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HYPERTHYROIDISM
DEFINITION- HYPERTHYROIDISM
Diagnosis Hyperthyroidism
T3 and/or FT4
TSH
RISK FACTORS
Female sex
Smoking
History of other autoimmune diseases
Genetic
Pregnancy/ post partum ( can trigger hyperthyroidism in
those who are genetically susceptible)
SYMPTOMS
Symptoms
Sweats, tremors, palpitations
Weight loss, increased appetite
Insomnia
Heat intolerance
Diarrhoea
Oligomenorrhoea
Irritability/ labile motions/ anxiety
SIGNS OF HYPERTHYROIDISM
Tachycardia, irregular pulse ( atrial fibrillation)
Warm, moist skin
Fine tremor
Palmar erythema
Thin hair
Lid lag
Lid retraction
Goitre
Thyroid nodules
Thyroid bruit
Hyper-reflexia
SIGNS AND SYMPTOMS OF
HYPERTHYROIDISM
Hoarseness/
Nervousness/Tremor Deepening of Voice
Family History of
First-Trimester Miscarriage/
Thyroid Disease
Excessive Vomiting in Pregnancy
or Diabetes
SIGNS OF GRAVES DISEASE
Exophthalmos
Ophthalmoplegia
Pretibial myxoedema
Thyroid acropachy ( extreme manifestation with
clubbing, painful finger & toe swelling & periosteal
reaction in limb bones)
THYROID EYE DISEASE
Department of Medicine,
RCSI
DIFFERENTIAL DIAGNOSIS
Diagnosis of Hyperthyroidism
Thyroid functions tests ( TFTs)
TSH low
Free T4 elevated
SCREENING FOR AETIOLOGY
Radionuclide scan
Normal
Normal uptake Graves - diffuse uptake
Graves
Graves
Department of Medicine,
RCSI
MANAGEMENT- ACUTE SYMTPOMATIC
Graves Disease
3 main treatment modalities to reduce thyroid hormone
production
Medical
Radio-iodine
Surgical
Department of Medicine,
RCSI
MECHANISM OF ACTION
Agranulocytosis
Failure of bone marrow to make enough white cells(neutrophils)
Can result in profound sepsis
Most feared side effect
0.37% for PTU; 0.35% for Carbimazole
Usually occurs within 90 days of treatment
Warn patient to stop medication & get urgent medical review
including FBC if fever, sore throat, mouth ulcers
Cross reactivity do not use the second agent
Also check FBC/ stop medication if bruising/ bleeding/ symptoms
of pancytopaenia
MANAGEMENT-RADIOACTIVE IODINE
Radioactive iodine
used for treatment for 50 years.
first line therapy in America.
transient worsening of hyperthyroidism can occur as the
gland is destroyed.
Avoid in pregnancy
SIDE EFFECT OF RADIOACTIVE IODINE
Hypothyroidism
often of gradual onset after RAI
~2-5% per year
requires life long monitoring
treat with L-thyroxine
Can worsen thyroid eye disease
Radiation is emitted from gland post treatment-
avoid prolonged contact with children/ pregnant
women until same subsides
Caution in active hyperthyroidism as risk of thyroid
storm/ hyperthyroid crisis
MANAGEMENT- SURGERY
Initially-
control the thyrotoxic state with medication
Definitive
Radioactive iodine or Surgery
Solitary Toxic Nodule
Atrial fibrillation
Heart failure
Angina
Osteoporosis
Ophthlamopathy
Oligomenorrhoea/ amenorrhoea
Gynaecomastia
PROGNOSIS-MEDICAL THERAPY
Clinical
Sub-acute, self limiting, post viral.
Flu-like illness, fever
Painful tender goitre
Initially hyperthyroid phase followed by hypothyroid
phase. TFTs usually normalise subsequently
Diagnosis
High ESR
TFT ( T4, TSH initially)
Radionucleotide scan no uptake
Department of Medicine,
TREATMENT OF THYROIDITIS
Beta-blockers
Department of Medicine,
RCSI
SUB-CLINICAL HYPERTHYROIDISM
Reasons to treat:
1. Atrial fibrillation
2. Osteoporosis
3. Increased cardiovascular disease risk
4. Progression to clinical hyperthyroidism
Department of Medicine,
RCSI
SUB-CLINICAL HYPERTHYROIDISM
A 45 year old lady attends her GP with anxiety, weight loss & heat intolerance.
The GP suspects hyperthyroidism.
Q1. List 7 signs that the GP should look for on exam to support the diagnosis of
hyperthyroidism ( 7 marks)
Answer= See slide 7
Q3. Thyroid function tests confirm hyperthyroidism. List 2 tests that can be subsequently
performed to confirm the aetiology of the hyperthyroidism. ( 4 marks)
Answer = Radionuclide scan ,TSH receptor antibodies often raised in Graves disease,Anti-
thyroid peroxidase antibodies ,ultrasound & FNA if nodule present
Q4. List 3 treatment options for hyperthyroidism & give 1 side effect of each. ( 6 marks)
Answer= Medications ( carbimazole or propylthiouracil), radio-iodine & surgical. See slides
for side effects
REFERENCES
Uptodate.com
Kumar & Clark- Clinical Medicine 2012
Harrisons clinical medicine 2012
Oxford handbook of clinical medicine 8th edition