MGR 다양한 임상양상을 보이는 갑상선 중독증 3 례 R2 변종규 R4 손정일/ Prof . 전 숙

CASE #1

History 11982601 권○은 (F/34) 외래 초진 2008.6.27 Chief Complaint Rt. neck pain O/S) 2개월 전 Present illness 34/F, 2008년 1월 열 감 있고 목 주위 압통 지속되어 외부에서 subacute thyroiditis 의심 하에 prednisone (20mg 4주 이상) 사용 후 tapering 하였던 자로 최근 경부종물 크기 증가하고 압통 동반되어 추가적 검사 위해 외래 방문함.

History Alcohol (-) Smoking (-) None Past Medical History HTN (-) DM(-) Hepatitis(-) Pulmonary TB(-) Operation Hx(-) Personal History Alcohol (-) Smoking (-) Family History None

Review of System General generalized weakness(+) , fatigue (+) Fever(-) Chill(-) Wt loss (-) Skin Rash(-) Pigmentation(-) Itching(-) H&N Headache(-) Sore throat (+) Neck pain (+) Resp. Cough(-) Sputum(-) Dyspnea(-) Cardiac Chest pain(-) Orthopnea(-) Palpitation(-) G-I Anorexia(-) Nausea(-) Vomiting(-) Abdominal pain(-)

CASE #2

History 11821926 정○아 (F/20) 외래 초진 2006.2.27 Chief Complaint Fatigue, palpitation o/s) 3~4 개월 전 Present illness 20/F 천식, 아토피 피부염 병력 있는 자로 3~4개월 전부터 목 주변에 이물 감 느껴지며 피로감, 빈 맥 증상 지속되어 local 방문 후 큰 병원 진료 권유 받고 추가 검사 위해 외래 방문함.

History Alcohol (-) Smoking (-) None Past Medical History HTN (-) DM(-) Hepatitis(-) Pulmonary TB(-) Asthma : medication 하지 않음 Atopic dermatitis : local 피부과에서 상세 불명의 약 복용 중 Personal History Alcohol (-) Smoking (-) Family History None

Review of System General generalized weakness(-) Fever(-) Fatigue(+) Wt loss (-) Skin Rash(-) Pigmentation(-) Itching(-) H&N Headache(+) Sore throat(-) Lid retraction (+) Resp. Cough(-) Sputum(-) Dyspnea(-) Cardiac Chest pain(-) Orthopnea(-) Palpitation(+) G-I Anorexia(-) Nausea(-) Vomiting(-) Abdominal pain(-)

CASE #3

History 12253896 오○락 (M/56) 외래 초진 2012.2.17 Chief Complaint Neck pain o/s) 한달 전 Present illness 56/M, 고혈압 병력 있는 자로 한 달 전부터 경부 통증, 발한, 오한, 열 감 있어 본원 이비인후과 외래 방문, ibuprofen 투여 후 증세 호전되었으나 목 부위 통증 지속되어 추가 검사 위해 내분비내과 외래 방문함.

History Alcohol (+) 소주 1.5 병. 1~2회/주 Past Medical History HTN (+) DM(-) Hepatitis(-) Pulmonary TB(-) HTN : 4년 전. Po med Amlodipine 5mg qd. Bisoprolol 2.5mg qd Candesartan 8mg qd , Aspirin 100mg qd ENT 외래 : Ibuprofen 400mg 2T Tid, Mucosta 1T Tid Personal History Alcohol (+) 소주 1.5 병. 1~2회/주 Smoking (-) ex-smoker : 15년 전 금연, 30 갑년 Family History 어머니 : gastric cancer 여동생 : breast cancer

Review of System General generalized weakness(-) Sweating , Chilling , febrile sensation : ENT 약 복용 후 호전 Wt loss (+) : 1달 반 사이 2kg 감소 Skin Rash(-) Pigmentation(-) Itching(-) H&N Headache(-) Sore throat(+) Rt. neck pain (+) Resp. Cough(+) Sputum(-) Dyspnea(+) Cardiac Chest pain(-) Orthopnea(-) Palpitation(-) G-I Anorexia(-) Nausea(-) Vomiting(-) Abdominal pain(-)

CASE #1 Problem List #1. Neck pain & tenderness #2 . Previous URI Hx #3. Known Rt. thyroid nodule Subacute thyroiditis Goiter (simple or multinodular) CASE #2 Problem List #1. Thyroid enlargement #2 . Palpitation #3. Lid retraction Graves’ disease

CASE #3 Problem List #1. sore throat, sweating, chilling, febrile sensation #2. dyspnea #3. Rt. neck pain # URI # Acute tonsilitis , peritonsillar abscess # Subacute thyroiditis : transient thyrotoxic phase

Thyrotoxicosis evaluation Physical examination Thyroid function test Neck Sono & FNA Thyroid scan , RAIU

Differential Diagnosis of Thyrotoxicosis Thyroid scan(RAIU)

Physical Examination V/S 109/79mmHg 53kg Case 1 (F/34, C.C : neck pain) Physical Examination V/S 109/79mmHg 53kg Neck swelling(+), Rt neck Tenderness(+) Regular heart beat without murmur No opthalmopathy : proptosis(-) lid retraction(-) periorbital edema(-)

Lab. Findings Case 1 CBC/DC 12600 /mm3 – 12 g/dL - 35% -287K /mm3 (Seg. 74%) Chemistry TB 0.64 mg/dL Prot/ Alb 7.2/4.2 g/dL AST/ ALT 13/12 U/L ALP /GGT 57/14 U/L BUN/ Cr 16/0.7 mg/dL Glucose 83 mg/dL T-chol 177 mg/dL TSH Binding Inhibiting(= Inhibition) Immunoglobulin T3(S) 80 ~ 200 ng/dL T4(S) 4.5 ~ 12 ㎍/dl TSH(S) 0.30 ~ 4.00 μU/mL Free-T4(S) 0.77 ~ 1.94 ng/dL Thyroglobuline(S) 0 ~ 50 ng/dl

