Graves' disease Graves 'penyakit

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Graves' disease Graves 'penyakit
Classification and external resources Klasifikasi & sumber
eksternal
ICD - 10 ICD - 10 E 05.0 E 05,0
ICD - 9 ICD - 9 242.0 242,0
OMIM OMIM 275000 275.000
MedlinePlus MedlinePlus 000358 000.358
med/929 ped/899 med/929
eMedicine eMedicine
ped/899
MeSH MESH D006111 D006111

Graves' disease is an autoimmune disease where the thyroid is overactive, producing an

excessive amount of thyroid hormones (a serious metabolic imbalance known as
hyperthyroidism and thyrotoxicosis ). 'Penyakit Graves adalah autoimmune penyakit mana
tiroid yang terlalu aktif, menghasilkan jumlah hormon tiroid berlebihan (ketidakseimbangan
metabolisme serius yang dikenal sebagai hipertiroidisme dan tirotoksikosis ). This is caused
by autoantibodies to the TSH -receptor (TSHR-Ab) that activate that TSH-receptor (TSHR),
thereby stimulating thyroid hormone synthesis and secretion, and thyroid growth (causing a
diffusely enlarged goiter ). Hal ini disebabkan oleh autoantibodies ke TSH reseptor-(TSHR-
Ab) yang mengaktifkan bahwa TSH-reseptor (TSHR), sehingga merangsang sintesis hormon
tiroid dan sekresi, dan pertumbuhan tiroid (menyebabkan diffusely diperbesar gondok ). The
resulting state of hyperthyroidism can cause a dramatic constellation of neuropsychological
and physical signs and symptoms, which can severely compromise the patients' ability to
maintain jobs and relationships. [ 1 ] Negara yang dihasilkan dari hipertiroidisme bisa
menyebabkan konstelasi dramatis dan fisik tanda-tanda dan gejala neuropsikologi, yang
sangat bisa kompromi pasien kemampuan untuk mempertahankan pekerjaan dan hubungan.
[1]

It is the most common cause of hyperthyroidism in children and adolescents, and usually
presents itself during early adolescence. [ 2 ] It has a powerful hereditary component, affects up
to 2% of the female population, and has a female:male incidence of 5:1 to 10:1. [ 3 ] Graves'
disease is also the most common cause of severe hyperthyroidism, which is accompanied by
more clinical signs and symptoms and laboratory abnormalities as compared with milder
forms of hyperthyroidism. [ 4 ] About 25-30% of people with Graves' disease will also suffer
from Graves' ophthalmopathy (a protrusion of one or both eyes), caused by inflammation of
the eye muscles by attacking autoantibodies. [ 5 ] Ini adalah penyebab paling umum dari
hipertiroid pada anak-anak dan remaja, dan biasanya menampilkan diri selama masa remaja
awal. [2] Ia memiliki kuat turun-temurun komponen, mempengaruhi hingga 2% dari populasi
wanita, dan memiliki laki-laki: kejadian perempuan dari 5 : 1 hingga 10:1. [3] 'penyakit
Graves juga merupakan penyebab paling umum dari hipertiroidisme parah, yang disertai
dengan tanda dan gejala klinis yang lebih dan kelainan laboratorium dibandingkan dengan
bentuk lebih ringan dari hipertiroidisme. [4] Tentang 25-30 % dari orang-orang dengan
'penyakit Graves juga akan menderita 'ophthalmopathy Graves (sebuah tonjolan salah satu
atau kedua mata), disebabkan oleh peradangan pada otot mata dengan menyerang
autoantibodies. [5]

Diagnosis is usually made on the basis of symptoms, although thyroid hormone tests may be
useful. [ 6 ] However, Graves' thyrotoxicosis often gradually affects the life of the patients,
usually for many months, but sometimes years, prior to the diagnosis. [ 7 ] This is partially
because symptoms can develop so insidiously that they go unnoticed; when they do get
reported, they are often confused with other health problems. Diagnosis biasanya dibuat
berdasarkan gejala, meskipun tes hormon tiroid dapat berguna. [6] Namun, 'tirotoksikosis
Graves sering secara bertahap mempengaruhi kehidupan pasien, biasanya untuk berbulan-
bulan, tapi kadang-kadang tahun, sebelum diagnosis. [ 7] Hal ini sebagian karena gejala dapat
mengembangkan sehingga diam-diam bahwa mereka tidak diketahui, ketika mereka
mendapatkan laporan, mereka sering bingung dengan masalah kesehatan lainnya. Thus,
diagnosing thyroid disease clinically can be challenging. [ 8 ] Nevertheless, patients can
experience a wide range of symptoms and suffer major impairment in most areas of health-
related quality of life. [ 9 ] Dengan demikian, penyakit tiroid diagnosis klinis dapat menantang.
[8]
Namun demikian, pasien dapat mengalami berbagai gejala dan menderita kerusakan besar
di sebagian besar wilayah yang berhubungan dengan kualitas kesehatan hidup. [9]

There is no treatment for Graves' disease. Tidak ada pengobatan untuk penyakit Graves '.
There are, however, treatments for its consequences: hyperthyroidism, ophthalmopathy and
mental symptoms. [ 10 ] The Graves' disease itself - as defined, for example, by high serum
TSHR-Ab concentrations or ophthalmopathy - often persists after its hyperthyroidism has
been successfully treated. [ 10 ] Namun demikian, pengobatan untuk konsekuensinya:
hipertiroidisme, ophthalmopathy dan gejala mental. [10] graves penyakit itu sendiri - seperti
yang didefinisikan, misalnya, dengan TSHR serum-Ab konsentrasi tinggi atau
ophthalmopathy - sering berlanjut setelah hipertiroidisme perusahaan telah berhasil
diperlakukan. [10]

Contents Isi
[hide]
 1 Symptoms and signs 1 Gejala dan tanda-tanda
o 1.1 Effects on skeleton 1,1 Efek pada kerangka

o 1.2 Eye symptoms 1,2 Eye gejala

 1.2.1 Due to Graves' ophthalmopathy 1.2.1 Karena ophthalmopathy

Graves 'untuk
 1.2.2 Due to hyperthyroidism 1.2.2 hipertiroidisme Karena
o 1.3 Neuropsychological manifestations 1,3 neuropsikologi manifestasi

 1.3.1 Effects on pre-existing psychiatric disorders 1.3.1 Efek pada

gangguan kejiwaan yang ada pre-
o 1.4 Subclinical hyperthyroidism 1,4 hipertiroidisme subklinis
 o 1.5 Children and adolescents 1,5 Anak-anak dan remaja

o 1.6 Older patients 1,6 lama pasien

o 1.7 Graves' disease and work 1,7 'penyakit Graves dan bekerja

 2 Cause 2 Penyebab
o 2.1 Neuropsychological manifestations 2,1 neuropsikologi manifestasi

 3 Pathophysiology 3 Patofisiologi
 4 Diagnosis 4 Diagnosis
 5 Treatment 5 Pengobatan
o 5.1 Symptomatic 5,1 simtomatik

o 5.2 Antithyroid drugs 5,2 antitiroid obat

o 5.3 Radioiodine 5,3 Radioiod

o 5.4 Surgery 5,4 Bedah

o 5.5 Thyroid hormones 5,5 hormon Tiroid

o 5.6 Neuropsychiatric symptoms 5,6 Neuropsychiatric gejala

o 5.7 Eye disease 5,7 Penyakit Mata

o 5.8 General measurements 5,8 pengukuran Umum

 6 Prognosis 6 Prognosis
o 6.1 Remission and relapses 6,1 Remisi dan kambuh

o 6.2 Mental impairment 6,2 Mental penurunan

o 6.3 Thyroid replacement treatment after thyroidectomy or radioiodine 6,3

penggantian pengobatan Thyroid setelah thyroidectomy atau radioiod
 7 Coping with Graves' disease & the patient-physician relationship 7 Mengatasi
'penyakit Graves & pasien-dokter hubungan
 8 Epidemiology 8 Epidemiologi
 9 History 9 Sejarah
 10 Notable cases 10 terkenal kasus
 11 Notes 11 Catatan
 12 See also 12 Lihat pula

 13 External links 13 Pranala luar

[ edit ] Symptoms and signs [ sunting Gejala] dan tanda-
tanda
Except for Graves' ophthalmopathy , goitre and pretibial myxedema (which all result from
the autoimmune processes of Graves' disease), virtually all signs and symptoms result from
the direct and indirect effects of hyperthyroidism. Kecuali untuk 'ophthalmopathy Graves ,
gondok dan myxedema pretibial (yang semua hasil dari proses autoimun dari 'penyakit
Graves), hampir semua tanda dan gejala hasil dari efek langsung dan tidak langsung dari
hipertiroidisme. These clinical manifestations are dramatic and involve virtually every system
in the body. Ini manifestasi klinis dramatis dan melibatkan hampir setiap sistem dalam tubuh.
The mechanisms that mediate these effects are not well-understood. Mekanisme yang bisa
menengahi efek-efek ini tidak dipahami dengan baik. The severity of the symptoms and signs
of hyperthyroidism is related to the duration of the disease, the magnitude of the thyroid
hormone excess, and the patient's age. Tingkat keparahan dari gejala dan tanda-tanda
hipertiroidisme adalah berkaitan dengan durasi penyakit, besarnya kelebihan hormon tiroid,
dan usia pasien. There is also significant variability in the individual response to
hyperthyroidism and individual sensitivity to thyroid hormone fluctuations generally. [ 11 ] It
should also be noted that Graves' disease patients can also undergo periods of hypo
thyroidism (for further information, see symptoms of hypothyroidism ). Ada juga variasi
yang signifikan dalam respon individu untuk hipertiroidisme dan sensitivitas individu untuk
fluktuasi hormon tiroid umumnya. [11] Juga harus dicatat bahwa penyakit pasien Graves juga
dapat mengalami periode thyroidism hipo (untuk informasi lebih lanjut, lihat gejala
hypothyroidism ) . This is usually due to the fact that finding the right dosage of thyroid
hormone suppression and/or supplementation during treatment can be difficult and takes
time. Hal ini biasanya karena kenyataan bahwa menemukan dosis yang tepat penekanan
hormon tiroid dan / atau suplemen selama pengobatan bisa sulit dan membutuhkan waktu.
The body's need for thyroid hormone can also change over time, eg the first months after
radioactive iodine treatment (RAI). Tubuh membutuhkan hormon tiroid juga dapat berubah
seiring waktu, misalnya bulan-bulan pertama setelah pengobatan yodium radioaktif (RAI).
Also, thyroid autoimmune diseases are sometimes volatile, and hyperthyroidism can
interchange with hypothyroidism and euthyroidism. [ 12 ] Juga, penyakit autoimun tiroid
kadang-kadang stabil, dan hipertiroidisme dapat pertukaran dengan hypothyroidism dan
euthyroidism. [12]

 Goitre (enlarged thyroid). Gondok (tiroid diperbesar). If the thyroid grows large
enough, it may compress the recurrent laryngeal nerve, producing vocal cord
paralysis, dysphonia, and even respiratory stridor. Jika tiroid tumbuh cukup besar,
mungkin memampatkan saraf laring berulang, menghasilkan kelumpuhan pita suara,
dysphonia, dan bahkan stridor pernafasan. A Horner's syndrome may also result from
compression of the sympathetic chain. Suatu sindrom Horner juga dapat terjadi karena
kompresi dari rantai simpatik.
 Graves' ophthalmopathy (protrusion of eyes) Graves ophthalmopathy (tonjolan mata)
 Pretibial myxedema (lumpy, reddish skin of the lower legs) Pretibial myxedema
(kental kemerahan kulit, kaki yang lebih rendah)

