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Thyrotoxicosis THYROTOXICOSIS: A RETROSPECTIVE STUDY OF CASES SEEN AT NUCLEAR MEDICINE UNIT (NEMROCK) Thesis Submitted for the fulfillment of master degree In nuclear medicine By Amira Hodhod Elsayed M.B.B.CH Under Supervision of Professor Dr. Shawky Ibrahim El.Haddad Professor of Radiotherapy and Nuclear Medicine Faculty of medicine –Cairo University Dr. Gehan Ahmed Yuonis Lecturer of Nuclear Medicine Faculty of medicine –Cairo University Faculty of medicine Cairo University 2013 Acknowledgments First, I would like to thank all my professors who allowed me to quote their work. I particularly grateful to professor Dr/ Shawky El.hadad for his encouragement and generosity in dealing with science and Dr/ Gehan Younis, this study would be much poorer without her help. I am grateful to everyone in Nuclear Medicine department, Cairo University. A special thanks to Dr/ Ahmed Sabrey who helped me in the statistical part of the study. I am deeply indebted to my dear husband Dr/ Hisham Aboelnasr, who was encouraging and supportive throughout. This list would not be completed without mentioning the role of my great mother in supporting me. And last but not least, to my family and my friends for patiently persevering with me. Index List of figures……………………………………………….…….…………………I List of tables………………………………………………………………………….III List of abbreviations………………………………………..………………..….V Introduction and aim of the study………………………..…………….…1 Review of literature……………………………………….………..……………5 Material, methods and data collection…………………………….….49 Results………………………………………………………………………………..52 Discussion……………………………………………………………………….….69 Conclusion…………………………………………………………………..……..78 References……………………………………………….…………..……..…….81 Arabic summary…………………………………………..………..…………….1 درا ر ت زدة ااز اة ار اددة وة ا اوى ل ا اوى درا ا / أة هه ا ااف أ.د / ااه ااد أذ اورام وا اوى آ ا – اهة د / ن أ رس ا اوى آ ا - اهة آ ا- اهة ٢٠١3 List of Figures Figure (1) iodine -123 thyroid scan in patient with Graves' disease …………………............................................................…….19 Figure (2) iodine-123 scan in patient with a toxic multinodular goiter ……………………………………………………………………..….…………20 Figure (3) iodine-123 scan in a patient with a toxic adenoma.……..………………………………………………………………….…..20 Figure (4) Tc 99m thyroid scan of toxic adenoma …….……………..22 Figure (5) Tc 99m thyroid scan of Graves' disease …….…………….22 Figure (6) Tc 99m thyroid scan of toxic multi nodular goiter ……23 Figure (7) color flow ultrasonogram in a patient with Graves' disease ………………………………………………………………..…………….…25 Figure (8) Comparison between age group and percentage of cases of each type of thyrotoxicosis………………….…………………..54 Figure (9) Figure showing sex and percentage of cases of each type of thyrotoxicosis …………………………………………..………………55 Figure (10) Treatment frequency according to the type of thyrotoxicosis and percentage of cases received medical treatment ….…………………………………………….…………….……….…..56 Figure (11) Thyrotoxicosis and percentage of cases with previous surgery …………………………………………………….……………57 I Figure (12) Relationship between response of primary type and dose value of radio-active iodine……………………..……………………63 Figure (13) Secondary type response and dose value of radio- active iodine ……………………………………………………..…………………..65 Figure (14) Percent of cases received one or more dose of radio-active iodine …………………………………………………..…………...66 Figure (15) Relationship between onset of hypothyroidism and dose value of radio-active iodine.………………………………..………..68 II List of tables Table (1) lists clinical manifestation of hyperthyroidism ….....14 Equation (1) calculation of I131 dose based on goiter size and radioactive iodine uptake …………………………………………………....32 Table (2) Relationship between the different age group in each type of thyrotoxicosis ………………………………………………………… 53 Table (3) Relationship between sex and percentage of cases of each type of thyrotoxicosis…………………………………………………55 Table (4) Frequency table of those received medical treatment in the two groups of patients.………………………………………………56 Table (5) Cases with previous surgery ……………………………………57 Table (6) The predominant symptoms in each type of thyrotoxicos…………………………………………………………………………..58 Table (7) Relation between TSH levels and type of thyrotoxicosis……………………………………………………………………….59 Table (8) Relation between T3 levels and type of thyrotoxicosis…………………………………………………………………….…60 Table (9) Relation between T4 levels and type of thyrotoxicosis……………………………………………………………………….60 Table (10) The relation between the percent of thyroid gland uptake and the response to radio-active iodine treatment….61 III Table (11) Relationship between response of primary type to different dose values of radio-active iodine during 2 years of follow up. ………………………………………………………………………….