Professional Documents
Culture Documents
An Overview
Matthew Volk
Morning Report
November 17th, 2009
Epidemiology
Thyroid
TSH
- Thyroid Stimulation
Blocking Ab (TSBAb)
Receptor
Autoimmune
Thyroid peroxidase Hypothyroidism
Thyroglobulin Ab (Hashimotos)
Ab (anti TPO)
The Classic Triad of Graves Disease
Hyperthyroidism (90%)
Ophthalmopathy (20-40%)
proptosis, ophthalmoplegia, conjunctival irritation
3-5% of cases require directed treatment
Dermopathy (0.5-4.3%)
localized myxedema, usually pretibial
especially common with severe ophthalmopathy
There is also a close association with autoimmune findings
(e.g. vitiligo) and other autoimmune diseases (e.g. ITP)
Syndrome of Hyperthyroidism
Asymmetric, raised,
firm, pink-to-purple,
brown plaques of
nonpitting edema
Hyperthyroidism Differential
Graves Disease
Toxic Multinodular Goiter
Toxic Adenoma
Thyroiditis
silent (Hashimotos) painless, often post partum
subacute (de Quervains) painful, post viral
drug-induced amiodarone, lithium, interferon
Thyrotoxicosis factitia
Laboratory Evaluation
T3:T4 > 20
- Graves Disease
- Toxic MN Goiter
T3:T4 < 20
- Non-thyroid illness
- Thyroiditis
- Exogenous thyroxine
Its Good to be Free
Total Thyroidectomy
Indications: suspicion for malignant nodule,
comorbid need for parathyroidectomy, radioactive
ablation contraindicated, compressive goiter
Recent metaanalysis showed this is the most cost
effective if surgery is < $19,300.
Prep with 6 weeks thionamides, 2 weeks iodide
Hypoparathyroidism and/or laryngeal nerve
damage in <2%
Lasting remission in 90%
Treatment of Ophthalmopathy
Mild Symptoms
Eye shades, artificial tears
Progressive symptoms (injection, pain)
Oral steroids typical dosage from 30-40mg/day
for 4 weeks
Impending corneal ulceration, loss of vision
Oral versus IV steroids
Orbital Decompression surgery
References
Alguire et al. MKSAP14 Endocrinology and Metabolism. 2006. 27-34.
Andreoli et al. Cecil Essentials of Medicine. 6th Edition, 2004. 593-7.
Nayak, B et al. Hyperthyroidism. Endocrinol Metab Clin N Am. 36
(2007) 617-656.
In H et al. Treatment options for Graves disease: a cost-effectiveness
analysis. J Am Coll Surg. 2009 Aug;209(2):170-179.e1-2.
Stiebel-Kalish H et al. Treatment modalities for Graves'
ophthalmopathy: systematic review and metaanalysis. J Clin Endocrinol
Metab, August 2009, 94(8):27082716
Uptodate Online Disorders that Cause Hyperthyroidism, Diagnosis of
Hyperthyroidism, Cardiovascular Effects of Hyperthyroidism, Treatment
of Graves Ophthalmopathy