Niedziela M, Warzywoda M, Korman E
Endokrynol Diabetol Chor Przemiany Materii Wieku Rozw. 2000;6(2):143-50.
Hashimoto's thyroiditis (HT) and Graves' disease (GD) constitute a spectrum of autoimmune thyroid diseases (AITD). They share an autoimmune pathogenesis, with a cellular and a humoral response to the thyroid gland. As a consequence, dysfunction of the gland itself may develop, characterized by hyperfunction in the case of GD and hypofunction in the case of HT, however at the onset of HT the hyperthyroidism might be observed as a result of a rapid destruction of thyrocytes. An abnormal thyroid echographic pattern characterized by a diffuse low echogeneity has been described in both AITD. This hypoechogeneity is due to three components: increase of intrathyroidal flow, functional changes in thyroid follicles with increased cellularity and decrease of the colloid content, resulting in the reduction of the cell/colloid interface, variable degree of lymphocytic infiltration. The first two components may be reversible during medical treatment and seem to be characteristic for GD, whereas lymphocytic infiltration may rather represent mostly HT. Here we present a 17-year-old girl with typical clinical signs of hyperthyroidism [firm goiter (II degrees), tachycardia, palpitations, nervousness, excessive sweating and tremor]. Laboratory tests were the following: fT3 - 6.59 pg/ml(increasing), fT4 - 1.99 ng/dl(increasing), TSH - 0.02 micro IU/ml(decreasing); anti-Tg-Ab - 840 IU/ml(increasing), anti-TPO-Ab - 190 IU/ml(increasing) (4 months later antithyroid antibodies were 2200 and 70, respectively). Ultrasound examination showed hypoechogeneity of the whole gland and enhanced vascular flow based on power Doppler analysis. Thyroid scan visualized the generally increased uptake of technetium. The girl was put on beta-blocker (propranolol) and later an antithyroid drug (thiamazole) was added. A course of disease was unstable, therefore the fine-needle aspiration biopsy was performed and showed the presence of single groups of normal thyrocytes and scanty colloid with no features of HT. Power Doppler analysis showed still enhanced blood flow within a gland inspite of euthyroid state. After a very unsteady period of the disease, the euthyroid state is maintained although the medical treatment was given up. The full recovery of normal blood flow and normal echogeneity of the thyroid was documented. The latter supports the diagnosis of GD. Follow-up of the thyroid echogeneity is of great diagnostic and prognostic value if the assay of TSHR-Ab is not available. On the other side, it has to be remembered that TSHR-Ab do not have to be positive in patients with GD and can be positive in patients with HT.
桥本甲状腺炎（HT）和格雷夫斯病（GD）构成了一系列自身免疫性甲状腺疾病（AITD）。它们具有共同的自身免疫发病机制，对甲状腺存在细胞和体液免疫反应。因此，甲状腺自身可能会出现功能障碍，在GD中表现为功能亢进，在HT中表现为功能减退，然而在HT发病初期，由于甲状腺细胞的快速破坏，可能会观察到甲状腺功能亢进。在这两种AITD中均已描述了一种以弥漫性低回声为特征的异常甲状腺超声图像模式。这种低回声由三个因素导致：甲状腺内血流增加、甲状腺滤泡功能改变伴细胞增多以及胶体含量减少，导致细胞/胶体界面减小，淋巴细胞浸润程度不一。前两个因素在药物治疗期间可能是可逆的，似乎是GD的特征，而淋巴细胞浸润可能主要代表HT。在此，我们报告一名17岁女孩，具有典型的甲状腺功能亢进临床症状[质地坚硬的甲状腺肿（II度）、心动过速、心悸、紧张、多汗和震颤]。实验室检查结果如下：游离三碘甲状腺原氨酸（fT3）-6.59皮克/毫升（升高），游离甲状腺素（fT4）-1.99纳克/分升（升高），促甲状腺激素（TSH）-0.02微国际单位/毫升（降低）；抗甲状腺球蛋白抗体（anti-Tg-Ab）-840国际单位/毫升（升高），抗甲状腺过氧化物酶抗体（anti-TPO-Ab）-190国际单位/毫升（升高）（4个月后抗甲状腺抗体分别为2200和70）。超声检查显示整个腺体低回声，基于能量多普勒分析血管血流增强。甲状腺扫描显示锝摄取普遍增加。该女孩开始服用β受体阻滞剂（普萘洛尔），后来加用抗甲状腺药物（甲巯咪唑）。病程不稳定，因此进行了细针穿刺活检，结果显示存在单组正常甲状腺细胞和少量胶体，无HT特征。尽管处于甲状腺功能正常状态，但能量多普勒分析显示腺体内血流仍增强。在经历了非常不稳定的病程后，尽管停止了药物治疗，但仍维持了甲状腺功能正常状态。记录到甲状腺血流和回声恢复正常。后者支持GD的诊断。如果无法检测促甲状腺素受体抗体（TSHR-Ab），对甲状腺回声的随访具有重要的诊断和预后价值。另一方面，必须记住，GD患者的TSHR-Ab不一定呈阳性，而HT患者的TSHR-Ab可能呈阳性。