….62 Table (12) Response of secondary type thyrotoxicosis and different dose values of radio-active iodine……………………….64 Table (13) Percentage of cases received one or more than one dose of radio-active iodine…………………………………………………65 Table (14) Relationship between the dose value of radio-active iodine and the onset of hypothyroidism……………………………..67 IV List of abbreviations B Bpm : beat per minute. C CI : THE CURIE (symbol CI) is a non-SI unit of radioactivity, named after Marie and Pierre Curie. One curie is roughly the activity of 1 gram of 10 Radium isotope Ra226 a substance studied by Curies. 1 Ci =3.7x 10 Bq=37 GBq. E EUGOGO : European Group on Graves' orbitopathy F FSH : follicle- stimulating hormone. FT3: free triiodothyronine FT4: free thyroxine G GnRH : Gonadotropin- Releasing Hormone Graves' disease: primary diffuse toxic goiter GY : gray is the unit of the International System of Units(SI) of absorbed radiation dose , defined as transfer of 1 joul of energy per kilogram of absorbing material (1 J/Kg); 1 gray equal 100 rads. V H HCG : Human Chorionic Gonadotropin. I 123 I : Radioactive Iodine isotope 123. 131 I : Radioactive Iodine isotope 131. L LH : luteinizing hormone. N NEMROCK: Kasr- El.Aini- Center of Radiotherapy and Nuclear Medicine. M MBq : The Becquerel is the International System of Units (SI) derived unit of radioactivity . One Bq is defined as the activity of a quantity of radioactive material in which one nucleus decays per second. mg : milligram mIU/L: milli International Unit per Liter mm : micro meter R Rad : The rad is deprecated unit of absorberd radiation dose, defined as 1 rad = 0.01 Gy = 0.01 J/kg. RAIU%: Radioactive Iodine Uptake percent. VI Rem : Is deprecated unit used to measure the biological effect of ionizing radiaton . The rem is defined as equal to 0.01 sievert. rhTSH : Recombinant Human thyroid -Stimulating Hormone. S SV : The Sievert (symbol: SV) is the International System of Units (SI) derived unit of equivalent radiation dose, effective dose, committed dose. T TAO : Thyroid-associated orbitopathy. T3: Triiodothyroxine. T4: Thyroxine. 99m Tc : Technetium Pertechnetate. TMNG : Toxic multinodular goiter. TRAb : Thyroid – Stimulating Hormone receptor antibodies. TSAb : Thyroid Stimulating Antibodies. TSbAB : Thyroid Stimulating blocking Antibodies. TSH : Thyroid Stimulating Hormone. TSI : Thyroid Stimulating Immunoglobulin. U -6 uci=1x10 ci VII U.K: United Kingdom. U.S: United States. VIII Introduction & aim of the study Thyrotoxicosis is the hypermetabolic condition associated with elevated levels of thyroxin (FT4) and free triiodothyronine (FT3). (Lee and Ananthakrishnan,2009). Graves’ disease: Graves’ disease is the most common cause of hyperthyroidism. It accounts for 60% to 80% of the total reported cases of hyperthyroidism in the U.S . (Weetman, 2000). Patients younger than 40 years are the highest risk for the development of Graves’ disease . (Davies and Larsen, 2003) . Women have a higher reported incidence of Graves’ disease than men, with a female to male incidence ratio of approximately 7:1 to 10:1. (Nayak and Hodak, 2007). Graves’ disease is an autoimmune disorder where antibodies mistakenly attack the thyroid gland, particularly the TSH receptor sites. The attack stimulates the gland to synthesize and overproduce thyroid hormone. (Werner, et al, 2000). Toxic Multinodular Goiter and Toxic Adenomas: Toxic multinodular goiter (TMNG), also known as Plummer’s disease , is a condition in which the thyroid gland contains multiple nodules or lumps that are hyper functional, causing an overproduction of thyroid hormones. (Werner, et al, 2000). TMNG usually occurs in patients who are more than 40 years old and accounts for 5% of the total cases of hyperthyroidism in the U.S. The incidence of TMNG is increased in iodine-deficient regions. (Werner, et al, 2000). 1 Toxic adenomas are independently functioning thyroid nodules that produce excessive amounts of thyroid hormones. Toxic adenomas are most commonly found in younger patients who live in iodine-deficient regions. ( Slatosky, et al, 2000). Thyroiditis: Thyroiditis is a condition where the thyroid gland becomes inflammed. Inflammation of thyroid causes excess thyroid hormone stored in the gland to leak into the systemic circulation. (Slatosky, et al, 2000). Other causes of thyrotoxicosis :- Iodide -induced hyperthyroidism is classified in two different types. Type 1 Iodide -induced hyperthyroidism manifested with a low level of TSH and high levels of T 3 and T 4. It is caused by uncontrolled excessive production of T 3 and T 4 by the solitarily functioning thyroid in response to iodine (Jod-Basedow phenomenon). (Baskin, et al, 2002). Type 2 Iodide -induced hyperthyroidism is the destructive inflammation of the thyroid (thyroiditis). (Baskin, et al, 2002). Some of
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