<Case
History>
A 25 y/o female patient was quite healthy before until she
suffered from gradually losing her body weight for 14 Kg in
recent 6 months. Her appetite was increased and palpitation
was frequently complained during this period. Other associated
symptoms including insomnia, sweating, easily fatigue and
dyspnea on exertion. No evidence of polyuria or nocturia. Due
to problems above, she visited our OPD for further
evaluations.
On physical examinations, this patient
appeared general well-being. Her consciousness was clear and
oriented. The blood pressure was 122/75 mmHg, body temperature
was 36.6 0
C,
pulse rate was 116 /min, and respiratory rate was 18/min. The
head was normal. The conjunctivae were not pale and the
sclerae were not icteric. The neck was supple without
lymphadenopathy. The jugular veins were not engorged. The
thyroid was not tender but slightly enlarged. The heart sounds
were regular without murmur. The breathing sounds were
bilaterally clear. The abdomen was soft and flat, no
tenderness or rebound tenderness was noted. The liver and
spleen were not palpable. The extremities moved freely without
edema or petechiae.
<Laboratory Data>
CBC
WBC K/μL |
RBC K/μL |
Hb g/dL |
Hct % |
MCV fL |
MCH pg |
MCHC g/dL |
PLT K/μL |
Seg % |
Eos % |
Baso % |
Lym % |
5.01 |
4200 |
13.9 |
39.8 |
98 |
30.1 |
38 |
152 |
57.8 |
3.7 |
0.6 |
32.2 | Biochemestry
Alb g/dL |
Glo g/dL |
T-Bil mg/dL |
D-Bil mg/dL |
AST U/L |
ALT U/L |
ALP U/L |
LDH U/L |
4.4 |
3.3 |
0.6 |
0.2 |
22 |
16 |
134 |
363 |
BUN mg/dL |
Crea mg/dL |
UA mg/dL |
Na Meq/L |
K Meq/L |
Cl Meq/L |
(T) Camg/dL |
Sugar mg/dL |
14.2 |
1.1 |
5.2 |
138 |
4.2 |
105 |
8.9 |
85 | Thyroid
function tests
TSH: < 0.1 U/ml (0.4 – 5 u/ml) |
T3: 483 ng/dl (80 – 200 ng/dl) |
T4: 26 μg/dl (4.5 – 11.5μg/dl) |
T3u: 46% (25 – 37%) |
<病情分析>
Thyrotoxicosis 是因身體各個組織器官暴露在高濃度的thyroid
hormone下所產生的一種clinical
syndrome,其形成原因大多是因甲狀腺hyperactivity或是因hyperthyroidism,當然也有少部分是因攝取過多thyroid
hormone或是有異位組織分泌thyroid hormone,臨床病症包括 Diffuse toxic
goiter(Graves' disease)、 Toxic adenoma、Toxic adenoma
(Plummer's disease)、 Toxic multinodular goiter、 Subacute
thyroiditis、 Hyperthyroid phase of Hashimoto's thyroiditis和
Thyrotoxicosis facititia 以及一些少見的病症包括Ovarian struma、 Metastatic
thyroid carcinoma (follicular)、 Hydatiform mole、 “ Hamburger
thyrotoxicosis“、 TSH-secreting pituitary tumor、Pituitary
resistance to T3 and T4.
甲狀腺機能亢進的病人因基礎代謝率增快,所以會出現心悸、手抖、怕熱、腹瀉、月經失調、失眠、坐立不安、
脾氣暴躁等現象,而且會伴隨體重減輕,但是食慾不會減少;如果是自體免疫所引起的,可能會合併出現眼睛的症狀,
例如:怕光、流淚、眼睛酸澀、眼凸、複視、結膜充血或水腫、視力減退等等;少數人會出現小腿前面至腳背處皮膚變粗
、多毛、發紅及發癢,此種症狀又稱脛前黏液水腫,此外在手指頭的末梢可以出現象鼓槌一樣的變化,稱為杵狀指或甲狀
腺肢端病變。
甲狀腺機能亢進的診斷一般經由病人所陳述的臨床症狀,加上甲狀腺腫大,特別是伴隨眼睛病變和脛前黏液水腫時, 幾乎可以確定診斷,但是通常會再抽血測定T3、T4或free T4以及TSH,除此之外,也可以測定甲狀腺抗體(主要是Tg Ab 及TPO
Ab)和甲促素受器抗體(TSH-R Ab),Tg Ab 及TPO Ab通常在Hashimoto's
thyroiditis 和Graves'disease都會出現,但是TSH-R Ab對Graves'disease則具有專一性。
甲狀腺機能亢進的治療一般以減少thyroid hormone製造的方法為原則,也就是利用藥物使thyroid
hormone形成減少,或是口服放射性碘藉以破壞甲狀腺組織,或是手術切除大部分的甲狀腺;在藥物治療方面,一般是
使用carbimazole、methimazole或是propylthiouracil,再加上症狀治療的藥物,例如:交感神經抑制劑和鎮定劑,在
藥物使用治療一個月左右,藥量就可以漸漸減少,抗甲狀腺藥物治療的好處是不會造成永久性功能低下的後遺症,而且
治癒後若症狀再度復發,也可再次使用;但是要注意藥物引起的副作用,有些人可能出現皮膚癢、紅疹、風疹塊或是關
節酸痛等症狀,少部分可能會出現膽汁鬱積性肝炎,比較重要的是可能會有白血球減少的現象,此時易受細菌感染,通
常以發燒、喉嚨痛來表現;這些副作用通常在治療開始後三個月內會出現。
如果抗甲狀腺藥物會引起過敏,就必須考慮其他的治療方法,例如放射性碘治療,一般治療的劑量為七豪居里以下,
通常治療後甲狀腺功能於八星期左右恢復至正常,但是其對甲狀腺的破壞作用可能會持續,因此有可能在幾年後漸漸出
現甲狀腺功能不足的現象;不宜使用放射碘的情形通常包括小孩子和孕婦,其他則無多大問題,放射性碘治療沒有多大
副作用,但是要注意治療前不宜食用高碘的食物。
另外還有手術治療,不過開刀前要先服用藥物把甲狀腺機能亢進控制好,這樣開刀後才不會出現甲狀腺風暴;開刀
的好處是可以很迅速去除大部分製造和儲存thyroid
hormone的組織,而在很短時間內使甲狀腺功能恢復至正常,但是開刀後也可能出現甲狀腺功能不足的現象,此外開刀
可能會出現副甲狀腺功能不足和聲帶麻痺的併發症。 |