Restless leg syndrome on an airplane. Restless Leg Syndrome, what is it? Symptoms and treatment. Treatment of RLS with medications

(or Graves' disease, diffuse toxic goiter) is a disease characterized by an increase in the activity of the thyroid gland, an increase in the size of this gland due to autoimmune processes in the body.

When goiter is noticed thyroid enlargement due to the rapid multiplication of cells in this gland.

As a rule, this disease is associated with a lack of iodine in the body.

Graves' disease is one of the most common thyroid diseases. Although the cases of this disease are less common than hypothyroidism, it is still In second place after him among diseases of the thyroid gland.

Graves' disease, in many cases, is inherited through the female line. Most often, the disease is transmitted through the generation - from grandmother to granddaughter.

Causes of Graves' disease

As mentioned above, Graves' disease is an autoimmune disease. It is the result of defects in the immune system, which begins to produce substances that interfere with the normal functioning of the body. Diffuse goiter is characterized by the fact that lymphocytes begin to produce an abnormal form of a protein that has a stimulating effect on the thyroid gland. This protein is called "long-acting thyroid stimulator".

Diffuse toxic goiter is a very common disease (1 patient per 100 people). It most often affects young and middle-aged women.

Causes of occurrence this disease can be different:

• long-term chronic infections in the body;
• hereditary predisposition.

Viral infections

Toxic goiter can appear as a result of various viral infections.

radioactive iodine

Radioactive iodine (used as a test) can also cause this disease.

Other reasons

Very often, diffuse goiter is promoted by chronic tonsillitis.

Also, Graves' disease can appear in patients:

• diabetes mellitus;
• Addison's disease;
• vitiligo;
• hypoparathyroidism.

Signs of diffuse toxic goiter

The symptoms of Graves' disease are almost the same as those of hypothyroidism, which in many cases is the initial form of the disease.

General symptoms

The disorder is characterized by symptoms such as:

• vomit;
• nausea;
• enlargement of the thyroid gland.

The patient experiences a feeling of heat even during cold weather.

Early symptoms of Basedow's disease

In the early stages of the disease, there are almost no visible symptoms. Graves' disease (Basedow's disease) in many cases has individual symptoms, which makes it difficult to determine the correct diagnosis. Among the first symptoms you can notice:

• sleep disturbance,
• trembling on the fingers,
• palpitations,
• increased sweating,
• mood swings.

More common symptoms are:

• poor heat tolerance;
• weight loss (even with a normal diet).

eye level changes

A specific symptom of Graves' disease is considered modifications in the eye area:

• pronounced shine of the eyes;
• rare blinking;
• Dalrymple symptom (wide-open eyes).

Other signs may appear, such as eye damage:

• enlargement and protrusion of the eyes (bulging eyes);
• feeling of "sand" in the eyes, double vision.
• when looking down with eyes open, a white streak appears above the pupil. In a healthy patient, this does not happen, because the eyelids, as usual, follow the eyeball.
• in patients, there is an increase and protrusion of the eyeball.
• sometimes, the eyelids are characterized by swelling.
• malnutrition of the eyes can cause various eye infections - inflammation of the mucous membrane of the eye ( conjunctivitis).
• the nutrition of the eyeball is disturbed, optic neuritis appears. As a result, the patient may experience blindness.

Skin modifications

With the evolution of the disease, the patient's trembling becomes more noticeable throughout the body. Skin becomes moist and patients are fussy. The skin throughout the body takes on a swarthy shade, and is more pronounced in the eyelid area. In some cases, the skin in the area of ​​​​the legs and feet is compacted in the form of a dense edema.

The volume of the thyroid gland increases and becomes more noticeable. When palpated, it has a dense character and pain is not felt.

Cardiovascular disorders

One of the most severe manifestations of diffuse toxic goiter are violations of the cardiovascular system. The patient begins to have problems such as:

• heart rhythm disturbances;
• palpitations (even during sleep).

Many older patients often experience angina attacks. There is an increase in blood pressure. This disease can cause fatal heart failure.

Increased motility of the gastrointestinal tract

Increased activity of the thyroid gland increases the motility of the gastrointestinal tract. The following symptoms appear:

• nausea;
• diarrhea and vomiting (less common).

liver problems

With an excess of thyroid hormones, the liver can suffer because they have a toxic effect on this organ. In some cases it develops fatty degeneration of the liver.

Violation of the nervous system

A high concentration of thyroid hormones in the blood can affect the functioning of the central nervous system. Thus, there are such states as:

• insomnia;
• dizziness;
• headaches;
• anxiety states.

impotence and infertility

With hyperactivity of the thyroid gland, there is also a violation of the function of other endocrine organs and even the sex glands.

In men potency decreases. For women, the situation can become more difficult because they are noticed menstrual disorders and even infertility.

Violation of sugar metabolism

There is a decrease in the production of hormones by the adrenal cortex and impaired glucose metabolism. Because of the latter, the patient is at risk of developing diabetes.

Graves' disease stages

There are three stages of Graves' disease:

• light;
• average;
• heavy.

First stage

During the first stage, the patient feels well.

• The purity of heart contractions does not go over 100 beats per minute.
• The patient has a 10% weight loss.

middle stage

• During an average degree of disorder, the pulse rises above 100 beats per minute.
• It also increases blood pressure and reduces weight by 20%.

severe stage

• The severe stage is characterized by a weight loss of more than 20%, the pulse rises above 120 beats per minute, side effects of the disease on other organs are noticed.

Diagnosis of Basedow's disease

Graves' disease diagnosis formed on the basis of:

• clinical picture;
• ultrasound examination;
• palpation of the thyroid gland;
• analysis of the concentration of thyroid hormones in the blood.

Treatment of Graves' disease

Medical treatment

Graves' disease is treated with medication.

The main prescribed drugs that suppress the activity of the thyroid gland are thyrostatics:

• propycil;
• carbimazole;
• thiamazole.

At the beginning of the disease, high doses of drugs are used, which decrease over time. Treatment of the disease is carried out by controlling the level of thyroid hormones in the blood until all signs of Graves' disease disappear (at least a year).

Also apply:

• beta blockers;
• glucocorticoids;
• immunocorrectors;
• levothyroxine.

Surgical intervention

If medical treatment does not help, then surgical treatment is performed. Thus, part of the thyroid gland is removed.

Removing part of the thyroid gland the cause of the disorder is not eliminated.

Treatment with radioactive iodine

Another method of treating Graves' disease, with the ineffectiveness of medications, is the treatment with radioactive iodine.

This technique unacceptable for young people childbearing age, but great for the elderly.

Radioactive iodine, when it enters the body, damages the cells of the thyroid gland and, as a result, the activity of this gland decreases.

During the treatment of the disease, you need to reduce the amount of iodine-rich foods and do not take iodized salt. Sunbathing during treatment is also not recommended, because there is a risk of making the treatment ineffective.

Prevention of diffuse toxic goiter

Prevention of the disease consists in such measures:

• lifestyle control;
• health monitoring;
• timely treatment of chronic and viral infections.

They, in many cases, can become the causes of Graves' disease.

You can not be nervous and sunbathing.

Stress can only hurt.

Graves' disease manifests itself most often at the age of 30 - 40 years, which is why it is recommended at this age go to the endocrinologist more often.

Graves' disease is common throughout the world and belongs to a severe autoimmune disease, ranking 2nd after hypothyroidism. It is difficult to treat, often recurs, so it is recommended to consult a specialist at the first sign. The disease has other names: diffuse toxic goiter, Graves' disease. In ICD 10, the disease has the code E05.0.

What is Basedow's disease

The disease occurs due to increased activity of the thyroid gland. Under its influence, disturbances occur both in the nervous system and in the tissues of the body, which leads to a strong deterioration in human health.

The etiology of the disease is not fully understood. It most often occurs between the ages of 30 and 40. During this period, the body may fail, which leads to the appearance of this serious illness. Numerous studies have confirmed that this disease develops in those people who have a family history of various pathologies of the thyroid gland. However, healthy people with good heredity can also get it. Moreover, deviations are more common in women than in men.

Can diffuse toxic goiter occur in children? Yes maybe. Such cases do occur. According to studies, it can appear in the age range from 10 to 15 years, but there have been cases of diffuse toxic goiter even in infants. In girls, the disease manifests itself 7-8 times more often than in boys.

Causes

Graves' disease occurs due to an overactive thyroid gland. The thyroid gland enlarges, producing more hormone than in the normal state. The main reason for this process is that the immune system of a sick person produces special antibodies, due to which the thyroid gland begins to function actively. For this reason, the concentration of hormones in the blood is greatly increased.

So far, scientists do not know why such autoimmune failures occur in the body. There are several different theories. One claims that the immune system is defective. Therefore, a person cannot contain the immune response that acts against him. In addition, there is a theory about the presence in the body of the wrong receptors that the immune system does not accept, defining them as foreign. It is also believed that this disease develops with a lack of iodine.

