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203: Theme 1: The Endocrine System > Thyroid disease: hyper, hypo and other > Flashcards

Thyroid disease: hyper, hypo and other Flashcards

1
Q

Hypothyroidism

A

Underproduction of thyroid hormone

Primary- due to a thyroid problem

Secondary- due to a hypothalamic/ pituitary problem

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2
Q

Hyperthyroidism

A

Thyrotoxicosis

Overproduction of thyroid hormone

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3
Q

Euthyroid

A

Normal production o f thyroid homrone

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4
Q

Goitre

A

Enlargement of thyroid gland

Patients may be

  • hyperthyroid
  • euthyroid
  • hypothyroid
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5
Q

Examining the thyroid

A

Low down in the neck

Feel for thyroid cartilage then down and laterally

Moves on swallowing

Listen for a bruit

Retrosternal extension

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6
Q

Normal range thyroid function tests

A

TSH: 0.3-4.2 mu/l

FT4: 12-22 pmol/l

FT3: 3.1-6.8 pmol/l

Thyroid antibodies

  • anti-TOP AB (thyroid peroxidase auto antibody)
  • TRAB (TSH receptor auto antibody)
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7
Q

TSH

A

The best biomarker of thyroid status

Slow to respond to change (about 6 weeks)

Assumes normal pituitary function

Remember the negative feedback regulation

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8
Q

Thyroid autoantibodies

A

Prevalence of autoAB > autoimmune disease
- marker of risk, or causal

Negative autoAB result does not exclude autoimmune disease; presence heps confirm diagnosis

Different types of thyroid autoantibodies

  • destructive- target thyroid for autoimmune destruction
  • stimulatory- stimulate TSH receptor
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9
Q

Symptoms of hypothyroidism

A

May be none

Lethargy

Mild weight gain

Cold intolerance

Constipation

Facial puffiness

Dry skin

Hair loss

Hoarseness

Heavy menstrual periods

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10
Q

Signs of serve hypothyroidism

A

Change in appearance e.g. face puffy and pale

Perioribital oedema

Dry flaking skin

Diffuse hair loss

Bradycardia

Sings 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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11
Q

Causes of primary hypothyroidism

A

Autoimmune hypothyroidism

Hypothyroidism after treatment for hyperthyroidism

Thyroiditis

Drugs (e.g. lithium, amiodarone)

Congenital hypothyroidism

Iodine deficiency

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12
Q

Causes of secondary hypothyroidism

A

Diseases of the hypothalamus or pituitary

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13
Q

Treatment for hypothyroidism

A

Start with thyroxine (T4) 100ug daily

  • shorter symptomatic period
  • unless elderly/ ischaemic heart disease

Usual dose 100-150ug daily
- some variation with body weight

Aim normal FT4 without TSH suppression
- individual variation: may need fine tuning within reference ranges

No evidence in properly conducted trials to support T4/T3 combination

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14
Q

Chronic autoimmune thyroiditis

A

Hasimoto’s disease

With a goitre

With a lymphocytic infiltration

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15
Q

Myxoedema (coma)

A

Accumulation of glycosaminoglycans in interstitial spaces of tissues

Very severe hypothyroidism

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16
Q

Symptoms of thyrotoxicosis

A

Weight loss

Lack of energy

Heat intolerance

Anxiety/ irritability

Increased sweating

Increased appetite

Thirst

Palpitations

Pruritus

Weight gain

Loose bowel

Oligomenorrhoea

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17
Q

Signs of thyrotoxicosis

A

Tremor

Warm, moist skin

Tachycardia

Brisk reflexes

Eye signs

Thyroid bruit

Muscle weakness

Atrial fibrillation

18
Q

Mild symptoms of thyroid eye disease/ thyroid associated opthalmopathy

A

Itchy/ dry eyes

Prominent eyes/ change in appearance

19
Q

Worrisome symptoms of TED/ TAO

A

Diplopia/ loss of sight

Loss of colour vision

Redness/ swelling of conjunctiva

Unable to close eyes fully

Ache/ pain/ tightness in or behind eye

20
Q

Signs associated with thyrotoxicosis

A

Hands

  • fine tremor
  • warm

Pulse

  • sinus tachycardia
  • atrial fibrillation

Neck

  • goitre
  • move when swallow
  • smooth/ not
  • bruit/ not

Eyes

  • lid retraction/ lid lag
  • proptosis/ exophthalmos
  • opthalmoplegia
  • inflammation
21
Q

