimes the centers of a necrosis and fibrosis are noted.

In a liver at gistol, a research the hyperemia, dilatation of capillaries and around sinusoidny spaces (Disse's spaces) which are filled with the liquid supporting squirrels come to light. Walls of capillaries bulk up, sometimes between hepatic beams hemorrhages are found. In a periportal zone accumulations of lymphoid cells meet. Hepatocytes diskompleksirutsya and exposed to granular and gidropichesky dystrophy, occasionally fatty degeneration and a brown atrophy. These processes can lead to focal necroses with the subsequent growth of connecting fabric preferential in subkapsulyarny departments and development of focal cirrhosis.

Changes in kidneys are changeable, possible dystrophic changes of epithelial cells of nephron, accumulation of serous liquid in a cavity of capsules (Shumlyansky's balls — Boumena).

In c. N of page come to light dystrophic changes of ganglionic cells, perivascular infiltrates, hemorrhages. In century of N of page, it is preferential in cervical sympathetic nodes, destructive processes in ganglionic cells, their atrophy, a thickening and granular disintegration of neurofibrilla are found.

Limf, nodes quite often of a giperplazirovana, increase in a thymus as a result of a hyperplasia of its bast layer is possible. These disturbances meet at children at a timiko-lymphatic state more often. Thinning of cortical substance of adrenal glands, generally puchkovy zone, the expressed its delipoidization, hemorrhages are noted at a heavy and long thyrotoxicosis.

At gistol, a research of a front share of a hypophysis increase in quantity of hromafinoblast and reduction of hromafinotsit sometimes is found. At a severe form 3. of t. at children, especially at girls, the arrest of development of gonads is possible, at women atrophic processes in ovaries and a moderate atrophy of mammary glands are observed, find in men gynecomastia (see) with limited development of ferruterous fabric around nipples, sometimes a considerable hyperplastic tissue.

The clinical picture

the Disease develops sharply or gradually. Usually forms with the acute beginning get further hron, a current; heavy loony, and physical. injuries, intercurrent infections, overheating to the sun, pregnancy and a lactation can lead to an exacerbation of a disease.

According to Sh. Milk (1954), allocate 4 stages of a disease: I \neurogenic, II — neurohormonal, III — vistseropatichesky, IV — cachectic (dystrophic). In a wedge, practice classification of forms of a disease by severity is more often used: easy, moderately severe, heavy. Main criteria: the general condition of patients and expressiveness of symptoms, degree of a lose of weight (to 10, 20 and St. 20%), increase in standard metabolism (to 30, 30—60, St. 60%), pulse rate (to 100, 120, St. 120 ud. in 1 min.), changes from cardiovascular system, went. - kish. path and liver.

The most characteristic symptoms: increase in the sizes of a thyroid gland, tachycardia, an ophthalmopathy, the increased mental excitability, small trembling of a body and extremities, weight loss at the increased appetite, the general weakness, perspiration, subfebrile temperature.

Fig. 3. The patient with a severe form of a thyrocardiac craw: sharp emaciation with almost total disappearance of hypodermic cellulose.

Skin at patients elastic and wet, sometimes with the expressed pigmentation and the phenomena of the localized myxedema (a thickening of skin on a front surface of shins and the back of foot). The hypodermic fatty layer is reduced, at a severe form of a disease perhaps sharp emaciation with almost total disappearance of hypodermic cellulose (fig. 3). Appetite is usually kept, quite often increased. Patients note thirst, badly transfer the elevated temperature of the environment. Muscular weakness is characteristic of most of patients, at a severe form there is an atrophy of muscles which was more expressed in proximal departments of extremities, occasionally the thickening of fingers of brushes and feet which is usually combined with the expressed ophthalmopathy or a pretibialny myxedema.

The thyroid gland is diffuzno increased, in it usually find consolidations in elderly persons. Most often the craw of II and III degrees meets, IV are slightly more rare (see. Craw ). Increase in the sizes of gland clearly comes to light by means of radio-gramophones, a method of a research — scanning (fig. 4). At palpation of a craw feel usually a pulsation of vessels; at its auscultation at a part of patients vascular noise are listened.