Case 1

Subclinical hyperthyroidism Case 1 Thyroid Function Test Reference Range T3 105 ng/dL 77~135 fT4 1.27 ng/dL 0.7~1.94 TSH 0.28 μU/mL 0.3~4.2 TG 0.7 ng/dL 1.3~31.8 TBII 0.1 % <15% Subclinical hyperthyroidism

Case 1 2008-7-3 Thyroid scan Rt. lobe mid portion에 hot nodule lesion 관찰됨. 양측 lobes의 크기는 정상이며, 균일한 trapping 양상 보임. Tc-99m pertechnetate 섭취율 (20분) = 2.4 % (Normal range: 1-4%)

Differential Diagnosis of Thyrotoxicosis Case 1 Differential Diagnosis of Thyrotoxicosis Thyroid scan(RAIU)

Case 1 Final diagnosis Thyroid toxic adenoma

Physical Examination Case 2(F/20, C.C : Fatigue, Palpitation) Neck swelling(+) Tenderness(-) lid retraction : not definite lid lag (+), proptosis(+) lagophthalmus : 2mm Rapid heart beat without murmur

Lab. Findings 7090 /mm3 – 13.4 g/dL 42% -315K /mm3 (Seg. 55%) Case 2 CBC/DC 7090 /mm3 – 13.4 g/dL 42% -315K /mm3 (Seg. 55%) Chemistry TB / DB 0.64/0.17mg/dL Prot/ Alb 7.3/3.9 g/dL AST/ ALT 31/39 U/L ALP /GGT 115/25 U/L BUN/ Cr 9/0.3 mg/dL Na/ K/ Cl 137/4.6/102 mmol/L Ca/P 9.3/5.2 mg/dL T-chol 168 mg/dL glucose 106 mg/dL 82UA T3(S) 80~200 ng/dl 218 82UC FT4(S) 0.77~1.94 ng/dl 2.75 82UE TG-Ab(S) <100 IU/ml <50 82UJ TMS(S) <8 ug/ml >7500 82UM TG(S) <50 ng/ml 0.9 82US TBII(S) <10 % 69.0 83VH TSH(S) 0.3~4.0 -u/ml 0.18 TMS : microsomal ab

Thyroid Function Test Case 1 Reference Range T3 218 ng/dL 77~135 fT4 0.7~1.94 TSH 0.18 μU/mL 0.3~4.2 TG 0.9 ng/dL 1.3~31.8 TG-Ab 0.9 IU/ml <50 TBII 69 % <10~15 Overt thyrotoxicosis

2006-6-15 Thyroid scan 2hr RAIU: 55.5% 24rh RAIU : 73.1% I-131 thyroid scintigraphy 판독소견 ] 크기 및 위치: Both thyroid glands가 미만성으로 커져 있음. 방사능 분포양상: even 갑상선 섭취율 (Radioactive iodine uptakes) 2hr = 55.5 %, 24hr = 73.1 % Cold or hot area: none Diffuse enlargement of both lobes with increased RAIU. 2hr RAIU: 55.5% 24rh RAIU : 73.1%

Differential Diagnosis of Thyrotoxicosis Case 2 Differential Diagnosis of Thyrotoxicosis

Case 2 Final diagnosis Graves’ disease

Physical Examination Case 3(M/56, C.C : neck pain) V/S 105/70mmHg PR 68 Wt 67.7kg Head & Neck neck pain(+) tenderness(+) neck swelling (+)

Case 3 Lab. Findings CBC/DC 6680/mm3 – 11.7 g/dL - 35.6% - 409K /mm3 (Seg. 63%) Chemistry TB 0.28mg/dL Prot/ Alb 7.5/4.0 g/dL AST/ ALT 25/25 U/L ALP /GGT 115/43 U/L Cr 0.6mg/dL Na/ K/ Cl 141/3.7/99mmol/L Ca 8.8 mg/dL CRP 4.67 mg/dL T-chol 105mg/dL ESR 99 mm/hr glucose 117 mg/dL 82UA T3(S) 80~200 ng/dl 218 82UC FT4(S) 0.77~1.94 ng/dl 2.75 82UE TG-Ab(S) <100 IU/ml <50 82UJ TMS(S) <8 ug/ml >7500 82UM TG(S) <50 ng/ml 0.9 82US TBII(S) <10 % 69.0 83VH TSH(S) 0.3~4.0 -u/ml 0.18 TMS : microsomal ab

Thyroid Function Test Case 3 Reference Range T3 191 ng/dL 77~135 fT4 0.7~1.94 TSH 0.02 μU/mL 0.3~4.2 TG-Ab 89.7 U/mL 0~60 TMS 1015 U/mL 0~8 TBII 0.1 <15% Overt thyrotoxicosis

2012-2-21 Thyroid scan Tc-99m pertechnetate thyroid scintigraphy 크기 및 위치: Both thyroid glands의 방사능 섭취가 관찰되지 않음. 갑상선 섭취율 (20min) : 1.7 % Nonvisualization of both thyroid glands.

Differential Diagnosis of Thyrotoxicosis Case 3 Differential Diagnosis of Thyrotoxicosis Thyroid scan(RAIU) URI Hx. Neck tenderness Thyroid inflammation

Case 3 Final diagnosis Subacute thyroiditis