The change in the clinical presentation of Graves disease: a 30 years retrospective survey in an academic Brazilian tertiary center

ABSTRACT Objective Graves' disease (GD) is the main cause of hyperthyroidism among adults. It is an autoimmune condition classically marked by the Merserburg Triad (goiter, thyrotoxicosis, and orbitopathy), but the change in presentation of GD over time has rarely been studied. To determine changes in the clinical presentation of patients with GD in the last 30 years. Subjects and methods The study evaluated 475 patients diagnosed with GD between 1986 and 2016 in a single center. Patients were evaluated regarding epidemiological aspects, thyroid function, inflammatory activity of the eyes evaluated by the Clinical Activity Score; CAS, severity evaluated by NOSPECS classification and thyroid volume estimated by ultrasonography. Results Patients assessment identified an increase in the mean age of diagnosis of GD (p < 0.02), a reduction in thyroid volume (p < 0.001) and less intense orbital involvement from 2007-2016 compared to 1986-2006 (p = 0.04). The number of smoking patients was smaller from 2007 to 2016 (28.7%) than 1986 to 2006 (42.8% p = 0.001). The TSH and TRAb values did not had significant changes. Conclusion GD presentation appears to be changed in the last years compared to the typical initial presentation. There is a less frequent inflammatory involvement of orbital tissue, smaller goiters, a lower number of smokers and diagnosis at older age.

Restless Legs Syndrome, and symptoms of Restless Syndrome in patients with Graves disease: a cross-sectional survey

OBJECTIVES: Restless legs syndrome (RLS) is a frequent comorbid condition associated with distinct unrelated diseases. While the incidence of RLS has not been definitively confirmed, RLS-like symptoms have been reported in a section of Asian population who also had hyperthyroidism. The prevalence of RLS is generally low in Asian populations. Under these circumstances, we hypothesized that in a population where RLS is common, such as in Brazil, RLS could manifest as a comorbid ailment alongside Graves' disease, a common hyperthyroid condition. METHODS: In a cross-sectional survey, 108 patients who presented with Graves' disease were analyzed for restless legs or associated symptoms. RESULTS: Twelve patients (11.1%) displayed symptoms of RLS prior to the incidence of Graves' disease. These patients experienced worsening of the symptoms during their hyperthyroid state. Six patients (5.6%) developed RLS, consequent upon the incidence of Graves' disease as per the consensus of the panel of the experts. Fifteen patients (13.9%) also presented with RLS-like symptoms without any discernible circadian feature of the syndrome. CONCLUSION: Our findings confirm that Graves' disease might trigger restless legs-like symptoms, while the condition of hyperthyroidism could also be complicated by definite RLS.

Relación entre linfocitos T reguladores (T regs) y anticuerpos anti-receptores de TSH (TRab) y el riesgo de cáncer de tiroides en enfermedad de Graves / Relationship between T regulatory lymphocytes (Tregs) and TSH receptor antibodies (TRab) on risk of thyroid cancer in Graves disease

Durante los últimos años se ha estudiado la relación entre enfermedad de Graves (EG), TSH, TRAb y cáncer de tiroides, existiendo estudios que demuestran mayor prevalencia y agresividad del cáncer de tiroides en pacientes con EG, mientras otros refutan estos hallazgos sugiriendo que serían producto del sesgo de selección. Aquellos estudios que plantean una relación causal entre EG y el desarrollo de cáncer de tiroides, la atribuyen a la presencia de autoanticuerpos TSI, que estimularían el foco de malignidad. Se cree que las citoquinas producidas localmente en pacientes con EG trabajarían en conjunto con los TRAb para determinar la agresividad del cáncer papilar de tiroides en estos pacientes. Dentro de las células reclutadas por el tumor para evadir la respuesta inmune se encuentran los linfocitos Treg, que estarían elevados en paciente con EG, llevando a la disminución de la respuesta inmune y creando un ambiente permisivo para la proliferación celular. Por tratarse de una línea de investigación reciente, no existe consenso sobre el tema y sus implicancias en el tratamiento de los pacientes con EG. La finalidad de este artículo es realizar una revisión de la literatura que exponga y contraste la información disponible a la fecha.

In recent years the relationship between Graves’ disease (GD), TSH, TRAb and thyroid carcinoma has been studied. Research studies show a higher prevalence and aggressiveness of thyroid carcinoma in patients with GD, however other researchers refute these findings suggesting it’s due to selection bias. Increasing evidence suggests a causal relationship between GD and the development of thyroid carcinoma, mainly because of the existence of TSI autoantibodies that could stimulate the focus of malignancy. It is believed that cytokines produced locally in patients with GD work alongside with TRAb regulating the aggressiveness of papillary thyroid carcinoma in these patients. Within the cells recruited by the tumor to elude the immune system we find Treg lymphocytes, which have been found to be increased in patients with GD, leading to a diminished immune response, creating a permissive environment for cell proliferation. Since this is a relatively new line of research, there is no consensus on the subject and its relevance for the treatment of patients with GD. The aim of this article is to show recent literature available on the subject.

