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MS2 Endocrine > 10/8- Disease of the Thyroid II > Flashcards

10/8- Disease of the Thyroid II Flashcards

1
Q

What is the most common cause/presentation of hyperthyroidism?

A

Graves disease

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2
Q

Graves’ disease is the most common cause of what?

A

Thyrotoxicosis (hyperthyroidism)

  • Excess thyroid hormone in the blood
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3
Q

How is Graves’ disease diagnosed?

A
  • TSH, fT4, T3 to establish toxicosis
  • RAIU scan to differentiate toxic conditions
  • Anti-TPO, TSI, if indicated
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4
Q

RAIU in hyperthyroid states- what conditions have high uptake?

A
  • Graves’
  • Toxic MNG
  • Toxic Adenoma
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5
Q

RAIU in hyperthyroid states- what conditions have low uptake?

A
  • Subacute Thyroiditis
  • Iodine Toxicosis
  • Thyrotoxicosis factitia
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6
Q

What is seen here?

A

Symptoms of Graves’ disease hyperthyroidism:

  • Exophthalmos: swollen soft tissues behind eye; pathognomonic
  • Clubbing (thyroid acropachy)
  • Pre-tibial edematous skin (non-pitting)
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7
Q

Clinical features of Graves’ disease?

A
  • Weight loss
  • Increased appetite
  • Palpitation, tachycardia or a-fib
  • Breathlessness
  • Eye complaints
  • Goiter
  • Gynecomastia
  • Tremor
  • Thyroid acropachy
  • Pretibial myxoedema (many more)
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8
Q

Treatment for Graves’ Disease?

A
  • Beta blockers for symptoms
  • Thionamide medications:
  • Methimazole: MMI is treatment of choice: fast acting, longer half-life
  • Propylthiouracil
  • Radioiodine ablation: Avoid RAI in children and pregnancy!
  • Surgery
  • Large goiters not amenable to RAI
  • Compressive symptoms
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9
Q

Timeline/prognosis of Graves’ disease treated with Thionamide?

A

(Methimazole, Propylthiouracil)

MMI is treatment of choice: fast acting, longer half-life

  • May re-establish euthyroidism in 6-8 weeks
  • 40% - 60% incidence of disease remission
  • 20% incidence of allergy (rash, itching)
  • 0.5% incidence of potentially fatal agranulocytosis
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10
Q

What causes thyrotoxicosis with toxic adenoma?

A

Hyperfunctioning nodule

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11
Q

What are possible treatments for Toxic Adenoma (nodule)?

A
  • Anti-thyroid medications
  • Radioiodine
  • Surgery
  • Ethanol injection
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12
Q

Details of using radioiodine for treating toxic adenoma (nodule):

  • Cure rate
  • ASEs
  • Risk of hypothyroidism
A
  • Cure rate > 80% (20 mCi I131)
  • 2nd dose of I131 needed in 10-20%
  • Hypothyroidism risk 5-10%
  • Pts who are symptomatically toxic may require control with thionamide medications before RAI to reduce risk of worsening toxicity
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13
Q

When is surgery preferred in treating toxic adenoma (nodule)?

  • Risk of hypothyroidism
A
  • Preferred for children and adolescents
  • Preferred for very large nodules when high I131 doses needed
  • Low risk of hypothyroidism
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14
Q

When is ethanol used to treat toxic adenoma (nodule)?

  • Cure rate
A
  • Rarely done in the US
  • May achieve cure in 80%
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15
Q

What is Thyroid Storm?

  • Prognosis
A

Dreaded complication in endocrinology:

  • Extreme form of hyperthyroidism
  • Very high mortality
  • Early diagnosis and aggressive therapy in ICU can be life-saving
  • Careful follow-up after d/c from hospital
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16
Q

How should Thyroid Storm be treated?

A
  • Admit to intensive care
  • General supportive measures
  • Beta-blockers (hyperadrenergic Sx)
  • Hyperthyroidism:
  • Anti-thyroid drugs: Methimazole (always give first before iodine)
  • Steroids
  • Iodine:
  • High doses for Wolff Chaikoff effect
  • NEVER give this before giving thionamides first (block formation of thyroid hormone with MMI and then prevent release with thionamides)
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17
Q

What is “apathetic hyperthyroidism”?

  • Symptoms
  • Epidemiology
A

Labs show hyperthyroid (elevated T4, normal TSH), but without many symptoms

  • Lack of tremor, diaphoresis, heat-intolerance, hyperdefecation and other classic symptoms of sympathetic over-activity
  • Less likely to have goiter

- Common symptoms:

  • Weight loss, anorexia
  • Constipation despite thyrotoxic
  • Tachycardia, Afib, CHF, angina
  • Cognitive dysfunction

Epidemiology:

  • Elderly population
  • TMNG more likely than in young (but Grave’s still most common)
18
Q

What is subclinical hyperthyroidism?

  • Lab values
  • Prognosis
  • Indications for treatment
A

Labs:

  • Low TSH
  • Normal FT4 and FT3

Progression to overt hyperthyroidism is low

Indications to treat:

  • Any cardiac disease (CAD, AFib, etc)
  • Age > 60 (10 year risk AFIB 32%, 10% if normal TSH)
  • Toxic MNG or toxic adenoma
  • Osteoporosis
19
Q

Describe the physiological function of Amiodarone and Thyroid?

A
  • Increase iodine pool in body and therefore decrease RAIU.
  • Decrease peripheral deiodination of T4 to T3.
20
Q

Amiodarone can induce what?

  • Timeline
A

Thyroid dysfunction:

  • 3 mo- 4 yrs after starting
  • Hypothyroidism (8%)
  • Thyrotoxicosis (3%)
21
Q

What are different types of hypothyroidism?

