Transcript Hyperthyroidism by Dr Sarma
HYPERTHYROIDISM
A Practical Approach to Dx. and Rx.
Dr. R.V.S.N.Sarma., M.D., M.Sc., (Canada) Consultant Physician and Chest Specialist www.drsarma.in
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Clinical Exam. of Thyroid
Have patient seated on a stool / chair Inspect neck before & after swallowing Examine with neck in relaxed position Palpate from behind the patient Remember the rule of finger tips Use the tips of fingers for palpation Palpate firmly down to trachea Pemberton’s sign for RSG
Where to look for Thyroid ?
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Clinical Anatomy of Thyroid
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Clinical Exam of Thyroid
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Clinical Exam of Thyroid
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Clinical Exam of Thyroid
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Thyromegaly
Hyperthyroidism
A hyper metabolic biochemical state It is a multi system disease with Elevated levels of FT 4 or FT 3 What is thyrotoxicosis ?
or both What is hyperthyroidism ?
What are the various causes ?
How to differentiate the causes ?
What is the appropriate treatment ?
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Causes of Hyperthyroidism
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Graves Disease – Diffuse Toxic Goiter Plummer’s Disease – Toxic MNG Toxic phase of Sub Acute Thyroiditis - SAT Toxic Single Adenoma – STA 5.
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Pituitary Tumours – excess TSH Molar pregnancy & Choriocarcinoma (↑↑ βHCG) Metastatic thyroid cancers (functioning) Struma Ovarii (Dermoid and Ovarian tumours) 9.
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Thyrotoxicosis Factitia ; INF, Amiodarone, SSRIs
Graves Disease
The most common cause of thyrotoxicosis (50-60%). Organ specific auto-immune disease The most important autoantibody is Thyroid Stimulating Immunoglobulin (TSI) or TSA TSI acts as proxy to TSH and stimulates T 4 • Anti thyro peroxidase (anti-TPO) antibodies and T 3 • • • Anti thyro globulin (anti-TG) Anti Microsomal and other Autoimmune diseases - Pernicious Anemia, T1DM RA, Myasthenia Gravis, Vitiligo, Adrenal insufficiency. www.drsarma.in
Graves Disease
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I 123
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TC 99m Normal v/s Graves
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Graves Disease
Toxic Multinodular Goiter (TMG)
TMG is the next most common hyperthyroidism - 20% More common in elderly individuals – long standing goiter Lumpy bumpy thyroid gland Milder manifestations (apathetic hyperthyroidism) Mild elevation of FT 4 and FT 3 Progresses slowly over time Clinically multiple firm nodules (called Plummer’s disease) Scintigraphy shows - hot and normal areas www.drsarma.in
Toxic Multinodular Goiter (TMG)
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Toxic Multinodular Goiter (TMG)
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Sub Acute Thyroiditis (SAT)
SAT is the next most common hyperthyroidism – 15% T 4 and T 3 are extremely elevated in this condition Immune destruction of thyroid due to viral infection Destructive release of preformed thyroid hormone Thyroid gland is painful and tender on palpation Nuclear Scintigraphy scan - no RIU in the gland Treatment is NSAIDs and Corticosteroids www.drsarma.in
Toxic Single Adenoma (TSA)
TSA is a single hyper functioning follicular thyroid adenoma.
Benign monoclonal tumor that usually is larger than 2.5 cm It is the cause in 5% of patients who are thyrotoxic Nuclear Scintigraphy scan shows only a single hot nodule TSH is suppressed by excess of thyroxines So the rest of the thyroid gland is suppressed www.drsarma.in
Toxic Single Adenoma (TSA)
Nucleotide Scintigraphy www.drsarma.in
Age and Sex
Age Graves disease Toxic MNG Toxic Single Adenoma Sub Acute Thyroiditis Sex M : F ratio Graves Disease Toxic MNG www.drsarma.in
20 to 40 > 50 yrs 35 to 50 Any age 1: 5 to 1:10 1: 2 to 1: 4
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Nucleotide Scintigraphy
Clinical Features
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Those that occur with any type of thyrotoxicosis Those that are specific to Graves disease Non specific changes of hyper metabolism www.drsarma.in
Common Symptoms
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Nervousness Anxiety Increased perspiration Heat intolerance Tremor Hyperactivity Palpitations Weight loss despite increased appetite Reduction in menstrual flow or oligo-menorrhea
Common Signs
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Hyperactivity, Hyper kinesis Sinus tachycardia or atrial arrhythmia, AF, CHF Systolic hypertension, wide pulse pressure Warm, moist, soft and smooth skin- warm handshake Excessive perspiration, palmar erythema, Onycholysis Lid lag and stare (sympathetic over activity) Fine tremor of out stretched hands – format's sign Large muscle weakness, Diarrhea, Gynecomastia www.drsarma.in
Specific to Graves Disease
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Diffuse painless and firm enlargement of thyroid gland Thyroid bruit is audible with the bell of stethoscope Ophthalmopathy – Eye manifestations – 50% of cases Sand in eyes, periorbital edema, conjunctival edema (chemosis), poor lid closure, extraocular muscle dysfunction, diplopia, pain on eye movements and proptosis.
