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Year 3 - TCD > Case 7 - Thyroid Disease > Flashcards

Case 7 - Thyroid Disease Flashcards

1
Q

What are the causes of primary hyperthyroidism?

A
  • Graves’ disease
  • Toxic multinodular goitre (MNG)
  • Toxic adenoma: single nodule
  • Drugs – Amiodarone, Interferon
  • De Quervain’s (subacute) thyroiditis
  • Sub clinical hyperthyroidism
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2
Q

What are the causes of secondary hyperthyroidism?

A
  • TSH secreting pituitary tumor

- Ectopic thyroid tissue

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3
Q

What is De Quervain’s (subacute) thyroiditis?

A
  • Painful swelling of the thyroid gland triggered by a viral infection.
  • Common in women aged 20 to 50.
  • Causes fever and pain in the neck, jaw or ear.
  • 2 phases: second phases = hypothroidism
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4
Q

What are the signs and symptoms of hyperthyroidism?

A
  • Heat intolerance
  • Excessive sweating
  • Weight loss despite increased appetite
  • Frequent bowel movements
  • Weakness
  • Fatigue
  • Hyperflexia
  • Tachycardia
  • Palpitations
  • Fine tremor
  • Myopathy
  • Oligo/amenorrhoea
  • Onycholysis: loosening of nail from nail bed
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5
Q

What the signs and symptoms of Graves’s eye disease?

A
  • Signs of hyperthyroidism
  • Exophthalmos/proptosis: bulging eyes
  • Upper eye lid retraction
  • Peri-orbital oedema
  • Lid lag
  • Chemosis
  • Ophthalmoplegia – paralysis of the muscles within or surrounding the eye
  • Acropachy
  • Pretibial myxodeama: non-pitting oedema on shins
  • Bruit: may be heard due to increased vascularity of the gland
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6
Q

How to diagnose hyperthyroidism?

A
  • TFT: low TSH, raised T3 and T4
  • Serum thyroid antibodies: Graves’ disease
  • Ultrasound: nodules, diffuse enlargement, nodules
  • Thyroid scintigraphy
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7
Q

What is thyroid scintigraphy and when is it/isn’t used?

A
  • Uptake of radioactive iodine
  • Graves’ disease: increase RAI uptake
  • Toxic MNG: hot and cold
  • Toxic adenoma: hot nodule
  • Not used pregnant or breast feeding women
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8
Q

What is the 1st line treatment for hyperthyroidism?

A

Radioactive iodine ablation:

  • Destroys thyroid with radioactive iodine 131 across 6 weeks.
  • Worsen Graves’ eye disease, esp smoking. Needs prednisolone.
  • Not given to pregnant women, breast feeding women and women shouldn’t get pregnant for 4-6 months after
  • Likely to have hypothyroidism so need levothyroxine
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9
Q

What is the 2nd line treatment for hyperthyroidism?

A
  • Anti-thyroid drugs: carbimazole and propylthiouracil
  • Low risk of hypothyroidism
  • Agranulocytosis
  • Propylthiouracil used in 1st trimester of pregnancy, shorter half life, works faster
  • Carbimazole used in 2nd + 3rd trimester of pregnancy
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10
Q

What is agranulocytosis?

A
  • Very low WCC
  • Seek medical advice if signs of infection, low fever, sore throat, rigors after taking medication.
  • Need FBC to rule out agranulocytosis
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11
Q

What are the different ways to take carbimazole?

A
  • Block and replace: high dose with levothyroxine to bring TFTs under control, Takes 6-24 months.
  • Titration: Start moderate dose, then reduce. Takes 18-24 months. Only in pregnancy.
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12
Q

What is the 3rd line treatment for hyperthyroidism?

A
  • Thyroidectomy
  • Hypothyroidism inevitable: need thyroxine
  • Scarring of neck
  • Possible voice changes if recurrent laryngeal nerve damaged
  • Haematoma: respiratory distress and stridor
  • Hypocalcaemia: damage to parathyroid glands
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13
Q

How are symptoms of hyperthyroidism controlled?

A

Beta blockers

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14
Q

What is Graves’ disease?

A
  • Autoimmune condition: TSH receptor antibodies stimulate thyroid
  • Most common type of hyperthyroidism (75% affected)
  • Mainly affects females
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15
Q

What are the investigations for Graves’ disease?