The following reasons lead to the progression of the disease:

• heredity;
• hormonal disorders during pregnancy and in the postpartum period;
• environmental degradation;
• stress and depression;
• chronic diseases.

In addition, diseases of the pituitary gland, radiation therapy, diabetes mellitus, diseases of viral origin can provoke the development of pathology.

The exact causes of the disease have not yet been fully identified, but it has been proven that the acute form develops as a result of severe stress, which was transferred shortly before the onset of the disease. Stress is a trigger for the development of pathology.

Symptoms of Basedow's disease

The signs of this disease in both men and women are similar to those characteristic of thyrotoxicosis, so it is not always possible to correctly diagnose at an early stage. In the body of the patient there is a violation of the work of various systems. The patient may notice that his pulse has become faster, sweating has become too active, and diarrhea has also appeared.

The nervous system is actively stimulated, so the patient becomes irritable and restless. His hands begin to shake periodically, he cannot stand hot weather, as his health deteriorates sharply under the scorching sun.

The person's appetite persists, but the patient begins to lose weight dramatically. Food entering the body does not have time to properly digest. The thyroid gland actively produces hormones and leads to the rapid breakdown of nutrients. At the same time, in young people with increased metabolism, weight gain is observed. In addition, many begin frequent urination, which can lead to severe dehydration.

A characteristic symptom of this disease is endocrine ophthalmopathy, which is expressed in bulging eyes. In many cases, both eyes are affected. Ophthalmopathy may develop earlier or later than the disease itself.

Excessive activity of thyroid hormones leads to increased irritability, mood swings, despondency and depression. A person becomes touchy and tearful, his sleep and appetite are disturbed, fears and anxiety appear. The mood often changes, which is associated with increased levels of thyroid hormones.

A goiter appears in the throat area - a tumor on the gland. A swelling occurs on the surface of the neck, which the doctor draws attention to when examining the patient.

There are 3 stages in the development of the disease. If it is at the initial stage, then the symptoms are mild. If the disease is in a neglected state, then the patient's well-being deteriorates greatly. The heart begins to work at an accelerated pace and intermittently, a person gradually loses weight, which leads to weakness and poor brain function.

A goiter appears in the throat area - a tumor on the gland, a swelling appears on the surface of the neck, which the doctor draws attention to when examining the patient.

If you do not take up the treatment of the disease in time, then a thyrotoxic crisis may develop.

Diagnostics

At the first suspicion of this disease, you should contact an endocrinologist. He will conduct an examination and direct the patient to take the necessary tests. During the study, the amount of thyroid hormones, the presence of antibodies and the ability of the body to accumulate iodine are determined.

In parallel with this, an ultrasound examination of the gland is prescribed. In addition, if diffuse toxic goiter is suspected, a thyroid biopsy may be necessary. It is carried out using a thin needle, which is used to collect cells. Then they are examined under a microscope.

Treatment

Treatment of the disease should be strictly controlled by a doctor.

In no case should you make decisions about the method of therapy yourself. Most often, with this disease, a specialist prescribes thyreostatic drugs. Medicines to reduce thyroid hormone production can be given to children, adolescents, and adults.

Exophthalmos in Basedow's disease affects both eyes. Sometimes treatment has a positive effect. If this does not happen, then surgery is recommended.

Quite often, the abolition of thyreostatic drug leads to a relapse. If the disease is advanced and cannot be cured in this way, then an operation will be required in which part of the thyroid gland must be removed. This intervention is called a thyroidectomy.

In addition, treatment with radioactive iodine is widely practiced. It causes destruction of body cells. The drug is available in the form of capsules. The necessary dosage should be calculated by the attending physician, depending on the neglect of the disease. After such treatment, the disease recedes. This takes several weeks. Sometimes a second dose of iodine is required.

Folk methods of treatment

Treatment of diffuse toxic goiter with folk remedies has been practiced for a long time. Such treatment is especially effective at the very beginning of the disease. However, all home procedures must be coordinated with the endocrinologist without fail, so as not to harm your health.

Larisa Rakitina on one of the most common thyroid diseases and its treatment options

A rare medical textbook that mentions the thyroid gland does without a photograph of a patient with a large formation in the neck and bulging eyes - a classic portrait of a person suffering from diffuse toxic goiter, or Graves' disease.

It is one of the best known endocrine diseases and the most common cause of thyrotoxicosis. They affect 1% of all women and 0.1% of men. Graves' disease, or Graves' disease, or diffuse toxic goiter (DTG), is an autoimmune organ-specific disease caused by hypersecretion of thyroid hormones. The term "diffuse toxic goiter" is accepted in domestic endocrinology, the name "Graves' disease" is used in English-speaking countries, and "Basedow's disease" or "Basedow's syndrome" in German-speaking countries.

This disease was first described in 1835 by the Irishman Robert James Graves (1797–1853). Almost simultaneously with him, in 1840, the German physician Karl Adolf von Basedow (1799–1854) described the so-called Merseburg triad observed by him in four patients (after the city of Merseburg, where he worked) - tachycardia, exophthalmos and goiter, which are characteristic symptoms of DTD. Basedow himself called the disease he described exophthalmic cachexia.

Etiology and pathogenesis

The basis of the mechanism of development of Graves' disease is the production of autoantibodies to the receptors of the plasma membranes of thyrocytes, close to thyrotropin receptors. These antibodies are called thyroid-stimulating immunoglobulins. The reason for their formation is unclear (just as the causes of other autoimmune diseases are unclear). It is believed that mental trauma, allergic reactions, inflammatory diseases can serve as a trigger, but congenital immunological deficiency associated with hereditary factors plays a major role in pathogenesis.

Genetic studies show that if one of the monozygotic twins suffers from Basedow's disease, then for the other the risk of the disease is 60%; in the case of dizygotic couples, this risk is only 9%.

Diffuse toxic goiter is often combined with other autoimmune diseases. They are more common in young and middle-aged women. Interestingly, antibodies produced during DTG have a stimulating effect on the target organ, and not a destructive effect, as in other autoimmune processes. Constantly being in a state of increased activity, the thyroid gland produces an excess amount of thyroid hormones. As a rule (but not always), this leads to its diffuse increase and the development of ophthalmopathy. Clinical manifestations of Graves' disease are determined by thyrotoxicosis - a syndrome that is caused by a prolonged increase in the concentration of thyroid hormones in the blood and tissues.

Since thyroid hormones are involved in the regulation of the functions of almost all body systems, an increase in their concentration has a negative effect on many organs and systems. In general, we can say that with thyrotoxicosis, all metabolic processes are accelerated.

Clinical picture in Graves' disease: causes and symptoms

Endocrinologists know that the diagnosis of thyroid diseases can often be made, as they say, “from the door”, that is, by one appearance and behavior of the patient, by the way he entered and spoke. Those suffering from Graves' disease, as a rule, look quite characteristic: they are emotionally labile, anxious, very mobile and restless. They are characterized by touchiness and tearfulness, they are prone to depression (however, they can also be euphoric). These patients are usually thin, with skin that is hot and moist to the touch, and they are always hot. Their eyes always shine unnaturally, often there is exophthalmos of varying severity.

On examination, they have tachycardia and, in most cases, a diffuse enlargement of the thyroid gland, which is called a goiter. If the neck is thin, it can be seen with the eye. On palpation, the gland is painless, soft-elastic consistency. In addition to these most common symptoms, described by Karl Basedow, there are many others that come to light with a more detailed examination.

1. The damaging effect of excess thyroid hormones on the cardiovascular system leads to the appearance of extrasystole, constant or less often paroxysmal sinus tachycardia, atrial fibrillation, systolic arterial hypertension, myocardial dystrophy and heart failure gradually develop.

2. Weight loss with increased appetite, hot skin, subfebrile condition, excessive sweating, muscle weakness are manifestations of the catabolic syndrome.

3. With damage to the central and peripheral nervous system, tremor of the fingers (“Marie's symptom”) and the whole body (“telegraph pole symptom”) are noted, tendon reflexes increase.

4. As a result of the action of an excess of T3 and T4, the autonomic innervation of the muscles of the eyeball and upper eyelid is disrupted and eye symptoms develop, of which more than 50 are described. The most common symptoms of Kocher and Graefe are the lag of the upper eyelid from the iris when looking down and, accordingly, up.