 Cardiovascular features may include hypertension (the systolic blood pressure is

frequently elevated, while the diastolic blood pressure is characteristically decreased),
[3]
and heart rate that may be rapid or irregular in character ; these may be perceived
 as palpitations . [ 3 ] Less common findings include left ventricular hypertrophy ,
premature atrial and ventricular contractions, atrial fibrillation , congestive heart
failure , angina , myocardial infarction , systemic embolization, death from
cardiovascular collapse and resistance to some drug effects ( digoxin , coumadin ). [ 3 ]
fitur kardiovaskular termasuk hipertensi (tekanan darah sistolik sering meningkat,
sedangkan tekanan darah diastolik bersifat menurun), [3] dan detak jantung yang
mungkin cepat atau tidak teratur dalam karakter ; ini dapat dianggap sebagai
palpitasi . [3] Dikurangi temuan umum termasuk hipertrofi ventrikel kiri , kontraksi
prematur atrium dan ventrikel, fibrilasi atrium , gagal jantung kongestif , angina ,
infark miokard , emboli sistemik, kematian dari keruntuhan kardiovaskular dan
ketahanan terhadap beberapa efek obat ( digoxin , coumadin ). [3]
 Hyperreflexia , with a rapid relaxation phase. [ 3 ] Hyperreflexia , dengan fase relaksasi
yang cepat. [3]
 A distinctly excessive reaction to all sorts of stimuli. [ 3 ] Sebuah reaksi yang
berlebihan jelas untuk segala macam rangsangan. [3]
 Hyperactivity/increased energy. Hiperaktif energi / meningkat. Patients remark that
they are impelled to incessant activity, which, however, causes great fatigue. [ 3 ]
Pasien pernyataan bahwa mereka terdorong untuk aktivitas tak henti-henti, yang,
bagaimanapun, menyebabkan kelelahan yang besar. [3]
 A marked increase in fatigability , or asthenia , is often prominent. Peningkatan
ditandai di fatigability , atau kelemahan , sering menonjol. This increased weariness
may be combined with hyperactivity. [ 3 ] Keletihan ini meningkat dapat digabungkan
dengan hiperaktivitas. [3]
 Insomnia Insomnia
 Tremor (usually fine shaking; tremor of the outstretched fingers). Getaran (biasanya
halus gemetar; getaran jari-jari terentang). In a small study of newly diagnosed
hyperthyroid patients, tremor was observed in 76%. Dalam sebuah penelitian kecil
pasien hipertiroid yang baru didiagnosa, gemetaran diamati di 76%. Some studies lay
the cause for hyperthyroid tremor with a heightened beta-adrenergic state, others
suggest an increased metabolism of dopamine. Beberapa studi berbaring penyebab
getaran hipertiroid dengan keadaan beta-adrenergik tinggi, yang lain menyarankan
peningkatan metabolisme dopamin.
 Weight loss despite normal or increased appetite. Berat badan meskipun nafsu makan
normal atau meningkat.
 Increased appetite . Meningkatkan nafsu makan . The effect of this increase is to
offset, in part (sometimes completely), the loss of weight that might be expected from
the increased catabolism in hyperthyroidism. [ 3 ] Dampak dari kenaikan ini adalah
untuk offset, pada bagian (kadang-kadang sama sekali), kehilangan berat badan yang
dapat diharapkan dari peningkatan katabolisme hipertiroidisme. [3]
 Some patients (especially younger ones) gain weight due to excessive appetite
stimulation, that exceeds the weigh loss effect of hyperthyroidism. Beberapa pasien
(khususnya yang lebih muda) kenaikan berat badan karena rangsangan nafsu makan
yang berlebihan, yang melebihi berat efek rugi hipertiroidisme.
 Weakness or muscle weakness (especially in the large muscles of the arms and legs)
occurs in 60 to 80 percent of patients with untreated hyperthyroidism. Kelemahan
atau kelemahan otot (terutama pada otot besar tangan dan kaki) terjadi dalam 60
sampai 80 persen dari pasien dengan hipertiroidisme tidak diobati. However, it is
uncommon for a patient with hyperthyroidism to present with muscle weakness as the
chief complaint. Namun, hal ini jarang terjadi untuk pasien dengan hipertiroidisme
untuk hadir dengan kelemahan otot sebagai keluhan utama. The likelihood and degree
of muscle weakness is correlated with the duration and severity of the hyperthyroid
state, and becomes more likely after the age of 40. Kemungkinan dan derajat
kelemahan otot yang berkorelasi dengan durasi dan keparahan negara hipertiroid, dan
menjadi lebih mungkin setelah usia 40. Muscle strength returns gradually over several
months after the hyperthyroidism has been treated. Kekuatan otot kembali secara
bertahap selama beberapa bulan setelah hipertiroidisme telah diobati.
 Muscle degeneration Otot degenerasi
 Shortness of breath [ 3 ] Sesak napas [3]
 Increased sweating Peningkatan berkeringat
 Heat intolerance Panas intoleransi
 Warm and moist skin Hangat dan lembab kulit
 Thin and fine hair Rambut tipis dan halus
 Redness of the elbows is frequently present. Kemerahan dari siku sering hadir. It is
probably the result of the combination of increased activity, an exposed part, and a
hyperirritable vasomotor system. [ 3 ] Ini mungkin adalah hasil dari kombinasi aktivitas
meningkat, merupakan bagian yang terbuka, dan sistem vasomotor hyperirritable. [3]
 Chronic sinus infections Kronis infeksi sinus
 Brittle nails Kuku rapuh
 Plummer's nail (nail in which there is onycholysis , or separation of the nail from the
nail bed, particularly affecting the ring and little fingers ). [ 13 ] Plummer's kuku (kuku
yang ada onycholysis , atau pemisahan kuku dari dasar kuku, terutama yang
mempengaruhi cincin dan jari-jari kecil ). [13]
 Abnormal breast enlargement in men Pembesaran abnormal payudara pada pria
 Gastrointestinal symptoms including increased bowel movements , but malabsorption
is unusual. [ 3 ] Gejala gastrointestinal termasuk gerakan usus meningkat , tetapi
malabsorpsi tidak biasa. [3]
 Augmented calcium levels in the blood (by as much as 25% - known as
hypercalcaemia ) can cause stomach upset, excessive urination, and impaired kidney
function. [ 14 ] Augmented tingkat kalsium dalam darah (sebanyak 25% - dikenal
sebagai hiperkalsemia ) dapat menyebabkan sakit perut, buang air kecil yang
berlebihan, dan fungsi ginjal. [14]
 Diabetes may be activated or intensified, and its control is worsened. Diabetes dapat
diaktifkan atau intensif, dan kontrol adalah memburuk. The diabetes is ameliorated or
 may disappear when the thyrotoxicosis is treated. [ 3 ] diabetes ini diperbaiki atau dapat
hilang bila tirotoksikosis diperlakukan. [3]
 Evidence of mild or severe liver disease may be found. [ 3 ] Bukti penyakit hati yang
parah atau ringan dapat ditemukan. [3]
 Reproductive symptoms in men may include reduced free testosterone (due to the
elevation of testosterone-estrogen binding globulin level), [ 3 ] diminished libido ,
erectile dysfunction and reversible impaired sperm production with lower mean sperm
density, a high incidence of sperm abnormalities, and reduced motility of the sperm
cells. [ 3 ] Women may experience infrequent menstruation or irregular and scant
menstrual flow along with difficulty conceiving, infertility and recurrent miscarriage .
Reproduksi gejala pada pria mungkin termasuk mengurangi testosteron bebas (karena
elevasi testosteron-estrogen tingkat globulin yang mengikat), [3] berkurang libido ,
disfungsi ereksi dan gangguan sperma produksi sperma reversibel dengan kepadatan
berarti lebih rendah, tingginya insiden kelainan sperma, dan mengurangi motilitas sel
sperma. [3] Wanita dapat mengalami menstruasi jarang atau tidak teratur dan aliran
menstruasi sedikit bersama dengan kesulitan untuk hamil, infertilitas dan berulang
keguguran .
 Neurologically seizures may occur, neuropathy from nerve entrapment by lesions of
pretibial myxedema, and hypokalemic periodic paralysis. [ 3 ] Rarely a thyrotoxic
neuropathy may occur, corticospinal tract disease with pyramidal tract damage, and
abnormal movements of chorea and athetoid movements. [ 3 ] Very rarely there may be
an acute thyrotoxic encephalopathy. [ 3 ] Neurologis dapat terjadi kejang, neuropati dari
jeratan saraf oleh lesi myxedema pretibial, dan kelumpuhan periodik hypokalemic. [3]
Jarang suatu neuropati thyrotoxic mungkin terjadi, penyakit saluran corticospinal
dengan kerusakan saluran piramidal, dan gerakan abnormal chorea dan gerakan
athetoid. [3] Sangat jarang mungkin ada ensefalopati thyrotoxic akut. [3]

[ edit ] Effects on skeleton [ sunting ] Efek pada kerangka

Overt hyperthyroidism is associated with accelerated bone remodeling (resulting in increased

porosity of cortical bone and reduced volume of trabecular bone ), a generally reduced bone
density , osteoporosis , and an increase in fracture rate. Hipertiroidisme jelas dikaitkan
dengan percepatan perbaikan tulang (yang mengakibatkan peningkatan porositas tulang
kortikal dan penurunan volume tulang trabecular ), yang umumnya mengurangi kepadatan
tulang , osteoporosis , dan peningkatan patah tingkat. The changes in bone metabolism are
connected with negative calcium balance , an increased excretion of calcium and phosphorus
in the urine ( hypercalciuria ) and stool, and, rarely, hypercalcemia . [ 14 ] In hyperthyroidism,
the normal cycle duration of bone resorption of approximately 200 days is halved, and each
cycle is associated with a 9.6 percent loss of mineralized bone . Perubahan metabolisme
tulang terhubung dengan negatif keseimbangan kalsium , suatu peningkatan ekskresi kalsium
dan fosfor dalam air seni ( hiperkalsiuria ) dan tinja, dan, jarang, hypercalcemia . [14] Pada
hipertiroidisme, siklus durasi normal resorpsi tulang sekitar 200 hari ini dibelah dua, dan
setiap siklus berhubungan dengan kerugian 9,6 persen dari mineralisasi tulang . In hypo
thyroidism, cycle length approximates 700 days and is associated with a 17 percent increase
in mineralized bone. Dalam thyroidism hipo, panjang siklus 700 hari mendekati dan
berhubungan dengan 17 persen peningkatan dalam mineralisasi tulang.
The extent of the reduction in bone density in most studies is 10-20%. Besarnya pengurangan
kepadatan tulang dalam kebanyakan studi adalah 10-20%. The clinical manifestations on
bone differ depending on the age of the patient. Postmenopausal woman are most sensitive to
accelerated bone loss from thyrotoxicosis. Manifestasi klinis pada tulang berbeda-beda
tergantung pada usia pasien. wanita menopause yang paling sensitif terhadap kehilangan
tulang dipercepat dari tirotoksikosis. Accelerated bone growth in growing children can
increase ossification in the short term, but generally results in short-stature adults compared
with the predicted heights. Percepatan pertumbuhan tulang pada anak-anak tumbuh dapat
meningkatkan osifikasi dalam jangka pendek, tetapi umumnya menghasilkan orang dewasa-
bertubuh pendek dibandingkan dengan tinggi diprediksi.

With the introduction of antithyroid drugs and radioiodine in the 1940s, clinically apparent
hyperthyroid bone disease became less common. Dengan diperkenalkannya obat antitiroid
dan radioiod tahun 1940-an, secara klinis jelas hipertiroid penyakit tulang menjadi kurang
umum. However, bone density measurements have demonstrated that bone loss is common in
patients with overt hyperthyroidism and, to a lesser extent, in those with subclinical
hyperthyroidism. Namun, pengukuran kepadatan tulang telah menunjukkan bahwa
kehilangan tulang adalah umum pada pasien dengan hipertiroidisme terang-terangan dan,
pada tingkat lebih rendah, pada pasien dengan hipertiroidisme subklinis. A history of overt
hyperthyroidism is a risk factor for hip fracture later in life, which in turn is one of the causes
of excess late mortality in previously hyperthyroid patients. Sejarah hipertiroidisme terbuka
merupakan faktor risiko patah tulang pinggul di kemudian hari, yang pada gilirannya
merupakan salah satu penyebab kematian akhir kelebihan pasien hipertiroid sebelumnya. It is
therefore reasonable to assume that in some hyperthyroid patients bone density does not
completely return to normal after antithyroid treatment. Oleh karena itu masuk akal untuk
menganggap bahwa dalam beberapa kepadatan tulang pasien hipertiroid tidak sepenuhnya
kembali normal setelah perawatan antitiroid.

However, if the thyrotoxicosis is treated early, bone loss can be minimized. [ 14 ] The level of
calcium in the blood can be determined by a simple blood test, and a bone density scan can
document the amount of bone loss. Namun, jika tirotoksikosis diperlakukan dini, keropos
tulang dapat diminimalisir. [14] Tingkat kalsium dalam darah dapat ditentukan dengan tes
darah sederhana, dan kepadatan tulang scan dapat dokumen jumlah kerugian tulang. There
are many medications that can help to rebuild bone mass and to prevent further bone loss. [ 14 ]
Risedronate treatment has been demonstrated to help restore bone mass in osteopenia /
osteoporosis associated with Graves' disease. [ 15 ] Nevertheless, weight-bearing exercises , a
balanced diet , calcium intake of about 1500 mg a day and enough vitamin D , are of course
elementary foundations. [ 14 ] Ada banyak obat yang dapat membantu untuk membangun
kembali massa tulang dan untuk mencegah kehilangan tulang lebih lanjut. [14] risedronate
pengobatan telah ditunjukkan untuk membantu memulihkan massa tulang di osteopenia /
osteoporosis yang terkait dengan 'penyakit Graves. [15] Meskipun demikian, menahan beban
latihan , suatu diet seimbang , asupan kalsium sekitar 1500 mg sehari dan cukup vitamin D ,
tentu saja dasar dasar. [14]

[ edit ] Eye symptoms [ sunting ] gejala Eye

Hyperthyroidism almost always causes general eye symptoms like dryness and irritation,
regardless of what the cause of the hyperthyroid state is. Hipertiroidisme hampir selalu
menyebabkan gejala mata umum seperti kekeringan dan iritasi, terlepas dari apa penyebab
hipertiroid adalah negara. However, these need to be distuingished from Graves'
ophthalmopathy , which can only occur in patients who have Graves' disease. Namun, ini
perlu distuingished dari 'ophthalmopathy Graves , yang hanya dapat terjadi pada pasien yang
memiliki 'penyakit Graves. (It may also, rarely, be seen in Hashimoto's thyroiditis , primary
hypothyroidism , and thyroid cancer ). (Hal ini juga mungkin, jarang, terlihat di 's tiroiditis
Hashimoto , primer hipotiroidisme , dan kanker tiroid ).

About 20-25% of patients with Graves' disease will suffer from clinically obvious Graves'
ophthalmopathy, and not just from the eye signs of hyperthyroidism. Sekitar 20-25% dari
pasien dengan penyakit Graves 'akan menderita ophthalmopathy Graves klinis jelas', dan
bukan hanya dari tanda-tanda mata hipertiroidisme. Only 3 to 5% will develop severe
ophthalmopathy. [ 16 ] However, when subjected to closer inspection (eg by magnetic
resonance imaging of the orbits ) many more patients have evidence of ophthalmopathy
(primarily enlargement of retroocular muscles). Hanya 3-5% akan mengembangkan
ophthalmopathy parah. [16] Namun, ketika mengalami pemeriksaan lebih dekat (misalnya
dengan pencitraan resonansi magnetik dari orbit ) pasien lebih banyak memiliki bukti dari
ophthalmopathy (terutama pembesaran otot retroocular). It is estimated that for every
100,000 persons, 16 women and 3 men have Graves' ophthalmopathy every year.
Diperkirakan bahwa untuk setiap 100.000 orang, 16 wanita dan 3 laki-laki memiliki
ophthalmopathy Graves 'setiap tahun.

Although it is true that in most patients ophthalmopathy, goiter, and symptoms of

thyrotoxicosis appear more or less coincidentally, it is also true that in certain cases eye signs
may appear long before thyrotoxicosis is evident, or become worse when the thyrotoxicosis is
subsiding or has been controlled by treatment. [ 3 ] In approximately 20% of ophthalmopathy
patients, ophthalmopathy appears before the onset of hyperthyroidism, in about 40%
concurrently, and in about 20% in the six months after diagnosis. Meskipun benar bahwa
dalam ophthalmopathy sebagian besar pasien, gondok, dan gejala tirotoksikosis tampak lebih
atau kurang kebetulan, benar juga bahwa dalam tanda-tanda mata kasus-kasus tertentu dapat
muncul lama sebelum tirotoksikosis jelas, atau menjadi lebih buruk ketika tirotoksikosis
tersebut mereda atau memiliki dikendalikan dengan pengobatan. [3] Pada sekitar 20% dari
pasien ophthalmopathy, ophthalmopathy muncul sebelum onset hipertiroidisme, di sekitar
40% secara bersamaan, dan pada sekitar 20% dalam enam bulan setelah diagnosis. In the
remainder, the eye disease first becomes apparent after treatment of the hyperthyroidism,
more often in patients treated with radioiodine. Dalam sisanya, penyakit mata pertama akan
tampak setelah pengobatan hipertiroidisme, lebih sering pada pasien yang diobati dengan
radioiod.

