大三上-各論ii25、甲狀腺

ENDOCRINE竺可青2014-5-22CLASSICALALGORHYTHMPITUITARYANTERIORPOSTERIORTHYROIDPARATHYROIDPANCREAS(endo.)ADRENALCORTEXMEDULLADEGENERATION(aka,“involution”)INFLAMMATIONNEOPLASMBENIGNMALIGNANT15-25gramsGOITERS甲狀腺腫

(aka,thyromegaly,diffuseornodular)IODINEdeficiencyIncreasedTSHGoitrogens,e.g.,cabbage卷心菜,Brusselssprouts,cauliflower菜花,turnips,cassava木薯)AssociatedwithHYPOthyroidismeventually,NOThyperthyroidismG

O

I

T

E

R

Mostgoitersworldwideareduetoiodinedeficiency.Thethyroidenlargestotrytotrapmoreiodine,whenserumlevelsarelow.Thisisaadaptiveresponse3stagesDiffusehyperplasticgoiter增生期Diffusecolloidgoiter膠質(zhì)儲(chǔ)積期Nodulargoiter結(jié)節(jié)期結(jié)節(jié)性甲狀腺腫Nodulargoiter

Theglandiscoarselynodularandcontainsareasoffibrosisandcysticchange.

Diffusenontoxicgoiter/simplegoiter/endemicgoiter

彌漫性非毒性甲狀腺腫（小結(jié)）Endemicgoiteroccursingeographicareaswherethesoil,water,andfoodsupplycontainonlylowlevelsofiodine.缺碘ThelackofiodineleadstodecreasedsynthesisofthyroidhormoneandacompensatoryincreaseinTSH,leadingtofollicularcellhypertrophyandhyperplasiaandgoitrousenlargement.Withincreasingdietaryiodinesupplementation,thefrequencyandseverityofendemicgoiterhavedeclinedsignificantly.

補(bǔ)碘

甲亢(hyperthyroidism)廣義上是指多種原因引起甲狀腺合成和/或釋放過(guò)多的甲狀腺激素（thyroidhormone,TH）,而導(dǎo)致的以高代謝為主要表現(xiàn)的一組臨床綜合征，其中以自身免疫紊亂所導(dǎo)致的彌漫性甲狀腺腫伴甲狀腺功能亢進(jìn)。

Graves病（GD)最為常見(jiàn)

甲狀腺毒癥病因

1.彌漫性毒性甲狀腺腫（toxicdiffusegoiter,Gravesdisease,Basedowdisease）

2.橋本甲狀腺毒癥(Hashitoxicosis)3.新生兒甲亢(neonatalhyperthyroidism)4.多結(jié)節(jié)性毒性甲狀腺腫(toxicmultinodulargoiter)5.甲狀腺自主高功能腺瘤（Plummerdisease,toxicadenoma）

6.濾泡狀甲狀腺癌(Follicularthyroidcancer)7.碘甲亢（IIH）

8.HCG相關(guān)甲亢(絨毛膜癌、葡萄胎)9.垂體性甲亢(腺瘤或TSH細(xì)胞增生,甲狀腺吸碘131率升高）HYPER-THYROIDISMHYPERMETABOLISMTachycardia,palpitationsIncreasedT3,T4Goiter甲狀腺腫Exophthalmos突眼TremorGIhypermotilityThyroid“storm”,lifethreateningHYPO-THYROIDISM1°Developmental1°Surgery,I-131,externalradiation1°Auto-immune(i.e.,Hashimoto’s)1°Iodinedeficiency1°Li+,iodides碘化物2°(pituitary)3°(hypothalamic,rare)HYPO-THYROIDISMCretinism呆小癥SevereretardationCNS/Musc-skelShortstatureProtrudingtongueUmbilicalherniaMaternaliodinedefic.Myxedema粘液水腫(coma)SluggishnessCoolskin,↑c(diǎn)holesterolTHYROIDITISHashimoto(Auto-Immune)(Lymphoidfollicleswithgerminalcenters),MOSTCOMMONcauseofacquiredhypothyroidisminUSASubacuteGranulomatousSubacuteLymphocytic(justlikeHashimoto’sbutNOfibrosisandnogerminalcenters),oftenpost-partum產(chǎn)后Ifthethyroidglandlookslikealymphnode,thediagnosisisHashimotothyroiditis