Fig. 4. Skanogramma of a thyroid gland: at the left — is normal (for comparison); on the right — an enlargement of the thyroid gland of the II degree at a thyrocardiac craw.
Fig. 5. An ophthalmopathy at a diffusion toxic craw: in the drawing on the right — an exophthalmos (pucheglazy), broad disclosure of a palpebral fissure, a symptom Gref (emergence of a white strip of a sclera between edge of a century and edge of a cornea at the movement of an eyeglobe from top to bottom); at the left — eyes of the healthy person at the same movement.
Fig. 6. The Ekzoftalmichesky ophthalmoplegia at a diffusion toxic craw: in the drawing on the right — restriction of the movement of eyeglobes up (emergence of a white strip of a sclera between the upper edge of a century and an iris); at the left — eyes of the healthy person at the same movement.

Damage of eyes, or ophthalmopathy, at 3. of t. arises at 40 — 80% of patients. It is most typical exophthalmos (see), usually more or less uniform, sometimes asymmetric. Quite often note unusual gloss of eyes. Characteristic eye symptoms: Gref — emergence of a white strip of a sclera between edge of a century and edge of an iris at the movement of an eyeglobe from top to bottom (fig. 5); Shtellvaga — a rare blinking; Dalrimplya — broad disclosure of a palpebral fissure; Möbius — disturbance of convergence. Symptoms are less often observed: Kokhera — retraction of an upper eyelid and emergence of a white strip of a sclera between edge of a lower eyelid and edge of a cornea at the bystry movement of an eyeglobe up; Zengera — Enrota — a subauriculate swelling a century; Ellineka — Telle — the strengthened pigmentation a century; Geoffroi — absence of wrinkles on a forehead at a look up. At the progressing ophthalmopathy the exophthalmos increases, hypostases increase a century, there are a hyperemia and puffiness of a conjunctiva, gripes, feeling of «sand», eye pain, lachrymation, a photophobia, function of oculomotor muscles — an ekzoftalmichesky ophthalmoplegia (fig. 6) is broken. The movement of eyeglobes up and up-knaruzhi is most often limited. There is a doubling of objects. At a considerable exophthalmos increase in intraocular pressure — secondary glaucoma can develop. Because of disturbance of a smykaniye the century at a sharp protrusion of an eyeglobe comes the drying and a keratohelcosis creating threat to sight.

Thyrocardiac heart — a symptom complex of disturbances in the blood circulatory system at 3. of t., caused by the increased concentration of iodthyroid hormones in blood. The term is entered by R. Kraus in 1899. In development of thyrocardiac heart major importance is attached to the disturbance of metabolism of a myocardium which is characterized by decrease in energy potential of cardiomyocytes, dominance in them catabolic processes over anabolic, reduction of maintenance of a glycogen, potassium, magnesium at increase in content of sodium. The increased need of peripheral fabrics for oxygen causes compensatory strengthening of cardiac performance and considerable changes of a hemodynamics: the minute volume of heart, speed of a blood-groove, volume of the circulating blood increase; decrease an arteriovenous difference on oxygen and peripheric resistance in a big circle of blood circulation.

The most constant symptom 3. of t., substantially reflecting weight thyrotoxicosis (see), is tachycardia (see). It has constant character and remains even during sleep. A Bouveret's disease at 3. of t. it is observed seldom and arises against the background of continuous increase of cordial reductions.

At a severe form 3. of t. there can be atrial fibrillation (a takhiaritmichesky form), sometimes an atrial flutter. These phenomena connect with toxic effect of thyroid hormones on a myocardium, formation of the heterotropic centers of excitement in a muscle of auricles, delay of conductivity of an impulse on auricles and shortening of the refractory period. Ciliary arrhythmia (see) in the beginning has paroxysmal character, then becomes a constant.

The ABP is characterized by big pulse amplitude. Increase in pulse pressure leads to the expressed pulsation of large vessels seen in a neck.

