Endocrine Flashcards
fxWhat is primary vs secondary vs congenital hypothyroidism?
primary hypothyroidism: there is a problem with the thyroid gland itself, for example an autoimmune disorder affecting thyroid tissue (see below)
secondary hypothyroidism: usually due to a disorder with the pituitary gland (e.g.pituitary apoplexy) or a lesion compressing the pituitary gland
congenital hypothyroidism: due to a problem with thyroid dysgenesis or thyroid dyshormonogenesis
What is the most common cause of hypothyroidism in the developed vs the devoloping world??
Hashimoto’s thyroiditis
most common cause in the developed world autoimmune disease, associated with type 1 diabetes mellitus, Addison's or pernicious anaemia may cause transient thyrotoxicosis in the acute phase 5-10 times more common in women
Iodine deficiency
the most common cause of hypothyroidism in the developing world
What is hashimotos thyroiditis? what is found o/e? what antibodies are assoc.?
Hashimoto’s thyroiditis (chronic autoimmune thyroiditis) is an autoimmune disorder of the thyroid gland. It is typically associated with hypothyroidism although there may be a transient thyrotoxicosis in the acute phase. It is 10 times more common in women
Features
features of hypothyroidism goitre: firm, non-tender anti-thyroid peroxidase (TPO) and also anti-thyroglobulin (Tg) antibodies
What associations are there with hashimotos thyroiditis?
other autoimmune conditions e.g. coeliac disease, type 1 diabetes mellitus, vitiligo
Hashimoto’s thyroiditis is associated with the development of MALT lymphoma
What diagnosis would be likely if there was a painful goitre and raised ESR with hypothyroidism?
Subacute thyroiditis (de Quervain’s)
associated with a painful goitre and raised ESR
What is subacute thyroiditis? what are the four phases?
Subacute thyroiditis (also known as De Quervain’s thyroiditis and subacute granulomatous thyroiditis) is thought to occur following viral infection and typically presents with hyperthyroidism.
There are typically 4 phases;
phase 1 (lasts 3-6 weeks): hyperthyroidism, painful goitre, raised ESR phase 2 (1-3 weeks): euthyroid phase 3 (weeks - months): hypothyroidism phase 4: thyroid structure and function goes back to normal
What are the investigations and management of subacute thyroiditis?
Investigations
thyroid scintigraphy: globally reduced uptake of iodine-131
Management
usually self-limiting - most patients do not require treatment thyroid pain may respond to aspirin or other NSAIDs in more severe cases steroids are used, particularly if hypothyroidism develops
What is riedel thyroiditis? What does this cause on examination?
Riedel thyroiditis
fibrous tissue replacing the normal thyroid parenchyma causes a painless goitre
On examination a hard, fixed, painless goitre is noted. It is usually seen in middle-aged women. It is associated with retroperitoneal fibrosis.
How can pregnancy affect thyroid function?
Postpartum thyroiditis - hypothyroidism
What is the most common cause of hyperthyroidism in pregnancy?
What is the management?
Graves’ disease is the most common cause of thyrotoxicosis in pregnancy. It is also recognised that activation of the TSH receptor by HCG may also occur - often termed transient gestational hyperthyroidism. HCG levels will fall in the second and third trimester
Management
propylthiouracil has traditionally been the antithyroid drug of choice however, propylthiouracil is associated with an increased risk of severe hepatic injury therefore NICE Clinical Knowledge Summaries advocate the following: 'Propylthiouracil is used in the first trimester of pregnancy in place of carbimazole, as the latter drug may be associated with an increased risk of congenital abnormalities. At the beginning of the second trimester, the woman should be switched back to carbimazole' maternal free thyroxine levels should be kept in the upper third of the normal reference range to avoid fetal hypothyroidism thyrotrophin receptor stimulating antibodies should be checked at 30-36 weeks gestation - helps to determine the risk of neonatal thyroid problems block-and-replace regimes should not be used in pregnancy radioiodine therapy is contraindicated
How is hypothyroidism managed in pregnancy?
