HYPOTHYROIDISM

From Big Medical Encyclopedia

HYPOTHYROIDISM (hypothyreosis; grech, hypo-+ lat. [glandula] of thyreoidea a thyroid gland + - osis; synonym: hypothyroidism, thyroid insufficiency, myxedema) — the clinical syndrome which is characterized by the resistant depression of function of a thyroid gland leading to exchange and clinical disturbances. The term «hypothyroidism» is entered in 1961 on the International congress of the socialist countries on a problem of a local craw which took place in Sofia.

Full switching off of function of a thyroid gland is called an athyreosis; usually it is connected with inborn lack of a thyroid gland (aplasia) or with an atrophy of earlier not changed thyroid fabric, surgical removal of gland, and also radiation destruction of a thyroid gland (e.g., at treatment of a malignant tumor).

Fig. 1. Scheme of a pathogeny of primary and secondary hypothyroidism. Interrelation of gipotalamogipofizarny system (1) and thyroid gland (2): and — is normal; — at localization of process in a thyroid gland (primary hypothyroidism); in — at localization of process in gipotalamogipofizarny area (a secondary hypothyroidism).

Distinguish primary and secondary G. (fig. 1). At primary G. the thyroid gland is primary localization patol, process, activity of thyritropic hormone is increased, and synthesis of thyroid hormones is sharply reduced. Carry also inborn aplasia and atrophic processes of a thyroid gland to primary G. At secondary G. patol, process is localized in the regulating system (a hypothalamus — a hypophysis).

Primary hypothyroidism is an independent disease, at secondary thyroid insufficiency is a symptom of defeat of gipotalamogipofizarny system or such diseases as a local craw, Hashimoto's thyroiditis.

History

In 1850 Karling (Th. Century of Curling) for the first time described G.'s symptoms at children, and in 1874. W. W. Gull — symptoms at adults. Hordes (W. The m of Ord) in 1878 as a result morfol, researches found an atrophy of a thyroid gland, the phenomenon of a myxedema in skin and hypodermic cellulose; he called these changes a myxedema.

From the middle of the 20th century a myxedema designate G.'s symptom — a myxedema of skin and hypodermic cellulose. In 1882 — 1883 independently from each other surgeons T. Kokher and Zh. Reverden paid attention that as a result of full removal of a thyroid gland at the patient developed a wedge, a picture, to-ruyu T. Kokher called strumiprivial, or thyroprival, a cachexia, and. Reverden — a postoperative myxedema. The stated pathogenetic concept in 1884 was validated by Schiff (M. Schiff) who successfully applied transplantation of tissue of thyroid gland to postoperative G.'s treatment. In 1891 G. R. Murray used extract of thyroid tissue of sheep for this purpose. Was the first endocrine disease, at Krom the idea of replacement hormonal therapy was carried out.

Statistics

G. — one of the endocrine diseases which are found generally at women, and also at elderly people. Increase in number of sick G. is noted that, apparently, it is connected with more exact and early diagnostic methods. Incidence on about 10 000 G. of the population makes 0,9 — 1,6; in local areas it is slightly higher — to 2,9 (V. Ia. Habert, 1972).

The etiology

primary G.'s Emergence can be caused by a variety of reasons: as a result of defects of embryonic development, enzymatic disturbances of biosynthesis of thyroid hormones, after various inflammatory processes, as a result of influence of anti-thyroid antibodies and an outcome of a diffusion toxic craw. Primary G. can appear also as a result to lay down. influences — surgery, introduction of a radioiodine, a roentgenotherapy of a thyroid gland, use of drugs of an imidazole, thiourea and iodine. Autoimmune processes are of great importance for G.'s emergence.

