Lecture 5 - Hyperthyroidism, thyrotoxicosis,

thhyrotoxicosis

thhyrotoxicosis

syndrome associated w/ tissue exposure to increased level HT + acceleration of metabolism

etiologies hyperthyroidism

• graves

• toxic thyroid adenoma

• toxic polynodular goiter

• hcg induced hyperthyroidism - transient gestational or trophoblastic (hydatidiform mole)

• iodine-induced

• struma ovarii

• hyperfxnal metastatic follicular thyroid carcinoma

• tsh secreting pituitary adenoma

• ht resistance syndrome

• hereditary nonautoimmune hyperthyroidism

excess exogenous HT is due to

th overdose, factitious thyroiditis, hamburger thyroiditis

BGD

autoimmune disease in karens, presenting as thyrotoxicosis, ophthalmopathy, goiter and dermopathy

pathogenesis bdg

tshr-abs formed from infection, stress, smoking, postpartum or excess iodine

symptoms bgd

nervous, sweating, thermophobia, palpitations, weight loss

clinical manifestations bgd depending on age

young - nervous, hyperkinetic cardiac syndrome

kids - accelerated growth

>60 - cardiovasc manifestations, myopathy

physical exam bgd

warm moist + velvety skin, brittle hair, onycholysis, vitiligo, orange peel dermopathy, Jellinek sign (eyelid hyperpigmentation)

cardiovasc exam bgd

increased CO, vasodilation, systolic htn, widened pulse p, increased HR

resp exam bgd

dyspnea, asthenia of resp m, exarcerbation asthma

digestive exam bgd

weight loss, malabsorption, more bowel movements, hyperphagia

genitourinary exam bgd

polyuria, nocturia, nocturnal enuresis in kids, oligomenorrhea, gynecomastia

osteo-articular exam bgd

scapulohumeral periarthritis, osteoporosis, acropachy

neurom exam bgd

behaviour changes, vivid reflexes, upper limb tremor

ocular signs bgd

dalrymple sign (eyelid retraction), Graefe’s sign (oculo-palpebral asynchrony), stellwag sign (infrequent blinking)

graves endocrine ophthalmopathy

tsh-r ab → hypertrophy ocular m + increase retrobulbar tissue v

risk factors for graves ophthalmology

genetic, female, smoking, radioiodine

clinical manifestations graves ophthalmology

foreign body sensation, tearing, sensation intraocular p, eyelid edema + exophthalmia

NO SPECS classification

0. no

1. hypersympatheticotonia

2. soft tissue involvement

3. proptosis

4. extraocular m involvement

5. corneal involvement

6. sight loss

activity score for graves ophthalmopathy

1. eyelid edema

2. palpebral erythema

3. conjunctival erythema

4. chemosis

5. caruncula

6. orbital pain

7. pain on forced gaze

labs graves

in late stages - tsh low, ft4+3 increased values

tshr ab +

glucose high, normo anemia

radiography graves

enlarged thyroid, hypoechoic thyroid w/ pseudonodular areas

chronic condition BBG evolution

periods of activity and remission

thyrotoxic crisis

most severe acute complication of graves

chronic complications in long-term hypertyroidism

cachexia, osteoporosis, cardiomyopathy, HF, cardiothyroidism (rhythm disorders + embolic risk)

treatment BGD

ATD drugs

radioiodine therapy

surgical ablation

b blockers

other drugs for bgd

synthetic antithyroid drugs

methimazole

PTU - in pregnant and lactating

adverse effects synthetic antithyroid drugs

skin rashes, vasculitis, hep if PTU, cholestasis if methimazole

how is euthyroidism obtained in bgd

adjusting doses of ATD + introducing LT4

when should you stop treatment w/ ATD and admninister glucocorticoids in a bgd patient

neutrophils decrease

when to give iodine in a bgd patient

in association w/ ATD

when to give sodium ipodate in bgd patient

thyrotoxic crisis or preop

side effects of treatment with radioactive iodine inpatient with bgd

radiation thyroiditis, exacerbation ophthalmopathy

COs to RIT

pregnancy + breastfeeding

when is surgery indicated in bgd

big obstructive goiter, suspicion thyroid carcinoma, CO ATD or RIT, pregnant + allergic to ATD

