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Year 2 Medicine > Thyroid disease: Hyper, Hypo and other > Flashcards

Thyroid disease: Hyper, Hypo and other Flashcards

1
Q

Define Hypothyroidism

A

Underproduction of thyroid hormone

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2
Q

Primary Hypothyroidism is due to what type of problem?

A

thyroid problem

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3
Q

Secondary Hypothyroidism is due to what type of problem?

A

hypothalamic/pituitary problem

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4
Q

Define Hyperthyroidism

A

overproduction of thyroid hormone

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5
Q

What is thyrotoxicosis ?

A

Thyrotoxicosis refers to the symptoms caused by the excessive circulation of thyroid hormones.

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6
Q

Define Euthyroid

A

normal production of thyroid hormone

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7
Q

Define Goitre

A

enlargement of thyroid gland

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8
Q

patients with a goitre may be: (3 things)

A

hyperthyroid, hypothyroid, euthyroid (normal thyroid function)

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9
Q

Examination of the thyroid

A

low down in neck feel for thyroid cartilage (‘Adam’s apple) then down and laterally moves on swallowing diffuse or nodular? listen for a bruit retrosternal extension (can you get below it? percuss over sternum) check cervical LNS

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10
Q

What does this image show?

A

X-ray of Retrosternal goitre causing tracheal deviation

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11
Q

Interpreting thyroid function tests

remember …

A

the thyroid axis and negative feedback regulation

what is not working properly?

what is driving the system?

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12
Q

Thyroid function tests are extremely common, … in every … have there thyroid function checked annually

A

1 in every 4

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13
Q

Normal thyroid function test ranges (info)

TSH?

FT4?

FT3?

What Thyroid antibodies are tested?

A

0.3 - 4.2 mu/l

12-22 pmol/l

3.1-6.8 pmol/l

Anti-TPO AB - thyroid peroxidase auto-antibody

TRAB - TSH receptor autoantibody

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14
Q

What are the two thyroid antibodies?

A

Anti-TPO AB - thyroid peroxidase auto-antibody

TRAB - TSH receptor autoantibody

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15
Q

Thyroid stimulating hormone is the best …

A

biomarker of thyroid status

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16
Q

Shape of TSH curve

  • there is a tail from … upwards
  • in this population, more patients have what?
A

tail from 3 upwards

increased frequency of thyroid antibodies

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17
Q

TSH is quite … to respond to change - takes about … weeks

A

slow - takes about 6 weeks

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18
Q

TSH assumes a normal … function

A

pituitary

must measure free thyroid hormones in patients with pituitary problem

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19
Q

Thyroid autoantibodies

The prevalence of autoantibodies is … than the prevalence of autoimmune disease

  • some are causal in disease, whereas some are viewed as a marker of …
  • many auto antigens are sequestered / …
  • negative autoAB result does not exclude …
A

higher

risk marker

intracellular

the disease - presence just helps confirm diagnosis

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20
Q

Different types of thyroid autoantibodies

  • “…” - target thyroid for autoimmune …
  • “…” - stimulate TSH receptor (TRAB)
A
  • destructive
  • stimulatory
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21
Q

What are the symptoms below a sign of?

  • may be none
  • lethargy
  • mild weight gain
  • cold intolerance
  • constipation
  • facial puffiness
  • dry skin
  • hair loss
  • hoarseness
  • heavy menstrual periods
A

hypothyroidism

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22
Q

Severe hypothyroidism signs include:

A
  • Change in appearance e.g face is puffy and pale
  • periorbital oedema
  • dry flaking skin
  • diffuse hair loss
  • bradycardia
  • signs of median nerve compression - carpal tunnel
  • effusions, e.g. ascites, pericardial
  • delayed relaxation of reflexes
  • croaky voice
  • goitre
  • rarely stupor or coma
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23
Q

The symptoms below are a sign of what?