Borders of heart at the beginning of a disease and at its easy form are not expanded, at heavy — also the right ventricle increases left, and occasionally. Cardiac sounds, especially the first, are strengthened, over a top and a pulmonary artery systolic noise is often listened. Rentgenol, a research reveals small protrusion of a cone of a pulmonary trunk with straightening of the left border of heart, usually without increase in the left auricle. On an ECG the normal provision of an axis of heart is more often noted. At the beginning of a disease the high voltage of teeth of P and T is registered; for progressing 3. of t. decrease, flattening and inversion of a tooth of T are characteristic. Signs of a hypertrophy of a left ventricle are found in a part of patients, the reflecting exchange disturbances in a myocardium and disappearing after effective treatment are more often. At 3. of t. developing of stenocardia is possible. On an ECG the changes characteristic of coronary insufficiency can appear: the depression of a segment of ST and a negative tooth of T. Odnako in the absence of arterial hypertension and the expressed atherosclerosis of change of a final part of a ventricular complex can disappear after effective treatment 3. of t.

Additional methods of a research, including catheterization of cardial cavities, reveal reduction of sokratitelny ability of a myocardium according to disease severity.

Dysfunction went. - kish. a path it is shown by increase of a chair because of increase in a vermicular movement of intestines, at a severe form — a loss of appetite, nausea, vomiting, ponosa, a gastric akhiliya. At forms of a disease easy and moderately severe appetite is often increased. The abnormal liver function insignificant also comes to light in the beginning only functional trials. During the progressing 3. of t. the liver increases, in blood the content of bilirubin increases, development of jaundice is possible. At patients with the previous pathology of a liver dystrophy and atrophic cirrhosis can develop. Emergence of jaundice always indicates the adverse course of process.

At 3. of t. also activity of other closed glands is broken. Function of bark of adrenal glands at the beginning of a disease at an easy form is quite often slightly strengthened; in process of an aggravation of symptoms at patients the hypocorticoidism with a hyperpegmentation of integuments develops. At a severe form function of gonads is considerably broken: women have a dysmenorrhea and an amenorrhea, at men the potentiality decreases and as a result of change of an oestrogenic background the gynecomastia can develop. After elimination of a thyrotoxicosis exchange of steroids in an organism is gradually normalized, the gynecomastia is exposed to involution. At a part of patients, usually young age, arises status thymicolymphaticus (see). At a long thyrotoxicosis patients can have symptoms of a diabetes mellitus — thyrogenic diabetes.

Mental disorders

Mental disorders are extremely characteristic for 3. of t. It gave the grounds to allocate special, nervous (psychological, neurovegetative) a form of a thyrotoxicosis. Structure and dynamics psikhopatol. symptoms 3. of t. reflect allocated with Bleyler (M. Bleuler) patterns of development of mental shifts at endocrinopathies: formation of an endocrine psychosyndrome at early stages of a disease; in cases of its rather high-quality current — gradation in an anamnestic and organic syndrome; development of acute and long psychoses — at increase of weight of toxicosis. Three groups of disturbances inherent to an endocrine psychosyndrome — decrease in mental activity, change of inclinations and frustration of mood — at a thyrotoxicosis are presented very brightly.

Decrease in mental activity is expressed in an adynamy with raised mental and physical. fatigue and bystry exhaustion, difficulty of concentration of attention and considerable decrease in working capacity; less often apathy and slackness meet.

Frustration from the emotional sphere at a thyrotoxicosis act into the forefront and come to light almost at all patients. The increased affective lability with lines of a dysthymia is observed: «an incontience of affect» — from faintheartedness and tearfulness to the expressed tendency to rough affective flashes and irascibility. Lability of mood is observed against the background of constant feeling by patients of internal tension, concern, alarm and shown by hypererethism, unmotivated irascibility, irritability, haste, sometimes a motive hyperactivity with small productivity. If at patients the expressed depressions develop, then they seldom represent so-called pure depressions; the mixed alarming depressions or states like «dysphoric depression», «a tearful depression», «an irascible depression», etc. are more often observed. Also depressive and hypochiondrial states which cornerstone senestopathetic feelings can be are frequent (unpleasant feelings in internals, skin).

The big place in a wedge, a picture is occupied by frustration of a dream — sleeplessness, a superficial dream, the shortened dream, an alarming dream with the corresponding dreams.

