Diffuse-nodular toxic goiter is a disease caused by hypertrophy and hyperthyroidism, which is accompanied by the development of thyrotoxicosis. This disease manifests itself with increased excitability, and, in addition, irritability, palpitations, weight loss, shortness of breath and sweating. A characteristic symptom is exophthalmia. The disease leads to changes in the cardiovascular system, as well as adrenal insufficiency. The main threat to the life of patients is the onset of thyrotoxic crisis.
About pathology
Diffuse-nodular toxic goiter differs in autoimmune nature and develops due to defects in the immune system, in which antibodies to TSH receptors are produced, which have a constant stimulating effect on the thyroid gland. This leads to a uniform growth of thyroid tissues, hyperfunctions and an increase in the level of thyroid hormones: T3 and T4. An enlarged gland is called goiter.
An excess of thyroid hormones can enhance the reactions of the main metabolism, significantly depleting the energy reserve in the body, which is required for normal cell life. The most susceptible to thyrotoxicosis are the cardiac, vascular and nervous systems.
About the causes of pathology
Nodular toxic goiter can develop mainly in women aged 20-50. In the elderly, as in childhood, such a disease occurs quite rarely. Endocrinology still cannot exactly answer the question about the cause and mechanism of triggering the autoimmune reaction that underlies toxic diffuse goiter. This disease is sometimes detected in patients who have a hereditary predisposition, realized under the influence of many factors of the internal and external environment.
Infectious and inflammatory diseases contribute to the appearance of toxic toxic goiter (ICD 10 E05.2) along with mental injuries, organic brain lesions (be it cranial trauma or encephalitis), autoimmune and endocrine disorders (we are talking about the functions of the pancreas, pituitary, sex glands and adrenal glands ) and many others. The risk of goiter is almost doubled when patients smoke.
Degrees of pathology and classification
Diffuse-nodular toxic goiter can be manifested by the following variations of thyrotoxicosis, regardless of the size of the thyroid gland:
- With a mild degree, the patient is dominated by complaints of a neurotic nature with the absence of cardiac arrhythmias. There may be complaints of tachycardia with a stroke frequency of not more than a hundred per minute. There is no pathological dysfunction of other endocrine glands.
- In the second degree of diffuse-nodular toxic goiter, weight loss in the range of eight to ten kilograms per month is noted. Pronounced tachycardia is also observed. Nodular toxic goiter of the 2nd degree is quite common.
- A severe degree is accompanied by weight loss to the limit of exhaustion, there are signs of functional impairment from the kidneys, heart and liver. Usually this is observed when toxic goiter is not treated for a long time.
Next, we will find out in detail what symptoms accompany this endocrine pathology.
Symptomatology
What are the symptoms of nodular toxic goiter? Let's consider further.
Since thyroid hormones are responsible for the performance of various physiological functions, the appearance of thyrotoxicosis is accompanied by a variety of clinical manifestations. Typically, patient complaints are directly related to cardiac and vascular changes, with the symptoms of endocrine ophthalmopathy and catabolic syndrome. Cardiac and vascular disorders can be manifested by rapid expressed palpitations, that is, tachycardia. A feeling of palpitations in patients can occur in the chest, in the abdomen, in the hands. Cardiac beats at rest in the presence of thyrotoxicosis can increase to 130 per minute. In the presence of moderate severity of thyrotoxicosis, an increase in systolic and a decrease in diastolic pressure is observed along with an increase in pulsation.
Myocardial dystrophy
In the case of a prolonged course of thyrotoxicosis, especially in elderly patients, a bright and pronounced myocardial dystrophy develops. It can be manifested by disturbances in the heart rhythm, which will be expressed by atrial fibrillation and extrasystole. Subsequently, all this will lead to changes in the myocardium and to stagnation. For example, peripheral edema, ascites, and cardiosclerosis may appear. Respiratory arrhythmia, as well as a tendency to frequent pneumonia, may be noted.
The onset of catabolic syndrome is characterized by a sharp weight loss of about 15 kilograms against a background of good appetite. General weakness and hyperhidrosis are not ruled out. Violation of thermoregulation, as a rule, manifests itself in the fact that the patient experiences a feeling of heat and does not freeze at sufficiently low ambient temperatures. In elderly patients, evening subfebrile condition may occur.
Symptoms from the organs of vision
For diffuse-nodular toxic goiter, the development of changes in the eyeballs is typical. In this case, we are talking about endocrine ophthalmopathy, against the background of which the palpebral fissures expand due to the raising of the upper eyelids and lowering of the lower ones. Thus, incomplete closure of the eyelids is observed in combination with a rare blinking, exophthalmos (beak-eyed eyes) and glitter of the eyes. In a patient with this pathology, the face acquires an obvious expression of fear, anger and surprise.
Due to incomplete closure of the eyelids, such patients have complaints about the appearance of sand in the eyes, dryness and chronic conjunctivitis. The development of edema and the growth of periorbital tissue compresses the eyeball and nerves, causing visual field defects along with increased intraocular pressure, eye pain, and sometimes complete loss of vision.
