Hyperthyroidism

hyperthyroidism

An overactive thyroid gland producing excess thyroid hormone (T3 and T4)

Women (5x), genetics/family Hx, Age (Graves 20-40, toxic MNG 55), smoking

Risk factors for hyperthyroidism

Graves

What type of hyperthyroidism is more common in younger women?

toxic multinodular goiter

What type of hyperthyroidism is more common in older women?

primary hyperthyroidism

High T3/T4 levels suppress TRH and TSH production, but the thyroid continues to produce hormones due to autonomous or autoimmune mechanism

Secondary hyperthyroidism (Get a MRI)

Pituitary gland (adenoma) produces lots of TSH so the thyroid continues to produce extra T3/T4

Subacute thyroiditis

Inflammation of the thyroid causes leakage of T3/T4 into circulation and increases hormone levels transiently - TSH should decrease as a response

Autoimmune - Thyroid-stimulation immunoglobulins (TSI) mimic TSH

Pathophys for Graves’ - most common cause of hyperthyroidism

Weight loss, tachy, heat intolerance, exophtalmos (bug eyes), pretibial myxedema

Features of graves

TSH, free T4/T3, maybe TSIs

45 y/o women presents to the clinic for palpitations and heat intolerance. She also notes weight loss despite eating more calories. On your physical exam you note tremors, a goiter, bulging eyes, and pretibial myxedema. You also see a positive Daryample sign, Kocher sign, and von Graefe sign. What labs do you want to order?

PACs, sinus tach, exertional dyspnea, increased CO, atrial fib, development of CHF

What changes might you see on an EKG due to hyperthyroidism?

RAUI (diffuse for graves, sporadic for toxic multinodular goiter, decreased for thyroiditis), U/S (may show diffuse enlargement)

What are some imaging modalities you can use for hyperthyroidism?

Methimazole (start here - preferred), propanolol for the cardiac symptoms

45 y/o women presents to the clinic for palpitations and heat intolerance. She also notes weight loss despite eating more calories. On your physical exam you note tremors, a goiter, bulging eyes, and pretibial myxedema. You also see a positive Daryample sign, Kocher sign, and von Graefe sign. TSH is low, Free T4 is high, and TSIs are elevated. What is our game plan team?

RAI therapy, Surgical treatment

What are the definitive treatments of Grave’s disease?

Medications are not working or are C/I

Indications for RAI or surgery with Grave’s

PTU for the 1st trimester

45 y/o women presents to the clinic for palpitations and heat intolerance. She also notes weight loss despite eating more calories. On your physical exam you note tremors, a goiter, bulging eyes, and pretibial myxedema. You also see a positive Daryample sign, Kocher sign, and von Graefe sign. TSH is low, Free T4 is high, and TSIs are elevated. She is currently 6 weeks pregnant, what is our game plan team?

elevated TSIs, diffuse RAIU

What are some ways we can confirm our diagnosis of Graves?

0.5 - 5.0 mIU/L

TSH reference range

0.9-2.3 ng/dL

Free T4 reference range