Eye symptoms should be distinguished from autoimmune ophthalmopathy, an independent autoimmune disease that develops in half of patients with DTG, mainly in men. With this disease, there is swelling of the retrobulbar tissue, impaired function of the oculomotor muscles and exophthalmos. Gradually, the connective tissue grows, and the changes become irreversible, conjunctivitis and keratitis develop with corneal ulceration, patients go blind. Oculists deal with ophthalmopathy. Treatment consists of maintaining a euthyroid state, prescribing glucocorticoids and NSAIDs. In the absence of adequate therapy, ophthalmopathy progresses. If changes in the paraorbital region have already become irreversible, ophthalmopathy persists in the patient even after the elimination of thyrotoxicosis.

5. Abdominal pain, unstable stools, and impaired liver function are possible.

6. There is a syndrome of ectodermal disorders (brittle nails, hair loss and brittleness).

7. There may be dysfunction of other endocrine glands. Often the adrenal glands suffer, in women - the reproductive system. There are menstrual irregularities, decreased fertility, hyperprolactinemia.

8. In a small percentage of cases of Graves' disease, pretibial myxedema is accompanied - thickening of the skin of the legs and feet.

Thyrotoxic crisis

The most dangerous complication of thyrotoxicosis is thyrotoxic crisis. This is an acutely developing clinical syndrome, which is a combination of thyrotoxicosis with thyroid adrenal insufficiency.

Thyrotoxic crisis develops against the background of inadequate thyrostatic therapy after surgical interventions and in acute extrathyroid diseases. The reasons for its occurrence are not well understood. Patients with thyrotoxic crisis are subject to observation and treatment in the intensive care unit.

Clinically, a thyrotoxic crisis is manifested by a sharp increase in the symptoms of thyrotoxicosis with a progressive dysfunction of the cardiovascular system, gastrointestinal tract, central nervous system, liver and kidneys. There is hyperthermia up to 40 ° C, tachycardia, depression of consciousness up to coma. Thyrotoxic coma almost always ends in death. In addition, extremely difficult to correct acute cardiovascular insufficiency, which is the most severe complication of a thyrotoxic crisis, often develops. Mortality in thyrotoxic crisis reaches 75%.

Patients with thyrotoxicosis are often very popular with people of the opposite sex, unless, of course, changes in their appearance and behavior are moderate and are not perceived by non-medics as painful. I remember how a patient whose symptoms disappeared after successful treatment complained to me that before she had no end to fans, now the sparkle in her eyes was gone, and with it her sexual attractiveness ...

Differential diagnosis of diffuse toxic goiter

1. With subclinical thyrotoxicosis, there may be no clinical manifestations, therefore, when establishing such a diagnosis, one cannot focus only on symptoms.

2. Mandatory for suspected Graves' disease is the study of TSH and thyroid hormones in the blood. A low TSH level is an absolute diagnostic criterion. It should not be forgotten that the level of T3 and T4 is increased in the case of clinically developed thyrotoxicosis, in the subclinical form T3 and T4 may be normal with reduced TSH. In addition, there is almost always a high level of antibodies to the TSH receptor and often circulating antibodies to thyroid peroxidase and thyroglobulin (AT-TPO and AT-TG).

3. Ultrasound revealed a diffuse enlargement of the thyroid gland. However, ultrasound data are not decisive, since an increase in the gland is possible in other conditions.

4. Scintigraphy reveals diffuse accumulation of the radiopharmaceutical throughout the gland tissue.

Differential diagnosis is carried out primarily with diseases and conditions that occur with thyrotoxicosis syndrome (cystic drift, TSH-secreting pituitary adenoma, some thyroiditis, functioning metastases of thyroid cancer), as well as with diseases of the cardiovascular system, adrenal glands, psychopathy.

Treatment of Basedow's disease

To date, there are three ways to treat diffuse toxic thyroid goiter: therapy with thyreostatics, radioactive iodine-131 and surgical treatment. They have been used for almost 100 years, and during this time no other effective methods of treating those suffering from Graves' disease have been invented.

1. If Graves' disease was detected for the first time, as well as to achieve a euthyroid state before surgery and radiotherapy, thyreostatic drugs are prescribed. Basically, thionamides are now used, blocking the synthesis and release of thyroid hormones, these are thiamazole and propylthiouracil. Thyreostatics are fairly safe drugs, clinically significant side effects are rarely observed when using them, but it must be remembered that agranulocytosis may develop against their background.

Indications for the use of thyreostatics are limited. It makes sense to prescribe them with moderate clinical manifestations of newly diagnosed thyrotoxicosis and in the absence of complications. In addition, the course of treatment is one and a half years and not every patient can afford it. Against the background of therapy, drug-induced hypothyroidism develops and, as a result, the thyroid gland increases compensatory. This makes it necessary to prescribe replacement therapy with levothyroxine upon reaching euthyroidism. Along with thyreostatics, beta-blockers are often prescribed to relieve manifestations of the cardiovascular system.

It is clear that thyreostatic drugs do not have any effect on the activity of the immune system, in other words, they do not affect the cause of the disease, but only reduce the negative impact of excess thyroid hormones on the body, that is, thyrotoxicosis. After a one and a half year course of treatment, about half of the patients recover. In addition, there are cases of spontaneous cure of DTG with little or no therapy (according to various sources, 2-5%). Thus, the disease either goes away or requires radical treatment.

With DTG, the rate of exchange of corticosteroids always increases: their breakdown and excretion increase, resulting in the development of relative adrenal insufficiency, which increases during a crisis.

Sometimes at the very beginning of drug therapy, you can make an assumption about its prospects and effectiveness. Experience shows that there is little chance of a cure for:

• patients with large goiter;
• men;
• patients with initially high levels of T3 and T4;
• patients with a high titer of antibodies to the TSH receptor.

2. Surgical treatment of Graves' disease consists in marginal subtotal resection of the thyroid gland or even thyroidectomy. The purpose of the operation is to achieve irreversible hypothyroidism, in connection with which lifelong replacement therapy with levothyroxine is prescribed.

3. During radioactive iodine therapy, iodine-131 is prescribed with a therapeutic activity of about 10–15 mCi. Indications for radioiodine treatment do not differ from indications for surgical treatment.

Once I happened to see a patient in whom, as a result of inadequate therapy with moderate clinical thyrotoxicosis, ophthalmopathy led to loss of vision in both eyes and necrotic changes in the cornea. Ophthalmologists sewed up his eyelids, and they did not succeed on the first attempt - the seams cut through, the exophthalmos was so pronounced.

The only contraindications to it are pregnancy and lactation. For women of reproductive age, radioactive iodine therapy is given only after a pregnancy test, and contraception is recommended for a year after treatment.

The half-life of radioactive iodine-131 is only 8 days, irradiation is carried out locally. Therefore, in terms of non-invasiveness and safety, this method is even preferable to surgical intervention, and in developed countries it has long been the method of choice.

We still have more popular surgical treatment. The use of radioactive iodine is an expensive method, and there is a long queue for it, because there is only one radiological center in Russia - in the city of Obninsk, Kaluga region. Domestic radioactive safety standards differ from Western ones and do not allow outpatient radioiodine treatment. In addition, patients are often afraid of the word "radioactive" and categorically refuse this method of treatment.

The tactics of treating patients with Graves' disease in different countries and medical schools can vary significantly. For example, in the United States, in 60% of cases of newly diagnosed DTG, patients are recommended to be treated with radioactive iodine.

For a year and a half, the patient takes thyreostatics, after which, at certain intervals, the level of TSH and thyroid hormones is assessed. If these figures indicate persistent thyrotoxicosis, the question of radical treatment is raised, which in Europe is likely to be radioactive iodine, and in our country - surgery.

Forecast

The prognosis is favorable in most cases. In the case of long-term drug treatment, and sometimes in its absence (this is also possible), patients develop extrathyroid complications, most often from the cardiovascular system. But thyrotoxicosis is sooner or later replaced by hypothyroidism: the thyroid gland, which has been functioning in an enhanced mode for a long time, is eventually depleted, and the amount of hormones it produces falls below normal.

Thus, patients, both those who received radical treatment and those who did not receive it at all, come to the same result - hypothyroidism. True, the quality of life of the latter in all the years of the existence of DTG is low, and the former, subject to further lifelong use of levothyroxine, live a full life.

There is a certain difference in domestic and Western terminology. In Western literature, along with the term "thyrotoxicosis" and in a synonymous sense, the concept of "hyperthyroidism" is used. Russian endocrinologists call hyperthyroidism any increase in the functional activity of the thyroid gland, which can be not only pathological, but also physiological, for example, during pregnancy. This fact should be taken into account when reading English-language literature.