Dermoacropathy – Skin/limb manifestations – 20% of cases Deposition of glycosamino glycans in the dermis of the lower leg – non pitting edema, associated with erythema and thickening of the skin, without pain or pruritus - called (pre tibial myxedema) www.drsarma.in
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Clinical Presentations
MNG and Graves
Huge Toxic MNG www.drsarma.in
Diffuse Graves Thyroid
Higher grades of Goiter
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Toxic MNG (Diffuse) Graves
Grade IV Toxic MNG
Huge Toxic MNG www.drsarma.in
Huge Toxic MNG
Thyroid Ophthalmopathy
Proptosis Lid lag www.drsarma.in
Ophthalmopathy in Graves
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Periorbital edema and chemosis
Ophthalmopathy in Graves
Occular muscle palsy www.drsarma.in
Laka Laka Laka
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Severe Exophthalmia
Thyroid Dermopathy
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Pink and skin coloured papules, plaques on the shin
Graves with Acropathy
Graves Goiter www.drsarma.in
Acropathy
Thyroid Acropathy
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Clubbing and Osteoarthropathy
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Onycholysis
Non specific changes
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Hyperglycemia, Glycosuria Osteoporosis and hypercalcemia ↓ LDL and Total Cholesterols Atrial fibrillation, LVH, ↑ LV EF Hyper dynamic circulatory state High output heart failure H/o excess Iodine, amiodarone, contrast dyes www.drsarma.in
Nine Square Approach
PRIMARY HYPERTHYROID
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LOW NORMAL HIGH THYROID STIMULATING HORMONE - TSH
Nine Square Approach
SUB CLINICAL HYPERTHYROID
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LOW NORMAL HIGH THYROID STIMULATING HORMONE - TSH
Diagnosis
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Typical clinical presentation Markedly suppressed TSH (<0.05 µIU/mL) Elevated FT 4 and FT 3 (Markedly in Graves) Thyroid antibodies – by Elisa – anti-TPO, TSI ECG to demonstrate cardiac manifestations Nuclear Scintigraphy to differentiate the causes www.drsarma.in
Algorithm for Hyperthyroidism
Measure TSH and FT4
TSH,
FT4
TSH, FT4 N
TSH,
FT4 N TSH, FT4 N Primary (T4) Thyrotoxicosis Measure FT3 Pituitary Adenoma FNAC, N Scan High T3 Toxicosis Features of Grave’s Yes No Normal Sub-clinical Hyper
RAIU Low RAIU Rx. Grave’s
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Single Adenoma, MNG Sub Acute Thyroiditis, I 2 F/u in 6-12 wks , ↑ Thyroxine
Treatment Options
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Symptom relief medications Anti Thyroid Drugs – ATD Methimazole, Carbimazole Propylthiouracil (PTU) Radio Active Iodine treatment – RAI Rx.
Thyroidectomy – Subtotal or Total NSAIDs and Corticosteroids – for SAT www.drsarma.in
Symptom Relief
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Rehydration is the first step β – blockers to decrease the sympathetic excess Propranalol, Atenelol, Metoprolol Rate limiting CCBs if β – blockers contraindicated Treatment of CHF, Arrhythmias Calcium supplementation SSKI or Lugol solution for ↓ vascularity of the gland www.drsarma.in
Anti Thyroid Drugs (ATD)
Imp. considerations Efficacy Duration of action In pregnancy Mechanism of action Conversion of T 4 to T 3 Adverse reactions Dosage www.drsarma.in
Methimazole Very potent Long acting BID/OD Contraindicated Iodination, Coupling No action Rashes, Neutropenia 20 to 40 mg/ OD PO Propylthiouracil Potent Short acting QID/TID Safely can be given Iodination, Coupling Inhibits conversion Rashes, ↑Neutropenia 100 to 150mg qid PO
How long to give ATD ?
Reduction of thyroid hormones takes 2-8 weeks Check TSH and FT 4 every 4 to 6 weeks In Graves, many go into remission after 12-18 months In such pts ATD may be discontinued and followed up 40% experience recurrence in 1 yr. Re treat for 3 yrs.
Treatment is not life long. Graves seldom needs surgery MNG and Toxic Adenoma will not get cured by ATD. For them ATD is not the best. Treat with RAI.
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Radio Active Iodine (RAI Rx.)
In women who are not pregnant In cases of Toxic MNG and TSA Graves disease not remitting with ATD RAI Rx is the best treatment of hyperthyroidism in adults The effect is less rapid than ATD or Thyroidectomy It is effective, safe, and does not require hospitalization. Given orally as a single dose in a capsule or liquid form. Very few adverse effects as no other tissue absorbs RAI www.drsarma.in
Radio Active Iodine (RAI Rx.)