Thyroid nodules and thyroid cancer in Graves’ disease / Nódulos tiroidianos e câncer de tiroide na doença de Graves

Objective The frequency of thyroid nodules accompanying Graves’ disease and the risk of thyroid cancer in presence of accompanying nodules are controversial. The aim of this study was to evaluate the frequency of thyroid nodules and the risk of thyroid cancer in patients operated because of graves’ disease. Subjects and methods Five hundred and twenty-six patients in whom thyroidectomy was performed because of Graves’ disease between 2006 and 2013 were evaluated retrospectively. Patients who had received radioactive iodine treatment and external irradiation treatment in the neck region and who had had thyroid surgery previously were not included in the study. Results While accompanying thyroid nodule was present in 177 (33.6%) of 526 Graves’ patients, thyroid nodule was absent in 349 (66.4%) patients. Forty-two (8%) patients had thyroid cancer. The rate of thyroid cancer was 5.4% (n = 19) in the Graves’ patients who had no nodule, whereas it was 13% (n = 23) in the patients who had nodule. The risk of thyroid cancer increased significantly in presence of nodule (p = 0.003). Three patients had recurrence. No patient had distant metastasis. No patient died during the follow-up period. Conclusions Especially Graves’ patients who have been decided to be followed up should be evaluated carefully during the follow-up in terms of thyroid cancer which may accompany. Arq Bras Endocrinol Metab. 2014;58(9):933-8 .

Objetivo A frequência da ocorrência de nódulos tiroidianos acompanhando a doença de Graves e o risco de câncer de tiroide na presença desses nódulos é controversa. O objetivo deste estudo foi avaliar a frequência de nódulos tiroidianos e o risco de câncer de tiroide em pacientes operados por doença de Graves. Sujeitos e métodos Quinhentos e vinte e seis pacientes anteriormente submetidos à tiroidectomia por doença de Graves entre 2006 e 2013 foram avaliados retrospectivamente. Os pacientes que receberam tratamento com iodo radioativo e irradiação externa da região do pescoço e que anteriormente passaram por cirurgia de tiroide não foram incluídos no estudo. Resultados Enquanto os nódulos de tiroide se apresentaram em 177 (33,6%) dos 526 pacientes com doença de Graves, eles estiveram ausentes em 349 (66,4%) pacientes. Um total de 42 (8%) dos pacientes teve câncer de tiroide. A ocorrência de câncer de tiroide foi 5,4% (n = 19) nos pacientes com doença de Graves que não apresentaram nódulos, e 13% (n = 23) nos pacientes com nódulos. O risco de câncer de tiroide aumentou significativamente na presença de nódulos (p = 0,003). Três pacientes apresentaram recidivas. Nenhum paciente apresentou metástase distante e nenhum paciente veio a óbito durante o período de acompanhamento. Conclusões Pacientes com doença de Graves devem ser avaliados cuidadosamente no acompanhamento para a possível ocorrência de câncer de tiroide. Arq Bras Endocrinol Metab. 2014;58(9):933-8 .

Disfunción tiroidea en adultos infectados por el virus de inmunodeficiencia humana

Los pacientes con infección por el virus de inmunodeficiencia humana (HIV) tienen una mayor prevalencia de disfunción tiroidea cuando se los compara con la población general. Las manifestaciones más frecuentemente observadas son: el síndrome del eutiroideo enfermo, la enfermedad de Graves y el hipotiroidismo subclínico. La relación entre el uso de la terapia antirretroviral y el incremento en la prevalencia de alteraciones tiroideas fue demostrada en varias series de pacientes. La enfermedad de Graves se reconoce claramente como una consecuencia del síndrome de restitución inmune. Además, existen estudios que sugieren una relación entre hipotiroidismo y el uso de inhibidores nucleósidos de la transcriptasa reversa, en particular estavudina y el inhibidor no nucleósido de la transcriptasa reversa efavirenz. Nuevos estudios podrán aportar evidencia adicional sobre la necesidad de evaluaciones rutinarias de la función tiroidea en pacientes infectados por HIV.

