Thyroid and Parathyroid Flashcards

1
Q

function of thyroid gland

list hormones as well

A

Secretion of hormones

  • Thyroxine T4
  • Triiodothyronine T3
  • Reverse T3 (inactive form of T3)
  • Calcitonin

Both modulate metabolism

  • Energy utilization
  • Heat production

Regulate/facilitate growth

Brain development

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2
Q

biofeedback control of thyroid hormones

A
  1. Hypothalamus releases Thyroid Releasing Hormone (TRH) –> Stimulates pituitary to release TSH
  2. TSH then binds to the thyroid, which then secretes T4 and T3 –> inhibit secretion of TSH
    • directly and indirectly by suppressing the release of TRH
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3
Q

list common dz assoc w/ hyperthyroidism

A

Graves disease (autoimmune) 60% of cases

  • Autoantibodies bind to the TSH receptor –> stimulate the gland to ‘hyper function’ –> excess hormones

Toxic multinodular goiter

  • Focal or diffuse follicular hyperplasia
  • High level of nodularity

Toxic nodular goiter (Plummer’s disease)

  • Single hyperfunctional nodule
  • “Hot” on thyroid scan

Other

  • Pituitary adenoma (TSH secreting)
  • Meds (ex. amiodarone, lithium)
  • Head/neck radiation
  • Neck surgery
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4
Q

si/sx of hyperthyroidism

A
  • Periorbital edema
  • Diplopia, Proptosis , Exophthalmos
  • Tachycardia/arrhythmia (ex. palpitations)
  • Irritability/nervousness
  • Sweating/heat intolerance
  • DEC concentration/ Fatigue
  • Muscle weakness/cramps
  • Weight loss despite ­ appetite
  • Skin Δ (dermopathy) on lateral aspects of shins
  • Acropathy (nail clubbing)
  • +/- hyperreflexia
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5
Q

dx hyperthyroidism

Graves?

A

DEC TSH

­ INC T3 (total) /T4 (free)

+/- abs (Graves)

  • Anti-thyroid perixodase antibody (Anti-TPO)
  • Anti- Thyrotropin receptor antibodies 80-90%
  • Thyroid-stimulating immunoglobulin (TSI)
  • ­INC Ca
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6
Q

imaging hyperthyroidism

A

US +/- doppler – FIRST line (Cyst vs. solid)

Nuclear scintigraphy w/ RAIU (­ uptake)

  • Technetium (Tc-99) or Iodine (I-123)
  • info about size/shape of gland
  • Location of functional activity within the gland

Type of functioning

  • Warm/hot “functioning nodule”
  • Cold “non-functioning nodule” (malignancy)
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7
Q

tx graves dz

A

Thioamides (side of choice agranulocytosis)

  • Methimazole –> Requires tapering down to maintenance
  • Propythiouracil (PTU) –> pregnancy & Also requires tapering

Mild disease, small goiter –> Goal of remission after 1 year of treatment

  • Treat additional year if still (+) antibodies

Pre-op patients –> To get them Euthyroid

Radioactive iodine – Tx of choice

Surgery (subtotal vs. total)

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8
Q

Tx of Toxic multinodular goiter

A

Sub-total thyroidectomy > Radioactive Iodine (131 Iodine)

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9
Q

tx of Toxic nodular goiter (Plummer’s disease)

A

Radioactive Iodine (131 Iodine) > unilateral lobectomy

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10
Q

Toxic multinodular goiter

VS

Toxic nodular goiter (Plummer’s disease)

A

Toxic multinodular goiter - High level of nodularity

  • Focal or diffuse follicular hyperplasia

Toxic nodular goiter (Plummer’s disease)

  • Single hyperfunctional nodule
  • “Hot” on thyroid scan
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11
Q

on Nuclear scintigraphy w/ RAIU (­ INC uptake) is a warm or cold nodule assoc w/ malignancy

A

Warm/hot “functioning nodule”

Cold “non-functioning nodule” (malignancy)

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12
Q

define thyroid storm

A

Untreated hyperthyroidism - SEVERE

•Can be brought on by stress (ex. trauma, MI, infection)

