桥本氏甲状腺炎全知道

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王女士今年 46 岁,是出了名的乐天派,走到哪里都是笑声一片,奇怪的是,最近一段时间,她好像变了个人似的,不爱讲话,见人也爱理不理的,精气神大不如前,干什么都提不起兴趣,一天到晚还老想睡觉
家人怀疑她患上了抑郁症,于是带她去当地精神卫生中心就诊,医生给开了抗抑郁药物,吃了一段时间不仅没有任何效果,体重反而增加,且原本稳定的生理期也不稳定了,于是去上级医院就诊,最终确诊为「桥本甲状腺炎
桥本氏甲状腺炎全知道
患者的甲功检查结果
图源:作者提供
桥本甲状腺炎「慢性淋巴细胞性甲状腺炎」,是一种自身免疫性疾病,临床并不少见,而且偏爱女性,男女比例大约 1:10,但该病在早期,或毫无症状或症状并不典型,很容易被漏诊、误诊或者过度治疗。今天笔者就参考文献结合上述病例为大家系统梳理下「桥本甲状腺炎」的诊治。
桥本氏甲状腺炎
一看命名就知道和日本人有关,1912 年,一位叫桥本的医生,最先在德国医学杂志上发表了 4 例甲状腺疾病病例,为了纪念他,这个疾病被命名为「桥本甲状腺炎」。其病因,目前认为主要分为两大类:基因遗传和环境因素。
在一定遗传易感性的基础上,可能有多种基因参与甲状腺的自身免疫过程。除此之外,还有各种环境因素的参与,如高碘摄入可以诱发自身免疫性损伤,使甲状腺细胞被破坏,促进甲减的发生,其他的环境因素如硒缺乏、精神压力过大、怀孕、吸烟、感染、颈部过量辐射等也可能起到一定的作用。
临床表现及自然病程
大多数患者「75 ~ 80%」甲状腺常呈弥漫性、轻至中度肿大,质地坚韧、疼痛少见,偶尔可见轻度疼痛或触痛,而甲状腺功能正常;约 25% 的患者甲状腺萎缩而有明显的临床甲减或亚临床甲减。
桥本甲状腺炎一般发展缓慢、病程长,发病早期可没有任何症状,呈现明显的隐蔽性,其自然病程一般经历三个阶段,不同的阶段可有不同的症状表现。
▼ 开始阶段 —— 甲亢期
由于机体免疫功能下降或紊乱,甲状腺组织被自身抗体攻击,导致正常储存在甲状腺滤泡中的甲状腺激素释放入血液循环,造成一过性甲亢,可引起心慌、手抖、出汗、腹泻、易怒、烦躁和失眠等甲亢症状。
通常这个阶段时间较短,一般数周或数月内消失,也有很多人症状不明显,在不知不觉中就度过了这个短暂的阶段。
▼ 第二阶段 —— 稳定期
随着被破坏的甲状腺滤泡细胞内激素释放的减少,甲亢症状逐渐消失,进入第二阶段,此时甲状腺虽然仍遭受着持续的破坏,但还能勉力维持正常功能,即稳定期。这个阶段可能存在较长的时间,患者可能没有任何临床症状。
▼ 第三阶段 —— 甲减期
随着时间的推移,在甲状腺自身抗体的不断攻击之下,甲状腺组织不断遭到破坏,功能逐渐下降,最终当甲状腺无法维持正常功能时,就形成了甲减,即进入第三阶段,甲减期。此期患者会出现乏力、嗜睡、浮肿、腹胀便秘、情绪低落、体重增加等甲减的表现。
以往认为桥本甲状腺炎引起的甲减是终生性,但近年有证据显示,有些桥本甲状腺炎甲减也可以是暂时性的,有近 20% 的患者,在使用甲状腺素治疗期间可自行缓解。
如何诊断?
根据临床表现结合血清高滴度甲状腺自身抗体水平可对典型病例做出诊,但目前对桥本甲状腺炎的诊断标准尚未统一,大概包括下列 5 项指标:
(1).甲状腺弥漫性肿大,质坚韧,表面不平或有结节;
(2).TGAb、TPOAb 阳性;
(3).血 TSH 升高;
(4).甲状腺超声可见甲状腺弥漫性低回声;
(5).高氯酸钾排泌试验阳性。
以上 5 项中有 2 项者可拟诊为桥本甲状腺炎,具有 4 项者即可确诊。
对临床表现不典型者,需要有高滴度的抗甲状腺抗体方能诊断;对于查血清 TGAb、TPOAb 显著阳性的患者,应给予必要的影像学检查协诊;怀疑本病,但临床表现不典型,抗体滴度升高不显著者或者阴性者,必要时作细针穿刺细胞学检查或组织活检以确诊。
如何治疗?
