THE PHENOMENON OF ASSOCIATED GRAVES146 AND PLUMMER146S DISEASE 150 A C - PDF document

1 13 THE PHENOMENON OF ASSOCIATED GRAVES&#
13 THE PHENOMENON OF ASSOCIATED GRAVES’ AND PLUMMER’S DISEASE – A CASE REPORT2. N.D. Paunkovic, J.A.Paunkovic: Autonomous functioning nodule and Graves’ disease. 12International Thyroid Congress, Kyoto 2000. Page 148 (abst P-171).3. Paunkovic N., Paunkovic J.2003 : Associated Graves’ and Plummer’s disease. Hellenic 4. Charkes DN 1972. Graves’ disease with functioning nodules (Marine-Lenhart syndrome). 5. Hirsch C, Laubenbacher C, Langhammer HR, Spyra L, Senekowitsch-Schmidtke, Schwaiger M 1995. Incidence of immunogenic thyroid disease following treatment of Plummer’s disease with I-131 therapy. Eur J Nucl Med, 22:79 (abstr 298) 6. Simova N 1994. A case of adenoma toxicum after radioiodine therapy of hyperthyreosis. 7. Chiovato L, Santini F, Vitti P, Bendineli G, Pinchera A 1994. Appearance of thyroid stimu-lating antibody and Graves’ disease after radioiodine therapy for toxic nodular goiter. str. 11-13 interesting from various aspects, we will limit the presentation of our ndings only to the thyroid side.The patient had enlarged thyroid gland with several palpable nodules. She had all clinical signs of moderate – severe hyperthyroidism. TSH was measured by an ultrasensitive method (TSH ultra, Walac), as well as concentration of free thyroxin (FT4 Farmacia). As thyroid scintigraphy showed three ‘hot’ nodules with non-suppressed paranodal tissue ( gure 2), we have also measured TRAb (BRAHMs). All these indicators are We have presented a patient with associated autoimmune (Graves’) and autono-mous (Plummer’) hyperthyroidism. The simultaneous occ

2 urrence of these two diseases is relativ
urrence of these two diseases is relatively rare; more often it begins as one of these two diseases followed after a period of time by the other – successive occurrence. Our patient was also diagnosed many years ago with euthyroid goiter. In our previous papers, we presented 17 cases, observed during the course of long-term monitoring (1,2,3). It was noted that only ve out of 17 patients met the diagnostic criteria for both diseases. In the rest of cases, we needed new ‘diagnostic criteria’ to con rm the diagnosis.Other authors have reported manifestation of isolated ‘diagnostic criteria’ i.e. appearance of functional nodules in patients with Graves’ disease (Marine-Lenhart syndrome) (4), a case report of adenoma toxicum after radioiodine therapy of hyper-thyreosis, occurrence oh immunogenic thyroid diseases after the treatment of Plummer’ disease with radio-iodine (6), appearance of thyrostimulating antibodies and Graves’ disease following the treatment of toxic nodular goiter with radioiodine (7), etc. Our patient has not had any prior treatment. The current disease occurred spontaneously – thyrostimulating antibodies were detected in the patient with already established multinodular euthyroid goiter. In conclusion: the diagnosis of associated Graves’ and Plummer’ disease was based on thyroid scintigraphy ndings of ‘hot’ nodules with clearly non-suppressed paranodal tissue. Clinical diagnosis of hyperthyroidism was supported by signi cantly suppressed TSH and high concentration of ‘free’ thyroxin, while high titer of detected TRAb was in

3 favor of autoimmune aetiology.1. Paunko
favor of autoimmune aetiology.1. Paunkovic N, Paunkovic J 1998. Associated Graves’ disease and Plummer’s disease: Vari-ant of Marine-Lenhart syndrome or distinct clinical entity? 25 Annual Meeting of the European Thyroid Association – Clinical Thyroid Day. Athens 1988 (abstract book). 11 THE PHENOMENON OF ASSOCIATED GRAVES’ AND PLUMMER’S DISEASE – A CASE REPORT Nebojša Paunkovi, Jane Paunkovi, Kosta NikoliGraves’ disease is the autoimmune hyperthyroidism. In addition to clinical signs and symptoms of the disease, it’s manifested in high diffuse accumulation of radio tracer on thyroid scintigraphy and presence of TSH-receptor autoantibodies (TRAb).Autonomous hyperthyroidism (Plummer’s disease) is, on the other hand, manifested in ndings of hyperfunctional nodules (multinodular goiter) and a complete suppression of paranodal tissue on thyroid scintigraphy. As the whole group of nonimmune hyperthyroidisms, this entity is also There is, however, a possibility for occurrence of associated both types of hyperthyroidism in the same patient. This disease will show clinical manifestation of hyperthyroidism with raised thyroid hormones and suppressed TSH. And yet, thyroid scintigraphy shows non - suppressed (stimulated by TRAb) thyroid tissue with ‘hot’ thyroid nodules.We have presented a case of the patient with associated both types of CASE REPORT: Patient K.S., age 63, had been earlier under our care for multinodular euthyroid goiter. She had all the clinical, laboratory and immunology signs of this disease, but also some ‘hot’ and ‘warm’

