Darrow, Hyperthyroid Flashcards
heat intolerance and palpitations
hyperthyroid
clubbing of fingers
hyperthyroid
What is higher in graves T3 or T4
T3
what are clinical signs of graves
goiter, exophthalmos, pretibial myxedema
what type of HS reaction is graves
type II
Ab dependent cytotoxicity
IgG
What HLA is graves
HLA-DRB1, DR8
HLA DR is MHC II
major cell causing pretibial myxedma
TH1
what cell drives graves disease
TH2
TH1 CD4 cells do what in graves
stimulate effector cells (macrophages, CTLs, NK cells) against TSH R and fibroblast to produce GAGs
What do CD4 TH2 cells do in graves
sitmulate TSH R Ab(TSI) that act on follicular cells to stimulate thyroid growth and secretion
cross react with antigens in fibroblasts, adipocytes etc
how do type II HS reactions cause disease
C’ mediated lysis through MAC
Ab dependent cytotoxic attack (CTL)
alter cell surface R function toward activation or blockade
What are other type II HS reaction diseases
autoimmune hemolytic anemia
blood transfusion reaction
graves
myasthenia gravis
if patient with graves has diplopia what do you have to keep
coexistant myasthenia gravis
what causes the proptosis and diplopia in graves
firbobalst proliferation with GAG deposits and lymphocytes that is caused by TH2
what can cause clubbing of fingers or ‘hypertrophic osteoarthropathy”
cardiac diseases pulmonary diseases GI diseases Rena failures thyroid disease (graveS) malignancies idiopathic
what classifies tyrotoxid cardiomyopathy
tach induced cardiomyopathy, Afib, high output failure, pulm HTN
how do you rule out factitial thyrotoxicosis
no thyroglobulin in factitial thyrotoxicosis
why does increased T3 lead to hyperCa
more bone turnover
what HLA is responsible for euthyroid Graves orbitopathy
HLA B40 DQw3
first line of Tx for graves
antithyroid drugs to block oxdation of Iodine, block organification iodine and couling
What are the antithyroid drugs used in graves
PTU
methimazole
How does PTU work
blocks T4 to T3
what is the first drug of choice for graves
methimazole because less hepatic necrosis
side effects of antithyroid drugs
agranulocytosis, hepattis, SLE
What do you give after starting thiourea drugs in graves
iodine to block T4 to T3
wolff chaikoff effect because blocks synthesis and release
besdies antithyroid drugs and iodine what other medicaiton is used in graves
lithium, K perchlorate
What is second line Tx graves
radioactive iodine
what is the final Tx for graves
surgery
what can stimulate primary hyperthyroidism by creating low TSH
acute steroid administration amphetamines Ca ch blockers dopamine NSAIDs opiates elderly euthyroid pregnancy or hCG secretion severe non-thyroidal illness (IL , TNF)
what heart condition can thyrotoxicosis caUSE
A FIB
Apathetic hyperthyroididsm signs
apathy, weight loss, angina, AF, CHF and less adrenergic Sx
What cuases apathetic hyperthyroidism
somatic mutations of TSH R and G alpha protein leading to cAMP cascade of inositol phosphate pathway
what drug can cause an autonomous thyroid nodule to become a toxic multinodular goiter
amiodarone excess iodine
someone on amiodarone will have what result in an radioactive thyroid scan
decreased uptake of iodine from iodine induced TMN goiter
thyroid already saturated of iodine
what is Jod basedown phenomenon
when patient has ample iodine so induces TMN goiter
What are the type I amiodarone induced thyrotoxicosis
- jod basedown type with TMNG and no thyroid Ab
- graves type with Ab
what is type II amiodarone induced thyrotoxicosis
thyroiditis
what can cause increased uptake on iodine scan
graves
adenoma(plummers)
inappropriate secretion TSH (pituitary adenoma)
TMN
Trophoblastic (embryonal carcinoma and hydatiform mole)
Tx for an autonomous thyroid nodule
RAI or surgery or antithyroid drugs
Tx for TMNG
RAI or surgery of ATDs
what should you do for RAI Tx in someone with low uptake
prime with PTU or recombinant TSH
patient has normal free T4 and low TSH
subclinical hyperthyroidism
risks of subclinical hyperthryoidism
AF and diastolic dysfunction
osteoporosis
dementia
Tx for subclinical hyperthyroidism
TAI or small dose of antithyroid drug
patient with normal T4 and TSH between 0.1- 0.3 (low)
what would you Tx
observation and consider beta blocker
what can cause thyrotoxic storm
acute illness, thyroid surgery or RAI therapy in inadequately Tx patient
signs thyroid storm
fever, tachycardia, tachypnea, hypotension, vomiting, diarrhea, irritability, delerium, coma and death
Tx for thyroid storm
thiourea with iodides
must start iodides after thiourea
start metoprolol and hydrocortisone as well
thyroid storm presents similar to what
sepsis, pheo, malignant hyperthermia
male on thyroid hormone replacement has muscle pain and weakness
gynecomastia, severe prosimal muscle weakness and dec reflexes
low K
Dx?
thyrotoxic periodic paralysis
what is thyrotoxic periodic paralysis
channelopathy with muscle weakness (Na/KATPase increased) hypopolarization
levels of K in thyrotoxic periodic paralysis
serum hypokalemia with heavy meal or post exercise in asian men
what drugs can increase ATPase activity in thyrotoxic periodic paralysis
thyroid hormone, catecholamines, insuline, testosterone
25 y.o F postpartum with shakiness, palpitations and heat intolerance BP 120/50 enlarged non tender thyroid gland tremor in hands increased T4 TSH low TPOAb low dec uptake on scan Dx?
postpartum
what are causes of hyperthyroidism with decreased uptake on RAI
Drugs: thyroxine
Iodine: jod basedown
Ectopic: struma ovarii, teratoma
Thyroiditis: painful types and painless types
what are the painful types of thyroiditis
subacute granulomatous–> viral, high ESR, HLA B-35
suppurative (staph)
radiation
drug induced
Amiodarone induced thyroiditis involves what IL?
IL-6
what are the painless types thyroiditis
postpartum- DR3 DR5 (precursor to hashimoto)
subacute or chornic autoimmune lymphocytic (DM, vitiligo, downs or turners)
Riedels fibrosis
