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Endocrinology > Thyrotoxicosis and hyperthyroidism > Flashcards

Thyrotoxicosis and hyperthyroidism Flashcards

1
Q

Are all cases of thyrotoxicosis associated with hyperthyroidism?

A

No, thyrotoxicosis is the result of increased thyroid hormone, but this excess thyroid hormone doesn’t always come from an overactive thyroid gland (Hyperthyroidism)

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2
Q

How can hyperthyroidism cause thyrotoxicosis?

A
  • Excessive thyroid stimulation
  • Autonomous thyroid nodules
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3
Q

What are some thyroid nodules that can become autonomous?

A

Toxic solitary nodule
Toxic multi-nodular goitre

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3
Q

What are some causes of excessive thyroid stimulation?

A

Grave’s disease
Hashitoxicosis
Thyrotropinoma (TSHoma)
Thyroid cancer
Choriocarcinoma

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4
Q

What are some non-hyperthyroid associated causes of thyrotoxicosis?

A

Thyroiditis
Exogenous thyroid hormones
Ectopic thyroid tissue

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5
Q

What are some causes of exogenous thyroid hormones in thyrotoxicosis?

A

Over-treatment with levothyroxine
Thyrotoxicosis factitia

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6
Q

What are some examples of ectopic thyroid tissue?

A

Metastatic thyroid carcinoma
Struma ovarii (Teratoma containing thyroid tissue)

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7
Q

What is Grave’s disease?

A

Grave’s disease is a type IIb autoimmune condition in which auto-antibodies bind to and activate TSH receptors, increasing T3 and T4 secretion

This causes hyperthyroidism

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8
Q

What is the most common cause of hyperthyroidism in younger patients (20-50)?

A

Grave’s disease

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9
Q

Describe the goitre formed in Grave’s disease

A

Smooth

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10
Q

What are the main symptoms in Grave’s disease?

A
  • Hyperthyroidism with diffuse enlargement of the thyroid (Smooth goitre)
  • Grave’s eye disease (Exophthalmos)
  • Pre-tibial myxoedema
  • Thyroid acropachy (Finger clubbing)
  • Thyroid bruit (Associated with large goitres, reflective of hypervascularity of the thyroid)
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11
Q

What symptom of Grave’s disease is shown here?

A

Pre-tibial myxoedema

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12
Q

What is Grave’s eye disease?

A

A TRAb driven condition occurring in 20% of Grave’s patients, in which there is bulging of the eyes and lid retraction

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13
Q

What are some other names of Grave’s eye disease?

A

Thyroid eye disease (TED)
Grave’s opthalmopathy

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14
Q

What will blood testing show in Grave’s disease?

A
  • Low TSH
  • Raised fT4/3
  • Hypercalcaemia and raised ALP (increased bone turnover)
  • Leucopenia
  • TSH receptor antibody (TRAb)
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15
Q

What is the most common antibody found in Grave’s disease?

A

TSH receptor antibody (TRAb) (70-100%)

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16
Q

What is the least common antibody found in Grave’s disease?

A

Anti-thyroglobulin (30-50%)

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17
Q

How will Grave’s disease be managed?

A

Mild disease is treated topically e.g. lubricants

Severe disease is treated with steroids, radiotherapy (Poor evidence) and surgery

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18
Q

What is the most common cause of primary hyperthyroidism in older patients (>50)?

A

Nodulatr thyroid disease

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19
Q

How will nodular thyroid disease present?

A

Insidious onset formation of asymmetrical goitre

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20
Q

What will testing show in nodular thyroid disease?

A
  • Raised fT3/4
  • Low TSH
  • TRAb negative
  • Scintigraphy shows high uptake (Iodine uptake scanning)
  • Thyroid ultrasound
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21
Q

What are the main symptoms of thyrotoxicosis?

A
  • Increased BMR
  • Very fast pulse rate
  • Increased nervousness and excessively emotional
  • insomnia
  • Sweating & heat intolerance
  • Tendency to lose weight easily
  • Tremors
  • Muscle weakness
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22
Q

What are some cardiac symptoms of thyrotoxicosis?

A

Palpitations
Atrial fibrillation

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23
Q

What are some neurological symptoms of thyrotoxicosis?