Patients infected with human immunodeficiency virus (HIV) have a higher prevalence of thyroid dysfunction when compared with the general population. The most frequently observed manifestations are euthyroid sick syndrome, Graves´ disease and subclinical hypothyroidism. The relationship between the use of highly active antiretroviral therapy and the increased prevalence of thyroid dysfunction has been demonstrated in several series of patients. Grave’s disease is recognized as a consequence of immune restitution syndrome. Besides, several studies have suggested an association between hypothyroidism and the use of nucleoside reverse transcriptase inhibitors, particularly stavudine and non-nucleoside reverse transcriptase inhibitors such as efavirenz. Further studies could provide additional evidence of the need for routine assessment of thyroid function in HIV-infected patients.

Agranulocitosis inducida por metimazol en pacientes con enfermedad de Graves / Methimazole-induced agranulocytosis in patients with Graves’ disease

Objetivo: Describir las características clínicas y epidemiológicas de los pacientes con enfermedad de Graves que presentaron agranulocitosis inducida por metimazol. Material y métodos: Estudio retrospectivo, tipo serie de casos. Se revisaron las historias clínicas de todos los pacientes con diagnóstico de agranulocitosis inducida por metimazol, atendidos en el Hospital Nacional Arzobispo Loayza, entre enero 2002 y diciembre 2008. Se buscó asociación entre las variables demográficas y clínicas con la mortalidad y el tiempo de recuperación. Resultados: Treinta (0,60%) pacientes con enfermedad de Graves fueron hospitalizados con el diagnóstico de agranulocitosis inducida por metimazol. La mediana de la edad fue 33,5 años y 86,67% fueron mujeres. Al ingreso, todos los pacientes presentaron fiebre y dolor de garganta. El manejo incluyó aislamiento invertido, suspensión del metimazol, administración de antibióticos y glucocorticoides. Doce (40%) pacientes recibieron GM-CSF. El número de granulocitos se normalizó después de 10,59 días y cuatro (13,33%) pacientes murieron por infecciones bacterianas y sepsis. En todos los casos, el tratamiento definitivo fue yodo radioactivo. No hubo diferencia significativa en la edad, sexo, dosis de metimazol, duración del tratamiento y uso de factor estimulante colonia, entre los pacientes fallecidos y los sobrevivientes. Además, el uso de factor estimulante de colonia no redujo el tiempo de recuperación de la agranulocitosis. Conclusión: La agranulocitosis inducida por metimazol es un evento adverso serio y potencialmente mortal. En este grupo de pacientes, la mortalidad fue elevada y el uso de factor estimulante de colonia no disminuyó el tiempo de recuperación.

Objective: To describe the clinical and epidemiological characteristics of patients with methimazole-induced agranulocytosis. Methods: A retrospective, case series study. We reviewed the medical records of all patients diagnosed with methimazole-induced agranulocytosis treated at Hospital Nacional Arzobispo Loayza between January 2002 and December 2008. We sought association between demographic and clinical variables with mortality and recovery time. Results: Thirty (0.60%) patients with GravesÆ disease were hospitalized with a diagnosis of methimazole-induced agranulocytosis. The median age was 33,5 years and 86,67% were women. On admission, all patients had fever and sore throat. The treatment included isolation, suspension of methimazole, antibiotics and glucocorticoids. Twelve (40%) patients received GM-CSF. The granulocyte count was normalized after 10,59 days and four (13.33%) patients died from bacterial infections and sepsis. In all cases, the final treatment was radioiodine. There was no significant difference in age, sex, methimazole dose, duration of treatment, and use of stimulating factor, among the patients who died and survivors. Furthermore, the use of stimulating factor did not reduce the recovery time from agranulocytosis. Conclusion: Methimazole-induced agranulocytosis is a serious and potentially deadly adverse event. In this group of patients, mortality was high and the use of stimulating factor did not decrease the recovery time.

Avaliação do surgimento de comorbidades em pacientes com doença de Graves tratados com iodo radioativo em acompanhamento por mais de 10 anos / Emerging comorbidities in Graves' disease patients treated with radioiodine with more than 10 years of follow-up

OBJETIVOS: Avaliar o surgimento de comorbidades cardiovasculares e/ou neoplásicas e a taxa de mortalidade nos pacientes com hipertireoidismo em decorrência da doença de Graves tratados com iodo radioativo há mais de 10 anos. MATERIAIS E MÉTODOS: Estudo retrospectivo com análise de prontuários do Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, entre janeiro de 1981 e novembro de 1999. RESULTADOS: Foram avaliados 107 pacientes (93 mulheres e 14 homens), com uma mediana de idade de 54 anos. Comparando o grupo de pacientes que receberam iodo radiativo com grupo de pacientes eutireoidianos pós-tratamento com drogas antitireoidianas (DAT), foi observado aumento significativo no surgimento de hipertensão arterial (HAS) e dislipidemia, mas não na taxa de mortalidade. CONCLUSÃO: Para avaliar a real influência da terapêutica com iodo radioativo no surgimento dessas comorbidades e na taxa de mortalidade, é necessário um tempo maior de acompanhamento. A idade e o tempo de exposição aos efeitos do hipertireoidismo parecem influenciar no surgimento dessas comorbidades.