桥本氏甲状腺炎没有特异性的治疗方法,多数患者不需要治疗,确诊后随访观察、对症治疗;根据其自然病程,不同阶段治疗措施不同,但主要是针对临床甲减使用激素替代治疗。
甲亢期
甲亢期一般不需治疗。
只有当症状特别明显时,才需要服用药物。常用药物是 β-受体阻滞剂(如普萘洛尔),可以改善心慌、手抖的症状,一般不主张使用抗甲状腺药物。
▼ 注意
临床上部分患者可伴发 Graves 病,即甲状腺同时有桥本甲状腺炎和 Graves 病的组织学改变,称作桥本甲亢,其甲亢的临床表现、体征及实验室检查特点和单纯 Graves 病一样。
此类患者的甲亢状态常需要抗甲状腺药物治疗,但剂量不宜过大,疗程要适当缩短,注意药物性甲减的发生,如果出现甲状腺肿大,需要加用甲状腺素,手术切除或放射性核素治疗均不适宜,易发生永久性甲减。
稳定期
稳定期一般也不需要治疗。
这个阶段只有甲状腺自身抗体升高,甲状腺功能是正常的,而我们治疗的目的恢复甲状腺功能,而不是让抗体转阴,但如果合并甲状腺肿大,也可适当服用优甲乐,将 TSH 抑制在 2.5 mU/L 以下,可减轻压迫感。
甲减期
需要服用甲状腺素替代治疗,一般需要终生服药。
治疗时应每 4 ~ 6 周监测 1 次 TSH 水平,根据结果逐渐调整药物剂量。治疗目标以临床症状基本缓解,T₃、T₄ 在正常范围,TSH 降至接近正常值低限(0.2 ~ 2.0 mU/L)为宜,达到目标剂量后,维持治疗期应 6 ~ 12 个月复查 1 次甲状腺功能。
▼ 注意
(1).药物从小剂量开始逐渐增加剂量,达到有效剂量后长期维持。
(2).老年人,尤其是伴有心血管疾病者,应从更小剂量开始治疗。
(3).妊娠期桥本甲减患者甲状腺素剂量应增加 25% ~ 30%
部分患者可能表现为亚临床甲减(TSH 升高,T₃、T₄ 正常),其治疗与甲减治疗相同,剂量宜偏小。另外有甲状腺肿大显著、压迫症状重,或经内科治疗后甲状腺肿大仍明显者,可以考虑外科手术切除,但应当注意患者教育 —— 手术后往往发生甲减,仍需要甲状腺激素长期替代治疗。
患者饮食禁忌?
碘是合成甲状腺激素的重要原料,但不代表甲减患者应高碘饮食,甲减患者是否需要补碘需要根据甲减的病因而区别对待:
如果甲减是由于单纯缺碘引起的(如地方性甲状腺肿),则可适当补碘;但对于桥本氏甲状腺炎患者来说,高碘饮食会增加甲状腺过氧化酶抗体(TPOAb)的浓度,诱发并加重自身免疫性甲状腺炎,所以在饮食方面桥本氏甲状腺炎需要限制碘饮食,少食用海带、紫菜等高碘食物。
如何避免漏诊误诊?
由于桥本起病缓慢、症状表现多种多样而且缺乏特异性,因此,很容易被漏诊或误诊。
例如,甲亢期常因怕热、出汗、手抖、心慌、情绪激动、甲状腺弥漫性肿大被误诊为「Graves 病」;甲减期因少言寡语、情绪低落被误诊为「抑郁症」,因心动过缓、心包积液被误诊为「冠心病」,因反应迟钝、记忆力减退、嗜睡被认为是老年痴呆症等等。
因此,临床上,当患者出现以下症状时,一定要检查下甲状腺功能(包括甲状腺自身抗体):
(1).中青年女性,甲状腺轻度弥漫性肿大、质地韧
(2).一过性怕热、出汗、手抖,心慌、情绪激动;
(3).怕冷、疲劳、精力不济;
(4).记忆力下降、反应迟纯、少言寡语、情绪低落;
(5).不明原因体重增加;
(6).厌食、腹胀、便秘;
(7).皮肤干燥、粗糙、指甲变脆;
(8).全身肌肉庝痛、四肢无力;
(9).不明原因全身浮肿、皮肤发黄;
(10).女性月经不调、不育,男性性欲减退、阳痿。
小结
桥本氏甲状腺炎有发展为甲状腺功能减退的趋势,但演变过程非常缓慢,对于已经发展为甲减的患者,目前也有很好的药物替代方案,其治疗并不复杂,一般来说预后比较好,虽然有发生甲状腺癌的可能性及淋巴瘤的危险倾向,但很少见。
本病重点在于能及时发现,及时诊断,若已经明确诊断,要定期复查甲功及超声,及时发现甲减,尽早开始甲状腺素药物替代治疗,避免长期甲减而引起的各种严重并发症。
参考资料:
[1] 张木勋 吴亚群 甲状腺疾病诊断学 [M]. 北京 中国医药科技出版社,2005:256-261.
[2] 中华医学会内分泌学分会《中国甲状腺疾病诊治指南》编写组. 中国甲状腺疾病诊治指南:甲状腺炎. 中华内科杂志, 2008, 47(9): 784-786.
[3] 高莹,刘明明,修瑞娟. 桥本甲状腺炎的免疫学发病机制进展. 内科理论与实践, 2013, 8(6): 392-396.
[4] 熊晓玲, 汪虹, 邵迎新. 桥本甲状腺炎的治疗策略 [J]. 基层医学论坛,2018,22(13):1833-1834.
[5] 刘丽华, 吴斯淳, 李晓静. 桥本甲状腺炎患者血清甲状腺过氧化物酶抗体和甲状腺球蛋白抗体表达水平及诊断意义 [J]. 实用医院临床杂志,2020,17(06):175-178.
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甲状腺消散结节药大脖子甲亢肿大桥本炎异物感囊肿外用穴位专用膏 券后价¥53 天猫 优惠券¥5 立即领券
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