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AIP: Acute confusional state > Thyroid disease > Flashcards

Thyroid disease Flashcards

1
Q

What proportion of the UK population has hypothyroidism?

A

2%

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2
Q

What is another name of hyperthyroidism?

A

thyrotoxicosis

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3
Q

What is the gender ratio of thyroid disease?

A

10:1 F:M

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4
Q

What is the hormone loop that the thyroid is involved in?

A
  • hypothalamus secreted thyrotropin-releasing hormone (TRH) which stimulates the anterior pituitary
  • Anterior pituitary gland secretes thyroid-stimulating hormone (TSH)
  • TSH acts on the thyroid gland increasing production of thyroxine (T4) and tri-iodothyronine (T3)
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5
Q

What is the role of T4 and T3?

A

act on variety of tissues helping to regulate use of energy sources, protein systhesis, and controls the body’s sensitivity to other hormones

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6
Q

What are the 3 groups that hypothyroidism can be classified into?

A
  1. Primary hypothyroidism
  2. Secondary hypothyroidism
  3. Congenital hypothyroidism
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7
Q

What is primary hypothyroidism?

A

problem with the thyroid gland itself, e.g. autoimmune

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8
Q

What is secondary hypothyroidism?

A

disorder with the pituitary gland (e.g. pituitary apoplexy) or lesion compressing pituitary gland

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9
Q

What is congenital hypothyroidism?

A

problem with thyroid dysgenesis or thyroid dyshormonogenesis

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10
Q

What is the most common cause of hypothyroidism?

A

Hashimoto’s thyroiditis

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11
Q

What are 3 diseases that Hashimoto’s is associated with?

A
  1. Type 1 diabetes mellitus
  2. Addison’s
  3. Pernicious anaemia
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12
Q

What can Hashimoto’s thyroiditis cause transiently in the acute phase?

A

thyrotoxicosis (hyPERthyroidism)

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13
Q

What is the commonest cause of thyrotoxicosis (hyperthyroidism)?

A

Graves’ disease

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14
Q

What is a feature of thyrotoxicosis specific to Graves’ disease?

A

thyroid eye disease

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15
Q

What are 6 other causes of hypothyroidism, in addition to Hashimoto’s thyroiditis?

A
  1. Subacute thyroiditis (de Quervain’s)
  2. Riedel thyroiditis
  3. Postpartum thyroiditis
  4. Drugs - lithium, amiodarone
  5. Iodine deficiency
  6. After thyroidectomy or radioiodine treatment
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16
Q

What are 2 features of subacute (de Quervain’s) thyroiditis?

A
  1. painful goitre
  2. raised ESR
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17
Q

What is Riedel thyroiditis?

A

fibrous tissue replacing the normal thyroid parenchyma

causes a painless goitre

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18
Q

What are 3 drugs which can cause hypothyroidism?

A
  1. Lithium
  2. Amiodarone
  3. Anti-thyroid drugs e.g. carbimazole
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19
Q

What is the most common cause of hypothyroidism in the developing world?

A

iodine

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20
Q

In addition to Graves’ disease what are 5 other causes of thyrotoxicosis?

A
  1. Toxic multinodular goitre
  2. Drugs - amiodarone
  3. Acute phase of subacute (de Quervain’s) thyroiditis
  4. Acute phase of post-partum thyroiditis
  5. Acute phase of Hashimoto’s thyroiditis
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21
Q

What is toxic multinodular goitre?

A

autonomously functioning thyroid nodules that secrete excess thyroid hormones

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22
Q

What are 10 symptoms of hypothyroidism?

A
  1. Weight gain
  2. Lethargy
  3. Cold intolerance
  4. Dry, cold, eyllowish skin
  5. Non-pitting oedema (face, hands)
  6. Dry, coarse scalp hair, loss of lateral aspect of eyebrows
  7. Constipation
  8. Menorrhagia
  9. Decreased deep tendon reflexes
  10. Carpal tunnel syndrome
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23
Q

What are 11 symptoms of thyrotoxicosis?

A
  1. Weight loss
  2. Manis, restlessness
  3. Heat intolerance
  4. Palpitations, may even provoke arrhythmias e.g. AF
  5. Increased sweating
  6. Pretibial myoxedema (above lateral malleoli)
  7. Thyroid acropachy: clubbing
  8. Diarrhoea
  9. Oligomenorrhoea
  10. Anxiety
  11. Tremor
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24
Q

What is the principle investigation in thyroid disease?

A

thyroid function tests

primarily look at serum TSH and T4

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25
Q

Which type of thyroid hormone is rarely used in cases of thyroid disease?