Intellectual disturbances, as a rule, at a stage of an endocrine psychosyndrome are absent. Only changes of rate of a course of thought processes towards acceleration, difficulties in long concentration of attention and the related reduced productivity of mental activity are noted. At a severe form of a disease when symptoms of an anamnestic and organic syndrome begin to develop, easy intellectual decrease with loss of criticism to the state and complacency can be found. As a rule, at this stage disturbances are more expressed and nevrol: increase in tendon jerks, instability in Romberg's pose (see. Romberg symptom ), strengthening of a tremor etc.

Psychoses at 3. of t. are rare and various on the wedge, a picture (depressive, depressive and crazy, delirious, delirious and amental, shizofrenopodobny, etc.).

In peripheral blood of patients 3. of t. essential changes are not noted, at a severe form are possible hypochromia anemia, sometimes with considerable decrease in hemoglobin, a leukopenia with a lymphocytosis and a relative neutropenia. In blood reveal reduction of amount of albumine and increase in globulins, preferential their a-fractions. Content of cholesterol decreases as a result of his accelerated metabolism and bystry removal with bile. Are noted bent to a hyperglycemia and diabetic change by glycemic glucose, curve after loading, that it is more often connected with the accelerated absorption of glucose in intestines. At timely effective therapy indicators of carbohydrate metabolism are normalized. Content of electrolytes in blood usually normal. Disturbances of water exchange are expressed in dehydration.

Standard metabolism at a severe form 3. of t. it is raised to 100%, acceleration and increase in absorption of a radioiodine a thyroid gland is characteristic. In blood the content of the proteinaceous and connected iodine, sometimes is increased to 25 mkg of % (norm of 4,0 — 8,5 mkg of %), and butanolekstragiruyemy iodine to 10 — 12 mkg of % (norm of 3 — 6,5 mkg of %) that reflects increase in secretion of thyroxine and triiodothyronine. Increase in content in blood of thyroxine to 20 — 30 mkg of the % determined by method of competitive binding (norm of 5,0 — 13,7 mkg of %) and triiodothyronine to 400 — 500 ng is observed by % (norm 100 — 300 ng %). An indicator of a hyperthyroidism increase in the coefficient of effective thyroxine (CET) serves higher than 1,13. This diagnostic test reflects the level of the general thyroxine and tiroksinsvyazyvayushchy ability of serum proteins.

The craw diffusion toxic at children's age

the Craw diffusion toxic at children's age (during the dopubertatny period) is observed less than at adults (1 — 2% of patients). Wedge, picture has the features: tendency to bystry progressing, expressiveness of emaciation, acceleration of growth at a delay of sexual development at girls, horeoidny twitchings. Cardiovascular pathology usually is the leader in clinic 3. of t. at children, being shown by high tachycardia (140 — 160 ud. in min.), lability of pulse, expansion of borders of heart, sharper, than at adults, changes of an ECG (especially deformation of a final part of a ventricular complex). At the same time the ciliary arrhythmia and the expressed circulatory unefficiency at children are extremely rare. Changes of mentality — tearfulness, easing of ability to concentrate attention and memories — are brightly expressed and can limit possibilities of the child to continue study at school, promote emergence of conflict situations. At inspection of children tests with introduction to an organism of radioactive materials are contraindicated.

A craw diffusion toxic at elderly people. Distinctive features of clinic 3. of t. at this age are defined by development of a thyrotoxicosis against the background of atherosclerosis that leads to more frequent emergence of a ciliary arrhythmia and circulatory unefficiency, heavier dystrophic changes of internals.

At men the thyrotoxicosis progresses more quickly more often than at women, the ophthalmopathy, a ciliary arrhythmia and a decompensation of cordial activity is observed.

Complications

Thyrocardiac crises, heart failure, ciliary arrhythmia, acute and Subacute dystrophy and cirrhosis. Psychoses arise at a severe disease and insufficiently effective treatment. Thyrocardiac crises can develop after a mental injury, acute infections, operation or treatment by a radioiodine and are characterized by bystry and sharp increase of symptoms of a thyrotoxicosis, a hyperthermia, dehydration, deterioration in action of the heart and strengthening of the phenomena of a hypocorticoidism. At increase of intoxication development of coma is possible. Mioplegiya, characterized by sharp weakness of muscles of the lower extremities, and the periodic tetany connected, apparently, much belong to rare complications paroxysmal calcitonin (see) which are eliminated at achievement of an euthyroid state.