Destructive and inflammatory processes (result of neuroinfection) and a tumor of gipotalamogipofizarny area, traumatic damages of c are secondary G.'s reason. N of page

the Pathogeny

the Main G. in a pathogeny — decrease in biosynthesis and reduction of secretion of iodinated hormones of a thyroid gland — thyroxine (see) and triiodothyronine (see). At primary G. disturbance of biosynthesis of thyroid hormones can be at various stages (defect of accumulation of iodine, disturbance of processes of diiodination of the iodated tironin, process of transition of a monoyodtironin and diyodtironin to triiodothyronine and thyroxine, etc.). At secondary G. as a result of insufficiency thyritropic hormone (see) decrease in concentration of iodides in a thyroid gland, secretory activity of an epithelium of follicles of a thyroid gland, reduction of number and the sizes of follicles is noted. It is resulted by delay of all processes of a metabolism with sharp decrease standard metabolism (see), and also heat exchange. Decrease in biosynthesis and an albuminolysis lead to a delay of nitrogenous products in an organism. In cordial and skeletal muscles creatinine collects, the content of creatine phosphate increases. In blood serum the general content of proteins increases, it is preferential at the expense of globulins. In fabrics contents nucleinic to - t decreases, exchange of mucopolysaccharides is broken, in blood the maintenance of the general geksozamin increases, the percentage ratio a galactose mine and a glycosamine raises, allocation with urine of uromukoid decreases. In skin and hypodermic cellulose a large amount of mucinous substance, the consisting hl collects. obr. from mucopolysaccharides, hyaluronic and chondroitinsulphuric to - t. Accumulation of these substances causes a peculiar myxedema — a myxedema; in connecting tissue of muscles, nervous trunks, internals there are phenomena of mucinous hypostasis. Exchange of collagen is at the same time broken, allocation with urine of oxyproline decreases.

Disturbance of lipidic exchange is expressed by the slowed-down digestion of fat fabrics; braking of processes of a catabolism and especially delay of release of decomposition products of fats causes increase in blood of content of cholesterol, triglycerides and p-lipoproteids, to a lesser extent phospholipids.

Disturbance of carbohydrate metabolism at G. is shown by delay of absorption of glucose in went. - kish. path and decrease in its utilization. However exchange of the soaked-up carbohydrates is significantly not broken. It is confirmed by preservation of a normal respiratory coefficient.

Disturbance of water exchange is connected with the increased hydration ability of mucin and change of hydrophily of colloids; the considerable delay of water in an organism, decrease in a diuresis and according to amount of the removed chlorides is noted. In a muscle of heart increase in potassium and reduction of sodium is noted.

Disbolism at an inborn form of primary G. leads to disturbance of development of a brain, and in later period to considerable disturbances of c. N of page

Pathological anatomy

Patol, changes of tissue of thyroid gland at primary G. can be characterized by an aplasia, a hypoplasia, an embryonal allotopia, an atrophy and sometimes a hyperplasia.

Atrophic processes in a thyroid gland can arise after inflammatory changes and sometimes after prolonged use of iodide and thyreostatic drugs. At inborn enzymatic disturbances of biosynthesis of thyroid hormones in a thyroid gland there are hyperplastic processes and there is a craw, usually diffusion, is more rare nodal with adenomatous growths. Atrophic changes of a thyroid gland are presented by considerable reduction of its size and weight. At gistol, a research reduction of the sizes of follicles is observed, flattening of a follicular epithelium, a dense colloid honor without vacuoles, considerable growth of connecting fabric, a hyalinosis and lipomatoz stromas, accumulation of lymphoid elements.

Change of connecting fabric at G. is characterized by adjournment in it the mucinous substance rich with acid mucopolysaccharides raised by hydrophily and increase in number of mast cells; these disturbances are called a myxedema (myxedema). At gistol, a research mucinous substance is found in a papillary layer and in a derma; it is located ekstratsellyulyarno between collagenic and elastic fibers. The hyperkeratosis, dystrophic changes of epidermal cells and obstruction of openings of follicles are noted. The phenomena of mucinous hypostasis are observed also in connecting tissue of mucous membranes of language, an oral cavity, nose, throat, went. - kish. path. In connecting fabric of peripheral nerves in endonevriya and perineuriums observe deposits of mucinous substance, dystrophic changes of axons and change of a myelin cover.