A

Anxiety
Nervousness
Irritability
Sleep disturbance

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24
What are some gastrointestinal symptoms of thyrotoxicosis?
Frequent, loose bowel movements
25
What are some visual symptoms of thyrotoxicosis?
- Lid retraction - Double vision (Diplopia) - Proptosis (Grave’s disease)
26
What are some hair and skin symptoms of thyrotoxicosis?
- Brittle, thin hair - Rapid fingernail growth
27
What are some menstrual cycle changes that occur in thyrotoxicosis?
Lighter bleeding Less frequent periods
28
What is a thyroid storm?
A medical emergency in which there is severe hyperthyroidism
29
What are some symptoms of thyroid storms?
- Respiratory or cardiac collapse - Hyperthermia - Exaggerated reflexes
30
Who is most at risk of thyroid storm?
Hyperthyroid patients, with an acute infection or recent thyroid surgery
31
How is thyroid storm managed?
- Lugol’s iodine - Glucocorticoids - PTU - ß-blockers - Fluids - Monitoring - Mechanical ventilation (If respiratory collapse)
32
What will blood detesting show in primary hyperthyroidism?
High fT3/4 Low TSH
33
What will blood testing show in secondary hypothyroidism?
High fT3/4 High TSH
34
How do anti-thyroid drugs?
They inhibit TPO, therefore blocking thyroid hormone synthesis
35
What are some examples of anti-thyroid drugs?
- Carbimazole - Propylthiouracil (PTU)
36
What is the first line antithyroid drug in hyperthyroidism?
Carbimazole
37
How often is carbimazole taken?
Once daily
38
What can occur is carbimazole is taken during early pregnancy?
Aplasia cutis (Missing patches of skin on the babies scalp) GI abnormalities Choanal and oesophageal atresia
39
When is PTU used 1st line in hyperthyroidism?
In early pregnancy
40
How often is PTU taken?
Twice daily
41
What disease are PTU patients more at risk of?
Liver failure (1 in 10,000)
42
What are some possible side effects of anti-thyroid drugs?
- Rash, urticaria, arthralgia - Cholestatic jaundice, raised liver enzymes - Agranulocytosis
43
What is agranulocytosis?
Agranulocytosis is a lack of granulocytes in the blood, meaning the patient is at a high risk of infection
44
Can anti-thyroid drugs be used again after agranulocytosis occurs?
NO!
45
What is done to screen patients on anti-thyroid drugs for agranulocytosis?
Patients should be warned verbally, and in writing to stop the drug or to have urgent FBC checking in event of fever, ulcer or oropharyngeal infection
46
What are some management options of hyperthyroidism?
Anti-thyroid drugs ß-Blockers Radioiodine Thyroidectomy
47
What is the use of ß-blockers in hyperthyroidism?
For immediate symptomatic relief of thyrotoxic symptoms due to its activity in reducing activity of the sympathetic nervous system
48
What is the main ß-blocker use din hyperthyroidism?
Propanolol
49
When is radio iodine used in hyperthyroidism?
relapsed Grave’s disease and nodular thyroid disease
50
When is radio iodine contraindicated?
It is contraindicated in pregnancy and is relatively contraindicated in active thyroid eye disease (Can be used with a steroid cover)
51
What is a possible complication of radio iodine usage in Grave's disease?
High risk of hypothyroidism when used in Grave’s disease
52
When is thyroidectomy indicated in hyperthyroidism?
When radio iodine is contraindicated
53
What are some possible risks of thyroidectomy in hypertension?
Recurrent laryngeal nerve palsy Hypothyroidism Hyperparathyroidism
54
How does hCG affect the thyroid?
hCG causes stimulation of thyroxine release, which causes suppression of TSH
55
What are some symptoms of high hCG levels that help to distinguish it from hyperthyroidism?
- Hyperemesis gravidarum - Not TRab antibody positive - TSH low and not fully suppressed - Resolves by 20 weeks gestation
56
When is gestational hCG-asscoiated thyrotoxicosis treated?
If it lasts longer than 20 weeks gestation
57
What can hyperthyroidism in pregnancy increase the risk of?
- Infertility - Ammenorhoea - Spontaneous miscarriage - Stillbirth - Thyroid crisis in labour - Transient neonatal thyrotoxicosi
58
What are some possible causes of hyperthyroidism in pregnancy?
- Grave’s disease - Toxic multinodular goitre - Toxic adenoma - Thyroiditis
59
How is hyperthyroidism usually managed in pregnancy?
Wait-and-see approach with supportive management given if necessary (ß-blockers)
60
If required, which low-dose antithyroid drugs given in pregnancy?
- Propylthiouracil 1st trimester - Carbimazole 2/3rd trimester
61
What are soem possible side effects of propylthiouracil (PTU) in pregnancy?
Embryopathy Liver toxicity
62

Endocrinology (42 decks)

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