It can sometimes be difficult to distinguish between eye symptoms due to hyperthyroidism

and those due to Graves' antibodies, not in the least because the two often occur coincidently.
Kadang-kadang bisa sulit untuk membedakan antara gejala mata karena hipertiroidisme dan
yang disebabkan oleh antibodi Graves ', tidak sedikit karena kedua sering terjadi kebetulan.
What can make things particularly difficult, is that many patients with hyperthyroidism have
lid retraction, which leads to stare and lid lag (due to contraction of the levator palpebrae
muscles of the eyelids). Apa yang bisa membuat hal-hal yang sulit, adalah bahwa banyak
pasien dengan hipertiroidisme memiliki pencabutan tutup, yang menyebabkan lag menatap
dan tutup (karena kontraksi m. levator palpebrae otot di kelopak mata). This stare may then
give the appearance of protruding eyeballs ( proptosis ), when none in fact exists. tatapan ini
kemudian dapat memberikan tampilan bola mata menonjol ( proptosis ), ketika tidak ada
sebenarnya ada. This subsides when the hyperthyroidism is treated. Ini mereda ketika
hipertiroidisme diperlakukan.
[ edit ] Due to Graves' ophthalmopathy [ sunting ] Karena 'ophthalmopathy Graves

Main article: Graves' ophthalmopathy Artikel utama: 'ophthalmopathy Graves

Graves' ophthalmopathy is characterized by inflammation of the extraocular muscles , orbital

fat and connective tissue. 'Ophthalmopathy Graves ditandai oleh peradangan pada otot
extraocular , jaringan lemak dan ikat orbital. It results in the following symptoms, which can
be extremely distressing to the patient: [ 3 ] Ini mengakibatkan gejala berikut ini, yang dapat
sangat menyedihkan kepada pasien: [3]

 Most frequent are symptoms due to conjunctival or corneal irritation: burning,

photophobia , tearing, pain, and a gritty or sandy sensation. [ 3 ] Gejala yang paling
sering adalah karena konjungtiva atau kornea iritasi: pembakaran, ketakutan dipotret ,
merobek, nyeri, dan sensasi atau berpasir berpasir. [3]
 Protruding eyeballs (known as proptosis and exophthalmos ). Bola mata menonjol
(dikenal sebagai proptosis dan exophthalmos ).
 Diplopia (double vision) is common. [ 3 ] Diplopia (penglihatan ganda) adalah umum.
[3]

 Limitation of eye movement (due to impairment of eye muscle function). Batasan

gerakan mata (karena penurunan nilai mata otot fungsi).
 Periorbital and conjunctival edema (accumulation of fluid beneath the skin around the
eyes). Periorbital dan konjungtiva edema (akumulasi cairan di bawah kulit di sekitar
mata).
 Infiltrative dermopathy ( pretibial myxedema ). Infiltrasi dermopathy ( pretibial
myxedema ).
 In severe cases, the optic nerve may be compressed and acuity of vision impaired. [ 17 ]
Pada kasus yang berat, yang saraf optik dapat dikompresi dan ketajaman penglihatan
terganggu. [17]
 Occasionally loss of vision . Kadang-kadang kehilangan visi .

[ edit ] Due to hyperthyroidism [ sunting ] Karena hipertiroidisme

In the absence of Graves' ophthalmopathy, patients may demonstrate other ophthalmic signs
due to hyperthyroidism: Dengan tidak adanya ophthalmopathy Graves ', pasien mungkin
menunjukkan tanda-tanda oftalmik lain karena hipertiroidisme:

 Dry eyes (due to loss of corneal moisture). [ 17 ] Kering mata (karena hilangnya
kelembaban kornea). [17]
 A sense of irritation, discomfort, or pain in the eyes. Sebuah rasa iritasi, rasa tidak
nyaman, atau nyeri di mata.
 A tingling sensation behind the eyes or the feeling of grit or sand in the eyes. Sebuah
sensasi geli di belakang mata atau rasa pasir atau pasir di mata.
 Excessive tearing that is often made worse by exposure to cold air, wind, or bright
lights. Merobek berlebihan yang sering diperburuk oleh paparan udara dingin, angin,
atau lampu terang.
  Swelling or redness of the eyes. Pembengkakan atau kemerahan mata.
 Stare Menatap
 Lid lag ( Von Graefe's sign ) Tutup lag ( Graefe's sign Von )
 Sensitivity to light . Sensitivitas terhadap cahaya .
 Blurring of vision. Mengaburkan visi.
 Widened palpebral fissures . Melebar palpebral fissures .
 Infrequent blinking. Jarang berkedip.
 The appearance of lid retraction. Munculnya pencabutan tutupnya.

[ edit ] Neuropsychological manifestations [ sunting ] manifestasi

neuropsikologi

Several studies have suggested a high prevalence of neuropsychiatric disorders and mental
symptoms in Graves' disease (and thyroid disease in general), which are similar to those in
patients with organic brain disease. [ 10 ] [ 18 ] [ 19 ] [ 20 ] [ 21 ] These manifestations are diverse,
affecting the central and peripheral nervous systems. Beberapa studi telah menyarankan
prevalensi tinggi dan gejala gangguan mental neuropsikiatri dalam 'penyakit Graves (dan
penyakit tiroid secara umum), yang sama dengan yang pada pasien dengan penyakit otak
organik. [10] [18] [19] [20] [ 21] Ini adalah beragam manifestasi, mempengaruhi pusat dan perifer
sistem saraf. The vast majority of patients with hyperthyroidism meet criteria for some
psychiatric disorders, [ 10 ] and those with milder presentations are probably not entirely free of
mental symptoms such as emotional lability, tension, depression and anxiety. [ 10 ] A study of
2006 failed to confirm a link between thyroid dysfunction and depression or anxiety. [ 22 ]
Sebagian besar pasien dengan hipertiroidisme memenuhi kriteria untuk beberapa gangguan
jiwa, [10] dan mereka yang presentasi lebih ringan mungkin tidak sepenuhnya bebas dari gejala
mental seperti lability emosional, ketegangan, depresi dan kecemasan. [10] Sebuah studi tahun
2006 gagal pastikan kaitan antara disfungsi tiroid dan depresi atau kecemasan. [22]

In one study on hospitalised elderly patients, over half had cognitive impairment with either
dementia or confusion. [ 23 ] However, a controlled study on 31 Graves' disease patients found
that while patients had subjective reports of cognitive deficits in the toxic phase of Graves'
thyrotoxicosis, formal testing found no cognitive impairment and suggested the reported
symptoms may reflect the affective and somatic manifestations of hyperthyroidism. [ 24 ]
Dalam sebuah penelitian pada pasien lansia dirawat di rumah sakit, lebih dari setengah telah
kerusakan kognitif dengan baik demensia atau kebingungan. [23] Namun, sebuah studi
terkontrol pada 'pasien penyakit Graves 31 menemukan bahwa sementara pasien laporan
subjektif defisit kognitif dalam fase beracun dari Graves' tirotoksikosis, pengujian formal
tidak menemukan penurunan kognitif dan menyarankan gejala-gejala yang dilaporkan
mungkin mencerminkan manifestasi afektif dan somatik dari hipertiroidisme. [24]

Treatment of hyperthyroidism typically leads to improvement in cognitive and behavioral

impairments. [ 24 ] Agitation, inattention, and frontal lobe impairment may improve more
rapidly than other cognitive functions. Pengobatan hipertiroidisme biasanya menyebabkan
peningkatan gangguan kognitif dan perilaku. [24] Agitasi, kekurangan perhatian, dan
kerusakan lobus frontal dapat meningkatkan lebih cepat daripada fungsi kognitif lainnya.
However, several studies confirm that a substantial proportion of patients with
hyperthyroidism have psychiatric disorders or mental symptoms and decreased quality of life
even after successful treatment of their hyperthyroidism. [ 19 ] Namun, beberapa penelitian
mengkonfirmasikan bahwa sebagian besar pasien dengan hipertiroidisme memiliki gejala
gangguan jiwa atau mental dan penurunan kualitas hidup bahkan setelah pengobatan
hipertiroidisme mereka sukses. [19]

Several studies point out that the severity of psychiatric symptoms could easily result in an
inappropriate referral to a psychiatrist prior to the diagnosis of hyperthyroidism. [ 25 ] [ 26 ]
Consequently, undiagnosed hyperthyroidism sometimes results in inappropriate use of
psychotropic medications; prompt recognition of hyperthyroidism (or hypothyroidism)
through thyroid function screening is therefore recommended in the evaluation of patients
with psychiatric symptoms. [ 26 ] [ 27 ] Naturally, the management of patients would be
improved by collaboration between a psychiatrist and an endocrinologist . [ 28 ] Beberapa studi
menunjukkan bahwa tingkat keparahan gejala psikiatri dengan mudah dapat menghasilkan
suatu arahan yang tidak tepat ke psikiater sebelum diagnosis hipertiroidisme. [25] [26]
Akibatnya, kadang-kadang tidak terdiagnosis hipertiroidisme menghasilkan penggunaan yang
tidak tepat obat-obatan psikotropika; pengakuan segera terhadap hipertiroidisme (atau
hipotiroidisme) melalui pemeriksaan fungsi tiroid dianjurkan dalam evaluasi pasien dengan
gejala kejiwaan. [26] [27] Tentu saja, manajemen pasien akan ditingkatkan dengan kerjasama
antara psikiater dan endokrinologi . [28]

Reported symptoms vary from mild to severe aspects of anxiety or depression, and may
include psychotic and behavioural disturbances: Dilaporkan gejala bervariasi dari ringan
sampai parah aspek kecemasan atau depresi, dan mungkin termasuk gangguan psikotik dan
perilaku:

 Varying degrees of anxiety , [ 19 ] such as a very active mind, [ 3 ] irritability , [ 19 ]

hyperactivity , agitation , restlessness, nervousness , distractible overactivity [ 29 ] and
panic attacks . [ 30 ] In addition patients may experience vivid dreams and, occasionally,
nightmares . Berbagai tingkat kecemasan , [19] seperti pikiran yang sangat aktif, [3]
lekas marah , [19] hiperaktif , gelisah , gelisah, gugup , overactivity terganggu [29] dan
serangan panik . [30] Pada pasien Selain mungkin mengalami mimpi hidup dan,
kadang-kadang, mimpi buruk .
 Depressive features of mental impairment, memory lapses, [ 19 ] diminished attention
span, [ 19 ] fluctuating depression [ 29 ] [ 31 ] fitur Depressive penurunan mental,
kehilangan ingatan, [19] rentang perhatian berkurang, [19] berfluktuasi depresi [29] [31]
 Emotional lability and in some patients, the emotional pattern is that of hypomania ,
[ 32 ]
or pathologic well-being ( euphoria ) or the hyperactivity may produce a state of
exhaustion, and profound fatigue or asthenia chiefly characterizes the picture. [ 3 ]
lability Emosional dan pada beberapa pasien, pola emosi adalah bahwa dari
hypomania , [32] atau patologis kesejahteraan ( euforia ) atau hiperaktif dapat
menghasilkan keadaan kelelahan, dan kelelahan mendalam atau kelemahan terutama
ciri gambar. [3]
 Erratic behaviour may include intermittent rage disorder , mild attention deficit
disorder [ 33 ] and some patients become hyperirritable and combative, which can
precipitate accidents or even assaultive behaviour. [ 3 ] perilaku tidak menentu mungkin
termasuk gangguan marah berselang , attention defisit ringan [33] dan beberapa pasien
 menjadi hyperirritable dan agresif, yang dapat memicu kecelakaan atau bahkan
perilaku Menyerang. [3]
 In more extreme cases features of psychosis , [ 34 ] with delusions of persecution or
delusions of reference . [ 35 ] pressure of speech Rarely, patients develop visual or
auditory hallucinations or a frank psychosis, [ 3 ] and may appear schizophrenic , lose
touch with reality and become delirious, [ 12 ] or hallucinate. [ 29 ] Such psychotic
symptoms may not completely clear up after the hyperthyroidism has been treated. [ 3 ]
Paranoia and paranoid-hallucionary psychosis in hyperthyroidism usually have a
manick disposition and it is therefore often not clear if the patient is experiencing a
paranoid psychosis with depressive streaks, or a depression that has paranoid streaks. [
12 ]
Dalam kasus yang lebih ekstrim fitur psikosis , [34] dengan khayalan penganiayaan
atau delusi referensi . [35] tekanan pidato Jarang, pasien mengembangkan visual atau
pendengaran halusinasi atau psikosis frank, [3] dan dapat muncul skizofrenia ,
kehilangan hubungan dengan realitas dan menjadi mengigau, [12] atau berhalusinasi. [29]
gejala psikotik tersebut mungkin tidak sepenuhnya jelas setelah hipertiroidisme telah
diobati. [3] Paranoia dan-hallucionary psikosis paranoid di hipertiroidisme biasanya
memiliki disposisi manick dan oleh karena itu sering tidak jelas apakah pasien
mengalami psikosis paranoid dengan streaks depresi, atau depresi yang memiliki
garis-garis paranoid. [12]

[ edit ] Effects on pre-existing psychiatric disorders [ sunting ] Efek pada gangguan

kejiwaan yang ada pre-

Patients with pre-existing psychiatric disorders, will experience a worsening of their usual
symptoms, as observed by several studies. Pasien dengan gangguan jiwa yang sudah ada,
akan mengalami gejala memburuk mereka yang biasa, seperti yang diamati oleh beberapa
studi. A study of 1999 found that Graves' disease exacerbated the symptoms of Tourette's
disorder and attention-deficit hyperactivity disorder (ADHD), and points out that the lack of
diagnosis of the Graves' disease compromised the efficacy of the treatment of Tourette's
disorder and ADHD. [ 36 ] Patients who are known to have a convulsive disorder may become
more difficult to control with the usual medications, and seizures may appear in patients who
have never previously manifested such symptoms. [ 3 ] Sebuah studi tahun 1999 menemukan
bahwa 'penyakit Graves memperburuk gejala itu gangguan Tourette dan perhatian-defisit
gangguan hiperaktif (ADHD), dan menunjukkan bahwa kurangnya diagnosis Graves
'penyakit membahayakan kemanjuran pengobatan yang gangguan Tourette dan ADHD. [36]
Pasien yang dikenal memiliki gangguan kejang mungkin menjadi lebih sulit dikendalikan
dengan obat biasa, dan kejang-kejang mungkin muncul pada pasien yang belum pernah
terwujud gejala seperti sebelumnya. [3]

[ edit ] Subclinical hyperthyroidism [ sunting ] hipertiroidisme subklinis

In subclinical hyperthyroidism, serum TSH is abnormally low, but T4- and T3-levels fall
within laboratory reference ranges. [ 37 ] It primarily affects the skeleton and the cardiovascular
system (abnormalities in other systems have also been reported), in a similar but less severe
and less frequent way than overt hyperthyroidism does. Pada hipertiroidisme subklinis, serum
TSH adalah rendah yang tidak normal, tetapi T3 T4-dan-tingkat jatuh dalam rentang referensi
laboratorium. [37] Ini terutama mempengaruhi kerangka dan sistem kardiovaskular (kelainan
pada sistem lain juga telah dilaporkan), dalam serupa tetapi cara kurang parah dan kurang
sering daripada hipertiroidisme tidak jelas. It can alter cardiac function, with increased heart
rate , increased left ventricular mass index, increased cardiac contractility , diastolic
dysfunction , and induction of ectopic atrial beats . Hal ini dapat mengubah fungsi jantung,
dengan denyut jantung meningkat , meningkat meninggalkan ventrikel indeks massa,
meningkatkan kontraktilitas jantung , disfungsi diastolik , dan induksi beats atrium ektopik .
Long-term mild excess of thyroid hormone can thus cause impaired cardiac reserve and
exercise capacity. [ 3 ] ringan jangka-panjang kelebihan hormon tiroid sehingga dapat
menyebabkan gangguan jantung dan kapasitas cadangan latihan. [3]