  • Change in appearance e.g face is puffy and pale
  • periorbital oedema
  • dry flaking skin
  • diffuse hair loss
  • bradycardia
  • signs of median nerve compression - carpal tunnel
  • effusions, e.g. ascites, pericardial
  • delayed relaxation of reflexes
  • croaky voice
  • goitre
  • rarely stupor or coma
A

severe hypothyroidism

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24
Q

Causes of Primary Hypothyroidism include: (6 things)

High TSH, low T4, low T3

A
  • autoimmune hypothyroidism
  • hypothyroidism after treatment for hyperthyroidism (iatrogenic)
  • thyroiditis
  • drugs (e.g. lithium, amiodarone)
  • congenital hypothyroidism
  • iodine deficiency (NOT UK)
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25
Q

Causes of Secondary Hypothyrodism is …

  • Caused by diseases of the … or …
  • Low TSH, low T4, low T3
A
  • rare
  • Diseases of they hypothalamus or pituitary
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26
Q

Investigations - Primary hypothyroidism

  • Bloods - TSH (normal range 0.3-4) and FT4 (normal range 10-24) ,what results would be expected?
  • Do these confirm the diagnosis?
  • What else could we check?
  • Is imaging necessary?
A

Higher TSH (E.g. 22miu/l) and Lower FT4 (e.g. 8pmol/l)

  • yes - diagnosis confirmed with blood results
  • could also check thyroid autoantibodies
  • no imaging is necessary
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27
Q

Treatment for hypothyroidism

  • start with …, … micrograms daily (Depending on size/weight of patient)
  • if patient has ischaemic heart disease or is over 65 - start with less (…-… micrograms daily) with increments 4-6 weekly
  • USUAL DOSE = ?
  • the aim is to achieve a normal … level without … suppression
  • no evidence in properly conducted trials to support combination therapy of … and …
A
  • start with thyroxine, 100micrograms
  • use less in these patients - 25-50 micrograms to begin with
  • usual dose is 100-150 micrograms
  • aim - normal FT4 without TSH suppression
  • no evidence for combo of T3 and T4
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28
Q

Chronic autoimmune thyroiditis

  • also known as … disease
  • this term is used to imply that the patient has a … or that their thyroid shows signs of … infiltration
A
  • hashimoto’s disease
  • this term is used to imply that the patient has a goitre or that their thyroid shows signs of thyroid infiltration
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29
Q

Myxoedema (coma)

  • the accumulation of … in interstitial spaces of tissues
  • it is a very … type of …thyroidism
A
  • glycosaminoglycans
  • very severe hypothyroidism
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30
Q

What are the symptoms below a sign of?

  • weight loss
  • lack of energy
  • heat intolerance
  • anxiety/irritability
  • increased sweating
  • increased appetite
  • thirst
  • palpitations
  • pruritus
  • weight gain
  • loose bowels
  • oligomenorrhoea
A

thyrotoxicosis / hyperthyroidism

31
Q

Symptoms of thyrotoxicosis (hyperthryoidism) include:

A
  • weight loss
  • lack of energy
  • heat intolerance
  • anxiety/irritability
  • increased sweating
  • increased appetite
  • thirst
  • palpitations
  • pruritus
  • weight gain
  • loose bowels
  • oligomenorrhoea
32
Q

Signs associated with thyrotoxicosis: (8)

A
  • tremor
  • warm, moist skin
  • tachycardia
  • brisk reflexes
  • eye signs
  • thyroid bruit
  • muscle weakness
  • atrial fibrilation
33
Q

What are the signs below associated with?

  • tremor
  • warm, moist skin
  • tachycardia
  • brisk reflexes
  • eye signs
  • thyroid bruit
  • muscle weakness
  • atrial fibrilation
A

thryotoxicosis/hyperthyroidism

34
Q

Thyroid eye disease (TED) / thyroid associated ophthalmopathy (TAO)

  • Associated with autoimmune … (known as … disease) in approx 20% of patients
  • They may not occur at same time, or at all
  • increased risk in …
  • … mediated
  • inflammation of all orbital tissues except the …
  • … scan imaging helpful
A
  • Associated with autoimmune hyperthyroidism (known as grave’s disease) in approx 20% of patients
  • They may not occur at same time, or at all
  • increased risk in smokers
  • autoantibody mediated
  • inflammation of all orbital tissues except the eye
  • CT scan imaging helpul
35
Q

Symptoms of thyroid eye disease (TED) / thyroid associated ophthalmopathy (TAO)

Mild:

  • eyes are … / …
    • artificial … may help
  • ‘….’ eyes / change in appearance
A
  • eyes are dry/ itchy
    • artificial tears may help
  • ‘prominent’ eyes / change in appearance
36
Q

Symptoms of thyroid eye disease (TED) / thyroid associated ophthalmopathy (TAO)

Worrisome:

  • loss of sight / …
  • loss of … vision (patches are …/…)
  • swelling of …/redness
  • unable to … eyes fully
  • ache/pain/tightness … or … eye
A
  • loss of sight /diplopia
  • loss of colour vision (patches are grey/blurred)
  • swelling of conjunctiva/redness
  • unable to close eyes fully
  • ache/pain/tightness in or behind eye
37
Q

What is shown in this image? (eyes - thyroid eye disease)

A
  • MRI T2 weighting STIR sequencing
  • shows inflammatory activity of extraocular muscles
38
Q

What disease is present?