OBJECTIVES: To evaluate the occurrence of cardiovascular disease and malignant tumors and the mortality rate in patients who received radioiodine treatment for hyperthyroidism due to Grave's disease with at least ten years of follow-up. MATERIALS AND METHODS: The medical records of all patients who were treated with I131 for Graves' disease at Hospital Universitário Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, were reviewed retrospectively, between January, 1981 and November, 1999. RESULTS: Data from 107 patients (14 men and 93 women), with median age of 54 years were analyzed. Comparing the group of patients who were treated with I131 therapy with a group of euthyroid patients post-treatment with antithyroid drugs, a significant increase in the occurrence of hypertension and dyslipidemia was observed, but not in mortality rate. CONCLUSION: To evaluate the real influence of the treatment with radioactive iodine in the occurrence of these comorbidities and the mortality rate, we need a longer follow-up. The age and time of exposure to the effects of hyperthyroidism seem to influence the occurrence of these comorbidities.

Doença de Graves na infância / Graves? disease in childhood

Relatamos um caso de doença de Graves na infância que, embora raro mas com manejo fácil, seu tratamento ainda é controverso. Foi iniciado o tratamento com drogas antitireoideanas (DAT), mas a paciente apresentou efeitos colaterais. Como apresentava descompensação do hipertireoidismo e intolerância às DAT, a radioablação com 131I foi indicada. Três semanas após a terapia actínica a paciente evoluiu com hipotireoidismo. Foi introduzida levotiroxina, com doses ajustadas através de acompanhamento ambulatorial.

Clinical study of cases with hyperthyroidism in Erbil Governorate, Kurdistan Region-Iraq

Thyrotoxicosis is a common and serious world-wide health problem, it's one of the common problems in Erbil governorate. Clinical analysis done for 675 patients proved to have thyrotoxicosis by thyroid function tests. Hyperthyroidism in females were 4 times more common than in males, the mean age was around 44 years, Graves disease being the most common cause, followed by multinodular goiter, Iodine-induced thyrotoxicosis, single nodule goiter, T3-Thyrotoxicosis, then finally auto-immune lymphocytic thyroditis. Weight loss was the most common feature, followed by other well known features of autonomic hyperactivity, tremor was the most common sign reported while periodic paralysis was the least common sign. Graves disease is the commonest cause of thyrotoxicosis. Iodinization of salt program resulted in transient increase and later on decrease of thyrotoxicosis in the region

Hipertiroidismo en niños y adolescentes / Hyperthyroidism in children and adolescents

Background: Hyperthyroidism (HT) prevalence is 0.1/100,000 children and 1/100,000 adolescents and Graves Disease is the most frequent etiology. Objective: To evaluate the clinical presentation, etiology and treatment in hyperthyroid children. Method: Retrospective review of clinical charts of children under 15 years-old, between June 2004 and August 2005. Hyperthyroidism diagnosis was performed with suppressed TSH and increased thyroid hormones levels. Etiological study was done by TRAb, ATPO, ATG, thyroid echotomography and I131 capture. Results: 26 patients were evaluated; 84.6 percent females and age at diagnosis was 9.8 +/- 3,5 years-old (range: 3,8 - 14,5). Goiter was the most frequent clinical sign (96,2 percent), tachicardy and swelling. Etiology: Graves Disease (73 percent),Hashitoxicosis (15,3 percent) and unknown etiology (11,5 percent). Treatment: 88,4 percent began with anti-thyroid drugs (DAT): 78 percent PTU and 22 percent Tiamazol. 62.5 percent became euthyroid after 6 months and 79.1 percent after 12 months. 31.5 percent of GD presented hypothyroidism at 6.3 +/- 4 months of DAT, requiring LT4 substitution. I131 was applied to 4 children (16.6 percent); 3 due to hepatic compromise pre or post PTU use and 1 girl for missing treatment, developing a thyrotoxic torment. Thyroidectomy was done in 2 patients (8.3 percent), both with GD; 1 for giant goiter without DAT response at 19 months and 1 for persistant hyperthyroidism after 25 months of DAT. 92 percent received (3-blockers (Propanolol) for adrenergic symptoms for 5 +/- 4 months. Conclusions: Goiter was the most frequent pediatric HT symptom and Graves disease the main etiology. DAT treatment control HT in 76.9 percent patients and no adverse reactions with I131 were observed. These resUIts promote DAT treatment as first line in HT management, prefering Tiamazol for its better adherence and less adverse reactions. Radioiodide therapy and thyroidectomy are alternatives if treatment fails...

