Hyperthyroidism

Question 1

what is Graves’s disease

Answer 1

autoimmune disease
antibodies attack the thyroid to make it overactive
can be associated with eye disease

Question 2

what are the clinical features of graves disease

Answer 2

smooth goitre with uniformly increased uptake on scintigraphy

Question 3

what is toxic multinodular goitre

Answer 3

multiple lumps (nodules) or enlarged thyroid (goitre)
often one or more lumps will be overactive
can get eyelid lag or lid retraction but no other features of thyroid eye disease
tends to occur as people age

Question 4

what is a toxic nodule

Answer 4

single overactive lump

Question 5

what is thyroiditis

Answer 5

temporary overactivity of thyroid
can be followed by a period of underactivity
triggered by pregnancy, infections or some drugs (amiodarone)

Question 6

what are common symptoms of hyperthyroidism

Answer 6

weight loss despite good appetite (often very hungry)
tiredness
tremor
hot, sweaty
palpitations
diarrhoea
light/absent menses
irritable mood, anxiety
eyes - change in appearance, red, gritty, painful, double vision
muscle weakness

Question 7

what are important features of patient history

Answer 7

past medical history - asthma (use of propranolol) heart disease (risk from tachycardia)
family history - thyroid or other autoimmune disease
social history (eyes), job and family (radio-iodine)

Question 8

what may be present upon examination of hyperthyroidism

Answer 8

agitated
talking fast
increased heart rate (may be in atrial fibrillation)
smooth goitre, multinodal goitre, single nodule, no goitre
bruit heard over goitre almost diagnostic of graves

Question 9

what are common eye problems seen in hyperthyroidism

Answer 9

lid retraction and lid lag - associated with any thyrotoxicosis, caused by activation of sympathetic NS (all other eye signs are associated with graves)
redness
gritty sensation
dry or watery eyes
pain on eye movement
swelling around the eyes
proptosis (pushed forward appearance of the eyes)
double vision
loss of colour vision

Question 10

diagnostic tests

Answer 10

TRAbs (TSH receptor antibodies) - significantly positive indicates graves
thyroid peroxidase (TPO) antibodies are less specific
if TRAbs are negative do scintigraphy

Question 11

drug management of hyperthyroidism

Answer 11

antithyroid drugs (ATDs)
carbimazole and propylthiouracil (PTU)
decrease production of thyroid hormone (block TPO)
not for thyroiditis
propranolol is good for tremor and increased heart rate but contraindicated in asthma

Question 12

why are ATDs contraindicated in thyroiditis

Answer 12

high T4 levels are due to the release of hormone stores from damaged gland not actually due to overactive gland

Question 13

radioactive iodine as treamtent

Answer 13

I131
risk of long-term hypothyroidism
avoid pregnancy for 6 months
restrict contact with children under 12 and pregnant people
limit close contact (don’t share bed with partner for 11 days)

Question 14

risks of surgery as treatment

Answer 14

long-term hypothyroidism
damage to recurrent laryngeal nerve and parathyroid glands (controls calcium)

Question 15

what is the first line treatment for graves

Answer 15

ATDs
12-18 month course of tablets
60-70% of recurrence

Question 16

what is I131 used for

Answer 16

recurrent graves 9once it returns it will keep coming back)
TMMG
toxic nodule (no chance of long-term remission with course of tablets)

Question 17

what are the risks of I131

Answer 17

risk of hypothyroidism (lower with TMNG and toxic nodule than graves)
thyroid eye disease flaring up

Question 18

when is surgery considered

Answer 18

large goitre
eye disease

Question 19

what does active thyroid eye disease look like

Answer 19

may respond to steroids
dynamic picture
active inflammation (redness, swelling, pain change in visual function)

Question 20

what does inactive thyroid disease look like

Answer 20

static picture
there may be severe damage left behind
will not respond to immunosuppression
may need surgical reconstruction

Question 21

what are the features of thyroid eye disease

Answer 21

can have eye disease without thyroid being overactive
thyroid eye disease can even present many months before thyroid disease develops

Question 22

what is the management of thyroid eye disease

Answer 22

unless mild should manage in joint thyroid eye clinic
achieve euthyroidism (both hyper/hypo are bad)
smoking cessation (9x increased risk of developing severe disease and respond less well to treatment)
topical lubricants
selenium 200 mcg daily (antioxidant)
steroids (oral or IV if active eye disease)

Question 23

what should be considered if initial treatments don’t work

Answer 23

consider additional immunosuppressant treatment as it is TRAbs that drive eye disease
consider orbital radiotherapy
surgical decompression if evidence of optic neuropathy and raised intraocular pressure

Question 24

what can be considered once eye disease is inactive

Answer 24

elective eye decompression to resolve residual proptosis
squint surgery if extra-ocular muscle restriction
eyelid surgery if residual swelling or retraction