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Endocrine II - Exam 1 > Thyroid Pathology - SRS > Flashcards

Thyroid Pathology - SRS Flashcards

1
Q

What are the three general disease processes associated with the thyroid?

A

Hyperthyroidism

Hypothyroidism

Mass Lesions

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2
Q

What will the following be in hyperthyroid?

TSH

T4

T3

A
  • TSH: Significantly decreased
  • T4: Significantly increased
  • T3: +/-
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3
Q

What will the following be in hypothyroid?

TSH

T4

T3

A
  1. TSH: Significantly increased
  2. T4: Significantly decreased
  3. T3: +/-
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4
Q

What can you glean from the attached ultrasound of this thyroid?

A

The isthmus is grossly enlarged, and is solid at the point of enlargement. Likely indicates Graves disease.

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5
Q

What does this radionucleotide uptake scan indicate about this patient’s thyroid?

A

Toxic Adenoma

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6
Q

What does this radionucleotide uptake scan indicate about this patient’s thyroid?

A

Graves disease - Diffusely exaggerated uptake

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7
Q

What does this radionucleotide uptake scan indicate about this patient’s thyroid?

A

Normal Thyroid

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8
Q

What does this radionucleotide uptake scan indicate about this patient’s thyroid?

A

Toxic Multinodular Goiter

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9
Q

What would you call a hypermetabolic state caused by elevated circulating levels of free T3 and T4?

A

Thyrotoxicosis

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10
Q

What are the three most common causes of thyrotoxicosis?

A
  1. Diffuse hyperplasia of the thyroid (Associated with Graves in 85% of cases)
  2. Hyperfunctional Multinodular Goiter
  3. Hyperfunctional thyroid adenoma
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11
Q

What broad classes of disorders associated with thyrotoxicosis are there?

A
  • Primary
  • Secondary
  • Not associated with hyperthyroidism
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12
Q

Give 5 examples of primary hyperthyroid disorders associated with thyrotoxicosis.

A
  1. Diffuse Hyperplasia (Graves)
  2. Toxic Multinodular Goiter
  3. Toxic Adenoma
  4. Iodine-induced hyperthyroidism
  5. Neonatal thyrotoxicosis associated with maternal Graves
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13
Q

What is an example of a secondary hyperthyroid disorder associated with thyrotoxicosis?

A

TSH-secreting pituitary adenoma (rare)

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14
Q

What are four examples of disorders associated with thyrotoxicosis that are not associated with hyperthyroidism?

A
  1. Granulomatous (de Quervain) thyroiditis
  2. Subacute lymphocytic thyroiditis
  3. Struma ovarii (Ovarian teratoma with ectopic thyroid)
  4. Factitious thyrotoxicosis (exogenous thyroxine intake)
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15
Q

Which is painful/painless…

  • Granulomatous thyroiditis
  • subacute lymphocytic thyroiditis
A
  • Granulomatous thyroiditis - painful
  • subacute lymphocytic thyroiditis - painless
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16
Q

The clinical manifestations of hyperthyroidism are protean and include changes referable to the hypermetabolic state induced by what two things?

A
  • Excess thyroid hormone
  • Overactivity of the sympathetic nervous system
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17
Q

Excessive levels of thyroid hormone result in an increase in the basal metabolic rate. The skin of thyrotoxic patients tends to be soft, warm, and flushed because of increased blood flow and peripheral vasodilation, adaptations that serve to increase heat loss.

What are some common complaints that a patient with this condition might have?

Go for 7

A
  1. Heat intolerance
  2. Excessive sweating
  3. Weight loss despite appetite
  4. Tachycardia
  5. Palpitations
  6. diarrhea
  7. malabsorption
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18
Q

What are typically the earliest and most consistent features of hyperthyroidism?

A

Cardia manifestations with tachycardia, palpitations and cardiomegally.

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19
Q

Tachycardia, palpitations, and cardiomegaly are common in patients with hyperthyroidism, what are some less common presentations that tend to arise in older patients?

A
  • Atrial fibrillation
  • CHF (particularly in patients with preexisting cardiac disease)
  • Left ventricular dysfunction (reversible)
  • Low output heart failure
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20
Q

What is the low output heart failure seen in hyperthyroidism referred to as?

A

Thyrotoxic or hyperthyroid cardiomyopathy

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21
Q

What are some signs that might indicate a hyperthyroid patient is experiencing overactivity of the sympathetic nervous system?

A
  1. Tremor
  2. hyperactivity
  3. emotional lability
  4. anxiety
  5. inability to concentrate
  6. insomnia
  7. Muscle weakness/atrophy
  8. Diarrhea
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22
Q

Ocular changes often call attention to hyperthyroidism, what are some examples of these sorts of changes?

A
  1. Wide staring gaze
  2. Lid lag
  3. Proptosis
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23
Q

What is the lid lag d/t in hyperthyroidism?