The diagnosis

Early diagnosis allows to eliminate timely symptoms of a thyrotoxicosis, to avoid complications and to achieve recovery. The greatest diagnostic value has a combination of such symptoms as persistent tachycardia, weight loss at the increased appetite and a diffusion craw, and also existence of an exophthalmos, Sharko's symptom — Mari (trembling of fingers of outstretched arms), perspiration and big pulse amplitude. The differential diagnosis — with a rheumatic carditis, tuberculosis, a hypertension in its initial stage, neurosises. The correct diagnosis is promoted by data of laboratory analyses: increase standard metabolism (see), contents in blood proteinaceous and connected iodine (see) and butanolekstragiruyemy iodine (see); change of indicators of radio iodindication of a thyroid gland (see. Thyroid gland, radio isotope research ). The differential diagnosis facilitates performing trial therapy by mercazolil in a dose of 20 — 40 mg a day during 2 — 3 weeks: the resistant urezheniye of pulse and an increase of weight indicate existence of a thyrotoxicosis. However absence in the specified terms of the expressed effect of treatment is not the basis for a complete elimination of the diagnosis 3. of t., as for elimination of a thyrotoxicosis more prolonged treatment can be required.

The expressed forms of damage of heart at 3. of t., followed by a ciliary arrhythmia, emergence of cordial noise, significant increase in a left ventricle, heart failure, it is necessary to differentiate with heart diseases, myocardites, an atherosclerotic cardiosclerosis, a cardiomyopathy.

Treatment

At heavy and medium-weight forms 3. of t. treatment should be begun in a hospital. Regardless of the choice of a method of treatment by the patient it is necessary to appoint good caloric nutrition with introduction to a diet of digestible products, vitamins and mineral salts, to provide mental and physical. rest, observance of a day regimen, deep 9 — 12-hour sleep; drugs of bromine, hypnagogues are shown.

Standard methods of treatment 3. of t.: treatment by anti-thyroid means, radioiodine therapy and surgical treatment.

Derivatives of thiouracil (methylthiouracil, propylthiouracil) and an imidazole are most effective (mercazolil, a synonym: Methothyrinum, Methimazolum). The main mechanism of their action comes down to braking of synthesis of thyroid hormones at the level of the iodated tyrosines. Long (for a year and more) treatment by these drugs with permanent preservation of an euthyroidism at a considerable part of patients leads to recovery. Anti-thyroid drugs are used also for elimination of a thyrotoxicosis before operational treatment or use of radioiodine therapy. Initial doses of methylthiouracil of 0,2 — 0,25 g 2 — 3 times a day, mercazolil of 0,01 g 2 — 3 times a day. At some patients at a severe form of a thyrotoxicosis or existence of resistance to drug the daily dose of mercazolil can be raised to 40 — 60 mg and more. After elimination of a thyrotoxicosis of a dose of drugs reduce and when long anti-thyroid therapy is chosen an independent method of treatment, gradually pass to the maintenance doses making for mercazolil 5 — 10 mg a day for methylthiouracil of 50 — 100 mg a day. An indispensable condition of a maintenance therapy is use of doses of the drugs sufficient for maintenance euthyroidism (see). The favorable sign indicating probability of recovery are normalization of capture 1311 thyroid gland and reduction of the sizes of a craw.

Initial doses of the potassium perchlorate having effect by blockade of accumulation of iodine a thyroid gland make 600 — 1000 mg a day. In view of the fact that the therapeutic effect is observed at decrease in capture 131I lower than 10%, it is reasonable to carry out selection of a dose of potassium perchlorate under control of absorption 131I a thyroid gland. Potassium perchlorate can be appointed along with mercazolil, action to-rogo it potentiates.

These drugs can have toxic effect on a marrowy hemopoiesis, up to an agranulocytosis. At their appointment overseeing by composition of peripheral blood in the beginning once a week is necessary, at a maintenance therapy — 1 time in 2 — 3 weeks. During the developing of quinsy at patients drugs should be cancelled before performing blood test. Allergic reactions are occasionally observed. Potassium perchlorate in the recommended doses malotoksichen.