In a large population-based study of 2008, the odds of having poorer cognitive function were
greater for subclinical hyperthyroidism than for stroke , diabetes mellitus , and Parkinson's
disease . [ 38 ] However, while clinical hyperthyroidism is associated with frank
neuropsychological and affective alterations , the occurrence of these alterations and their
treatment in mild and subclinical hyperthyroidism remains a controversial issue. [ 39 ] But
regardless of the inconsistent findings, a 2007 study by Andersen et al. Dalam sebuah
penelitian berbasis populasi besar tahun 2008, kemungkinan memiliki lebih miskin fungsi
kognitif yang lebih besar untuk hipertiroidisme subklinis dibandingkan stroke , diabetes
mellitus , dan Penyakit Parkinson . [38] Namun, sementara hipertiroidisme klinis dikaitkan
dengan jujur dan afektif perubahan neuropsikologi , terjadinya perubahan tersebut dan
pengobatan mereka dan hipertiroidisme subklinis ringan tetap merupakan isu yang
kontroversial. [39] Tetapi terlepas dari temuan tidak konsisten, sebuah studi 2007 oleh
Andersen et al. states that the distinction between subclinical and overt thyroid disease is in
any case somewhat arbitrary. [ 40 ] Sublicnical hyperthyroidism has been reported in 63% of
euthyroid patients with Graves' ophthalmopathy. menyatakan bahwa perbedaan antara terang
dan subklinis penyakit tiroid adalah dalam hal apapun agak sewenang-wenang. [40] Sublicnical
hipertiroidisme telah dilaporkan di 63% dari pasien euthyroid dengan 'ophthalmopathy
Graves.

[ edit ] Children and adolescents [ sunting Anak-anak] dan remaja

Hyperthyroidism has unique effects in children on growth and pubertal development, eg

causing epiphyseal maturation. Hipertiroidisme memiliki efek unik pada anak-anak pada
pertumbuhan dan perkembangan pubertas, misalnya menyebabkan epifisis pematangan. In
growing children, accelerated bone growth from hyperthyroidism can increase osteogenesis
in the short term, but generally results in short-stature adults compared with the predicted
heights. Pada anak-anak tumbuh, percepatan pertumbuhan tulang dari hipertiroidisme dapat
meningkatkan osteogenesis dalam jangka pendek, tetapi umumnya menghasilkan orang
dewasa-bertubuh pendek dibandingkan dengan tinggi diprediksi. Pubertal development tends
to be delayed, or slowed. pembangunan pubertas cenderung ditunda, atau diperlambat. Girls
who have undergone menarche may develop secondary amenorrhea . Gadis yang telah
mengalami menarche dapat mengembangkan sekunder amenore . Hyperthyroidism is
associated with high sex hormone-binding globulin ( SHBG ), which may result in high
serum estradiol levels in girls and testosterone levels in boys. Hipertiroidisme dikaitkan
dengan hormon seks-mengikat globulin tinggi ( SHBG ), yang dapat berakibat dalam serum
tinggi estradiol tingkat pada anak perempuan dan testosteron tingkat anak laki-laki. However,
unbound or free levels of these hormones are decreased. Namun, tidak terikat atau tingkat
bebas dari hormon ini menurun. Hyperthyroidism before the age of four may cause
neurodevelopmental delay. Hipertiroidisme sebelum usia empat dapat menyebabkan
keterlambatan neurodevelopmental. A study by Segni et al. Sebuah studi oleh Segni et al.
suggests that permanent brain damage can occur as a result of the illness. [ 3 ] [ 41 ] permanen
menunjukkan bahwa kerusakan otak dapat terjadi sebagai akibat dari penyakit. [3] [41]
Ophthalmopatic findings are more common but less severe in children (severe infiltrative
exophthalmos is virtually unknown before mid-adolescence), but besides that, many of the
typical clinical features of hyperthyroidism in children and adolescents are similar to those in
adults. [ 3 ] An important difference between children and adults with Graves' disease, is that
children have not yet developed like adults have (psychological and physiological), and that
they are a lot more dependent on their environment. Ophthalmopatic temuan yang lebih
umum namun kurang parah pada anak-anak (parah exophthalmos infiltrasi hampir tidak
diketahui sebelum pertengahan masa remaja), tetapi selain itu, banyak fitur khas
hipertiroidisme klinis pada anak-anak dan remaja adalah sama dengan yang pada orang
dewasa. [3] An perbedaan penting antara anak dan orang dewasa dengan penyakit Graves ',
adalah bahwa anak-anak belum berkembang seperti orang dewasa (psikologis dan fisiologis),
dan bahwa mereka jauh lebih banyak bergantung pada lingkungan mereka. The
encephalopathy will have profound effects on children's developing personalities and
developing relationship with their environment. Para ensefalopati akan memiliki dampak
yang luar biasa pada kepribadian anak-anak yang sedang berkembang dan mengembangkan
hubungan dengan lingkungan mereka. Disturbments in bodily development further
complicates matters. Disturbments dalam pembangunan tubuh semakin merumitkan masalah.
The consequences for the development and the somatic and psychological wellbeing of the
child can be very radical and sometimes irreversible. Konsekuensi untuk pembangunan dan
kesejahteraan somatik dan psikologis anak bisa sangat radikal dan kadang-kadang ireversibel.
The earlier a person is affected by thyroid disease, the less (s)he has been able to develop
himself or herself, and the more the development of personality is affected and the bigger the
delay from their potential development level. Semakin awal seseorang dipengaruhi oleh
penyakit tiroid, kurang (s) ia telah mampu mengembangkan dirinya sendiri, dan semakin
pengembangan kepribadian dipengaruhi dan menunda lebih besar dari tingkat perkembangan
potensi mereka. The child gets behind in its cognitive, emotional and sexual growth, which,
by itself, also influences its processing abilities of the endocrine disease. [ 12 ] Anak itu akan
tertinggal dalam, yang emosional dan seksual pertumbuhan kognitif, yang, dengan
sendirinya, juga mempengaruhi kemampuan pengolahannya dari penyakit endokrin. [12]

Children with hyperthyroidism tend to have greater mood swings and disturbances of
behavior, as compared with adults. Anak-anak dengan hipertiroidisme cenderung memiliki
lebih mood dan gangguan perilaku, dibandingkan dengan orang dewasa. Their attention span
decreases, they are usually hyperactive and distractable, they sleep poorly, and their school
performance deteriorates. Mereka span perhatian menurun, mereka biasanya hiperaktif dan
distractable, mereka tidur buruk, dan kinerja sekolah mereka hancur. Because devastating
personality and emotional changes often appear in the child or adolescent with Graves'
disease, many hyperthyroid children are (similar to many adults) referred to a developmental
specialist or child psychiatrist to evaluate emotional and behavioral symptoms before the
presence of hyperthyroidism is suspected. [ 3 ] Karena menghancurkan kepribadian dan
perubahan emosional sering muncul dalam atau anak remaja dengan penyakit Graves ', anak-
anak banyak hipertiroid (mirip dengan orang dewasa banyak) dirujuk ke spesialis
perkembangan atau anak psikiater untuk mengevaluasi gejala emosional dan perilaku
sebelum adanya hipertiroidisme dicurigai. [3]

[ edit ] Older patients [ sunting ] pasien lama

In older patients, emotional instability may be less evident, or depression may occur, and the
symptoms and signs are manifestly circulatory. Pada pasien yang lebih tua, ketidakstabilan
emosional mungkin kurang jelas, atau depresi dapat terjadi, dan gejala dan tanda-tanda yang
nyata-nyata peredaran darah. In many, the thyroid is not readily palpable. [ 3 ] Symptoms such
as rapid heart rate , shortness of breath on exertion, and edema may predominate. Dalam
banyak, tiroid tidak mudah teraba. [3] Gejala seperti detak jantung yang cepat , sesak napas
pada tenaga, dan edema dapat mendominasi. Older patients also tend to have more weight
loss and less of an increase in appetite. pasien yang lebih tua juga cenderung memiliki berat
badan lebih dan kurang dari peningkatan nafsu makan. Thus anorexia in this group is fairly
frequent, as is constipation . [ 3 ] Jadi anoreksia dalam kelompok ini cukup sering, seperti
sembelit . [3]

Elderly patients may have what is called "apathetic thyrotoxicosis", a state in which they have
less and less severe symptoms, except for weakness, depression and lethargy (making it even
more prone to escape diagnosis). Lansia pasien mungkin memiliki apa yang disebut
"tirotoksikosis apatis", sebuah negara di mana mereka memiliki lebih sedikit dan kurang
parah gejala, kecuali kelemahan, depresi dan kelesuan (membuatnya bahkan lebih mudah
untuk menghindari diagnosis).

[ edit ] Graves' disease and work [ sunting Graves 'penyakit] dan kerja

Considering the many signs and symptoms, the generally delayed diagnosis, and the
possibility of residual complaints after treatment, it is little wonder that a significant number
of people with Graves' disease have difficulty keeping their job. Mengingat banyak tanda dan
gejala, umumnya diagnosis tertunda, dan kemungkinan keluhan sisa setelah perawatan, itu
adalah mengherankan bahwa sejumlah besar orang dengan penyakit Graves 'mengalami
kesulitan mempertahankan pekerjaan mereka. One study found that of 303 patients
successfully treated for hyperthyroidism (77% had Graves' disease) 53% dealt with lack of
energy. Satu studi menemukan bahwa dari 303 pasien berhasil diobati untuk hipertiroidisme
(77% memiliki penyakit Graves ') 53% berhubungan dengan kekurangan energi. About one-
third were unable to resume their customary work, mainly due to persistent mental problems.
[ 10 ] [ 42 ]
In their 1986 study of 26 patients (10 years after successful treatment of
hyperthyroidism), Perrild et al. Sekitar sepertiga tidak dapat melanjutkan pekerjaan adat
mereka, terutama karena masalah mental yang terus-menerus. [10] [42] Dalam studi mereka
tahun 1986 dari 26 pasien (10 tahun setelah pengobatan berhasil hipertiroidisme), Perrild et
al. note that four patients had been granted disability pensions on the basis of intellectual
dysfunction. [ 43 ] Between 2006 and 2008, Ponto et al. diketahui bahwa empat pasien telah
diberikan pensiun cacat berdasarkan disfungsi intelektual. [43] Antara 2006 dan 2008, Ponto et
al. surveyed 250 Graves' disease patients. 250 disurvei Graves 'penyakit pasien. Of these,
36% were written of sick and 5% even had to take early retirement . Dari jumlah tersebut,
36% ditulis dari sakit dan 5% bahkan harus mengambil pensiun dini . In the same study, 34%
of 400 questioned physicians reported treating patients with fully impaired earning capacity.
[ 44 ]
Dalam penelitian yang sama, 34% dari 400 dokter mempertanyakan melaporkan merawat
pasien dengan gangguan sepenuhnya kapasitas produktif. [44]

A 2008 meta-article by De groot states that the patient with Graves' disease should have time
away from normal duties to help in reestablishing his or her psychic and physiologic
equilibria. A meta-2008 artikel oleh De groot menyatakan bahwa pasien dengan penyakit
Graves 'harus punya waktu jauh dari tugas rutin untuk membantu dalam mengembalikan
kesetimbangan nya psikis dan fisiologis. Patients can and do recover with appropriate therapy
while continuing to work, but more rapid and certain progress is made if a period away from
the usual occupation can be provided. [ 15 ] Pasien dapat dan tidak sembuh dengan terapi yang
tepat sambil terus bekerja, tetapi lebih cepat dan kemajuan tertentu dibuat jika periode dari
pendudukan biasa dapat disediakan. [15]

[ edit ] Cause [ sunting ] Penyebab

The trigger for autoantibody production is unknown. Pemicu untuk otoantibodi produksi
tidak diketahui.

Since Graves' disease is an autoimmune disease which appears suddenly, often quite late in
life, it is thought that a viral or bacterial infection may trigger antibodies which cross-react
with the human TSH receptor (a phenomenon known as antigenic mimicry , also seen in
some cases of type I diabetes ) [ citation needed ] . Sejak 'penyakit Graves adalah penyakit autoimun
yang muncul tiba-tiba, cukup sering terlambat dalam hidup, ia berpikir bahwa suatu virus
atau bakteri infeksi dapat memicu antibodi yang bereaksi silang dengan reseptor TSH
manusia (fenomena yang dikenal sebagai mimikri antigenik , juga terlihat di beberapa kasus
diabetes tipe I ) [ rujukan? ]. One possible culprit is the bacterium Yersinia enterocolitica (a cousin
of Yersinia pestis , the agent of bubonic plague). Salah satu penyebabnya mungkin adalah
bakteri Yersinia enterocolitica (sepupu pestis Yersinia , agen penyakit pes). However,
although there is indirect evidence for the structural similarity between the bacterium and the
human thyrotropin receptor, direct causative evidence is limited. [ 45 ] Yersinia seems not to be
a major cause of this disease, although it may contribute to the development of thyroid
autoimmunity arising for other reasons in genetically susceptible individuals. [ 46 ] It has also
been suggested that Y. Namun, meskipun ada bukti langsung untuk kesamaan struktur antara
bakteri dan reseptor thyrotropin manusia, bukti-bukti penyebab langsung adalah terbatas. [45]
Yersinia tampaknya tidak menjadi penyebab utama penyakit ini, meskipun mungkin
memberikan kontribusi pada pengembangan tiroid autoimmunity timbul karena alasan lain di
genetik individu yang rentan. [46] Ia juga telah menyarankan bahwa Y. enterocolitica infection
is not the cause of auto-immune thyroid disease, but rather is only an associated condition;
with both having a shared inherited susceptibility. [ 47 ] More recently the role for Y.
enterocolitica infeksi bukan penyebab penyakit tiroid kekebalan otomatis, melainkan hanya
sebuah terkait kondisi; dengan kedua memiliki kerentanan mewarisi bersama. [47] Baru-baru
ini peran untuk Y. enterocolitica has been disputed. [ 48 ] enterocolitica telah diperdebatkan. [48]

Some of the eye symptoms of hyperthyroidism are believed to result from heightened
sensitivity of receptors to sympathetic nervous system activity, possibly mediated by
increased alpha-adrenergic receptors in some tissues. Beberapa mata gejala hipertiroidisme
yang diyakini hasil dari kepekaan yang meningkat dari reseptor ke sistem saraf simpatik
kegiatan, mungkin dimediasi oleh meningkat -adrenergik reseptor alpha di beberapa jaringan.