A

Sympathetic stimulation of the superior tarsal muscle (Müller’s muscle), which helps to raise the upper eye lid.

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24
Q

Does proptosis occur in all hyperthyroid conditions?

A

Nope, only in Graves

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25
Q

What impact does hyperthyroidism have on the skeletal system?

A

Stimulates bone resorption, increasing porosity of cortical bone and reducing volume of trabecular bone. Ultimately leading to osteoporosis and increased fracture risk.

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26
Q

What is a thyroid storm?

In what patients is it most common?

A

Abrupt onset of severe hyperthyroidism - typically seen in patients with underlying Graves disease.

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27
Q

What is the likely triggering event for a thyroid storm?

How would a patient present?

A

Likely d/t acute elevation of catecholamine levels - as would occur during surgery, infection, cessation of antithyroid meds or just by stress.

Presentation includes febrile state with tachycardia out of proportion to the fever.

28
Q

Thyroid storms are a medical emergency. What is the problem we are worried about in these cases?

A

A significant number of untreated patients die of cardiac arrhythmias

29
Q

Therapeutic options for hyperthyroidism include several medications, each with a different mechanism of action.

What do these typically include?

What is their purpose/specific goal?

A
  1. β-blocker to control adrenergic tone
  2. thionamide to block new hormone synthesis
  3. Iodine solution to block release of thyroid hormone
  4. agents (not specified) to inhibit peripheral conversion of T4 to T3.
30
Q

How is thryoid ablation accomplished?

A

With radioiodine, which is incorporated into thyroid tissues.

31
Q

Hypothyroidism is a condition caused by a structural or functional derangement that interferes with the production of thyroid hormone, and can be primary or secondary.

What is the most common primary cause of hypothyroidism?

A

Hashimoto thyroiditis

32
Q

Worldwide, congenital hypothyroidism is most often the result of what?

A

Endemic iodine deficiency in the diet.

33
Q

Describe the areas of the united states that tend to be iodine deficient.

A

The goiter belt

34
Q

What is the most common cause of hypothyroidism in iodine-sufficient areas of the world?

A

Autoimmune hypothyroidism

35
Q

What is going on with this kid?

A

Cretinism - refers to hypothyroidism that develops in infancy or early childhood.

36
Q

What are 5 common clinical features of hypothyroidism of the cretinism variety?

A
  1. Severe mental retardation
  2. short stature
  3. coarse facial features
  4. protruding tongue
  5. umbilical hernia
37
Q

What is a term applied to hypothyroidism developing in the older adult or child?

A

Myxedema

38
Q

How is hypothyroidism diagnosed?

A

Measurement of the serum TSH level is the most sensitive screening test for this disorder

39
Q

Myxedema is marked by a slowing of what two things?

A

Physical and mental activity.

40
Q

What are the initial symptoms of hypothyroidism typically?

A
  1. Generalized fatigue
  2. Apathy
  3. Mental sluggishness
41
Q

What impact can hypothyroidism have on the vasculature?

A

Promotes an atherogenic profile with increased total cholesterol and LDL levels leading to atherosclerosis.

This likely contributes to the increased cardiovascular mortality seen in this disease.

42
Q

Histologically, there is an accumulation of matrix substances, such as glycosaminoglycans and hyaluronic acid, in skin, subcutaneous tissue, and a number of visceral sites. This results in what phenotypic changes?

A
  1. Non-pitting edema
  2. broadening/coarsening of facial features
  3. enlargement of the tongue
  4. deepening of the voice
43
Q

Thyroiditis, or inflammation of the thyroid gland, encompasses a diverse group of disorders characterized by some form of thyroid inflammation. What are the three most common and clinically significant subtypes?

A

(1) Hashimoto thyroiditis
(2) Granulomatous (de Quervain) thyroiditis
(3) Subacute lymphocytic thyroiditis

44
Q

Your overweight, tired patient consented to a biopsy of their thyroid and this is what you found. Describe what you see and make the diagnosis!

A

Dx: Hashimoto Thyroiditis

Thyroid parenchyma contains a dense lymphocytic infiltrate with germinal centers. Residual thyroid follicles lined by deepls eosinophilic Hurthle cells are also seen.

45
Q

How does Hashimotos most often come to clinical attention?

A

Painless enlargement of the thyroid gland with some degree of hypothyroidism.

46
Q

What is Hashitoxicosis?

A

In the usual case, hypothyroidism develops gradually. In some patients, however, it may be preceded by transient thyrotoxicosis caused by disruption of thyroid follicles, leading to release of thyroid hormones

47
Q

Individuals with Hashimoto thyroiditis are at increased risk for developing other autoimmune diseases, both endocrine (type 1 diabetes, autoimmune adrenalitis) and nonendocrine (systemic lupus erythematosus, myasthenia gravis, and Sjögren syndrome.

