thyroid disease pdf

8/2/2019 Thyroid Disease PDF

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Thyroid Disease

Dr Mastura Hj Ismail

FMSKK Seremban 2


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Thyroid Hormone Excess

Clinical Features General

Heat intolerance, fatigue, tremor, sweating

Cardiovascular Tachycardia, heart failure.

Gastrointestinal

Weight loss, diarrhoea Ophthalmological

Lid lag, ophthalmopathy


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Thyroid Hormone Excess

Clinical Features Genitourinary

Amenorrhea, infertility.

Neuromuscular Proximal muscle weakness

Psychiatric

Irritability, agitation, anxiety, psychosis Dermatological

Pruritus, hair thinning, onycholysis, vitiligo.


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Diagnosis High Free T4, T3 and supressed

sTSH

If sTSH is high suspect pituitary tumouror rare cases of thyroid hormoneresistance


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There may be mild normochromicanemia, mild leucopaenia,

Raised ESR, Se Calcium and LFT

Thyroid antibodies


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Causes of Thyroid Hormone

Excess Increased radioactive iodine uptake

Graves

TMG

Toxic solitary adenoma

Pituitary tumour


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Causes of Thyroid Hormone

Excess Reduced radioactive iodine uptake

Thyroiditis

Iodine induced (amiodarone)

Lithium (hypothyroid is commoner)

Factitious: thyroxine intoxication

Struma ovarii: ovarian teratoma containingthyroid tissue

Metastatic follicular thyroid carcinoma


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Isotope scan If cause is unclear, to detect nodular

disease or subacute thyroiditis


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Isotope scan


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Graves Disease Common between 30-50 years

Diffuse Goitre

Hyperthyroidism

Ophthalmopathy

Dermopathy Autoimmune. TSI.


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Grave Disease only Eye disease: exopthalmos,

ophthalmoplegia

Pre-tibial myxoedema oedematousswelling above lateral malleleolai

Thyroid acropachy-extreme

manisfestation with clubbing, painfulfingers, toes swelling and periostealreaction in limbs bones


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TMG Older

Nodules that secrete thyroid hormones

Usually less severe hyperthyroidism

May have subclinical hyperthyroidism

May have long history of goitre


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Toxic Solitary Adenoma Rare cause (< 2% of patients with

hyperthyroidism)

Younger people 30s and 40s

Scansolitary hot nodule

Benign follicular adenomas


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Thyroiditis Self-limiting viral infection

Painful goitre(subacute, de Quervains),

fever, raised ESR

Painless (post partum)

Hyperthyroid, hypothyroid andeuthyroid phases

Anti thyroid drug therapy does not work

Tx: NSAIDs


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Treatment of hyperthyroidism

Antithyroid drugs Carbimazole 20-45 mg/24 hours

Reduce to maintenance after 4 -8weeks accordingTFT

Maintenance :minimum for 18 months Side effect: Rash, GI, agranulocytosis (can lead to

life threatening sepsis). Warn to stop and dourgent FBC if sign of infection

Alternative: PTU Graves maintain for 12-18 months then

withdraw drugs after course of treatment. 50%will relapse, requiring RAI or surgery


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Treatment of hyperthyroidism Block Replacement Regime: Give

carbimazole and thyroxine

simultaneously (less risk of iatrogenichypothyroidism)


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Rapid symptom control Beta blocker: e.g propranolol


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Treatment of hyperthyroidism Radio-iodine

Inflammatory response followed by fibrosis

May be used for Graves, TMG or TA

? Need for drug treatment before and after

May need retreatment

CI: pregnancy. Lactation Caution in active thyroidism can cause

thyroid storm

Long term risk of hypothyroidism


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Treatment of Hyperthyroidism Surgery

Rarely used nowadays

Need to be rendered euthyroid beforesurgery

Lugols iodine 0.1-0.3 mls tid for 10 days

before surgery Risk damage to recurrent laryngeal nerve

and hypoparathyroidism


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Treatment of Hyperthyroidism In pregnancy and infancy: get expert

help


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Treatment of Hyperthyroidism Patient presents with hyperthryoidism

Make diagnosis, get RAI uptake.

Beta block (propranolol 40-80 mg tid).

If RAI uptake is high treat with RAI.

If RAI is low - symptomatic


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Thyroid Storm Carbimazole (or PTU)

Propranolol, 80mg qid

Iodine (Lugols 5 drops q6)

Dexamethasone 2mg q6

Other supportive measures


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Graves Eye Disease

Occur in 25-50% pts

May not be correlate with the severity

Main known risk factor is smoking

Onset relative to hyperthyroidism is variable.

Pain, watering, photophobia, blurred vision,double vision

Usually mild Tx, protective glasses, elevatehead of bed, conjunctival lubricants


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Graves Eye Disease High dose steroids

External radiotherapy

Orbital decompression


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Complications Heart failure (thyrotoxic

cardiomyopathy esp in elderly)

Angina, AF

Osteoporosis

Opthalmopathy

Gynecomastia

Thyroid storm


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Causes Hypothyroidism Autoimmune:

i)Hashimotos

ii) Primary atrophic hypothyroidism: no goitre Iodine deficiency: poor intake

Drug induced: antithyroid drugs, amiodarone,

lithium, iodine Congenital

Hypopituitarism


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Symptom hypothyroidism Tiredness, lethargy, depression, dislike

of cold, weight gain, constipation,

menorrhagia, hoarse voice, poorcognition/dementia, myalgia


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Signs Bradycardia

Dry skin and hair

Non-pitting oedema (eye lids, hands,feet)

Cerebellar ataxia

Slow relaxing reflexes, peripneuropathy, toad-like face

There may be goitre


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Diagnosis Raised TSH, Low T4


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Treatment Thyroxine 100-150ug daily.

Adjust 6 weekly with clinical state and

TFT

Aim to normalize sTSH

Once normal check TFT yearly

In patients with CAD start with lowerdose e.g. 25ug perday. Increase doseslowly


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Subclinical hypothyroidism Suspec t if TSH high but normal T4 and

T3, no obvious symptoms

Common, 10% of those above 55 yearsold

Risk progression to frank

hypothyroidism is about 2% andincrease as TSH higher


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Mx subclinical hypothyroidism Confirm that raised TSH is persistent (recheck

in 2-4 months)

Recheck the history for any non-specificfeatures e.g depression

Discuss benefit of tx with patients

One approach is to treat (thyroxine) if TSH >10, positive thyroid autoantibodies present,previously treated Grave disease


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Subclinical hyperthyroidism Low TSH, normal T4 and T3

Confirm that raised T4 is persistent (recheck in 2-4months)

Recheck for non-thyroidal causes:illness, pregnancy,pituitary insufficiency

Discuss benefit of tx with patients

If TSH


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Simple non-toxic goitre Normal TFTs

No treatment required

Surgery if obstructive symptoms


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Non-thyroidal illness Ill patients may have low T3 and/or T4

usually with a normal sTSH

Psychotic patients may have elevatedT3 and/or T4.


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Thyroid Nodule FNA

Benign no further intervention

Malignant or suspicious papillary orfollicular.


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Papillary Cancer Controversies

Extent of surgery (near total

thyroidectomy). Follow up with sTSH,thyroglobulin exam and US.

Radioactive iodine ablation for high risktumours. Follow up with RAI scans plusthe above.


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Follicular cancer Less common than papillary

Total thyroidectomy (or near total).

Routine remnant ablation with RAI dueto increased risk of metastatic disease.

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