A

T3 - only clinically useul in small number of cases

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26
Q

What is an easy way to remember how cases of hyper- and hypothyroidism present in terms of TFTs?

A

often opposite: T4 low, TSH high in hypothyroidism and vice versa in hyperthyroidism

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27
Q

Which thyroid hormone is most sensitive for monitoring patients with existing thyroid problems and for guiding treatment?

A

TSH

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28
Q

How will thyroid function tests present in thyrotoxicosis e.g. Graves’ disease?

A

Low TSH, high free T4

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29
Q

How will thyroid function tests present in primary hypothyroidism e.g. Hashimoto’s thyroiditis?

A

High TSH, low free T4

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30
Q

What will TFTs show in secondary hypothyroidism?

A

low TSH, low free T4

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31
Q

What will TFTs show in sick euthyroid syndrome?

A

Low TSH, low free T4

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32
Q

When does sick euthyroid commonly occur and what is the management?

A

common in hospital inpatients; changes reversible upon recovery frmo systemic illnes and no treatment is usually needed

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33
Q

What are do TFTs show in subclinical hypothyroidism?

A

High TSH, normal T4

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34
Q

What does subclinical hypothyroidism represent?

A

common finding, represents patients on the way to developing hypothyroidism but still have normal thyroxine levels

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35
Q

What do TFTs show in poor compliance with thyroxine?

A

TSH high, T4 normal

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36
Q

What causes the abnormal TFTs in poor thyroxine compliance?

A

if poorly compliant may only take thyroxine in days before routine blood test, so thyroxine levels normal but TSH lags and reflects longer term low thyroxine levels

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37
Q

What are the 3 main thyroid autoantibodies that can be tested for in thyroid disease?

A
  1. Anti-thyroid peroxidase (TPO) antibodies - Hashimoto’s thyroiditis
  2. TSH receptor antibodies - Graves’ disease
  3. Thyroglobulin antibodies
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38
Q

What thyroid condition are TSH receptor antibodies associaed with?

A

Graves’ disease (90-100% of cases)

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39
Q

What thyroid condition are anti-TPO antibodies associated with?

A

Hashimoto’s thyroiditis

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40
Q

In addition to TFTs what is another test sometimes performed in thyroid disease and what can it show?

A

nuclear scintigraphy: toxic multinodular goitre reveals patchy uptake

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41
Q

What is the treatment of hypothyroidism?

A

thyroxine given in form of levothyroxine

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42
Q

What are 3 things that patients with thyrotoxicosis may be treated with?

A
  1. Propranolol - thyrotoxic symptoms e.g. tremor
  2. Carbimazole
  3. Radioiodine treatment
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43
Q

How does carbimazole work to treat thyrotoxicosis?

A

blocks thyroid peroxidase from coupling and iodinating the tyrosine residues on thyroglobulin - reduces thyroid hormone production

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44
Q

What is an important adverse effet of carbimazole to be aware of?

A

agranulocytosis

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45
Q

What may be seen in TFTs when steroid therapy is being used?

A

low TSH, normal T4

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46
Q

What can cause secondary hypothyroidism?

A

pituitary failure

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47
Q

What are 3 conditions that can be associated with hypothyroidism (in addition to the autoimmune conditions)?

A
  1. Down’s syndrome
  2. Turner’s syndrome
  3. Coeliac disease
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48
Q

What is the commonest cause of hypothyroidism in children (juvenile hypothyroidism)?

A

autoimmune thyroiditis

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49
Q

What are 3 causes of hypothyroidism in children?

A
  1. Autoimmune thyroiditis
  2. Post total-body irradiation eg. treatment for acute lymphoblastic leukaemia
  3. Iodide deficiency
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50
Q

What is the danger of not treating congenital hypothyroidism in babies?

A

irreversible cognitive impairment

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51
Q

What are 5 features of congenital hypothyroidism?

A
  1. Prolonged neonatal jaundice
  2. Delayed mental and physical milestones
  3. Short stature
  4. Puffy face, macroglossia
  5. Hypotonia
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52
Q

What is the significant of subclinical hypothyroidism?

A

risk of progressing to overt hypothyroidism 2-5% (higher in men)

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53
Q

Whatt are 2 factors that increase the risk of subclinical hypothyroidism becoming overt hypothyroidism?

A
  1. Male
  2. Presence of thyroid autoantibodies
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54
Q

What is the managemet of subclinical hypothyroidism if TSH is between 4-10 U/L (normal 0.5-5) and the patient is younger than 65?