Purpose of drugs of iodine in view of their passing, though bystry braking action on synthesis of thyroid hormones is limited to special indications: in need of bystreyshy decrease in a thyrotoxicosis because of serious condition of patients, impossibility of use of other anti-thyroid drugs in connection with a lactation, allergic and agranulocytic reactions. Drugs of iodine are used also against the background of the eliminated thyrotoxicosis before operational treatment for the purpose of reduction of a krovenapolneniye of a thyroid gland. Drugs of iodine can be appointed in combination with mercazolil or methylthiouracil, but not with potassium perchlorate.

Administration of anti-thyroid drugs is quite often combined with drugs of Rauwolfia, usually Reserpinum, and redoxons, In, And. Doses of Reserpinum: 0,1 — 0,25 mg 2 — 3 times a day before elimination of a thyrotoxicosis. The combination of thyreostatic means to drugs of Rauwolfia accelerates approach of an euthyroid state. More bystry elimination of symptoms of a thyrotoxicosis is observed also at the combined use of thyreostatic means and beta adrenoblockers (anaprilin, Xing: Obsidanum, etc.) on 10 — 40 mg 2 — 3 times a day.

At decrease in food anabolic steroids can be appointed (Nerobolum, retabolil, etc.) in usual doses and insulin. Drugs of bark of adrenal glands are shown to patients with a heavy current in the presence of a hypocorticoidism, a timiko-lymphatic state, the expressed ophthalmopathy, a leukopenia with a granulocytopenia. Doses of drugs are individual. At the phenomena of cardiovascular insufficiency and a ciliary arrhythmia carry out the corresponding cardial therapy. At the expressed mental disturbances by the patient 3. of t. neuroleptics of various action spectrum, antidepressants, etc. are shown.

At thyrocardiac crisis vigorous complex therapy is necessary: parenteral (it is more preferable intravenous) introduction of 1000 mg of a hydrocortisone a day, 5 — 10 ml of solution of Lugol kapelno with glucose, cardiac glycosides (Korglykonum or strophanthin), at the expressed tachyarrhythmia — beta adrenoblockers, cocarboxylase, intravenous administration of 5% of solution of glucose with insulin, Ringer's solution — Locke, Neocompensanum, febrifugal (analginum, Rheopyrinum, pyramidon). As a rule, it is necessary to enter 1,5 — 2, 3 l of liquid are more rare, the quantity a cut is controlled by a diuresis and size of sweating. Apply physical. cooling: bubbles with ice on area of the main vessels of hips, a liver.

Lech. action of a radioiodine 131I (see. Iodine, radioactive ) it is based on destruction by beta particles of giperplazirovanny thyroid fabric. Indications to radioiodine therapy: lack of lasting effect from medicamentous therapy at patients (40 years are preferential more senior) with a diffusion craw of the II—III degree, the complicated forms 3. of t., at which an operative measure, a recurrence 3 is impossible. of t. in the presence of postoperative complications. Contraindications: 3. of t. at children and teenagers, pregnancy, a lactation, the retrosternal and ring craw squeezing a trachea. Drug is appointed orally. Treatment shall provide destruction 9/10 parenchyma of gland. It is recommended to enter in one step from 60 to 120 mkkyur of isotope on 1 g of a thyroid gland. Calculation of weight of body is based on data of a palpation (at I, II, III and IV extent of increase the weight of gland respectively reaches 30—40, 50—60, 80—110, 120 — 150 g) or scannings. Also calculation of radiation influencing gland is made; at the same time dose 131 I is expressed in labor. Treatment is effective at a dose 131 I in 5000 — 7000 is glad. 2 methods of radioiodine therapy are used: single-step and «fractional», fractional, at Krom isotope is entered in 2 — 3 portions at an interval of 2 — 3 days. If necessary the course is repeated in 2 — 6 months. Complications: an exacerbation of a thyrotoxicosis, occasionally with thyrocardiac crisis, and a hypothyroidism (sometimes in several years after radioiodine therapy). For the prevention of aggravations 3. of t. preliminary treatment of patients with thyreostatic drugs — before permanent remission is recommended. Use of a fractional method of administration of isotope also reduces the frequency of complications.