El hipertiroidismo (HT) tiene una prevalencia de 0,1/100 000 en niños y 1/100 000 en adolescentes, siendo la enfermedad de Graves (EG) la etiología más frecuente. Objetivo: Revisar presentación clínica, etiología y manejo de niños con HT. Método: Estudio retrospectivo de fichas clínicas de niños con HT menores de 15 años, evaluados entre Junio/04 y Agosto/05. El diagnóstico de HT se hizo con TSH suprimida y hormonas tiroideas elevadas. El estudio etiológico se realizó en base a anticuerpos TRAb, ATPO, ATG; Ecotomograña tiroidea, y captación de I131. Resultados: Se evaluaron 26 pacientes; 84,6 por ciento fueron mujeres. Edad promedio al diagnóstico fue 9,8 +/- 3,5 años (rango 3,8 a 14,5). La presentación clínica más frecuente fue bocio (96,2 por ciento), seguidos por taquicardia y sudoración. Etiología: Enfermedad de Graves 73 por ciento, Hashitoxicosis 15,3 por ciento y etiología no precisada 11,5 por ciento. Manejo: 88,4 por ciento inician con drogas antitiroideas (DAT); 78 por ciento PTU y 22 por ciento con Tiamazol. 62,5 por ciento se hizo eutiroideo a los 6 meses y 79,1 por ciento a los 12 meses. El 31,5 por ciento de EG presentó hipotiroidismo a los 6,3 +/- 4 meses de uso de DAT, requiriendo sustitución con LT4. El I131 fue indicado a 4 niños (16,6 por ciento): en 3 casos por compromiso hepático importante pre o post uso de PTU y 1 niña por abandono de tratamiento y reingreso con tormenta tiroidea. Tiroidectomía: se indicó a 2 pacientes (8,3 por ciento), ambos con EG; uno por bocio gigante, sin respuesta a DAT después de 19 meses de uso y el otro por persistir hipertiroideo después de 25 meses de uso de DAT. El 92 por ciento recibió (3 bloqueador (propanolol) para manejo de los síntomas adrenérgicos, (5 +/- 4 meses). Discusión y conclusiones: El bocio es el síntoma principal en pediatría. La etiología más frecuente es la Enf de Graves. Las DAT permitieron controlar el HT en 76,9 por ciento de los pacientes, no observamos complicaciones con el uso de I131...

Hipertensão arterial pulmonar e doenças da tireoide: [revisão] / Pulmonary arterial hypertension and thyroid disease: [review]

Estudos recentes têm sugerido uma associação entre hipertensão arterial pulmonar (HAP) e tireoidopatias (hipotireoidismo e hipertireoidismo). Esta associação tem um bom prognóstico, porque o aumento na pressão da artéria pulmonar geralmente é leve e reversível com o tratamento da tireoidopatia. O mecanismo exato envolvido na patogênese desta associação não está estabelecido, e a influência direta dos hormônios da tireoide e a autoimunidade são consideradas como hipóteses. Devido à alta prevalência de doenças da tireoide em pacientes com HAP, testes de função tireoidiana devem ser considerados na investigação de todo paciente com HAP. Neste artigo de revisão, descrevemos a prevalência de HAP em pacientes com doenças da tireoide e a prevalência de tireoidopatias em pacientes com HAP, assim como destacamos os principais efeitos das doenças da tireoide no sistema respiratório. A seguir, relatamos os efeitos do tratamento destas patologias.

Recent studies have suggested an association between pulmonary arterial hypertension (PAH) and thyroid diseases (hypothyroidism and hyperthyroidism). This combination has a good prognosis, because the increase in the pulmonary artery pressure is usually slight and reverses after the treatment of the thyroid disease. Although the exact mechanism involved in the pathogenesis of this combination has not yet been established, it has been hypothesized that thyroid hormones and autoimmunity have a direct influence. Due to the high prevalence of thyroid disease in patients with PAH, thyroid function tests should be considered in the investigation of every patient with PAH. In this review, we describe the prevalence of PAH in patients with thyroid diseases and the prevalence of thyroid disease in patients with PAH, as well as addressing the principal effects that thyroid diseases have on the respiratory system. In addition, we report the treatment effects in patients with these diseases.