A

thyroid eye disease

39
Q

Signs associated with thyrotoxicosis:

  • Hands (2 signs)
A
  1. fine tremor
  2. warm
40
Q

Signs associated with thyrotoxicosis:

  • Pulse (2 signs)
A
  • sinus tachycardia
  • atrial fibrillation
41
Q

Signs associated with thyrotoxicosis:

Neck (4 signs)

A
  • goitre
  • move when swallow
  • smooth/not
  • bruit/not
42
Q

Signs associated with thyrotoxicosis:

Eyes (4 signs)

A
  • lid retraction/lag
  • proptosis/exophthalmos
  • ophthalmoplegia (abnormal eye movements, causes diplopia)
  • inflammation (conjunctiva)
43
Q

What is diplopia?

A

technical term for double vision.

44
Q

What is Ophthalmoparesis?

A

refers to weakness (-paresis) or paralysis (-plegia) of one or more extraocular muscles which are responsible for eye movements.

45
Q

What is proptosis/exophthalmos?

A

Exophthalmos, also known as proptosis, is the medical term for bulging or protruding eyeballs.

46
Q

Causes of thyrotoxicosis

  • most common cause is … … (also known as what disease?)
    • what happens in this disease? (autoantibody….)
  • named after doctor who discovered it
    • accounts for …% of hyperthyroidism, typically women of what age?
A
  • Autoimmune hyperthyroidism (Grave’s disease)
  • autoantibody stimulates the TSH receptor, causing excess thyroid hormone production and thyroid growth (goitre)
  • 75% of hyperthyroidism - typically women 30-50 yrs
47
Q

Other causes of thyrotoxicosis (4 things)

  1. toxic … goitre
  2. toxic …
  3. thyroiditis
  4. drugs (such as…)
A
  1. toxic multinodular goitre
  2. toxic adenoma
  3. thyroiditis
  4. drugs (E.g. amiodarone)

Main cause is autoimmune hyperthyroidism

48
Q

Gestational thyrotoxicosis

  • HCG made by the … has a very similar structure to …
  • more likely if hyperemesis (morning sickness) / twin pregnancy
  • settles after … trimester
A
  • HCG made by the placenta has a very similar structure to TSH
  • more likely if hyperemesis / twin pregnancy
  • settles after 1st trimester
49
Q

Helpful diagnostic features (Cause of hyperthyrodism)

more likely to be Grave’s disease if:

  • … or … hx of any autoimmune thyroid/endocrine disease
  • Goitre with a …
  • 20% of those with … have grave’s disease
  • positive thyroid … titre
A
  • Personal or family history
  • Goitre with a bruit
  • thyroid eye disease
  • positive thyroid autoantibody titre
50
Q

Thyroid function tests for hyperthyroidism (e.g. Grave’s disease)

  • TSH < 0.1 miu/l (hyperthyroidism) vs normal range? higher or lower in hyperthyroidism?
  • FT4 30pmol/l (hyperthyroidism) vs normal range? higher or lower in hyperthyroidism?
  • FT3 10pmol/l (hyperthyroidism) vs normal range? higher or lower in hyperthyroidism?
A
  • TSH < 0.1 miu/l (hyperthyroidism) what is normal range? - 0.3-4 (lower in hyperthyroidism)
  • FT4 30pmol/l (hyperthyroidism) what is normal range? - 10-24 (higher in hyperthyroidism)
  • FT3 10pmol/l (hyperthyroidism) what is normal range? - 3-7 (higher in hyperthyroidism)

remember the negative feedback loop

TSH suppressed because thyroid overactivity is supressing TSH production

51
Q

Further investigations for hyperthyroidism (after thyroid function tests)

  • thyroid …
  • may not need any …
  • thyroid … scan (isotope scan)
    • functional scan - darker areas of … activity
A
  • thyroid autoantibodies
  • may not need any imaging
  • thyroid uptake scan (isotope scan)
    • functional scan - darker areas of increased activity
52
Q

Grave’s disease treatment options include: (4 things)

  1. …
  2. …
  3. …
  4. … control - use … blockers but not in people who are …

OR - no treatment - what are the risks?