4 gure 1).On this occasion, she was refer
gure 1).On this occasion, she was referred to our Polyclinic for tumor marker HE-4 testing for suspected ovarian cancer. Although this patient is Nebojša Paunkoviar. Zdravstveni centar Zajear, Nuklearna medicina. str. 7-10 6. Simova N. 1994. A case of adenoma toxicum after radioiodine therapy of hyperthyreosis. 7. Chiovato L, Santini F, Vitti P, Bendineli G, Pinchera A. 1994. Appearance of thyroid stimu-lating antibody and Graves’ disease after radioiodine therapy for toxic nodular goiter. 9 UDRUŽENA POJAVA GRAVES-OVE I PLUMMER-OVE BOLESTI – PRIKAZ BOLESNIKAPrikazali smo jednu bolesnicu sa istovremeno prisutnom autoimunom (Graves) i autonomnom (Plummer) hipertireozom. Relativno je retko da se obe ove bolesti is-polje simultano, e je da se prvo prezentuje kao jedna, pa posle izvesnog vremena nastane i druga vrsta hipertireoze – sukcesivna pojava bolesti. I naša bolesnica je pre U našim prethodnim radovima prikazali smo 17 bolesnika ali opserviranih u toku dugotrajnog „longitudinalnog” praenja (1,2,3). Tada smo zapazili da, od 17 obolelih, samo njih 5 je imalo dijagnostike kriterijume za obe bolesti. Kod svih ostalih bilo je neophodno za postavljanje dijagnoze pojava „novog dijagnostikog Drugi autori su opisivali pojavu pojedinih „dijagnostikih kriterijuma”, npr. pojavu funkcionih nodusa kod bolesnika sa Graves-ovom bolešu (Marine-Lanhart sindrom) (4), pojavu imunogenih tireoidnih oboljenja posle leenja Plummer-ove bolesti radiojodom (5), pojavu toksinog adenoma posle leenja radiojodom difuzne hipertireoze (6), pojavu tireostimulantnih antitela i Graves-

5 ove bolesti posle leradiojodom toksine n
ove bolesti posle leradiojodom toksine nodozne strume (7), itd. Naša bolesnica nije imala nikakve pret-hodne intervencije, tj. sadašnja bolest je nastala spontano – pojava tireostimulantnih antitela u prethodno prisutnoj polinodoznoj eutireoidnoj strumi. Ukratko, za postav-ljanje udružene Graves-ove i Plummer-ove bolesti imali smo: strumu sa scintigrafski im” nodusima ali sa jako vizualizovanim, nesuprimiranim paranodalnim tkivom. ki znaci hipertireoze potvreni su maksimalno suprimiranim TSH i povišenom koncentracijom slobodnog tiroksina, a njena autoimuna etiologija prisustvom TRAb 1. Paunkovic N, Paunkovic J. 1998. Associated Graves’ disease and Plummer’s disease: Vari-ant of Marine-Lenhart syndrome or distinct clinical entity? 25 Annual Meeting of the European Thyroid Association – Clinical Thyroid Day. Athens 1988 (abstract book).2. N.D. Paunkovic, J.A. Paunkovic: Autonomous functioning nodule and Graves’ disease. 12International Thyroid Congress, Kyoto 2000. Page 148 (abst P-171).3. Paunkovic N, Paunkovic J. 2003: Associated Graves’ and Plummer’s disease. Hellenic 4. Charkes DN 1972. Graves’ disease with functioning nodules (Marine-Lenhart syndrome). 5. Hirsch C, Laubenbacher C, Langhammer HR, Spyra L, Senekowitsch-Schmidtke, Schwaiger M 1995. Incidence of immunogenic thyroid disease following treatment of Plummer’s disease with I-131 therapy. Eur J Nucl Med, 22:79 (abstr 298). str. 7-10 paranodal tissue. In this paper we discussed our previous experiences Key words: Graves’ disease, Plummer’s disease, hyperthyroidism, Graves-ova (ili Basedow-ljeva