1. Fadeev V.V. "Handbook of the thyroidologist", 2002 2. Bahn R.S., Burch H.B., Cooper D.S., Garber J.R., Greenlee M.C., Klein I., Laurberg P., McDougall I.R., Montori V.M., Rivkees S.A., Ross D.S., Sosa J.A., Stan M.N. Hyperthyroidism and Other Causes of Thyrotoxicosis: Management Guidelines of the American Thyroid Association and American Association of Clinical Endocrinologists. // Thyroid - 2011 - Vol. 21. 3. Muller A.F., Berghout A., Wiersinga W.M., Kooy A., Smit J.W.A., Hermus A., working group Thyroid Function Disorders of the Netherlands Association of Internal Medicine. Thyroid function disorders - Guidelines of the Netherlands Association of Internal Medicine// Neth. J. Med. 2008. V. 66. P. 134–142. Translation and comments by V.V. Fadeeva "Clinical and experimental thyroidology" 2008, volume 4, no. 2, (http://medi.ru) 4. Balabolkin M.I. Endocrinology, 1998 http://med-lib.ru 5. Petunina N.A. Conservative treatment of diffuse toxic goiter: opportunities, problems, solutions (2009) medi.ru 6. Olovyanishnikova I.V. The effectiveness of the use of various schemes of drug therapy for diffuse toxic goiter. Prognostic Aspects (2005)

Thanks

The site provides reference information for informational purposes only. Diagnosis and treatment of diseases should be carried out under the supervision of a specialist. All drugs have contraindications. Expert advice is required!

What is Basedow's disease?

Basedow's disease- is genetically determined hereditary) a disease of the endocrine system, characterized by excessive production and release into the systemic circulation of thyroid hormones - thyroxine ( T4) and triiodothyronine ( T3). An excess of these hormones in the blood ( thyrotoxicosis) leads to the development of pathological changes in various organ systems - cardiovascular, nervous, muscular and others. At the same time, the thyroid gland itself increases in size, and the increase is diffuse in nature ( that is, all departments and sections of the gland increase).

Basedow's disease got its name in honor of the ophthalmologist Basedow, who in 1840 first revealed the relationship between an enlarged thyroid gland and bulging eyes ( which is one of the signs of this pathology). However, from a clinical point of view, another name for this disease is more correct - diffuse toxic goiter. It more accurately determines the main pathogenetic moments of the disease ( diffuse enlargement of the thyroid gland in combination with clinical signs of thyrotoxicosis) and is currently used by most doctors.

Epidemiology of diffuse toxic goiter

Diffuse toxic goiter occurs in all countries of the world. Predominantly people of working age are ill The peak incidence occurs between 20 and 50 years of age.), but quite often the symptoms of thyrotoxicosis begin to appear in childhood or adolescence. Graves' disease occurs about 10 times more often among women than among men.

After conducting many studies, a clear family predisposition to the development of the disease was revealed. Despite this, to date, it has not been possible to identify a gene that would be responsible for the development of the pathological process. Based on this, scientists suggested that the cause of the development of diffuse toxic goiter may be damage to several genes at once, which, when combined with certain provoking factors, can lead to the development of the clinical picture of the disease.

Why does the thyroid gland increase in Graves' disease?

pathogenesis ( development mechanism) Graves' disease has not been studied accurately enough to date. However, it is certainly known that the immediate cause of the development of the disease is a violation of the activity of the immune system of the body, which entails a violation of the function of the thyroid gland.

Under normal conditions, the formation and release of thyroid hormones is controlled by several regulatory mechanisms. In order for the synthesis of hormones to start in the cells of the thyroid gland, it is necessary to have a special substance - thyrotropin ( thyroid-stimulating hormone, TSH). This substance is secreted by the pituitary gland a special gland, which is located in the base of the skull and controls the activity of all endocrine glands of the body).

Thyrotropin secreted in the pituitary gland interacts with special receptors on thyroid cells. This leads to an increase in the process of iodine uptake by it and stimulates the synthesis of thyroid hormones, which are then released into the peripheral bloodstream. An increase in the concentration of thyroxine in the blood leads to the fact that the production of TSH in the pituitary gland decreases, which leads to a uniform decrease in the secretory function of the thyroid gland itself. Thus, the level of thyroid hormones in the blood is maintained at a constant level.

It is also worth noting that the regulation of TSH secretion is also carried out with the help of the so-called thyroliberin, a hormone produced by the hypothalamus ( thyroliberin stimulates the production of TSH). The hypothalamus is a region of the brain whose cells secrete biologically active substances ( hormones), regulating the activity of the pituitary gland ( and therefore all the glands in the body). The hypothalamus is connected to almost all the nervous structures of the human body, due to which it is considered a link between the nervous and endocrine systems.

With diffuse toxic goiter, a violation of the activity of the patient's immune system occurs. Under normal conditions, cells of the immune system ( lymphocytes) are active only against foreign microorganisms ( bacteria, viruses, tumor cells) and are inactive against the cells of their own body. With Basedow's disease, this rule is violated, as a result of which lymphocytes begin to produce antibodies against cells of their own body ( in particular, against receptors that are located on the surface of thyroid cells and with which thyroid-stimulating hormone of the pituitary gland interacts under normal conditions). The interaction of these antibodies with specific receptors of thyroid cells stimulates an increase in its size and enhancement of its functional activity, which ultimately leads to excessive formation and entry into the blood of thyroid hormones.

It is also worth noting that with Graves' disease, many organs and tissues throughout the body are restructured, as a result of which they become more sensitive to the action of thyroid hormones.

Reasons for the development of diffuse toxic goiter

As mentioned earlier, the main cause of the development of the disease is a genetic predisposition, leading to a violation of the activity of the immune system. However, various factors that affect the human immune system in a certain way can provoke the onset of the disease and the appearance of clinical symptoms.

The development of diffuse toxic goiter can be facilitated by:

• Female. Hormonal changes that occur in the female body ( refers to the menstrual cycle, pregnancy, the period of breastfeeding, menopause) cause lability ( instability) of the nervous, endocrine and immune systems, which explains the more frequent development of this disease in women.

• The period of puberty. At this time, a restructuring of the nervous and endocrine systems of a teenager occurs, which may be associated with increased sensitivity of tissues to thyroid hormones.
• Psychic trauma. Psycho-emotional experiences ( especially in childhood or adolescence) can cause dysfunction of the nervous system. This, in turn, can lead to dysfunction of the hypothalamic-pituitary system, followed by a violation of the activity of the thyroid gland and an increase in the sensitivity of tissues to its hormones. It has been scientifically proven that psychological trauma occurred in more than 80% of patients who were diagnosed with Basedow's disease. It is important to note here that it can play a decisive role as a one-time ( acute) mental trauma, and long-term ( chronic) negative mental influences.
• Infectious diseases. The penetration of infectious agents into the body leads to the activation of the immune system ( to fight foreign agents). However, in individuals predisposed to diffuse toxic goiter, prolonged or frequently recurring viral or bacterial infectious diseases ( influenza, tonsillitis, measles, scarlet fever, tuberculosis and others) can provoke a violation of immunity and the beginning of the production of antibodies to thyroid receptors. This is of particular importance in children whose immune system is not yet fully formed and "does not know how" to properly respond to foreign antigens.
• Brain injury. Damage to various structures of the central nervous system can provoke ( via the hypothalamus) the development of Basedow's disease.
• infectious encephalitis. Encephalitis is an inflammation of the brain tissue, which can also cause the development of diffuse toxic goiter.

Symptoms and signs of diffuse toxic goiter

Clinical manifestations of diffuse toxic goiter are due to excessive production of thyroxine and triiodothyronine. And since these hormones affect many tissues and organs, the clinical picture of Basedow's disease will also be very diverse.

Thyroid hormones are needed for the normal growth and development of organs and the whole organism. They regulate metabolism proteins, fats and carbohydrates), stimulate the processes of cell division in various tissues, while increasing their need for oxygen and nutrients. They also stimulate the activity of almost all systems in the body ( especially cardiovascular and nervous), activate thought processes and increase the psycho-emotional excitability of a person. In addition, it is worth noting that thyroid hormones increase tissue sensitivity to catecholamines ( to the hormones epinephrine and norepinephrine), which further enhances their stimulating effect on the cardiovascular, nervous and other body systems.

Graves' disease manifests itself:

• enlargement of the thyroid gland;
• eye damage;
• damage to various organs and systems.

Thyroid enlargement in Graves' disease

Enlargement of the thyroid gland is one of the characteristic signs of diffuse toxic goiter. However, it should be noted that this symptom can also be observed in a number of other diseases, so it should be evaluated only in combination with other clinical and laboratory data.

In Graves' disease, the thyroid gland usually enlarges diffusely ( evenly), however, sometimes there is a predominant increase in one of its shares. The gland itself is soft or moderately dense, painless and not soldered to the surrounding tissues, the skin over it is not changed.

The size of the thyroid gland varies depending on the stage of the disease. However, it should immediately be noted that the severity of the clinical manifestations of diffuse toxic goiter is determined not by the size of the gland, but by the level of hormones produced by it in the blood.

