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year 2 > thyroid > Flashcards

thyroid Flashcards

1
Q

what vertebra levels is the thyroid gland

A

C5-T1

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2
Q

what is the part called that joins the two lobes of the thyroid

A

isthmus

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3
Q

what tracheal cartilages does the isthmus lie anterior to

A

2nd and 3rd

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4
Q

how will a lump in the thyroid/enlarged gland move during swallowing

A

superior then inferior

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5
Q

what are two anatomical variants of the thyroid gland

A

pyramidal lobe

thyroidea ima

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6
Q

where does a pyramidal lobe usually arise

A

from left lateral lobe

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7
Q

where does a pyramidal lobe usually attach superiorly

A

thyroid cartilage

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8
Q

true/false

all pyramidal lobes are connected to the main gland

A

false - some may not be connected

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9
Q

how high may a pyramidal lobe go

A

the hyoid bone

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10
Q

what gives the thyroid its parasympathetic innervation

A

CN X

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11
Q

what gives the thyroid its sympathetic innervation

A

cervical portion of sympathetic trunk (superior, middle and inferior)

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12
Q

from what do the inferior and superior thyroid arteries branch

A

ECA

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13
Q

where do the superior and middle thyroid veins drain

A

IJV

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14
Q

where does the inferior thyroid vein drain

A

brachiocephalic vein

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15
Q

what is the berry ligament

A

attached posterior medial aspect of the gland

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16
Q

the thyroid develops from the evagination of the _____ epithelium

A

pharyngeal

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17
Q

where does the thyroid begin its development and as what

A

begins as a midline epithelial proliferation at the foramen caecum

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18
Q

through what does the thyroid migrate inferiorly

A

thyroglossal duct

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19
Q

when does the thyroid reach its final position

A

7th week development

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20
Q

what can be found along the thyroglossal duct

A

ectopic tissue (thyroglossal duct cyst)

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21
Q

what is the thyroid made up of

A

follicles

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22
Q

what makes up a follicle

A

follicular cells enclosing a colloid

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23
Q

what is a colloid

A

tyrosine containing thyroglobulin filled sphere

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24
Q

what surrounds each follicle

A

flat to cuboidal follicular epithelial cells

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25
Q

what are the parafollicular cells and what do they secrete

A 
slightly larger cells with clearer cytoplasm
secrete calcitonin (lowers serum Ca but insignificant)
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26
Q

what is at the centre of each follicle

A

dense amorphic pink material containing thyroglobulin

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27
Q

what do the follicular cells take up

A

iodine

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28
Q

how do follicular cells form MIT and DIT

A

iodine taken up is attached to tyrosine residues on thyroglobulin

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29
Q

what makes up T3

A

MIT + DIT

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30
Q

what makes up T4

A

2 x DIT

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31
Q

where are T3 and T4 stored and secreted from

A

colloid thyroglobulin until required

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32
Q

how are thyroid hormones transported in the blood

A

bound to plasma proteins and some free

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33
Q

what are the main transporters of thyroid hormones

A

thyroid binding globulin
thyroid binding prealbumin
albumin (5%)
transthyretin

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34
Q

does TBG or TBPA carry more thyroid hormones

A

TBG (70%) TBPA (20%)

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35
Q

how do thyroid hormones cause transcription of genes

A

bind to receptors in target cells
complex translocation to nucleus
bind to thyroid response elements on target genes
stimulates transcription of genes

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36
Q

what is more common T4 or T3

A

T4 (90%)

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37
Q

is T4 or T3 more potent

A

T3 is 4 times more potent

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38
Q

does T4 or T3 bind better

A

T4 binds better

T3 bound much less avidly by TBG and not significantly by TTR

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39
Q

does T4 or T3 have more rapid onset/offset action

A

T3

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40
Q

what hormone is released from the hypothalamus to start the HPT axis

A

TRH

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41
Q

what hormone is released from the anterior pituitary in response to TRH

A

TSH

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42
Q

what cells release TSH in the anterior pituitary

A

thyrotroph cells

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43
Q

what kind of receptor does TRH act on

A

GPCR - Gq

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44
Q

what kind of receptor does TSH act on to stimulate release of thyroid hormones

A

the TSH receptor on surface of thyroid epithelial cells is a GPCR

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45
Q

what happens when the TSH GPCR is stimulated

A

GTP –> GDP and cAMP is produced - causes production and secretion of T3 and T4

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46
Q

what feedback do the thyroid hormones have on the hypothalamus and pituitary

A

negative feedback (T4–>T3 which causes -ve feedback)