6 bolest) je autoimuna hipertireoza. Pore
bolest) je autoimuna hipertireoza. Pored kliniznakova i simptoma prezentuje se scintigrafski pojaanom difuznom akumulacijom radiotrasera i prisustvom antitela na TSH receptore (TRAb). S druge strane, autonomna hipertireoza (Plummer-ova bolest) prezentuje se sa nekoliko hiperfunkcionalnih nodusa (struma polynodosa toxica), i kompletnom supre-sijom paranodalnog tkiva na scintigramu. Kao sve vrste neimunogenih hipertireoza, e biti TRAb negativan.pacijenta. Klinie se ispoljiti hipertireoza, imae povišene tireoidne hormone i suprimiran TSH. I pored ovog jasno e se prikazati nesuprimirano tireoidno tkivo (stimulisano od strane TRAb), ali i „vruMi smo prikazali sluaj jedne naše bolesnice sa udruženom pojavom oba ova Bolesnica K.S, životne dobi 63 godine, ranije se kontrolisala kod nas zbog nodozne eutireoidne strume. Naravno, imala je klinike i laboratorijske znake koji odgovaraju ovoj dijagnozi, kao i jedan „topli” (izo ksantni) nodus na radionuklidnom Sada je upuena u našu polikliniku radi odreivanja markera HE4 zbog sumnje na karcinom ovarijuma. Mada je bolesnica „interesantna” sa više aspekata, u ovom Imala je uveanu štitastu žlezdu, sa nekoliko palpabilnih nodusa. Imala je kli-ke znake i simptome umereno teške hipertireoze. Odreen je TSH ultrasenzitnom metodom (TSH ultra, Walac) i koncentracija „slobodnog” tiroksina (FT4 Farmacia). Pošto je scintigram štitaste žlezde pokazao tri „vrua” nodusa (slika 2), ali uz jasan prikaz nesuprimiranog paranodalnog tkiva, odredili smo i TRAb (BRAHMs). Sve 7 UDRUŽENA POJAVA GRAVES-OVE I PLUMMER-OVE BOLESTI –

7 PRIKAZ BOLESNIKA Nebojša Paunkovi, Dže
PRIKAZ BOLESNIKA Nebojša Paunkovi, Džejn Paunkovi, Kosta NikoliPrikazali smo sluaj jedne bolesnice sa istovremeno ispoljenom autoimunom (Graves-Bazedow-ljeva bolest) i autonomnom (Plummer-ova bolest) hipertireozom. Bolesnica se godinama kontrolisala kod nas zbog eutireoidne strume, ali su se poslednjih meseci ispoljili znaci „hipertireoidnog sindroma”. Izvršeno je detaljno ispitivanje štitaste žlezde. Udružena pojava ove dve vste hipertireoza dokazana je na osnovu klinikog stanja hipermetabolizma, maksimalno suprimiranog TSH, povišenog „slobodnog” tiroksina, i pozitivnog nalaza antitela na TSH receptore, i scintigrafskog prikaza „vruih” nodusa sa delimisuprimiranim paranodalnim tkivom. U radu su komentarisana prethodna ne reGraves-Basedow-ljeva bolest, Plummer-ova bolest, hi- We have presented the case of a female patient with the simul-taneous occurrence of autoimmune hyperthyroidism (Graves’ disease) and autonomous hyperthyroidism (Plummer’s disease). She has been under our care for euthyroid goiter for many years, but when last seen it was noted that she showed signs of ‘hyperthyroid syndrome’. We carried out extensive examination and testing. The diagnosis of associated two types of hyperthyroidisms was based on the following criteria: features of clinical hypermetabolic state, maximal suppression of TSH, raised ‘free’ thyroxin and presence of TSH receptor autoantibodies, associated with scintigraphic ndings of ‘hot’ nodules with partially suppressed Nebojša Paunkoviar. Zdravstveni centar Zajear, Nuklearna medicina