Some people may have a genetic predisposition to develop TSH autoantibodies. HLA DR
(especially DR3) appears to play a significant role. [ 45 ] Beberapa orang mungkin memiliki
kecenderungan genetik untuk mengembangkan autoantibodies TSH. HLA DR (terutama
DR3) tampaknya memainkan peran penting. [45]

[ edit ] Neuropsychological manifestations [ sunting ] manifestasi neuropsikologi

Hyperthyroidism plays a major role in psychiatric morbidity in Graves' disease, and is

associated with long-term mood disturbances. [ 32 ] [ 49 ] Although hyperthyroidism has been
considered to induce psychiatric symptoms by enhancement of the sensitivity and turnover in
catecholaminergic neurotransmission , the precise mechanism of cognitive and behavioral
dysfunction in hyperthyroidism is not known. [ 50 ] According to Gonen, the direct influence of
thyroid hormones on brain functions stems from the presence of wide distribution of T3
receptors throughout the brain. [ 51 ] Improvement of some clinical features (attention and
concentration) with beta-blocker therapy suggests a role for a hyperthyroid-induced
hyperactivity of the adrenergic nervous system, possibly disrupting the adrenergic pathways
between the locus ceruleus and frontal lobe that subserve attention and vigilance, and thereby
accounting for many physical and mental symptoms. [ 52 ] Others propose that hyperthyroidism
may produce oxidative stress , producing neuronal injury and hastening a presentation of
degenerative or vascular dementia . Hipertiroidisme memainkan peran utama dalam angka
kesakitan jiwa di 'penyakit Graves, dan berhubungan dengan gangguan mood jangka panjang.
[32] [49]
Meskipun hipertiroidisme telah dianggap menginduksi gejala psikiatris oleh
peningkatan sensitivitas dan omset di catecholaminergic neurotransmission , yang mekanisme
yang tepat dan perilaku disfungsi kognitif pada hipertiroidisme tidak diketahui. [50] Menurut
Gonen, pengaruh langsung dari hormon tiroid pada fungsi otak berasal dari adanya distribusi
luas di seluruh T3 reseptor otak. [51] Perbaikan beberapa klinis fitur (perhatian dan
konsentrasi) dengan terapi beta bloker menunjukkan peran untuk hipertiroid hiperaktivitas
yang disebabkan sistem saraf adrenergik, mungkin mengganggu jalur adrenergik antara
seruleus lokus dan lobus frontalis yang mengabdi perhatian dan kewaspadaan, dan dengan
demikian akuntansi bagi banyak fisik dan gejala mental. [52] Lain-lain mengusulkan bahwa
hipertiroidisme dapat menghasilkan stres oksidatif , memproduksi cedera saraf dan datang
dengan presentasi dari degeneratif atau demensia vaskular . A study of 2002 suggests another
possible mechanism, involving activational and translational regulation of functional proteins
in the brain. [ 50 ] Whatever the precise mechanisms, it is clear that thyroid hormones influence
adult brain functioning, and may interact with mood regulation via targets in specific brain
circuits. [ 49 ] Singh et al. Sebuah studi tahun 2002 menyarankan mekanisme lain mungkin,
yang melibatkan activational dan peraturan translasi protein fungsional di dalam otak. [50] Apa
pun mekanisme yang tepat, jelas bahwa hormon tiroid mempengaruhi fungsi otak orang
dewasa, dan dapat berinteraksi dengan peraturan mood melalui target dalam spesifik sirkuit
otak. [49] Singh et al. formulate that "differential thyroidal status is known to cause decrease
in cell number and induces irreversible morphometric changes in adult brain resulting in
different neuronal abnormalities". [ 53 ] This is underscored by recent studies, who document a
thyroid hormone effect on the neurotransmitters serotonin and norepinephrine , with changes
in neurotransmitter synthesis and receptor sensitivity being noted. [ 54 ] De Groot points out
that, in spite of the fact that epinephrine levels and catecholamine excretion are actually not
elevated, propranolol (presumably acting by inhibition of alpha-adrenergic sympathetic
activity) certainly reduces anxiety and tremor in a very useful manner, indicating that some of
the central nervous system irritability is a manifestation of elevated sensitivity to circulating
epinephrine (though this has not been proved). [ 3 ] Thompson mentions that T3 can increase
the activity of serotonin in the brain, while serotonin has been shown to inhibit thyroid
function. merumuskan bahwa "status thyroidal diferensial diketahui menyebabkan
penurunan jumlah sel dan menginduksi ireversibel morphometric perubahan dalam otak
orang dewasa mengakibatkan kelainan saraf yang berbeda ". [53] Hal ini ditekankan oleh
studi baru-baru ini, yang dokumen efek hormon tiroid pada neurotransmitter serotonin dan
norepinefrin , dengan perubahan dalam sintesis neurotransmitter dan sensitivitas reseptor
yang dicatat. [54] De Groot menunjukkan bahwa, meskipun fakta bahwa epinefrin tingkat dan
ekskresi Katekholamin sebenarnya tidak meningkat, propranolol (mungkin bertindak dengan
penghambatan adrenergik simpatik kegiatan-alpha ) tentu mengurangi kecemasan dan
gemetar dalam cara yang sangat berguna, yang menunjukkan bahwa beberapa sistem saraf
pusat lekas marah adalah manifestasi dari sensitivitas tinggi untuk beredar epinefrin
(meskipun ini belum terbukti). [3] Thompson menyebutkan bahwa T3 dapat meningkatkan
aktivitas serotonin di otak, sedangkan serotonin telah ditunjukkan menghambat fungsi
thyroid. Thus, although a complex system of interaction between thyroid hormone and
neurotransmitters has been recognized and examined, no clear-cut explanation for the effect
of thyroid hormone on depression has emerged. [ 54 ] Jadi, meskipun sistem yang kompleks
dari interaksi antara hormon tiroid dan neurotransmitter telah diakui dan diteliti, tidak ada
penjelasan jelas untuk memotong pengaruh hormon tiroid pada depresi telah muncul. [54]

A literature study of 2006 mentions that ophtalmopathy may also contribute to psychiatric
morbidity, probably through the psychosocial consequences of changed appearance. [ 10 ]
However, the observation that a substantial proportion of patients have an altered mental state
even after successful treatment of hyperthyroidism, has led some researchers to suggest that
the automimmune process itself may play a role in the presentation of mental symptoms and
psychiatric disorders in Graves' disease, whether or not ophtalmopathy is present. [ 10 ]
Persistent stimulation of TSH-Rs may be involved. Sebuah studi literatur tahun 2006
menyebutkan bahwa ophtalmopathy juga dapat berkontribusi untuk morbiditas psikiatri,
mungkin melalui konsekuensi psikososial penampilan diubah. [10] Namun, pengamatan bahwa
sebagian besar pasien memiliki kondisi mental berubah bahkan setelah pengobatan
hipertiroidisme sukses, telah memimpin beberapa peneliti untuk mengatakan bahwa proses
automimmune sendiri dapat berperan dalam presentasi gejala gangguan mental dan jiwa di
'penyakit Graves, atau tidak ophtalmopathy apakah hadir. [10] Persistent stimulasi TSH-R
mungkin terlibat. In Graves' disease, the TSH-R gives rise to antibodies and in some patients
these antibodies persist after restoration of euthyroidism. Pada penyakit graves, dengan TSH-
R menimbulkan antibodi dan pada beberapa pasien antibodi ini tetap ada setelah pemulihan
euthyroidism. The cerebral cortex and hippocampus are rich in TSH-Rs. The cerebral korteks
dan hipokampus kaya TSH-R. Antibody stimulation of these brain receptors may result in
increased local production of T3 . [ 10 ] Antibodi stimulasi reseptor otak ini dapat
menyebabkan produksi lokal meningkat dari T3 . [10]

Thus, despite ongoing research, a full understanding of the causes of mental disability in
Graves' disease awaits a full description of the effects on neural tissue of thyroid hormones as
well as of the underlying autoimmune process. [ 32 ] Jadi, meskipun penelitian yang sedang
berlangsung, pemahaman penuh penyebab cacat mental di 'penyakit Graves menunggu
keterangan lengkap dari efek pada jaringan saraf dari hormon tiroid serta proses autoimun
yang mendasarinya. [32]

[ edit ] Pathophysiology [ sunting ] Patofisiologi

Graves' disease is an autoimmune disorder, in which the body produces antibodies to the
receptor for thyroid-stimulating hormone (TSHR) . 'Penyakit Graves adalah autoimun
disorder, dimana tubuh menghasilkan antibodi terhadap reseptor untuk thyroid-stimulating
hormone (TSHR) . (Antibodies to thyroglobulin and to the thyroid hormones T3 and T4 may
also be produced.) These antibodies (TSHR-Ab) bind to the TSH receptors, which are located
on the cells that produce thyroid hormone in the thyroid gland ( follicular cells ), and
chronically stimulate them, resulting in an abnormally high production of T3 and T4.
(Antibodi untuk thyroglobulin dan ke hormon tiroid T3 dan T4 juga mungkin dihasilkan (.)
antibodi ini (TSHR-Ab) mengikat reseptor TSH, yang berada di atas sel-sel yang
memproduksi hormon tiroid dalam kelenjar tiroid sel follicular ), dan kronis merangsang
mereka, yang mengakibatkan abnormal tinggi produksi T3 dan T4. This causes the clinical
symptoms of hyperthyroidism , and the enlargement of the thyroid gland (visible as goitre ).
Hal ini menyebabkan gejala klinis hipertiroidisme , dan pembesaran kelenjar thyroid (terlihat
sebagai gondok ).

The infiltrative exophthalmos that is frequently encountered, has been explained by

postulating that the thyroid gland and the extraocular muscles share a common antigen which
is recognized by the antibodies. The infiltrasi exophthalmos yang sering ditemui, telah
dijelaskan dengan mendalilkan bahwa kelenjar tiroid dan otot extraocular berbagi bersama
antigen yang diakui oleh antibodi. Antibodies binding to the extraocular muscles would cause
swelling behind the eyeball. Antibodi mengikat ke otot extraocular akan menyebabkan
pembengkakan di belakang bola mata. The "orange peel" skin has been explained by the
infiltration of antibodies under the skin, causing an inflammatory reaction and subsequent
fibrous plaques. The "kulit jeruk" kulit telah dijelaskan oleh antibodi infiltrasi di bawah kulit,
menyebabkan reaksi peradangan dan plak berserat berikutnya.

There are 3 types of autoantibodies to the TSH receptor currently recognized: Ada 3 jenis
autoantibodies dengan reseptor TSH saat ini diakui:

 TSI , Thyroid stimulating immunoglobulins : these antibodies (mainly

Immunoglobulin G ) act as LATS (Long Acting Thyroid Stimulants), activating the
cells in a longer and slower way than the normal thyroid-stimulating hormone (TSH),
leading to an elevated production of thyroid hormone. TSI, thyroid stimulating
immunoglobulin : antibodi ini (terutama Immunoglobulin G ) bertindak sebagai lats
(Long Acting Thyroid Stimulan), mengaktifkan sel-sel dalam cara yang lebih lama
dan lebih lambat dibandingkan dengan hormon thyroid-stimulating normal (TSH),
yang menyebabkan meningkatnya produksi tiroid hormon.

 TGI , Thyroid growth immunoglobulins: these antibodies bind directly to the TSH-
receptor and have been implicated in the growth of thyroid follicles . TGI,
pertumbuhan imunoglobulin Thyroid: antibodi ini mengikat secara langsung ke
reseptor-TSH dan telah terlibat dalam pertumbuhan folikel tiroid .

 TBII , Thyrotropin Binding-Inhibiting Immunoglobulins: these antibodies inhibit the

normal union of TSH with its receptor. TBII, Thyrotropin Binding-Menghambat
Imunoglobulin: antibodi ini menghambat serikat normal TSH dengan reseptornya.
Some will actually act as if TSH itself is binding to its receptor, thus inducing thyroid
function. Beberapa benar-benar akan bertindak seolah-olah TSH itu sendiri adalah
mengikat ke reseptornya, sehingga mendorong fungsi thyroid. Other types may not
stimulate the thyroid gland, but will prevent TSI and TSH from binding to and
stimulating the receptor. jenis lainnya tidak dapat merangsang kelenjar tiroid, tetapi
akan mencegah TSI dan TSH dari mengikat dan merangsang reseptor.