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13
Q

si/sx of thyroid storm

A

Exaggerated presentation of hyperthyroidism

  • Tachycardiac (>140 bpm)
  • HTN à CHF
  • Fever (104-106°)
  • AMS - Agitation, delirium, psychosis, stupor, or coma
  • N/V / Abdominal pain
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14
Q

tx thyroid storm

A

Beta-blocker – control HR

IV thionamide - to block new hormone synthesis

PO Lugol’s solution - to block the release of thyroid hormone

Iodinated radiocontrast- to inhibit the peripheral conversion of T4- to-T3

Hydrocortisone - ↓T4-to-T3 conversion

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15
Q

define thyrotoxicosis & most commonc cause of it

define subacute thyroititis & common cause

A
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16
Q

thyroid scan - diffuse uptake or irregular/diminished upstake

Graves

Toxic multinod

Toxic goiter - plummers dz

A

diffuse uptake - Graves

irregular/diminished upstake

  • Toxic multinod
  • Toxic goiter - plummers dz
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17
Q

list types of Hypothyroidism

A

Hashimoto’s (autoimmune thyroiditis)

  • B-lymphocytes invade thyroid and produce autoabs
  • Hashimoto’s is #1 cause in US
  • Iodine Deficiency #1 cause in developing countries
  • Most common inflammatory condition of thyroid gland
  • Most common cause of goiter
  • ‘Body attacks thyroid’, destroys thyroidà B-lymphocytes invade the thyroid gland –> “chronic lymphocytic thyroiditis”

Other:

  • Iodine deficiency
  • Thyroidectomy
  • Deficient HPO axis - Central hypothyroidism
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18
Q

Most common inflammatory condition of thyroid gland

Most common cause of goiter

developing countries?

A

hashimotos hypothyroidism

Iodine Deficiency #1 cause in developing countries

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19
Q

si/sx of hypothyroidism

A
  • Fatigue/lethargy
  • Cold intolerance
  • Constipation
  • Weight gain / Depression
  • Menorrhagia
  • Hoarseness
  • Weakness/ Myalgias/arthralgias
  • HA
  • Dry skin
  • Coarse, thinning hair
  • Periorbital edema
  • Bradycardia
  • Hyporeflexia - ↓DTRS

Gland is diffusely enlarged; firm and rubbery and nodular –> atrophic and fibrotic

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20
Q

dx hypothyroid

A

INC­ TSH

DEC T3/T4

+/- abs (Hashimoto’s)

  • (+) autoantibodies (hallmark)
  • High titers of abs to thyroglobulin, thyroid peroxidase
  • ↑Anti-Thyroid Peroxidase (TPOAb)
  • ↑Thyroglobulin antibody (TgAb)
  • Thyroid Stimulating Blocking Antibodies (TSbAb)

Imaging:

  • US +/- doppler
  • Nuclear scintigraphy w/ RAIU –> (DEC uptake)
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21
Q

tx hypothyroidism

A

Levothyroxine (Synthroid) synthetic T4

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22
Q

Hyperthyroidism - ___TSH & ___ T3/T4

Hypothyroidism - ___TSH & ___ T3/T4

A

Hyperthyroidism - DEC TSH & INC T3/T4

Hypothyroidism - INC TSH & DEC T3/T4

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23
Q

define Myxedema coma

A

complciation opf hypothyroidism

Medication cessation

  • Impaired cognition, confusion à coma (myxedema coma)
  • Most often seen in elderly and those who have stopped taking meds
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24
Q

