What is hyperthyroidism
Increased secretion of thyroid hormones
In what sex is hyperthyroidism more common
Ten times more common in women than men
What is the most common cause of hyperthyroidism
Graves disease (80%–90% of U.S. cases)
What are some other causes of hyperthyroidism
Plummer disease (toxic adenoma); toxic multinodular goiter; subacute thyroiditis; amiodarone therapy
What are some of the signs and symptoms of hyperthyroidism
Heat intolerance, weight loss, exophthalmos , tachycardia , anxiety, palpitations, atrial fibrillation, tremor, sweating, fatigue ,weakness , diarrhea, increased reflex amplitude
What is Graves disease
Autoimmune disease causing hyperthyroidism. It is due to antibody stimulation of TSH receptors causing excess secretion of free thyroid hormone.
What are the two symptoms only seen in Graves disease
1. Pretibial myxedema
2. Infiltrative ophthalmopathy
What is pretibial myxedema
Pruritic, non pitting edema found on shins that usually remits spontaneously
What is infiltrative ophthalmopathy
Exophthalmos that may not resolve despite treatment of Graves disease most likely due to
autoimmune damage in extraocular muscles
How is Graves disease diagnosed
All hyperthyroidism is diagnosed via measurement of TSH, free T4, and free T3. In Graves disease, since there is excess stimulation of the thyroid gland causing increased production of thyroid hormone, laboratory tests show high levels of free T4 and free T3, and low levels of TSH (because of negative feedback) Also, a radioactive iodine uptake scan should be done. If uptake is low, then thyroiditis or medication-induced hyperthyroidism is considered.
What is another name for toxic multinodular goiter
Plummer’s disease
What is the underlying cause of hyperthyroidism in Plummer disease
Multiple thyroid nodules develop autonomous T4 secretion and, therefore, more T4 is released.
How is Plummer disease diagnosed
Radioactive iodine uptake tests show “hot” nodules with the rest of the gland being “cold”;also, clinically ,nodules can sometimes be felt.
What is another name for subacute thyroiditis
de Quervain thyroiditis
What are the signs and symptoms of subacute thyroiditis
Prodrome of viral urinary tract infection (UTI) followed by rapid onset of thyroid swelling and tenderness as well as hyperthyroid symptoms that can later turn into a hypothyroid state.
What is the treatment for de Quervain thyroiditis
Usually self-limiting, but asprin and corticosteroids may be indicated to control inflammation
What are the treatment options for a hyperthyroid state
1. Medication: propylthiouracil (PTU) or methimazole
2. Radioactive iodine ablation
3. Surgery: subtotal thyroidectomy
What is the first-line treatment for Graves disease
Radioactive iodine ablation
What is radioactive iodine ablation
Radioactive iodine is concentrated in the gland and destroys tissue
What are the possible side effects of radioactive iodine ablation?
Hypothyroidism; thyrotoxic crisis secondary to the release of thyroid hormone into the blood stream
What is the mechanism by which PTU works
It inhibits the peripheral conversion of T4 to T3, decreases iodine uptake, decreases T4 synthesis
Do patients need to be on therapy for the rest of their lives
No. After a 1–2 year course of treatment about 50% no longer need to be treated.
What is the potential side effects of PTU?
Leukopenia, rash, nausea
What other adjunctive treatment is given to patients with hyperthyroidism
Beta-blocker,usually propranolol, to control symptoms
What is the most serious complication of hyperthyroidism?
Thyroid storm
What can induce thyroid storm
Infection, surgery, trauma, abrupt stop of antithyroid medication, serious acute medical problems such as cerebrovascular accident or myocardial infarction
What are the signs and symptoms of thyroid storm
Exaggerated symptoms of hyperthyroidism are tachycardia, high outputcongestive heart failure (CHF), abdominal pain, fever, altered mental status (ultimately coma)
What is the mortality rate of thyroid storm
Up to 50%
What is the initial treatment for thyroid storm?
It is an emergency so think of the ABCs:
Airway stabilization
Breathing/oxygen administration
Circulation (check pulse/blood pressure [BP]) and start IV fluids
After primary stabilization of the patient, what is the medical management of thyroid storm
Beta-blocker, PTU, or methimazole. Tylenol for fever, cold iodine about 2 hours after PTU, and glucocorticoids.
What are the signs and symptoms of hypothyroidism?
