Associated Graves' Disease and Plummer's Disease

From the clinical point of view, hyperthyroidism is generally presented as diffuse hyperactivity of thyroid tissue induced by autoimmune stimulation (Graves’ disease), or as the consequence of one, or more hyperactive autonomous nodules (Plummer’s disease). These two entities are relatively perceivable in clinical routine. Thyroid scintigraphy of the patient with Graves’ disease, presents a pattern of a diffusely enlarged gland with homogenous distribution of radioactive tracer. In Plummer’s disease, one nodule (“toxic adenoma”) or rarely few nodules (toxic nodular goiter), are presented as scintigraphicaly “hot” nodules with complete suppression of paranodular tissue. Occasionally, some scintigraphic findings that could not be so simplified are registrated. Thyroid glands of some patients with Graves' disease present nodules that can accumulate radioactive tracer of the comparable intensity to paranodular tissue (warm nodules). This occurence of the functioning adenoma in Graves' disease has been named by Charks (1,2) » Marine-Lenhart syndrome«. Rational assumption of coexistent presence of Graves' disease and Plummer's disease is comprehensible. It is difficult to confirm such association, since both hyperfunctioning autonomous nodules and stimulated paranodular tissue accumulate radioactive tracer intensively. Nevertheless, consequent melioration of Graves’ disease may unveil presence of hyperfunctioning autonomus nodules (toxic adenoma). Successive appearance of Graves’ disease and Plummer’s disease is diagnostically simple and some cases have been reported (3,4,5,6,7). Differential diagnosis of some untypical scintigraphic findings of non-immune hyperthyroidism could also be presented as a problem. Diffuse toxic goiter does not always have pathological substrate of Graves’ disease. Occasionally, hyperactive autonomous follicles are dispersed throughout the gland – disseminated thyroid autonomy (8), and sometimes in addition to visible hyperfunctioning nodule (toxic adenoma), a part of autonomous paranodular tissue is also presented (9). The aim of this study was to assort those cases of a distinct hyperthyroidism with neither clearly diffuse, nor focal scintigraphic findings, and to establish associated presence of Graves’ disease and Plummers’ disease with the special focus.