I 123 is used for Nuclear Scintigraphy (Dx.) I 131 is given for RAI Rx. (6 to 8 milliCuries) Goal is to make the patient hypothyroid No effects such as Thyroid Ca or other malignancies Never given for children and pregnant/ lactating women Not recommended with patients of severe Ophthalmopathy Not advisable in chronic smokers www.drsarma.in
Surgical Treatment
Subtotal Thyroidectomy, Total Thyroidectomy Hemi Thyroidectomy with contra-lateral subtotal ATD and RAI Rx are very efficacious and easy – so 1.
Surgical treatment is reserved for MNG with Severe hyperthyroidism in children 2.
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Pregnant women who can’t tolerate ATD Large goiters with severe Ophthalmopathy 4.
Large MNGs with pressure symptoms 5.
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Who require quick normalization of thyroid function
Preoperative Preparation
ATD to reduce hyper function before surgery βeta blockers to titrate pulse rate to 80/min SSKI 1 to 2 drops bid for 14 days This will reduce thyroid blood flow And there by reduce per operative bleeding Recurrent laryngeal nerve damage Hypo parathyroidism are complications www.drsarma.in
Dietary Advice
Avoid Iodized salt, Sea foods Excess amounts of iodide in some Expectorants, x-ray contrast dyes, Seaweed tablets, and health food supplements These should be avoided because The iodide interferes with or complicates the management of both ATD and RAI Rx.
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Summary of Hyperthyroidism
Hyperthyroidism Age % Enlarged Pain
Graves (TSI Ab eye, dermo, bruit)
20 - 40 60% Diffuse
Toxic MNG
> 50 20% Lumpy None Pressure RAIU Treatment
↑↑ ↑
ATD – 18 m RAI, Surgery
Single Adenoma
35 - 50 5% Single None ± RAI, ATD
S Acute Thyroiditis
Any age 15% None Yes
↓↓
NSAID, Ster.
TSH is markedly low, FT4 is elevated
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Thyrotoxicosis Factitia
Excessive intake of Thyroxine causing thyrotoxicosis Patients usually deny – it is willful ingestion This primarily psychiatric disorder May lead to wrong diagnosis and wrong treatment They are clinically thyrotoxic without eye signs of Graves High doses of Thyroxine lead to TSH suppression This causes shrinkage of the thyroid Stop Thyroxine and give symptom relief drugs www.drsarma.in
Algorithm for Thyroid Nodule
Thyroid Nodule Low TSH Normal TSH TC 99 Nuclear Scan Hot Nodule RAI Ablation, Surgery or ATD 4% Malignant Cold Nodule 10% Suspicious or follicular Ca 69% Benign
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Surgery T4 suppression FNAC or US guided biopsy Cyst 17% Non diagnostic – repeat FNAC Surgery or Cytology
Case # 1
A patient complains of “sandy” sensation in his eyes,weight loss, and a tremor. His extraocular muscles are inflammed. His thyroid is diffusely enlarged and non tender.
The most likely diagnosis is a. Iodine deficiency b. Sub-acute thyroiditis c. Multinodular goiter d. Graves’ disease e. Silent thyroiditis www.drsarma.in
Case # 2
A 55 year old woman is anxious, irritable, frequent semi solid stools and she reports weight loss of 5 kgs in the past six months. She was having a lumpy bumpy painless swelling in her neck for past 20 years.
The most likely diagnosis is a. Iodine deficiency goiter b. Sub-acute thyroiditis c. Multinodular goiter d. Graves’ disease e. Solitary toxic adenoma www.drsarma.in
Case # 3
A 60 year patient from a mountain region complains of constipation. He has a heart rate of 60, dry thick skin, and a tongue that has scalloped edges from teeth indentation. He has a goiter.
The most likely diagnosis is a. Iodine deficiency b. Subacute thyroiditis c. Graves’ disease d. Silent thyroiditis www.drsarma.in
Case # 4
A 25 year old woman is three months pregnant. She has a large goiter. Her exam is otherwise normal. Her thyroid tests are normal.
You recommend a. Cassava five times weekly b. Fish three times weekly c. Formula milk for the baby when it is born d. A very low salt diet www.drsarma.in
Case # 5
A 72 year old man complains of tremor and inability to concentrate. On exam, he has a heart rate of 100 beats per minute. He has a large goiter with many nodules. He has a fine tremor. His serum T4 is very high and TSH is very low.
Treatments that are likely to improve his symptoms are a. Iodine therapy b. Ethanol injection of his thyroid (PEI) c. 6 weeks of Methimazole d. Radio Active Iodine therapy www.drsarma.in
Case # 6
In Nuclear Scintigraphy Scan I 123 uptake is very high in the thyroid of patients with a. Silent thyroiditis b. Single functional adenoma c. Sub-acute thyroiditis d. Acute ingestion of animal thyroid extract e. Graves’ disease www.drsarma.in
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