A
  • Primary: thyroid gland failure
  • Secondary: pituitary failure
  • Tertiary: hypothalamic failure
  • Peripheral resistance
22
Q

How is hypothyroidism diagnosed (labs)?

  • What should be done in each situation?
A

Primary (check for Abs):

  • Low FT4
  • High TSH

Secondary/Tertiary (TRH stimulation test, MRI):

  • Low FT4
  • Low TSH
23
Q

How is hypothyroidism treated?

  • Benefits of treatment?
A

Levothyroxine (T4) due to longer half life

  • Don’t take with food/supplements

Treatment prevents:

  • Bone loss
  • Cardiomyopathy
  • Myxedema
24
Q

What are some causes of hypothyroidism?

A

Agenesis- congenital

Thyroid destruction

  • Hashimoto’s thyroiditis
  • Surgery
  • I131 ablation
  • Infiltrative diseases
  • Post-laryngectomy

Inhibition of function

  • Iodine deficiency
  • Iodine administration
  • Anti-thyroid medications (PTU, Methimazole, Lithium, Interferon)
  • Inherited defects

Transient:

  • Post-partum
  • Thyroiditis
25
Q

Symptoms of hypothyroidism?

A
  • Tiredness/malaise
  • Weight gain
  • Anorexia
  • Cold intolerance
  • Poor memory
  • Depression
  • Goiter
  • Dry, brittle hair and skin
  • Constipation
  • Ataxia
  • Slow-relaxing reflexes
  • Deafness
  • Loss of eyebrows
  • Bradycardia
  • Pericardial effusion

And more…

26
Q

What is Levothyroxine?

  • Uses
  • Average dose
  • Relationship to T3
  • Results
A

Synthetic T4

  • Most commonly prescribed treatment for hypothyroidism
  • Dosing: avg 1.6 ug/kg
  • If > 50-60 yo or cardiac disease, must start at low dose (25 ug/d)
  • Recheck thyroid hormone levels every 4-6 wks after dose change
  • Aim for normal TSH level
  • No T3 (but 85% of T3 comes from T4 conversion)
  • All pts made euthyroid biochemically
27
Q

What is Myedema Coma?

  • Prognosis
  • Treatment
A

Extreme for of hypothyroidism (mirror image of thyroid storm)

  • Very high mortality
  • Early diagnosis and aggressive therapy in ICU can be life-saving
  • Careful follow up after d/c from hospital
28
Q

What are the different types of thyroid cancer?

A
  • Differentiated thyroid cancer
  • Papillary
  • Follicular
  • Medullary thyroid cance
  • Anaplastic cancer
29
Q

Which is the most common subtype of thyroid cancer?

A

Papillary thyroid cancer

30
Q

Peak incidence of papillary thyroid cancer?

A
  • 30-50 yo
  • 2-3x more in women
31
Q

How does papillary thyroid cancer typically present?

  • Mets?
  • Physiological activity?
A
  • Usually presents as a slowly growing neck mass
  • Local invasion may cause:
  • Cord paralysis
  • Dysphagia
  • Lymph node involvement Metastases occur to cervical and upper mediastinal LNs, and occasionally to the lungs

Physiology:

  • Activation of receptor tyrosine kinases (RET/PTC, TRK, MET), appear to be specific for the transformation of thyroid follicular cells into papillary thyroid carcinomas
32
Q

How is papillary thyroid cancer diagnosed?

  • Treated?
A

Diagnosis by FNA

Treatment:

  • Thyroidectomy +/- LN dissection
  • Followed by radioiodine therapy and annual surveillance
33
Q

Describe Follicular Thyroid Cancer?

  • Prevalence
  • Peak incidence
A
  • 10-30% of thyroid cancers (2nd most common)

Peak incidence:

  • 40-60 yo
  • 3x more in women
34
Q

Pathogenesis and prognosis of Follicular thyroid cancer?

A
  • This cancer invades blood vessels early, with metastases to the lungs and bone being fairly common
  • Mortality up to 50% at 10 yrs
  • Metastases occur to cervical and upper mediastinal LNs, and occasionally to the lungs
35
Q

How is follicular thyroid cancer diagnosed?

  • Treated?
A

Diagnosed by FNA

Treatment:

  • Thyroidectomy +/- LN dissection
  • Followed by radioidone therapy and annual surveillance
36
Q

Describe Medullary Thyroid Cancer

  • Neoplasia of what
  • Prevalence
  • Survival rate
  • Types
A
  • Neoplasia of parafollicular cell
  • 5-7% of all thyroid cancers
  • Survival higher in absence of nodal involvement

Types:

  • Sporadic
  • Familial: could be related to multiple endocrine neoplasias types 2A/2B, associated with RET oncogene
37
Q

How is medullary thyroid cancer diagnosed?

A
  • Calcitonin estimations
  • Genetic analysis for RET mutation
38
Q

Describe anaplastic thyroid cancer:

  • Neoplasia of what
  • Prevalence
  • Prognosis
A
  • Undifferentiated tumors of the thyroid follicular epithelium
  • 2-5% of all thyroid cancers
  • Extremely aggressive; disease-specific mortality ~ 100%
  • Early recognition of the disease is essential to allow prompt initiation of therapy

Epidemiology:

  • Mean age at diagnosis is 65 yo
  • < 10% are younger than 50 yo
  • 60 -70 % of tumors occur in women
39
Q

What are the primary symptoms of anaplastic thyroid cancer?

A

Primary symptom = rapidly enlarging neck mass

  • Occurs in ~ 85% of pts
40
Q

Treatment for anaplastic thyroid cancer?

A
  • Surgery
  • Radiation
  • Chemotherpay

In addition to supportive measures

MS2 Endocrine (25 decks)

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