si/sx of Myxedema coma

A
  • AMS
  • Severe hypothermia
  • Hypoventilation
  • Hyponatremia
  • Hypoglycemia
  • Hypotension
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25
Tx Myxedema coma
**IV Levothyroxine** – LARGE DOSES **Treat hypothermia** – slowly warm to prevent cardiac events +/- intubation/ mechanical ventilation Monitor for infection **+/- hydrocortisone** - Suspected concomitant adrenal insufficiency
25
Complication of hyperthyroid \_\_\_ Complication of hypothyroid \_\_\_
Complication of **hyperthyroid**: _Thyroid storm_ Complication of **hypothyroid**: _Myxedema coma_
26
2 classifications of Thyroiditis
**Painful**- Subacute granulomatous thyroiditis **Painless** * Med induced (ex. amiodarone, lithium) * Hashimoto’s
27
list typea of thyroid nodules
Mostly Benign ## Footnote * Cyst * Follicular adenoma * Colloid nodule * Malignancy
28
malignnancy suspicition w/ thyroid nodule if..?
* History of head/neck radiation * Young age * Recent onset, rapid growth * Family h/o medullary thyroid cancer
29
dx thyroid nodule
**RAIU scan (hot vs. cold)** * The hotter the nodule on scan, the less likely lesion/nodule is cancerous **Tissue Bx**
30
List types of thyroid cancer
Papillary 60% Follicular 20% Anaplastic 14% Medullary 5%
31
si/sx of Thyroid cancer
**•Painless, palpable, firm/fixed nodule** **•Rapid growth** * Vocal cord paralysis * Hoarseness
32
thyroid cancer dx of choice
US guided fine needle aspiration
33
type of thyroid cancer Linked to iodine deficiency
Follicular 20%
34
thyroid cancer w/ ## Footnote ↑ serum calcitonin levels confirm diagnosis
Medullary 5%
35
tx of choice for what type of thyroid cancer: ## Footnote Surgical isthmusectomy to Prevent tracheal compression
Anaplastic 14%
36
tx of thyroid cancers ## Footnote Papillary 60% Follicular 20%
Lobectomy on lesions \< 1.5 cm 1.5 cm lesions = near-total thyroidectomy Life-long levothyroxine after surgery
37
thyroid cancer seen in those \>50 y/o
Anaplastic 14%
38
thyroid cancer seen families (AD)
Medullary 5%
39
dx thyroid cancer: reasons to use ## Footnote **US guided fine needle aspiration** – **RAIU thyroid scan** - **+/- CT/MRI w/o contrast** -
**US guided fine needle aspiration** – dx of choice **RAIU thyroid scan** - Can provide hint whether malignant or not **+/- CT/MRI w/o contrast** - Evaluate soft tissue extension of large or suspicious thyroid mass
40
tx of thyroid cancer
**Surgery (subtotal vs. total)** * Near-total’ vs lobectomy * Depends on lesion size and type * Modified neck dissection if evidence of lymph node metastases **Medication** _Post-op triiodothyronine (T3_) x 3 months * Stop T3, 2 weeks later _Thyroid Scan with radioactive Iodine-131_ * _uptake_…tx w/ radioactive Iodine-131 * _no uptake_…levothyroxine to suppress TSH Annual f/u
41
tx thyroid cancer: Thyroid Scan with radioactive Iodine-131 * uptake…tx w/ \_\_\_\_\_ * no uptake…\_\_\_\_\_\_to suppress\_\_\_\_
Thyroid Scan with radioactive Iodine-131 * _uptake_…tx w/ r**adioactive Iodine-131** * _no uptake_…**levothyroxine** to suppress **TSH**
42
PTH monitors & regulates blood Ca++ Low Ca++ ...? High Ca++....?
**Low Ca++** --\> _Parathyroid_ glands secrete _PTH_ --\> **↑Ca++** **High Ca++** --\> _Thyroid_ gland release _calcitonin_ --\> **↓Ca++**
43
when do you need to correct serum Ca++
**When hypo or hyperalbuminemia** ## Footnote Hypoalbuminemia can cause pseudohypocalcemia Ca++ = Ca++ measured + (0.8 (4- measured albumin))
44
PTH monitors & regulate PO4 levels Low PO4 High PO4