A
  • if <65 years with symptoms suggestive of hypothyroidism, give trial of levothyroxine
  • if asymptomatic, observe and repeat thyroid function in 6 months
55
Q

What is the managemet of subclinical hypothyroidism if TSH is between 4-10 U/L (normal 0.5-5) and the patient is older than 65?

A

follow watch and wait strategy, genearlly avoiding hormonal treatment

56
Q

What is the management of subclinical hypothyroidism if TSH is >10 mU/L?

A

start treatment even if asymptomatic with levothyroxine if 70 years old or younger

in older people, especially over 80, follow watch and wait strategy, avoiding hormonal treatment

57
Q

What are 3 key features of Hashimoto’s thyroiditis?

A
  1. Features of hypothyroidism
  2. Goitre: firm, non-tender
  3. Ant-thyroid peroxidase (TPO) and also anti-thyroglobulin (Tg) antibodies
58
Q

What are 2 types of antibodies which may be present in Hashimoto’s thyroiditis?

A
  1. Anti-thyroid peroxidase (TPO)
  2. Anti-thyroglobulin (Tg)
59
Q

What are 4 associations of Hashimoto’s thyroiditis?

A
  1. Coeliac disease
  2. Type 1 diabetes mellitus
  3. Vitiligo
  4. MALT lymphoma
60
Q

What is thought to cause subacute (de Quervain’s) thyroiditis?

A

thought to occur following viral infection, typically presents with hyperthyroidism

61
Q

How does subacute (de Quervain’s) thyroiditis typically present?

A

hyperthyroidism

62
Q

What are the 4 phases of subacute (de Quervain’s) thyroiditis?

A
  1. Phase 1: (lasts 3-6 weeks) hyperthyroidism, painful goitre, raised ESR
  2. Phase 2: (1-3 weeks): euthyroid
  3. Phase 3: (weeks - months): hypothyroidism
  4. Phase 4: thyroid structure and function goes back to normal
63
Q

How long does each phase of subacute (de Quervain’s) thyroiditis last?

A
  • Phase 1: 3-6 weeks
  • Phase 2: 1-3 weeks
  • Phase 3: weeks- months
  • Phase 4: back to normal
64
Q

What is a useful investigation in subacute (de Quervain’s) thyroiditis and what does it show?

A

Thyroid scintigraphy: globally reduced uptake of iodine-131

65
Q

What are 3 aspects of management of subacute/de Quervain’s thyroiditis?

A
  1. Usually self-limiting - most patient’s don’t require treatment
  2. Thyroid pain may respond to aspirin or other NSAIDs
  3. In more severe cases steroids are used, particularly if hypothyroidism develops
66
Q

What is found on examination in Riedel’s thyroiditis?

A

hard, fixed, painless goitre

67
Q

What age/gender group is Riedel’s thyroidit typically seen in?

A

middle-aged women

68
Q

What is an association of Riedel’s thyroiditis?

A

Retroperitoneal fibrosis

69
Q

What are 4 patient groups in whom the starting dose of levothyroxine should be lower when treating hypothyroidism?

A
  1. Elderly patients / patiennts >50 years
  2. Ischaemic heart disease
  3. Other cardiac disease
  4. Severe hypothyroidism
70
Q

What starting dose of levothyroxine is recommended in severe hypothyroidism or in patients over 50?

A

25mcg od

71
Q

How is the dose of levothyroxine changed over time in those who start on a lower dose?

A

titrated slowly

72
Q

If a lower than normal dose is not indicated, what is the usual dose of levothyroxine that patients are started on?

A

50-100mcg od

73
Q

Following a change in thyroxine dose in those being treated for hypothyroidism, when should TFTs be checked?

A

after 8-12 weeks

74
Q

What is the therapeutic goal in hypothyroidism?

A

normalisation of the thyroid stimulating hormone (TSH) level - usually 0.5 - 2.5 mU/L so preferable to aim in this range

75
Q

When should the dose of levothyroxine be increased and by how much?

A

women who become pregnant should have it increased by at least 25-50 mcg due to increased demands of pregnancy

76
Q

What monitoring should be performed when adjusting the levothyroxine dose in pregnancy?

A

monitor TSH carefully, aiming for low-normal value

77
Q

What are 4 side-effects of thyroxine therapy?

A
  1. Hyperthyroidism: due to over treatment
  2. Reduced bone mineral density
  3. Worsening of angina
  4. Atrial fibrillation
78
Q

What are 2 drug interactions with levothyroxine?

A
  1. Iron
  2. Calcium carbonate
79
Q

What must be done due to the risk of interaction of levothyroxine with iron or calcium carbonate?

