Thyroid and Parathyroid

gland is hyperplastic, and the epithelium is columnar, with minimal colloid present.
The nuclei exhibit mitosis, and papillary projections of hyperplastic epithelium are
common. There may be aggregates of lymphoid tissue, and vascularity is markedly
. increased
Clinical Features Common to All Forms of Thyrotoxicosis
The clinical symptoms and signs of thyrotoxicosis are the same in patients with
Graves' disease and toxic nodular goiter, except that patients with Graves' disease
usually have more severe hyperthyroidism and have extrathyroidal manifestations of
disease. Attention should be paid to a family history of autoimmune thyroid disease,
. including Graves' disease, Hashimoto's thyroiditis, and other autoimmune disorders
Manifestation of the increased caloric turnover may be evident. Patients develop heat
intolerance, increased thirst, sweating, and weight loss despite adequate caloric intake.
Women may develop amenorrhea and decreased fertility and have an increased
incidence of miscarriage. Cardiovascular manifestations are tachycardia or atrial
fibrillation. In cases in which high-output cardiac failure ensues, signs and symptoms
of congestive cardiac failure such as dyspnea and peripheral edema or even anasarca
may become evident. Adrenergic stimuli may be particularly distressing, and fatigue,
agitation and excitability, disturbed sleep pattern, emotional lability, hyperkinesis, and
tremor may be present. In marked cases, psychosis can develop. Diarrhea or increased
bowel frequency are the most common gastrointestinal manifestations and run an
. intermittent course during the disease
On physical examination, weight loss and facial flushing may be evident. The skin
may be warm and moist, and patients often have inappropriate sweating in a cool
environment. African-American patients often note darkening of their skin.
Examination of the pulse usually reveals tachycardia or atrial fibrillation (the latter is
especially apparent in the elderly). Cutaneous vasodilation leads to a widening of the
pulse pressure and a rapid falloff in the transmitted pulse wave (collapsing pulse). A
fine tremor, muscle wasting, and proximal muscle group weakness with hyperactive
. tendon reflexes often are present
Clinical Features Specific to Graves' Disease
Graves' disease is characterized by the classic triad of goiter, thyrotoxicosis, and
exophthalmos. These features may occur singularly or in any combination.
Additionally, patients present with a goiter that is characteristically diffuse, enlarged,
and smooth. Evidence that the whole gland is enlarged is demonstrated by
enlargement of the pyramidal lobe, which can be palpated as it crosses the cricoid
cartilage (Fig. 36-12). Patients with Graves' disease also may have onycholysis or
thyroid acropathy, hair loss, pretibial myxedema (3 to 5 percent) (Fig. 36-13), and
gynecomastia (3 to 5 percent). An audible bruit resulting from markedly increased
vascularity of the gland can be heard over the gland in up to 50 percent of patients.
. Splenomegaly also may be present
Exophthalmos may be present in association with thyrotoxicosis (Graves'
ophthalmopathy) or as an isolated condition with no evidence of thyrotoxicosis
(euthyroidal or ophthalmic Graves' disease). The condition is characterized by: (1)
spasm of the upper eyelid, with retraction revealing the sclera above the corneoscleral
limbus (Dalrymple's sign) and lid lag (von Graefe's sign); (2) external