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Endocrinology > Thyroid Pathology > Flashcards

Thyroid Pathology Flashcards

1
Q

List the 3 most common embryological abnormalities that affect the thyroid gland

A

Failure of descent – lingual thyroid
Excessive descent – retrosternal location in mediastinum
Thyroglossal duct cyst-

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2
Q

How does a thyroglossal duct cyst present

A

localised lump in midline of neck

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3
Q

How can the size of the thyroid gland be pathological

A

Enlargement can have many causes but has potential to cause local mass effects - most severe is complicating the airway
Atrophy can lead to reduced function

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4
Q

What is a goitre

A

enlargement of thyroid for any reason

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5
Q

What are the 2 most common autoimmune conditions that affect the thyroid

A

Grave’s disease - hyperfunction
Hashimoto’s thyroiditis - hypofunction

Both cause inflammation

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6
Q

Does autoimmune thyroiditis have a genetic cause

A

There is susceptibitly associated with HLA haplotype
Incidence increased in family members
Associated with other autoimmune diseases - If you have one type then you are at higher risk of others

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7
Q

What causes thyrotoxicosis

A 
Excess of T3 and T4 
85% due to Graves 
Tumours of the thyroid can cause excess production 
Thyroiditis 
Ectopic production 
Excessive intake of thyroid drugs
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8
Q

Grave’s disease is an autoimmune condition - true or false

A

True

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9
Q

What is the cause of symptoms in Grave’s disease

A

Auto-antibodies to TSH receptors - specific to Grave’s (TRAb)
They stimulate the thyroid gland (mimic TSH) to produce more hormones
This bypasses the feedback loop
Decreased TSH but increased free T4/3

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10
Q

What are the clinical features in Grave’s

A

Hyperthyroidism with diffuse enlargement of the thyroid (can come with a bruit)
Eye changes - exophthalmos and inflammation
Pretibial myxoedema - bilateral plaques
Severe clubbing - thyroid acropachy

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11
Q

What can cause hypothyroidism

A 
Mostly Hashimoto's thyroiditis - autoimmune 
Iodine deficiency 
Certain drugs 
Post therapy 
Congenital abnormality 
IBEM
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12
Q

What causes the hypothyroidism in Hashimoto’s

A

Autoantibodies (anti-TPO) attack enzymes involved in hormone production and damage the thyroid tissue
Gradual failure
Also causes inflammation so inflammatory cells and cytokines also cause damage

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13
Q

Which age group tends to get Hashimoto’s

A

45-60

More common in women

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14
Q

Which age group tends to get Grave’s

A

20-40

More common in women

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15
Q

Which other conditions does Hashimoto’s increase your risk of

A

Other auto-immune conditions

B cell NHL - lymphoma

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16
Q

Describe the presentation of a diffuse goitre

A

Usually euthyroid - functions normally
Get mass effects
T3 / T4 normal but TSH high

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17
Q

What causes diffuse goitres

A

Ingestion of substances limiting T3/T4 production
Inborn errors of metabolism
Most cases – cause unknown

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18
Q

What causes a multinodular goitre

A

Evolution from long standing simple goitre
Recurrent hyperplasia and involution
Enlargement

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19
Q

What can multinodular goitres cause

A

Rupture of follicles, haemorrhage, scarring, calcification

Mass effects

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20
Q

What are the 4 types of carcinoma that can affect the thyroid (from most common to least)

A

Papillary - 75-85%
Follicular -10-20%
Medullary - 5%
Anaplastic - <5%

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21
Q

Describe adenomas of the thyroid

A

Discrete solitary mass
Benign
Encapsulated by a surrounding collagen cuff
Composed of neoplastic thyroid follicles
Usually non-functional but may secrete thyroid hormones

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22
Q

Which age and sex are mostly affected by carcinomas

A

ANY age

Female predominance

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23
Q

Which cells do thyroid carcinomas develop from

A

Folliuclar - Follicular epithelium
Papillary - papillary cells
Medullary - parafollicular C cells
Anaplastic - poorly differentiated so hard to tell

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24
Q

What can lead to papillary thyroid carcinomas

A

Ionising radiation

Mutation in the RAS/ MAP kinase pathway

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25
Q

What can lead to follicular thyroid carcinomas

A

Iodine deficiency
Mutations in PI3K/ATK pathway
Variety of other mutations

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26
Q

What can lead to medullary thyroid carcinomas

A

Mutations in MEN2

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27
Q

What can lead to anaplastic thyroid carcinomas

A 
Many mutations (similar ones to P and F) 
p53 mutation
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28
Q