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47
Q

what is the function of deiodinase enzymes

A

activation/deactivation of thyroid hormones by addition/removal of an iodine atom

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48
Q

where is D1 found

A

liver and kidney

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49
Q

where is D2

A 
heart
skeletal muscle
CNS
fat
thyroid 
pituitary
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50
Q

where is D3 found

A

foetal tissue
placenta
brain (not pituitary)

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51
Q

what does D1 do

A

converts T4 to T3

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52
Q

what does D2 do

A

converts T4 to T3

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53
Q

what does D3 do

A

converts T4 to rT3

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54
Q

what is it called when the thyroid fails to descend

A

lingual thyroid

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55
Q

where is the thyroid found if it descends excessively

A

retrosternal location in mediastinum

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56
Q

thyroxine is

A

T4

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57
Q

triiodothyronine is

A

T3

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58
Q

what drugs prevent iodine attaching to tyrosine residues on thyroglobulin to form MIT and DIT

A

carbimazole and propylthiouracel

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59
Q

is T3 or T4 the major biologically active molecule

A

T3

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60
Q

where is T4 converted to T3 mainly

A

liver and kidney

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61
Q

what is measured in ninewells with regard to thyroid function

A

free T3 and free T4

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62
Q

what do thyroid hormones do to the BMR

A

increase BMR

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63
Q

what do thyroid hormones do to thermogenesis

A

increase thermogenesis

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64
Q

what do thyroid hormones do to carbohydrate metabolism

A

increase CHO metabolism

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65
Q

what do thyroid hormones do to to lipid metabolism

A

increase lipid metabolism

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66
Q

what do thyroid hormones do to protein synthesis

A

increase protein synthesis

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67
Q

the production and secretion of what requires thyroid hormones

A

GHRH

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68
Q

what hormones require presence of thyroid hormones for activity

A

GH/somatomedins

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69
Q

what part of foetal development/neonatal brain development requires thyroid hormones

A

myelinogenesis and axonal growth

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70
Q

what do thyroid hormones do to responsiveness to adrenaline and noradrenaline and how

A

increase responsiveness by increasing number of receptors

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71
Q

what do thyroid hormones do to to cardiovascular responsiveness

A

increased rate and force of contraction

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72
Q

what do low temperatures in babies and young children do to TRH release

A

low temperatures stimulate TRH release

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73
Q

what does stress do to the release of TRH and TSH

A

inhibits it

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74
Q

when are thyroid hormones highest and lowest

A

highest late at night and lowest in morning

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75
Q

what is the biochemistry of primary hypothyroidism

A

low fT4/fT3

high TSH

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76
Q

what is the biochemistry of primary hyperthyroidism

A

high fT4/fT3

low TSH

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77
Q

what is the biochemistry of secondary hypothyroidism

A

low/normal TSH

low fT4/fT3

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78
Q

what is the biochemistry of secondary hyperthyroidism

A

high/normal TSH

high fT4/fT3

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79
Q

MCV in primary hypothyroidism

A

increased

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80
Q

CK in primary hypothyroidism

A

increased

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81
Q

LDL cholesterol in primary hypothyroidism

A

increased

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82
Q

Na in primary hypothyroidism

A

hyponatraemia

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83
Q

prolactin in primary hypothyroidism

A

hyperprolactinaemia

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84
Q

ESR, Ca and LFTs in hyperthyroidism

A

increased

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85
Q

what is the main cause of hypothyroidism

A

Hashimoto’s thyroiditis

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86
Q

what are some other causes of hypothyroidism

A 
iodine deficiency
drug induced - amiodarone, lithium
atrophic thyroiditis
post ablative therapy/post radio therapy
post thyroidectomy
pituitary/hypothalamic pathology
87
Q

what 4 autoimmune conditions are commonly seen with hypothyroidism

A

T1DM, Addisons, pernicious anaemia, vitiligo

88
Q

what can hypothyroidism cause in babies

A

cretinism - dwarfism and limited mental function

89
Q

what the main symptoms of hypothyroidism

A 
lethargy/fatigue
slow pulse
constipation
reduced BMR
weight gain but decreased appetite
coarse/sparse hair
hyperlipidemia
cold intolerance
slow responses
mental sluggishness
obstructive sleep apnoea
cramps
deep hoarse voice
depression
menorrhagia/amenorrhoea/oligomenorrhoea
prolonged tendon jerks
90
Q