Key points
thyroxine is safe during pregnancy serum thyroid-stimulating hormone measured in each trimester and 6-8 weeks post-partum women require an increased dose of thyroxine during pregnancy by up to 50% as early as 4-6 weeks of pregnancy breastfeeding is safe whilst on thyroxine
What drugs can cause thyroid dysfunctions
Drugs
lithium - hypo amiodarone - either
What is the most common cause of hyperthyroidism?
Graves’ disease
most common cause of thyrotoxicosis as well as typically features of thyrotoxicosis other features may be seen including thyroid eye disease It is typically seen in women aged 30-50 years
What 3 features are seen in graves but not in other forms of graves disease?
Features seen in Graves’ but not in other causes of thyrotoxicosis
eye signs (30% of patients) exophthalmos ophthalmoplegia pretibial myxoedema thyroid acropachy, a triad of: digital clubbing soft tissue swelling of the hands and feet periosteal new bone formation
What autoantibodies are found in graves disease? what is found on thyroid scintigraphy?
Autoantibodies
TSH receptor stimulating antibodies (90%) anti-thyroid peroxidase antibodies (75%)
Thyroid scintigraphy
diffuse, homogenous, increased uptake of radioactive iodine
What is the general management of grave’s disease?
Anti-thyroid drugs have emerged as the most popular first-line therapy for Graves’ disease in recent years. Factors that particularly support their use include anti-thyroid drugs significant symptoms of thyrotoxicosis, or patients with a significant risk of hyperthyroid complications (e.g. elderly patients, cardiovascular disease).
Initial treatment to control symptoms
propranolol is used to help block the adrenergic effects
NICE Clinical Knowledge Summaries recommended that patients with Graves’ disease are referred to secondary care for ongoing treatment.
NICE suggest carbimazole should be considered in primary care if patients symptoms are not controlled with propanolol
Describe two regimes of anti-thyroid drug therapy for graves disease?
ATD therapy
carbimazole is started at 40mg and reduced gradually to maintain euthyroidism typically continued for 12-18 months the major complication of carbimazole therapy is agranulocytosis an alternative regime is termed 'block-and-replace' carbimazole is started at 40mg thyroxine is added when the patient is euthyroid treatment typically lasts for 6-9 months patients following an ATD titration regime have been shown to suffer fewer side-effects than those on a block-and-replace regime
What is the mechanism of action of carbimazole? what adverse effects exist?
Mechanism of action
blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin → reducing thyroid hormone production in contrast propylthiouracil as well as this central mechanism of action also has a peripheral action by inhibiting 5'-deiodinase which reduces peripheral conversion of T4 to T3
Adverse effects
agranulocytosis crosses the placenta, but may be used in low doses during pregnancy
When is radioiodine treatment used for graves disease? what are contraindications?
Radioiodine treatment
often used in patients who relapse following ATD therapy or are resistant to primary ATD treatment contraindications include pregnancy (should be avoided for 4-6 months following treatment) and age < 16 years. Thyroid eye disease is a relative contraindication, as it may worsen the condition the proportion of patients who become hypothyroid depends on the dose given, but as a rule the majority of patient will require thyroxine supplementation after 5 years
What is a toxic multinodular goitre? does this cause hypo or hyper thyroidism?
Toxic multinodular goitre
autonomously functioning thyroid nodules that secrete excess thyroid hormones
What is sick euthyroid and what TFTs are assoc?
Common in hospital inpatients. Changes are reversible upon recovery from the systemic illness and no treatment is usually needed
T4 - low
TSH - low
What are the 3 main types of thyroid antibody?
A number of thyroid autoantibodies can be tested for (remember the majority of thyroid disorders are autoimmune). The 3 main types are:
Anti-thyroid peroxidase (anti-TPO) antibodies TSH receptor antibodies Thyroglobulin antibodies
Which antibodies are seen in Graves disease? which ones are assoc. with hashimoto?
There is significant overlap between the type of antibodies present and particular diseases, but generally speaking TSH receptor antibodies are present in around 90-100% of patients with Graves’ disease and anti-TPO antibodies are seen in around 90% of patients with Hashimoto’s thyroiditis.
What is seen on nuclear scintigraphy with toxic multinodular goitre?
Other tests include:
nuclear scintigraphy; toxic multinodular goitre reveals patchy uptake