How do papillary carcinomas present

A

Usually solitary nodule in thyroid
Often cystic
May be calcified or multifocal
May have lymph node mets

Normal or slightly raised TSH

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29
Q

What are the main symptoms of papillary carcinoma

A 
Lesion in thyroid or nodes 
Hoarseness 
Dysphagia 
Cough 
Dyspnoea 
(resp features suggest advanced disease)
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30
Q

How does papillary carcinoma spread

A

Usually to lungs

Haem spread uncommon

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31
Q

How are the survival rates for papillary carcinoma

A

Good

95% at 10 years

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32
Q

How does follicular carcinoma present

A 
Usually single nodule 
Slowly enlarging 
Painless 
Non-functional
Rarely presents with mets 
Invasive growth pattern 
Older age group

Normal or slightly raised TSH

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33
Q

How does follicular carcinoma spread

A

Through blood
Mets in bone, lungs and liver
Node spread is rare

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34
Q

What is the prognosis of follicular carcinoma

A

Depends on extent of invasion and stage at presentation

Mortality 50% at 10 years

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35
Q

What is medullary carcinoma associated with

A

Multiple Endocrine Neoplasia II - if you have this genetic background then it can present very young
Familial medullary carcinoma - seen in adults
Amyloid deposition

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36
Q

How does medullary carcinoma present

A

Sporadic - single nodule
Familial case - bilateral or multicentric
Some form of thryoid mass

Calcitonin or CEA elevated

Composed of spindle or polygonal cells arranged in nests
Associated with amyloid deposition

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37
Q

What are the symptoms of medullary carcinomas

A

Neck mass with local effects (dysphagia, hoarseness, airway compromise)
Paraneoplastic syndromes: Diarrhoea due to VIP production or Cushings due to ACTH production

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38
Q

What is the treatment for medullary carcinoma

A

Total thyroidectomy
5 year survival 70-80%
May recur

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39
Q

List some good prognostic factors for medullary carcinoma

A

Young age
Female
Familial setting
Tumour size and if confined to the gland

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40
Q

Describe the presentation of anaplastic carcinoma

A

Undifferentiated and aggressive tumours
Usually older patients and those with history of thyroid cancer
Rapid growth and involvement of neck structures (airway issues, hoarseness) and death

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41
Q

How do you determine the likelihood of thyroid malignancy

A 
Thyroid cytology - aspirate and analyse
Thy 1 – insufficient/uninterpretable
Thy 2 – benign
Thy 3 – atypia probably benign/equivocal
Thy 4 – atypia suspicious of malignancy
Thy 5 – malignant
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42
Q

What cells make up the parathyroid gland

A

Chief cells
round cells with moderate cytoplasm and bland round central nuclei
Secrete PTH

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43
Q

What can cause Hyperparathyroidism

A

Usually small adenoma
Hyperplasia
Secondary to renal failure, low Ca intake, Vit D deficiency (overactive to compensate)
It can become autonomous

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44
Q

What are the symptoms of hyperparathyroidism

A 
Bone disease - pain, fracture, osteoporosis 
Renal stones 
Constipation, nausea
Gall stones 
Depression
Lethargy, weakness and fatigue 
Calcification of valves
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45
Q

What can cause hypoparathyroidism

A

Post-op
Rare congenital absence in Di George syndrome
Very rare

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46
Q

What are the symptoms of hypoparathyroidism

A

Tetany - muscle spasm
Altered mental state - anxiety, depression, confusion etc
Calcification of lens and cataract formation
Prolong QT interval in ECG
Basal ganglia calcification, Parkinsonian

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47
Q

what is a key sign of a thyroglossal cyst

A

It will move when you stick out your tongue

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48
Q

What is a potential complication of thyroglossal cyst

A

If it gets too large it can compress other structures such as airway

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49
Q

How does hypo/hyperthyroidism impact fertility

A

Reduced fertility

Causes anovulatory cycles

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50
Q

How is the thyroid gland affected by pregnancy

A

increased demand during pregnancy - increased size and production
plasma protein binding increases
maternal thyroxine is important for foetal development - especially CNS

51
Q

How do you manage pre-existing hypothyroidism in pregnancy

A

Increase dose of thyroixine by 25mcg as soon as pregnant
On average dose will be increased by 50%
regular testing is needed

52
Q

What are the potential complications of not treating hypothyroidism in pregnancy

A

Increased abortion, preeclampsia, abruption, postpartum haemorrhage, preterm labour,
Affects foetal neuropsychological development

53
Q

What impact does hCG have on thyroxine

A

Increased it secretion as needed in pregnancy

Same affect as TSH as similar structure

54
Q

What common pregnancy condition can mimic hyperthyroidism

A

Hyperemesis gravidarum - extreme morning sickness

Raised hCG caused Gestational hCG-asscociated Thyrotoxicosis

55
Q

How do you distinguish between Hyperemesis and Hyperthyroidism?