With Basedow's disease, 5 degrees of enlargement of the thyroid gland are distinguished, namely:

• I degree- it is impossible to visually determine the thyroid gland ( normal neck shape), however, on palpation ( probing) can reveal an increase in one or both of its shares.
• II degree- the thyroid gland is determined visually during the patient's swallowing movements, and its enlarged lobes are easily palpated.
• III degree- the gland is enlarged so much that it changes the structure of the front of the neck ( the neck becomes thicker than usual).
• IV degree- an overly enlarged thyroid gland protrudes on the front surface of the neck, significantly deforming it.
• V degree- an enlarged gland can reach a gigantic size ( up to several tens of centimeters in diameter).

Eye damage in Basedow's disease

eye injury ( endocrine ophthalmopathy) is observed in more than 20% of patients with Basedow's disease. It is important to note that the pathological changes that develop in this case are associated not so much with an excess of thyroid hormones, but with immune disorders. This is also proved by the fact that such changes in the eyes can also occur in other diseases, including hypothyroidism ( a condition characterized by low levels of thyroid hormones in the blood).

Endocrine ophthalmopathy can manifest itself:

• Bilateral exophthalmos ( bulging eyes). The mechanism of development of bulging eyes is quite complicated, but the main cause of this phenomenon is retrobulbar edema ( located behind the eyeball) fiber and oculomotor muscles, as a result of which the eyeball itself is “pushed out” of the orbit. In edematous tissue and muscles, an inflammatory process develops. With a long course of the disease in inflamed tissues, there is a proliferation of connective ( cicatricial) tissues, as a result of which exophthalmos becomes irreversible.
• Damage to the oculomotor muscles. As a result of spasm pronounced reduction) the muscle that lifts the upper eyelid, it ( eyelid) is constantly elevated. If the patient tries to follow the downward moving object, the eyelid “lags behind” the movement of the eyeball, as a result of which a white strip of sclera is determined between it and the cornea of ​​​​the eye. In addition, patients may present with convergence weakness ( eye information), that is, they cannot focus on closely spaced objects.
• Corneal damage. With Graves' disease, there may be a decrease in corneal sensitivity, as a result of which patients blink less often than ordinary people ( 2 - 3 times per minute at a rate of 6 - 8 times per minute).
• Wide eye opening. This is due to paresis of the circular muscles of the eyelids.
• Prominent gleam in the eyes.
• Swelling of the eyelids.
• Tremor ( shaking) closed eyelids.

Damage to various organs and systems in Graves' disease

As stated earlier, thyroid hormones affect the function of many organs and tissues throughout the body. That is why their excess in the blood will be manifested by violations from various systems.

With diffuse toxic goiter, the following can be affected:

• the cardiovascular system;
• nervous system;
• digestive system;
• musculoskeletal system;
• skin and its appendages;
• reproductive system.

The defeat of the cardiovascular system in Basedow's disease is characterized by:

• palpitations ( tachycardia). Patients may complain of increased over 90 beats per minute) and increased heart rate, which is sometimes accompanied by the occurrence of stabbing pains in the chest. Tachycardia with diffuse toxic goiter is constant and persistent ( persists even during night sleep), which makes it possible to distinguish it from that of other diseases.
• Shortness of breath. shortness of breath ( feeling short of breath) can occur in the early stages of the disease, which is associated with a violation of the pumping function of the heart. A distinctive feature is the nature of shortness of breath, which many patients describe as "dissatisfaction with inspiration."

Damage to the nervous system in Basedow's disease can manifest itself:

• An increase in body temperature. Permanent subfebrile condition ( increase in body temperature to 37.3 - 37.5 degrees) develops as a result of the effect of thyroid hormones on the thermoregulatory center located in the hypothalamus, as well as as a result of accelerating metabolism throughout the body.
• Change in the behavior of the patient. A change in the mental state and behavior of the patient is characteristic of severe forms of the disease, however, the first signs of these deviations can be observed for the first time after the onset of the development of the pathological process. Patients with Basedow's disease are characterized by irritability and aggressiveness, impulsivity, mild excitability and increased fatigue. They also often complain about sleep disturbance ( frequent nocturnal awakenings and/or insomnia) and emotional instability ( which is manifested by increased tearfulness). With prolonged progression of the disease, memory impairment and severe psychosis may occur.
• Damage to peripheral nerves. This is manifested by a characteristic fine tremor ( shaking) fingers, toes, tongue, eyelids, and so on ( up to trembling of the whole body in severe forms of the disease).
• Frequent headaches.

The defeat of the digestive system is characterized by:

• Increased appetite. This is due to increased production of acidic gastric juice, which is observed in the initial stages of the disease. Also, increased appetite is due to the acceleration of metabolic processes and the increased needs of the body for energy and other nutrients.
• diarrhea ( diarrhea). At the onset of the disease, there may be frequent ( 2 - 3 times a day) decorated chair ( due to increased appetite). With further progression of the disease, there is an increase in intestinal motility, as well as a violation of the function of the pancreas ( in particular, the amount of digestive enzymes produced by it is reduced). As a result, the food eaten is poorly processed, which leads to diarrhea. Diarrhea with diffuse toxic goiter is not accompanied by abdominal pain or tenesmus ( painful false urge to defecate).
• Vomit. Vomiting of recently eaten food is rare in Graves' disease. Its occurrence is explained by increased peristalsis ( motility) of the gastrointestinal tract, as well as possible spasm of the pyloric sphincter ( muscle located at the border of the stomach and intestines and controls the passage of gastric contents into the small intestine).
• Decrease in body weight. Despite the increased appetite, the body weight of patients with diffuse toxic goiter is significantly reduced, due to the accelerated metabolism in the body. This is most clearly seen in overweight people during the first few months after the onset of the disease.
• Liver damage. Under normal conditions, thyroid hormones are detoxified in the liver. In Basedow's disease, as a result of their increased entry into the liver, the organ's reserves are depleted and its blood vessels are damaged, which ultimately leads to the development of an inflammatory process ( hepatitis A). Patients complain of heaviness or stabbing pain in the right hypochondrium, indigestion, nausea or vomiting. On palpation, the liver is enlarged, it can be painful. Sometimes jaundice may appear, which is an extremely unfavorable prognostic sign.

The defeat of the musculoskeletal system is characterized by:

• Muscle damage. With prolonged course of the disease, muscle atrophy is noted ( decrease in muscle mass), muscle weakness progresses. In severe forms of the disease, paralysis may occur ( intermittent bouts of extreme muscle weakness lasting from hours to days). The cause of their occurrence is a violation ( flaw) potassium in the blood.
• Bone damage. Bone tissue is in a state of constant renewal - some cells ( osteoclasts) destroy the bone substance, while others ( osteoblasts) form it again. An excess of thyroid hormones in the blood leads to excessive activation of osteoclasts, as a result of which, in Graves' disease, there is a decrease in bone strength throughout the body.

Damage to the skin and its appendages can manifest itself:

• thinning hair;
• increased fragility of nails;
• excessive sweating ( due to dysregulation of sweat gland activity);
• redness of the skin;

The defeat of the reproductive system in diffuse toxic goiter is characterized by a decrease in sexual desire and potency in men. In women, menstrual irregularities may occur, and with a long course of the disease, atrophy may develop ( size reduction and dysfunction) ovaries and uterus , which will cause infertility .

It is worth noting that the symptoms described above may appear in various combinations, and some of them may be completely absent. It is also possible the appearance of other non-specific manifestations on the part of various organs and tissues, which sometimes greatly complicates the diagnostic process.

Thyrotoxic crisis in Basedow's disease

Thyrotoxic crisis develops as a result of improper treatment of diffuse toxic goiter, as well as under the influence of various provoking factors ( infection, intoxication, surgery and other stressful situations).

From a pathogenetic point of view, a thyrotoxic crisis is characterized by a critical increase in the level of thyroid hormones in the blood, which leads to an exacerbation of all clinical manifestations of the disease. Important is the fact that this violates the production ( and accelerated destruction) hormones of the adrenal cortex ( glucocorticoids), specifically cortisol. Cortisol is a powerful anti-stress and anti-shock hormone ( that is, it supports the functions of the body in any stressful situations, and is also necessary for normal daily human activity). The lack of this hormone can lead to disruption of the functions of vital systems, which can lead to the death of the patient.

The clinical picture of thyrotoxic crisis is characterized by a sharp ( during few hours) an increase in the intensity of all the above symptoms of the disease.

Symptoms of a thyrotoxic crisis are:

• pronounced psychomotor agitation;
• aggressiveness;
• increase in body temperature ( up to 40 degrees or more);
• increase in heart rate ( up to 200 beats per minute);
• indomitable vomiting;
• profuse ( extremely pronounced) diarrhea;
• profuse sweating;
• severe muscle weakness;
• extremely rare blinking;
• rapid breathing;
• asthma attacks;
• fear of death;
• psychoses;
• rave;
• intermittent loss of consciousness.