Enfermedad de Basedow Graves en pacientes pediátricos / Graves-Basedow disease in pediatric patients

Objective: Determine differences in the epidemiology, clinical features and diagnosis of Graves-Basedow disease (GBD) in prepubertal and pubertal patients. Method: Retrospective study analyzing medical records of 38 patients with GBD at Pontificia Universidad Católica de Chile between 1992-2007. Statistical analysis was performed with non parametric test of Mann-Whitney U and proportions difference with Fisher Test (SPSS 10.0 for Windows and Graphpad Prism 4). Results: 21 patients were prepubertal and 17 were pubertal, with ages between 3 and 15,9 years. There were more girls than boys in both groups (5:2 and 15:2, respectively; p = 0.2). The most common clinical presentations were diffuse goiter, hyperactivity, frequent bowel movements, insomnia and heat intolerance. The prepubertal group had a taller stature (+2.4 SDS) compared with the pubertal group (+0.2 SDS; p = 0.03) and the most frequent ocular manifestation was exophthalmus in both groups. Conclusions: We did not find any differences in the clinical presentations of Graves-Basedow disease among prepubertal and pubertal patients. Neuropsychiatric symptoms such as hyperactivity and insomnia, together with tall stature are common features in children with GBD.

Objetivo: Determinar si existen diferencias en las características epidemiológicas y clínicas al momento del diagnóstico de hipertiroidismo por Basedow Graves (BG) en sujetos pre-púberes y púberes. Pacientes y Método: Estudio descriptivo y retrospectivo. Universo: Pacientes con diagnóstico de BG en control en endocrinología pediátrica en la Pontificia Universidad Católica de Chile, entre 1991 y abril 2007 (n = 38). Se registraron los hallazgos clínicos y de laboratorio. Se evaluó las diferencias entre los grupos con pruebas no paramétricas (Mann-Whitney U), las diferencias de proporciones con la Prueba de Fisher (SPSS 10.0 para Windows y graphpad Prism 4). Resultados: El rango de edad fue 3 a 15,9 años. Veintiún sujetos eran pre-púberes y 17 eran púberes; hubo más mujeres que hombres (5: 2 y 15: 2, respectivamente; p = 0,2). Los síntomas y signos más frecuentes fueron bocio difuso, hiperactividad, polidefecación, insomnio e irradiación de calor. No hubo diferencias entre los pre-púberes y púberes. El grupo pre-púber tenía talla más alta que su carga genética (+2,4 DS) comparados con los púberes (+0,2 SDS; p = 0,03). El compromiso ocular más frecuente fue el exoftalmo. Conclusión: No encontramos diferencias en la forma de presentación del BG entre los niños pre-púberes y púberes. Los síntomas neuropsiquiátricos tales como hiperactividad e insomnio, y una talla mayor a la esperada para la diana familiar, fueron hallazgos frecuentes en los niños con BG.

Remission of Graves' hyperthyroidism treated with methimazole / Remisión del hipertiroidismo de la enfermedad de Graves tratado con metimazol Antecedentes

BACKGROUND: Long-term thionamide treatment is considered one of the main resources for Graves' hyperthyroidism. Although a 54.2 remission rate in patients so treated in Mexico was previously reported, most articles have shown a wide variation over time. In the present article we report the actual remission rate of long-term methimazole (MMZ) therapy of Graves' hyperthyroidism in Mexico. METHODS: We carried out a retrospective study of long-term MMZ treatment in 80 patients with Graves' hyperthyroidism with a postreatment follow-up of at least twelve months. Remission was considered by clinical as well as biochemical criteria. RESULTS: We studied 63 females and 17 males, mean age 37.7 +/- 10.4 years. Duration of symptoms was 13.3 +/- 20.7 months. Daily MMZ dose: 20.0 +/- 8.8 mg, treatment duration 16.7 +/- 8.9 months and follow-up was 34.8 +/- 60.3 months. Fourteen patients (17.5) are in remission and sixty six relapsed (82.5). Relapse occurred after a mean of an 11.9 +/- 11.8 month follow-up. Goiter size was the only statistically significant remission sign whereas age, disease duration, MMZ dose, exophthalmos, treatment duration or 1-thyroxine concomitant use were not useful predictive factors. CONCLUSIONS: Remission rate of long-term MMZ treatment of Graves' hyperthyroidism has substantially decreased in Mexico, since the previous report. We suggest that our results may be related to an increase of iodine intake or poor treatment, compliance. Goiter size was the only remission predictive sign. Due to our low remission rate we suggest Graves' disease patients must be selected for this kind of treatment.