Isthis“granulomatous”thyroiditis?Answer:Ofcourseitis!GRAVESDISEASE

(aka,diffusetoxicgoiter)HYPERTHYROIDISMEXOPHTHALMOSPRE-TIBIALMYXEDEMAAutoimmune,auto-antibodiestoTSHreceptors,therebystimulatingthemSCALLOPING扇貝

DiffuselyhyperplasticthyroidinacaseofGravesdisease（小結(jié)）

1濾泡上皮增生呈高柱狀/乳頭狀；2腔內(nèi)膠質(zhì)稀薄見(jiàn)吸收空泡；3間質(zhì)血管豐富淋巴組織增生。

臨床表現(xiàn)（一）甲狀腺毒癥表現(xiàn)(甲狀腺激素分泌過(guò)多)1.高代謝癥狀群：產(chǎn)熱和散熱增多，蛋白質(zhì)、脂肪和碳水化合物分解加速2.神經(jīng)精神系統(tǒng)興奮表現(xiàn)3.心血管系統(tǒng)：心動(dòng)過(guò)速，房性心律失常，房顫，脈壓增大，心臟病4.消化系統(tǒng)：胃腸蠕動(dòng)增快；肝功能異常5.肌肉骨骼系統(tǒng):周期性麻痹，急慢性甲亢肌病，骨質(zhì)疏松6.其他(生殖、血液）（二）甲狀腺腫：彌漫性、質(zhì)軟、無(wú)壓痛；動(dòng)脈雜音彌漫性甲狀腺腫甲狀腺左葉、右葉和峽部彌漫性腫大美國(guó)甲狀腺協(xié)會(huì)Graves眼病的分級(jí)

(ATA,NOSPECS)分級(jí)眼部癥狀和體征0(N)無(wú)癥狀和體征(Nosignsorsymptoms)1(O)僅有體征,無(wú)癥狀(Onlysigns,nosymptoms)2(S)軟組織受累(Softtissueinvolvement)(既有體征又有癥狀,signsandsymptoms）3(P)突眼(Proptosis,＞18mm)4(E)眼外肌受累Extaocularmuscleinvolvement

5(C）角膜受累(Cornealinvolvement)6(S)視力喪失Sightloss(opticnerveinvolvement）局限性黏液性水腫（脛前黏液性水腫）見(jiàn)于Graves病，病因不明好發(fā)于脛前區(qū)，亦可見(jiàn)于足背、趾、踝局部皮膚增厚，突出表面無(wú)壓痛，淡紅色或淡紫色毛孔粗，內(nèi)陷明顯，壓之無(wú)凹陷切跡

脛前黏液性水腫ThyroidNeoplasms“Nodules”vs.trueneoplasmsAdenomasvs.Carcinomas“NODULES”Solitaryvs.MultipleYoungervs.OlderMalevs.FemaleHx.neckradiationvs.NORx.“Cold”vs.HOT(reallyNOT-cold)NEOPLASMSADENOMASFOLLICULARHüRTHLE(oxyphilic)CARCINOMASFOLLICULARPAPILLARYMEDULLARY(AMYLOID)ANAPLASTIC(worst)Tomakethingssimple,let’sjustsayyoucanregardALLpapillarythyroidneoplasmsasmalignant!ORPHANANNIECELLSinPAPILLARYCARCINOMAMEDULLARYCARCINOMAofthethyroidwith“HYALINIZATION”,i.e.,AMYLOID!!!HYALINIZATIONshowingAPPLEGREENbirefringenceinCONGOREDstain,i.e.,AMYLOIDPapillarycarcinoma砂粒體/毛玻璃狀核ofthethyroid.