how to treat endocrine ophthalmopathy

normalize thyroid fxn, glucocorticoids from std III

if progresses - retrobulbar irradiation or surgery

toxic thyroid adenoma

solitary hyperfxnal nodule from mutations in R-TSH gene or protein G gene or iodine deficiency/GFs, in karens

clinical manifestations toxic thyroid adenoma

cardiovasc manifestations

labs toxic thyroid adenoma

low tsh, high ft4+3, high RIU

radio toxic thyroid adenoma

hypoechoic nodule, ± central cystic degeneration

treatment toxic thyroid adenoma

RIT administration, surgical ablation, percutaneous intranodal injection ethanol

ATD as prep or post RIT

toxic multinodular goiter

form hyperthyroidism, grandmas w/ old multinodular goiter after exposure increased amount iodine

clinical manifestations toxic multinodular goiter

mild thyrotoxicosis, tachy + AF, m asthenia

thyroid firm + irregular + big on palpation, compressive phenomena

labs toxic multinodular goiter

mild hyperthyroidism

treatment toxic multinodular goiter

admnistration RIT, surgical ablation + preop ATD

TSH secreting pituitary adenoma - manifestations

thyrotoxic syndrome

pituitary tumour syndrome + visual field changes

menstrual cycle disorders

TSH secreting pituitary adenoma labs

increased thyroid hormones, tsh

macroadenoma on imaging

treatment tsh secreting pituitary adenoma

surgery OR dopaminergic agonists

octreotide

iodine-induced hyperthyroidism

admnistration iodine in ppl w/ endemic goiter or autoimmune thyroid patho = Jod-Basedow

in elderly (polynodular goiters) or young (diffuse, + tsh-r atb)

ppl with increased risk hyperthyroidism (polynodular goiter or history hyperthyroidism, autoimme), what can be given as prevention when they’re given high iodine drugs

k perchlorate, methimazole

amiodarone can induce

hypothyroidism

thyrotoxicosis - type 1 (Jod-Basedow effect in iodine deficient regions), type 2 (thyroiditis w/ TH release from thyroid destruction)

imaging amiodarine induced thyrotoxicosis

1. vasc increased, enlarged thyroid

2. vasc absent, reduced thyroid

treatment amiodarine induced thyrotoxicosis

1. methamizole + K+ perchlorate

2. prednisone

surgery if drugs don’t workQu

Quervain’s thyroiditis

acute inflammation of thyroid parenchyma → thyrotoxicosis, from virus, HLA B35

clinical manifestations Quervain’s thyroidits

fever, increase thyroid v, pain spontaneously + @ palpation and irradiation, signs thyrotoxicosis (sweat, palpitations, nervous)

lab quervains thyroiditis

inflammatory values raised (fibrinogen, crp, esr), leukopenia, low tsh, high ft4+3, low RIU

hypoechogenic us

treatment quervain’s thyroiditis

nsaids

no improvement - corticotherapy

b blockers + sedatives for thyrotoxicosis

acute infectious thyroditis is due to

immunosuppressed patient by hema dissemination, local signs inflammation

risks of hyperthyroidism in pregnancy

abortions, preeclampsia, premature, neonatal mortality

hCG mediated hyperthyroidism in pregnancy

transient gestational thyrotoxicosis w/ subclinical hyperthyroidism

hyperemesis gravidarum

trophoblastic hyperthyroidism

treatment in forms of hyperthryoidism in pregnancy but not mediated by hcg

b blockers, ATD

persistent neonatal hyperthyroidism

activating mutations of tsh receptor, mccune albright syndrome

manifestations fetal hyperthyroidism

fast hr

manifestations neonatal hyperthyroidism

low weight, tachycardia, irritable, goiter

treatment neonatal hyperthyroidism

methimazole, propanolol, steroids + iodine if severe → surgery

late complications neonatal hyperthyroidism

craniosynostosis, growth retardation, behavioural disorders

thyrotoxic crisis manifestations

tachy, afib, hf, hyperpyrexia

treatment thyrotoxic crisis

hydrovolemic + cardiovasc rebalancing, propanolol, MTU or PTU, after ATD → lugol, lithium carbonate, steroids, sedatives

if no improvement - plasmapheresis, surgery