A

they reduce absorption of levothyroxine so give at least 4 hours apart

80
Q

In which age and gender group is Graves’ disease typically seen?

A

women aged 30-50 years

81
Q

What are 3 features seen in Graves’ disease but not other causes of thyrotoxicosis?

A
  1. Eye signs
  2. Pretibial myxoedema
  3. Thyroid acropachy
82
Q

What are the 2 key eye signs of Graves’ disease?

A
  1. Exophthalmos
  2. Ophthalmoplegia
83
Q

What are the 3 things in the triad of thyroid acropachy?

A
  1. Digital clubbing
  2. Soft tissue swelling of hands and feet
  3. Periosteal new bone formation
84
Q

What are 2 autoantibodies seen in Graves’ disease?

A
  1. TSH receptor stimulating antibodies (90%)
  2. Anti-thyroid perixodiase antibodies (75%)
85
Q

What are 4 treatment options for the management of Graves’ disease?

A
  1. Anti-thyroid drugs e.g. carbimazole
  2. Block-and-replace regimes
  3. Radio-iodine treatment
  4. Surgery
86
Q

What is often given initially when a diagnosis of Graves’ disease is made and why?

A

Propranolol - block adrenergic effects

87
Q

What dose of carbimazole is started and continued in Graves’ disease?

A

started at 40mg, reduced gradually to maintain euthyroidism

88
Q

How long is treatment with carbimazole usually contined in Graves’ disease?

A

12-18 months

89
Q

What is the benefit of a carbimazole titration regime for Graves’ disease?

A

patients suffer fewer side-effects than those on a block and replace regime

90
Q

What does a block-and-replace regime for Graves’ disease involve?

A

carbimazole started at 40mg, thyroxine then added when patient is euthyroid

91
Q

How long does block-and-replace treatment for Graves’ disease last?

A

6-9 months

92
Q

What are 2 absolute and one relative contraindication for radioiodine treatment for Graves’ disease?

A
  1. Absolute: pregnancy
  2. Absolute: age <16 years
  3. Relative: thyroid eye disease
93
Q

Why is thyroid eye disease a relative contraindication for radioiodine treatment of Graves’ disease?

A

may worsen condition

94
Q

How long should pregnancy be avoided for following radioiodine treatment for Graves’ disease?

A

4-6 months

95
Q

What does hypothyroidism following radioiodine treatment for Graves’ disease depend on? How comon is it?

A

dose given

majority will require thyroxine supplementation after 5 years

96
Q

What proportion of patients with Graves’ disease are affected by thyroid eye disease?

A

25-50% of patients

97
Q

What is thought to be the pathophysiology behind thyroid eye disease?

A
  • thought to be caused by autoimmune response against autoantigen, possibly the TSH receptor –> retro-orbital inflammation
  • inflammation results in glycosaminoglycan and collagen deposition in the msucles
98
Q

What is the most improtant modifiable risk factor for the development of thyroid eye disease?

A

smoking

99
Q

What therapy can increase the inflammatory symptoms seen in thyroid eye disease?

A

radioiodine treatment

100
Q

What is a drug that may help reduce the risk of worsening thyroid eye disease with radioiodine treatment?

A

prednisolone

101
Q

What thyroid status might a patient have at the time of presentation with thyroid eye disease?

A

may be eu-, hypo- or hyperthyroid

102
Q

What are 5 possible features of thyroid eye disease?

A
  1. Exophthalmos
  2. Conjunctival oedema
  3. Optic disc swelling
  4. Ophthalmoplegia
  5. Inability to close eyelides - may lead to sore, dry eyes, risk of exposure keratopathy
103
Q

What are 4 aspects of the management of thyroid eye disease?

A
  1. Topical lubircants may be needed to help prevent corneal inflammation caused by exposure
  2. Steroids
  3. Radiotherapy
  4. Surgery
104
Q

What are 6 signs in established thyroid eye disease that indicate the need for urgent review by an ophthalmologist?

A
  1. Unexplained deterioration in vision
  2. Awareness of change in intensity or quality of colour vision in one or both eyes
  3. History of eye suddenly ‘popping out’ (globe subluxation)
  4. Obvious corneal opacity
  5. Cornea still visible when eyelide are closed
  6. Disc swelling
105
Q

What proportion of patients taking amiodarone develop thyroid dysfunction?

A

1 in 6 patients

106
Q

What is thought to be the pathophysiology of amiodarone-induced hypothyroidism?

A

high iodine content of amiodarone causing Wolff-Chaikoff effect - autoregulatory phenomenon where thyroxine formation is inhibited due to high levels of circulating iodide

107
Q

What are 2 overall effects that amiodarone can have on the thyroid?