La maladie de Basedow en Cote d'Ivoire: Reflexion et perspectives

La maladie de Basedow est la cause la plus frequente des hyperthyroidies en Cote d'Ivoire; (79;17 pour cent). Notre travail est une etude transversale couvrant une periode de 14 ans; allant du premier Janvier 1986 au 31 Decembre 1999. Il a ete realise a la consultation d'Endocrinologie et maladies metaboliques du CHU de Treichville. Elle avait pour but de definir le profil type du patient ou de la patiente basedowien (ne) en Cote d'Ivoire et de proposer la strategie diagnostique et therapeutique la plus adaptee a nos conditions d'exercice. Le depouillement nous a permis d'identifier 152 patients repondant a notre critere d'inclusion. Nous avons obtenu les resultats suivants a savoir la frequence annuelle de la maladie de Basedow etait d'environ 10 a 11 patients. La majorite des patients avait un age compris entre 20 et 50 ans (soit 84;2 pour cent) avec une predominance feminine (sex ratio F/M 6;6). Le groupe ethnique KWA etait predominant (41;5 pour cent). Les patients etaient dans la majorite des cas de niveau socio-economique faible (67;8 pour cent des cas). La symptomatologie clinique ne se singularise que par son caractere caricatural en rapport avec une consultation tardive. Parmi les signes dominants de la thyrotroxicose et les signes propres de la maladie de Basedow: le goitre diffus 65;1 pour cent) et l'exophtalmie (80;2 pour cent) ont ete les plus frequents. Sur le plan therapeutique; le traitement medical domine par les ATS; a ete propose dans 92 pour cent des cas; l'efficacite du traitement a ete constatee dans 68;2 a 77;8 pour cent. Enfin 75 pour cent des malades ont ete perdus de vue. Ainsi les problemes therapeutiques restent preoccupants et la prevalence elevee de patients perdus de vue (sans doute en raison du cout eleve d'un traitement medical long et couteux) doit nous interpeller. Aussi parait-il souhaitable dans nos pays peut-etre plus encore qu'ailleurs; de privilegier la chirurgie et d'oeuvrer a vaincre la reticence des patients vis-a-vis d'elle. Une collaboration etroite entre chirurgien et endocrinologue est indispensable. Elle doit absolument fonctionner avant et apres un tel acte. Le patient repere par l'endocrinologue devant obligatoirement lui etre adresse aux fins d'une surveillance clinique et biologique incontournable

Orbitopatia tireóidea: análise clínica e epidemiológica / Thyroid Orbitopathy: Clinical and epidemiological analysis

Objetivo: Fazer uma análise estatística dos aspectos clínicos e epidemiológicos dos pacientes portadores de orbitopatia tireóidea. Local: Setor de Oftalmologia do Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro. Método: Realizou-se um estudo prospectivo de 14 pacientes portadores de orbitopatia tireóidea, os quais foram submetidos a exame oftalmológico completo. Resultado: As queixas mais freqüentes foram ardência e sensaçäo de corpo estranho em 85.71 dos casos. Ao exame, foi detectado diminuiçäo do tempo de ruptura do filme lacrimal em 85.71 por cento dos casos, retraçäo palpebral em 78.57 por cento (unilateral em 28.65 por cento e bilateral em 50 por cento), proptose em 50 por cento (unilateral em 14.29 por cento e bilateral em 35.71 por cento), alteraçöes corneanas em 21.43 por cento e de motilidade extrínseca em 14.29 por cento. Em nehum caso foi diagnosticada neuropatia óptica. Conclusäo: Os pacientes com orbitopatia tireóidea, em grande parte das vezes, apresentam queixas inespecíficas que devem ser consideradas como elementos de suspeiçäo para o diagnóstico.

Radioiodoterapia em pacientes com doença de Basedow-Graves / Radioiodine therapy in patients with Graves' disease

Foram estudados, retrospectivamente, 104 pacientes com doença de Basedow-Graves submetidos a radioiodoterapia entre 1983 e 1993. As atividades administradas variaram entre 2,0 mCi e 9,0 mCi (74 MBq e 333 MBq). Os pacientes responderam a questionário em 1994 e em 1998 e foram considerados em hipotireoidismo quando em terapia hormonal substitutiva. Discutiu-se a importância da radioiodoterapia, suas indicaçöes e as diversas maneiras de se calcular a atividade administrada. Os resultados foram comparados aos da literatura. Ao final da avaliaçäo, 62,4 por cento dos pacientes estavam em hipotireoidismo e 37,6 por cento em eutireoidismo. Näo foi encontrada diferença significativa na evoluçäo para hipotireoidismo em relaçäo ao sexo, número de tratamentos realizados, atividades total (em mCi) administrada, atividade em µCi por grama de tecido e uso de medicaçäo antitireoidiana. Concluiu-se que o tempo pós-radioiodoterapia foi o fator de maior importância na análise dos resultados, capaz de interferir na evoluçäo para o hipotireoidismo.

