USMLE Step 2 Lesson 15: Thyroid Disease

THYROID DISEASE
HYPOTHYROIDISM
Clinical features

Signs of metabolic slow-down, ie, lethargy, fatigue, slowness of speech

Cold intolerance
Constipation
Weight gain

HYPOTHYROIDISM
Clinical features

Voice and hair change

Nonpitting edema, ie, myxedema
Diminished deep tendon reflexes
Bradycardia

HYPOTHYROIDISM
Myxedema coma

Untreated severe hypothyroidism

May be triggered by acute precipitant, eg, infection
Patients may present with hypothermia, hypoglycemia, shock, and
hypoventilation
Therapy: thyroid and adrenal hormone replacement

HYPOTHYROIDISM
Diagnosis of hypothyroidism

Low total T4 and T3

Elevated TSH
Low radioactive iodine uptake

HYPOTHYROIDISM: Chronic Thyroiditis (Hashimotos Thyroiditis)

Autoimmune disorder usually affecting women

Antithyroid antibodies present
Thyromegaly due to lymphocytic infiltration

Hypothyroidism gradually develops

HYPOTHYROIDISM: Chronic Thyroiditis (Hashimotos Thyroiditis)

Diagnosis

Antimicrosomal antibodies or antithyroglobulin antibodies

Suspected in patients with symmetric, usually nontender, nontoxic goiters
Patients may be euthyroid or hypothyroid
Treat with L-thyroxine to decrease size of gland and for the hypothyroidism

HYPOTHYROIDISM
Therapy

Thyroid hormone replacement, ie, synthetic L-thyroxine

Begin with low doses in older patients and in those with severe
hypothyroidism

HYPERTHYROIDISM
Clinical features

"Overactive" metabolism
Sweating
Heat intolerance
Weight loss
Sinus tachycardia
Atrial fibrillation (apathetic hyperthyroidism in the elderly)

HYPERTHYROIDISM
Etiology

Graves' disease
Nodular toxic goiter
Subacute thyroiditis
Factitious
Pituitary tumors

HYPERTHYROIDISM
Clinical features

Diarrhea

Warm, moist skin

Restlessness and tremor
Ophthalmic findings: lid lag and the hyperthyroid stare
Thyroid exophthalmos: seen only in Graves disease; due to infiltration of
the extraocular muscles

HYPERTHYROIDISM
Thyroid storm

Severe exacerbation of hyperthyroidism

Often precipitated by infection, surgery, or delivery
High fevers, tachycardia with associated high mortality

HYPERTHYROIDISM
Laboratory studies

Elevated total T4 and T3

Elevated T3 resin uptake
Elevated radioactive iodine uptake
Low TSH

HYPERTHYROIDISM
Treatment

Antithyroid drugs
Methimazole and propylthiouracil (PTU)
o Decrease the synthesis of thyroid hormone by inhibiting the
oxidation of iodide
o PTU also inhibits the conversion of T4 to T3
o Skin rash, joint pain, or agranulocytosis may occur

HYPERTHYROIDISM
Treatment

Methimazole and propylthiouracil (PTU)

o Allows out-patient therapy
o Less likelihood of subsequent hypothyroidism
Beta-blockers: do not affect thyroid function but will block adrenergic effects
of hyperthyroidism

HYPERTHYROIDISM
Treatment

Subtotal thyroidectomy
o Allows for cure of hyperthyroidism
o Patient compliance with long-term medication is necessary
o Less hypothyroidism than with radioactive iodine
o Patient should be euthyroid before surgery

HYPERTHYROIDISM
Treatment

Radioactive iodine
o Most patients require 1 or 2 doses of radioactive iodine to cause
decrease in function and size
o Allows outpatient treatment
o Very high success rate

HYPERTHYROIDISM
Treatment

After 10 years, up to half of patients may become hypothyroid and require

thyroid hormone replacement
No increase in leukemia risk, thyroid cancer, or other malignancies; slight
risk of genetic defects in offspring

HYPERTHYROIDISM
Treatment of thyroid storm

IV sodium iodide inhibits the release of thyroid hormones

Antithyroid drugs block further hormone synthesis
Beta-blockers block peripheral effects of thyroid hormone