In the absence of timely medical care, the patient may fall into the so-called thyrotoxic coma, which is extremely unfavorable ( for life) as a prognostic sign.

Why is diffuse toxic goiter dangerous in children?

Diffuse toxic goiter in childhood is relatively rare. However, the course of this disease in children and adolescents has a number of distinctive features ( compared to that of adults).

The clinical picture of Basedow's disease in children is characterized by:

• More pronounced enlargement of the thyroid gland.
• Frequent headaches and memory impairment, which may result in a decrease in children's performance in school.
• Accelerated growth and ossification of bones.
• Delayed sexual development.
• More pronounced emotional instability.
• more sweeping ( compared to adults) tremor of the fingers and limbs.

It should be noted that diffuse toxic goiter in children occurs in a milder form than in adults. Also, children relatively rarely develop formidable complications, such as heart failure or thyrotoxic crisis.

Diffuse toxic goiter and pregnancy

Diffuse toxic goiter can adversely affect the course of pregnancy, which is often manifested by spontaneous abortion, intrauterine fetal death, or premature birth. Also, the presence of a pronounced clinical picture of the disease can contribute to the development of folate deficiency anemia in a pregnant woman.

Folic acid is a special vitamin that is necessary for the normal growth and development of all tissues ( it takes part in the processes of cell division). Since the reserves of this vitamin in the body are relatively small, during pregnancy ( when part of the folic acid from the mother's body passes into the body of the fetus) may develop its insufficiency, one of the manifestations of which will be anemia ( a decrease in the number of red cells in the blood due to a violation of the process of their formation in the bone marrow). Graves' disease, in turn, also contributes to the development of folic acid deficiency ( due to impaired absorption in the gastrointestinal tract), which further increases the risk of anemia.

At the same time, it is worth noting that the course of pregnancy can in a certain way change the clinical picture of Basedow's disease. In the first half of pregnancy, the severity of the symptoms of the disease may increase, which is associated with the restructuring of the nervous, immune and endocrine systems of the mother's body. However, in the second half of pregnancy, the clinical manifestations of diffuse toxic goiter may subside or disappear altogether. This is explained by the fact that during this period there is an increase in the concentration of estrogens ( female sex hormones) in the blood of a pregnant woman. Estrogens stimulate the growth of the uterus and cause a number of other changes necessary for the normal course of pregnancy, as well as stimulate the formation in the liver of the so-called thyroxin-binding protein, which binds and “neutralizes” excess thyroid hormones.

Diagnosis of diffuse toxic goiter

Diagnosis and treatment of diffuse toxic goiter is carried out by an endocrinologist, however, a doctor of any specialty can identify the main manifestations of the disease. It is possible to assume the diagnosis after a simple examination and clinical examination of the patient. At the same time, to confirm the diagnosis, as well as to assess the general condition of the patient and prescribe the correct treatment, it is necessary to conduct a number of additional laboratory and instrumental studies.

Diagnosis of diffuse toxic goiter includes:

• clinical examination;
• laboratory tests;
• ultrasound procedure ( ultrasound);
• other instrumental studies.

Clinical examination

Clinical examination of the patient is an important diagnostic measure, which in most cases allows the doctor to assume the correct diagnosis.

Clinical examination includes:

• Inspection. During the examination, the doctor pays attention to those external signs that could indicate an increased concentration of thyroid hormones. First of all, the type of physique of the patient and the state of subcutaneous fat are assessed ( with a severe form of Basedow's disease, it is extremely poorly developed). Then the condition of the skin is assessed ( its color, elasticity) and its appendages ( nails, hair). Even with a mild form of the disease, a slight exophthalmos can be determined ( bulging eyes) and an unnaturally pronounced gleam in the patient's eyes. The behavior of the patient during the examination also plays an important role. With diffuse toxic goiter, patients are excited, impatient, cannot remain motionless for a long time.
• Palpation ( probing). During this study, palpatory determination of the size of the thyroid gland is of primary importance. To do this, the doctor stands in front of the patient, puts his left hand on the back of his head, and places the fingers of his right hand on the front surface of the neck ( in the area of ​​the thyroid cartilage). Then the doctor asks the patient to perform swallowing movements, at the same time as he probes the thyroid tissue. Palpation allows you to determine the size of the organ, as well as to identify some other changes characteristic of diffuse toxic goiter ( for example, an increase in the temperature of the skin over the gland).
• auscultation ( listening). During auscultation, the doctor applies the membrane of the stethoscope to the front of the neck. With Basedow's disease, this method allows you to listen to a kind of blowing noise, the occurrence of which is due to increased blood flow through the blood vessels of the enlarged thyroid gland.

Tests for diffuse toxic goiter

A general blood test for this disease is uninformative, since it does not reveal any changes characteristic of diffuse toxic goiter. At the same time, biochemical research reveals changes in protein, fat and carbohydrate metabolism. In addition, with Basedow's disease, a number of other studies are prescribed, the purpose of which is to determine the functional state of the thyroid gland and pituitary gland.

During the diagnostic process, the doctor may prescribe:

• blood chemistry;
• determination of the level of thyroid hormones in the blood;
• determination of thyrotropin level ( TSH) in blood;
• determination of protein-bound iodine.

Biochemical blood test for Basedow's disease

Indicator	What does it mean?	Norm
Cholesterol level	Cholesterol is the main component of fat metabolism in the body.	3 - 6 mmol / liter.	Thyroid hormones increase the breakdown of cholesterol and its excretion with bile, as a result of which its level in the blood will be lowered.
Albumin level	Albumins are proteins that are formed in the liver and circulate in the blood, performing transport ( bind and transport hormones, drugs and other substances ) and many other features.	35 - 50 grams / liter.	Reduced as a result of a violation of the synthetic function of the liver.
Glucose level	Glucose is the main carbohydrate that serves as a source of energy for most cells in the human body.	3.3 - 5.5 mmol / liter.	Thyroid hormones increase the concentration of glucose in the blood, as a result of which, with Basedow's disease, this indicator can be significantly higher than normal.
Creatinine level	Creatinine is the end product of protein metabolism, which is formed as a result of protein breakdown in the body.	Among women: 53 - 97 µmol/liter. For men: 62 - 115 µmol/liter.	Because thyroid hormones stimulate protein breakdown, creatinine levels may be slightly elevated ( a pronounced increase is not observed, since in the normal functional state of the kidneys, creatinine is quickly excreted from the body with urine ).

Thyroid Function Assessment

Indicator	What does it mean?	Norm	Changes in Basedow's disease
Triiodothyronine level (T3 )	Major thyroid hormones.	1.04 - 2.5 nmol / liter.	Significantly above the norm.
thyroxine level (T4 )		65 - 160 nmol/liter.
Thyroid Stimulating Hormone Level (TSH )	A pituitary hormone that stimulates the synthesis of thyroid hormones in the thyroid gland.	0.4 - 4.0 international units per litre.	With diffuse toxic goiter, the amount of thyroid hormones in the blood is increased, which, by a feedback mechanism, inhibits the secretion of TSH, as a result of which its level in the blood will be reduced or normal.
Level of protein-bound iodine (SBY )	Under normal physiological conditions, more than 95% of the iodine in the peripheral blood is contained in thyroxin, which is fixed by plasma proteins.	315 - 670 nmol / liter.	With increased production of thyroxine, the amount of SBY will increase several times.

Ultrasound for diffuse toxic goiter

Ultrasound procedure ( ultrasound) in diffuse toxic goiter has limited diagnostic value. The study allows you to determine the size of the thyroid gland and its consistency, but does not provide information about its functional activity.

However, ultrasound plays an important role in distinguishing Graves' disease from other pathologies that also present with an enlarged thyroid gland. So, for example, with diffuse toxic goiter, no nodes are determined in the gland tissue, which can be observed in benign or malignant tumors. The gland itself in Graves' disease is enlarged relatively evenly ( that is, both its shares are increased), which is not characteristic of tumor diseases. It is also important to determine the size of the enlarged thyroid gland ( with a significant increase, conservative treatment is usually ineffective).

Other instrumental studies

Radioisotope studies can help determine the state of the functional activity of the thyroid gland. Also important diagnostic value is information about the state of metabolism in the patient's body.

With Graves' disease, the doctor may prescribe:

• determination of the absorption of radioactive iodine by the thyroid gland;
• scintigraphy of the thyroid gland;
• definition of the main exchange.

Determination of the absorption of radioactive iodine by the thyroid gland
This study allows you to evaluate the functional activity of the thyroid gland. The fact is that for the synthesis of thyroid hormones, she needs iodine, which is captured from the blood plasma. If a radioactive ( labeled) iodine, you can track how much of it and how fast it will be captured by the thyroid gland for hormone synthesis. With diffuse toxic goiter, this indicator can be significantly increased compared to normal data. However, it is worth noting that the absorption of radioactive iodine can also be increased in individuals who are chronically deficient in this substance ( i.e. living in certain areas where the iodine content of foods is reduced).

