Cazuri

practice V+VI

Glanda tiroida
Hipertiroidia
Hipotiroidia

Glanda tiroida - Generalitati
Hipertiroidia
Hipotiroidia
 Patologia tiroidiana
II. Hipotiroidism = sinteza si secretie ↓h. tiroidieni
Mixedem= hipotiroidism sever cu infiltrarea tesuturilor
•  Primar: leziune tir. TSH ↑
(95%) Boala tiroidiana autoimuna
Iatrogen: posttiroidectomie, post-RAIU, administrare ↑ ↑ iod

sau medicamentos (amiodarona, ATS)
Deficit iodat

•  Secundar: leziune hipofizara

•  Tertiar (ff rar) : leziune hipotalamus

•  Sd rezistenta la h. tiroidieni generalizat (sd Refetoff)

selectiv

Caz 1. Patricia, 29 ani
•  Acuze:
–  Fatigabilitate
–  Dificultati in conceptie
–  Crestere ponderala (IMC=29 kg/m2)

•  Clinic:
–  Nu se palpeaza gusa

•  AHC:
–  Mama: tiroidita cronica autoimuna
 Determinari laborator
Valoare Interval referinta

Hb 11.2 mg/dl 12-14 mg/dl

184 mg/dL <200 mg/dL
Colesterol total
8.7 mg/dL 8.5-10.1 mg/dl
Ca total
9.8 ng/mL 30-100 ng/mL
25-OH Vit D

Creatinina serica 0.9 mg/dl 0.55-1 mg/dl

Sodiu seric 140 mmol/L 136-144 mmol/L

Potasiu seric 3.7 mmol/L 3.5-5 mmol/L

Determinari hormonale si imunologice
Determinare Valoare Interval referinta
TSH 6.91 mIU/L 0.55-4.78 mIU/L
FT4 16.56 pmol/L 11.50-22.70 pmol/L
FT3 4.82 pmol/L 3.54-6.47 pmol/L

Anti TPO 859 U/mL 0-60 U/mL

Anti Tg 128 U/mL 0-60 U/mL

Boala tiroidiana autoimuna cu hipotiroidie subclinica

 Ecografia tiroidiana
•  Volum tiroidian total = 16.6 ml, parenchim hipoecogen, neomogen

•  Vascularizatie normala

•  Fara formatiuni nodulare

Dg:
•  Tiroidita cronica autoimuna cu hipotiroidie
subclinica
•  Deficit de vitamina D

Rec:
–  Euthyrox (L-Tiroxina) cp 25 mcg, 1 cp/zi, dimineata cu min 40
min inainte de micul dejun, fara alte medicamente administrate
concomitent
–  Colecalciferol 2000 UI, 2 cp/zi – 1 luna, apoi 1 cp/zi
–  Reevaluare cu dozare TSH, FT4 peste 3 luni
Caz 2. Marin, 57 ani
•  Acuze
–  Dispnee, fatigabilitate progresiva
–  Somnolenta, ameteli
–  Frilozitate, constipatie
–  Dureri musculare mb inferioare
•  Simptomatologie debutata/accentuata in urma cu 2-3
saptamani
•  APP:
–  Dislipidemie (Rosuvastatina 10 mg/zi)
–  HTA gr I controlata sub tratament
•  Clinic:
–  Tegumente reci, uscate,
descuamari - predominant coate
–  Gusa difuza
–  Facies: edem palpebral, santuri nazo-labiale sterse
–  Par aspru, cu zone de alopecie
–  Auscultatoric cardiac: zgomote asurzite
–  Bradicardie, FC=50 b/min, TA=110/80 mmHg
 Dg. Interval
referinta
Hb (g/dL) 12.0 13.1–17.2
Creatinina (mg/dL) 1.5 0.7–1.4
ALT(U/L) 357 3–45
AST (U/L) 278 3–45
Colesterol total (mg/dL) 252 130–200
TG (mg/dL) 127 35–200
CK (IU/L) 9300 43–198
CK-MB, (ng/mL) 52.07 0–4.87
TSH (mIU/mL) >  100
0.55-4.78
T4 (pmol/L) 4.32
11.5-22.7
T3 (pmol/L) 2.47
3.54-6.47
Anti TPO >1300 U/mL
0-60 U/mL

Anti Tg 538 U/mL 0-60 U/mL

•  ECG: traseu microvoltat, ritm sinusal, FC=50 b/min
•  Eco cardiac:
–  Lama de lichid pericardic (posterior 15 mm)
–  FE pastrata (55–60%).
 Ecografia tiroidiana
•  Tiroida de volum crescut
•  Parenchim neomogen, vascularizatie redusa
 DG:
•  Mixedem sever pe fond de tiroidita cronica
autoimuna
•  Sd de rabdomioloza
•  Leziune acuta rinichi
 Rec
•  Sol reechilibrare hidroelectrolitica
•  Sistarea tratamentului cu statina
•  Euthyrox 150 mcg/zi (1.6 mcg/kgc)
( !! > 60 ani – nu se recomanda substitutia direct cu
doza necesara – se creste treptat)

Evolutie
•  Favorabila cu tratament
 Diagnostic -> evolutie
Dg. ziua 7 ziua 20 Interval
referinta
Hb (g/dL) 12.0 12.2 13.1–17.2
Creatinina (mg/dL) 1.5 1.11 1.16 0.7–1.4
ALT(U/L) 357 273 47 3–45
AST (U/L) 278 147 27 3–45
Colesterol total (mg/dL) 252 130–200
TG (mg/dL) 127 35–200
CK (IU/L) 9300 1530 235 43–198
CK-MB, (ng/mL) 52.07 5.94 0–4.87
TSH (mIU/mL) >  100 53.65 48.17
0.55-4.78
T4 (pmol/L) 4.32 9.65 14.63
11.5-22.7
T3 (pmol/L) 2.47 3.63 4.12
3.54-6.47