At treatment of children good nutrition and redoxons is appointed, In and And. Medicamentous anti-thyroid therapy is carried out by the same means, as at adults. Mercazolil, an initial dose to-rogo 10 — 30 mg on 1 mg of a body surface, on average 15 — 20 mg a day is most effective. Reduction of a daily dose is carried out gradually after elimination of a thyrotoxicosis; the doses supporting an euthyroid state usually correspond to maintenance doses at adults. Duration of treatment at most of patients up to 1 — 1,5 years. Overseeing by a picture of blood is carried out each 7 — 14 days. Mercazolil the first 2 — 4 months combine treatment with administration of drugs of Rauwolfia, usually Reserpinum: 0,05 mg 2 times a day to children of 5 — 7 years and 0,1 mg 2 times a day to children of school age.

Operational treatment

the Strumectomy — the eurysynusic term for designation of operations of various volume on a thyroid gland. In the literal translation the strumectomy means removal of a craw, i.e. its extirpation. Apparently, it is more reasonable to specify the nature of the carried-out intervention, napr, a subtotal resection of a thyroid gland, enucleation of a node or enucleation with a partial resection of one or both shares.

By the most radical method of treatment 3. of t. the subtotal resection of a thyroid gland is. The technique of operation shall provide reliability of a hemostasis, an integrity of guttural nerves and parathyroids, safety of 5 — 6 g of a thyroid gland. The subtotal resection of a thyroid gland is carried out by two methods. The first, Lakhi offered by T. Kokher and modified (F. The N of Lahey, 1949), consists in a subtotal resection of a thyroid gland after the preliminary isolated bandaging of four main arteries, allocation of guttural nerves and parathyroids for the prevention of their injury. This technique is widely applied an amer. and Western European surgeons. The second method is offered and in details developed by O. V. Nikolaev (1952).

At it the field of intervention is limited to limits of an intra cervical fascia, bandaging of vessels is made only within its visceral plate without preliminary alloying of the main arterial trunks. The left tissue of a thyroid gland is located in the form of two plates (it is powerful 2 — 3 g everyone) tracheas on each side, covering zones of an arrangement of parathyroids and guttural nerves.

Nikolaev's method can be applied also at a recurrence 3. of t.: the available hems are considered as a thickening of a fascia of a thyroid gland, and operation is essentially carried out the same as at primary intervention.

Indications to operation: lack of lasting effect from correctly carried out medicamentous therapy, the large sizes of a craw and existence in it of nodes, difficulties during the performing conservative treatment (e.g., granulocytopoietic or allergic reactions), existence of associated diseases or complications (e.g., a diabetes mellitus, a ciliary arrhythmia) which can be aggravated at a recurrence of a thyrotoxicosis.

Absolute contraindications to surgical treatment 3. of t., irrespective of age of the patient, weight of the basic and existence of associated diseases, does not exist.

A main objective of preoperative preparation — the maximum compensation of vistseropatichesky effects of a thyrotoxicosis and achievement of an euthyroid state.

The complex of means applied for this purpose shall include and high-calorific fiziol, a diet. Despite a possibility of the expressed goitrogenic effect, use of tireostatik, in particular mercazolil (in a dose of 40 mg a day), in combination with diiodotyrosine (150—200 of mg a day), allows to reach an euthyroid state in most cases.

Preparation for surgery includes cardial therapy. Insufficiency of function of bark of adrenal glands is the indication to purpose of steroid hormones (Prednisolonum on 5 — 10 mg a day inside or a hydrocortisone of 25 — 50 mg a day intramusculary). Duration of use and a dose of hormones depend on expressiveness of a hypocorticoidism. For reduction of psychomotor excitement purpose of tranquilizers (Elenium, Seduxenum), psychotherapy is reasonable.

Improvement of cardiovascular activity, normalization of the ABP, an increase in weight, reduction of expressiveness of a xanthopathy, psychomotor excitement, normalization of a dream are a wedge, signs of sufficient readiness of the patient to operation.