what are some cardiac effects of hypothyroid

A

cardiac dilation
worsening heart failure
pericardial effusion
reduced HR

91
Q

what are some GI effects of hypothyroid

A

intestinal obstruction
megacolon
ascites

92
Q

what nerve problem is seen in hypothyroidism

A

carpal tunnel

93
Q

other s/s of hypothyroid

A 
pale, cool doughy skin
periorbital oedema
pitting oedema
macroglossia
hyperprolactinaemia
reduced memory
cerebellar ataxia
hypercarotenaemia
myalgia
dull/expressionless face
94
Q

what is the treatment for hypothyroidism in young patients

A

50-100 ug levothyroxine (T4) daily

95
Q

what is the treatment for hypothyroidism in elderly or history of IHD

A

25-50 ug levothyroxine (T4) daily

adjust every 4 weeks according to response

96
Q

when should thyroxine be taken

A

before breakfast

97
Q

how much may dosage increase by in pregnancy

A

by 50%

98
Q

how soon should TSH be checked after a dose change

A

8 weeks

99
Q

how often should TSH be checked once stabilised

A

12-18 months

100
Q

is there any benefit of using T3 and T4 combination therapy

A

no

101
Q

why is T3 rarely used in the treatment of hypothyroidism

A

effects develop within a few hours and disappear within 24-48 hours of discontinuation

102
Q

in secondary hypothyroidism what should amount of thyroxine be titrated against

A

free T4 level - TSH unreliable as decreased

103
Q

when is myxoedema coma mostly seen

A

elderly women with longstanding untreated or unrecognised hypothyroidism

104
Q

what ECG changes are seen in myxoedema coma

A 
bradycardia
low voltage complexes
varying degrees of heart block
T wave inversion
QT interval prolonged
105
Q

how is myxoedema coma treated

A 
ABCDE
passively rewarm
monitor for arrhythmias
monitor urine output, fluid balance, CVP, BG, O2 sats
thyroxine cautiously
106
Q

why might you give hydrocortisone in myxoedema coma

A

10% patients have co-existing adrenal failure

107
Q

what type of respiratory failure does myxoedema coma cause

A

T2RF

hypoxia, hypercapnia, resp. acidosis

108
Q

what can mortality be up to in myxoedema coma

A

60%

109
Q

what is hashimotos thyroiditis

A

autoimmune destruction of the thyroid gland leading to decreased thyroid hormone production

110
Q

what group is hashimotos thyroiditis most seen in

A

females

45-60

111
Q

what HLA genes is hashimotos thyroiditis associated with

A

HLA-PR3

HLA-DR5

112
Q

what antibodies are seen in hashimotos thyroiditis

A

anti-thyroid peroxidase (anti-TPO)

anti-thyroglobulin

113
Q

what do anti-TPO and anti-thyroglobulin cause when bound

A

antibody dependent cell mediated cytotoxicity

114
Q

what is seen microscopically in hashimotos

A

T cell infiltrate and inflammation

115
Q

describe the cytokine mediated cell death seen in hashimotos

A

Y-IFN from T cell activation recruits macrophages

116
Q

what is hashitoxicosis

A

transient hyperfunction preceding hypofunction in hashimotos thyroiditis

117
Q

is hashimotos goitrous

A

yes - lymphatic and plasma cell infiltrate

118
Q

what are you at increased risk of with hashimotos thyroiditis

A

other AI disease

B cell non-hodgkins lymphoma

119
Q

is primary atrophic hypothyroidism goitrous

A

no

120
Q

what are the main symptoms of hyperthyroidism

A 
palpitations
weight loss
heat intolerance
sweating
insomnia
excessively emotional
increased BMR
very fast pulse
nervousness
tremor
irritability
diarrhoea
121
Q

what are some other features of hyperthyroidism

A 
proptosis
AF
diplopia
muscle weakness (upper arms and thighs)
lid retraction
hair brittle and thin
lighter/less frequent periods
rapid fingernail growth
122
Q

what are 4 diseases causing excessive thyroid stimulation and therefore thyrotoxicosis

A

GRAVES
hashitoxicosis
thyrotropinoma
choriocarcinoma

123
Q

what is a thyrotropinoma

A

TSH secreting pituitary adenoma

rare

124
Q

what is a choriocarcinoma

A

trophoblast tumour secreting hCG

125
Q

what are 2 nodular diseases causing thyrotoxicosis

A

toxic solitary nodule

toxic multinodular goitre

126
Q

what is a toxic solitary nodule usually

A

adenoma

127
Q

where is toxic multinodular goitre seen usually

A

elderly

iodine deficient areas

128
Q

what is seen in nodular disease

A

asymmetrical goitre

129
Q

would nodular disease show high uptake on scintigraphy

A

yes - high nodular uptake

130
Q

when would toxic multinodular goitre be treated with surgery

A

symptoms of an enlarged thyroid (dysphagia/dyspnoea)