What else are they at increased risk of developing?

A

extranodal marginal zone B-cell lymphomas

48
Q

Subacute lymphocytic thyroiditis, which is also referred to as painless thyroiditis, usually comes to clinical attention because of mild hyperthyroidism, goitrous enlargement of the gland, or both. In what age group/gender is it most common?

A

Although it can occur at any age, it is most often seen in middle-aged adults and is more common in women

49
Q

What antibodies do most patients with subacute lymphocytic (painless) thyroiditis have?

A

antithyroid peroxidase antibodies

50
Q

Your 43 y/o female patient with a history of fatigue and weight gain consents to biopsy of the thyroid and you find this. The thyroid appeared grossly normal on inspection.

What is going on?

A

Microscopy reveals lymphocytic infiltration with large germinal centers within the thyroid parenchyma and patchy disruption and collapse of thyroid follicles.

There is an absence of fibrosis and Hurthle cells.

This leads us to a diagnosis of Subacute Lymphocytic (Painless) Thyroiditis

51
Q

Subacute Lymphocytic (Painless) Thyroiditis progresses to overt hypothyroidism in what percentage of cases over a ten year period?

A

33%

52
Q

Your patient is a 40-50 ish (she doesn’t know as she was abandoned by her parents sometime as a child) and presents with an enlarged thyroid gland that is painful.

What is believed to be the cause of this patients condition?

A

Granulomatous thyroiditis is believed to be triggered by a viral infection. The majority of patients have a history of an upper respiratory infection just before the onset of thyroiditis.

Histo analysis: Thyroid parenchyma has chronic inflammatory infiltrate with a multinucleate giant cell in the upper left and a colloid follicle in the bottom right.

53
Q

Granulomatous thyroiditis has a seasonal incidence with occurrences peaking in the summer, and clusters of cases have been reported in association with what specifically mentioned viruses?

A
  1. coxsackievirus
  2. Mumps
  3. Measles
  4. Adenovirus
54
Q

Graves disease can present with what lower extremity symptoms (relatively uncommon)?

A

Localized, infiltrative dermopathy, sometimes called pretibial myxedema, which is present in a minority of patients

55
Q

Graves disease has a peak incidence between 20 and 40 years of age. What is the gender distribution?

A

Women 10 times more often than men.

56
Q

Graves disease is an autoimmune disorder characterized by the production of autoantibodies against multiple thyroid proteins, most importantly the TSH receptor. What is the most common antibody in Graves?

A

Thyroid stimulating immunoglobulin (TSI)

57
Q

You decide to shadow the Denver medical examiner for a day and they show you a case where a patient was strangled by their own thyroid (**does not actually happen**), and he tells you the reason the thyroid killed her was because it was getting super soldier serum (TSI antibodies, she has graves). You section the thyroid and make slides. On microscopy you see the image at right. describe the pertinent findings that confirm the ME’s diagnosis of Graves.

A

Diffusely hyperplastic thyroid with follicles lined by tall calumnar epithelium. The crowded, enlarged epithelial cells project into the lumens of the follicles. These cells actively resorb the colloid in the centers of the follicles resulting in the scalloped appearance of the edges of the colloid.

58
Q

In Monday’s US lab your partners decide to take a look at your thyroid and switch on doppler mode. They obtain the attached image.

What does it show?

What do you have?

If placed your stethoscope over the thyroid what might you hear?

A

Reveals diffuse thickening of the thyroid and isthmus. Doppler indicates increased flow of blood through the hyperactive gland.

You probably have Graves’ disease.

You might hear a bruit.

59
Q

What has this Graves patient developed?

A

Pretibial myxedema

60
Q

Graves disease can be managed with meds, ablated with radioiodine or surgically removed. In what patients is surgical intervention most useful?

A

Surgery is used mostly in patients who have large goiters that are compressing surrounding structures.

61
Q

What is the characteristic triad of Graves disease?

A

Thyrotoxicosis

ophthalmopathy

dermopathy

62
Q

The thyroid in graves id characterized by diffuse hypertrophy and hyperplasia of follicles and lymphoid infiltrates. What is responsible for the ophthalmopathy and dermopathy?

A

Glycosaminoglycan deposition and lymphoid infiltrates.

63
Q

What are the autoantibodies seen in Hashimotos?

A

Anti-TPO

64
Q

What is the most common cause of thyroid pain?

A

Granulomatous thyroiditis

65
Q

What does a radioiodine uptake scan look like in granulomatous thyroiditis?

A

Decreased uptake.

66
Q

What is Riedel thyroiditis?

What does it simulate clinically?

A

A rare disorder characterized by extensive fibrosis involving the thyroid and continuous neck structures.

Simulates a thyroid carcinoma as it is a hard fixed thyroid mass.

67
Q
A

Endocrine II - Exam 1 (6 decks)

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