Relaçäo cronológica entre o aparecimento do diabetes mellitus do tipo I e das tiroidopatias nas síndromes poliglandulares auto-imunes (SPAs) / Chronologic relation between the appearance of diabetes mellitus type I and of thyroid diseases in the autoimmune polyglandular syndromes

As síndromes poliglandulares auto-imunes (SPAs) caracterizam-se pela associaçäo de duas ou mais endocrinopatias auto-imunes no mesmo indivíduo. A relaçäo cronológica entre o aparecimento das tiroidopatias auto-imunes (moléstia de Basedow Graves e tiroidite de Hashimoto) e do diabetes mellitus tipo I nas SPAs näo está bem estabelecida. A fim de melhor avaliar essa seqüência de eventos, analisamos 44 portadores de diabetes mellitus do tipo I e quadro clínico e/ou laboratorial de outra endocrinopatia ou doença auto-imune associada (SPA), sendo 38 mulheres e seis homens, com idades variando entre 10 e 73 anos. Observamos que nesses pacientes, o diabetes incide predominantemente na quarta década de vida e, em 93 por cento dos casos está associado a uma tiroidopatia auto-imune. A moléstia de Basedow Graves usualmente precede o desenvolvimento do diabetes diferentemente da tiroidite de Hashimoto (p=0,002). Esses dados enfatizam a importância da pesquisa de diabetes mellitus do tipo I em portadores de moléstia de Basedow Graves, assim como da investigaçäo de tiroidite de Hashimoto em portadores de diabetes mellitus do tipo I, através da avaliaçäo da funçao dos órgäos-alvo e/ou verificaçäo de marcadores imunológicos.

Estudo anatomopatológico de 794 peças cirúrgicas da tireóide / Anatomopathologic study of 794 surgical specimens of the thyroid gland

Com a finalidade de se conhecer a frequência das doenças da tireóide em peças cirúrgicas, fez-se estudo retrospectivo de 11 anos (1981/1991) nos arquivos do Serviço de Patologia Cirúrgica da Faculdade de Medicina da UFMG, Belo Horizonte - MG. A casuística compreendeu 794 espécimes, sendo 710 (89,4 por cento) de pacientes do sexo feminino e 84 (10,6 por cento) do masculino. Em 80 casos (10,1 por cento), havia associaçäo de duas doenças. As doenças isoladas mais frequentes foram: bócio colóide nodular (399 casos, 50,3 por cento), adenoma folicular (119 casos, 15,0 por cento), bócio hiperplásico difuso (Doença de Graves, 55 casos, 6,9 por cento), carcinoma papilífero (33 casos, 4,1 por cento), doença de Plummer (19 casos, 2,4 por cento), cisto da tireóide (15 casos, 1,9 por cento), tireoidite de Hashimoto (14 casos, 1,8 por cento), carcinoma folicular (11 casos, 1,4 por cento), carcinoma indiferenciado (5 casos, 0,6 por cento), carcinoma medular (4 casos, 0,5 por cento). As associaçöes de doenças mais comuns foram bócio colóide nodular + adenoma folicular (50 casos, 6,3 por cento) e carcinoma papilífero + bócio colóide nodular (8 casos, 1,0 por cento). Lesöes neoplásicas estiveram presentes em 252 pacientes (31,7 por cento), isoladamente ou associadas a outras doenças. Ao todo, foram encontrados 70 casos (8,8 por cento) de neoplasias malignas.

Tratamiento quirúrgico de la enfermedad de graves / Surgical treatment of graves disease

Se presenta una serie de sesenta pacientes portadores de enfermedad de Graves y operados entre enero de 1980 y diciembre de 1991. Representan el 7,2// de las tiroidectomías durante este período. El promedio de edad fue de 28 años y 43 (72//) fueron mujeres. Todos ellos tuvieron hipertiroidismo clínico y biológico, y fueron inicialmente con drogas antitiroideas, propanolol o una combinación de ambas. A 46 pacientes se le realizó una tiroidectomía subtotal bilateral, a 11 una lobectomía total de un lado y parcial contralateral, y a 3 unilateral, otros dos mostraron infección de la herida, y hubo un caso de hematoma sofocante. Dos pacientes tuvieron hipocalcemia transitoria. El estudio patológico reveló un carcinoma papilar coincidente en una oportunidad (1,6//). El tratamiento quirúrgico de la enfermedad de Graves tiene un bajo índice de complicaciones y permite un rápido control de la tirotoxicosis