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endocrine > Clinical thyroid disease > Flashcards

Clinical thyroid disease Flashcards

1
Q

What will happen if hypothyroidism is severe?

A
  • FBC (MCV (mean corpuscular volume) increased)
  • Lipids (hypercholesterolaemia)
  • Hyponatraemia (low sodium) due to SIADH (high secretion of antidiuretic hormone)
  • Increased muscle enzymes (ALT and CK)
  • Hyperprolactinaemia
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2
Q

What are the common tests for hypothyroidism?

A

○ TSH/ fT4

○ Autoantibodies: TPO (Thyroid peroxidase antibodies)

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3
Q

What are the common tests for hyperthyroidism?

A
  • Thyroid peroxidase antibodies
  • TSH receptor antibodies
  • Review personal/ family history for concurrent autoimmune disease
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4
Q

What are the common presentations of hypothyroidism?

A 
○ Weight gain
○ Lethargy
○ Heavy periods
○ Feeling cold
○ Dry skin/ hair
○ Slow reflexes
○ Constipation
○ Bradycardia 
○ Goitre 
○ Severe
        - Puffy face
	- Large tongue
	- Hoarseness
	- Coma
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5
Q

What are the common presentations of hyperthyroidism?

A
  • Weight loss
  • Sensitive to heat
  • Light periods
  • Anxiety/ irritability
  • More bowel movements
  • Palpitations
  • Sweaty palms
  • Hyperreflexia/ tremor
  • Thyroid eye symptoms/ signs
  • Goitre
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6
Q

What are the common presentations for grave’s disease

A
  • Thyroid eye disease (10%)
  • Gynecomastia
  • Thyroid acropathy
  • Goitre
  • Grave’s demopathy
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7
Q

What are the different types of hypothyroidism?

A 
○ Primary (thyroid)
○ Secondary (pituitary) 
○ Subclinical (compensated)
○ Acquired
○ Pituitary/ hypothalamic damage
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8
Q

What are the different types of hyperthyroidism

A

○ Primary
○ Secondary
○ Thyrotoxicosis without hyperthyroidism
○ Subclinical hyperthyroidism

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9
Q

What are the general hyperthyroid management strategies?

A 
○ Surgery
○ Antithyroid drugs 
○ Radioiodine 
○ Beta blockers
	- Symptom management
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10
Q

Explain antithyroid drugs in more detail

A 
- Drugs
	□ Carbimazole 
	□ Propylthiouracil
- Side effects
	□ Rash
	□ Agranulocytosis 1:500 
- Administration 
	□ Titration regime 
		® start at a high dose and then decrease the dose when stable
		® 50% cure
		® 30% hypothyroidism 
	□ Blockage
		® Start at a high dose and then add in thyroxine when stable
		® 50% cure
		® 30% hypothyroidism
		® Higher side effects 
- Selected cases for long term low dose administration
	□ Elderly 
	□ Cardiac complications
	□ Unwilling for radioiodine
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11
Q

Explain radioiodine in more detail

A
  • Types
    □ High ablative dose
    ® 90% cure
    ® 70% hypothyroidism
    □ Variable calculated
    ® 60-90% cure
    ® Less hypothyroidism
  • Side effects
    □ Cannot have contact with children or pregnant women for 4 weeks
    □ It could cause eye problems (steroids)
    □ For a month or two security alarms at the airport will go off
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12
Q

Discuss the principles of treatment of hypothyroidism

A

• Levothyroxine (T4) tablets
• Liothyronine (T3) doesn’t really work and a combination of T3 and T4 doesn’t work either
• Initial dose of levothyroxine is 50mcg/ day increase after 2 weeks to 100mcg
• Alter dose until TSH is normal (or fT4 is in normal range in secondary)
• After stabilisation there should be annual testing of TSH
• Compliance
• Ischemic heart disease
○ Start at lower dose 25mcg
○ Increase cautiously
○ Risk of precipitating angina
• Pregnancy
○ Most patients need an increase (35-40%) in LT4 dose
○ If they have subclinical hypothyroidism treat
○ Inadequate treatment of hypothyroidism linked with increased foetal loss and lower IQ
○ At diagnosis of pregnancy
- Increase LT4 dose by about 25% and monitor closely
- Aim to keep TSH in low normal range and FT4 in high normal range
• Postpartum thyroiditis
○ Trial withdrawal
○ Measure TFTs in 6 weeks
• Myxoedema coma
○ Very rare emergency
○ May need IV T3 (steroid)
• Subclinical hypothyroidism
○ Consider treating TSH >10
○ TSH >5 with positive thyroid antibodies
○ TSH elevated with symptoms: trial therapy of 3-4 months and continue if symptomatic improvement
○ Risk of overtreatment
- Osteopenia
- Atrial fibrillation

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13
Q

What are the types of thyroid cancer

A
  • Papillary
  • Follicular
  • Anaplastic
  • Lymphoma
  • Medullary
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14
Q

How is thyroid cancer managed?