131
Q

is toxic multinodular goitre antibody positive or negative

A

negative

132
Q

what are 2 causes of ectopic production causing thyrotoxicosis

A

metastatic follicular thyroid cancer

strauma ovarii

133
Q

what is a strauma ovarii

A

ovarian teratoma with thyroid tissue - mostly benign tumours but can be malignant

134
Q

what are 2 other causes of hypothyroidism

A

iodine excess

thyroiditis

135
Q

what is the 1st line antithyroid drug

A

carbimazole once daily

136
Q

what is 2nd line antithyroid drug

A

propylthiouracil twice daily

137
Q

which ATD is used in 1st trimester of pregnancy

A

propylthiouracil

138
Q

what can carbimazole cause in early pregnancy

A

aplasia cutis

139
Q

does carbimazole or propythiouracil cause more side effects

A

propythiouracil

140
Q

how do ATDs work

A

inhibit thyroid peroxidase therefore blocking thyroid hormone synthesis

141
Q

what does propythiouracil also do (aswell as blocking TPO)

A

inhibits DIO1 so stops T4–>T3

142
Q

what 3 effects can ATDs have on the liver

A

cholestatic jaundice
increased liver enzymes
fulminant hepatic failure

143
Q

what is the major side effect of ATDs

A

agranulocytosis

144
Q

what % of people on ATDs get agranulocytosis

A

< 0.5%

145
Q

when is the highest risk of getting agranulocytosis with ATDs

A

first 6 weeks

146
Q

what must you say to a patient starting ATDs

A

written and verbally tell them to stop drug and get urgent blood count in event of fever, oral ulcer or oropharyngeal infection

147
Q

what % of people get an allergic type reaction with ATDs

A

1-5% - urticarial, rash, arthralgia

148
Q

what drug is used for immediate symptomatic relief in hyperthyroid and why

A

propranolol

149
Q

how do beta blockers help in hyperthyroid

A

B-adrenoreceptor blockade, reduced sympathetic activity

also inhibition of DIO1

150
Q

when are beta blockers contraindicated and what should be used instead

A

asthmatics

CCB - diltiazem

151
Q

what is the first line treatment in relapsed Graves and nodular thyroid disease

A

radioiodine

152
Q

when is radioiodine contraindicated

A

pregnancy
breast feeding
active TED (can be used with steroid cover)

153
Q

what is there a risk of when radioiodine is used with graves

A

hypothyroid

154
Q

when is a thyroidectomy useful

A

when radioiodine is contraindicated

155
Q

what causes graves disease

A

circulating IgG autoantibodies binding to and activating GPCR of thyrotropin. this causes smooth thyroid enlargement and increased hormone production

156
Q

what antibodies are seen in graves

A

TSH receptor antibodies (TRAb)

not specific - thyroid peroxisomes + thyroglobulin

157
Q

what group is graves most likely to occur in

A

females

20-50 yr old

158
Q

what acts as TSH in graves

A

thyroid stimulating immunoglobulin (TSI) - unchecked by T3 and T4

159
Q

is there goitre in graves

A

yes - smooth

160
Q

what Ig is seen in graves

A

IgG

161
Q

what are the TSH and fT3/fT4 levels seen in graves

A

decreased TSH

increased fT4/fT3

162
Q

what are the levels of Ca and ALP seen in graves and why

A

Increased ALP
hypercalcaemia
- due to increased bone turnover and osteoporosis

163
Q

what happens to the WCC in graves

A

decreased (leuropenia)