**Low PO4** --\> _Parathyroid_ glands secrete _PTH_ --\> **↑PO4** **High PO4-**-\> _Parathyroid_ glands secrete _PTH_ --\> **↓PO4**
45
2 causes of Hypocalcemia (Ca+ \< 8.5) more common cause?
**↓ calcium entering the blood-** Most common cause * Vitamin D deficiency- may be ingesting Ca but unable to absorb from GI tract * Hypoparathyroidism/Pseudohypoparathyroidism **Too much calcium leaving the blood** * Kidney failure- cannot reabsorb Ca++ * 2o Hyperparathryoidism * Tissue injury & Inflammatory process * Acute pancreatitis- Free fatty acids bind to free Ca++ * Too many blood transfusions- Additives bind to free Ca++ * Hyperphosphatemia- Ca++ going to bone and extra-skeletal tissue
46
pathophys of hypocalc
PTH stimulates bone resorption --\> release Ca++ from bones into blood PTH ↑ reabsorption of Ca++ in the kidneys PTH activates 1, 25-(OH)2 VitD (active form) from 25-(OH) VitD (storage form from diet/sunlight) Active Vitamin D (1,25-(OH)2 Vit D= calcitriol) * Active Vit D --\> ↑intestinal Ca++ absorption
47
si/sx of hypocalc
**Chvostek sign & Trousseaus sign** **Hyperreflexia** **Tetany** **Muscle spasms** Seizures Abd pain **Prolonged QTc**
48
dx hypocalcemia
**Chvostek sign & Trousseaus sign** **ECG** (prolonged QTc) DEC Ca Albumin (corrected Ca) **Dec PTH, Mg, 25-OH Vit D** **INC PO4**
49
etiology of hypocalcemia * (INC/DEC ) PTH- Hypoparathroidism * (INC/DEC ) PTH- Kidney disease, Vit D deficiency, pseudohypoparathyroidism
**↓PTH**- Hypoparathroidism **↑PTH**- Kidney disease, Vit D deficiency, pseudohypoparathyroidism
50
tx hypocalcemia
**Severe (\<7.5), symptomatic** * Supp. Mg FIRST * IV Ca+ gluconate * Admit to telemetry **Mild (\>7.5), asymptomatic** * PO Ca+ replacement * Vit D repletion
51
most common cause of Hypoparathyroidism
↓PTH (cannot make PTH) * **Surgery** (thyroid or parathyroid-ectomy, * head/neck ca.) * Neck radiation * Autoimmune * Genetics
52
si/sx of Hypoparathyroidism acute mild-mod severe
**Acute –** Tetany (hallmark) - neuromuscular irritability **Mild-Mod** * Asymptomatic * Perioral numbness, paresthesias of the hands and feet * Irritability, lethargy, anxiety * Muscle cramps/spasms **Severe** * Carpopedal spasm (ex. Trouseau’s sign) * Laryngospasm * Refractory heart failure * Seizures
53
dx Hypoparathyroidism
**↓Ca++ (**(PTH causes this to inc normally) Cr / Albumin **↓PTH** Mg 25-(OH) Vit D **↑PO4 (**PTH causes this to dec normally) **ECG** --\> QTc prolongation
54
tx Hypoparathyroidism severe mild-mod
**Severe** * IV Ca++ * IV Calcitriol (1,25-(OH)2 VitD – active form) **Mild- Moderate** * PO Ca++ * IV Calcitriol (1,25-(OH)2 VitD – active form)
55
define Pseudo - hypoparathyroidism
Condition associated with resistance to PTH
56
dx Pseudo - hypoparathyroidism
↓Ca++ ↑PO4 **↑PTH (appropriately high due to low Ca++)**
57
common causes of Hypercalcemia (Ca+ \> 10.5)
**Too much calcium entering the blood** * Excessive bone resorption * _Hyperparathyroidism_ * _Malignant Tumors_ * Thyrotoxicosis * Paget Disease, others **Excessive calcium absorption** * Excess Vit D * Milk alkali syndrome * Medications (thiazide dueretics) **Less calcium leaving the blood** * Adrenal insufficiency * Adrenal failure
58
si/sx of hypecalc
**“Bones, Stones, Groans, & Psychiatric Moans”** * **Bone pain, Muscle weakness** * Nephrolithiasis * Polyuria * Fatigue/lethargy * Confusion, hallucinations * Anxiety/ depression * Constipation, Nausea * **Slow / absent reflexes** _Calcitonin_ * Secreted from Thyroid gland * Opposes PTH --\> ↓Ca++ in blood
59
dx hypercalc