A
  1. Amiodarone-induced hypothyroidism
  2. Amiodarone-induced thyrotoxicosis
108
Q

What are the 2 types of amiodarone-induced thyrotoxicosis?

A
  1. AIT type 1
  2. AIT type 2
109
Q

What is the pathophysiology of AIT type 1?

A

excess iodine-induced thyroid hormone synthesis

110
Q

What is the pathophysiology of AIT type 2?

A

amiodarone-related destructive thyroiditis

111
Q

In which type of amiodarone-induced thyrotoxicosis is goitre present?

A

AIT type 1

112
Q

What is the management of AIT type 1? 2 options

A

carbimazole or potassium perchlorate

113
Q

What is the management of AIT type 2?

A

corticosteroids

114
Q

In amiodarone-induced thyrotoxicosis vs amiodarone-induced hypothyroidism, when should you stop amiodarone?

A

can continue if desirable in hypothyroidism but must stop in AIT

115
Q

What is thyroid storm?

A

rare but life-threatening complication of thyrotoxicosis; usually established thyrotoxicosis rather than presenting feature

116
Q

What cause of thyrotoxicosis does not usually cause thyroid storm?

A

iatrogenic thyroxine excess

117
Q

What are 4 types of precipitating events of thyrotoxicosis?

A
  1. Thyroid or non-thyroidal surgery
  2. Trauma
  3. Infection
  4. Acute iodine load e.g. CT contrast media
118
Q

What are 7 clinical features of thyroid storm?

A
  1. Fever > 38.5oC
  2. Tachycardia
  3. Confusion and agitation
  4. Nausea and vomiting
  5. Hypertension
  6. Heart failure
  7. Abnormal liver function test - jaundice may be seen
119
Q

What are 6 aspects of the management of thyroid storm?

A
  1. Symptomatic treatment e.g. paracetamol
  2. Treatment of underlying precipitating event
  3. Beta blockers: typically IV propranolol
  4. Anti-thyroid drugs e.g. methimazole or propylthiouracil
  5. Lugol’s iodine
  6. Dexamethasone e.g. 4mg IV qds
120
Q

Why is dexamethasone useful to treat thyroid storm?

A

blocks conversion of T4 to T3

121
Q

What physiological changes to thyroid hormones occur in pregnancy?

A

increase in levels of thyroxine-binding globulin (TBG) this causes an increase in the levels of total thyroxine but does not affect the free thyroxine level

122
Q

What are 3 risks of thyrotoxicosis in pregnancy?

A
  1. Fetal loss
  2. Maternal heart failure
  3. Premature labour
123
Q

What is the most common cause of thyrotoxicosis in pregnancy?

A

Graves’ disease

124
Q

What can cause transient gestation hyperthyroidism? How does this change throughout pregnancy?

A

activation of the TSH receptor by hCG

hCG levels will fall in second and third trimester

125
Q

What is drugs are used to manage thyrotoxicosis in pregnancy (depending on the point in pregnancy)?

A
  • first trimester: propylthiouracil
  • at start of second trimester: switch to carbimazole
126
Q

What is the risk of using carbimazole in the first trimester of pregnancy?

A

may be associated with increased risk of congenital abnormalities

127
Q

What should be the aim for maternal free thyroxine levels when treating thyrotoxicosis in pregnancy and why?

A

should keep in the upper third of the normal reference range

to avoid fetal hypothyroidism

128
Q

What investigation should be performed during pregnancy with thyrotoxicosis and when?

A

thyrotrophin receptor stimulating antibodies, at 30-36 weeks gestation

129
Q

Why is it recommended to check thyrotrophin receptor stimulating antibodies at 30-36 weeks gestation in the case of thyrotoxicosis?

A

helps determine risk of neonatal thyroid problems

130
Q

What are 2 types of treatment for thyrotoxicosis that should not be used in pregnancy?

A
  1. Block and replace regimes
  2. Radioiodine therapy
131
Q

What is safe for the management of hypothyroidism in pregnancy?

A

thyroxine

132
Q

What monitoring should be performed in a woman being treated for hypothyroidism in pregnancy and when?

A

Serum thyroid-stimulating hormone (TSH) in each trimester and 6-8 weeks post-partum

133
Q

How does the treatment of hypothyroidism change in pregnancy?

A

require increased dose of thyroxine, by up to 50% as early as 4-6 weeks of pregnancy

134
Q

Is breastfeeding safe while the mother is on thyroxine?

A

yes

AIP: Acute confusional state (14 decks)

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