A
  • TFTs

- Autoantibodies: raised TSH receptor autoantibody (TRAbs), anti-TPO and anti-Tg (thyroglobulin)

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16
Q

What is thyroid storm (thyrotoxic crisis)?

A
  • Exacerbation of hyperthyroidism

- Due to a spontaneous excessive release of thyroid hormones.

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17
Q

How to treat thyroid storm?

A

BAIS

  • Beta blockers – propranolol
  • ATDs – Propylthiouracil
  • Potassium iodide: Lugol solution
  • IV steroids: glucocorticoids
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18
Q

What is the biggest risk factor for Graves’ disease?

A

Smoking

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19
Q

What is the complication of hyperthyroidism?

A
  • Heart failure (thyroid cardiomyopathy)

- Atrial fibrillation

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20
Q

What are thyroid nodules?

A

Fibrous changes to thyroid, not visible.

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21
Q

How to test for nodules?

A
  • Radionuclide test.
  • Hot = producing more hormone than usual. Benign/tumour.
  • Warm = producing normal amounts. Benign/swelling, normal.
  • Cold = producing lower amounts. Malignant
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22
Q

What rules to follow after radioactive iodine treatment?

A
  • Avoiding close contact
  • Sleep alone
  • Wash your clothes separate
  • Flush the toilet twice
  • Radioiodine still in blood, urine, poo, saliva
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23
Q

How to treat hyperthyroidism in pregnancy?

A
  • Propylthiouracil: 1st trimester of pregnancy, shorter half life, works faster
  • Carbimazole: 2nd + 3rd trimester of pregnancy
  • Beta blocker: symptom control
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24
Q

What is euthyroid sick syndrome?

A

– Systemic illness in which serum levels of all thyroid hormones (T3, T4 and TSH) are low.

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25
Q

What is a goitre?

A

Enlarged thyroid due to a swelling which is visible.

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26
Q

What are the different types of goitre?

A
  • Diffuse: iodine deficiency, Hashimotos, Graves’

- Multi nodular: Toxic multi nodular goitre, toxic adenoma, carcinoma

27
Q

What is a thyroglossal cyst?

A
  • Fibrous structure resulting from incomplete closure of the thyroglossal duct
28
Q

What moves on swallowing AND sticking tongue out?

A

Thyroglossal cyst

29
Q

What moves on swallowing but NOT sticking tongue out?

A

Goitre

30
Q

How do goitres expand?

A
  • Limited

- Superiorly, inferiorly and laterally

31
Q

What are the differentials for hyperthyroidism?

A
  • Anxiety
  • Bipolar
  • Atrial fibrillation
  • Toxic multinodular goitre
  • Graves’
32
Q

What are congenital causes of hypothyroidism?

A

Thyroid dysplasia or aplasia

33
Q

What are the acquired causes of hypothyroidism?

A
  • Primary: Hashimotos thyroiditis (
  • Secondary: Sheehans syndrome, post-patrum thyroiditis, pituitary adenoma
  • Drugs: Amiodarone, Lithium, Iodine, anti-thyroid drugs
  • De Quervains thyroiditis (second phase)
  • Subclinical hypothyroidism
34
Q

What are the signs and symptoms of hypothyroidism?

A
  • Tired/lethargic
  • Cold intolerance
  • Low mood
  • Weight gain
  • Constipation
  • Menorrhagia
  • Hoarse voice
  • Decreased memory/cognition
  • Myalgia
  • Cramps
  • Weakness
  • Bradycardia
  • Dry/Thin hair and skin
  • Puffy face with peaches and cream complexion
  • Slow reflexes
35
Q

What are the risk factors for hypothyroidism?

A
  • Female
  • Iodine deficiency
  • Middle age
  • Family history of autoimmune thyroiditis or other auto immune disorders
36
Q

What investigations are done in hypothyroidism?

A
  • Primary hypo: Raised TSH, reduced T4
  • Secondary hypo: Decreased TSH and T4
  • Radioactive iodine: decreased uptake
37
Q

What are the associated conditions with hypothyroidisms?

A
  • Hypercholesterolemia

- Give levothyroxine and if hypercholesterolemia doesn’t resolves, add statins

38
Q

How to treat hypothyroidism?

A
  • Long term Levothyroxine (T4)
  • Start at 75 mcg. increase in 25 mcg
  • In elderly or cardiac patients start with 25 mcg to prevent AF
39
Q

What is myxoedema coma?