A

Hyperemeiss will have high hCG and low TSH
Wont be TRab antibody positive
Will resolve by 20 weeks
Treat for hyperthyroidism if it persists past this stage

56
Q

What complications can hyperthyroidism cause in pregnancy

A

Infertility
Spontaneous miscarriage
Stillbirth
Thyroid crisis in labour - particularly in C section

57
Q

What causes Transient Neonatal thyrotoxicosis

A

Thyroid receptor antibodies cross placenta and cause baby’s thyroid to become hyperactive – will go away eventually once the antibodies leave the system (baby doesn’t produce its own)

58
Q

How do you manage hyperthyroidism in pregnancy

A

At first wait to see if it settles (around 20 weeks)
If it doesn’t give B blockers if needed
Low dose anti-thyroid drugs - Propylthiouracil 1st trimester
- Carbimazole 2/3rd trimester

59
Q

What are the risks of taking carbimazole in pregnancy

A

Can cause embryopathy in 1st trimeter
Scalp abnormalities
GI abnormalities
Choanal & Oesophageal atresia

60
Q

What are the risks of taking propylthiouracil in pregnancy

A

Risk of liver toxicity

Best avoided except possibly in 1st trimester, but then switch to CBZ

61
Q

Describe Post Partum Thyroiditis

A

Thyroxine rises 6-8 weeks after delivery – becomes overactive
Then crashes after 4 months and becomes underactive - this is linked to post-partum depression
Usually corrects over time

62
Q

How do you treat post-partum thyroiditis

A

Don’t give carbimazole in hyper phase as it makes the crash much worse
Do give thyroxine during hypo phase – if symptomatic

63
Q

What is a primary thyroid disease

A

Disease affecting the thyroid gland itself
Can occur with or without a goitre
Autoimmune disease is the most common cause

64
Q

What is a secondary thyroid disease

A

One with no thyroid gland pathology
Usually caused by hypothalamic or pituitary disease
Much rarer than primary

65
Q

Describe the hormone levels in primary hypothyroidism

A

Free T3/4 low

TSH high

66
Q

Describe the hormone levels in primary hyperthyroidism

A

Free T3/4 high

TSH low

67
Q

Describe the hormone levels in secondary hypothyroidism

A

Free T3/4 low
TSH low (or ‘normal’)
TSH isn’t able to increase to counteract low T3/4

68
Q

Describe the hormone levels in secondary hyperthyroidism

A 
Free T3/4 high
TSH high (or ‘normal’)
Often a TSH secreting tumour of pituitary (extremely rare) so doesn’t respond to negative feedback and will continuously stimulate release of thyroid hormones
69
Q

List some causes of Goitrous primary hypothyroidism

A 
Chronic thyroiditis (Hashimoto’s thyroiditis)
Iodine deficiency
Drug-induced (e.g. amiodarone, lithium)
Maternally transmitted (e.g. antithyroid drugs)
Hereditary biosynthetic defects
70
Q

List some causes of non-goitrous primary hypothyroidism

A

Atrophic thyroiditis
Post-ablative therapy (e.g. radioiodine, surgery)
Post-radiotherapy (e.g. for lymphoma treatment)
Congenital developmental defect

71
Q

List some causes of self-limiting primary hypothyroidism

A

Following withdrawal of antithyroid drugs
Subacute thyroiditis with transient hypothyroidism
Post-partum thyroiditis

72
Q

What are the hair and skin clinical features of hypothyroidism

A 
Coarse, sparse hair
Dull, expressionless face
Periorbital puffiness
Pale cool skin that feels doughy to touch
Vitiligo may be present
Cold intolerance 
Fluid retention - pitting oedema
73
Q

What are the cardiac features of hypothyroidism

A

Bradycardia
Worsening of pre-existing heart failure
Cardiac dilatation
Pericardial effusion

74
Q

What are the metabolic features of hypothyroidism

A

Hyperlipidaemia
Decreased appetite
Weight gain
Low metabolic rate

75
Q

What are the GI features of hypothyroidism

A

Constipation
(Megacolon and intestinal obstruction)
(Ascites)

76
Q

What are the respiratory features of hypothyroidism

A

Deep hoarse voice - uncommon
Macroglossia - enlarged tongue
Obstructive sleep apnoea