Thyroid scintigraphy
The essence of this study is the introduction into the body of a radioactive ( labeled) iodine. Iodine is captured by thyroid cells, after which the patient is examined in a special chamber that records the radiation of the labeled drug. With the help of scintigraphy, it is possible to determine the most active areas of the enlarged gland ( they will contain the most iodine and emit the most radiation), as well as to identify thyroid tissue in atypical places ( e.g. behind the chest).

It should be noted that the doses of radiation used in the process of research are negligible and do not pose any danger to humans.

Definition of basal metabolism
The basal metabolic rate is the amount of heat ( thermal energy), which is released by the human body in the process of ensuring the functions of vital organs in a state of complete rest. The essence of the study is to determine the amount of oxygen absorbed per unit time ( which is the main source of energy) and carbon dioxide released over the same period of time ( by-product of energy processes). The more intense the metabolic processes in the body, the more oxygen it will need, and the more carbon dioxide it will release.

The study of the basic metabolism is carried out in the morning, on an empty stomach ( not earlier than 12 hours after the last meal, as the process of digestion is associated with additional energy costs). In addition, 3 days before the study, you need to exclude meat, fish and poultry from the diet, as well as stop taking sedative medications. The study itself takes no more than 10 minutes and is carried out using special devices that take into account the amount of oxygen absorbed and carbon dioxide released.

Classification ( severity) diffuse toxic goiter

Depending on the severity of the clinical manifestations of diffuse toxic goiter, as well as on the basis of clinical and laboratory examination data, several forms of the disease are distinguished. This is necessary to assess the general condition of the patient, as well as to plan further treatment tactics.

The severity of diffuse toxic goiter

Criterion	Light form	Middle form	Severe form
Patient's mental state	Moderate nervous excitability.	Marked nervous excitability.	Extreme nervous excitability.
performance	Not broken or slightly reduced.	Pronounced decrease in work capacity.	Patients are disabled.
weight loss (depending on the initial body weight )		15 - 20% or more.
Heart rate	Up to 100 beats per minute.	100 - 120 beats per minute.	Over 120 beats per minute.
Basal metabolic rate	Increased by 30%.	Increased by 30 - 60%.	Increased by more than 60%.

Differential diagnosis of diffuse toxic goiter

The purpose of differential diagnosis is to distinguish diffuse toxic goiter from other diseases that occur with a similar clinical picture.

Diffuse toxic goiter should be differentiated:

• From a hormone-producing pituitary adenoma. Adenoma is a benign tumor. If it develops from hormone-producing cells of the pituitary gland ( which produce thyroid-stimulating hormone), this can lead to an increase in the level of TSH in the blood, resulting in an increase in the size of the thyroid gland and increased production of thyroid hormones. The main diagnostic criterion in this case will be the level of TSH in the blood ( with adenoma it is increased, and with Basedow's disease it is reduced).
• From toxic thyroid adenoma. Toxic adenoma is characterized by the formation of benign nodules in the thyroid gland, which produce thyroid hormones regardless of the level of thyrotropin. Nodules in the thyroid gland can be detected using ultrasound or scintigraphy ( in the latter case, “hot” foci of increased accumulation of radioactive iodine will be determined, which is not typical for diffuse toxic goiter).
• from rheumatic heart disease rheumatic heart disease). The need for differential diagnosis of these two diseases is due to heart damage, which is often observed in Graves' disease and in rheumatism. In favor of rheumatic heart disease in this case, the anamnesis data will testify ( the patient has been suffering from rheumatism for a long time), as well as signs of damage to the joints and the central nervous system. The determination of antistreptococcal antibodies in the blood is of decisive importance ( streptococci - pathogenic bacteria that cause the development of rheumatism).
• From neuroses. Neurosis develops as a result of dysfunction of the central nervous system and can also be manifested by irritability, aggressiveness, trembling of the hands and feet, and so on, however, the level of thyroid hormones in the blood of such patients is usually normal, which makes it possible to exclude Basedow's disease.

Treatment of diffuse toxic goiter

Treatment of diffuse toxic goiter should be comprehensive and include both medical and surgical ( if necessary) Events. In any case, the initial task is to normalize the function of the thyroid gland and the level of thyroid hormones in the blood, after which a decision is made on further treatment tactics.

For the treatment of diffuse toxic goiter, you can use:

• medications;
• radioactive iodine;
• diet therapy;
• surgical methods of treatment.

Medications for diffuse toxic goiter

The essence of drug therapy is the appointment of drugs that block the formation of thyroid hormones in the thyroid gland, which leads to a decrease in their concentration in the peripheral blood. For this purpose, the drug thiamazole is prescribed ( mercazolilum, methothyrine), which should be taken orally after meals.

With a mild and moderate form of the disease, the drug is prescribed at a dose of 5 mg, which must be taken 3-4 times a day. After laboratory-confirmed normalization of thyroid function ( which is usually observed 3 to 6 weeks after the start of treatment) the daily dose of the drug begins to be reduced by 5 mg every 7 to 10 days until they reach the maintenance dose ( 5 mg 2-4 times a week).

In severe Graves' disease, the drug is prescribed 15-20 mg 3-4 times a day ( the daily dose for an adult should not exceed 60 mg). After normalization of the clinical picture, the daily dose is gradually reduced to 5-20 mg. The course of treatment in this case can last up to 12 - 18 months.

The criteria for the effectiveness of the treatment are:

• The disappearance of clinical symptoms of the disease- normalization of the pulse, weight gain, disappearance of irritability, normalization of the emotional state, and so on.
• Normalization of laboratory parameters- in particular, the level of thyroid hormones in the blood and basal metabolism.
• Reducing the size of the thyroid gland.

It should be noted that these drugs have a certain toxic effect, which is manifested by inhibition of the formation of leukocytes ( immune system cells) in the red bone marrow. That is why during the treatment period it is necessary to regularly ( every 7 - 14 days) take a general blood test and assess the state of the patient's immune system.

In addition to the main antithyroid) treatment, patients are also shown symptomatic therapy, the purpose of which is to correct developing disorders of the cardiovascular and other systems.

Symptomatic treatment of diffuse toxic goiter includes:

• Normalization of the heart. With tachycardia ( increase in heart rate) drugs from the group of beta-blockers can be prescribed ( anaprilin, oxprenolol), which slow down the conduction of nerve impulses in the heart muscle, thereby reducing the heart rate. At the same time, with the development of symptoms of heart failure ( what is observed with prolonged progression of Basedow's disease) cardiac glycosides are prescribed ( digoxin, digitoxin), which increase the contractile activity of the heart, helping it perform its pumping function.
• The use of hormonal anti-inflammatory drugs ( glucocorticoids). Drugs from this group ( prednisolone, hydrocortisone) reduce the activity of thyroid hormones in the body, and also, to a certain extent, inhibit the formation of thyrotropin in the pituitary gland and stabilize the function of the immune system.
• Administration of antihistamines ( peritol). This drug has a certain sedative effect, and also increases appetite, which contributes to the normalization of the patient's body weight.
• Normalization of the neuropsychic state. Sedatives and sleeping pills are prescribed ( valerian, diazepam).

Treatment of diffuse toxic goiter with radioactive iodine

The essence of this method is the appointment of radioactive iodine, which is captured by the cells of the thyroid gland, after which the radiation emitted by it causes the death of these cells. As a result, the functional activity of the gland decreases, and the level of thyroid hormones in the blood normalizes. In place of the thyroid cells destroyed by radiation, connective tissue scars are formed.

The radioactive iodine treatment itself is safe and painless. The drug is introduced into the patient's body through the gastrointestinal tract. For this, the patient after carrying out all the necessary examinations) are given to drink 1 capsule containing a certain dose of radioactive iodine. After that, the patient must remain under the supervision of doctors for 12 to 24 hours, and then can go home. A positive effect begins to appear after about a month, and the most pronounced therapeutic effect is observed after 8-12 weeks.

It is important to note that 5 to 7 days before the procedure, it is necessary to stop taking antithyroid drugs, otherwise hypothyroidism may develop ( a condition characterized by excessively low levels of thyroid hormones in the blood).

Indications for radioactive iodine treatment are:

• Moderate or severe form of Graves' disease.
• Lack of effect from ongoing medical treatment.
• Presence of contraindications to surgical treatment ( severe damage to the cardiovascular, respiratory or other systems).
• Relapses ( repeated exacerbations) diseases after previous surgical treatment.

Treatment with radioactive iodine is contraindicated:

• with a mild form of the disease;
• in the presence of nodes in the thyroid gland;
• during pregnancy;
• during breastfeeding;
• in diseases of the blood system.