In their study of thyrotoxic patients, Sensenbach et al. Dalam studi mereka pasien thyrotoxic,
Sensenbach et al. found the cerebral blood flow to be increased, the cerebral vascular
resistance decreased, arteriovenous oxygen difference decreased, and oxygen consumption
unchanged. menemukan aliran darah otak menjadi meningkat, resistensi pembuluh darah otak
menurun, perbedaan oksigen arteri menurun, dan konsumsi oksigen tidak berubah. They
found that during treatment, brain size was shown to decrease significantly, and ventricular
size increased. Mereka menemukan bahwa perawatan selama, ukuran otak ditunjukkan untuk
mengurangi secara signifikan, dan ukuran ventrikel meningkat. The cause of this remarkable
change is unknown, but may involve osmotic regulation. [ 55 ] Penyebab perubahan yang luar
biasa tidak diketahui, tetapi mungkin melibatkan regulasi osmotik. [55]

A study by Singh et al. Sebuah studi oleh Singh et al. showed for the first time that
differential thyroidal status induces apoptosis in adult cerebral cortex . T3 acts directly on
cerebral cortex mitochondria and induces release of cytochrome c to induce apoptosis.
menunjukkan untuk pertama kalinya bahwa perbedaan status thyroidal menginduksi
apoptosis pada orang dewasa korteks otak . T3 bekerja langsung pada korteks cerebral
mitokondria dan menyebabkan pelepasan sitokrom c menginduksi apoptosis. They note that
adult cerebellum seems to be less responsive to changes in thyroidal status. [ 53 ] Mereka
mencatat orang dewasa yang otak kecil tampaknya kurang responsif terhadap perubahan
dalam status thyroidal. [53]

Hyperthyroidism causes lower levels of apolipoprotein (A), HDL , and ratio of total/HDL
cholesterol . [ 3 ] The processes and pathways mediating the intermediary metabolism of
carbohydrates , lipids , and proteins are all affected by thyroid hormones in almost all tissues.
[ 56 ]
Protein formation and destruction are both accelerated in hyperthyroidism.
Hipertiroidisme menyebabkan tingkat yang lebih rendah dari apolipoprotein (A), HDL , dan
rasio total / HDL kolesterol . [3] Proses dan jalur mediasi perantaraan metabolisme karbohidrat
, lipid , dan protein semuanya dipengaruhi oleh hormon tiroid di hampir semua jaringan. [ 56]
pembentukan protein dan kehancuran keduanya dipercepat di hipertiroidisme. The absorption
of vitamin A is increased and conversion of carotene to vitamin A is accelerated (the
requirements of the body are likewise increased, and low blood concentrations of vitamin A
may be found). Penyerapan vitamin A meningkat dan konversi karoten menjadi vitamin A
dipercepat (persyaratan dari tubuh adalah juga meningkat, dan konsentrasi darah rendah
vitamin A mungkin ditemukan). Requirements for thiamine and vitamin B6 and B12 are
increased. Persyaratan untuk tiamin dan vitamin B6 dan B12 yang meningkat. Lack of the B
vitamins has been implicated as a cause of liver damage in thyrotoxicosis. [ 3 ]
Hyperthryoidism can also augment calcium levels in the blood by as much as 25% (known as
hypercalcaemia ). Kekurangan vitamin B telah terlibat sebagai penyebab kerusakan hati di
tirotoksikosis. [3] Hyperthryoidism juga dapat meningkatkan tingkat kalsium dalam darah
sebanyak 25% (dikenal sebagai hiperkalsemia ). An increased excretion of calcium and
phosphorus in the urine and stool can result in bone loss from osteoporosis . [ 14 ] Sebuah
peningkatan ekskresi kalsium dan fosfor dalam air seni dan tinja dapat menyebabkan
hilangnya tulang dari osteoporosis . [14]

[ edit ] Diagnosis [ sunting ] Diagnosa

Graves' disease Symptoms Graves 'penyakit Gejala

The onset of Graves' disease symptoms is often insidious: the intensity of symptoms can
increase gradually for a long time before the patient is correctly diagnosed with Graves'
disease, which may take months or years. [ 7 ] (Not only Graves' disease, but most
endocrinological diseases have an insidious, subclinical onset. [ 57 ] ) One study puts the
average time for diagnosis at 2.9 years, having observed a range from 3 months to 20 years in
their sample population. [ 32 ] A 1996 study offers a partial explanation for this generally late
diagnosis, suggesting that the psychiatric symptoms (due to the hyperthyroidism) appeared to
result in delays in seeking treatment as well as delays in receiving appropriate diagnosis. [ 19 ]
Also, earlier symptoms of nervousness, hyperactivity, and a decline in school performance,
may easily be attributed to other causes. [ citation needed ] Many symptoms may occasionally be
noted, at times, in otherwise healthy individuals who do not have thyroid disease (eg,
everyone feels anxiety and tension to some degree), and many thyroid symptoms are similar
to those of other diseases. [ 11 ] Thus, clinical findings may be full blown and unmistakable or
insidious and easily confused with other disorders. [ 58 ] The results of overlooking the thyroid
can however be very serious. [ 29 ] Also noteworthy and problematic, is that in a 1996 survey
study respondents reported a significant decline in memory, attention, planning, and overall
productivity from the period 2 years prior to Graves' symptoms onset to the period when
hyperthyroid. [ 19 ] A large 2002 study found " no statistical association between thyroid
dysfunction, and the presence of depression or anxiety disorder ." [ 22 ] Timbulnya penyakit
gejala 'Graves sering membahayakan: intensitas gejala dapat meningkatkan secara bertahap
untuk waktu yang lama sebelum pasien didiagnosis dengan benar dengan' penyakit Graves,
yang mungkin mengambil bulan atau tahun. [7] ('penyakit hanya Graves Tidak, tapi
endokrinologis penyakit yang paling memiliki subklinis, onset membahayakan. [57] ) Satu
studi menempatkan waktu rata-rata untuk diagnosis sebesar 2,9 tahun, memiliki rentang
diamati dari 3 bulan sampai 20 tahun di populasi sampel. [32] Sebuah studi 1996 menawarkan
penjelasan parsial untuk diagnosis akhir ini secara umum, menunjukkan bahwa gejala
psikiatri (karena hipertiroidisme itu) tampaknya mengakibatkan penundaan dalam mencari
pengobatan serta penundaan dalam menerima diagnosis yang tepat. [19] Selain itu, gejala awal
gugup, hiperaktif, dan penurunan kinerja sekolah, dengan mudah dapat dihubungkan dengan
penyebab lainnya. [ rujukan? ] Banyak gejala kadang-kadang mungkin perlu dicatat, pada waktu,
di dinyatakan sehat individu yang tidak memiliki penyakit tiroid (misalnya, semua orang
merasa cemas dan ketegangan tingkat tertentu), dan gejala tiroid banyak yang mirip dengan
penyakit lainnya. [11] Oleh karena itu, temuan klinis mungkin penuh ditiup dan jelas atau
membahayakan dan mudah bingung dengan penyakit lain. [58] Hasil menghadap tiroid namun
bisa sangat serius. [ 29] Juga penting dan bermasalah, adalah bahwa dalam studi responden
survei 1996 melaporkan penurunan yang signifikan dalam memori, perhatian, perencanaan,
dan produktivitas secara keseluruhan dari periode 2 tahun sebelum 'Graves gejala awal pada
saat hipertiroid. [19] A 2002 besar studi menemukan "tidak ada hubungan statistik antara
disfungsi tiroid, dan adanya depresi atau gangguan kecemasan". [22]

The resulting hyperthyroidism in Graves' disease causes a wide variety of symptoms. Yang
mengakibatkan penyakit hipertiroidisme Graves 'menyebabkan berbagai gejala. The two
signs that are truly 'diagnostic' of Graves' disease ( ie, not seen in other hyperthyroid
conditions) are exophthalmos (protuberance of one or both eyes) and pretibial myxedema , a
rare skin disorder with an occurrence rate of 1-4%, that causes lumpy, reddish skin on the
lower legs. Kedua tanda yang benar-benar 'diagnostik' dari 'penyakit Graves (yaitu, tidak
terlihat dalam kondisi hipertiroid lain) exophthalmos (benjol salah satu atau kedua mata) dan
myxedema pretibial , penyakit kulit langka dengan tingkat kejadian 1-4% , yang
menyebabkan kental, kulit kemerahan pada bagian bawah kaki. Graves' disease also causes
goitre (an enlargement of the thyroid gland) that is of the diffuse type ( ie, spread throughout
the gland). 'Penyakit Graves juga menyebabkan gondok (pembesaran kelenjar thyroid) yang
tipe difus (misalnya, tersebar di seluruh kelenjar). This phenomenon also occurs with other
causes of hyperthyroidism, though Graves' disease is the most common cause of diffuse
goitre. Fenomena ini juga terjadi dengan penyebab lain hipertiroidisme, meskipun penyakit
Graves 'adalah penyebab paling umum gondok difus. A large goitre will be visible to the
naked eye, but a smaller goitre (very mild enlargement of the gland) may be detectable only
by physical exam. Sebuah gondok besar akan terlihat dengan mata telanjang, tetapi lebih
kecil gondok (pembesaran kelenjar sangat ringan) mungkin akan terdeteksi hanya dengan
pemeriksaan fisik. Occasionally, goitre is not clinically detectable but may be seen only with
CT or ultrasound examination of the thyroid. Kadang-kadang, gondok tidak terdeteksi secara
klinis, tetapi hanya dapat dilihat dengan CT atau USG pemeriksaan tiroid.

A highly suggestive symptom of hyperthyroidism, is a change in reaction to external

temperature. Gejala yang sangat sugestif dari hipertiroidisme, adalah reaksi terhadap
perubahan temperatur eksternal. A hyperthyroid person will usually develop a preference for
cold weather, a desire for less clothing and less bed covering, and a decreased ability to
tolerate hot weather. [ 3 ] When thyroid disease runs in the family, the physician should be
particularly wary: studies of twins suggest that the genetic factors account for 79% of the
liability to the development of Graves' disease (whereas environmental factors account
presumably for the remainder). [ 3 ] Other nearly pathognomonic signs of hyperthyroidism are
excessive sweating, high pulse during sleep, and a pattern of weight loss with increased
appetite (although this may also occur in diabetes mellitus and malabsorption or intestinal
parasitism ). [ 3 ] [ 12 ] Seseorang hipertiroid biasanya akan mengembangkan preferensi untuk
cuaca dingin, keinginan untuk pakaian tidur kurang dan kurang mencakup, dan penurunan
kemampuan untuk mentolerir cuaca panas. [3] Ketika penyakit tiroid berjalan dalam keluarga,
dokter harus sangat waspada: studi kembar menunjukkan bahwa faktor genetik account untuk
79% dari kewajiban untuk pengembangan 'penyakit Graves (sedangkan faktor lingkungan
account mungkin untuk sisanya). [3] Lain-lain hampir patognomonik tanda-tanda
hipertiroidisme adalah keringat berlebihan, denyut tinggi selama tidur, dan pola menurunkan
berat badan dengan nafsu makan meningkat (meskipun ini juga mungkin terjadi pada diabetes
mellitus dan malabsorpsi atau parasitisme usus ). [3] [12]
Hyperthyroidism in Graves' disease is confirmed, as with any other cause of hyperthyroidism,
by a blood test. Pada penyakit hipertiroidisme Graves 'dikonfirmasi, karena dengan penyebab
lain hipertiroidisme, oleh tes darah. Elevated blood levels of the principal thyroid hormones (
ie free T3 and T4), and a suppressed thyroid-stimulating hormone (low due to negative
feedback from the elevated T3 and T4), point to hyperthyroidism. Peningkatan kadar hormon
tiroid utama (T3 dan T4 bebas yaitu), dan ditekan -stimulating hormone tiroid (rendah karena
umpan balik negatif dari peningkatan T3 dan T4), arahkan ke hipertiroidisme. However, a
2007 study makes clear that diagnosis depends to a considerable extent on the position of the
patient's unique set point for T4 and T3 within the laboratory reference range (an important
issue which is further elaborated below ). [ 40 ] Namun, sebuah studi 2007 menjelaskan bahwa
diagnosis bergantung hingga batas tertentu pada posisi yang unik set point sabar untuk T4
dan T3 dalam rentang referensi laboratorium (suatu hal yang penting yang akan dibahas lebih
lanjut di bawah ). [40]

Differentiating Graves' hyperthyroidism from the other causes of hyperthyroidism (

thyroiditis , toxic multinodular goiter , toxic thyroid nodule , and excess thyroid hormone
supplementation) is important to determine proper treatment. Graves 'hyperthyroidism
Membedakan dari penyebab lain hipertiroidisme ( tiroiditis , multinodular gondok beracun ,
nodul tiroid beracun , dan suplemen hormon tiroid berlebihan) adalah penting untuk
menentukan perawatan yang tepat. Thus, when hyperthyroidism is confirmed, or when
bloodresults are inconclusive, thyroid antibodies should be measured. Jadi, ketika
hipertiroidisme dikonfirmasi, atau ketika bloodresults yang tidak meyakinkan, antibodi tiroid
harus diukur. Measurement of thyroid stimulating immunoglobulin (TSI) is the most accurate
measure of thyroid antibodies. Pengukuran imunoglobulin merangsang tiroid (TSI) adalah
ukuran paling akurat dari antibodi tiroid. They will be positive in 60 to 90 % of children with
Graves' disease. Mereka akan positif dalam 60 sampai 90% dari anak-anak dengan penyakit
Graves '. If TSI is not elevated, then a radioactive iodine uptake should be performed; an
elevated result with a diffuse pattern is typical of Graves' disease. Biopsy to obtain
histological testing is not normally required but may be obtained if thyroidectomy is
performed. Jika TSI tidak ditinggikan, maka serapan yodium radioaktif harus dilakukan; hasil
yang tinggi dengan pola diffuse khas 'penyakit Graves. Biopsi untuk mendapatkan histologis
pengujian biasanya tidak diperlukan, tetapi bisa diperoleh jika thyroidectomy dilakukan.

[ edit ] Treatment [ sunting ] Pengobatan

It is yet unknown how to interrupt the autoimmune processes of Graves' disease, which
means treatment has to be indirect. Hal ini belum diketahui bagaimana untuk mengganggu
proses autoimmune penyakit Graves ', yang berarti pengobatan harus tidak langsung. The link
that is targeted is the thyroid gland , via three different methods (which have not changed
fundamentally since the introduction of antithyroid drugs and radioactive iodine in the
1940s). Link yang ditargetkan adalah kelenjar tiroid , melalui tiga metode yang berbeda
(yang tidak berubah secara mendasar sejak diperkenalkannya obat antitiroid dan yodium
radioaktif pada tahun 1940). These are the use of antithyroid drugs (which reduce the
production of thyroid hormone ), partial or complete destruction of the thyroid gland by
ingestion of radioactive iodine ( radioiodine ), and partial or complete surgical removal of the
thyroid gland ( thyroidectomy ). Ini adalah penggunaan obat anti thyroid (yang mengurangi
produksi hormon tiroid ), sebagian atau lengkap penghancuran kelenjar tiroid oleh konsumsi
yodium radioaktif ( radioiod ), dan sebagian atau pembedahan lengkap kelenjar tiroid (
thyroidectomy ).
There is no standard choice for treating Graves' hyperthyroidism; it is not straightforward and
often involves complex decision making. Tidak ada pilihan standar untuk mengobati
hipertiroidisme Graves ', akan tetapi tidak mudah dan sering melibatkan pengambilan
keputusan yang kompleks. The physician must weigh the advantages and disadvantages of
the different treatment options and help the patient arrive at an individualized therapeutic
strategy that is appropriate and cost-effective. dokter harus mempertimbangkan keuntungan
dan kerugian dari pilihan-pilihan pengobatan yang berbeda dan membantu pasien tiba di
sebuah strategi terapi individual yang sesuai dan hemat biaya. Kaplan summarizes that " the
choice of therapy varies according to nonbiological factors - physicians' training and
personal experience; local and national practice patterns; patient, physician, and societal
attitudes toward radiation exposure; and biological factors including age, reproductive
status, and severity of the disease ". [ citation needed ] Therapy with radioiodine is the most common
treatment in the United States, whilst antithyroid drugs and/or thyroidectomy is used more
often in Europe, Japan, and most of the rest of the world. Kaplan merangkum bahwa "pilihan
terapi bervariasi sesuai dengan faktor nonbiological - dokter 'pelatihan dan pengalaman
pribadi; lokal dan pola kebiasaan nasional; pasien, dokter, dan sikap masyarakat terhadap
paparan radiasi, dan faktor biologis seperti usia, status reproduksi, dan tingkat keparahan
penyakit ". [ rujukan? ] Terapi dengan radioiod adalah perawatan yang paling umum di Amerika
Serikat, sedangkan antitiroid obat-obatan dan / atau thyroidectomy lebih sering digunakan di
Eropa, Jepang, dan sebagian besar bagian dunia lainnya. However, due to the varying success
of every treatment option, patients are often subjected to more than one of these, when the
first attempted treatment didn't prove entirely successful. Namun, karena berbagai
keberhasilan setiap pilihan pengobatan, pasien sering mengalami lebih dari satu ini, ketika
mencoba pengobatan pertama tidak sepenuhnya berhasil membuktikan.