A
  • Severe hypothyroidism

- Triggered by infections, surgery, and trauma.

40
Q

What are the features of myxoedema coma?

A
  • Typical hypothyroid features +
  • Low temperature
  • Decreased reflexes
  • Low blood glucose
  • Bradycardia
  • Coma
  • Seizures
  • HF
  • Cyanosis
  • Hypotension
41
Q

How to treat myxoedema coma?

A

IV T4 + T3

42
Q

Which antibodies are associated with Hashimoto’s thyroiditis?

A
  • Anti-TPO

- Anti-Tg

43
Q

What problems can hypothyroidism cause in pregnancy?

A
  • Eclampsia
  • Anaemia
  • Prematurity
  • Low birth weight
  • PPH
  • Stillbirth
44
Q

When does post partum thyroiditis occur?

A

1-8 months after delivery

45
Q

How doe post partum thyroiditis present?

A
  • Transient thyrotoxicosis followed by hypothyroidism
  • Weight loss, palpitations, heat intolerance and anxiety
  • T4 increased to a greater degree than T3 and TPO autoantibodies.
46
Q

What are the signs of post partum thyroiditis?

A
  • Tremor, tachycardia, warm and moist skin, muscle weakness, lid retraction, lid lag
47
Q

What is Sheehan’s syndrome?

A
  • Postpartum necrosis of the pituitary gland occurs following post-partum haemorrhage.
48
Q

How does Sheehan’s syndrome affect women?

A
  • Affects breastfeeding

- No periods

49
Q

How to treat Sheehan’s syndrome?

A
  • No TSH so monitor T3/4

- Life long hormone replacement

50
Q

What are the 5 different types of thyroid cancer?

A
  • Papillary
  • Follicular
  • Medullary
  • Anaplastic
  • Lymphoid
51
Q

What is the typical presentation of papillary thyroid cancer?

A
  • Young woman with lymph node metastases

- Raised thyroglobulin

52
Q

In which thyroid cancer would serum calcitonin be raised and CEA present?

A

Medullary carcinoma

53
Q

What is the typical presentation of anaplastic thyroid cancer?

A

Elderly women, rapid growth and local invasion

54
Q

What the typical presentation of follicular thyroid cancer?

A
  • Middle aged, solitary thyroid nodule, may have spread to lung and bone
  • Raised thyroglobulin
55
Q

What are the 5 possible FNAC results of thyroid biopsy?

A 
Thy 1 - non diagnostic 
Thy 2 - benign 
Thy 3 - intermediate 
Thy 4 - suspicious 
Thy 5 - malignancy
56
Q

What are the 6 anterior pituitary hormones?

A

FLAT (cause more hormone release) PEG:

  • FSH
  • LH
  • ACTH
  • TSH
  • Prolactin
  • Endorphins
  • Growth hormones
57
Q

What are the 2 hormones released by posterior pituitary gland?

A

ADH and oxytocin (made by hypothalamus)

58
Q

Describe the pathway for thyroid hormone release (HPT)

A
  • Hypothalamus releases TRH
  • Anterior pituitary releases TSH
  • Thyroid releases T4
  • T4 converted to T3 in periphery and bound to thyroxine binding globulin
  • T4/3 release inhibits pituitary gland
  • Less TSH released, less T4/3
59
Q

When does raised TSH, T4 and T3 occur?

A

Non compliance hypothyroidism - Meds taken just few days before blood test
- Doesn’t allow TSH to decrease

60
Q

What is lymphoma thyroid cancer associated with?

A

Hashimoto’s thyroiditis

61
Q

Which inherited condition is medullary carcinoma most likely to be associated with?

A
  • MEN 2
  • Pheochromocytoma
  • Hyperparathyroidism
62
Q
  • What is MEN condition?

- What are the different types?

A
  • MEN - multiple endocrine neoplasia. Hereditary disease.
  • Type 1 affects parathyroid, pituitary, and pancreas.
  • Type 2 causes medullary thyroid cancer and pheochromocytomas
63
Q

What is a typical exam question for medullary carcinoma?

A

A patient is diagnosed with a thyroid tumour. Her family history is positive for diabetes, hypertension, and her brother has been treated for a pheochromocytoma, what type of tumour is she likely to have?

64
Q

What cells does medullary carcinoma arise from?

A

Calcitonin-producing (C-cells) in the thyroid

Year 3 - TCD (17 decks)

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