The same changes find in skeletal muscular tissue in perimysiums and endomiziya, to a lesser extent and less often in connecting fabric of unstriated muscles of a gullet, intestines, gall bladder and uterus. At gistol. a research of skeletal muscles note disappearance of a fibrillar structure, striation, dystrophic changes of a sarcoplasm (muddy swelling, granular regeneration), variations in the size of fibers from small to large, changes in kernels of muscle fiber (increase in their number, emergence of big bubbly kernels with well noticeable kernels).

At a heavy current of primary G. mucinous liquid accumulates in serous cavities of a pericardium, a pleura and an abdominal cavity. In a myocardium observe the expressed hypostasis of muscle fibers and intersticial fabric, regarding muscle fibers — vacuolation, pycnosis of kernels, partial disappearance of cross striation. At elderly people these changes have diffusion character, the centers of fibrosis, and also the phenomenon of atherosclerosis with defeat of coronal vessels are found in them. The front share of a hypophysis at primary G. is increased, the quantity of eosinophial cells in it is reduced, the number of the cells with rare amfofilny granularity called mucoid cells or gamma cells is considerably increased; believe that they were formed of basphilic cells. At sharply expressed it is also long not treated G. also the adenomas consisting of 7 cells are found nodal a hyperplasia.

At secondary G. in gipotalamo-pituitary area find inflammatory changes, necroses, tumors. Owing to loss of tropny functions of a hypophysis in a thyroid gland, adrenal glands and gonads moderately expressed atrophic changes are noted.

After surgical intervention is caused by excess removal of thyroid fabric and easing in the rest of reparative processes; it is excessive cicatricial fabric is formed. In a thyroid gland at G. which resulted from a roentgenotherapy or use of a radioiodine atrophic processes, fibrosis of connecting fabric, sometimes multinuclear syncytial cellular forms with a large amount of chromatin, quite often pycnosis of kernels appear.

The clinical picture

the Disease usually develops slowly. Patients quite often long time do not notice the disturbances arising at them and do not see a doctor, often they complain of slackness, unwillingness to move, a sharp memory impairment, drowsiness, hypostases, a xeroderma, locks. Expressiveness of symptoms depends on degree of thyroid insufficiency. Outward of patients changes, the movements at them are slowed down, a look indifferent, quiet, the person roundish, bloated, there is considerable hypostasis in lower eyelids, a lip of a tsianotichna, on a pale face an easy cyanochroic flush of cheeks. Patients are warmly dressed in any weather because of constant cold sense. Skin is pale, sometimes with a yellowish shade because of a hyper carotenemia, cold to the touch, dry, shelled, rough, reinforced. The peeling of skin is quite often more expressed on a front surface of shins. Excessive keratinization and a thickening of epidermis on a lap and elbows (Bør's symptom) is characteristic. There is a myxedema of hypodermic cellulose which is especially expressed on a face, shoulders and shins. Hypostasis has a peculiar character: during the pressing of a pole does not remain, skin does not gather in folds. Hypostasis quite often extends to mucous membranes, in particular language, a nose and a throat in this connection phonation of the speech (a hoarse voice) can be broken. Hair grow slowly, they fragile, easily drop out. Quite often there comes baldness. Sometimes hair of a lateral third of eyebrows drop out. Nails fragile with cross and longitudinal grooves. Body temperature at many patients is a little lowered. The thyroid gland at primary G. usually is not probed, at secondary can be a normal amount. From cardiovascular system at the vast majority of patients note bradycardia, reduction of the circulating blood and decrease in minute volume, dullness of tones, increase in borders of heart. In a cavity of a pericardium accumulation of mucinous liquid is frequent. On an ECG reveal a sinus bradycardia, a low voltage of teeth; the tooth of T izoelektrichen, is flattened or negative, amplitude of QRS is reduced. Sometimes at sick G. observe delay of atrioventricular conductivity; disturbance of a rhythm arises very seldom. According to data of elektrokimografichesky researches, sokratitelny function of a myocardium is reduced moderately, heart failure at patients in the absence of associated diseases of cardiovascular system develops seldom. Systolic the ABP it is quite often a little reduced, diastolic normal or is a little raised; as a result pulse pressure decreases. Most of researchers assumes that G. in connection with disturbance of lipid metabolism promotes development of atherosclerosis and coronary heart disease. At disturbances went. - kish. a path patients often complain of a loss of appetite, a meteorism, locks. Secretory and motor activity of a stomach changes, motive function and absorption are reduced. The liver is not increased. Decrease in filtrational ability of balls of kidneys is noted.