In the short term, treatment of hyperthyroidism usually produces a parallel decrease in

endocrine symptoms and in psychiatric symptoms. Dalam jangka pendek, pengobatan
hipertiroidisme biasanya menghasilkan penurunan gejala paralel di endokrin dan gejala
kejiwaan. When prolonged treatment normalizes thyroid function, some psychiatric
symptoms and somatic complaints may persist (as has been thoroughly clarified above). [ 32 ]
Ketika perawatan berkepanjangan menormalisir fungsi thyroid, beberapa gejala psikiatri dan
keluhan somatik bisa bertahan (sebagaimana telah dijelaskan di atas sepenuhnya). [32]

A 2009 study shows that in spite of modern therapeutic modalities, Graves' disease is
accompanied by seriously impaired quality of life. Sebuah studi 2009 menunjukkan bahwa
walaupun modalitas terapi modern, penyakit Graves 'disertai oleh gangguan serius kualitas
hidup. Several recent studies stress the importance of early prevention, speedy rehabilitation,
and a thorough follow-up of hyperthyroid patients. [ 59 ] Patients who do not have a
spontaneous remission with the use of antithyroid drugs, become lifelong thyroid patients.
Beberapa studi baru-baru ini menekankan pentingnya pencegahan dini, rehabilitasi cepat, dan
menyeluruh tindak lanjut dari pasien hipertiroid. [59] Pasien yang tidak memiliki remisi
spontan dengan penggunaan obat antitiroid, menjadi pasien tiroid seumur hidup.

[ edit ] Symptomatic [ sunting ] simtomatik

Beta blockers (such as propranolol ) may be used to inhibit the sympathetic nervous system
symptoms of rapid heart rate and nausea until such time as antithyroid treatments start to take
effect. Penyekat beta (seperti propranolol ) dapat digunakan untuk menghambat sistem saraf
simpatik gejala denyut jantung cepat dan mual sampai waktu seperti perawatan antitiroid
mulai berlaku.
[ edit ] Antithyroid drugs [ sunting ] obat antitiroid

Scan of affected thyroid before and after radioiodine therapy. Scan tiroid yang terkena
dampak sebelum dan sesudah radioiod terapi.

Treatment with antithyroid medications must be given for six months to two years, in order to
be effective. Pengobatan dengan obat antitiroid harus diberikan selama enam bulan sampai
dua tahun, agar efektif. Even then, upon cessation of the drugs, the hyperthyroid state may
recur. Bahkan kemudian, penghentian pada obat, keadaan hipertiroid bisa kambuh. Side
effects of the antithyroid medications include a potentially fatal reduction in the level of
white blood cells. Efek samping dari obat antitiroid termasuk pengurangan fatal pada tingkat
sel darah putih. The main antithyroid drugs are carbimazole (in the UK), methimazole (in the
US), and propylthiouracil /PTU. Obat antitiroid utama adalah carbimazole (di Inggris),
methimazole (di AS), dan propylthiouracil / PTU. These drugs block the binding of iodine
and coupling of iodotyrosines. Obat golongan ini menghambat pengikatan iodium dan
kopling dari iodotyrosines. The most dangerous side-effect is agranulocytosis (1/250, more in
PTU); this is an idiosyncratic reaction which does not stop on cessation of drug. Bahaya-efek
samping yang paling adalah agranulocytosis (1 / 250, lebih dalam PTU), ini adalah reaksi
aneh yang tidak berhenti pada penghentian obat. Others include granulocytopenia (dose
dependent, which improves on cessation of the drug) and aplastic anemia . Lain-lain
termasuk granulocytopenia (dosis tergantung, yang meningkatkan tentang penghentian obat)
dan anemia aplastik . Patients on these medications should see a doctor if they develop sore
throat or fever. Pasien pada obat ini harus ke dokter jika mereka mengembangkan radang
tenggorokan atau demam. The most common side effects are rash and peripheral neuritis .
Efek samping yang paling umum adalah ruam dan perifer neuritis . These drugs also cross the
placenta and are secreted in breast milk . Obat ini juga melintasi plasenta dan disekresikan
dalam ASI . Lugol's iodine is used to block hormone synthesis before surgery. Lugol yodium
adalah digunakan untuk memblokir hormon sintesis sebelum operasi.

A randomized control trial testing single dose treatment for Graves' found methimazole
achieved euthyroid state more effectively after 12 weeks than did propylthyouracil (77.1% on
methimazole 15 mg vs 19.4% in the propylthiouracil 150 mg groups). [ 60 ] But generally both
drugs are considered equivalent. Sebuah percobaan kontrol secara acak pengujian pengobatan
dosis tunggal untuk 'ditemukan methimazole Graves dicapai negara euthyroid lebih efektif
setelah 12 minggu ketimbang propylthyouracil (77,1% pada methimazole 15 mg vs 19,4%
pada kelompok propylthiouracil mg 150). [60] Tapi pada umumnya kedua obat tersebut
dianggap setara.

A study has shown no difference in outcome for adding thyroxine to antithyroid medication
and continuing thyroxine versus placebo after antithyroid medication withdrawal. Penelitian
telah menunjukkan tidak ada perbedaan dalam hasil untuk menambahkan tiroksin untuk
antitiroid pengobatan dan tiroksin terus versus plasebo setelah penarikan obat antitiroid.
However two markers were found that can help predict the risk of recurrence. Namun
ditemukan dua penanda yang dapat membantu memprediksi risiko kekambuhan. These two
markers are an elevated level of thyroid stimulating hormone receptor antibodies (TSHR-Ab)
and smoking. Kedua penanda adalah peningkatan kadar hormon tiroid merangsang reseptor
antibodi (TSHR-Ab) dan merokok. A positive TSHR-Ab at the end of antithyroid drug
treatment increases the risk of recurrence to 90% ( sensitivity 39%, specificity 98%), a
negative TSHR-Ab at the end of antithyroid drug treatment is associated with a 78% chance
of remaining in remission. A-Ab TSHR positif pada akhir pengobatan antitiroid
meningkatkan risiko kekambuhan sampai 90% ( sensitivitas 39%, spesifisitas 98%), sebuah
TSHR negatif-Ab pada akhir pengobatan antitiroid dikaitkan dengan 78% kesempatan tersisa
dalam pengampunan. Smoking was shown to have an impact independent to a positive
TSHR-Ab. [ 61 ] Merokok terbukti memiliki dampak independen ke-TSHR positif Ab. [61]

If treatment with antithyroid drugs fails to induce remission, RAI or surgery must be
considered. Jika perawatan dengan obat antitiroid gagal menginduksi remisi, RAI atau
pembedahan harus dipertimbangkan.

[ edit ] Radioiodine [ sunting ] Radioiod

See also: Iodine-131 Lihat juga: Yodium-131

Radioiodine (radioactive iodine-131 , abbreviated as RAI) was developed in the early 1940s
at the Mallinckrodt General Clinical Research Center . Radioiod (radioaktif yodium-131 ,
disingkat RAI) dikembangkan pada awal 1940-an di Mallinckrodt General Clinical Research
Center . This modality is suitable for most patients, although some prefer to use it mainly for
older patients. modalitas ini cocok untuk sebagian besar pasien, meskipun beberapa memilih
untuk menggunakannya terutama bagi pasien yang lebih tua. Indications for RAI are failed
medical therapy or surgery, and where medical or surgical therapy are contraindicated.
Indikasi untuk RAI yang gagal terapi medis atau operasi, dan di mana terapi medis atau
bedah yang kontraindikasi. Contraindications to RAI are pregnancy (absolute),
ophthalmopathy (relative; it can aggravate thyroid eye disease), and solitary thyoid nodules .
RAI adalah kontraindikasi untuk kehamilan (absolut), ophthalmopathy (relatif, yang dapat
memperburuk penyakit mata tiroid), dan nodul soliter thyoid .

The radio-iodine treatment acts slowly (over months to years) to partially or completely
destroy the thyroid gland (depending on the administered dose). Perlakuan radio-iodine
bertindak perlahan-lahan (selama bulan sampai tahun) untuk sebagian atau seluruhnya
menghancurkan kelenjar tiroid (tergantung pada dosis yang diberikan). Patients must
therefore be monitored regularly with thyroid blood tests to ensure that they don't evolve to
hypothyroidism (incidence rate of 80%), in which case they will become lifelong thyroid
patients. Oleh karena itu pasien harus dimonitor secara teratur dengan tes darah tiroid untuk
memastikan bahwa mereka tidak berevolusi untuk hypothyroidism (tingkat insiden 80%),
dalam hal ini mereka akan menjadi pasien tiroid seumur hidup. For some patients, finding the
correct thyroid replacement hormone and the correct dosage may take many years and may
be in itself a much more difficult task than is commonly understood. [ citation needed ] Untuk
beberapa pasien, menemukan penggantian hormon tiroid yang benar dan dosis yang tepat
dapat berlangsung bertahun-tahun dan mungkin dalam dirinya sendiri suatu tugas yang jauh
lebih sulit daripada yang umumnya dipahami. [ rujukan? ]

Graves' disease-associated hyperthyroidism is not cured in all persons by radioiodine, but has
a relapse rate that depends on the administered dose of radioiodine. hipertiroidisme Graves
'penyakit-asosiasi tersebut tidak sembuh dalam semua orang oleh radioiod, namun memiliki
tingkat kambuh yang tergantung pada dosis dari radioiod.

[ edit ] Surgery [ sunting ] Bedah

See also: Thyroidectomy Lihat juga: Thyroidectomy

Scar in the neck, ten weeks after a total thyroidectomy. Bekas luka di leher, sepuluh minggu
setelah total thyroidectomy. Current surgical techniques typically leave a smaller scar. teknik
bedah saat ini biasanya meninggalkan bekas luka yang lebih kecil.

This modality is suitable for young patients and pregnant patients. modalitas ini cocok untuk
pasien muda dan pasien hamil. Indications are: a large goitre (especially when compressing
the trachea ), suspicious nodules or suspected cancer (to pathologically examine the thyroid)
and patients with ophthalmopathy. Indikasi adalah: a gondok besar (terutama bila
mengompresi trakea , curiga nodul) atau diduga kanker (untuk memeriksa tiroid patologis)
dan pasien dengan ophthalmopathy. As operating on a frankly hyperthyroid patient is
dangerous, prior to thyroidectomy preoperative treatment with antithyroid drugs is given to
render the patient "euthyroid" ( ie normothyroid). Sebagai operasi pada pasien hipertiroid
terus terang berbahaya, sebelum thyroidectomy pengobatan pra operasi dengan obat antitiroid
diberikan untuk membuat pasien "euthyroid" (normothyroid yaitu). Preoperative
administration of (not radioactive) iodine, usually by Lugol's iodine solution, decreases
intraoperative blood loss during thyroidectomy in patients with Grave's disease. [ 62 ] However,
it appears ineffective in patients who are already euthyroid due to treatment with anti-thyroid
drugs and T4 . [ 63 ] administrasi pra operasi dari (tidak radioaktif) yodium, biasanya dengan
itu yodium Lugol solusi, penurunan kehilangan darah intraoperative selama thyroidectomy
pada pasien dengan Penyakit Makam. [62] Namun, tampaknya tidak efektif pada pasien yang
sudah euthyroid karena pengobatan dengan-tiroid obat anti dan T4 . [63]

Doctors can opt for partial or total removal of the thyroid gland (subtotal thyroidectomy vs
total thyroidectomy). Dokter dapat memilih untuk memindahkan sebagian atau seluruh
kelenjar tiroid (subtotal thyroidectomy thyroidectomy vs total). A total removal excludes the
difficulty in determining how much thyroid tissue must be removed. A total penghapusan
termasuk kesulitan dalam menentukan berapa banyak jaringan tiroid harus dihilangkan. More
aggressive surgery has a higher likelihood of inducing hypothyroidism ; less aggressive
surgery has a higher likelihood of recurrent hyperthyroidism . agresif operasi lebih memiliki
kemungkinan lebih tinggi mendorong hypothyroidism ; agresif pembedahan kurang memiliki
kemungkinan yang lebih tinggi berulang hipertiroidisme . Around 10–15% of patients who
had a subtotal thyrodectomy will develop underactive thyroids many years after their
operation. Sekitar 10-15% dari pasien yang memiliki thyrodectomy subtotal akan
mengembangkan thyroids kurang aktif bertahun-tahun setelah operasi mereka. This is not
counting those who develop underactive thyroids immediately after the operation (within 6
weeks). [ 64 ] Thyroid remnants smaller than 4 grams are associated with postoperative
hypothyroidism in 27 to 99 percent of patients. Ini tidak termasuk mereka yang kurang aktif
mengembangkan thyroids segera setelah operasi (dalam jangka waktu 6 minggu). [64] Tiroid
sisa-sisa lebih kecil dari 4 gram berhubungan dengan hipotiroidisme pasca operasi di 27-99
persen pasien. Patients who have thyroid remnants of 7 to 8 g become euthyroid, but may
have subclinical hyperthyroidism. Pasien yang memiliki sisa-sisa tiroid dari 7 sampai 8 g
menjadi euthyroid, tapi mungkin hipertiroidisme subklinis. In addition, 9 to 12 percent
develop recurrent overt hyperthyroidism. Selain itu, 9 sampai 12 persen mengembangkan
hipertiroidisme terbuka berulang. As repeat surgery is associated with a high risk of
complications, further permanent treatment should be with radioiodine. Seperti operasi ulangi
dikaitkan dengan risiko tinggi komplikasi, perawatan permanen lebih lanjut harus dengan
radioiod.