- often mild and not a sign of agranulocytosis

164
Q

what is a definitive diagnosis of graves

A

raised titre of TRAb

165
Q

what is the triad of features seen in graves

A

hyperthyroid +

  • diffuse enlargement of thyroid
  • eye changes
  • pretibial myxoedema
166
Q

what is thyroid acropatchy

A

soft tissue swelling of hands and clubbing of fingers seen in graves

167
Q

what are the eye changes seen in graves

A

TED

168
Q

is there a thyroid bruit in graves

A

yes - with large goitres, not heard in other goitrous conditions

169
Q

is TED uni or bilateral

A

either

170
Q

what is the treatment of mild TED

A

lubricants

171
Q

what is the treatment of severe TED

A

steroids, radiotherapy, surgery

172
Q

how is diplopia treated in TED

A

Fresnal prism

173
Q

what autoimmune conditions is graves assoc. with

A

vitiligo
addisons
T1DM

174
Q

what is a thyroid storm

A

medical emergency - severe hyperthyroidism

175
Q

when is a thyroid storm seen

A

hyperthyroid patients with acute infection/illness/recent thyroid surgery

176
Q

what is seen in a thyroid storm

A

exaggerated reflexes
respiratory/cardiac collapse
hyperthermia

177
Q

what is the treatment of a thyroid storm

A 
ABCDE
lugols iodine
PTU
glucocorticoids
BBs 
fluids and monitoring
178
Q

what is thyroiditis

A

inflammation of the thyroid gland

179
Q

what are some causes of thyroiditis

A 
autoimmune - graves and hashimotos
infection
de quervains/sub acute (viral)
post partum
radiation
drug induced
acute suppurative thyroiditis (bacterial)
180
Q

what are 2 polymorphisms in immune regulation genes assocaited with autoimmune thyroiditis

A

CTLA-4

PTPN-22

181
Q

what does CTLA-4 do

A

negative receptor of T cell responses

182
Q

what does PTPN-22 do

A

inhibits T cell function

183
Q

what is seen in the free T4/T3 levels in sub-acute thyroiditis

A

T4 rises then falls then normal

184
Q

what is seen in the TSH levels of sub acute thyroiditis

A

TSH falls then rises then normal

185
Q

who is sub-acute thyroiditis most likely to occur to

A

females
20-50 years
following viral infection

186
Q

what kind of goitre is seen in sub-acute thyroiditis

A

painful goitre with low uptake on scintigraphy

187
Q

what is the treatment of sub-acute thyroiditis

A

self limiting

NSAIDs

188
Q

what is the effect of amiodarone on thyroid function

A

iodine rich drug structurally similar to T4

can cause hypothyroid due to toxicity from iodine excess or amiodarone induced thyrotoxicosis

189
Q

what is the biochemistry of subclinical hypothyroidism

A

increased TSH

normal T4/T3

190
Q

what is the biochemistry of subclinical hyperthyroidism

A

decreased TSH

normal T4/T3

191
Q

when is treatment advised in subclinical hypothyroidism

A

when TSH > 10

192
Q

when is treatment advised in subclinical hyperthyroidism

A

when TSH < 0.1

or co-existing osteoporosis/fracture/AF

193
Q

when is sick euthyroid syndrome seen

A

unwell hospital patients

194
Q

what is seen in sick euthyroid syndrome

A

TSH typically suppressed initially due to intercurrent illness and then rises during recovery

195
Q

should you check thyroid function in unwell patients

A

not unless clinical suspicion of thyroid disease

196
Q

why may graves settle in pregnancy

A

pregnancy suppresses autoimmune disease - post partum there is an exacerbation of AI diseases

197
Q

why may hyperthyroidism occur in pregnancy

A

hCG increases thyroxine production

198
Q

why may hypothyroidism occur in pregnancy

A

thyroid under extra demand and may not be able to compensate

199
Q

what is the treatment for hyperthyroid with pregnancy

A

supportive
BB if needed
low dose antithyroid drugs (PU 1st trimester)

200
Q

what is post partum thyroiditis

A

previously functioning thyroid gland becomes inflamed within 1st year after child birth - small diffuse non-tender goitre, transiently thyrotoxic then hypothyroid

201
Q

what is a dermoid cyst

A

rare congenital cyst

202
Q

when would a dermoid cyst usually present

A

teens

203
Q

how would you describe a dermoid cyst

A

midline swelling that is soft and non-fluctuant

204
Q

where does a thyroglossal cyst occur

A

anywhere along thyroglossal tract - midline swelling

205
Q

when would a thyroglossal cyst present

A

teens

206
Q

where does a brachial cyst occur

A

upper anterior triangle swelling

207
Q

what is a brachial cyst

A

persisting 2nd brachial arch

208
Q

when does a brachial cyst present

A

teens

209
Q

“half filled water bottle”

A

brachial cyst

210
Q

what is seen on FNA of a brachial cyst

A

cholesterol crystals

211
Q

where does a cystic hygroma occur

A

posterior triangle swelling

212
Q

when would a cystic hygroma present

A

1st year of life

213
Q

how would you describe a cystic hygroma

A

can be large - can cause pressure symptoms
lymph filled
transilluminate

year 2 (19 decks)

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