Function of bark of adrenal glands at G. is broken slightly, but in connection with the slowed-down metabolism of hormones in urine find the lowered allocation of 17 ketosteroids and 17 oxycorticosteroids.

Function of gonads decreases, women can have uterine bleedings, sometimes note an amenorrhea.

Standard metabolism is lowered. In blood the quantity of erythrocytes decreases, there is a hypochromia iron deficiency anemia (see. Anemia, thyroprival ). At patients with hypochromia anemia quite often reveal a leukopenia, note decrease in content in peripheral blood of the thyroxine, triiodothyronine, iodine connected with protein, and butanolekstragirovanny iodine, a hypercholesterolemia and the increased maintenance of p-lipoproteids. At primary G. the caption of the circulating thyroid autoantibodies (directed against thyreoglobulin) is considerably raised, at secondary G. their caption is low or they are absent. At patients with primary G. note bent to hypercoagulative processes: tolerance of plasma to heparin is increased, in blood concentration of fibrinogen is increased, the content of free heparin is reduced.

At G. there occur changes both in central, and in a peripheral nervous system. They are characterized by disturbance of psychological functions, a cherepnomozgovy innervation, the motive sphere, the shown gipomimiya, a bradykinesia, muscular weakness, coordination frustration. Sensitive frustration and changes in the reflex sphere, such as anizorefleksiya, patol, reflexes, decrease and lengthening of time of Achilles reflexes (Voltman's symptom) and their loss are observed.

Mental disturbances at G. depend on age, the disease, degrees of manifestation of endocrine and somatic disturbances develops in Krom.

Dysmnesias and intellectual decrease on organic type are inherent. These frustration define different degrees of manifestation of weak-mindedness which can vary in these cases from easy moronity to an idiocy. The delay of mental development at G. is most expressed of early children's age and at an inborn Form.

In mild cases of G. at adults only slowness of thinking and the speech, decrease in memory, fatigue can be noted. Patients are slowed down and have a peculiar outward — a bloated, roundish face.

At moderately severe G. indifference, apathy is noted; such patients seldom laugh or cry. Irritability, the grumbling suppressed mood and a depression can sometimes be observed.

At the expressed hypothyroid weak-mindedness patients are emotionally stupid, indifferent to surrounding or are monotonously good-natured, but can be spiteful and unfriendly.

Also frustration of an inclination and mood is characteristic of patients with an endocrine psychosyndrome at G. (see. Endocrine mental syndromes ).

Against the background of the listed hron, mental changes there can be psychoses as exogenous and organic character, and approaching on the structure endogenous psychoses (e.g., schizophrenia, maniac-depressive psychosis). Alarming depressions, so-called grumbling depressions, shizofrenopodobny psychoses with catatonic symptoms and excitement, and also shizofrenopodobny paranoid psychoses are described delirious, delirious and hallucinatory (with dominance of auditory hallucinations). The caused psychoses arising in an insignificant occasion in which structure struporous manifestations are noted meet and reaktivno. Also epileptic seizures, attacks of a katalepsy and narcolepsy are observed (however these phenomena are rather rare).

Complications

the Heavy complication of primary G. is the hypothyroid (myxedematous) coma developing at the patients who were long not receiving treatments, usually in winter time; the contributing factors for its emergence are serious associated diseases — pneumonia, malignant tumors, etc. The main differential sign distinguishing it from other comas is the hypothermia (body temperature lower than 35 °) in this connection a hypothyroid coma call also hypothermal. Distinguish two of its main phases: preky and to whom. In the first phase confusion of consciousness is periodically noted, quite often there are spasms, perhaps struporous state (see. Coma ). In the second there comes deep dead faint, the coma at most of patients comes to an end with death.