Symptoms of deviation in the activity of the nervous system
On the part of the functioning of the nervous system, in the presence of thyrotoxicosis, mental instability is observed in the form of mild excitability, increased irritability and aggressiveness, anxiety and fussiness, tearfulness, mood changes and difficulty concentrating if necessary. Sleep may be disturbed, depression may develop, and in a severe case, persistent changes in the psyche and personality of the patient are observed.
Often in the presence of diffuse-nodular toxic goiter, small tremor of the fingers occurs. If the course is severe, tremors can occur throughout the body, making speech, movement, and writing difficult. Proximal myopathy is characteristic of such a patient, along with a decrease in the muscles of the limbs, it is difficult for the patient to get up from his squat or stool. Sometimes an increased tendon reflex is noted.
Under the influence of an excess of thyroxin, calcium is washed out of bone tissue, bone resorption and the development of osteopenia syndrome (decrease in bone mass) are observed. In addition, pain in the fingers is noted, which can take the form of drum sticks.
Symptoms of the digestive system
Ovarian dysfunction in combination with menstrual irregularities is rare in this disease. In premenopausal women, a decrease in the frequency of menstruation and the development of fibrotic and cystic mastopathy can be noted. The presence of a mild disease does not affect the conception process, a woman has every chance of becoming pregnant. Antibodies to TSH, which stimulate the thyroid gland, are transmitted transplacentally from a pregnant woman with toxic goiter to the fetus. As a result, a child may develop neonatal transient thyrotoxicosis. This pathology in men is often accompanied by erectile dysfunctions and gynecomastia.
Patients may be concerned about abdominal pain, as well as diarrhea, unstable stools, nausea, and vomiting. In severe forms of the disease, thyrotoxic hepatosis can gradually develop. Some patients may develop adrenal insufficiency, which is usually manifested by hyperpigmentation of the skin and hypotension.
Skin changes
In the presence of this pathology, the skin is usually soft, warm to the touch, and in some patients vitiligo occurs, folds of the skin darken, especially on the elbows. In 5% of patients with this pathology, pretibial myxedema develops, which is expressed in edema, compaction and erythema of the skin in the region of the lower leg and feet.
In the presence of diffuse toxic goiter, a uniform increase in the thyroid gland is noted. Sometimes iron is significantly increased, and sometimes goiter may even be absent (this happens in 25% of cases). The severity of the pathology is not determined by the size of the goiter, since with a small volume, a severe form of thyrotoxicosis can also occur.
Now we turn to the consideration of treatment methods for this disease and find out how it is eliminated in modern medicine.
Treatment of diffuse nodular toxic goiter
Conservative therapy of thyrotoxicosis consists in taking antithyroid drugs. These are Merkazolil, Metizol, Tyrosol and Propitsil. They are able to accumulate in the thyroid gland and inhibit the production of thyroid hormones. Reducing the dose of drugs is carried out strictly individually, which depends on the disappearance of symptoms of thyrotoxicosis. It is necessary that the pulse normalizes to eighty beats per minute, the body weight increases and tremors disappear with sweating.
Surgical intervention
Surgical treatment of nodular toxic goiter of the thyroid gland is used when total organ removal is required, which will lead to postoperative hypothyroidism, which is compensated by medication. Indications for the operation are allergic reactions to drugs in combination with a persistent decrease in leukocyte levels with conservative treatment. In addition, the operation is needed when the goiter is large, there are cardiovascular disorders in combination with the pronounced goitre effect of mercazolil. Surgery for this pathology is possible only after drug compensation of the patient's condition in order to prevent the onset of thyrotoxic crisis at the stage of the early postoperative period.
Radioactive Iodine Treatment
This is perhaps one of the main methods of therapy for toxic thyroid nodular goiter. This technique is non-invasive, it is considered effective and relatively inexpensive and does not cause complications that can develop during surgery on the thyroid gland. A contraindication to such treatment is pregnancy. An isotope with radioactive iodine accumulates in the cells of the endocrine organ, where it begins to decay and thereby provides local irradiation along with the destruction of thyrocytes. Treatment with radioactive iodine is carried out with the mandatory hospitalization of the patient in specialized departments. The condition of hypothyroidism in patients, as a rule, develops within six months after using iodine.
Therapy during pregnancy
In the presence of a toxic diffuse goiter in a pregnant patient, it should be under the regular supervision of not only a gynecologist, but also an endocrinologist. Treatment of this disease during pregnancy is carried out with "Propylthiouracil" (this drug does not pass well through the placenta) at the minimum dosage necessary to support the amount of thyroxine. With an increase in gestational age, the patient’s need for thyreostatics decreases, and most women do not take this medication after the thirtieth week of pregnancy. After childbirth, they usually develop relapses of thyrotoxicosis.
Treatment for nodular toxic goiter of thyrotoxic crisis involves the intensive use of large doses of thyreostatics. Propylthiouracil is preferred. If it is impossible to independently use the drug by the patient, it is administered through a nasogastric tube. In addition, glucocorticoids are prescribed in combination with adrenergic blockers, therapy, plasmapheresis and so on.