Thyroid Disease

FY1 Sejal Nirban

Thyroid Gland

Predominantly secretes T4 and small amounts of T3

Most T3 is produced by peripheral conversion of T4

Iodine is an essential requirement for thyroid hormone synthesis

99% of T4 and T3 circulate bound to plasma proteins (Thyroid Binding Globulin)

Free hormones are available to control the metabolic rate of many tissues

Thyroid function is measured using Serum TSH and free T4 and T3

Hyperthyroidism

Affects 1/50 females and 1/250 males

Due to an excess of T3 and T4 causing thyrotoxicosis

An acute exacerbation of symptoms is called a thyrotoxic crisis- usually brought on by infection

Diagnosis is made by measuring TSH, free T3 and free T4

Raised TSH suggests the fault is in the pituitary or hypothalamus whereas low TSH is due to a thyroid
problem

Symptoms
Weight loss
Increased appetite
Heat intolerance
Palpitations
Fatigue
Sweating
Diarrhoea
Oligomenorrhoea
Psychiatric symptoms
Irritability
Emotional lability
Psychosis
Signs
General
Hair thinning
 Goitre
Lid lag, lid retraction
Pre-tibial myxoedema
Eye signs
Palmar erythema
CVS
Tachycardia
AF
Neuro
Fine tremor

Causes:
1. Graves Disease- most common cause. IgG antibodies bind to TSH receptor
stimulating thyroid hormone production
2. Toxic Multinodular Goitre
3. Solitary adenoma
4. De Quervains Thyroiditis- acute inflammation of thyroid gland (fever, malaise and
neck pain)
5. Postpartum thyroiditis

Management:
1. Anti-thyroid drugs: Carbimazole (UK) Methimazole (USA)- both block thyroid hormone
biosynthesis and also have immunosuppressive affects. Clinical benefit is not seen for 10-20
days. Carbimazole can cause agranulocytisis- seek urgent blood count if patient develops
unexplained fever or sore throat
2. Beta blockers: Propanolol used for symptomatic control
3. Radioactive Iodine: contraindicated in pregnancy and breast feeding. Accumulates in the
gland and results in local irridation
4. Surgery: thyroidectomy can only be performed in euthyroid patients. Complications of
surgery include bleeding, hypocalcaemia and hypothyroidism.

Thyroid Storm
Life threatening condition- severe thyrotoxicosis
Precipitated by infection, stress and surgery
Treated with large doses of carbimazole, propranolol, potassium iodide and hydrocortisone

Graves Disease

Goitre

Eye signs- oedema, proptosis, lid retraction, lid lag, and opthalmoplegia- worse in smokers.

Thyrotoxicosis

Cause: T lymphocytes react with antigens shared by the orbit and thyroid leads to retro orbital
inflammation. Swelling and oedema of extra-ocular muscles leading to limitation of movement and
proptosis. Increased pressure on the optic nerve may cause optic atrophy.

Treatment is low dose of carbimazole, surgery or radioiodine and stop smoking advice
Hypothyroidism

Affects 1/100 females and 1/500 males. Incidence increases with age.

T3 and T4 levels are low with a raised TSH

If TSH is low then there is likely to be a hypothalamic or pituitary lesion

Symptoms
Weight gain
Fatigue, lethargy
Cold intolerance
Constipation
Menorrhagia
Hoarse voice
Myalgia
Carpal tunnel syndrome
Psychiatric symptoms
Depression
Dementia
Signs
General
Dry skin and hair
Goitre
Non-pitting oedema
Facial features purple lips, malar flush, periorbital oedema, lateral
eyebrow loss
CVS
Bradycardia
Neuro
Cerebellar ataxia
Slow relaxing reflexes
Peripheral neuropathy

Causes

1. Iodine deficiency
2. Autoimmune thyroiditis- Hashimotos thyroiditis
3. Iatrogenic- thyroidectomy, radioactive iodine
4. Drug induced- carbimazole, lithium, Amiodarone
5. Congenital hypothyroidism- thyroid aplasia

Management: Lifelong Levothyroxine. Aim to normalise TSH

Myxoedema coma
Severe hypothyroidism with swelling of subcutaneous tissues- typically around eyes and back of
hands bunch of banana hands

Unresponsive, decreased respiratory rate, low bp, low glucose, low temperature

Pregnancy and Thyroid

Increased concentration of TBG

Total T4 and T3 increase
Free T4 and T3 remain within normal range
TSH does not change

Two pregnancy-related hormoneshuman chorionic gonadotropin (hCG) and estrogencause

increased thyroid hormone levels in the blood. Made by the placenta, hCG is similar to TSH and
mildly stimulates the thyroid to produce more thyroid hormone. Increased estrogen produces higher
levels of thyroid-binding globulin.

Transient autoimmune thyroiditis can occur postpartum resulting in hypo or hyperthyroidism

Hyperthyroid management: Propylthiouracil. Carbimazole is associated with congenital defects

including aplasia cutis of the neonate.
Hypothyroid management: Levothyroxine is safe to give in pregnancy

Thyroid Malignancy

Most present as asymptomatic thyroid nodules

Types:

1. Papillary- 70%. Good prognosis

2. Follicular- 20%. Good prognosis
3. Anaplastic <5%. Aggressive, poor prognosis
4. Lymphoma 2%. Poor prognosis
5. Medullary 5%. Often familial. Poor prognosis

Investigation: FNAC distinguishes between benign and malignant nodules

Treatment: Radioactive iodine, thyroidectomy with wide local lymph node excision. External
radiotherapy and palliative care for anaplastic and lymphomas.