* **ECG** (shorted QTc) * 24-hour urine * INC Ca * Albumin **(↑corrected Ca)** * _↓PTH- Malignancy_, VitD intoxication * _↑PTH-_ 1o hyperparathyroidism, familial hypocalciuric hypercalcemia, 3o hyperparathyroidism * DEC Mg * INC 25-OH Vit D
60
tx hypercalc mild mod-severe
**Mild, asymptomatic** * Treat underlying etiology * Oral fluids & PO4 repletion **Mod-severe (\>14), symptomatic** * IV fluids * Loop diuretics * Calcitonin * Bisphosphonates * Denosumab * Prednisone
61
complciations hypocalc hypercalc
hypocalc - cardiac arrythmias _(Torsades, afib)_ hypercalc - cardiac arrythmias (_bradycardia_, AV block)
62
names types of Hyperparathyroidism
**Primary** - Parathyroid gland secretes ↑PTH regardless of Ca++ leve * _Parathyroid adenoma_ * Hyperplasia * _Carcinoma_ * FHH **Secondary** - Parathyroid gland hyperplasia * Prolonged CKD * Vit D deficiency **Tertiary** - 2/2 2o Hyperparathyroidism after many years, Parathyroid gland secretes ↑PTH regardless of Ca++ level even if original cause corrected * ESRD
63
Hyperparathyroidism Dx: Ca PO4 PTH Primary Secondary Tertiary
**Primary - ALL INC PTH** * _INC Ca_ * _DEC PO4_ * INC PTH **Secondary** - ONLY one to DEC Ca - (Ca and PO4 Oppisites) * _DEC Ca_ * _INC PO4_ * INC PTH **Tertiary** * INC Ca * INC PTH
64
dx imaging of Hyperparathyroidism
**DXA scan**- BMD **Skull Xray**- “salt and pepper” --\> Cystic bone spaces **Renal imaging** to evaluate for stones --\> XRay, CT, MRI **Sestamibi pararthyroid scan** --\>Indicated if doing surgery
65
Tx Hyperparathyroidism asymp symp acyte hypercalcemia
**Asymptomatic** : Observation +/- surgery **Symptomatic** * Parathyroidectomy * Cinacalcet **Acute hypercalcemia** * IV Fluids * Loop Diuretics
66
complications of Hyperparathyroidism
**Parathyroid adenoma** * Profound hypocalcemia (_Hungry Bone Syndrome)_ **Parathyroid carcinoma**: Mets to bone & lung
67
2 associations of Parathyroid Adenoma
**Associated with MEN I** (parathyroid, pancreatic tumor, pituitary adenoma) **Associated with MEN IIa** (medullary carcinoma of the thyroid, pheochromocytoma, hyperplasia of the parathyroid)
68
Parathyroid Adenoma most common location
**Right inferior gland** most common location--\> Hyperactivity of one gland --\> atrophy of remaining 3
69
Parathyroid Adenoma si/sx
Si/sx of hypercalcemia **“Bones, Stones, Groans, & Psychiatric Moans”** * Bone pain, Muscle weakness * Nephrolithiasis * Polyuria * Fatigue/lethargy * Confusion, hallucinations * Anxiety/ Depression * Constipation, Nausea * **Slow / absent reflexes**
70
dx Parathyroid Adenoma
**↑Ca++** **↓PO4** **↑PTH** **Sestamibi scan** – localizes the mass
71
complication of Parathyroid Adenoma
**Hungry Bone Syndrome** after excision * Remove adenoma --\> Remove excess PTH * _Rapid, profound, prolonged hypocalcemia_ (calcium taken up by bone
72
si/sx of Parathyroid Carcinoma
Symptoms of **hypercalcemia** * More likely to have sx vs a parathyroid adenoma, more likely to have neck mass **“Bones, Stones, Groans, & Psychiatric Moans”** * Bone pain, Muscle weakness * Nephrolithiasis * Polyuria * Fatigue/lethargy * Confusion, hallucinations * Anxiety/ Depression * Constipation, Nausea * **Slow / absent reflexes**
73
dx Parathyroid Carcinoma
↑Ca++ ↓PO4 ↑PTH (more likely to be abnormal vs parathyroid adenoma)
74
complication of Parathyroid Carcinoma
Can metastasize to bone and lung
75
Hypercalc - Hypo/er reflexia hypocalc - Hypo/er rreflexia
Hypercalc - hyporeflexia hypocalc - Hyperreflexia
76
hypercal ECG - hypocal ECG -
hyp**_e_**rcal ECG - short**_e_**d QTc hyp**_o_**cal ECG - _prolonged_ QTc