Diet for diffuse toxic goiter

A special diet for patients with diffuse toxic goiter has not been developed. Patients can eat ordinary foods, but they should adhere to certain rules.

First of all, it is worth remembering that with this pathology, the metabolism in the body is significantly accelerated. Therefore, even with minimal physical activity, a sick person will need more food ( than normal) to make up for energy costs. At the same time, we should not forget that an increase in the concentration of thyroid hormones accelerates the processes of destruction of proteins and fats in the body, so the food taken by patients should contain all the essential nutrients in the required quantities.

The basic rules for the nutrition of patients with Basedow's disease are:

• Fractional nutrition. It is recommended to eat food 5-6 times a day in small portions. This will avoid a pronounced feeling of hunger during the working day, as well as reduce the likelihood of developing nausea and vomiting.
• Balanced diet. Patients should take enough protein and fat. Moreover, with severe clinical manifestations of the disease, the amount of easily digestible proteins ( contained in eggs, beef, veal and other meat products) should be somewhat larger to cover the increased needs of the body for them.
• Limited carbohydrate intake. As mentioned earlier, an excess of thyroid hormone leads to an increase in blood glucose levels. That is why patients with Basedow's disease should limit the use of glucose in its pure form ( refers to sugar, chocolate, marmalade, marshmallows and so on). At the same time, you should not completely exclude carbohydrates from the diet, as this can further enhance the process of destruction of muscles and adipose tissue.
• Eating foods rich in vitamin A. Vitamin A is necessary for the normal functioning of the organ of vision, so its lack in the diet can aggravate the course of endocrine ophthalmopathy. Vegetables are rich in vitamin A
  With Graves' disease, you can use:
  • A decoction of wild strawberries. Contains vitamin C, and also to a certain extent normalizes the function of the thyroid gland. To prepare a decoction of 100 - 200 grams of freshly picked berries, pour 500 ml of water and boil in a water bath for 30 - 40 minutes, then cool at room temperature and take 100 ml orally 2 - 3 times a day.
  • Infusion of rose hips. Rosehip contains a large amount of vitamin C, the need for which increases significantly with Graves' disease. It is important to remember that vitamin C is destroyed at a temperature of 100 degrees ( i.e. boiling), so it is better to use wild rose in the form of infusions. To prepare the infusion, 2 tablespoons of rose hips should be crushed, placed in a thermos and pour 300 - 400 milliliters of hot water ( not boiling water), then insist for 3-4 hours. The resulting infusion is recommended to be taken orally 1 tablespoon 3-4 times a day.
  • Infusion of valerian root. Valerian has a pronounced sedative effect, which will help eliminate such symptoms of Basedow's disease as irritability and nervousness. Valerian also has a certain antispasmodic effect ( relaxes the smooth muscles of the internal organs), which will be useful in violation of the motility of the gastrointestinal tract. To prepare the infusion, 1 tablespoon of valerian root should be crushed and poured into a glass ( 200 ml) boiling water, then insist in a dark place for 2 - 3 hours. The resulting infusion should be filtered and taken orally 1 - 2 teaspoons before bedtime. In the morning or afternoon, it is recommended to reduce the dose of infusion to 1 teaspoon, as side effects may develop ( drowsiness, lethargy, inhibition of reactions).

  Is surgery necessary for diffuse toxic goiter?

  Surgical removal of part of the thyroid gland is a radical method of treating diffuse toxic goiter, which allows for a long time to eliminate the clinical manifestations of the disease.

  Indications for surgical treatment of diffuse toxic goiter are:

  • A pronounced enlargement of the thyroid gland, which compresses the surrounding organs and tissues, while violating the patient's quality of life. In this case, the likelihood of normalization of the size of the gland after only conservative treatment is extremely small, so doctors usually recommend surgical treatment.
  • Preservation of the large size of the thyroid gland for 2 or more years after the normalization of the level of thyroid hormones against the background of ongoing drug treatment.
  • Failure of conservative treatment.
  An absolute contraindication to surgery is a severe form of the disease, in which irreversible changes in the cardiovascular system have developed.

  The essence of the operation itself is to remove most of the thyroid gland ( leave no more than 5 - 7 grams of functional tissue). The operation is performed under general anesthesia ( anesthesia), that is, the patient is asleep and does not feel or remember anything. In the postoperative period, it is extremely important to strictly follow the doctor's instructions and take all the medicines prescribed by him ( glucocorticoids and others), which will prevent the development of unwanted side effects.

  It should be noted that, despite the radical nature of the surgical method of treatment, some patients may experience a relapse of the disease ( that is, the re-growth of thyroid tissue and its increased activity).

  Complications and consequences of diffuse toxic goiter

  Complications of diffuse toxic goiter develop in severe forms of the disease, as well as with its prolonged course or with improper treatment. At the same time, signs of damage to the cardiovascular system, which suffers most from an excess of thyroid hormones, come to the fore. Also, with this pathology, complications from the nervous system and various internal organs can develop.

  Diffuse toxic goiter can be complicated by:

  • Atrial fibrillation. This is a life-threatening condition in which the process of synchronous contraction of the heart muscle is disrupted. At the same time, the muscle fibers of the heart contract chaotically, separately, as a result of which its pumping function is significantly reduced or completely absent.
  • Heart failure. A pronounced increase in heart rate in Graves' disease significantly overloads the heart muscle. With a long course of the disease, the compensatory capabilities of the heart can be depleted, as a result of which it will not be able to pump blood in the right amount, that is, heart failure will occur. The development of this complication is an extremely unfavorable prognostic sign.
  • liver failure. Under normal conditions, thyroid hormones are detoxified in the liver. However, with diffuse toxic goiter, the amount of these hormones is so high that the liver cannot cope with its neutralizing function, which leads to damage to hepatocytes ( liver cells) and can cause cirrhosis. With cirrhosis of the liver, the number of functioning hepatocytes decreases, as a result of which absolutely all functions of the organ are violated, in particular, neutralizing, excretory and synthetic ( blood plasma proteins, bile acids and many other substances are formed in the liver).
  • Psychosis. With a pronounced increase in the concentration of thyroid hormones in the blood ( especially in thyroid storm) possible development of psychosis, characterized by impaired consciousness ( until his loss), uncritical and inadequate ( usually aggressive) the behavior of the patient, delirium, hallucinations and other neurological manifestations.
  • Psycho-emotional disorders. With a long course of the disease, patients with Basedow's disease may develop depressive states or neuroses that require the intervention of a specialist ( neuropathologist).

  Prevention of diffuse toxic goiter

  Since diffuse toxic goiter is genetic ( hereditary) disease, it is impossible to completely prevent the likelihood of its development. Nevertheless, knowledge and exclusion of predisposing external factors will reduce the risk of developing this pathology. This is especially important for people whose parents suffer from diffuse toxic goiter.

  Prevention of diffuse toxic goiter includes:

  • Exclusion of stressful situations. Stress is one of the main factors that can provoke the development of the disease. Of course, it is impossible to completely eliminate stress from life. Nevertheless, persons predisposed to this pathology are advised to lead a calm, measured life, avoid chronic overexertion and lack of sleep.
  • Adequate treatment of infectious diseases. Bacterial and viral infections ( especially angina, influenza, scarlet fever) contribute to the activation of the human immune system, which under certain conditions can provoke the development of diffuse toxic goiter ( this is especially true for children whose immune systems are not yet fully developed). That is why timely and complete treatment of infectious diseases is an important element in the prevention of this pathology.
  • hardening. This is a non-specific method of prevention that strengthens the human immune system and increases the body's resistance to many diseases ( including before infections). Water procedures are considered the most effective ( cold shower, rubdown, bathing in cold water). Hardening should begin in the warm season ( late spring or summer), when the likelihood of complications ( such as colds) is minimal. It is important to remember that when the procedures are stopped, the hardening effect disappears.
  • Complete nutrition. Improper or inadequate nutrition can cause a lack of many nutrients necessary for the normal functioning of various systems and organs. This, in turn, can contribute to the dysfunction of the immune system and the development of Basedow's disease.

  Prognosis for Basedow's disease

  It is important to note that with Basedow's disease for a long time, most of the changes in the internal organs and tissues are of a functional nature, that is, with the timely start of adequate treatment, it is possible to normalize the function of the thyroid gland and eliminate all symptoms of the disease. At the same time, with a long-term progressive pathology, as well as in the case of inadequate treatment ( for example, if the patient spontaneously stops taking antithyroid drugs) the prognosis is less favorable. Over time, functional disorders lead to irreversible organic damage to organs and tissues. First of all, the cardiovascular, nervous and hepatic systems suffer.

  With the development of irreversible organic changes, the prognosis for the patient's life is unfavorable.

  Before use, you should consult with a specialist.