A
  1. medical
  2. radioiodine
  3. surgery
  4. symptom control (beta blockers - propranolol but not if asthmatic)

OR - no treatment - what are the risks?

  • symptoms worsening
  • AF -> stroke
  • osteoporosis -> fractures
53
Q

Medical Therapy for Grave’s disease

  • 2 drug examples, what are they?
  • how long do you treat for?
  • you can block replace or …
  • rare side effect is …
  • What is the long term cure rate?
  • how many relapse?
A
  • carbimazole or propylthiouracil (PTU)
  • 18 months - 2 years
  • titrate or block replace
  • agranulocytosis is a rare side effect
  • 1/3 long term cure rate
  • 2/3 relapse - usually in first year, cannot predict in advance
    *
54
Q

What is Agranulocytosis?

A

A rare condition in which your bone marrow doesn’t make enough of a certain type of white cell, most often neutrophils.

55
Q

Radioiodine therapy for Grave’s disease

  • it is given …
  • radioiodine is concentrated in the … and kills … cells
  • medical therapy first until thyroid status is …
  • approx 40% risk of permanent … after treatment
  • do not give if … or breast feeding
  • need to avoid prolonged close contact with others for … - … weeks after - tricky if young children
  • not if severe … … disease
  • future pregancies - women wait … months, men … months
  • warn patients about … security systems
A
  • it is given orally
  • radioiodine is concentrated in the thyroid and kills thyroid cells
  • medical therapy first until thyroid status is euthyroid
  • approx 40% risk of permanent hypothyroidism after treatment
  • do not give if pregnant or breast feeding
  • need to avoid prolonged close contact with others for 1 - 2 weeks after - tricky if young children
  • not if severe thyroid eye disease
  • future pregancies - women wait 6 months, men 4 months
  • warn patients about airport security systems
56
Q

Surgery for Grave’s disease

  • sub-total … (“almost total”)
  • patients must be … pre-op
    • medical therapy first
  • risks include:
  1. …
  2. … scar
  3. vocal cord … (recurrent laryngeal nerve damage)
  4. hypothyroidism
  5. hypoparathyroidism
A
  • sub-total thyroidectomy (“almost total”)
  • patients must be euthyroid pre-op
    • medical therapy first
  • risks include:
  1. anaesthetic
  2. neck scar
  3. vocal cord palsy
  4. hypothyroidism
  5. hypoparathyroidism
57
Q

Treatment for a toxic adenoma or toxic multinodular goitre

  • initial treatment - short term … therapy - to control thyroid function tests
  • subsequent curative treatment - …
A
  • initial treatment - short term medical therapy - to control thyroid function tests
  • subsequent curative treatment - radioiodine
58
Q

Agreeing expectations - treating hyperthyroidism

  • reassurance that variety of symptoms all relate to condition e.g …
  • may take time to feel normal again - there will be a ‘…’ phase of a few months
  • treatments for thyroid do not help with … disease
  • risk of weight …
  • confirm family plans - why?
A
  • swings in emotion, anxiety, panic, irritability
  • lag phase
  • eye disease - treatment doesnt help
  • risk of weight gain
  • starting a family - have to wait after radioiodine
59
Q

Blood results - what condition did the person have before starting treatment?

What stays suppressed for a while? what is best to monitor?

A

Hyperthyroidism

TSH stays suppressed for some time - monitor FT4

60
Q

Thyroid Eye Disease - treatment options

Active disease options include

  • encourage … cessation
  • steroids , examples?
  • other immunosuppressive/ …-sparing agents
  • …therapy
A
  • encourage smoking cessation
  • steroids - pulsed IV methylpred/ oral prednisolone
  • other immunosuppressive/ steroid-sparing agents
  • radiotherapy
61
Q

Thyroid Eye Disease - treatment options

‘Burnt out’ thyroid eye disease:

  • may be left with … causing impaired QOL and social avoidance
  • treatment is … - 2 options are
A
  • may be left with disfigurement causing impaired QOL and social avoidance
  • treatment is surgical - 2 options are
  1. orbital decompression
  2. eyelid surgery
62
Q

A rare but dangerous complication of Grave’s disease is called thyroid … or thyrotoxic …

A

thyroid storm or thyrotoxic crisis

63
Q

Who gets thyrotoxic crisis (thyroid storm?)

is it common?

