? Hyperthyroidism with high RIU
- Grave's Disease
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- Toxic Multinodular Goitre- Toxic Adenoma
- TSH- producing Pituitary Adenoma
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Etiology
? Hyperthyroidism with low/ normal RIU
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- Sub-Acute Thyroiditis- Exogenous Hormone intake
- Struma Ovarii
- Metastatic Follicular Thyroid CA
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- Amiodarone inducedDiffuse toxic goitre ( Graves')
? Autoimmune Disease
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? Abnormal Thyroid Stimulating Antibodies to TSH
receptors
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? 50% familial, with other autoimmune endocrinediseases
? Younger females
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? Primary thyrotoxicosis with eye signs
Toxic Multinodular Goitre
? Only 5% of all cases
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? 10 times more common in iodine deficient
area
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? Typically occurs in patients older than 40 withlong standing goitre
? Secondary thyrotoxicosis, eye signs rare
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Toxic Adenoma ( Plummers')
? More common in young patients
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? Autonomous functioning single nodule? Somatic mutations in the TSH receptor gene
? Size usual y > 3 cm
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? Visualized as a hot nodule on RAI uptake scan
Sub-acute Thyroiditis ( De Quervain)
? Abrupt onset due to leakage of preformed
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hormones following injury to gland
? Follows viral infection
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? Resolves within eight months? Rapid response to Prednisone
? Can re-occur
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Treatment Induced Hyperthyroidism
? Iodine induced
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? Radiographic contrast media? Medication
? Amiodarone Induced
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? Jod-Basedow thyrotoxicosis
? Thyroid Hormone Induced
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? Metastatic thyroid cancer? Struma ovarii
? TSH secreting tumor
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Pathology
Clinical symptoms (Skin)
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? Warm, Erythematous
? Smooth- due to decrease in keratin
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? Sweaty and heat intolerance? Infiltrative dermopathy on shins
? Onycholysis ?softening of nails and loosening of nail beds
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? Thinning of hair
Clinical symptoms
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? Graves disease has ophthalmopathy
? Antibody mediated effect on ocular muscles
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? Exophthalmos? Infiltration of retro-bulbar tissues with fluid &
round cells with lid retraction/spasm*
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? *Due to sympathetic over activity
Clinical symptoms (Eye)
? Impaired extraocular eye muscle function (Diplopia)
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? Periorbital and conjunctival edema
? Corneal ulceration due to lid lag and proptosis
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? Optic neuritis and even blindness? Gritty feeling or pain in the eyes
Eye signs
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? Lid retraction ( Dalrymple's sign)
? Lid lag ( von Graefe's sign )
? Periorbital puffiness* (Enroth's sign)
? Difficulty in eversion of upper lid (Gifford's sign)
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? Infrequent blinking (Stellwag's sign)? Absent creases on forehead on superior gaze (Goffroy's sign)
? Difficulty in convergence (Moebius sign)
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Long-standing thyroid ophthalmopathy with typical features of lidretraction (upper & lower) and visible sclera with proptosis.
Lid lag ( von Graefe's sign )
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Periorbital puffiness (Enroth's sign)
Difficulty in convergence (Moebius sign)
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Clinical symptomsCardiovascular System
? Increased cardiac output (due to increased oxygen
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demand and increased cardiac contractibility.
? Tachycardia persists in sleep
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? Stages of thyrotoxic arrhythmias? Multiple extrasystoles
? Paroxysmal atrial tachycardia
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? Paroxysmal atrial fibrillation
? Persistent atrial fibrillation
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Clinical symptoms (GI System)
? Weight loss due to increased calorigenesis
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? Hyperphagia (weight gain in younger patient)
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? Hyperdefecation
? Malabsorption
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? Steatorrhea
? Celiac Disease (in Grave's Disease)
Neuromuscular System
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? Tremors-outstretched hand and tongue
? Hyperactive tendon reflexes
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Psychiatric? Hyperactivity
? Emotional lability
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? Anxiety? Decreased concentration
? Insomnia
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Muscle Weakness? Proximal muscle weakness in 50% pts.