The diagnosis

primary G.'s Diagnosis is made in the presence of a number of characteristic symptoms: peculiar outward, xeroderma, existence of characteristic hypostases, physical. and mental block, chill, locks. From datas of laboratory the greatest diagnostic value has hypercholesterolemia (see), decrease in standard metabolism, decrease in absorption by a thyroid gland of a radioiodine (it is lower than 10%), decrease in content in blood of the iodine connected with protein (it is lower than 3,5 — 4,0 mkg of %), and butanolekstragirovanny iodine (it is less than 2,5 — 3,0 mkg of %). Elimination of symptoms at treatment by thyroid drugs confirms the diagnosis.

Secondary G. differs from primary in smaller expressiveness of symptoms, existence patol, process in gipotalamogipofizarny system, considerable decrease in activity of bark of adrenal glands and gonads in connection with insufficient secretion adrenocorticotropic and gonadotropic hormones of a hypophysis.

Fig. 2. The roentgenogram of a thorax of the patient primary hypothyroidism with the phenomena of a hydrocardia: the dotted line specified borders of heart in 2 months after an initiation of treatment by thyroid hormones.

Rentgenol, a research reveals changes in heart and went. - kish. path. Rentgenol, a picture of heart is characterized by significant increase in its sizes, slow and sluggish reductions. Quite often find availability of liquid in a pericardium, disappearing or considerably decreasing in the course of replacement hormonal therapy (fig. 2). In went. - kish. a path — decrease in motility of intestines and hypostasis of a mucous membrane. The bone system at adults at G. is not broken.

Test has differential and diagnostic value with thyritropic hormone (see). At secondary G. after introduction of 5 — 10 PIECES of thyritropic hormone absorption of a radioiodine by a thyroid gland and the content in blood of the iodine connected with protein is normalized; at primary G. these indicators remain reduced. Sick G. patients with hron can have external looking alike, nephrite, but existence of changes in urine allows to differentiate G. from damage of kidneys.

Treatment

sick G.' Food shall be full; at obesity restriction of caloric content of food is necessary. Appoint redoxons, groups B and A; at development of hypochromia anemia — iron preparations, at hyperchromic — vitamin B 12 . Drug treatment comes down to purpose of the corresponding doses of the thyroid drugs which are gradually eliminating G. Primenyayut's symptoms the dried-up drug of a thyroid gland — Thyreoidinum, thyroxine and triiodothyronine. Action of Thyreoidinum is defined generally by thyroxine. The daily dose for each patient is established by gradual increase in amounts of the entered hormones. Reasonablly simultaneous introduction of Thyreoidinum or thyroxine and triiodothyronine that provides activity of a thyroid gland, necessary for an organism. Thyroxine works slowly, triiodothyronine quickly and more vigorously therefore it is reasonable to select a daily dose, changing amount of triiodothyronine. The patient of young and middle age without changes of coronal vessels of heart appoint Thyreoidinum on 0,1 — 0,2 g a day and with addition of triiodothyronine on 5 — 10 mkg each 3 — 5 days before normalization of pulse rate and reduction of other symptoms. At overdose the phenomena are possible thyrotoxicosis (see) which disappear after cancellation of triiodothyronine or temporary reduction of its dose. By sick primary G. and coronary heart disease it is necessary to appoint thyroid drugs with care since strengthening of activity of a myocardium can cause acute coronary insufficiency. Initial doses of Thyreoidinum of 0,005 — 0,01 g 2 times a day. If there is no deterioration in indicators of an ECG and there are no symptoms of stenocardia, in 5 — 10 days the dose of Thyreoidinum is increased by 0,01 g. At use of triiodothyronine an initial daily dose of 5 — 10 mkg, tactics of observation same. At development of a hypothyroid coma appoint triiodothyronine on 100 mkg 2 times a day, the patient with coronary insufficiency on 10 mkg 2 — 3 times a day. After removal from a coma the daily dose is gradually reduced. At secondary G. before purpose of thyroid drugs for elimination of the phenomena of a hypocorticoidism appoint glucocorticoids.

