CM & SURGERY
Toxic MNG (Plummer’s disease) Secondary:
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Multiple overactive nodules
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Goiter present (multiple nodules palpable)
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Secondary hyperthyroidism: This is overactivity that develops in an already hyperplastic gland. It is a disease of the middle age and occurs in patients with a preexisting euthyroid enlarged nodular gland. i.e. Long history of MNG.
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Develops from multinodular goiter. Nodules become autonomous i.e., become hyper active- independent of TSH
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Cardiac symptoms more common, eye symptoms-rare
ENT
Primary Thyrotoxicosis (Grave’s disease)
Definition
It is an autoimmune disease that leads to the formation of thyroid stimulating antibodies (IgG).
Clinical Picture
The disease has an abrupt onset and shows remissions and exacerbations.
Symptoms
- CNS: irritability, nervousness, insomnia, nightmares, and tremors.
- CVS: palpitations, dyspnea (if heart failure).
- Metabolic: increased appetite with weight loss and heat intolerance.
- Eye: protrusion of eyeball and diplopia.
- Muscles: easy fatigability.
- GIT: diarrhea.
- Urinary: polyuria.
- Sexual:
- Male: impotence
- Female: menorrhagia, late amenorrhea.
Signs
- Pulse: Rapid, may be irregular (A. F.).
- Blood pressure: high systolic, low diastolic & wide pulse pressure.
- Temperature: increase if thyrotoxic crises.
- Eye: true exophthalmos, eye signs
- Von Graefe’s (lid lag sign): lagging of the upper eyelid on looking downward without moving the head.
- Upper Limbs (UL): fine tremors, moist warm skin.
- Lower Limbs (LL): pretibial myxedema, myopathy of proximal muscles.
Local Examination
- Inspection: symmetrical swelling in the front of the neck moves up & down with deglutition.
- Palpation: symmetrical diffuse, firm, non-tender, freely mobile swelling.
- Auscultation: bruit over upper lateral part of the gland.
Investigation
- Thyroid function tests:
- Free T3 & T4: high.
- TSH: suppressed.
- Ultrasound of the neck: mild diffuse enlargement.
- Thyroid scan: diffuse uptake and exclude retrosternal goiter.
- Thyroid Antibodies: present.
Treatment
A. Medical Treatment (main line of treatment)
- Thiouracil group (inhibit peroxidase and iodine binding to tyrosine) as Neomerazole.
- Beta-blockers (propranolol): it protects the heart from arrhythmia.
B. Surgical Treatment
- Total thyroidectomy after preparation
- Indicated in: failure of medical treatment, RSG or huge sized goitre.
C. Radioactive Iodine
- Indicated in: failure of medical treatment in patients > 45 years.