77
Q

What are the neurological/ CNS symptoms of hypothyroidism

A 
Decreased intellectual and motor activities
Depression, psychosis, neuro-psychiatric
Muscle stiffness, cramps
Peripheral neuropathy
Prolongation of the tendon jerks
Carpal tunnel syndrome
Decreased visual acuity
78
Q

What are the gynae/reproductive symptoms of hypothyroidism

A

Menorrhagia - heavy periods
Later oligo- or amenorrhoea - missed periods
Hyperprolactinaemia - ↑TRH causes ↑ PRL secretion

79
Q

Describe the typical biochemical picture of primary hypothyroidism

A 
Increased TSH 
Decreased free t3/4 
Increased mean cell volume 
Increases creatinine kinase 
Increased LDL cholesterol 
Hyponatraemia 
Hyperprolactin
80
Q

How do you treat hypothyroidism

A

Younger patients: start levothyroxine at 50-100 μg daily
In the elderly with a history of IHD: start levothyroxine at 25-50 μg daily, adjusted every 4 weeks according to response
Check TSH 2 months after every change and then every 12-18 months

81
Q

What is a myxoedema coma

A

Severe and often a first presentation of untreated hypothyroidism - causes a coma
Typically affects elderly women
High mortality

82
Q

What are the symptoms of a myxoedema coma

A

Bradycardia, heart block, T wave inversion, prolonged QT
Type 2 respiratory failure - hypoxaemia and hypercapnia
Hypothermia
Also get very oedematous - hold onto water, become hyponatraemic and may get pleural effusions

83
Q

How do you treat myxoedema coma

A

Intensive care, remember – A, B, C!
Passively rewarm
Cardiac monitoring
Antibiotics - broad spectrum
Close monitoring of BP, urine output, oxygen
Give thyroxine
Can give T3 if you have it as it has a more rapid onset

84
Q

What is thyrotoxicosis

A

clinical, physiological and biochemical state arising when the tissues are exposed to excess thyroid hormone
Caused by hyperthyroidism

85
Q

What are the cardiac symptoms of thyrotoxicosis

A

Palpitation, atrial fibrillation (AF)
Increased CO - force and rate
Cardiac failure (very rare)

86
Q

What are the CNS symptoms of thyrotoxicosis

A 
Tremor 
Sweating 
Anxiety and irritability 
Sleep disturbance 
heat Intolerance
87
Q

What are the GI symptoms of thyrotoxicosis

A

Frequent, loose bowel movements

88
Q

What are the eye symptoms of thyrotoxicosis

A 
Lid retraction (not specific to Graves’)
Double vision (diplopia)
Proptosis (Graves’)
89
Q

What are the hair and skin symptoms of thyrotoxicosis

A

Hair change – brittle, thin hair

Rapid fingernail growth

90
Q

What are the reproductive symptoms of thyrotoxicosis

A

menstrual cycle changes - lighter and less frequent

loss of libido

91
Q

What are the muscle symptoms of thyrotoxicosis

A

Muscle weakness - especially in thighs and upper arms

92
Q

What are the metabolic symptoms of thyrotoxicosis

A

weight loss
increased appetite
due to increase in metabolic rate

93
Q

How does thyrotoxicosis affect thermogenesis

A

Intolerance to heat

94
Q

What conditions associated with hyperthyroidism can cause thyrotoxicosis

A 
Excessive thyroid stimulation
Graves’ disease
Hashitoxicosis
Thyrotropinoma (very rare)
Thyroid cancer
Thyroid nodules with autonomous function
95
Q

What is hashitoxicosis

A

early stage of hashimotos where they get temporary hyperthyroid before their gland failure and they go hypo

96
Q

What conditions NOT associated with hyperthyroidism can cause thyrotoxicosis

A

Thyroid inflammation (thyroiditis)

  • Subacute (de Quervain’s)
  • Post-partum thyroiditis
  • Drug-induced (e.g. amiodarone)

Exogenous thyroid hormones

  • Over-treatment with levothyroxine
  • Thyrotoxicosis factitial

Ectopic thyroid tissue

  • Metastatic thyroid carcinoma
  • Struma ovarii (teratoma containing thyroid tissue)
97
Q

What causes a thyroid bruit

A

Hypervascularity of thyroid
Seen in Grave’s
Associated with large goitres

98
Q

Is smoking related to Grave’s disease

A

YES

very significant - must encourage cessation

99
Q

describe nodular thyroid disease

A

seen in older patients and has insidious onset
thyroid may feel nodular, often assymterical
Get high fT3/4 and low TSH