A

○ Prognosis poorer
- Age <16 or >45
- Tumour size
- Spread outside thyroid capsule and metastases
- TNM stage
○ Near total thyroidectomy
○ High dose radioiodine (ablative)
○ Long term suppression doses of thyroxine
○ Follow up
- Thyroglobulin
- Whole body iodine scanning (following 2-4 weeks of thyroxine withdrawal)

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15
Q

What happens in primary hypothyroidism?

A
  • Raised TSH (thyroid secreting hormone)

- Low FT4 and FT3 (free thyroid 3 and 4)

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16
Q

What happens in secondary hypothyroidism?

A
  • Low TSH

- Low FT4 and FT3

17
Q

What happens in subclinical hypothyroidism?

A
  • Raised TSH

- Normal FT4 and FT3

18
Q

Explain acquired hypothyroidism

A
  • Autoimmune thyroid disease (this is the most common in the UK)
    □ Hashimotos
    □ Atrophic
  • Iatrogenic
    □ Postoperative/ post radioactive iodine
    □ External RT for head and neck cancers
    □ Antithyroid drugs, Amiodarone, Lithium, Interferon
  • Chronic iodine deficiency (commonest worldwide)
  • Post subacute thyroiditis
    □ Postpartum thyroiditis
19
Q

What sort of pituitary/ hypothalamic damage causes hypothyroidism?

A
  • Pituitary tumour
  • Craniopharyngioma
  • Post pituitary surgery or radiotherapy
  • Sheehan’s syndrome (where a woman has a massive postpartum haemorrhage)
  • Isolated TRH deficiency
20
Q

Describe primary hyperthyroidism

A
  • Grave’s disease
    □ 70-80% of hyperthyroidism
    □ Thyroid antibodies (TSH receptor antibodies)
  • Toxic multinodular goitre
    □ Most common cause of thyrotoxicosis in the elderly
    □ Characteristic goitre and absence of grave’s disease
    □ Will not go into spontaneous remission
  • Toxic adenoma
21
Q

What causes secondary hyperthyroidism?

A

Pituitary adenoma secreting TSH (quite rare)

22
Q

Explain thyrotoxicosis without hyperthyroidism

A
  • Destructive thyroiditis (postpartum, subacute, amiodarone induced)
    □ Subacute
    ® Generally younger patients <50 years
    ® Viral trigger (e.g. enterovirus, coxsackie)
    ® Often painful goitre +/- fever/ myalgia; ESR increased
    ® May require short term steroids and NSAIDs
  • Excessive thyroxine administration
23
Q

Explain subclinical hyperthyroidism

A
  • TSH suppressed
  • Normal free thyroid hormones
  • Concerns
    □ Bone: decreased bone density in postmenopausal; no clear fracture data
    □ AF: 3 fold increased risk in over 60
  • Treatment: consider ATD or RAI if persistent especially in the elderly or those with increased cardiac risk
24
Q

Explain papillary thyroid cancer

A

○ Commonest
○ Multifocal, local spread to lymph nodes
○ Good prognosis

25
Q

Explain follicular thyroid cancer

A

○ Usually a single lesion
○ Metastasis to lung and bone
○ Good prognosis if resectable

26
Q

Explain anaplastic thyroid cancer

A

○ <5% of thyroid cancers
○ Aggressive, locally invasive
○ Very poor prognosis, do not respond to radioiodine
○ External RT may help briefly

27
Q

Explain thyroid lymphoma

A

○ Rare; may arise from pre-existing Hashimoto’s thyroiditis

○ External RT more helpful, combined with chemotherapy

28
Q

Explain medullary thyroid cancer

A

○ Tumour arises from parafollicular C cells
○ Often associated with MEN 2
- Pheochromocytoma
- Hyperparathyroidism
○ Serum calcitonin levels raised
○ Treatment: total thyroidectomy, no role for radioiodine
○ Prognosis variable

endocrine (20 decks)

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