In a study of 380 patients undergoing subtotal thyroidectomy, the complications were as

followed: Dalam studi dari 380 pasien yang menjalani thyroidectomy subtotal, komplikasi
adalah sebagai berikut:

 Transient vocal cord paralysis in 3% Transien kelumpuhan pita suara di 3%

 Prolonged postoperative hypocalcemia in 3% Berkepanjangan pascaoperasi
hypocalcemia dalam 3%
 Permanent hypoparathyroidism in 1% (due to removal of one or more parathyroid
glands ) Tetap hypoparathyroidism dalam 1% (karena penghapusan satu atau lebih
kelenjar paratiroid )
 Recurrent hyperthyroidism in 2% Berulang hipertiroidisme dalam 2%

A scar is created across the neck just above the collar bone line. Seorang bekas luka dibuat di
leher tepat di atas tulang kerah garis. However, the scar is very thin, and eventually recedes to
appear as nothing more than a crease in the neck. Namun, bekas luka itu sangat tipis, dan
akhirnya berkurang untuk muncul sebagai tak lebih dari lipatan di leher. Patients may spend
one or more nights in hospital after the surgery, and endure the effects of general anesthesia (
ie , vomiting), as well as a sore throat, a raspy voice, and a cough from having a breathing
tube stuck down the windpipe during surgery. [ citation needed ]

Removal of the gland enables complete biopsy to be performed to have definite evidence of
thyroid cancer , since needle biopsies are not so accurate at predicting a benign state of the
thyroid. No further treatment of the thyroid is required, unless cancer is detected. Radioiodine
treatment may be done after surgery, to ensure that all remaining (potentially cancerous)
thyroid cells are destroyed ( ie , those near the nerves to the vocal chords , which cannot be
surgically removed without damage to those vocal chords). Besides this, the only remaining
treatment will be thyroid replacement pills (to be taken for the rest of the patient's life), if the
surgery results in hypothyroidism.

[ edit ] Thyroid hormones [ sunting ] hormon Tiroid

See also: Hypothyroidism#Treatment

Many Graves' disease patients will become lifelong thyroid patients, due to the surgical
removal or radioactive destruction of their thyroid. In effect, they are then hypothyroid
patients, requiring perpetual intake of artificial thyroid hormones. [ 65 ] Given the one-week
plasma half life of levothyroxine (T4), it takes about five-six weeks (half-lives) before a
steady state is attained after the dosage is initiated or changed. After the optimal thyroxine
dose has been defined, long-term monitoring of patients with an annual clinical evaluation
and serum TSH measurement is appropriate. [ 65 ] However, the difficulty lies in determining
and controlling the proper dosage for a particular patient, which can be an intricate process.
Because levothyroxine has a very narrow therapeutic index, the margin between overdosing
and underdosing can be quite small. [ 66 ] Being treated with too much or too little thyroid
hormone can lead to a chronic state of (possibly subclinical) hypo- or hyperthyroidism.
Several studies show that this is not an uncommon occurrence. [ 8 ] [ 67 ] [ 68 ]

[ edit ] Neuropsychiatric symptoms

A substantial proportion of patients have an altered mental state, even after successful
treatment of hyperthyroidism. When psychiatric disorders remain after restoration of
euthyroidism and after treatment with beta blockers , specific treatment for the psychiatric
symptoms, especially psychotropic drugs , may be needed. [ 10 ] A literature study concluded
in 2006, found that, after being diagnosed with Graves' hyperthyroidism, approximately one-
third of patients are prescribed psychotropic drugs. Sometimes these drugs are given to treat
mental symptoms of hyperthyroidism, sometimes to treat mental symptoms remaining after
amelioration of hyperthyroidism, and sometimes when the diagnosis of Graves'
hyperthyroidism has been missed and the patient is treated as having a primary psychiatric
disorder. There are no systematic data on the general efficacy of psychotropic drugs in the
treatment of mental symptoms in patients with hyperthyroidism, although many reports
describe the use of individual agents. [ 10 ] De Groot mentions that a mild sedative or
tranquilizer is often helpful. [ 15 ]

[ edit ] Eye disease

See also: Graves' ophthalmopathy

Mild cases are treated with lubricant eye drops or non steroidal anti-inflammatory drops.
Severe cases threatening vision ( corneal exposure or optic nerve compression) are treated
with steroids or orbital decompression . In all cases cessation of smoking is essential. Double
vision can be corrected with prism glasses and surgery (the latter only when the process has
been stable for a while).

Eyelid muscles can become tight with Graves, making it impossible to completely close the
eyes. Difficulty closing the eyes can be treated with lubricant gel at night, or with tape on the
eyes to enable full sleep. Eyelid surgery can be performed on upper and/or lower eyelids to
reverse the effects of Graves' on the eyelids. Eyelid surgery involves an incision along the
natural crease of the eyelid, and a scraping away of the muscle that holds the eyelid open.
This makes the muscle weaker, which allows the eyelid to extend over the eyeball more
effectively. Eyelid surgery helps reduce or eliminate dry eye symptoms.

Orbital decompression can be performed to enable bulging eyes to be retracted again. In this
procedure, bone is removed from the skull behind the eyes, and space is made for the
enlarged muscles and fatty tissue to be moved back into the skull.

[ edit ] General measurements

Graves' disease patients are nutritionally depleted in proportion to the duration and severity of
their illness. Until metabolism is restored to normal, and for some time afterward, caloric and
protein requirements may be well above normal. Specific deficiencies may exist, and
multivitamin supplementation is indicated. The intake of calcium should be above normal.
All in all, the physician should pay heed to the patient's emotional needs, as well as to his or
her requirements for rest, nutrition , and specific (anti)thyroid medication. [ 15 ]

[ edit ] Prognosis [ sunting ] Prognosis

The disease typically begins gradually, and is progressive unless treated. [ 3 ] If left untreated,
more serious complications could result, including bone loss and fractures , inanition , birth
defects in pregnancy, increased risk of a miscarriage . [ 3 ] Graves disease is often
accompanied by an increase in heart rate , which may lead to cardiovascular damage and
further heart complications including loss of the normal heart rhythm ( atrial fibrillation ),
which may lead to stroke . [ 3 ] If the eyes are bulging severely enough that the lids do not
close completely at night, severe dryness will occur with a very high risk of a secondary
corneal infection which could lead to blindness . Pressure on the optic nerve behind the globe
can lead to visual field defects and vision loss as well. In severe thyrotoxicosis, a condition
frequently referred to as thyroid storm , the neurologic presentations are more fulminant,
progressing if untreated through an agitated delirium to somnolence and ultimately to coma .
All in all, untreated Graves' disease can lead to significant morbidity , disability and even
death . However, the long-term history also includes spontaneous remission in some cases
and eventual spontaneous development of hypothyroidism if autoimmune thyroiditis coexists
and destroys the thyroid gland. [ 3 ]

When effective thyroid treatment is begun, the general response is quite favorable: physicial
symptoms resolve, vitality returns and the mental processes become efficient again. [ 29 ]
However, symptom relief is usually not immediate and is achieved over time as the
treatments take effect and thyroid levels reach stability. In addition, not all symptoms may
resolve at the same time. Prognosis also depends on the duration and severity of the disease
before treatment.

[ edit ] Remission and relapses

A literature study in 2006 found that patients who have residual mental symptoms have a
significantly higher chance of relapse of hyperthyroidism. Patients with recurrent Graves'
hyperthyroidism, compared with patients in remission and healthy subjects, had significantly
higher scores on scales related to depression and anxiety , as well as less tolerance of stress .
[ 10 ] [ 49 ]
According to a 2010 publication, a total thyroidectomy offers the best chance of
preventing recurrent hyperthyroidism. [ 69 ]

[ edit ] Mental impairment

A literature review in 2006, whilst noting methodology issues in the consistency of Graves'
disease diagnostic criteria , found many reports about residual complaints in patients who
were euthyroid after treatment with a high prevalence of anxiety disorders and bipolar
disorder , as well as elevated scores on scales of anxiety , depression and psychological
distress. [ 10 ] Bunevicius et al. point out that this "substantial mental disability" is more severe
in patients with residual hyperthyroidism but is present even in euthyroid patients. [ 32 ] Delay
in therapy markedly worsens the prognosis for recovery, but complications can be prevented
by early treatment. [ 70 ] In rare cases, patients will experience psychosis -like symptoms only
after they have been treated for hypo- or hyperthyroidism, due to a rapid normalisation of
thyroid hormone levels in a patient who has partly adapted to abnormal values. [ 12 ]

[ edit ] Thyroid replacement treatment after thyroidectomy or radioiodine

Several studies point out aa high frequency of TSH level abnormalities in patients who take
thyroid hormone supplemenation, and stress the importance of periodic assessment of serum
TSH . [ 67 ] [ 68 ]

[ edit ] Coping with Graves' disease & the patient-

physician relationship
Mentally, Graves' disease can be very disturbing. Mood swings , thinking impairment and
other mental symptoms can be difficult to handle, and make it appear that the patient is
suffering from a severe mental disorder. There have even been cases where patients have
been placed in mental institutions . [ 1 ] [ 11 ] Given the sometimes dramatic impact and long
duration of the disease and its treatment, identifying and maintaining emotional support
systems (which are frequently affected) can help patients and their families cope. [ 15 ] [ 19 ]
Because emotional lability of the thyrotoxic patient may create interpersonal problems (often
producing significant marital stress and conflict), thorough explanation of the disease can be
invaluable. [ 15 ] [ 19 ] In Graves' disease, the accent should lie on written information, as a host
of mental problems, such as decreased attention span and memory problems , can impair a
patient's ability to absorb details of doctor visits. In a complicated and difficult illness like
Graves' disease, physicians should therefore furnish patients with educational materials or
resources such as handouts, website links and community support groups. [ 71 ]
However, many patients indicate they are not getting the information they need from the
general medical community, and are concerned that they have not obtained a full
understanding of their condition. [ 1 ] [ 72 ] De Groot et al. feel that sympathetic discussion by
the physician, possibly together with assistance in environmental manipulation, is an
important part of the general attack on Graves' disease. [ 15 ] Patient education is the "drug of
choice" for prevention and treatment of every medical condition, and open communication
with health care professionals can be highly beneficial in maximizing health and outlook on
life. [ 15 ] [ 71 ] During the initial and subsequent interviews, the physician must determine the
level of the psychic and physical stresses. Frequently, major emotional problems come to
light after the patient recognizes the sincere interest of the physician. Personal problems can
strongly affect therapy by interfering with rest or by causing economic hardship. [ 15 ] It is
therefore recommended that physicians implement a social questionnaire as part of the initial
intake, allowing the patient to communicate essential, non-medical information about their
lives. [ 71 ]

The communication and health management skills of Graves' disease patients can be
seriously impaired. This is something physicians should be conscious of while dealing with
these patients, as mounting evidence demonstrates that the effectiveness of the patient-
physician relationship directly relates to health outcomes. The report of a large 2003 summit
of physicians and patients notes a number of barriers to achieving desired patient-centered
outcomes. It mentions insufficient or unreliable clinical information, lack of communication
or inability to communicate effectively, lack of trust between patient and physician, lack of
appropriate coordination of care, lack of physician cooperation, and the need to work with too
many caregivers, all of which can be very relevant to Graves' disease. [ 71 ]

[ edit ] Epidemiology [ sunting ] Epidemiologi

Recent studies in England put the incidence of Graves' disease at 1 to 2 cases per 1,000
population per year (in England). It occurs much more frequently in women than in men. The
disease frequently presents itself during early adolescence or begins gradually in adult
women, often after childbirth , and is progressive until treatment. It has a powerful hereditary
component. [ 3 ]

Graves' disease tends to be more severe in men, even though it is rarer. It appears less likely
to go into permanent remission and the eye disease tends to be more severe, but men are less
likely to have large goitres . [ 73 ] In a statistical study of symptoms and signs of 184 thyrotoxic
patients (52 men, 132 women), the male patients were somewhat older than the females, and
there were more severe cases among men than among women. Cardiac symptoms were more
common in women, even though the men were older and more often had a severe form of the
disease; palpitations and dyspnea were more common and severe in women. [ 3 ]

Cigarette smoking , which is associated with many autoimmune diseases, raises the incidence
of Graves' ophthalmopathy 7.7-fold. [ 74 ]

[ edit ] History [ sunting ] Riwayat

Graves' disease owes its name to the Irish doctor Robert James Graves , who described a
case of goitre with exophthalmos in 1835. [ 75 ] [ 76 ] However, the German Karl Adolph von
Basedow independently reported the same constellation of symptoms in 1840. [ 77 ] [ 78 ] As a
result, the term Basedow's syndrome/disease is more common on the European continent
than Graves' disease. [ 79 ] [ 80 ] It has also been called exophthalmic goitre . [ 81 ] Less
commonly, it has been known as Parry's disease , Begbie's disease , Flajani's disease ,
Flajani-Basedow syndrome , and Marsh's disease , in honor of other pioneer investigators
of the disorder, whose earlier reports were not widely circulated: Caleb Hillier Parry , James
Begbie , Giuseppe Flajani , and Henry Marsh . [ 79 ] [ 81 ] For example, cases of goitre with
exophthalmos were published by the Italians Giuseppe Flajani and Antonio Giuseppe Testa,
in 1802 and 1810, respectively. [ 82 ] [ 83 ] [ 84 ] Prior to these, Caleb Hillier Parry, a notable
provincial physician in England of the late 18th century, first noted the condition in 1786. [ 85 ]
[ 86 ]
This case was not published until 1825, but still 10 years ahead of Graves. [ 87 ]

However, fair credit for the first description of Graves' disease goes to the 12th century
Persian physician Sayyid Ismail al-Jurjani , [ 88 ] [ verification needed ] who noted the association of
goitre and exophthalmos in his "Thesaurus of the Shah of Khwarazm" , the major medical
dictionary of its time. [ 79 ] [ 89 ] [ 90 ] [ verification needed ]

One of the first reports of the adverse effects of hyperthyroidism on the skeleton dates from
1891, when von Recklinghausen described the "worm eaten" appearance of the long bones of
a young woman who died from hyperthyroidism.

[ edit ] Notable cases [ sunting ] kasus terkenal

 Ayaka , Japanese singer/songwriter [ 91 ]
 George HW Bush , US president, developed new atrial fibrillation and was diagnosed
in 1991 with hyperthyroidism due to the disease and treated with radioactive iodine.
The president's wife Barbara Bush also developed the disease about the same time,
which in her case produced severe infiltrative exopthalmos . [ 92 ]
 Maggie Cheung Ho-Yee , Hong Kong actress [ 93 ]
 Toni Childs , American singer/songwriter [ 94 ]
 Gail Devers , Athletic champion [ 95 ]
 Marty Feldman , British comedian [ 96 ]
 Diane Finley , Canadian cabinet minister [ 97 ]
 Faith Ford , American actress [ 98 ]
 Sia Furler , Australian singer [ 99 ]
 Sammy "The Bull" Gravano , Former Gambino Family Underboss [ citation needed ]
 Nadezhda Krupskaya , the wife of Lenin [ 100 ]
 Barbara Leigh , an American former actress and fashion model, now spokeswomen
for the National Graves' Disease Foundation [ 101 ]
 Yūko Miyamura , Japanese voice actress [ 102 ]
 Christopher Monckton, 3rd Viscount Monckton of Brenchley [ 103 ]
  Christina Georgina Rossetti , British Victorian Poet [ 104 ]
 Cecil Spring-Rice , British Ambassador to the USA from 1912 to 1918 [ 105 ]
 Mary Webb , English author and poet, descendant of Sir Walter Scott [ 106 ]

[ edit ] Notes [ sunting ] Catatan

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[ edit ] See also