For anesthesia the endotracheal anesthesia which is absolutely shown at operations at children and in cases with considerable technical difficulties (a recurrence of a disease, the located craw big retrotrakhealno) is most optimum. At the adult patient with a small craw the subtotal resection of a thyroid gland can be carried out under a local anesthesia of 0,25 — 0,5% solution of novocaine. In cases of intolerance of novocaine 0,25% solutions of a xycain (lidocaine) or Trimecainum (in the absence of reaction to administration of the specified substances are applied at an intracutaneous test).

Methodically correctly performed operation at adequately prepared patient, as a rule, takes place without complications. Complications (bleeding, a laryngospasm, injury of guttural nerves and parathyroids, thyrocardiac crisis, a hypothyroidism), as a rule, are result of errors of the operative measure or unexpected kliniko-anatomic features of a disease. Frequency of complications increases at repeated operations.

Long-term results operations depend on duration and disease severity, efficiency of preoperative preparation, timeliness and radicalism of operation. The recovery rate and recovery of working capacity at timely operation makes 90 — 98%.

The forecast

leads Timely treatment to recovery and recovery of working capacity at the vast majority of patients. It is longest the ophthalmopathy, in some cases irreversible can remain. Surgical treatment and radioiodine therapy at a part of patients can lead to the hypothyroidism demanding continuous replacement therapy. The forecast worsens at development of a resistant decompensation of thyrocardiac heart, dystrophy and cirrhosis. Hazard to life is posed by heavy thyrocardiac crises and not recognizable status thymicolymphaticus (at a stressful situation).

Prevention

Observance of the correct work-rest schedule, psychohygiene, actions for a hardening of an organism, exercises, prevention of respiratory infections, tonsillitis.


Bibliography: Habert V. Ia. Organization of endocrinological service, page 23, M., 1972; Golber L. M. and Kandror V. I. Thyrocardiac heart, M., 1972, bibliogr.; Dobrzhanskaya A. K. Mental and neurophysiological disturbances at endocrine diseases, M., 1973, bibliogr.; Zhukovsky M. A. Children's endocrinology, page 37, M., 1971; Kilinskiye.L. islavinat. C. Damages of heart at endocrine diseases, page 160, M., 1972, bibliogr.; Klyachkov.R. Topical issues of conservative treatment of a toxic craw, M., 1965; The Multivolume guide to internal diseases, under the editorship of E. M. Tareeva, t. 7, page 29, L., 1966; H and-kolayev O. V. Hirurgiya of endocrine system, M., 1952; Petrovskiyb.V. both Semenov of V. S. Klinik and surgical treatment of a thyrocardiac craw, M., 1961; The Guide to clinical endocrinology, under the editorship of V. G. Baranov, L., 1977, bibliogr.; The guide to endocrinology, under the editorship of B. V. Alyoshin, etc., page 118, M., 1973; Skripnichenko D. F. Surgical treatment of a toxic craw, Kiev, 1976, bibles ogr.; Spesivtseva V. G. Radio-gramophones active yod131 in diagnosis and le-. cheniya of a diffusion toxic craw, M., 1967; Shereshevsky N. A. Thyrotoxicoses, M., 1962; The Thyroid gland, Physiology and clinic, under the editorship of S. Verner, the lane with English, L., 1963; In e an u g i e J. M. Principles of thyroid surgery, Oxford, 1975, bibliogr.; B 1 e u-1 e r M. Endokrinologische Psychiatrie, Stuttgart, 1954, Bibliogr.; H a y 1 e s A. B. Problems of childhood graves disease, Proc. Mayo Clin., v. 47, p. 850, 1972; Labhart A. Klinik der inneren Sekretion, B. u. a., 1971; Montgomery D. A. D. a. W e 1 b o u r n R. B. Medical and surgical endocrinology, L., 1975; Oberdisse K. u. Klein E. Die Krankheiten der Schilddriise, Stuttgart, 1967; Zografski of S. Han-dokrinna surgery, Sofia, 1973.

V. R. Klyachko; K. N. Kazeev (hir.), D. D. Orlovskaya (psikhiat.).

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