Causes of thyrotoxicosis

A

Graves disease

Autoantibody stimulates the TSH receptor

Causes excess thyroid hormone production and thyroid growth

22
Q

Other causes of thyrotoxicosis

A

Toxic multinodular goitre

Toxic adenoma

Thyroiditis

Drugs (e.g. amiodarone)

23
Q

Gestational thyrotoxicosis

A

Placental B-human chorionic gonadotrophin is structurally similar to TSH and TSH like action on the thyroid

Increased likeliness if hyperemesis/ twin pregnancy

Settles after 1st trimester of pregnancy

24
Q

Likely Graves disease if

A

Personal or family history of any autoimmune thyroid/ endocrine disease

Goitre with a bruit = graves disease

Thyroid eye disease = graves disease (20%)

Positive thyroid autoantibody titre

25
Q

Graves disease treatment options

A

Medical

Radioiodine

Surgery

Symptom control
- beta blockers

Risks of no treatment

  • symptoms worsening
  • atrial fibrillation
  • osteoporosis
26
Q

Medical therapy of Graves disease

A

Carbimazole of propylthiouracil

18 months - 2 years

Titrate or block replace

Rare side effect: agranulocytosis

Approx 1/3 long term cure rate

2/3 relapse
- usually first year

27
Q

Radioiodine

A

Oral treatment, radioiodine concentrated in thyroid, radiation kills thyroid cells

Medical therapy first till euthyroid

Not if pregnant. breast feeding

Need to acoid prolonged close contact with other for 1-2 weeks after

Not if severe thyroid eye disease

28
Q

Surgery

A

Sub-total thyroidectomy

Patients must be euthyroid pre-operatively

Risks

  • anaesthetic
  • neck scar
  • hypothyroidism
  • hypoparathyroidism
  • coval cord palsy
29
Q

Treatment for a toxic adenoma or toxic multinodular goitre

A

Initial treatment: short term medical therapy

Subsequent curative treatment: radioiodine

30
Q

Thyroid eye disease treatment options

A

Active

  • encourage smoking cessation
  • steroid
  • other immunosuppressive/ steroid sparing agents
  • radiotherapy

Burn out

  • may be left with disfigurement causing impaired quality of life
  • surgical treatment (orbital decompression, eyelid surgery)
31
Q

Thyroid storm

A

Thyrotoxic crisis

32
Q

Who gets thyroid storm?

A

Usually secondary graves

Unrecognised

Incompletely treated

  • start- stop
  • erratic compliance
  • early on in course of treatment
  • surgery/ radioiodine treatment without adequate preparation
33
Q

What triggers thyroid storm?

A

Surgery

Childbirth

Acute severe illness

  • infection
  • trauma
  • diabetic ketoacidosis
  • stroke
  • pulmonary embolus
34
Q

What are the features of thyroid storm?

A

Multi-system

Graves (goitre, TED)

Hyperpyrexia

CNS (agitation, delirium)

CV (tachycardia, atrial dysrhythmias, ventricular dysfunction, heart failure)

GI (nausea and vomiting, diarrhoea, hepatocellular dysfunction)

35
Q

Thyroiditis

A

Transient mild thyrotoxicosis

  • always resolves
  • beta blockers if required
  • isotope scan would be cold
  • anti thyroid drugs will not work

Longer hypothyroid phase

  • 80% normal at 1 year
  • may require thyoxine treatments for a while
36
Q

Consider thyroiditis if

A

Patient is pregnant/ within 1 year post partum

Patient has very tender thyroid

Clinical thyroid status does not fit with lab results

No diagnostic features of Graves disease

Current/ recent treatment with immunomodulatory medication

37
Q

Associations of autoimmune thyroid disease with other autoimmune endocrine diseases

A

Type 1 diabetes

Pernicious anaemia

Coeliac disease

Premature ovarian failure

Addison’s disease

38
Q

Association of autoimmune thyroid disease with syndromes

A

Turner syndrome

Down’s syndrome

39
Q

Association of autoimmune thyroid disease with medication for other diseases

A

Lithium
- inhibits thyroid hormone synthesis and secretion

Amiodarone

40
Q

Euthyroid goitre

A

Common

More common in iodine deficient areas

May be multinodular

Usually nothing to worry about

41
Q

Thyroid nodule

A

Must exclude thyroid cancer

Ultrasound scan characteristics helpful

Fine needle aspiration biopsy for cytology

203: Theme 1: The Endocrine System (22 decks)

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