Treatment of mental disturbances consists first of all in treatment of the basic endocrine disease (replacement hormonal therapy); apply also symptomatic psikhofarmakol, means (stimulators, antidepressants, etc.).

The forecast

At primary G. timely and correct treatment eliminates G.'s symptoms, recovers working capacity, however recovery does not occur and at cancellation of thyroid drugs the recurrence is observed. At secondary G. the forecast depends on the nature of defeat of gipotalamogipofizarny area and extent of loss of functions of a hypophysis.

Prevention the acquired G. it is connected with improvement of the equipment of surgical intervention on a thyroid gland, with the correct selection of a dose of a radioiodine at treatment of a thyrotoxicosis, with careful treatment by drugs of usual iodine, with purposeful and early treatment of an acute and subacute thyroiditis.

The hypothyroidism at children

the Hypothyroidism at children as well as at adults, is divided on primary and secondary. Primary G. can be inborn — spontaneous cretinism (see) and acquired (a juvenile hypothyroidism). Is one of the most widespread endocrine diseases at children.

The etiology of the acquired G. does not differ from primary G.'s etiology at adults. Inborn G. develops at a hypoplasia of thyroid fabric, its embryonal allotopias, and also at disturbance of biosynthesis of thyroid hormones in the form of defect of absorption of iodide a thyroid gland, lack of organic binding of iodide, disturbance of dehalogenation of iodtyrosines, defect of condensation of the iodated tyrosines in yodtironina, educations patol, an iodprotein.

The pathogeny is connected with a lack of an organism of the child of iodinated hormones.

Pathoanatomical changes

the underdevelopment of gonads, sharply expressed changes of bone system is characteristic Of inborn G.: growth inhibition, processes of ossification and differentiation of a skeleton; deformations of a skull, disturbance of development of cartilaginous tissue of an epiphysis of tubular bones with subsequent changes in ossification — the numerous wrong focuses disseminated through all zone of the changed cartilage (so-called epiphyseal disgenez). The same changes observe at the children who got sick at early age. At early children's age leads also to an arrest of development of a brain and to the dystrophic phenomena in nervous cells of bark, a myelencephalon and cerebellum (a chromatolysis, vacuolation, the eccentric provision of kernels).

Clinical picture

Fig. 3. An inborn hypothyroidism at the 3-year-old child: badly holds the head, a face odutlovato, the mouth is half-open, language is edematous.

Part of children with inborn G. at the birth weighs more than 4000 g, fiziol, jaundice at them has long character, after usual the umbilical cord disappears, herniation is possible. Children badly take a breast. By 3 — 6 months slackness and indifference of the child attracts attention, he does not recognize mother, is not interested in toys. Skin is pale, dry, cold to the touch, the general puffiness. Come to light a delay in growth and lag in physical. and intellectual development. Children in usual terms do not hold the head (fig. 3), do not sit down; start walking only after 2 — 3 years. The head in comparison with a trunk big, a parietal fontanel remains open at children 2 years are more senior. The teething is late, they quickly collapse. Hair are rare, dry, fragile. The voice is low, rough. The stomach is increased, a meteorism, locks are characteristic. Growth is slowed sharply down, ossification centers appear late. Bradycardia, arterial hypotension, dullness of cardiac sounds is often noted; changes of an ECG same, as at adults, but less expressed. The delay of intellectual development, sluggishness, slackness, indifference, sometimes aggression is observed, disturbances of mentality are possible. Degree of manifestation of disturbances, and in particular a myxedematous edema, varies. At the acquired G. which developed after 6 — 10 years, a wedge, a picture same as at adults, but usually with less expressed symptoms.

At inborn G. exclusive value early diagnosis since timely begun treatment provides normal physical has the diagnosis. development and improvement of activity of a brain. However because of late manifestation of symptoms of G. seldom find to six-months age. Establishment of the diagnosis is promoted by emergence characteristic a wedge, pictures: increase in blood of content of cholesterol, decrease in the level of the iodine in it connected with protein and butanolekstragirovanny iodine (children about one year respectively less than 5 and 4 mkg of %, at more adult children have criteria of diagnosis same, as at adults). Decrease in standard metabolism has smaller diagnostic value. The diagnosis is validated by efficiency of use of thyroid hormones. Sometimes causes difficulty differential diagnosis of inborn G. with rickets. At inborn G. find a peculiar dry skin, myxedematous edemas, insufficient formation of ossiform fabric, a hypothermia; at rickets these signs are absent.