Cold intolerance, fatigue, lethargy, weakness , constipation, weight gain, arthralgias, hoarse voice, skin is dry, coarse, and with nonpitting edema, loss of outer third of eyebrows, delayed relaxation phase of deep tendon reflexes
What is primary hypothyroidism
Thyroid gland dysfunction
What are some examples of primary hypothyroidism
Hashimoto thyroiditis, thyroid ablation or neck radiation therapy in the past, subacute thyroiditis, iodine excess or deficiency, medication-induced
What medication can cause hypothyroidism
Lithium
What is the most sensitive lab test for primary hypothyroidism
Elevated TSH
What other lab results are present in primary hypothyroidism
Low T3 and T4
What is Hashimoto thyroiditis
Painlesschronic autoimmune thyroid inflammation of autoimmune etiology
What laboratory results can help diagnose Hashimoto thyroiditis
Elevated antithyroglobulin and antimicrosomal antibody titers
What is subacute thyroiditis
Tender,enlarged thyroid; often post-viral infection can begin with hyperthyroid symptoms, then hypothyroid symptoms
How can you distinguish Hashimoto from subacute thyroiditis
On clinical examination, in Hashimoto the thyroid gland isnot tender to palpation but in subacute thyroiditis it istender to palpation.
How can Graves disease and increased Hashimoto’s thyroiditis be distinguished
Radioactive iodine uptake is with Graves and decreased with Hashimoto.
What is secondary hypothyroidism
Hypothyroidism caused by pituitary dysfunction
What are some examples of secondary hypothyroidism
Sheehan syndrome, pituitary neoplasm, TB
What is Sheehan syndrome
Postpartum pituitary necrosis
What lab results indicate a secondary hypothyroidism
Low to normal TSH as well asnormal thyrotropin-releasing enzyme (TRH), low levels of T3 and T4
What is tertiary hypothyroidism
Deficiency of TRH
What is an example of tertiary hypothyroidism
Hypothalamic radiation
Other than TSH, TRH, T3, T4, what other abnormal lab tests may be found in a hypothyroid patient
Elevated serum cholesterol (TG , LDL,total cholesterol); elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT); anemia; hyponatremia
What is the treatment for hypothyroidism
Levothyroxine
What is subclinical hypothyroidism
Elevated TSH levels but with normal thyroid hormone levels and with no clinical symptoms
What is the life-threatening complication of hypothyroidism called
Myxedema coma
What are the signs and symptoms of myxedema coma
Severe lethargy or coma, hypothermia, areflexia, bradycardia
What causes myxedema coma?
Prolonged cold exposure, infection, sedatives, narcotics, trauma, or surgery
What is the treatment for myxedema coma
This is an emergency, so start with ABCs (airway, breathing, circulation); IV fluids, steroids, levothyroxine, treat any precipitating causes
What is the initial appropriate workup of a thyroid mass
Fine needle biopsy and TSH
What other studies are done to workup a thyroid mass?
Thyroid ultrasound to determine the number and sizes of masses; and thyroid technetium 99m scan
What is a hot nodule and a cold nodule on a thyroid scan
Hot nodule indicates a hyperactive nodule and isless likely to be malignant. A cold nodule indicates a hypoactive nodule that is more likely to be malignant
What is the most common type of thyroid cancer
Papillary cancer
What is the prognosis for papillary cancer
85%, 5-year survival
What is seen on pathology
Psammomabodies, Orphan Annie nucleus
Which type of thyroid carcinoma is associated with multiple endocrine neoplasia types 2 and 3 (MEN 2 and 3)
Medullary cancer
What can be used to monitor medullary carcinoma
Calcitonin, because it is a calcitonin-secreting tumor
Which type of thyroid carcinoma has the worst prognosis?
Anaplastic cancer
In what patient population is anaplastic carcinoma usually found
Older patients
What is the 5-year prognosis for anaplastic carcinoma
0% survival at 5 years
Which thyroid cancer has the second worst prognosis
Medullary cancer
Which thyroid carcinoma often has metastasis to the bone and lungs?
Follicular cancer
Name the tumors that are part of each of the MEN syndromes
MEN 1: Wermer syndrome. three P’s prolactinoma, parathyroid, pancreatoma
MEN 2: Sipple syndrome pheochromocytoma, medullary thyroid, parathyroid
MEN 3: same as MEN 2B pheochromocytoma, medullary thyroid, mucocutaneous neuromas
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