Widening of palpepral Fissures Lid retraction
Paralysis of right Rectus muscle
Conjuntival injection and chemosis
Failure to close lid
Paralysis of upward Gaze on the right
(b) In this transverse view the enlarged muscles are seen (appearing dark against the light fat signal) and the exophthalmos is apparrent.
Differential Diagnosis
• Between the cricoid cartilage and the suprasternral notch • 12-20g in size, highly vascular ,and soft in consistency • Parathyroid gland are located to each pole of the thyroid • Recurrent laryngeal nerves traverse the lateral borders
frequent in men • Typically occurs between 20 and 50years
of age
Pathogenesis
• Genetic factors Polymorphisms in HLA-DR,CTLA-4,and PTPN22 (a T cell regulatory gene)
•
chronic colonitis heart diseasse
•
intraorbital tumors
Hyperthyroidism with a high radioiodine uptake
Laboratory Evaluation
• Measurement of Thyroid Hormones
• TSH suppressed with thyrotoxicosis • Free T3 and Free T4 Increased in Thyrotoxicosis • Total T3 and total T4 Increased in Thyrotoxicosis
Influenced by TBG
Factors affecting TBG
• Increased TBG
• pregnancy • Estrogen • hepatitis • Medications • Genetic disorders
Decreased TBG
Androgen Glucocorticoids Nephrotic Syndrome Genetic disorders
b. Cold nodule in the right lobe imaged by 99mTc.
c. Elderly woman with obvious multinodular goiter and the corresponding radioiodide scan on the right.
NO SPECS is not always satisfactory for prospective objective assessment of orbital changes and determining an overall activity score is sometimes more helpful. This is done by assigning 1 point for the presence of each of the following findings:
• Environmental factors stress smoking infection
Figure 7-15 Possible sequence and clinical outcome in AITD, indicating the interrelation of envirenmental and genetic factors, and dependence of the clinical picture on the type of immune response.
Image Evaluation
• Radioiodine Uptake and thyroid scanning • Ultrasound of the thyroid • CT or MRI
Figure 6-6. Thyroid Scans.
a. Normal thyroid imaged with 123I.
Figure 12-3. End stage in severe involvement of extraocular muscles in ophthalmopathy
Assessment of severity
• NO SPECS — NO connotes absence or mild degree of involvement; SPECS the more serious degrees of involvement.
• Etiology of thyrotoxicosis 131I Uptake and scan
TSI TPO TG
• Simple goitor 单纯性甲状腺肿
• Pheochromocytoma 嗜铬细胞瘤
• Phsychosis 神经官能症 更年期综合征 抑郁症
• Others：TB、tumors、diabetes、
甲状腺疾病
Overview of the Thyroid Gland
• The thyroid produces two related hormones,thyroxine(T4) and triiodothyronine(T3)
• Thyroid hormones play a critical role in cell differentiation during development and help maintain thermogenic and metabolic homeostasis in the adult
• Spontaneous retrobulbar pain • Pain on eye movement • Eyelid erythema • Conjunctival injection • Chemosis • Swelling of the carbuncle • Eyelid edema
• Autoimmune disorders can either stimulate the overproduction of thyroid hormones (thyrotoxicosis) or cause glandular destruction and hormone deficiency(hypothyroidism)
Laboratory Evaluation
Tests to determine the etiology of thyroid dysfunction:
TSI Thyroid stimulating Immunoglobulin TPO Thyroid peroxidase TG Thyroglobulin
Figure 13-1. Hot nodule in right lobe of thyroid. Note that uptake of radioactivity in the contralateral lobe issuppressed.
Figure 10-5.
(a) This MRI image from a patient with Graves' ophthalmopathy provides a coronal view of the eyes. In this depiction the muscles appear white, and are enormously enlarged, especially in the left eye.
胫前粘液性水肿
Figure 12-6. A case of severe pretibial myxedema showing the coarsened, nodular, infiltrated, pigmented lesions on the lower extremities.
Figure 12-7. (a) Massive infiltrative , localized myxedema in a female patient with Graves' disease and progressive exophthalmos. The lesions have become confluent over the lower extremities. (b) In the same patient, localized myxedema, involving the phalanges, is evident.
Major etiologies of thyrotoxicosis are hyperthyroidism caused by Graves' disease
Graves' disthyrotoxicosis • Up to 2% of women ,but is one-tenth as
Hypothalamic-Pituitary-Thyroid Axis
Thyrotoxicosis
The state of thyroid hormone excess and is not synonymous with hyperthyrodism,which is the result of excessive thyroid function