Fig. 4. The roentgenogram of a brush of the boy of 14 years at an inborn hypothyroidism (on the right): ossification corresponds to 2-year age; at the left for comparison — the roentgenogram of a brush of the healthy 14-year-old boy.
Fig. 5. The roentgenogram of a shoulder joint of the boy of 6 years at an inborn hypothyroidism: disturbance of development of cartilaginous tissue of an epiphysis of a humeral bone with existence of the centers of ossification (it is specified by shooters), 1 — a clavicle; 2 — an acromial shoot of a shovel; 3 — a head of a humeral bone.

Changes of bone system note at inborn G. and at the children who got sick at early age, usually up to 5 — 6 years. Radiological sharp delay of ossification, growth and a differentiation of bones of a skeleton is defined. The later treatment is begun with thyroid hormones, the these disturbances are expressed more sharply. The skull is rather big, its brain part is increased in the perednezadny direction and shortened from top to down. The facial skull is deformed with formation of the pulled-in nose. All ossification centers of a skeleton appear with considerable delay, epiphyseal lines long remain open. The endostosis is slowed down much more, than periosteal. Tubular bones the short, but thick, closing plates of their metafizarny ends are sclerosed. Additional ossification centers are often observed. The delay of ossification is well visible on roentgenograms of a brush (fig. 4) and area of a radiocarpal joint. At inborn G. development of cartilaginous tissue of an epiphysis and round tubular bones with the subsequent abnormalities in ossification is broken. On the roentgenogram according to a stage of process many small centers of ossification in the form of dot, porous or separate fragments (fig. 5) are visible. Further they increase and merge, forming one irregular shape the center. These disturbances have generalized character and have differential value for inborn G.'s diagnosis since do not meet at other forms of a nanism (see. Dwarfism ). Rentgenol, a research not only promotes identification of bone changes at G., but also is a valuable control method of results of treatment.

Treatment

the Main type of therapy is use of thyroid hormones. Treatment shall begin immediately after establishment of the diagnosis or even at assumed to G. Dozirovk appoint individually, depending on age and expressiveness a wedge, pictures, in the course of treatment it is specified according to the received results. Due to the need of bystry and full elimination of symptoms of G. apply the highest doses of thyroid drugs.

The highest daily doses of Thyreoidinum for children: 0,03 g up to 6 months, 0,06 g from 6 months to 1 year, 0,09 g in 2 years, 0,15 g in 3 — 4 years, 0,25 g in 5 — 6 years, 0,3 g in 7 — 9 years and 0,45 g in 10 — 14 years. As well as at adults, reasonablly simultaneous introduction of Thyreoidinum and triiodothyronine: in days to 2/3 highest doses of Thyreoidinum add triiodothyronine in a dose of 5 mkg to children from a year to 5 years and in a dose of 10 — 15 mkg to children 5 years are more senior. At the same time appoint vitamins of group B, C, A, D. The dosage of thyroid drugs is validated by disappearance or considerable reduction a wedge, symptoms within 2 — 3 months from an initiation of treatment and normalization of content of cholesterol in blood. At a growth inhibition within a year, despite purpose of adequate doses of thyroid drugs, to children 8 — 10 years are more senior appoint drugs of anabolic steroids in the doses corresponding to age: Nerobolum, nerobolil, retabolil, etc. Treatment is carried out by 2 — 3 months, 3 courses in a year. Good nutrition, education and training of sick children at speech pathologists are of great importance.

The forecast

G. which arose at children is hron, a disease. Timely begun treatment can provide normal physical. development and to improve a condition of mental processes.

Prevention it is carried out by the same principles, as at adults.

See also Thyroid gland .


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