Hyperthyroid

Question 1

Presentation of Hashitoxicosis

Answer 1

-Chronic autoimmune
-Transient hyperthyroid phase (acute phase)
-Women (10:1)
-Hypothyroidism features
-Firm, small, non-tender goitre
-Other autoimmune disease
-Associated development of MALT lymphoma

Question 2

Investigations of Hashitoxicosis

Answer 2

-TPO (anti-thyroid peroxidase)
-Tg (anti-thyroglobulin) antibodies
-Low TSH, high T4 and T3
-Positive but low-titre TPO
-Low radioiodine uptake

Question 3

Management of Hashitoxicosis

Answer 3

-Usually observation
-Beta-blocker or CCB with or without corticosteroid if moderate to severe/ cardiovascular disease

Question 4

Describe toxic adenoma

Answer 4

-Presentation: unilateral, non-tender thyroid mass/ hard and irregular suggests malignancy, iodine deficiency risk factor, 20-40yrs

-Investigation: suppressed TSH, thyroid ultrasound, hot nodule with suppression of extra-nodular tissue, no antibodies

-Management: radioactive iodine therapy, antithyroid drugs pre-treatment, subtotal thyroidectomy (first line if compression symptoms)

Question 5

Presentation of toxic multinodular goitre

Answer 5

-Compressive symptoms (breathlessness, hoarse voice, dysphagia, neck pressure).
-Non-tender irregular thyroid nodules- at least 2 autonomously functioning (benign follicular adenomas)
-60+ in iodine deficiency areas.

Question 6

Investigations of toxic multinodular goitre

Answer 6

-Nuclear scintigraphy (patchy uptake, multiple hot and cold)
-Peripheral thyroid hormone levels not as high as Graves’
-Radioactive iodine uptake normal
-No antibodies
-Suppressed TSH
-Ultrasound and fine needle aspiration to investigate unknown nodules

Question 7

Management of toxic multinodular goitre

Answer 7

-Radioactive iodine
-Pre-treatment antithyroid drugs
-Thyroid surgery (especially when suspicion of cancer)

Question 8

Describe TSH-mediated hyperthyroidism

Answer 8

-Presentation: history of brain or metastatic cancer, headache, visual field defects, no autoimmune relevant

-Investigation: inappropriately normal or elevated serum TSH level (not fully suppressed) associated with elevated free T4 and total T3 concentrations, MRI pituitary gland= tumour

Question 9

Presentation of de Quervain’s/ subacute thyroiditis

Answer 9

-Tender, firm, irregular, diffusely enlarged thyroid gland which may be asymmetrical
-Thyroid pain
-Fever- post viral inflammatory process.
-Hyperthyroid in phase 1, 3-6 weeks
-Neck pain
-Palpitations
-Myalgia

Question 10

Investigation and management of de Quervain’s thyroiditis

Answer 10

-Investigation: ESR, CRP, thyroid scintigraphy (globally reduced uptake of iodine-131), no antibodies

-Management: usually self-limiting, aspirin/ NSAIDs, steroids in severe cases, beta-blocker

Question 11

Describe post-partum thyroiditis

Answer 11

-Presentation: between 2-6 months postpartum, lasts 1-2 months, followed by hypothyroidism

-Investigation: thyroid peroxidase antibodies

-Management: propranolol (symptomatic)

Question 12

Describe amiodarone-related hyperthyroidism

Answer 12

-Presentation: small goitre

-Investigation: low TSH, raised FT4, raised or normal FT3

-Management: carbimazole