? Decreased muscle mass and strength
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? May take up to six months after euthyroid state to gain
strength
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? Myesthenia Gravis, especially in Grave's disease.Thyroid function test
TSH level
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Low TSH
High TSH (rare)
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Measure T4High
Secondary
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hyperthyroidism
Image pituitary gland
Low TSH
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Measure Free T4 Level
Normal
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HighMeasure Free T3 Level
Primary hyperthyroidism
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Thyroid uptakeNormal
High
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-Subclinical
T3 Toxicosis
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hyperthyroidismLow
High
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-Resolving
Measure thyroglobulin
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HyperthyroidismDIffuse
Nodular
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-Medication
decreased
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Increased Graves MultipleOne "hot" area
-Pregnancy
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Exogenous
disease areas
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hormoneThyroiditis
Iodide exposure Toxic multinodular
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Toxic
Exrtraglandular goiter
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adenomaproduction
Treatment
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? Goal: To correct hyper-metabaolic state with least side
effects and lowest incidence of hypothyroidism.
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? Treatment depends upon-Cause and severity of disease
-Patients age
-Goiter size
-Comorbid condition
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-Treatment desiredOptions
? Anti-thyroid drugs
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? Radioactive iodine? Surgery
? Beta-blocker and iodides are adjuncts to above treatment
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Anti-thyroid Drugs
? They interfere with uptake and organification of iodine--
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suppress thyroid hormone levels? Two agents:
-Carbimazole
-PTU (Propylthiauracil)
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Anti-thyroid Drugs? Short term therapy: Prepare patients for RAI/ Surgery
? Medium term therapy: For remission in Graves Disease
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? Relapse more common in
-smokers
-elevated TS antibodies at end of therapy
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Anti-thyroid DrugsCarbimazole
Drug of choice for non-pregnant patients because of :
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? Dose 20 mg/day
? Low cost
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? Lower incidence of side effects? Can be given in conjunction with beta-blocker
? Beta-blockers can be tapered off after 4-8 weeks of therapy
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Anti-thyroid DrugsPTU
? Preferred for pregnant patients
? Carbimazole is associated with genetic abnormalities like
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aplasia cutis
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Dose 100 mg t.i.dInhibit peripheral deiodination of T4 to T3
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Breast feeding is not contraindicatedAnti-thyroid Drugs
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Complications
? Agranulocytosis up to 0.5% cases
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? High with PTU? Advised to stop drug if they develop sudden fever or sore throat
? Hepatitis
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? Skin rashes
? Lupus like syndromes
Beta Blockers
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? Prompt relief of adrenergic symptoms
? Propranolol widely used
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? Start with 10-20 mg q6h? Increase progressively until symptoms are controlled
? Most cases 80-320 mg qd is sufficient
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? CCB can be used if beta blocker not tolerated or
contraindicated
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IodidesIodide blocks peripheral conversion of T4 to T3 and inhibits
hormone release.
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These are used as adjunct therapy
?
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Before emergency non-thyroid surgery?
Beta blockers cannot curtail symptoms
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?
Decrease vascularity before surgery for Grave's disease
Radioactive Iodine
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Treatment of choice for Grave's disease and toxic nodular goiter
? Inexpensive
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? Highly effective? Easy to administer
? Safe
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? Dose depends on estimated weight of gland
? Higher dose increases success rate but higher chance of
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hypothyroidismRadioactive Iodine
? Higher dose is favored in older patient
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? Dose individualization is difficult
? Arbitrary dosage of 200-600 MBq
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? Effective for both Graves Disease and Toxic MNG? Transient thyroiditis is side effect
Surgery
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? Radioactive iodine has replaced surgery for Tx ofhyperthyroidism
? Indications:
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? Large Toxic MNG
? Large Diffuse Toxic Goitre
? Toxic adenoma
? Childhood Graves' Disease
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? Thyrotoxicosis in pregnancyNew Treatment
? Minimally invasive subtotal thyroidectomy
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? Embolization of thyroid arteries
? Plasmapheresis
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? Percutaneous ethanol injection into toxic nodule? L-Carnitine supplementation may improve symptoms and may
prevent bone loss
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