100
Q

What is a thyroid storm

A

Medical emergency
Most severe presentation of overactive thyroid - rare
Get respiratory and cardiac collapse, hyperthermia and exaggerated reflexes
Typically seen in hyperthyroid patients with an acute infection/illness or recent thyroid surgery
Has a high mortality

101
Q

How do you treat a thyroid storm

A

Lugol’s Iodine - shocks the gland to buy you time
Glucocorticoids
PTU
β-blockers
Lithium can also be used - reduces T4 to T3 conversion
May give muscle relaxants to reduce tremor and heat production
May need ICU for fluids, ventilation monitoring

102
Q

Describe the use of carbimazole

A 
1st line drug
Once daily dosing
Lower rate of side effects compared to PTU (14 vs 52%)
Risk of aplasia cutis in early pregnancy
Treats hyperthyroidism
103
Q

Describe the use of propylthiouracil

A 
1st line only in 1st trimester of pregnancy
Twice daily dosing
10x less potent compared to carbimazole
Inhibits DIO1 (↓T4 to T3 conversion)
1:10,000 risk of liver failure
104
Q

What are the side affects of anti-thyroid drugs

A

Generally well tolerated
allergic type reaction - rash, urticaria etc
PTU can cause jaundice and liver failure
Agranulocytosis

105
Q

How are B blockers used in treatment of hyperthyroidism

A

Propranolol is the drug of choice

Useful for immediate symptomatic relief - slows heart

106
Q

How is radioiodine used in treatment of hyperthyroidism

A

1st choice for relapsed Grave’s and nodular thyroid disease
Cant use in pregnancy
Easy to give but must avoid other people until radioactivity has decreased
High risk of hypothyroidism when used in Graves’ disease

107
Q

How is thyroidectomy used in treatment of hyperthyroidism

A

Used when radioiodine is contraindicated
Leaves you with a scar
Comes with the surgical/anaesthetic risk

108
Q

What is thyroiditis

A

inflammation of the thyroid

109
Q

What can cause thyroiditis

A 
Hashimoto’s
De Quervain’s/subacute (viral)
Post-partum
Drug-induced (amiodarone, lithium)
Radiation
Acute suppurative thyroiditis (bacterial)
110
Q

Describe subacute thyroiditis

A

Ages 20-50 years
May be triggered by viral infection
May be associated with neck tenderness, fever, or other viral symptoms
Usually self limiting

111
Q

What is sick euthyroid syndrome

A

Non-thyroid based illness
Occurs in unwell, hospitalised patietns
Severe infection, sepsis or recent surgery can lead to abnormal thyroid function
Will give abnormal test results at the time but no real issue

112
Q

Describe typical hormone levels in someone with Grave’s disease

A

High T4
T3 either high or normal
Low TSH

113
Q

What causes exophthalmos in Grave’s disease

A

Water build up and retroorbital swelling
Collagen fibres may also be deposited

Eyes become pushed forward and may have difficulty with eye movement and redness

114
Q

What are toxic multinodular goitres

A

Functioning autonomous nodules that secrete large amounts of thyroid hormones
2nd most common cause of hyperthyroidism

115
Q

Describe de Quervain’s thyroiditis

A

Caused by acute inflammatory process - usually viral
Cause of hyperthyroidism
Get usual symptoms as well as fever, malaise and local tenderness

116
Q

Describe the appearance of Grave’s disease on Thyroid scintigraphy

A

If the thyroid is enlarged and has high uptake across whole gland it is graves

117
Q

Describe the appearance of thyroiditis on Thyroid scintigraphy

A

Homogenously reduced tracer uptake

118
Q

Describe the appearance of a multi-nodular goitre on Thyroid scintigraphy

A

Focal uptake

One large area of increased uptake (black)

119
Q

What structure can be damaged by thyroid surgery

A

Recurrent larygeal nerve hooks around the back so can be damaged - will lead to a hoarse voice

120
Q

How can amiodarone cause a thryoid abnormality

A

It contains a lot of iodine which can then be used in the production of thyroid hormone

121
Q

List primary thyroid causes of hyperthyroidism

A

Graves
Toxic adenomas
Multinodular goitres
Thyroiditis

122
Q

How can you measure thyroid hormones

A

Blood test for T4 and T3 and TSH levels

T3 and T4 are measured as free hormones rather than the total including those bound to other proteins as only the free is physiologically active

123
Q

Why does radioactive iodine not affect other organs when given

A

Thyroid is the only gland which uses iodine so can give it safely without affecting other organs

Endocrinology (13 decks)

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