A
  • usually secondary to grave’s
  • unrecognised
  • incompletely treated e.g. start stop, erratic compliance, early on in course, surgery/radioiodine treatment without adequate prep
  • very rare
64
Q

What triggers thyrotoxic crisis (thyroid storm?) (3 things)

A
  • surgery (GA)
  • childbirth
  • acute severe illness such as infection, trauma, diabetic ketoacidosis, stroke, PE
65
Q

Features of thyroid storm

  • It is a …-… condition
  • typical features of … disease
  • hyperpyrexia
  • CNS - agitation, delirium
  • CNS symptoms include (4 things)
  • GI symptoms include (3 things)
A
  • It is a multi-system condition
  • typical features of grave’s disease
  • hyperpyrexia
  • CNS - agitation, delirium
  • CNS symptoms include (4 things)
  1. tachycardia >140bpm
  2. atrial dysrhythmias
  3. ventricular dysfunction
  4. heart failure
  • GI symptoms include (3 things)
  1. nausea and vomiting
  2. diarrhoea
  3. hepatocellular dysfunction
66
Q

What is hyperpyrexia?

A

A term for a very high fever

(occurs in thyroid storm)

67
Q

Thyroid storm has a … mortality rate and involves … level care

A

High mortality rate and involves ITU-level care

68
Q

Does degree of elevation of thyroid hormone concentrations distinguish between uncomplicated thyrotoxicosos and thyroid storm?

A

NO - does not distinguish - harder to recognise

69
Q

Thyroiditis

  • To begin, transient mild …
    • always …
    • B-blockers if required
    • isotope scan would be ‘…’
    • anti-thyroid drugs - do they work?
  • longer phase of what? (4-6months)
    • what % are normal within a year?
    • what treatment may be required for a while? (during this phase)
A
  • transient mild thyrotoxicosis
    • always resolves (1-2months)
    • B-blockers if required
    • isotope scan would be ‘cold’
    • anti-thyroid drugs - do they work? - no
  • longer hypothyroid phase (4-6months)
    • ​80% normal at 1 year
    • may require thyroxine treatment for a while
70
Q

Annual TFTs for thyroiditis patients:

  • What % hypothyroid at 1 year?
  • What % hypothyroid at 3 years?
A
  • What % hypothyroid at 1 year? - 30%
  • What % hypothyroid at 3 years - 50%
71
Q

Thyroiditis, consider if:

  • patient is …/ within one year …-…
    • increased risk in type 1 …, FHx of thyroid …, smoker
  • patient has a very … thyroid
    • may be raised … markers
  • clinical thyroid status does not fit with lab results, why?
  • no diagnositic features of … disease
  • current/recurrent treatment with … medication
A
  • patient is pregnant/ within one year post-partum
    • increased risk in type 1 diabetes, FHx of thyroid disease, smoker
  • patient has a very tender thyroid
    • may be raised inflammatory markers
  • clinical thyroid status does not fit with lab results, why? - rapidly changing thyroid function tests
  • no diagnositic features of grave’s disease
  • current/recurrent treatment with immunomodulatory medication
72
Q

Thyroid function tests - what condition? (thyroid)

  • baby in Jan
A

postpartum thyroiditis

initially, low TSH, high FT4 - thyrotoxic - mildy

then, hypothyroid phase - high TSH, low FT4

73
Q

Association of autoimmune thyroid disease with other diseases

other autoimmune endocrine diseases include: (5)

  1. … . …
  2. … …
  3. … disease
  4. … … …
  5. … disease

syndromes: (2)

  1. … syndrome
  2. …’s syndrome

Medication for other diseases:

  1. lithium - what does this do?
  2. amiodarone

Annual Thyroid function test screening recommended in all of these situations

A
  1. Type 1 diabetes
  2. Pernicious anaemia
  3. Coeliac disease
  4. Premature ovarian failure
  5. Addison’s disease
  6. Turner syndrome
  7. Down’s syndrome
  8. lithium - inhibits Thyroid hormone synthesis and secretion
  9. amiodarone
74
Q

Goitre and thyroid nodules in euthyroid patients

Euthyroid Goitre:

  • is it common?
  • where is it common?
  • may be …
  • usually nothing to worry about

Thyroid nodule:

  • must exclude thyroid … - 5% cancerous, rest benign
  • … scan characterists helpful
  • fine-needle … biopsy for cytology
A

Euthyroid Goitre:

  • is it common? - yes
  • where is it common - in iodine-deficient areas
  • may be multinodular
  • usually nothing to worry about

Thyroid nodule:

  • must exclude thyroid cancer - 5%
  • ultrasound scan characterists helpful
  • fine-needle aspiration biopsy for cytology

Year 2 Medicine (162 decks)

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